Emotional and behavioural difficulties encompass a wide range of difficulties and needs and include both problems which manifest in either emotional or behavioural terms and problems which have both emotional and behavioural dimensions (Maras and Redmayne 1997). At an extreme these difficulties may be experienced as fear and rage and can manifest as violence to self, to carers, to peers, to others. This fear and rage is very like the ‘panic’ states described by Dockar-Drysdale (1990). Both states are similar to what Winnicott (1965) described as state of ‘unthinkable anxiety’. Winnicott spells out these ‘unthinkable anxieties’ or ‘primitive agonies’ as:
• Feelings of going to pieces
• Falling forever
• Having no relation to the body
• Having no orientation
• Complete isolation because of there being no means of communication
(collated in Davis and Wallbridge 1981)
It appears that these young people lack the internal image of arms that can safely hold, of a mind and face that responds to pain and joy – of a mother that can soothe terrors, of a father that can keep monsters at bay. (Woodhead 2001).
Many of the young people with whom we will work are in the care of local authorities and one of the defining characteristics is a seeming inability to tolerate the experience of being cared for in families in the community. Professionals have frequently defined their needs in terms of conditions such as autism, aspergers syndrome, attention deficit, dyslexia, depression, conduct disorder and attachment disorder. They may be regarded by adults as manipulative, attention seeking, irritating, untrustworthy, selfish, difficult and frustrating to manage.
The child’s primary care-giver and the relationships closest to him will have created the images built up. However the inner world soon builds and extends to siblings, friends, teachers and others. A complicated network of personal images of the self and others emerges. For children who experience serious disruption and distortion, it becomes difficult to create such images and sustain a ‘sense of me’ (Ward1998). For children who experience abuse, sexual, physical or emotional, the whole picture becomes distorted and painful (Ward. 1998).
For young people in the care system this can be extremely painful as they also have to bear the feelings of loss. We all experience loss in our lives and many children will suffer the loss of someone close to them, for example a grandparent. We learn to cope with losses such as this, with appropriate support, as part of our development. However many children in the care system will not only have the loss and separation from their families but also loss of foster families, as the breakdown of foster placements is an all too familiar event. I have worked with young people who have had as many as seventy different foster placements. How can these young people gather together experiences into any meaningful or positive whole? They don’t, they become numb to any further attachment, to protect themselves from further pain.
Unintegrated young people will not have experienced a meaningful attachment, for them loss will more likely to be experienced as instinctual painful feelings which they most likely will not be able to acknowledge or express in any way, they do not know how to grieve, they are more likely to experience rage and envy. These feelings of rage and envy will often be ‘acted out’ when triggered by something else disconnected from the original feelings. This ‘acting out’ behaviour happens because the child has no other way of communicating. Dockar-Drysdale (1990) states that all ‘acting out’ is a breakdown in communication and it is the responsibility of the worker to keep in communication with the child. She discusses the importance of being careful to respond when the child reaches out to us. This is what Winnicott described as the most important thing in the child’s early emotional development, the sensitive response of the primary care giver, to the child’s needs.
If we are going to be able to help these children we need to be clear about the task. Understanding a child’s early primary care experience helps us think about their present needs. Learning to deduce the emotional content of the child’s early experiences provides an understanding of each child. We need to help the children come to know, that their needs will be met within a consistent containing predictable and loving way. This is essential in the therapeutic task.
Holding and containment provide a safe world with boundaries, within which relationships with others can be negotiated. Children who have not experienced sufficient holding and containment demonstrate this with chaotic and disruptive behaviour. A major part of the task is then to provide a safe world where they can develop a secure base on which to grow.
The holding environment and therapeutic childcare
Winnicott (1965) used the term ‘ holding environment’ to refer to the totality of the parents’ provision of physical and metaphorical holding of its emotional well-being. This metaphor has been extended to incorporate the total treatment environment in which care and treatment is provided for in a range of residential settings including children’s units.
The holding environment will consist of a number of key elements:
• Provision of appropriate boundaries on behaviour and expression of emotions, strong feelings can be expressed but do not get ‘out of hand’.
• Providing an element of ‘giving’ and tolerance in relationships, so that people will feel genuinely cared for and where appropriate, looked after; the ‘giving’ in the relationship may also include some degree of interpretation or at least ‘reaching out’ in communication.
• Appropriate containment of anxiety (see Bion 1962) for example the adult can take the anxiety on for the child, conveying to the child that the problem will be managed by the adult and child together until they are able to manage it alone.
• Working towards maximum clarity in communication. Misunderstandings need to be resolved. People under stress may interpret things in a distorted way. People feeling ‘unheld’ may feel undervalued or persecuted. (Ward, A.1998 and 2003).
• We must also take into account the provision of appropriate ‘holding’ for the staff team who are engaged in the ‘holding process’. The quality of the ‘holding environment’ of staff is the determinant of the quality of the holding environment for the children. This is created by the organisation and the process of management. (Miller 1993).
• The ‘culture’ in which thinking is embedded. How physical and structural holding mechanisms are understood and founded on staff thinking together (Ward, A. 2003).
• The children need to feel they are being held in mind. Care and thinking needs to be underpinned by what Winnicott calls ‘primary maternal preoccupation’ (Winnicott 1958). That is in order to develop mentally one must not be forgotten.(Ward, A. 2003).
Managing violence in children and young people
Winnicott argued that unintegrated children cannot contain violent feelings. We need to help them to communicate, by listening and responding appropriately. The therapeutic task at this stage is to hold onto the child, survive the attacks and manage the behaviour, until they can begin to control themselves.
In a lecture on deprivation and delinquency and work in substitute caring, Winnicott (1970) shortly before his death said, ‘it may be a kind of loving but often it has to look like a kind of hating, and the key word is not treatment or cure but rather it’s survival. If you survive then the child has a chance to grow and become something like the person he or she would have been if the untoward environmental breakdown had not brought disaster. Children who have experienced trauma and environmental breakdown need adults who can allow them to process their rage and who can survive their angry attacks.
All children and young people who enter substitute care require the most sensitive understanding of their difficulties experienced in their development. Bettelheim (1950) in his book “Love is Not Enough” stated that love alone would not effect change in working with disturbed children and young people. If they have the opportunity to change they have to be able to express and work with their destructive, hateful feelings and they have much to feel enraged about. The roots of their disturbance, and the intensity of their pain and the powerful effects it has on others needs to be understood and survived by their substitute carers. For their pain to be relieved and their development to be freed, they need an approach which is sensitive to their inner world.
Assessment of integrated/non-integrated child
The un-integrated child shows both panic and disruption
Panic, often described as a temper tantrum, is the hallmark of un-integration. It represents traumatic, unthinkable experience at an early age. It produces claustrophobia, agoraphobia, states of disorientation, and a total loss of identity. The victim may become immobilized in a state beyond terror, but is more likely to hit out, scream, destroy things and attack other people.
Disruption, often described as anti-social behaviour, is easily recognized. The child comes into contact with other, functioning children and immediately, compulsively breaks into the group and breaks up their activity (work or play). Un-integrated children break down into violence at times of total disintegration. They cannot contain violent feelings. It is only possible to accept responsibility with a functioning ego. This is not present in these children, and therefore, the staff have to supply the functioning ego themselves, and hold both the child and the violence together.
Sunday 6 June 2010
Obsessive Compulsive Disorder (OCD)
OCD is a neuropsychiatric illness:
* Neuro: originates in the brain
* Psychiatric: affects thoughts, feelings and behaviours
It is predominantly biological. Obsessions sometimes develop after a major stressful experience, but that does not mean the obsession is caused by the experience, or is a natural reaction to it. Mostly, OCD starts insidiously, without rhyme or reason.
Although it is not caused by stress in the environment, it can be triggered or made worse by environmental factors, and stress makes OCD more difficult to resist.
Typically, people with OCD have insight (at least some of the time) into how irrational their thinking is. They may be secretive and shameful about their obsessive thoughts, and may conceal the condition for years. “OCD tricks you into thinking what it wants you to do makes sense, but nothing about OCD is real”. Intrusive thoughts bring feelings of shame and guilt, “Just because OCD makes you feel bad, that doesn’t mean you are bad”.
People with OCD frequently also suffer from depression.
Definition: OCD
* Obsessions and/or compulsions that are time consuming, distressing and/or interfere with normal routines, relationships and daily functioning
Obsessions
* Persistent impulses, ideas images, or thoughts that intrude into a person’s thinking and cause excessive worry and anxiety
Compulsions
* Mental states or repetitive behaviours performed in response to obsessions to relieve or prevent worry and anxiety
* Often have the intent to magically prevent some dreaded event
OCD is not the person, it is an illness; a misfiring of the system that in other people turns off our alarm system once a worrying thought has registered and been assessed. A feedback loop is established and the person feels the only escape from the worry is to perform magic rituals.
What OCD is saying to the child may not be obvious, but obsessions are so intrusive that they interfere with many parts of life. Sometimes it is possible to know the trigger for an OCD attack, but not always. Knowing the trigger can help us be more empathetic, but changing the behaviour that keeps OCD going is the key to stopping the sequence of events that is OCD. Performing the compulsions feeds the OCD, which demands more and more from the child. Left untreated, obsessions expand, morph and multiply.
Basic types
* Checkers
* Washers/cleaners
* Pure Obsessionals
* Hoarders
* People with scrupulosity (religious, moral, ethical)
Working with OCD
Gradually learning to resist the same compulsions reduces the obsessive thoughts. By taking control of how they respond to OCD, the young person can change the brain so that OCD brain responses are replaced by normal ones.
Important conversation: taking risks
“If I don’t do my rituals, what will I do to feel safe?”
By taking a chance and dealing with discomfort by not doing rituals, you open up other ways of handling discomfort.
“If I confront my fear of germs, how can I guarantee that the catastrophe I fear will not happen?” You cannot guarantee a life free of risk, pain loss, etc. The problem is your brain has made the mistaken connection between your compulsions and feelings of comfort and safety. Exposure-Response Prevention (ERP) can help break the stranglehold they have on your life.
NICE guideline for treating OCD
The main treatments for children and young people:
* Talking to someone and getting help with anxious feeling from thoughts or actions
* Mild symptoms - given a self-help book to help thoughts and actions. Healthcare professional should help to follow some of the exercises in the book. Family or carers may be given information about OCD and the treatments
* If the exercises do not help, or person does not want to try them, they should be offered a Cognitive Behavioural therapy including exposure and response prevention (CBT with ERP)
* Family or carers should be involved in the treatment
* Offered the choice treatment alone, or with a group
* For more severe symptoms CBT with ERP should be offered.
Medication
* Medication can help children and young people with OCD but they should be offered therapy before medication
* Medication offered also dependent on age. It is less likely to be offered to very young children
* Usually person should be having CBT withy ERP while taking medicine
* SSRIs (antidepressants) often work best for people with OCD
* Only offered medicines being seen by a child and adolescent psychiatrist
Evidence from research
There is a growing body of research that indicates that CBT with ERP is an effective treatment for pediatric OCD. A meta-analysis of research by Barnet et al (2008) found that remission rates varied between 40% and 85% for exposure based CBT. O’Kearney (2007) compared the research on expose based CBT interventions with medication only and with no treatment and found a 37% improvement in remission rates in the treatment groups. There was no significant difference between CBT and medication. CBT combined with medication offered potential for best health outcomes.
Cognitive Behavioural Therapy with Exposure and Response
Prevention (CBT with ERP)
CBT is a psychological treatment based on the idea that the way we feel is affected by our thoughts (or ‘cognitions’) and beliefs, and by how we behave. For example, a negative thought can lead to negative behaviour, which can affect feelings. CBT helps people to reassess the meaning of their thoughts and actions.
ERP consists of two parts: exposure to feared situations, thoughts or images, and response prevention, the voluntary blocking of compulsive behaviors. ERP requires the supervised or self-controlled blocking of compulsive rituals. This needs willingness to tolerate high levels of discomfort and it involves purposefully allowing anxiety to be present
Exposure relies on two related learning processes: habituation and extinction. It an be thought of as a behavioural experiment, a way of the individual gathering evidence from their own experience that the way hey currently understand the world is distorted.
Habituation harnesses the nervous system’s natural tendency to numb out to repeated and prolong contact with a stimulus. Extinction uses the way behaviour is governed by its consequences. Because the ritual brings relief from the anxiety that accompanies the obsession, the obsession is reinforced. When the ritual response is prevented, it no longer reinforces the obsession.
Exposure can be in therapy, but can also be in vivo, the prolonged, face-to-face confrontation in real-life with anxiety provoking situations, objects, thoughts or images.Once the response is blocked, the brain has the opportunity to provide the natural habituation to the fear-provoking situation, and more realistic and adaptive interpretations can replace the fearful ones. For response prevention to be effective it is necessary to eliminate, block or contain all the behaviours that neutralize or lessen the feelings of anxiety and discomfort brought on by the obsessions, and purposefully allowing the anxiety to be present.
Obsessive thoughts without obvious compulsions can still be treated with CBT with ERP. However the ERP will focus on mental rituals and any methods used to deal with obsessive thoughts.
Cognitive therapy for OCD
Most psychological treatment for OCD consists of CBT with ERP, but if someone does not feel comfortable starting ERP they may be offered cognitive therapy that has been adapted for people with OCD. Cognitive therapy can help people change their beliefs about things they may find distressing, but it does not usually involve being ‘exposed’ to what makes them frightened or anxious as in ERP.
CBT involves actively challenging and confronting the distorted thinking and beliefs that drive and maintain the obsessions and compulsions. Table 1 lists the key cognitive errors of people with OCD.
Cognitive error
Example
Black-and-White or All-or Nothing Thinking
If I’m not completely safe, then I’m in overwhelming danger
Magical Thinking
If I think bad thoughts, bad things will happen
Over-estimating Risk
If I take eve a slight risk, I will come to great harm
Perfectionism
I’ve got to do everything perfectly
Hyper-morality
I’ll be punished for every mistake
Over-responsibility for Others
I must always guard against making mistakes that even remotely harm an innocent person
Over-importance of Thought
If I think about a terrible event occurring, it is much more likely to happen
Exclusivity Error
Bad things are much more likely to happen to me than to other people
Martyr Complex
Suffering and sacrificing my life by doing endless rituals is a small price to pay to protect those I love. Since no harm has come to them, I must be doing something right
“What If” Thinking
In the future, what if I get it wrong
Intolerance of uncertainty
I can’t relax until I am 100% certain of everything, and know everything will be OK
Other than the treatments described above, there is no evidence that other psychological treatments or therapies can help improve OCD.
These include psychoanalysis, transactional analysis, and hypnosis.
CBT is a time limited intervention. Typically, a client may see the therapist for anything from six weeks to three months. It is also very hard work. It is a challenging approach, and may involve homework, for example keeping a journal. More recently, CBT has begun to emphasise the therapeutic alliance more, acknowledging that therapy proceeds within a relationship, and therefore, in common with other psychotherapies, in order for CBT to be effective, the client must feel able to invest in the therapist. It is not enough to be referred and just turn up.
Supporting recovery
* Realize that a person with OCD cannot control the powerful urges they experience. A chemical imbalance is ruling their thoughts and behaviours
* Never force or impose treatment or help
* Do not criticise or scold if they cannot meet expectations
* Encourage, guide, monitor, help and support
* Do not judge the person with OCD by their progress
* Expect relapses
* Reward progress with praise
* Expect the symptoms to make no sense
* Do not expect the symptoms to have symbolic meaning; they are just OCD
Warning: “enabling” OCD
It is important to avoid enabling the OCD by colluding with the rituals by offering reassurance, and by accommodating the OCD.
Assessment
A thorough assessment of OCD obsessions and compulsions is the first step to breaking free. This is usually conducted through as self-report questionnaire that identifies an individual’s obsessions and compulsions and assigns a past and present disruption score to each.
It can be overwhelming to think of making improvements to each symptom at once, but the road to recovery is taken one step at a time, singling out one or two symptoms that are casing the most disruption to everyday life.
* Neuro: originates in the brain
* Psychiatric: affects thoughts, feelings and behaviours
It is predominantly biological. Obsessions sometimes develop after a major stressful experience, but that does not mean the obsession is caused by the experience, or is a natural reaction to it. Mostly, OCD starts insidiously, without rhyme or reason.
Although it is not caused by stress in the environment, it can be triggered or made worse by environmental factors, and stress makes OCD more difficult to resist.
Typically, people with OCD have insight (at least some of the time) into how irrational their thinking is. They may be secretive and shameful about their obsessive thoughts, and may conceal the condition for years. “OCD tricks you into thinking what it wants you to do makes sense, but nothing about OCD is real”. Intrusive thoughts bring feelings of shame and guilt, “Just because OCD makes you feel bad, that doesn’t mean you are bad”.
People with OCD frequently also suffer from depression.
Definition: OCD
* Obsessions and/or compulsions that are time consuming, distressing and/or interfere with normal routines, relationships and daily functioning
Obsessions
* Persistent impulses, ideas images, or thoughts that intrude into a person’s thinking and cause excessive worry and anxiety
Compulsions
* Mental states or repetitive behaviours performed in response to obsessions to relieve or prevent worry and anxiety
* Often have the intent to magically prevent some dreaded event
OCD is not the person, it is an illness; a misfiring of the system that in other people turns off our alarm system once a worrying thought has registered and been assessed. A feedback loop is established and the person feels the only escape from the worry is to perform magic rituals.
What OCD is saying to the child may not be obvious, but obsessions are so intrusive that they interfere with many parts of life. Sometimes it is possible to know the trigger for an OCD attack, but not always. Knowing the trigger can help us be more empathetic, but changing the behaviour that keeps OCD going is the key to stopping the sequence of events that is OCD. Performing the compulsions feeds the OCD, which demands more and more from the child. Left untreated, obsessions expand, morph and multiply.
Basic types
* Checkers
* Washers/cleaners
* Pure Obsessionals
* Hoarders
* People with scrupulosity (religious, moral, ethical)
Working with OCD
Gradually learning to resist the same compulsions reduces the obsessive thoughts. By taking control of how they respond to OCD, the young person can change the brain so that OCD brain responses are replaced by normal ones.
Important conversation: taking risks
“If I don’t do my rituals, what will I do to feel safe?”
By taking a chance and dealing with discomfort by not doing rituals, you open up other ways of handling discomfort.
“If I confront my fear of germs, how can I guarantee that the catastrophe I fear will not happen?” You cannot guarantee a life free of risk, pain loss, etc. The problem is your brain has made the mistaken connection between your compulsions and feelings of comfort and safety. Exposure-Response Prevention (ERP) can help break the stranglehold they have on your life.
NICE guideline for treating OCD
The main treatments for children and young people:
* Talking to someone and getting help with anxious feeling from thoughts or actions
* Mild symptoms - given a self-help book to help thoughts and actions. Healthcare professional should help to follow some of the exercises in the book. Family or carers may be given information about OCD and the treatments
* If the exercises do not help, or person does not want to try them, they should be offered a Cognitive Behavioural therapy including exposure and response prevention (CBT with ERP)
* Family or carers should be involved in the treatment
* Offered the choice treatment alone, or with a group
* For more severe symptoms CBT with ERP should be offered.
Medication
* Medication can help children and young people with OCD but they should be offered therapy before medication
* Medication offered also dependent on age. It is less likely to be offered to very young children
* Usually person should be having CBT withy ERP while taking medicine
* SSRIs (antidepressants) often work best for people with OCD
* Only offered medicines being seen by a child and adolescent psychiatrist
Evidence from research
There is a growing body of research that indicates that CBT with ERP is an effective treatment for pediatric OCD. A meta-analysis of research by Barnet et al (2008) found that remission rates varied between 40% and 85% for exposure based CBT. O’Kearney (2007) compared the research on expose based CBT interventions with medication only and with no treatment and found a 37% improvement in remission rates in the treatment groups. There was no significant difference between CBT and medication. CBT combined with medication offered potential for best health outcomes.
Cognitive Behavioural Therapy with Exposure and Response
Prevention (CBT with ERP)
CBT is a psychological treatment based on the idea that the way we feel is affected by our thoughts (or ‘cognitions’) and beliefs, and by how we behave. For example, a negative thought can lead to negative behaviour, which can affect feelings. CBT helps people to reassess the meaning of their thoughts and actions.
ERP consists of two parts: exposure to feared situations, thoughts or images, and response prevention, the voluntary blocking of compulsive behaviors. ERP requires the supervised or self-controlled blocking of compulsive rituals. This needs willingness to tolerate high levels of discomfort and it involves purposefully allowing anxiety to be present
Exposure relies on two related learning processes: habituation and extinction. It an be thought of as a behavioural experiment, a way of the individual gathering evidence from their own experience that the way hey currently understand the world is distorted.
Habituation harnesses the nervous system’s natural tendency to numb out to repeated and prolong contact with a stimulus. Extinction uses the way behaviour is governed by its consequences. Because the ritual brings relief from the anxiety that accompanies the obsession, the obsession is reinforced. When the ritual response is prevented, it no longer reinforces the obsession.
Exposure can be in therapy, but can also be in vivo, the prolonged, face-to-face confrontation in real-life with anxiety provoking situations, objects, thoughts or images.Once the response is blocked, the brain has the opportunity to provide the natural habituation to the fear-provoking situation, and more realistic and adaptive interpretations can replace the fearful ones. For response prevention to be effective it is necessary to eliminate, block or contain all the behaviours that neutralize or lessen the feelings of anxiety and discomfort brought on by the obsessions, and purposefully allowing the anxiety to be present.
Obsessive thoughts without obvious compulsions can still be treated with CBT with ERP. However the ERP will focus on mental rituals and any methods used to deal with obsessive thoughts.
Cognitive therapy for OCD
Most psychological treatment for OCD consists of CBT with ERP, but if someone does not feel comfortable starting ERP they may be offered cognitive therapy that has been adapted for people with OCD. Cognitive therapy can help people change their beliefs about things they may find distressing, but it does not usually involve being ‘exposed’ to what makes them frightened or anxious as in ERP.
CBT involves actively challenging and confronting the distorted thinking and beliefs that drive and maintain the obsessions and compulsions. Table 1 lists the key cognitive errors of people with OCD.
Cognitive error
Example
Black-and-White or All-or Nothing Thinking
If I’m not completely safe, then I’m in overwhelming danger
Magical Thinking
If I think bad thoughts, bad things will happen
Over-estimating Risk
If I take eve a slight risk, I will come to great harm
Perfectionism
I’ve got to do everything perfectly
Hyper-morality
I’ll be punished for every mistake
Over-responsibility for Others
I must always guard against making mistakes that even remotely harm an innocent person
Over-importance of Thought
If I think about a terrible event occurring, it is much more likely to happen
Exclusivity Error
Bad things are much more likely to happen to me than to other people
Martyr Complex
Suffering and sacrificing my life by doing endless rituals is a small price to pay to protect those I love. Since no harm has come to them, I must be doing something right
“What If” Thinking
In the future, what if I get it wrong
Intolerance of uncertainty
I can’t relax until I am 100% certain of everything, and know everything will be OK
Other than the treatments described above, there is no evidence that other psychological treatments or therapies can help improve OCD.
These include psychoanalysis, transactional analysis, and hypnosis.
CBT is a time limited intervention. Typically, a client may see the therapist for anything from six weeks to three months. It is also very hard work. It is a challenging approach, and may involve homework, for example keeping a journal. More recently, CBT has begun to emphasise the therapeutic alliance more, acknowledging that therapy proceeds within a relationship, and therefore, in common with other psychotherapies, in order for CBT to be effective, the client must feel able to invest in the therapist. It is not enough to be referred and just turn up.
Supporting recovery
* Realize that a person with OCD cannot control the powerful urges they experience. A chemical imbalance is ruling their thoughts and behaviours
* Never force or impose treatment or help
* Do not criticise or scold if they cannot meet expectations
* Encourage, guide, monitor, help and support
* Do not judge the person with OCD by their progress
* Expect relapses
* Reward progress with praise
* Expect the symptoms to make no sense
* Do not expect the symptoms to have symbolic meaning; they are just OCD
Warning: “enabling” OCD
It is important to avoid enabling the OCD by colluding with the rituals by offering reassurance, and by accommodating the OCD.
Assessment
A thorough assessment of OCD obsessions and compulsions is the first step to breaking free. This is usually conducted through as self-report questionnaire that identifies an individual’s obsessions and compulsions and assigns a past and present disruption score to each.
It can be overwhelming to think of making improvements to each symptom at once, but the road to recovery is taken one step at a time, singling out one or two symptoms that are casing the most disruption to everyday life.
The Residential Task (Part 1)
Although developmental difficulties can be recovered from in nurturing social relationships, children with attachment difficulties display a range of problematic behaviours. Some of these behaviours are the child’s still immature attempts to have their primary needs met, some are learnt in a history of broken, breaking and disrupted relationships: the child’s internal disturbances act out in the world, which finds them disturbing and disturbed, and so frequently responding to them from bewilderment or anger, and sometimes fear or hostility; responses that confirm the child self-other belief that they are worthless and unwanted and others are rejecting and hostile. However, attachment behaviour are an intrinsic aspect of human nature, and the expression of attachment behaviours later in life is neither regrettable nor regressive, as it is often labelled, but is a result of the individual attempting to find a secure base with an available attachment figure.
The developmental niche
The environment in which a child grows up greatly influences their development. There are many influences in this environment, but in their early years their caregivers’ beliefs, values and ways of caring are the most significant. As the child develops and explores, peer relationships become increasingly influential. They are also influenced by teachers, relatives’, and activities in the community and greater society. These influences can be thought of providing a developmental niche that is different for each child. However, development is not a one-way process; when exploring their world the child is both influenced by it and an influence upon it.
A child thrives the developmental niche is a good fit to the needs of the child, but if there is a poor fit between the child’s needs and their developmental niche, it is stressful for all concerned, the child is like “a square peg” forced into “a round hole”. The child will develop behaviours that provide ways of coping with these pressures, behaviours which may further d=reduce the goodness of fit. In extreme cases a child’s healthy development can be significantly impaired.
Attachment
Attachment is a relationship played out across time and contexts with a particular partner. Attachment resolves two competing drives: to explore and to be safe. These drives are reconciled by through the proximity, the sensitive responsiveness and the availability of the attachment figure. When this is “good enough”, a secure relationship develops, in which both child and attachment figure find satisfaction. A primary caregiver who is predictable and sensitively responsive engenders in the child feeling of trust and security. The relationship becomes as secure base for exploration and a safe haven at times of danger, and so most infants learn to deal with stressful circumstances and negative emotions in an organized manner. However, when caregiving is not “good enough”, the child can become anxious that their need for comfort and safety will not be met. Although the child may feel insecure, they are still able to organize their thinking and feeling about the attachment figure in a manner in which these unmet needs are partially resolved.
Disorganized attachment
However, a primary caregiver who is frightening and unpredictable leaves the child with an unsolvable dilemma: “do I approach or do I avoid (for comfort and safety)”. Traumatized by severe neglect and/or abuse, such a child is left with fear without a solution; they are unable to organize their internal world in a way that can be relied upon to have attachment needs met.
By age six, these children are beginning to organize their behaviour in ways that controls this approach-avoidance dilemma. Whilst they remain unable to form an organized mental representation of the attachment figure, they may acquire a brittle layer of coping skills. In order to control the fear that is intertwined with the attachment figure the child may create a kind of role-reversal, beginning to control and dominate the attachment figure through controlling and punitive behaviours. Punitive-controlling behaviours seek to keep the attachment figure from occupying the role of the carer, as it is too frightening to let the helpless/hostile carer be in control. The child begins to be hostile, aggressive and directive towards the attachment figure. Interactions are intended to humiliate them into submission, or aggressively control the attachment figure. The child takes responsibility for their own care and protection and never seeks adult advice, guidance or protection. They generalize these controlling behaviours onto other adults.
Whilst some children are unable to develop even these brittle coping skills and remain disorganized and unresolved, others become controlling overbright-caregiving, taking on the role of parenting and controlling their parents. Overbright-caregiving behaviours develop when the attachment figure’s needs, vulnerabilities and dependencies take precedence over the child’s. The child is frightened by the adult’s helplessness and cannot find an attachment strategy to increase security. As a way of attempting to engage the attachment figure, the child begins to act like a parent towards the adult, who responds by emphasising their own dependence on the child’s precocious qualities. The child directs the parent’s interaction in a helpful, positive manner, and is excessively cheery, polite and helpful. They are orientated to protect the parent. The child’s needs are suppressed and remain beneath the child’s petrified surface, erupting as rage or panic when the child is under pressure.
Faced with these attempts at control, parents can feel hostile and helpless, overwhelmed and that their very integrity is threatened. Under such threat, caregivers need to defend themselves, and caught in the child’s hostility, can feel either that the child is impossible or that they are not up to the job of caring for them.
Mentalizing
Two systems in the human brain that seem to be closely linked are the attachment system and the area of the brain that allows us to think about other people’s mental states. The ability to carry out this process, called mentalizing, is reduced when the attachment system is activated by a threat. In evolutionary terms this makes sense. Under threat, to think about your own danger and signal for safety through proximity kept early humans alive. If the mental state of eh other was thought about, that may seem more important than the threat. Child with highly anxious attachments are frequently hyper-vigilant, and hyper-aroused; states that are accompanied by reduced capacity to consider the mental states of others.
Recovery
Although often overlooked, a powerful intervention to promote recovery is organized at the level of the caregiving system. This can be thought of as operating at two levels: the psycho-social environment and individual parenting style.
The psycho-social environment needs to sooth arousal and support and enable exploration. This requires consistency and predictability, but also requires that over restriction is guarded against: the planned environment promotes safety and exploration. Caregivers can manage the child’s arousal level by adjusting the elements of structure and challenge, as if pulling levers in response to the child’s needs.
Parenting style is a product of beliefs and values interacting with experience. Some of our core beliefs and assumptions may be hidden from our immediate gaze. Although therapeutic work has a mystique around it, we should not underestimate the work done by carers who have intimate knowledge of the child. They may be the child’s most valuable resource.
Therapeutic parenting supports therapy, but also attempts to diminish intensity of the memories, emotions, bodily sensations, thoughts by allowing the child to revise memories of past trauma in a safe environment. Progress is likely to be slow, the child can remain stuck in their familiar ways and it takes time to learn to trust being dependent yet safe. But, recovery happens in relationships with others who are attentive and sensitive to the child’s performance, and provide helpful and encouraging response to difficulties and success.
Therapeutic parenting requires adults who are appropriately mindful of their own needs, and are able to set and maintain boundaries. The child’s recovery requires that they can set and high expectations for now and future development, and that these expectations are accompanied by good explanation of expectations, boundaries, actions and choices. These two elements of therapeutic parenting are bound together by authentic, unconditional warmth. The child can explore the world around, and return knowing that they will be welcomed, physically and emotionally nourished, comforted and reassured.
Supporting and enabling
Therapeutic work requires explicit expectations and clear explanations (against a backdrop of authentic warmth). The consequences of actions need to be well understood and made explicit, and individuals nhttp://www.blogger.com/pages.g?blogID=1824609228345427485eed to be (or become) responsible for their own actions. Left to their own devices, the child may not be able to make progress, so it is our task to make explicit how we will support and enable progress. The child’s primitive coping places us under a huge pressure that we will at times inevitably be defended against, either rejecting the child for their behaviour or feeling overwhelmed by their pain.
Supporting caregivers
Caregivers carry the burden of the emotional labour of the work, and to promote recovery they too need supporting and enabling. Support needs to be matched to their needs. The bleak terror of the child’s inner world can leave us uncertain and defended. Like the recovering child, the caregiver needs to know there is nothing so terrible it cannot be talked about.
The developmental niche
The environment in which a child grows up greatly influences their development. There are many influences in this environment, but in their early years their caregivers’ beliefs, values and ways of caring are the most significant. As the child develops and explores, peer relationships become increasingly influential. They are also influenced by teachers, relatives’, and activities in the community and greater society. These influences can be thought of providing a developmental niche that is different for each child. However, development is not a one-way process; when exploring their world the child is both influenced by it and an influence upon it.
A child thrives the developmental niche is a good fit to the needs of the child, but if there is a poor fit between the child’s needs and their developmental niche, it is stressful for all concerned, the child is like “a square peg” forced into “a round hole”. The child will develop behaviours that provide ways of coping with these pressures, behaviours which may further d=reduce the goodness of fit. In extreme cases a child’s healthy development can be significantly impaired.
Attachment
Attachment is a relationship played out across time and contexts with a particular partner. Attachment resolves two competing drives: to explore and to be safe. These drives are reconciled by through the proximity, the sensitive responsiveness and the availability of the attachment figure. When this is “good enough”, a secure relationship develops, in which both child and attachment figure find satisfaction. A primary caregiver who is predictable and sensitively responsive engenders in the child feeling of trust and security. The relationship becomes as secure base for exploration and a safe haven at times of danger, and so most infants learn to deal with stressful circumstances and negative emotions in an organized manner. However, when caregiving is not “good enough”, the child can become anxious that their need for comfort and safety will not be met. Although the child may feel insecure, they are still able to organize their thinking and feeling about the attachment figure in a manner in which these unmet needs are partially resolved.
Disorganized attachment
However, a primary caregiver who is frightening and unpredictable leaves the child with an unsolvable dilemma: “do I approach or do I avoid (for comfort and safety)”. Traumatized by severe neglect and/or abuse, such a child is left with fear without a solution; they are unable to organize their internal world in a way that can be relied upon to have attachment needs met.
By age six, these children are beginning to organize their behaviour in ways that controls this approach-avoidance dilemma. Whilst they remain unable to form an organized mental representation of the attachment figure, they may acquire a brittle layer of coping skills. In order to control the fear that is intertwined with the attachment figure the child may create a kind of role-reversal, beginning to control and dominate the attachment figure through controlling and punitive behaviours. Punitive-controlling behaviours seek to keep the attachment figure from occupying the role of the carer, as it is too frightening to let the helpless/hostile carer be in control. The child begins to be hostile, aggressive and directive towards the attachment figure. Interactions are intended to humiliate them into submission, or aggressively control the attachment figure. The child takes responsibility for their own care and protection and never seeks adult advice, guidance or protection. They generalize these controlling behaviours onto other adults.
Whilst some children are unable to develop even these brittle coping skills and remain disorganized and unresolved, others become controlling overbright-caregiving, taking on the role of parenting and controlling their parents. Overbright-caregiving behaviours develop when the attachment figure’s needs, vulnerabilities and dependencies take precedence over the child’s. The child is frightened by the adult’s helplessness and cannot find an attachment strategy to increase security. As a way of attempting to engage the attachment figure, the child begins to act like a parent towards the adult, who responds by emphasising their own dependence on the child’s precocious qualities. The child directs the parent’s interaction in a helpful, positive manner, and is excessively cheery, polite and helpful. They are orientated to protect the parent. The child’s needs are suppressed and remain beneath the child’s petrified surface, erupting as rage or panic when the child is under pressure.
Faced with these attempts at control, parents can feel hostile and helpless, overwhelmed and that their very integrity is threatened. Under such threat, caregivers need to defend themselves, and caught in the child’s hostility, can feel either that the child is impossible or that they are not up to the job of caring for them.
Mentalizing
Two systems in the human brain that seem to be closely linked are the attachment system and the area of the brain that allows us to think about other people’s mental states. The ability to carry out this process, called mentalizing, is reduced when the attachment system is activated by a threat. In evolutionary terms this makes sense. Under threat, to think about your own danger and signal for safety through proximity kept early humans alive. If the mental state of eh other was thought about, that may seem more important than the threat. Child with highly anxious attachments are frequently hyper-vigilant, and hyper-aroused; states that are accompanied by reduced capacity to consider the mental states of others.
Recovery
Although often overlooked, a powerful intervention to promote recovery is organized at the level of the caregiving system. This can be thought of as operating at two levels: the psycho-social environment and individual parenting style.
The psycho-social environment needs to sooth arousal and support and enable exploration. This requires consistency and predictability, but also requires that over restriction is guarded against: the planned environment promotes safety and exploration. Caregivers can manage the child’s arousal level by adjusting the elements of structure and challenge, as if pulling levers in response to the child’s needs.
Parenting style is a product of beliefs and values interacting with experience. Some of our core beliefs and assumptions may be hidden from our immediate gaze. Although therapeutic work has a mystique around it, we should not underestimate the work done by carers who have intimate knowledge of the child. They may be the child’s most valuable resource.
Therapeutic parenting supports therapy, but also attempts to diminish intensity of the memories, emotions, bodily sensations, thoughts by allowing the child to revise memories of past trauma in a safe environment. Progress is likely to be slow, the child can remain stuck in their familiar ways and it takes time to learn to trust being dependent yet safe. But, recovery happens in relationships with others who are attentive and sensitive to the child’s performance, and provide helpful and encouraging response to difficulties and success.
Therapeutic parenting requires adults who are appropriately mindful of their own needs, and are able to set and maintain boundaries. The child’s recovery requires that they can set and high expectations for now and future development, and that these expectations are accompanied by good explanation of expectations, boundaries, actions and choices. These two elements of therapeutic parenting are bound together by authentic, unconditional warmth. The child can explore the world around, and return knowing that they will be welcomed, physically and emotionally nourished, comforted and reassured.
Supporting and enabling
Therapeutic work requires explicit expectations and clear explanations (against a backdrop of authentic warmth). The consequences of actions need to be well understood and made explicit, and individuals nhttp://www.blogger.com/pages.g?blogID=1824609228345427485eed to be (or become) responsible for their own actions. Left to their own devices, the child may not be able to make progress, so it is our task to make explicit how we will support and enable progress. The child’s primitive coping places us under a huge pressure that we will at times inevitably be defended against, either rejecting the child for their behaviour or feeling overwhelmed by their pain.
Supporting caregivers
Caregivers carry the burden of the emotional labour of the work, and to promote recovery they too need supporting and enabling. Support needs to be matched to their needs. The bleak terror of the child’s inner world can leave us uncertain and defended. Like the recovering child, the caregiver needs to know there is nothing so terrible it cannot be talked about.
Tuesday 1 June 2010
A Secure Base, a Safe Haven - Supported caregiving to children with disorganized attachment
Substitute caregivers may be the most valuable resource for children whose lives are blighted by extremes of abuse and neglect and the failure of primary carers to provide warmth, safety and comfort. Caregivers who think and work therapeutically offer a therapeutic alliance with the child to support their recovery from the failure of their earlier experiences. These children are invariably troubled and vulnerable. They are often identified as needing therapeutic help and may even be fortunate enough access therapy. But therapy is happening in a context: the where and the how of the child’s daily living. This paper focuses on how we support caregivers in the emotional labour of therapeutic living.
Attachment theory reframes the child’s disturbing behaviour as having meaning for the child. Models of therapeutic care developed from attachment theory require that we consider the impact of the child’s disturbing social relatedness on caregiving adults. Theories of adult attachment can provide a model to support caregivers.
Exposure to warm, consistent and reliable caregiving can change children’s expectations both of close adults and of themselves, but in order to support reliable and consistent caregiving we must understand what caregivers find difficult. They are living with uncertainty and risk, and they need training, support and consultancy that develop therapeutic practice and hold onto the powerful and disturbing emotional experiences inherent in the work.
Caregivers are more secure with a clear task, and we should therefore be clear what that task is. Attachment theory is a theory of developmental pathways; early experiences are probabilistic, not deterministic. We all bring our relationship history with us, and subsequent development builds upon as well as transforms what preceded.
As children recover, caregivers will see them initiate safe-haven and secure-base behaviours in appropriate ways. The child is living in the here and now, and recovery does not mean tortuous exploration of early trauma, but the acquiring of “earned security” though gaining a coherent account of their attachment history, so that they are able to look for and accept support, develop a stronger sense of identity and belonging, and possess healthier self-esteem.
Providing secure base experiences is an integral aspect of therapeutic caregiving; the child can explore the world around, and return knowing that they will be welcomed, physically and emotionally nourished, comforted and reassured. Secure base experiences are reliably provided within a planned environment, a holistic approach to living that provides a backdrop which supports therapy. Through predictable and consistent attitudes and responses a planned environment promotes the child’s organization of mental representation of others: caregivers are a safe haven at times of stress and distress, and a secure base from which to explore the social world in the here and now. In order to survive this troubling work, caregivers need to feel secure, but they are parenting under pressure. Where is their safe haven?
Attachment is a relationship played out across time and contexts with a particular partner. During the first years of life, infants learn to deal with stressful circumstances and negative emotions in an organized manner through the shared intersubjectivities and contingent responses of their attachment figure. At the heart of attachment are two competing drives, the drive to explore and the drive to keep close to the attachment figure for safety (proximity). The attachment system operates as a feedback loop. When the attachment figure is near and sensitively responsive to the child, the child feels loved, valued and effective. They are joyful and sociable and are able to elicit the proximity of the caregiver. However, it is in separation that we seen the working of attachment. When the caregiver is not present, the child feels some separation distress, compounded by threat or danger. The child’s attachment behaviours are activated, from visual monitoring to intense protest and searching. These behaviours exist to bring about the attachment figure’s return, and if this happens to an optimal level, the child learns to feel secure within this relationship. However, when the attachment figure does not return or is unpredictable in returning, the child develops an insecure or anxious attachment, either resisting comforting or learning to avoid the need to be comforted.
From the second year onwards, infants begin to represent the world to themselves in symbolic form. Based on experience, the child represents themself, the attachment figure and the relationship as an Internal Working Model (IWM) with emotional and cognitive components. Although the IWM exists outside consciousness, it guides the child’s actions and enables the developing child to predict the behavioural responses of the attachment figure to their attachment behaviours, allowing them to plan an appropriate response. This process of anticipation and response promotes attachment organization: the development of a repeatable strategy that allows maximum proximity to and security from the attachment figure. Over time, this IWM functions as a kind of filter and predictor for other relationships.
By observing infant and attachment figure separation and reunion, three categories of organized attachment have been identified (see, for example Ainsworth & Bell, 1970). These are: Secure, Anxious-Avoidant and Anxious-Ambivalent (also known as Anxious-Resistant). Anxiously attached children show some anxiety over separation but still demonstrate an organized response. However, a group of children show an unpredictable and disorganized pattern of responses to separation and reunion, and are categorized as Disorganized.
Disorganized attachment is strongly related to early trauma. The sudden, uncontrollable breaking of affectional bonds is traumatic. The child is unable to deactivate their attachment system. The attachment figure is the source of fear, the child is caught between incompatible behaviours: flight and proximity seeking, and is unable to develop a repeatable, consistent strategy to meet their need to be safe and to be comforted. Caught in this approach-avoidance dilemma, they are left with a feeling of fright without solution (Main & Cassidy 1990). They cannot predict danger, and are dazed, confused and apprehensive, without a coherent system for dealing with separation.
Disorganized attachment is not uncommon, but is more widespread in families with low social economic status. Van Ijzendoorn et al (1999) suggest that as many as 15 – 25% of children have disorganized attachment, but this rises to 43% in families with substance abuse and 48% in maltreating families. This, along with observational data, suggests that many children within the care system have a disorganized pattern of attachment.
Although attachment patterns not immutable, disorganized attachment is highly stable over time (Weinfield et al, 2004), and is influential in a child’s maladaptive developmental pathway. The longer an outlying pathway is explored, the less likely a return to centrality, and the child becomes caught in a series of self-fulfilling prophecies of self-loathing and rejection.
By age six, some children with disorganized attachment attempt to resolve the paradox of a frightened/frightening attachment figure by developing a brittle overlay of behavioural organization. Whilst still lacking any underlying organized mental representation, these children adopt either controlling-punitive or controlling-overbright caregiving behaviours (Solomon, et al, 1995). As the child attempts to regulate their emotions by controlling the source of fear through “role reversal” with the attachment figure, caregivers can feel punished, controlled and overwhelmed, and their very integrity can feel threatened.
In thinking about how caregivers can be adequately supported for this onslaught, we make use of the model of adult attachment expounded in the Adult Attachment Interview (George, Kaplan & Main, 1984) and relate this to important psychodynamic concept: transference-counter transference. The child’s maladaptive coping strategies exert pressure on adult carers that is comparable to the parental “role reversal” identified by Lyons-Ruth (2004, 2007). A strong pressure is exerted on caregivers to adjust to these controlling behaviours by becoming hostile-helpless, hostile-self referential, or helpless-fearful.
In order to survive feelings of helplessness in the face of the child’s distress, caregivers protect themselves from feeling negative about themselves either by becoming negative about the child (“this child is impossible”) or from becoming negative about the child by becoming negative about themselves (“I’m not up to the job”). The ability to seek and accept support are secure traits, but they may diminish under the child’s increasing pressure on the adult’s own attachment security. Without a safe haven, caregivers cannot remain autonomous and secure, and are squeezed toward being dismissive, becoming critical and punitive towards the child, or toward becoming entangled, being either indulgent or neglectful.
Utilizing George, Kaplan & Main’s (1984) model of adult attachment styles is not intended as a clinical investigation into caregiver’s attachment. It is a reflective, iterative process of support and personal development through which organizations, and those placed to support caregivers, provide a safe haven as part of their support and development role. Caregivers need support from trusted others, and should be encouraged to recognize that it’s OK to need help. A safe haven support model reflects individual experiences and is attuned to the caregiver’s needs. Exploring how the caregiver experiences the child develops a coherent account of their thoughts and feelings. Caregivers who feel they are becoming dismissive need help to unravel the link between the child’s early trauma and their troubling behaviour in the here and now. Whereas caregivers who become entangled need support to move beyond the powerful feelings of distress engendered as the child rejects them.
In providing this support we use an explanation of attachment and reflective questions to help establish these connections. This process is iterative. Equipped with insight into our own attachment needs and the unmet needs of the child, the questions “What am I thinking and feeling?” and “Why am I thinking and feeling this?” can be approached again. Caregiver and supporter reflect on what the pressure on their own feelings of security tells them about the child’s inner world. This process reduces reactivity to the disorganized child’s maladaptive coping and allows caregiving to resist retaliating to the child’s controlling-punitive adjustment, and to remain consistent and predictable, promoting the child’s internal representation of the caregiver as a secure base.
Caregivers are the probably greatest resource for recovery for children with disorganized attachment. Their hard “emotional labour” requires effective support. Within a holistic therapeutic environment we have consistently found that thinking about and reflecting on the adult attachment style and needs of caregivers and those who support them utilizes this resource in endlessly creative and effective ways.
References:
George, Kaplan & Main, (1984), cited in, Prior, V. & Glaser, D. (2006). Understanding Attachment and Attachment Disorders: theory, evidence and practice. London: Jessica Kingsley.
Lyons-Ruth, K., Melnick, S., Patrick, M. & Hobson, R.P. (2007). A controlled study of Hostile-Helpless states of mind among borderline and dysthymic women. Attachment & Human Development. 9(1), 1-16.
Lyons-Ruth, K. & Spielman, E. (2004) Disorganized infant attachment strategies and helpless-fearful profiles of parenting: integrating attachment research with clinical intervention. Infant Mental Health Journal. 25(4), 318–335.
Main, M. & Cassidy J. (1988). Categories of Response to Reunion With the Parent at Age 6: Predictable From Infant Attachment Classifications and Stable Over a 1-Month Period. Developmental Psychology 24(3), 415-426.
Solomon, J., George. C., & De Jong. A. (1995). Children classified as controlling at age six: evidence of disorganized representational strategies and aggression at home and at school. Development and Psychopathology, 7, 447 -464.
Taylor, C. (2010). A Practical Guide to Caring for Children and Adolescents with Attachment Difficulties. London and Philadelphia: Jessica Kingsley Publishers.
van Ijzendoorn, M.H., Schuengel, C. & Bakers-Kranenberg, M.J. (1999). Disorganized attachment in early childhood: Meta-analysis of precursors, concomitants, and sequelae, Development and Psychopathology 11, 225-246.
Weinfield, N. S., Whaley, G. J. L & Egeland, B. (2004). Continuity, discontinuity, and coherence in attachment from infancy to late adolescence: Sequelae of organization and disorganization. Attachment & Human Development. 6(1) 73 – 97.
Attachment theory reframes the child’s disturbing behaviour as having meaning for the child. Models of therapeutic care developed from attachment theory require that we consider the impact of the child’s disturbing social relatedness on caregiving adults. Theories of adult attachment can provide a model to support caregivers.
Exposure to warm, consistent and reliable caregiving can change children’s expectations both of close adults and of themselves, but in order to support reliable and consistent caregiving we must understand what caregivers find difficult. They are living with uncertainty and risk, and they need training, support and consultancy that develop therapeutic practice and hold onto the powerful and disturbing emotional experiences inherent in the work.
Caregivers are more secure with a clear task, and we should therefore be clear what that task is. Attachment theory is a theory of developmental pathways; early experiences are probabilistic, not deterministic. We all bring our relationship history with us, and subsequent development builds upon as well as transforms what preceded.
As children recover, caregivers will see them initiate safe-haven and secure-base behaviours in appropriate ways. The child is living in the here and now, and recovery does not mean tortuous exploration of early trauma, but the acquiring of “earned security” though gaining a coherent account of their attachment history, so that they are able to look for and accept support, develop a stronger sense of identity and belonging, and possess healthier self-esteem.
Providing secure base experiences is an integral aspect of therapeutic caregiving; the child can explore the world around, and return knowing that they will be welcomed, physically and emotionally nourished, comforted and reassured. Secure base experiences are reliably provided within a planned environment, a holistic approach to living that provides a backdrop which supports therapy. Through predictable and consistent attitudes and responses a planned environment promotes the child’s organization of mental representation of others: caregivers are a safe haven at times of stress and distress, and a secure base from which to explore the social world in the here and now. In order to survive this troubling work, caregivers need to feel secure, but they are parenting under pressure. Where is their safe haven?
Attachment is a relationship played out across time and contexts with a particular partner. During the first years of life, infants learn to deal with stressful circumstances and negative emotions in an organized manner through the shared intersubjectivities and contingent responses of their attachment figure. At the heart of attachment are two competing drives, the drive to explore and the drive to keep close to the attachment figure for safety (proximity). The attachment system operates as a feedback loop. When the attachment figure is near and sensitively responsive to the child, the child feels loved, valued and effective. They are joyful and sociable and are able to elicit the proximity of the caregiver. However, it is in separation that we seen the working of attachment. When the caregiver is not present, the child feels some separation distress, compounded by threat or danger. The child’s attachment behaviours are activated, from visual monitoring to intense protest and searching. These behaviours exist to bring about the attachment figure’s return, and if this happens to an optimal level, the child learns to feel secure within this relationship. However, when the attachment figure does not return or is unpredictable in returning, the child develops an insecure or anxious attachment, either resisting comforting or learning to avoid the need to be comforted.
From the second year onwards, infants begin to represent the world to themselves in symbolic form. Based on experience, the child represents themself, the attachment figure and the relationship as an Internal Working Model (IWM) with emotional and cognitive components. Although the IWM exists outside consciousness, it guides the child’s actions and enables the developing child to predict the behavioural responses of the attachment figure to their attachment behaviours, allowing them to plan an appropriate response. This process of anticipation and response promotes attachment organization: the development of a repeatable strategy that allows maximum proximity to and security from the attachment figure. Over time, this IWM functions as a kind of filter and predictor for other relationships.
By observing infant and attachment figure separation and reunion, three categories of organized attachment have been identified (see, for example Ainsworth & Bell, 1970). These are: Secure, Anxious-Avoidant and Anxious-Ambivalent (also known as Anxious-Resistant). Anxiously attached children show some anxiety over separation but still demonstrate an organized response. However, a group of children show an unpredictable and disorganized pattern of responses to separation and reunion, and are categorized as Disorganized.
Disorganized attachment is strongly related to early trauma. The sudden, uncontrollable breaking of affectional bonds is traumatic. The child is unable to deactivate their attachment system. The attachment figure is the source of fear, the child is caught between incompatible behaviours: flight and proximity seeking, and is unable to develop a repeatable, consistent strategy to meet their need to be safe and to be comforted. Caught in this approach-avoidance dilemma, they are left with a feeling of fright without solution (Main & Cassidy 1990). They cannot predict danger, and are dazed, confused and apprehensive, without a coherent system for dealing with separation.
Disorganized attachment is not uncommon, but is more widespread in families with low social economic status. Van Ijzendoorn et al (1999) suggest that as many as 15 – 25% of children have disorganized attachment, but this rises to 43% in families with substance abuse and 48% in maltreating families. This, along with observational data, suggests that many children within the care system have a disorganized pattern of attachment.
Although attachment patterns not immutable, disorganized attachment is highly stable over time (Weinfield et al, 2004), and is influential in a child’s maladaptive developmental pathway. The longer an outlying pathway is explored, the less likely a return to centrality, and the child becomes caught in a series of self-fulfilling prophecies of self-loathing and rejection.
By age six, some children with disorganized attachment attempt to resolve the paradox of a frightened/frightening attachment figure by developing a brittle overlay of behavioural organization. Whilst still lacking any underlying organized mental representation, these children adopt either controlling-punitive or controlling-overbright caregiving behaviours (Solomon, et al, 1995). As the child attempts to regulate their emotions by controlling the source of fear through “role reversal” with the attachment figure, caregivers can feel punished, controlled and overwhelmed, and their very integrity can feel threatened.
In thinking about how caregivers can be adequately supported for this onslaught, we make use of the model of adult attachment expounded in the Adult Attachment Interview (George, Kaplan & Main, 1984) and relate this to important psychodynamic concept: transference-counter transference. The child’s maladaptive coping strategies exert pressure on adult carers that is comparable to the parental “role reversal” identified by Lyons-Ruth (2004, 2007). A strong pressure is exerted on caregivers to adjust to these controlling behaviours by becoming hostile-helpless, hostile-self referential, or helpless-fearful.
In order to survive feelings of helplessness in the face of the child’s distress, caregivers protect themselves from feeling negative about themselves either by becoming negative about the child (“this child is impossible”) or from becoming negative about the child by becoming negative about themselves (“I’m not up to the job”). The ability to seek and accept support are secure traits, but they may diminish under the child’s increasing pressure on the adult’s own attachment security. Without a safe haven, caregivers cannot remain autonomous and secure, and are squeezed toward being dismissive, becoming critical and punitive towards the child, or toward becoming entangled, being either indulgent or neglectful.
Utilizing George, Kaplan & Main’s (1984) model of adult attachment styles is not intended as a clinical investigation into caregiver’s attachment. It is a reflective, iterative process of support and personal development through which organizations, and those placed to support caregivers, provide a safe haven as part of their support and development role. Caregivers need support from trusted others, and should be encouraged to recognize that it’s OK to need help. A safe haven support model reflects individual experiences and is attuned to the caregiver’s needs. Exploring how the caregiver experiences the child develops a coherent account of their thoughts and feelings. Caregivers who feel they are becoming dismissive need help to unravel the link between the child’s early trauma and their troubling behaviour in the here and now. Whereas caregivers who become entangled need support to move beyond the powerful feelings of distress engendered as the child rejects them.
In providing this support we use an explanation of attachment and reflective questions to help establish these connections. This process is iterative. Equipped with insight into our own attachment needs and the unmet needs of the child, the questions “What am I thinking and feeling?” and “Why am I thinking and feeling this?” can be approached again. Caregiver and supporter reflect on what the pressure on their own feelings of security tells them about the child’s inner world. This process reduces reactivity to the disorganized child’s maladaptive coping and allows caregiving to resist retaliating to the child’s controlling-punitive adjustment, and to remain consistent and predictable, promoting the child’s internal representation of the caregiver as a secure base.
Caregivers are the probably greatest resource for recovery for children with disorganized attachment. Their hard “emotional labour” requires effective support. Within a holistic therapeutic environment we have consistently found that thinking about and reflecting on the adult attachment style and needs of caregivers and those who support them utilizes this resource in endlessly creative and effective ways.
References:
George, Kaplan & Main, (1984), cited in, Prior, V. & Glaser, D. (2006). Understanding Attachment and Attachment Disorders: theory, evidence and practice. London: Jessica Kingsley.
Lyons-Ruth, K., Melnick, S., Patrick, M. & Hobson, R.P. (2007). A controlled study of Hostile-Helpless states of mind among borderline and dysthymic women. Attachment & Human Development. 9(1), 1-16.
Lyons-Ruth, K. & Spielman, E. (2004) Disorganized infant attachment strategies and helpless-fearful profiles of parenting: integrating attachment research with clinical intervention. Infant Mental Health Journal. 25(4), 318–335.
Main, M. & Cassidy J. (1988). Categories of Response to Reunion With the Parent at Age 6: Predictable From Infant Attachment Classifications and Stable Over a 1-Month Period. Developmental Psychology 24(3), 415-426.
Solomon, J., George. C., & De Jong. A. (1995). Children classified as controlling at age six: evidence of disorganized representational strategies and aggression at home and at school. Development and Psychopathology, 7, 447 -464.
Taylor, C. (2010). A Practical Guide to Caring for Children and Adolescents with Attachment Difficulties. London and Philadelphia: Jessica Kingsley Publishers.
van Ijzendoorn, M.H., Schuengel, C. & Bakers-Kranenberg, M.J. (1999). Disorganized attachment in early childhood: Meta-analysis of precursors, concomitants, and sequelae, Development and Psychopathology 11, 225-246.
Weinfield, N. S., Whaley, G. J. L & Egeland, B. (2004). Continuity, discontinuity, and coherence in attachment from infancy to late adolescence: Sequelae of organization and disorganization. Attachment & Human Development. 6(1) 73 – 97.
An Interview with Chris Taylor
Interview with Chris Taylor
How does understanding attachment help childcare and social workers?
I think we have to caution against suggesting that an individual’s attachment is a catch-all for their current condition. Development is a pathway, and each individual is where they are because of a huge and complex array of innate and environmental factors acting on each other. However, that basic biological drive to be close to the primary caregiver for safety, comfort and reassurance is a powerful mechanism in an individual’s early development. Although initially the attachment relationship is a descriptor of the dyadic relationship between child and caregiver, as the child becomes older, the pattern of attachment becomes increasingly an aspect of their individual functioning. Our attachment history affects us all, and children who have had sub-optimal early care are likely to be anxiously attached and to carry this anxiety as a self-fulfilling prophecy into other relationships, developing behavioural coping mechanisms that may make them difficult to care for. If the caregiver is also frightening, the child cannot organize their coping strategy in a coherent way. Such a child presents a huge challenge to be adequately cared for. Understanding attachment allows professionals charged with this task to unpack the child’s adjustment and work out ways of responding to the child that answers their attachment need and switches of the child’s self-defeating behaviours. Understanding caregivers’ attachment history can give us insight into the kind of support they may need to adequate parent a trouble child.
Would you be able to tell us about your work in a therapeutic unit?
For the last ten years, I have managed a four-bedded therapeutic unit. In that time, every child who has been resident has had some degree of attachment difficulty. The children (or young people) may access individual psychotherapy, but, helpful though that can be, therapeutic means something more than that. The model is one of supporting and enabling development whilst challenging maladaptive coping mechanisms. We promote a holistic, planned environment that provides a secure base for the child to explore their past and current relationships in the here and now. Working as a symbolic attachment figure, the staff team provides the sensitive attunement to enable the child to begin to use information from both emotions and cognition in a flexible way, to gather a coherent understanding of their attachment history and gradually possess “earned security”. We also think about the staff’s needs from an attachment perspective. The children we care for challenge the secure representations of their caregivers; support needs to be matched to the internal pressure exerted on the caregiver by the child’s coping mechanisms. Adult attachment models provide a powerful framework for doing this.
What developments have been made in the area since you first started working with children with attachment difficulties, and what is your hope for the future?
Many foster-carers, residential workers and social workers are now hugely interested in Attachment theory, which has become one of the foremost paradigms in child development. It is now more common to see at least an attempt to think about the child’s current experiences in the light of their attachment pattern. I think some fostering agencies have gone a long way in thinking about both the foster child’s and the carers’ attachment styles when trying to make placements. I also now see more placement decisions in residential care where the child’s attachment needs are mentioned, but there still seems to be little serious thought about what to do with this. What this means is that there is often a description but little idea what may help, perhaps a vague idea that something therapeutic is required. I’d hope that in the future we may continue to develop holistic, psycho-social models for promoting recovery; children develop anxious attachments in their first relationships, recovery takes place in supportive and enabling relationships and social environments. I also hope that the resources careful and effective work requires are forthcoming; social are budgets are going to be under pressure, but these children deserve a chance to have useful and fulfilling lives.
How does understanding attachment help childcare and social workers?
I think we have to caution against suggesting that an individual’s attachment is a catch-all for their current condition. Development is a pathway, and each individual is where they are because of a huge and complex array of innate and environmental factors acting on each other. However, that basic biological drive to be close to the primary caregiver for safety, comfort and reassurance is a powerful mechanism in an individual’s early development. Although initially the attachment relationship is a descriptor of the dyadic relationship between child and caregiver, as the child becomes older, the pattern of attachment becomes increasingly an aspect of their individual functioning. Our attachment history affects us all, and children who have had sub-optimal early care are likely to be anxiously attached and to carry this anxiety as a self-fulfilling prophecy into other relationships, developing behavioural coping mechanisms that may make them difficult to care for. If the caregiver is also frightening, the child cannot organize their coping strategy in a coherent way. Such a child presents a huge challenge to be adequately cared for. Understanding attachment allows professionals charged with this task to unpack the child’s adjustment and work out ways of responding to the child that answers their attachment need and switches of the child’s self-defeating behaviours. Understanding caregivers’ attachment history can give us insight into the kind of support they may need to adequate parent a trouble child.
Would you be able to tell us about your work in a therapeutic unit?
For the last ten years, I have managed a four-bedded therapeutic unit. In that time, every child who has been resident has had some degree of attachment difficulty. The children (or young people) may access individual psychotherapy, but, helpful though that can be, therapeutic means something more than that. The model is one of supporting and enabling development whilst challenging maladaptive coping mechanisms. We promote a holistic, planned environment that provides a secure base for the child to explore their past and current relationships in the here and now. Working as a symbolic attachment figure, the staff team provides the sensitive attunement to enable the child to begin to use information from both emotions and cognition in a flexible way, to gather a coherent understanding of their attachment history and gradually possess “earned security”. We also think about the staff’s needs from an attachment perspective. The children we care for challenge the secure representations of their caregivers; support needs to be matched to the internal pressure exerted on the caregiver by the child’s coping mechanisms. Adult attachment models provide a powerful framework for doing this.
What developments have been made in the area since you first started working with children with attachment difficulties, and what is your hope for the future?
Many foster-carers, residential workers and social workers are now hugely interested in Attachment theory, which has become one of the foremost paradigms in child development. It is now more common to see at least an attempt to think about the child’s current experiences in the light of their attachment pattern. I think some fostering agencies have gone a long way in thinking about both the foster child’s and the carers’ attachment styles when trying to make placements. I also now see more placement decisions in residential care where the child’s attachment needs are mentioned, but there still seems to be little serious thought about what to do with this. What this means is that there is often a description but little idea what may help, perhaps a vague idea that something therapeutic is required. I’d hope that in the future we may continue to develop holistic, psycho-social models for promoting recovery; children develop anxious attachments in their first relationships, recovery takes place in supportive and enabling relationships and social environments. I also hope that the resources careful and effective work requires are forthcoming; social are budgets are going to be under pressure, but these children deserve a chance to have useful and fulfilling lives.
Attachment Disorder
I am often asked about “attachment disorder”. This term is sometimes loosely applied to children or young people with attachment difficulties. I think this is unfortunate because it has specific meaning and, in my opinion, we need to be clear about its use. Attachment disorder is a psychiatric diagnosis and would usually refer to classifications form either the Diagnostic Statistical Manual version IV (DSM IV) or the International Classification of Disease 10 (ICD 10), and would therefore be, respectively, Reactive Attachment Disorder (RAD) with a subset of inhibited or disinhibited, or Reactive Attachment Disorder (RAD) / Disinhibited Attachment Disorder (DAD). These diagnoses are based on clinically assessing a range of social functioning observable before age 5, but do not consider the relationship specific behaviours that are usually associated with attachment, and are therefore at odds with attachment theory and research, which emphasizes the relationship context of attachment patterns.
Attachment theory (the best explanation we currently have of how the parent-child primary bond functions) considers the security of the relationship (secure or insecure) and the organization (organized/disorganized). Some insecurely attached children, although they may be avoidant or resistant, do have organized patterns of attachment, however, children with disorganized
attachment are always insecurely attached and have no coherent way of getting their attachment needs met.
Securely attached children develop an internal working model of themselves as worthy and loveable, the attachment figure as loving and available, and the relationship as a secure base from which to explore the world. Children who are insecurely attached lack this confidence.
Patterns of attachment tend to be stable over time, and of course, the conditions that promoted the attachment patterns in infancy are often continued in the family dynamic over the child's life. Disorganized attachment is over-represented in clinical groups.
Attachment theory posits developmental pathways. The child is at the point they are now, and recovery (earned security) happens in relationships. Recovery is not found in regression (Bowlby specifically rejected regression therapy). Work that is founded on attachment theory requires that we develop understanding with the child of their current difficulties, especially interpersonal relations, and allow the relationship with us to become a secure base, building enough trust to explore current relationships. It is important to recognize that the child's difficulties are rooted in real-life experiences, not fantasies, and to support exploration and review of earlier experiences to improve interpersonal relationships in here-and-now.
Attachment theory (the best explanation we currently have of how the parent-child primary bond functions) considers the security of the relationship (secure or insecure) and the organization (organized/disorganized). Some insecurely attached children, although they may be avoidant or resistant, do have organized patterns of attachment, however, children with disorganized
attachment are always insecurely attached and have no coherent way of getting their attachment needs met.
Securely attached children develop an internal working model of themselves as worthy and loveable, the attachment figure as loving and available, and the relationship as a secure base from which to explore the world. Children who are insecurely attached lack this confidence.
Patterns of attachment tend to be stable over time, and of course, the conditions that promoted the attachment patterns in infancy are often continued in the family dynamic over the child's life. Disorganized attachment is over-represented in clinical groups.
Attachment theory posits developmental pathways. The child is at the point they are now, and recovery (earned security) happens in relationships. Recovery is not found in regression (Bowlby specifically rejected regression therapy). Work that is founded on attachment theory requires that we develop understanding with the child of their current difficulties, especially interpersonal relations, and allow the relationship with us to become a secure base, building enough trust to explore current relationships. It is important to recognize that the child's difficulties are rooted in real-life experiences, not fantasies, and to support exploration and review of earlier experiences to improve interpersonal relationships in here-and-now.
A Truly Useful Book for Caregivers and Other Professionals
A Practical Guide to Caring for Children and Teenagers with Attachment Difficulties
Chris Taylor
‘A Practical Guide to Caring for Children and Teenagers with Attachment Difficulties is an important bridge between attachment theory and research and providing appropriate care for children who are most in need. Most importantly, it reminds us that in order for these children and young people to successfully recover from their relational traumas, those providing their care must keep in mind the key concepts of attachment security. The author successfully utilizes cognitive and behavioral interventions in the context of attachment, maximizing their effectiveness and demonstrating how best to care for these children and young people.’
- Dan Hughes, Ph.D., Psychologist and author of Building the Bonds of Attachment, 2nd ed., Attachment-Focused Family Therapy, and Attachment-Focused
Parenting.
‘This book provides a wealth of information and practical ideas for parenting young people who have experienced early trauma and disrupted attachments. This book is a treasure trove of theory and practical ideas for foster carers, residential care workers and for the professionals who are supporting them.’
- Kim S. Golding, MSc Clinical Psychology, DClinPsy
Vulnerable and traumatized children and young people who suffer from attachment difficulties are in need of a safe and therapeutic environment in order to recover. By understanding attachment issues, the people who live and work with these young people are better equipped to help and support them in their recovery.
This book provides a comprehensive guide to caregivers by explaining what attachment is, what different patterns of attachment look like in children and young people, and how this understanding can help them to develop therapeutic ways of caring. Based on extensive practical experience, the author shows how to promote recovery through secure base experiences and provides practical solutions and methods to tackle challenging and problem behaviour, anger, and the effects of trauma in children with attachment problems. By drawing together theory and practice, this book provides caregivers with the theoretical understanding and the practice skills required to develop and sustain a caring and supportive environment.
A Practical Guide to Caring for Children and Teenagers with Attachment Difficulties is an essential and invaluable guide for foster carers, residential carers, social workers and other caregivers working or living with children or young people with attachment difficulties.
Chris Taylor has over twenty years experience as a practitioner and manager working with vulnerable and traumatized children. He is interested in a therapeutic approach to recovery from early trauma that is rooted in attachment theory. Although he continues day-by-day to manage a small, therapeutic, residential unit, he is actively involved in training residential workers, foster carers, social workers, therapists and managers in an attachment perspective to residential and foster care.
Chris Taylor
‘A Practical Guide to Caring for Children and Teenagers with Attachment Difficulties is an important bridge between attachment theory and research and providing appropriate care for children who are most in need. Most importantly, it reminds us that in order for these children and young people to successfully recover from their relational traumas, those providing their care must keep in mind the key concepts of attachment security. The author successfully utilizes cognitive and behavioral interventions in the context of attachment, maximizing their effectiveness and demonstrating how best to care for these children and young people.’
- Dan Hughes, Ph.D., Psychologist and author of Building the Bonds of Attachment, 2nd ed., Attachment-Focused Family Therapy, and Attachment-Focused
Parenting.
‘This book provides a wealth of information and practical ideas for parenting young people who have experienced early trauma and disrupted attachments. This book is a treasure trove of theory and practical ideas for foster carers, residential care workers and for the professionals who are supporting them.’
- Kim S. Golding, MSc Clinical Psychology, DClinPsy
Vulnerable and traumatized children and young people who suffer from attachment difficulties are in need of a safe and therapeutic environment in order to recover. By understanding attachment issues, the people who live and work with these young people are better equipped to help and support them in their recovery.
This book provides a comprehensive guide to caregivers by explaining what attachment is, what different patterns of attachment look like in children and young people, and how this understanding can help them to develop therapeutic ways of caring. Based on extensive practical experience, the author shows how to promote recovery through secure base experiences and provides practical solutions and methods to tackle challenging and problem behaviour, anger, and the effects of trauma in children with attachment problems. By drawing together theory and practice, this book provides caregivers with the theoretical understanding and the practice skills required to develop and sustain a caring and supportive environment.
A Practical Guide to Caring for Children and Teenagers with Attachment Difficulties is an essential and invaluable guide for foster carers, residential carers, social workers and other caregivers working or living with children or young people with attachment difficulties.
Chris Taylor has over twenty years experience as a practitioner and manager working with vulnerable and traumatized children. He is interested in a therapeutic approach to recovery from early trauma that is rooted in attachment theory. Although he continues day-by-day to manage a small, therapeutic, residential unit, he is actively involved in training residential workers, foster carers, social workers, therapists and managers in an attachment perspective to residential and foster care.
The Relationship Between Therapy and a Therapeutic Approach
I manage a small therapeutic unit. The children/young people present a range of social and emotional difficulties: self harm, risk-taking, problematic and conflicted relationships. It is not uncommon to find “therapeutic” homes that provide therapy, however, we consider ourselves to be “therapeutic” for two reasons. First, we have a track record of good outcomes for young people that arise from their supported recovery from traumatic experiences of abuse and/or neglect. Second, we adopt a therapeutic approach. I am sure that for some young people to recover, therapy is helpful, even essential, but I suspect it is often not sufficient. Working with very trouble kids, I’ve come to understand that what is required in many cases is an over-all, therapeutic approach.
Individual therapy is an important aspect of an over-all therapeutic approach, but the two are not synonymous. From the perspective of Attachment Theory, children who experience sub-optimal parenting develop an insecure and anxious attachment. Without a secure attachment the child does not have a secure base to explore their social world, and they develop an Internal Working Model (IWM) of themselves as unwanted and ineffective in the world, with a corresponding IWM of the attachment figure as unreliable, hostile and interfering. In early development, the attachment pattern is a property of the relationship between the child and the attachment figure, but as the child develops, the attachment security becomes increasingly a property of the child. The anxiously attached child’s IWM predicts that relationships will fail and sets up a kind of “self-fulfilling prophecy” where the child’s inability to find safety in a caring relationship undermines the caregiver’s ability to provide the supportive parenting the child requires.
The first task, then, in the therapeutic approach is to provide secure base experiences that promote recovery from the anxious and insecure attachment experiences. Without a secure base (which in a secure attachment is internalized as the child’s IWM) the child cannot explore their experiences in the here and now. Within a planned therapeutic environment the consistent and attuned provision of secure base experiences develops a therapeutic alliance between the child and their caregivers, which over time promotes the child’s ability to further explore relationships. Further, establishing a secure base is a necessary pre-requisite of making the move to engaging in individual therapy.
Individual therapy is not a “silver bullet” to recovery from insecure attachment. Indeed, Bolwby specifically stated that the idea of attachment therapy is at odds with attachment theory. Recovery happens in relationships; the continual and predictable provision of secure base experiences promotes the cognitive restructuring of the IWM and the development of “earned security” that provides the bedrock for autonomy and healthy psychological functioning.
Individual therapy is an important aspect of an over-all therapeutic approach, but the two are not synonymous. From the perspective of Attachment Theory, children who experience sub-optimal parenting develop an insecure and anxious attachment. Without a secure attachment the child does not have a secure base to explore their social world, and they develop an Internal Working Model (IWM) of themselves as unwanted and ineffective in the world, with a corresponding IWM of the attachment figure as unreliable, hostile and interfering. In early development, the attachment pattern is a property of the relationship between the child and the attachment figure, but as the child develops, the attachment security becomes increasingly a property of the child. The anxiously attached child’s IWM predicts that relationships will fail and sets up a kind of “self-fulfilling prophecy” where the child’s inability to find safety in a caring relationship undermines the caregiver’s ability to provide the supportive parenting the child requires.
The first task, then, in the therapeutic approach is to provide secure base experiences that promote recovery from the anxious and insecure attachment experiences. Without a secure base (which in a secure attachment is internalized as the child’s IWM) the child cannot explore their experiences in the here and now. Within a planned therapeutic environment the consistent and attuned provision of secure base experiences develops a therapeutic alliance between the child and their caregivers, which over time promotes the child’s ability to further explore relationships. Further, establishing a secure base is a necessary pre-requisite of making the move to engaging in individual therapy.
Individual therapy is not a “silver bullet” to recovery from insecure attachment. Indeed, Bolwby specifically stated that the idea of attachment therapy is at odds with attachment theory. Recovery happens in relationships; the continual and predictable provision of secure base experiences promotes the cognitive restructuring of the IWM and the development of “earned security” that provides the bedrock for autonomy and healthy psychological functioning.
Theory and Practice
A theory is an organized system of accepted knowledge that applies in a variety of circumstances to explain a specific set of phenomena. All practice is informed by both informal theories that individuals construct from their social experience and formal theories that have a more deliberate and academic beginning. These formal theories of practice are official, formally recorded and evidence based. Their basis is in formal teaching and research. Because they are explicit they are open to question. Practice theories are founded in practice wisdom, informal knowledge and assumptions. They are based on observing events, and are culturally transmitted. Whilst they are and adaptable to practice, because they are implicit, they can be difficult to question. Good practice draws knowingly on both and is aware of the limitations of each.
I think "good" ideas emerge in a cycle. Experience (our own and other people's) is important, but we can learn poor practice through experience as well. Experience requires reflection - what has gone? well what hasn't? what could I change? etc - but whatever is learnt in one specific case is not always generalizable to others. So I think we also need theory and research. This is sometimes hard for residential workers, after all they have often come to the work to do a practical job and want to work with children, but we need to be able to look at our practice in the light of what theory explains and what research confirms. Reading, studying, training are all part of this, but need to be integrated into practice. And I think there is one other vital ingredient: what the lives and voices of the children/young people say. They are experts in their own experience, and "good" practice needs to be experienced by them as good, both in the here and now and in terms of outcomes.
I think "good" ideas emerge in a cycle. Experience (our own and other people's) is important, but we can learn poor practice through experience as well. Experience requires reflection - what has gone? well what hasn't? what could I change? etc - but whatever is learnt in one specific case is not always generalizable to others. So I think we also need theory and research. This is sometimes hard for residential workers, after all they have often come to the work to do a practical job and want to work with children, but we need to be able to look at our practice in the light of what theory explains and what research confirms. Reading, studying, training are all part of this, but need to be integrated into practice. And I think there is one other vital ingredient: what the lives and voices of the children/young people say. They are experts in their own experience, and "good" practice needs to be experienced by them as good, both in the here and now and in terms of outcomes.
Subscribe to:
Posts (Atom)