Developing a Secure Base:Application of Attachment Theory to

Clinical Practice

Douglas Goldsmith, Ph.D.

Executive Director

The Children’s Center

Overview Foundations of Clinical Practice Attachment theory

– Strange Situation Internal Working Models Reflective Functioning Maternal Representations

– Adult Attachment Interview Insightfulness Treatment implications

Clinical Practice

Referral

Intake

Assessment

Treatment

Discharge

Good Progress!

Poor Progress

Child

Parents

System

Med Management

Alternative Hypotheses

Inadequate assessment Failure to accurately diagnose the child Failure to accurately assess family

dynamics Failure to formulate the case Failure to address the relationship

issues

Added value of attachment theory and developmental concepts:

Provides foundation for conceptualization of the parent-child relationship

Able to focus interventions on repair of relationship-based issues even when a diagnosable condition exists

Attachment

Emotional bond with another person Behaviors promote proximity with one

perceived as older, stronger, and wiser Motivational system to seek proximity Enhances feelings of security Motivates baby to take action when

frightened

Attachment Theory

When I am close to my loved one I feel good, when I am far away I am anxious, sad or lonely

Attachment is mediated by looking, hearing, and holding

When I’m held I feel warm, safe, and comforted

Results in a relaxed state so that one can, again, begin to explore Holmes (1993)

Attachment in Action

Behaviors shown by careseeker and caregiver

Aware of and seek each other out if careseeker is in danger due to physical separation, illness, or fright

Attachment Classifications

The strange situation– Secure 65%– Avoidant 20%– Ambivalent 10%– Disorganized 5-10% (80% maltreated)

Secure (B)

Uses mother as secure base Signs of missing mother Actively greets with smile or gesture Signals or seeks contact if upset Once comforted resumes exploration

Solomon & George (1999) p.291

Secure Attachment

Child feels safe and secure

Avoidant (A)

Explores readily Little visible distress when left alone Upon reunion, looks away or actively

avoids May stiffen or lean away if picked up

Solomon & George (1999) p. 291

Ambivalent (C)

Distressed, fretful, passive Fails to explore Unsettled, distressed by separation Alternates bids for contact with signs of

angry rejection Fails to find comfort from the parent

Solomon & George (1999) p.291

Insecure Attachment

Intense love and dependency Fear of rejection Irritability Vigilance Punish their attachment figure for any

sign of abandonment

Insecure Attachment

The insecurely attached person is saying:“Cling as hard as you can to people –they are likely to abandon you: hangon to them and hurt them if they showsigns of going away, then they may be less likely to do so.”

Holmes (1993)

Disorganized (D)

Behavior lacks an observable goal Look fearful Behavior is bizarre May try to leave after the reunion or

freeze

Attachment Relationship

Proximity Seeking Secure base effect Separation protest

Attachment Behavioral System

Attachment figure:Near, responsive,

attunedFelt security, love,

self-confidence

Playful, smiling,Exploratory, sociable

Holmes (1993)

Attachment Behavioral SystemAttachment

Figure:Distant,

UnresponsivePoor attunement

FearAnxiety Defensive

AvoidantWatchful

Wary

AmbivalentClingingAngry

Holmes (1993)

Visual checkingPleadingClinging

Attachment ProblemsBowlby

A severely hurt child fails to seek comfort

Signals that ordinarily activate attachment behavior fail to do so

System controlling attachment, and the feelings and desires associated, is rendered incapable of being aroused

Classification vs. Disorder

Secure infants are at a decreased risk for psychopathology but not immune

There is no clear link between insecure infants and psychopathology

Links to Other Disorders

An avoidant child may develop a hostile, aggressive, antisocial pattern in response to experience with a rejecting and emotionally unavailable caregiver

An ambivalent child may be easily overstimulated, showing impulsivity, restlessness, short attention span, and low frustration tolerance

(Greenberg, 1999 p.481)

Video

Internal Working Model

Based on the child’s real-life experience of day to day interactions with his parents

Reflects the images the parents have of the child

Images communicated by how each parent treats the child and what each parent says to the child

Impact of the Internal Working Model

The model governs how children feel toward each parent and about themselves, how they expect to be treated and how they plan their own behavior toward their parent

Securely Attached Child

Internal Working Model– Responsive, loving, reliable caregiver– Self is worthy of love and attention

Holmes (1993)

Insecurely Attached Child

The world is dangerous Treat others with great caution Self is ineffective and unworthy of love These assumptions are stable and

enduring and terribly difficult to modify Holmes (1993)

Video

Development of Relationships

“For a relationship between any two individuals to proceed harmoniously each must be aware of the other’s point-of-view, his goals, feelings, and intentions, and each must so adjust his own behavior that some alignment of goals is negotiated.

Development of Relationships

This requires that each should have reasonably accurate models of self and other which are regularly updated by free communication between them. It is here that the mothers of securely attached children excel, and those of the insecure are markedly deficient.”

Bowlby (1988) p. 131

Mothers of Secure Infants

Continuously monitor the infant’s state Accurately interpret the signal for

attention Act accordingly to meet the infant’s

needs

Mother’s of Anxious Infants

Monitor the infant’s state only sporadically

Inconsistently notice the infant’s signals May interpret the signal inappropriately Respond to the signal inappropriately,

or tardily

Impact of Anxious Attachment

“By the age of 12 months, there are children who no longer express to their mothers one of their deepest emotions or the equally deep-seated desire for comfort and reassurance.”

Bowlby (1988)

Ambivalently Attached Child

Shows overt aggression toward the inconsistent mother

“Don’t you dare do that again!” but has to cling because he knows from experience that she will.

Holmes (1993)

Avoidant Child

Outbursts of unprovoked aggression Needs to appease to the mother

because the child wants so badly to feel close

Fears she’ll rebuff him if needs are revealed too openly; or if anger about abandonment is shown too openly

Holmes (1993)

Impact of Empathic Failure

“Whatever she fails to recognize in him he is likely to fail to recognize in himself. In this way, it is postulated, major parts of a child’s developing personality can become split off from, that is, out of communication with, those parts of his personality that his mother recognizes and responds to, which in some cases include features of personality that she is attributing to him wrongly.” Bowlby (1988) p.132

Reflective Function

“The reflective function refers to the psychological processes underlying the capacity to mentalize. . . mentalizing refers to the capacity to perceive and understand oneself and others’ behavior in terms of mental states, i.e., reflection.”

Fonagy, Steele, Steele & Target (1997)

Reflective Function

Allows the individual to make sense of his or her own and others’ psychological experience, to enter into another’s experience, to “read” another’s mind

Allows the child to make others’ behavior meaningful and predictable, and permits him to respond adaptively

Slade (1999)

Reflective Function

The mother’s capacity to understand the child’s mental states create the context for a secure attachment relationship

The mother is able to view the infant as intentional

Reflective functioning provides protection against damaging effects of abuse and trauma

Slade (1999)

Reflective Function

The capacity to tell a story that is affectively believable

The capacity to understand emotional processes

The ability to accurately understand ones own and others behavior

Slade (2002)

Adult Attachment Interview

Secure-Autonomous– Coherent– Not overwhelmed by emotion– Show compassion, humor, forgiveness,

awareness of unconscious, awareness of lack of perfection

AAI

Preoccupied– No overview– Ramble, get lost in memories– Talk about irrelevant issues– “We did this, that, and the other thing”– Seems angry, passive, or fearful

AAI

Dismissing– Push aside experiences– May idealize parents– Avoid emotional aspects– “Nothing negative in my childhood”

AAI Unresolved

– Lapses in monitoring– Indicate belief that a dead person is still

alive or the person was killed by a childhood thought

– Long silences

Dyadic Patterns Marvin et al (2002)

Secure child – Autonomous Parent– Easily approach and interact when distressed– The reunion calms the child and facilitates

exploration– Child can shift between exploration and using the

parent as a safe harbor with little anxiety– Close attunement – disruptions easily repaired

Dyadic Patterns Marvin et al (2002)

Insecure child – Dismissing Parent– Both partners minimize intimate

attachment-caregiving interactions– Miscue – I’m really more interested in

playing– “Independence” is highly valued– Overregulated affect, little emotional self-

knowledge

Dyadic Patterns Marvin et al (2002)

Insecure Child –

Ambivalent/Preoccupied Parent– Both partners minimize independent

exploration– Child is overly dependent on the parent– Miscue – don’t explore, there really is

something to be anxious about– Under-regulated affect

Dyadic Patterns Marvin et al (2002)

Insecure, Disordered Child

Disorganized/ Insecure Parent– Parent fears or becomes angry in response

to child’s attachment behavior and abdicates caregiving

– Caregiver has unresolved trauma– Role reversed relationship

Maternal Attributions

Fixed beliefs that the mother has about the child – “beliefs that she perceives as objective, accurate perceptions of the child’s essence.”

Lieberman (2000)

Positive Maternal Attributions

“When a mother sees her child as the cutest, most intelligent, most endearing being ever created, she is summoning from the depths of herself the capacity for ecstasy that allows her to put up with the inevitably annoying, exasperating, or simply tedious aspects of raising a child.”

Lieberman (2000)

Maternal Attributions:Protective Function

Child feels adored Allow child to cope with self-doubts and

feelings of despair Allow parent to better tolerate self-

sacrifices that are integral to the parenting process

Lieberman (2000)

Affect Regulation

We must develop in the mother flexible, affectively balanced and coherent representations of the child and the self as a parent.

Slade (2002)

Parental Insightfulness

“Parental empathic understanding involves the capacity to see things from the child’s point of view within a balanced, accepting, and coherent frame.”

Oppenheim (2000)

Balanced

Able to see experiences through their child’s eyes and make attempts to understand the underlying motives

Talk openly about positive and negative aspects

Oppenheim (1999)

One-sided

Preset conception of their child Difficulty staying focused on their child

and their relationship with the child Talk about their own feelings/issues

Oppenheim (1999)

Disengaged

Lack emotional involvement Minimally attempt to understand what’s

on their child’s mind

Oppenheim (1999)Video

Goal of Treatment

Therapy must help the parents place the child’s behavior in the appropriate context in order to facilitate a response to the behavior that will nurture trust and security.

Ports of Entry

Developmental Information Parent-child relationship Projections onto the child

Lieberman (1999)

Treatment Considerations

Secure-Autonomous– Cooperative with treatment– Appreciate attachment issues

Dismissing– Dismiss importance of attachment issues– Uncomfortable, resistant, hostile

Preoccupied– Want help but struggle to focus on task– Enmeshed in their own issues Dozier (2003)

Circle of SecurityMarvin, Cooper, Hoffman & Powell (2002)

Child’s Exploratory System and Needs– The child can move off and explore, if he

believes and expects that the attachment figure will be available if, or when, needed

Attachment System– The child needs the attachment figure to

be available to protect, comfort, delight, and organize his feelings when he becomes overwhelmed

Secure Attachment Formula

Always be bigger, wiser, and kindWhenever possible, follow the

child’s leadWhenever necessary, take charge

Marvin, et al (2002)

Cooper, Hoffman, Marvin &Powell , 2000

Cooper, Hoffman, Marvin &Powell , 2000

Cooper, Hoffman, Marvin &Powell , 2000

Cooper, Hoffman, Marvin &Powell , 2000

Cooper, Hoffman, Marvin &Powell, 2000

Negative Maternal Attributions

Determine whether and how mother will respond to, misinterpret, or ignore certain behaviors

Lieberman (2000)

Observation of Parent-Child Relationship

Observe proximity seeking behaviors Observe parental sensitivity and

insightfulness Who does child seek out when

frustrated or frightened Use doll play to assess attachment

hierarchy

Assessment – Secure Base

Over the past two weeks can you think of a time when your child was:– Hurt?– Frightened?– Separated from you?

What did your child do? How did you respond?

Assessment of Parent’s Point of View Interview questions:

– Could you give me a thumbnail sketch of your child?

– Tell me about a time in the past two weeks when you and your child really clicked.

– Tell me about a time when you didn’t.– What gives you the most joy in your relationship?– What gives you the most pain?– Where do you turn for emotional support?

Steele (2003)

Treatment ConsiderationsExample of Typical Process

Parent complains about the child’s destructive behavior

The therapist understands how upsetting the behavior must be to the parents

The therapist responds by discussing ways to control the destructive behavior

Empathic Therapeutic Failures

It is critical for the clinician to avoid making the faulty assumption that it is obvious why the referral behavior was so offensive to the parent. We must, instead, “get into the parent’s head.”

Treatment ConsiderationsAvoiding Empathic Failures

Avoid being an “expert” Be careful not to intellectualize Avoid being in a hurry to solve the

problem The goal of the process is to

thoughtfully explore with the parent the impact of the child’s behavior

Thoughtful Exploration

Don’t jump to your own conclusion, let the parent’s responses guide you.

Wonder aloud why the behavior of this child is so distressing for this parent.

Listen for emotionally laden words,

e.g. “Control”, “manipulate”.

Parental Empathic Understanding

“Parental empathic understanding involves the capacity to see things from the child’s point of view within a balanced, accepting, and coherent frame.”

Oppenheim (2000)

Goal of Treatment

Therapy must help the parents place the child’s behavior in the appropriate context in order to facilitate a response to the behavior that will nurture trust and security.

Circle of Security

Understanding Secure Base– Did/Does parent have a secure base?

Negative Projections– He doesn’t care if I’m there for him– He doesn’t need me– She gets so frantic it’s like she’s crazy!

Safe Haven

Comfort level with nurturing Emotional/Physical availability Negative projections

Treatment Approaches

Bridging affect Present the child’s point of view “Challenge” the parent’s interpretation

of the child’s behavior

Secure Base Interventions

Nurturing Anticipating needs Helping child regulate emotions Parental emotional availability Structure and consistency Experience of being in one’s mind

Time In

Stay close by to help the child calm down

Avoid processing until the child is calm If child becomes aggressive distance

yourself while reassuring the child that you’ll be available once the child is calm

Secure Base

“When a child is held in mind, the child feels it, and knows it. There is a sense of safety, of containment, and, most important, existence in that other, which has always seemed to me vital. . . It seems to me that one of life’s greatest privileges is just that – the experience of being held in someone’s mind.”

Pawl (1995)