Attachment and Mentalizing: Helping Children with Attachment Trauma

Attachment and Mentalizing: Helping Children with Attachment Trauma Chris Taylor MSc(Psych) ChrisTaylorSolutions.org.uk Seminar Outline Recap Att...
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Attachment and Mentalizing: Helping Children with Attachment Trauma Chris Taylor

MSc(Psych)

ChrisTaylorSolutions.org.uk

Seminar Outline

Recap Attachment Theory

Think about Models of attachment

The effects of Attachment trauma

Introduce Mentalizing

Experiential activity

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Multi-Level Explanation “There’s nothing so useful as a good theory” – Kurt Lewin

Biological and evolutionary basis

Behavioural level – patterns of relating

Cognitive level – internal working model

Affective level – emotional content of relationships / secure base

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What is Attachment?

Unable to cling, unable to move themselves, human infants are born supremely adapted for sociability. ChrisTaylorSolutions.org.uk

Attachment Theory Proposes 

A biologically-based need for relationships across the lifespan  Forming

and maintaining attachments is a key biologically based developmental task

Attachment to a significant “other” provides support and protection against stress and distress  Early bond with primary carers influences future, intense, reciprocal relationships  Relationships with a few specific people are crucial for an child’s developing brain  Without these relationships, important neural networks are not laid down 

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Shared Minds Build Bonds of Affection The human capacity to represent ourselves and others as thinking, wishing, feeling beings does not arrive as a consequence of maturation, but is a developmental achievement rooted in the quality of early relationships.  Develops from the inherent capacity to have a visceral reaction to each other’s actions, mishaps and feelings  Seen in a new-born baby’s rudimentary capacity to influence their mother  7-9 months - a growing awareness of that inner, subjective experiences can be shared with someone else 

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Shared Minds Build Bonds of Affection Bonding Caregiver ‘s feelings and capacity to: • Nurture • Be responsive • Protect

Messages given

Child internalizes image of themselves in their caregiver’s mind Internal Working Model of Attachment learnt from experiences of exploration and protection (first 18 months of life)

Attachment An affectionate bond that endures through space and time and joins individuals emotionally. A psychological bond to a person who provides protection

You’ll take care of me I need to stay close to you I look to you to take care of me You’ll teach me about myself and the world I’m OK I’m loveable

I love you I’ll take care of you You are important to me I’ll keep my eye on you I’ll keep you warm I’ll keep you fed I’ll keep you clean

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Internal Working Model 



Exerts a direct influence over behaviour and responsiveness in all settings Failure to accurately mirror a child’s mental states is responsible for establishing impairments in the child knowing their self and empathising with others ChrisTaylorSolutions.org.uk

Models of Attachment Positive About Self Insecure – Avoidant Predictable danger (e.g. of being neglected) Learnt not to rely on caregiver Negative About Other

Secure Predictable and attuned caregiving Caregiver trusted to support exploration and provide safety “because I’m worth it”

Positive About Other

Disorganized Insecure – Ambivalent Attachment figure is also the source Unpredictable and inappropriate of fear caregiving. Incompatible behaviours: flight and Wants to increase caregiver proximity seeking responsiveness, but angry because Context-dependent failure of protection can't be relied upon mentalisation Negative About Self ChrisTaylorSolutions.org.uk

Models of Attachment

“New brain”: Imagination, Planning, Rumination, Integration

want support, “I’llyou, manage but alone” angry with you” “I“Ifear you, but cannot tolerate separation” Implicit emotional “I trust memory youI’m support of connectedness me” “Old brain”: Emotions, Motives, Relationship seeking creature

ChrisTaylorSolutions.org.uk

Models of Attachment

“New brain”: Imagination, Planning, Rumination, Integration

Implicit emotional “I trust you,memory you support of connectedness me” “Old brain”: Emotions, Motives, Relationship seeking creature

ChrisTaylorSolutions.org.uk

Models of Attachment

“New brain”: Imagination, Planning, Rumination, Integration

“I’llyou, manage alone” Implicit emotional “I trust memory you support of connectedness me” “Old brain”: Emotions, Motives, Relationship seeking creature

ChrisTaylorSolutions.org.uk

Models of Attachment

“New brain”: Imagination, Planning, Rumination, Integration

“I want support, “I’llyou, manage but alone” angry with you” Implicit emotional “I trust memory youI’m support of connectedness me” “Old brain”: Emotions, Motives, Relationship seeking creature

ChrisTaylorSolutions.org.uk

Models of Attachment

“New brain”: Imagination, Planning, Rumination, Integration

want support, “I’llyou, manage but alone” angry with you” “I“Ifear you, but cannot tolerate separation” Implicit emotional “I trust memory youI’m support of connectedness me” “Old brain”: Emotions, Motives, Relationship seeking creature

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A “Hidden” Problem…  

 1. 2.

3. 

Secure attachment is a basic human need of all infants, but is not always met Children can experience high levels of stress and anxiety without necessarily showing outward displays of distress We need to do three things Improve the general understanding of the issue of attachment Improve the skills and awareness of the workforce so that attachment problems are recognised and where possible addressed Improve access to specialist support where necessary Growing evidence for the usefulness of MZ-based approaches (Sadler et al 2006; Suchman et al, 2008; Schechter & Willheim, 2009). ChrisTaylorSolutions.org.uk

Prevalence of Disorganized Attachment 80%

48% 40% 25% 15%

Overall

Poverty

Substance misuse

Maltreatment

van Izjendoorn et al 1999 Disorganized attachment

Maltreatment Carlson, Cicchetti et al (1989); LyonsRuth (1996)

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Brains Under Attack!     

Risk of dysregulation at bio-behavioural level For most children, cortisol levels drop throughout the day to near zero at night Cortisol levels relate to stress These children show very high levels of cortisol throughout the day In the context of early childhood, attachment trauma means acquired brain injury as a result of unregulated stress induced in the attachment relationship ChrisTaylorSolutions.org.uk

Brains Under Attack! Cortisol released in stress travels into the brain and binds to the receptors inside many neurons  Through a cascade of reactions, this causes neurons to admit more calcium through channels in their membrane.  In the short-term, cortisol helps the brain to cope with the life-threatening situation  However, if neurons become over-loaded with calcium they fire too frequently and die – they are “excited” to death. 

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Brains Under Attack!

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We need a general direction….     

Brain is now wired like this Therapeutic task…to rewire the brain How???? Mz approach is rooted in Attachment Theory Provides a “compass” to reach the hard to reach ChrisTaylorSolutions.org.uk

The Therapeutic Task Thinking about Trauma



A “companion for exploration” (Bowlby)

Thinking about Attachment Thinking about Minds (Mentalizing)

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Mentalizing



The active, imaginative process by which we make sense of our selves as persons whose actions are based in mental states



This process comes so naturally to us that we easily overlook its significance ChrisTaylorSolutions.org.uk

Broad Scope of Mentalizing Thoughts

Self

Others

Feelings

Metacognition; Mindfulness

Emotional Literacy

Theory of Mind

Empathy ChrisTaylorSolutions.org.uk

Mindful Mind: Mentalizing Self Mindful mind

“New brain”: Imagination, Planning, Rumination, Integration

Emotional memory of connectedness

“Old brain”: Emotions, Motives, Relationship seeking creature

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Mentalizing Other: Curiosity To understand therapeutic work we must pay careful attention to mentalizing and the conditions under which this basic human capacity becomes impaired

Siegel: “Integration develops when we focus our mind on the internal nature of own experience (insight) and on internal nature of some-one else’s experience (empathy)”

Three Sub-Domains of Mentalizing

Self – Other

Responding to other’s emotions… Nodding sympathetically

Why was she so abrupt with me? Why have I binged on that ice-cream?

Mentalizing

“We must keep in mind that the mental states perceived and the process of perception are suffused with emotion” – Peter Fonagy

Implicit – Explicit

Cognitive - Affective

Implicit: nonconscious, nonverball, nonreflective (e.g. mirroring another)

Explicit: interpretive, conscious, verbalised, reflective

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Mentalizing Spectrum Being self-aware

• Identifying emotion, controlling impulses

Flexible thinking

• Emotions regulated, paying attention, thinking about thinking and feeling

Thinking whilst feeling

• Empathy, support and attunement; Distress tolerance

Curiosity

• Clarification, elaboration and challenge

Dialectic

• Highlighting alternative perspectives

Interpretive

• Assisting other person to put their thoughts and feelings into words ChrisTaylorSolutions.org.uk

A Dynamic Continuum NonMentalizing

Mentalizing

• Avoiding intense emotions • Rigid, stereotypical thinking • Excessive significance given to subjective exeprience • Hyper arousal

• Thinks explicitly about own and others’ mental states • Understands own and others’ emotional states • Empathic • Understand and repairs relationship ruptures

Distorted Mentalizing • Frequent, unwarranted assumptions about the mental states of others • Emotionally aroused, angry manner • Overlays other’s minds with own traumatic memories • Hyperkynetic

Anxious activation of attachment behaviours impairs capacity to mentalize Attachment-trauma – a context dependent failure of mentalizing ChrisTaylorSolutions.org.uk

Mentalizing Treatments 



Designed to correct underlying impairments in mentalizing by adopting a non-interpretive, “notknowing,” inquisitive stance Intended to facilitate the accurate recognition and acceptance of one’s own and others’ mental states (including the therapist’s) ChrisTaylorSolutions.org.uk

What is Therapeutic? 1.

Children with attachment difficulties need something they don’t want  Therapeutic

work must provide gentle challenge through our own interactional style  This needs to provide “security inducing” nurturance or it is likely to disorganize insecure attachment 2. 3.

The objective is to develop more trusting relationships We must also provide a controllable interpersonal world www.ChrisTaylorSolutions.org.uk

The Mind of the Caregiver Children change first in caregivers’ minds  Adult mentalizing of the child’s actions allows them to experience being the subject of coherent, reliable and rational thinking  Mentalizing provides a relational context in which it is safe to explore thinking that does not over-activate the attachment system 

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The “Push-Pull Trap”  







Therapeutic work is based on building a relationship But close relationship is experienced as both soothing and fear inducing (“I hate you, don’t leave me!”) However, without activation of the attachment system, the child cannot develop the capacity to function in interpersonal relationships

Mentalizing may resolve this “push-pull trap” through mindful regulation of intimacy It also seems that young people “catch up” this capacity if later, secondary attachment figures mentalize accurately and explicitly ChrisTaylorSolutions.org.uk

Mentalizing milieu  

Commitment to each child’s future by paying attention to our minds Provides a professional version of human understanding (perhaps something close to love)  Caring  Sharing



Milieu is rooted in understanding attachment and trauma ChrisTaylorSolutions.org.uk

Outcomes       

   



RCT for BPD in adolescents (Rossouw and Fonagy, 2012) Good research with foster carers in approaches that are implicitly “mentalizing” (e.g. Dozier) No empirical data for LACYP – yet Young people report feeling safe, respected, listened to and helped Staff report a sense of purpose (80% retention) Placement stability (2 – 4 years) Improved educational attainment Better physical health – inc. reduction in self-harm Greater mental well-being (seem happier) Less exploitation and abuse (inc. missing from care) Less involvement in crime and substance abuse Staff observed Improved flexible thinking  Greater capacity for empathy  Greater self insight  Improved insight into others 

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Mentalizing capacity Mentalizing stance – recognizes interpersonal problem connected to low mentalizing Inaccurate mentalizing - assumes that the other has same capacity as they do, and acts accordingly Poor Mentalizing capacity- difficulty in understanding the expectations and motivations of others Watch out for these during this activity…….

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Let’s Try It… 1. 2.

3. 4. 5. 6.

7.

What were you thinking as the situation unfolded? How did you feel? What do you think the waitress might have thought Robert was thinking? How might this have left her feeling? What do you think Robert was thinking about the waitress? What do you think Robert was thinking when he became angry? Why do you think Robert’s and the waitress’s thought / feelings were different (or similar)? Can you comment on differences or similarities? ChrisTaylorSolutions.org.uk

Some References Allen. J. G., (2006) Mentalizing in practice, in J. G Allen and P. Fonagy, (Eds) (2006). Handbook of Mentalization-Based Treatment. Chichester: John Wiley and Sons. Bateman, A., and Fonagy, P. (2010). Mentalization based treatment for borderline personality disorder. World Psychiatry, 9, 11-15. Blakemore, S-J., (2008). The social brain in adolescence, Nature Reviews Neuroscience, 9, 267-277. Clough, R. Bullock, R. & Ward, A. (2006) What Works in Residential Child Care. London: NCERCC & National Children’s Bureau. Chungai, H. T. (1999). Metabolic imaging: A window on brain development and plasticity. Neuroscientist, 5, 29-40. Fonagy, P. (1989). On tolerating mental states: theory of mind in borderline patients. Bulletin of the Anna Freud Centre, 12, 91-115. Main, M. and Soloman, J. (1986). Discovery of an insecure/disorganized attachment pattern. In T. B. Brazelton, and M. W. Yogman (Eds) Affective Development in Infancy, Norwood, N. J.: Ablex. Rossouw, T., Kovacova, K., Stathopoulou, E., Wright, C., and Vrouva, I. (in press) http://www.deviersprong.nl/files/Viersprong_Academy/Maintaining_a_mentalizing_focus_in_the_stor ms_of_high_risk-trauma-hallucinations_and_admidst_a_busy_inpatient_unit.pdf. Sadler, L., Slade, A., & Mayes, L. (2006). Minding the baby: a mentalization-based parenting program. In J. G. Allen, & P. Fonagy (Eds.), Handbook of mentalization-based treatment (pp. 201-222). Chichester: John Wiley & Sons. Schechter, D., & Willheim, E. (2009). When parenting becomes unthinkable: Intervening with traumatized parents and their toddlers. Journal of the American Academy of Child & Adolescent Psychiatry, 48(3), 249-253. Suchman, N., DeCoste, C., Castiglioni, N., Legow, N., & Mayes, L. (2008). The Mothers and toddlers program: Preliminary findings from an attachment-based parenting intervention for substance-abusing mothers. Psychoanalytic Psychology, 25(3), 499-517. Søderstrøm, K., & Skårderud, F. (2009). Mentalization-based treatment in families with parental substance use disorder: Theoretical framework. Nordic Psychology, 61(3), 47-65. Taylor, C. (2012), Emphatic Care for Children with Disorganized Attachments A Model for Mentalizing, Attachment and Trauma-Informed Care. Jessica Kingsley Publishers: London and New York ChrisTaylorSolutions.org.uk

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