Saturday 12 February 2011

Transference and countertransference

As concepts, transference and counter transference essentially derive from Freud. Although empirical human behavioural sciences have moved on from many of his ideas, the usefulness of these two concepts to clinicians remains, and they are seen as essential elements in the therapeutic relationships; elements that need to be recognized, understood, and worked with. I think most psychotherapists would say that we need to be thoroughly trained in working with transference / countertransference, and I would not disagree that that would be useful; however, that is not likely to happen for residential staff and foster carers, and yet they will go through this process many times in their work. So it seems useful, in the spirit of working therapeutically, rather than being a therapist, for front line staff and their managers to have affirm grasp of the processes involved.
The other aspect of the therapeutic relationship is the therapeutic alliance. The therapeutic alliance is the rational relationship that exists between the child and the therapeutic worker; it is the mutual understanding that the one needs help, support and assistance and that it is the other’s role to provide it. This may be an overt and uncomplicated therapeutic relationship, but in many cases it is complicated by “unconscious” expectations of close relationships that have grown out of past trauma, relational failure, and unresolved separation and loss.
Transference involves the projection of a mental representation of a previous experience onto the present, transferring an inappropriate aspect of a past relationship onto the other person in the therapeutic relationship. (It is not inappropriate to mistrust someone who let you down in the past and therefore to mistrust someone who lets you down now, but it is inappropriate to assume someone will let you down in the here and now when they have never done so).
Transference is much more likely when the child / young person is under real or imagined threat, and when they have rigid and inflexible personality traits (e.g in individuals who show signs of borderline personality disorder).
Transference needs managing, or it will wreck the therapeutic relationship:
• Recognize the importance of the relationship to the child / young person(this happens when we get close)
• Maintain professional boundaries, and be aware of professional ways of working and responding so we can recognize when we begin to act in response to transference
• Not being pulled into complementary roles that reinforce transference
• Reflecting and interpreting these experiences for the child / young person at a pace and level that is bearable for them.
Countertransference is the response elicited in the worker by the child / young person’s communication of their distressing experiences through transference, and includes the feelings that are evoked in the worker (e.g. helplessness, hostility, fear). Countertransference can be a useful guide to the child’s experiences (e.g. being helpless, rejection, threat). Melanie Klein developed the idea of countertransference by recognizing that it could flow in both directions. I think you see this very strongly when placements are under pressure: adults may feel overwhelmed and needing a break (transferring fear and failure on the child / young person), and this elicits feelings of blame and rejection in the child (countertransference). Staff can feel very responsible for the troubling feelings engendered by the work, and become defensive, whereas understanding that these feelings may have been elicited in them by the distressed child, and can be seen as a window on their inner world, can reduce feelings of being overwhelmed and/or blamed, and therefore reduce the need to be defensive.
Countertransference also needs to be worked with:
• Countertransference is more easily recognized when it is out of character with how we would usually feel or respond
• It requires reflection: a reasonable level of self-awareness, a questioning attitude towards our own feelings and motives, recognition that we all have “blind spots”
• Understanding that we are all affected by the child / young person’s distress, although in different ways,
• Recognizing that they will have strong feelings for us (both negative and positive)
One of the most useful helping resources is the team; sharing our countertransference experiences to clarify what the child / young person projects onto each of us, and unpicking what these feelings tell us about the child / young person’s experience in the here and now. Another useful resource is external consultancy, both for the team and for individuals. It is important that understanding of the internal changes implicit in these processes are matched to individual’s own typical self-defence style; that is if an individual tends to become enmeshed in a child / young person’s difficulties, they need help to process feeling of rejection, but if they tend to dismiss these difficulties as behavioural, they need help in understanding the link between the behaviour and early trauma.

Friday 11 February 2011

Placement stability and attachments: two strands in a single braid

Many Looked-After Children and Young People have difficulties around their early attachments that cast long shadows over the present. At some level, all children living away from home will have experienced loss and separation, but a significant number will have developed insecure attachments that make this loss and separation more difficult to handle. Estimates vary, but between 25 and 40% of children across the country may be insecurely attached. However, experience tells us that Looked-After Children are more frequently anxious in their attachments than the general population.

Looking after children with attachment difficulties is demanding work. Their very difficulties make relationships difficult, and placements are at risk through impoverished relational abilities. However, what such children need most is stability. Stability requires commitment from commissioners and expertise from providers. Without these, placements are tenuous, uncertain and unstable, which creates further difficulties for the child in developing secure relationships. Coming into care is often about safeguarding, and rightly so, but, when a child has had a difficult early life, being in care should also be about recovery and opportunity.

Children possess an attachment system that is activated as soon as an internal or external threat appears; if their own resources are insufficient to eliminate the danger, attachment behaviours are triggered. These feelings, expectations and behaviours are directed towards an attachment figure, who is selected by the child on the basis of proximity and availability. This is the child’s first experience of an intimate relationship; it balances safety and exploration and over the first years of life, as the developing child becomes more aware of the inner world of others, it becomes a reciprocal relationship. The degree to which the child learns to trust the relationship is dependent on the quality of the attachment figures responses to the child’s need for safety and exploration. Good enough care promotes secure relationships, but constant failures in caregiving leave the child feeling anxious and insecure.

Attachment theory is a theory of human development across the life span. As we become older the nature of our attachment relationships change, the circumstances that elicit attachment behaviours alter, our attachment behaviours mature, but the need for this primary bond remains. Initially, attachment security can be seen as a function of the relationship between the child and the attachment figure. However, as the child develops, these early encounters become internalized, and the attachment pattern established early in life becomes increasingly a property of the child themselves. The good news is that these patterns are not unchangeable; rather they represent developmental pathways probable unless there is a change in caregiving. However, although attachment style is amenable to change, the way that attachment is organized has been shown to be highly stable over time.
Attachment organization represents a coherent way for the child to achieve the maximum bearable proximity to their attachment figure at times of threat and maintain the maximum bearable distance for exploration. However, some children are so dazed and confused by their early experiences that that they cannot form a coherent strategy, and are seen as disorganized and disoriented.

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 that this rises to 43% in families with substance abuse, and 48% in maltreating families. This, along with observational data, suggests that many socially excluded children have a disorganized pattern of attachment.

Allen et al (1996) have shown substantial links between adolescent attachment organization and mental health. They found in a clinical sample that preoccupied adolescents were highly sensitive to parental responses: if met with parenting responses that were passive or enmeshed, they showed internalizing symptoms such as depression and anxiety, but with rejecting or ignoring parental responses, preoccupied adolescents show externalizing responses, becoming involved in delinquency, substance misuse and promiscuity. Encouragingly, positive friendships reduced delinquency.

In contrast, dismissing adolescents were less influenced by parental reciprocation; they coped by distracting themselves and others from their attachment cues through substance abuse and conduct problems.

Kiriakardis (2006) investigated the backgrounds and beliefs of 152 young offenders, using the Parental Bonding Instrument (Parker et al 1979) and self-reports of beliefs and attitudes around reoffending. He found that maternal over-protection correlated with both intentions to reoffend and positive views of offending behaviour, whereas, offenders who recalled high levels of parental care evaluated their offending behaviour more negatively.

Good care in a planned therapeutic environment can be therapeutic, but multiple placements and changing caregiving styles can further disorganize the child’s inner world. Not all children who come into care have the same degree of difficulties. Clough et al (2006) suggest a framework:
 Tier 1: Relatively simple & straightforward needs: Placements may be stable because they are relatively low cost.
 Tier 2: Deep rooted, complex needs: Difficulties often emerge with adolescence, putting strain on possible fairly stable placements, however, placement moves may disorganize attachments.
 Tier 3: Extensive, complex & enduring needs: This group of children / young people require expertise, support, long-term commitment, and they may require support beyond childhood.

Whilst short-term, timely intervention may be sufficient for the first group of children, for those in the other groups only carefully planned and skilfully delivered caregiving (which exceeds normal good parenting) is needed (Cameron & Maginn, (2009). Those with enduring needs may well require levels of support that are not available after leaving care, so drift into adult mental health or prisons.
But recovery is possible. A critical idea is the planned environment; by working with attachment in mind, caregivers provide a secure base for the child to explore relationships in the here and now, promoting cognitive restructuring, and safely containing and expressing emotions (Taylor, 2010).

The child’s experience of being in care should be one of recovery, but we have to ask critical questions about the quality of a service that for many children seems to replicate the disorganizing factors of their early experiences.

Recommendations
 Support therapeutic approaches that keep attachment in mind in social settings and through individual psychotherapy
 Develop a two-strand, integrated approach: a therapeutic social milieu and individual work
 Interventions should take account of how to maintain the child/young person’s safe relationships

References:
Allen, J.P., Hauser, S.T., and Borman-Spurrell, E. (1996). Attachment theory as a framework for understanding sequelae of severe adolescent psychopathology: An 11-year follow-up study. Journal of Clinical Psychology. 64(2): 254-263.
Bogaerts, S., Vanheule, S., & Declercq, F. (2005). Recalled parental bonding, adult attachment style, and personality disorders in child molesters: A comparative study. Journal of Forensic Psychiatry and Psychology, 16(3), 445-458.
Cameron, R. J., & Maginn. C. (2009). Achieving Positive Outcomes for Children in Care. Sage: London.
Clough, R. Bullock, R. & Ward, A. (2006) What Works in Residential Child Care. London: NCERCC & National Children’s Bureau.
Haapsalo, J., Puupponen, M., and Crittenden, P. M. (1999). Victim to victimizer: The psychology of isomorphism in a case of a recidivist pedophile in Finland. Journal of Child Sexual Abuse, 7, 97-115.
Kiriakardis, S.P. (2006). Perceived parental care and supervision: a relation with cognitive representations of future offending in a sample of young offenders. International Journal of Offender Therapy and Comparative Criminology. 50 (2): 187-203.
Liska, A.E., and Reed, M.D. (1985). Ties to conventional institutions and delinquency: estimating reciprocal effects. American Sociological Review. 50(4): 547-560.
Sampson, R. J. & Laub J. H. (2005). A Life-Course View of the Development of Crime. Annals of the American Academy of Politics and Social Science, 602, 12-45.
Smallbone, S.W., and Dadds, M.R. (1998). Childhood attachment and adult attachment in incarcerated adult male sex offenders. Journal of Interpersonal Violence. 13: 555-573.
Taylor, C.J. (2010). A Practical Guide to Caring for Children and Teenagers with Attachment Difficulties. London and Philadelphia: Jessica Kingsley Publishing.
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.