Theororetical
Rationale
for the Treatment of Disorders of Attachment
by Victoria J. Kelly Psy.D, - 1,2 2003
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Purpose
The field of attachment therapy continues to grow and evolve.
It currently includes a broad array of interventions and modalities
based on common principles and theories of attachment and healthy
development. The membership of the Association for Treatment and
Training in the Attachment of Children (ATTACh) represents diversity
both in terms of professional and parent members, as well as in
the utilization of specific interventions and modalities. Attachment
therapy has been erroneously construed as synonymous with Holding
Therapy. However, attachment therapy increasingly encompasses
an ever-expanding continuum of interventions. The unifying theme
across this continuum is the goal of providing corrective experiences
of attunement. Attunement is the experience of “feeling
felt” by another person and “forms the nonverbal basis
of collaborative, contingent communication” (Siegel, 1999).
“(A)
transforming attuned relationship would involve
the following fundamental elements: contingent, collab-
orative
communication; psychobiological state attunement;
mutually
shared interactions that involve the amplification
of
positive affective states and the reduction of negative ones;
reflection
on mental states; and the ensuing development
of mental models of security that enable emotional modulation
and
positive expectancies for future interactions” (p. 118).
ATTACh
accepts that the use of nurturing holding (as a specific intervention
or as a position in which to conduct other interventions) may
be one of many tools in the process of attachment therapy. Research-
and theory-based explanations for this intervention, indicate
that the use of appropriate holding techniques are within the
boundaries of currently accepted psychotherapeutic thinking and
practice. However, holding is never sufficient in and of itself.
If used, it must occur within a context that recognizes and addresses
the multifaceted etiology and dynamics of attachment disorders
within an integrated, well-reasoned continuum of interventions.
This paper has four purposes. First, it seeks to outline research
and theory that support the need for a broad continuum of attachment-focused
interventions and applications. Second, it seeks to provide a
beginning theoretical rationale, as well as precautions, for the
use of nurturing holding when appropriate. Third, it seeks to
compare and synthesize theoretical rationales from other modalities
(i.e., psychodynamic, cognitive-behavioral,
and trauma therapy) so that the interventions of attachment therapy
can be understood from various conceptualizations. Fourth, it
seeks to provide both therapists and parents a theoretically sound
rationale against which they can evaluate and adjust applications
for specific children with attachment-related disorders.
Good
practice is based on recognized knowledge, which provides theoretical
and empirically based knowledge rationales for interventions utilized
by a clinician. Attachment therapy does not have a well-developed
body of empirical support of its efficacy or effectiveness. This
is not an unusual occurrence within the field of child therapy
as a whole, as the accumulation of empirical knowledge is a costly
and lengthy process. Given the multifaceted etiology and dynamics
of attachment disorders, the development of a reliable empirical
knowledge base faces many barriers that will slow the process.
That limitation does not excuse us from exercising professional
diligence. Therapy should be based upon established scientific
and professional knowledge. In emerging and innovative treatments,
professional codes of ethics provide important instruction. For
example, there is a professional responsibility to exercise judgment
and take responsible steps to ensure competence and protection
of clients from harm (APA, 2002; NASW, 1996). Further, the therapist
should “inform the client of the developing nature of the
treatment, the potential risks involved, alternative treatments
that may be available, and the voluntary nature of their participation”
(APA, 2002). These precautions help insure that the client makes
a truly informed decision about the therapy.
Attachment
therapists face rapidly expanding research findings from the fields
of academic attachment, neuroscience, trauma, and developmental
psychopathology, among others. In an effort to develop and maintain
competency in this ever-changing field, clinicians are struggling
to incorporate new research into ever-evolving applications of
attachment-informed therapy. “The greater a therapist’s
theory base, the less dependence there will be on techniques learned
by rote” (Rothschild, 2002). Understanding the basic dynamics
of attachment and trauma enables the therapist to choose and adapt
interventions to meet the needs of a particular client. This document
is intended as an overview of the research and theory, in order
to provide a foundation for the interventions used in attachment-focused
therapy.
One of the major criticisms of the attachment therapy field has
been the problems of validity and reliability with the diagnosis
of attachment disorder. For many years, authors have discussed
the range of serious behavioral disturbances observed in children
who are presumed to have attachment disorders deriving from experiences
of significant abuse, deprivation, and loss of significant attachment
relationships (Levy, 1937; Bender and Yarnell, 1941; Goldfarb,
1943; Tizard and Hodges, 1978; Fahlberg, 1991; James, 1994; Keck
and Kupecky, 1995; and Hughes, 1997). Their characterizations
of the extreme behavior problems resulted in a burgeoning consensus
of how disorders of attachment manifest in clinical presentations.
The Diagnostic and Statistical Manual of Mental Disorders (DSM-III)
(APA, 1980) provided the first set of diagnostic criteria for
Reactive Attachment Disorder. These criteria have been further
refined in subsequent editions of the DSM (APA, 1987; 1994). However,
the current diagnosis still focuses on the presumed etiology and
two subtypes (i.e., Inhibited and Disinhibited), without much
elaboration of behavioral criteria. Many clinicians believe the
existing diagnostic criteria fail to adequately capture the range
of behavioral symptoms (Zeanah, Mammen, and Lieberman, 1993).
A critical point these authors make is that attachment disorders
represent a profound and pervasive disturbance in the child’s
basic feelings of safety and security (p. 337).
Zeanah,
Mammen, and Lieberman (1993, p. 346; expanding on the work of
Lieberman and Pawl, 1988, 1990) have proposed an alternative nosology,
as well as a list of behavioral disturbances in attachment disorders
among young children. These may include extreme examples of: lack
of warmth and affection, coupled with indiscriminate affection
toward strangers; lack of appropriate or organized comfort seeking
behaviors; excessive dependence or compulsive self reliance; problems
with cooperation; problems with appropriate exploration; significant
controlling behaviors; and finally, failure to reestablish appropriate
interactions with caregivers following separations.
Richter and Volkmar (1994) reported on the revisions of this diagnosis
for the DSM IV (APA, 1994). They argue that while Reactive Attachment
Disorder does not fit attachment as explained by the developmental
research, it does provide “clinical evidence for a constellation
of symptoms and atypical development not captured by other diagnostic
categories” (p. 331). These authors further identify how
“…integrating
the findings from diverse fields of research
will
greatly enhance our ability to identify and treat affected
children.
In addition, developing a reliable and valid diagnosis
will
require longitudinal, prospective studies that will help
characterize
the disorder, validate the criteria, and document
developmental
trajectories” (p. 332).
Until
that level of validity and reliability is reached, these researchers
acknowledge the value of diagnosing attachment disorders, when
indicated, as a way of facilitating the clinician’s understanding
of the child’s distress and resultant behaviors, so that
effective conceptualization and interventions can follow (Zeanah,
et al, 1993; Richters and Volkmar, 1994).
Historical
Background
Attachment-focused
therapy as endorsed by ATTACh now encompasses a broad continuum
of interventions aimed at facilitating the capacity for healthy
attachment in children. This continuum is the product of an evolution
of techniques and strategies drawing on various well-established
modalities of therapy, which have themselves also evolved over
time.
The
form of attachment therapy originally associated with ATTACh had
its roots in the rage reduction therapy of the 1960’s and
1970’s, which was used to treat severely disturbed children
(Zaslow and Breger, 1969). Applications of this therapy were utilized
to address the challenges of character-disordered children, whose
histories of profound early relational trauma had resulted in
hardened characterological defenses against healthy attachment
(Cline, 1992). Their personality structures were more primitively
organized around defending against the hurtful or withholding
caregiver. Thus, their chronic experience of deprivation reinforced
defenses against the caregiver, resulting in significant developmental
liabilities. Most important among these was the resulting inability
to even partially internalize a belief in the possibility of a
nurturing caregiver. The capacity to internalize a nurturing caregiver
serves as the critical developmental foundation for the capacity
for empathy, intimacy, and prosocial values (Kohut, 1978; Feshbach,
1987). However, children’s development can be negatively
skewed by the absence of such an internalized experience of attunement
or the traumatic disruption of the child’s attachment relationship
(see review by Kobacks, 1999). This skewed interpersonal development
can give rise to antisocial and dangerous traits. Techniques of
purposeful provocation were deemed necessary given the level of
pathology and hardened defenses exhibited by these children. The
rationale for this provocation was the perceived need to induce
a heightened level of arousal in the child, in order to access
heavily defended feelings of vulnerability and need for connection.
It was this historical beginning that contributed to the ongoing
misperception that attachment therapy is still something “done
to” the child. Attachment therapy has been mistakenly assumed
to be synonymous with other interventions such as rage reduction
therapy, rebirthing, etc. It is important to remember this approach
to attachment therapy originated in residential and intensive
treatment settings for most severely disturbed children.
The
form of attachment therapy endorsed by ATTACh today has evolved
significantly over the last 30 years. The evolution of techniques
mirrors developments in both the academic field of attachment
research, as well as in other therapeutic modalities (to be discussed
below).
The
field of academic attachment research has continued to grow and
evolve over the last forty years. Attachment therapy draws on
important contributions from many researchers. The following list
is meant to be illustrative, but certainly not comprehensive:
Allan Sroufe’s contributions on the role of attachment in
development (Sroufe, 1977; Sroufe, Cooper, & DeHart, 1992);
Mary Main’s on the role of states of mind in the development
of coherent versus incoherent narratives (Main, 1990; Main, 1995;
Main & Hesse, 1990); Peter Fonagy’s on states of mind
and the capacity for the reflective self (Fonagy, 1996; Fonagy,
et.al., 1991); Jay Belsky’s on the importance of well-synchronized
parent-child interactions (Isabella & Belsky, 1991); Daniel
Stern on the critical role of affective attunement (Stern, 1985);
Allan Schore on the effects of attachment on brain development
(Schore, 2001a & b); Daniel Siegel on the effects of attachment
on the child’s developing mind (Siegel, 1999); Trevarthen
on the developmental effects of contingent emotional sharing between
the child and parent (Trevarthen, 2001); Emde on the role of emotional
connection in developing capacity for morality and emotional regulation
(Emde, et al., 1991; Sameroff and Emde, 1989); Greenspan on the
developmental remediation approaches (Greenspan, 1997) and interventions
with “challenging” children (Greenspann, 1996); and
several researchers who continue to develop applications for parent-child
therapy with young children (Mary Dozier, 2000 & 1999; Alicia
Lieberman, 1992; Marti Erickson and Byron Egeland, 1992; Edward
Tronick, 1989; and Paul Trad, 1992).
The
important contributions from academic attachment research promote
and inform an ever-broadening continuum of interventions for attachment-related
difficulties. Today, this continuum of interventions is increasingly
grounded in attachment theory and ongoing research; trauma theory
and research; and findings from neuroscience and developmental
psychopathology. The treatment may include a wide array of interventions
that can span a continuum from very relaxed, fun, reciprocal activities
(e.g., involving touch, eye contact, and exchange of positive
emotions) at one end, to more active containment interventions
at the other end. The choice of intervention is dictated by an
ongoing assessment of the child’s level of functioning,
accessibility, and response, as well as the therapist’s
chosen theoretical orientation and methodology. Not all attachment
therapists utilize the full continuum of interventions. A growing
number of attachment therapists, who by utilizing interventions
from narrative therapy, EMDR, Theraplay, as well as other techniques,
are able to promote resolution of attachment issues without the
use of directly confrontive techniques.
The unifying theme across the continuum is the provision of a
specific type of “corrective emotional experience”
(Alexander and French, 1946). This experience is of one of attunement.
Attunement is more than sympathy for the child’s distress
or imitation of the child’s emotional expression. Rather,
it is powerful emotional connection in which the caregiver recognizes,
connects with, and shares the child’s inner states (Stern,
1985). The caregiver’s attuned response then matches the
child’s expression in a complementary form of intensity
and expression. It is the experience of “feeling with rather
than feeling for” (McWilliams, 1994). Caregivers who sensitively
respond to the affective and attentive rhythms of the child are
able to foster developmental organization in the child (Field,
1985).
The
provision of attunement is the fundamental guiding principle in
attachment therapy. An attuned relationship provides several critical
elements: “contingent, collaborative communication; psychobiological
state attunement; mutually shared interactions that involve the
amplification of positive affective states and the reduction of
negative ones; reflection on mental states; and the ensuing development
of mental models of security that enable emotional modulation
and positive expectancies for future interactions” (Siegel,
1999, p. 118).
This
broader perspective derives from important contributions from
academic researchers in the field of attachment. Therefore, attachment
therapy is not something “done to” the child; it is
an interactive process of helping the child forge positive emotional
connections with a caregiver. Attachment therapists recognize
and respect the risk of retraumatization . This recognition requires
that the therapist appreciate that the child’s defensive
strategies of avoidance, disconnection, and dissociation evolved
as survival strategies and therefore require thoughtful, careful
management in doses the child can manage. Attachment therapy is
a sensitive, collaborative process of trauma resolution within
a context of developmental remediation, in which the new (or rehabilitated)
parent actively provides the safe containment, support and attunement
necessary to revise conditioned emotional responses that derive
from early experiences of maltreatment and deprivation.
Corrective
experiences of attunement require sensitive and thoughtful consideration
of the nature of the child’s experiences and the coping
(indeed, survival) strategies generated by those experiences.
Careful attention must also be paid to the type and extent of
maltreatment experienced; the age of the child at the time; the
resulting developmental effects; as well as current resources
and functioning. The differential effects of various types of
abuse and neglect are only now beginning to be understood. Increasingly
attachment therapists are recognizing more common subtypes of
attachment-related psychopathology. One group is the more classical
group of children, whose attachment-related problems present with
serious aggressive symptoms, similar to the childhood onset subtype
of Conduct Disorders (Waldman, Lilienfeld, and Lahey, 1995). Another
group consists of children who have experienced such profound
neglect that they appear frozen in their disconnected, emotionally
void world, while compulsively relying on themselves to the exclusion
of all others (Weil, 1992). Another group are those children,
who due to prenatal exposure, genetic disorders, and/or other
neurological impairment, experience profound difficulties in bonding
and attachment (for example, regulatory disorders—Greenspan
and Wieder, 1993). While each of these subgroups benefits from
the experience of attunement in developing greater capacity for
emotional and self-regulation, each subgroup requires sensitively
individualized approaches.
Attachment-focused interventions today incorporate strategies
from nurturing parenting, trauma therapy, cognitive-behavioral
therapy, narrative therapy, psycho-drama, object relations therapy,
family therapy, reality therapy, etc. Children treated today with
attachment therapy themselves represent a broad continuum of experience.
Some have had experiences of abuse and/or deprivation—these
forms of maltreatment range from profound to less severe. Some
have had lengthy institutional care. Some have had overwhelming
losses of attachment figures. Some came into the world with organic
problems that interfered with their ability to form attachments.
Attachment therapy is an evolving, dynamic, heterogeneous set
of interventions whose over-arching goal is the promotion of healthy
attachment behaviors in families.
Implications
of Attachment Theory
The attachment system as identified by Bowlby (1969) served as
a biologically programmed behavioral control system that operated
to motivate infant behavior. Attachment behaviors included signaling
behaviors (such as crying, calling and searching for the caregiver)
that are designed to promote proximity to the caregiver to ensure
survival. “The attachment system has an external goal of
motivating the infant to seek proximity to the attachment figure
and an internal goal of motivating the infant to seek felt security”
(Zeanah, Mammen, Lieberman, 1993, p. 333). Times of stress or
distress activate the attachment system and the child then uses
the attachment figure as a “safe haven” for comfort
and protection (Bretherton, 1980). Children develop different
attachment patterns (secure, avoidant, resistant, and disorganized)
based primarily on early experiences of caregiving. The type of
attachment pattern the child develops will dictate the strategies
the child then employs when distressed.
Attachment
disorders are not synonymous with individual differences in patterns
of attachment as measured by the Strange Situation Procedure,
but instead represent profound and pervasive disturbances in a
child’s feelings of safety and security (Zeanah, Mammen,
and Lieberman, 1993). These children do not seek comfort or engage
in reciprocal emotional interactions with caregivers. Their response
is typically the result of the either failing to develop an adequate
attachment relationship or subsequently losing the attachment
figure. When a child’s display of attachment behaviors then
fails to secure or regain contact and assistance from the attachment
figure, the child is forced to “marshal defensive strategies
that exclude this painful information from consciousness”
(Solomon and George, 1999, p. 6). These defensive processes can
include deactivation and disconnection of both affect and cognitions
related to attachment experiences. “The degree of exclusion
is likely associated with the intensity and persistence of the
child’s experience of the parent as able versus failing
to provide protection and care” (Solomon and George, 1999,
p. 26).
Children who have experienced profound early deprivation and/or
maltreatment within the context of the primary caregiving relationship,
often exhibit a significantly disorganized attachment system.
These children’s behavior evidences extremes of either “(1)
active suppression or “blocking” of attachment behavior,
representation, and related affects…(2) out-of-context and
out-of-control attachment behavior, representation and affect;
or (3) the alternation of these two states” (Solomon and
George, 1999, p. 7). Their coping strategies may further include
other barriers to connection. First, they often operate by a strategy
referred to as “compulsive self reliance” (Bowlby,
1973), meaning that they fundamentally do not perceive others
as a source of help, nurturance, or beneficence. Second, their
impaired capacity for empathy may result in seeing others as mere
things to be manipulated (Weil, 1992).
Bowlby (1969, 1973) described the young child’s construction
of internal working models as states of mind that represent the
child’s perceptions of self, others, and the world. For
the young child, the primary variable in the construction of the
model is the perception of the caregiver’s accessibility
when the child experiences a need. The internal working model
is based on perceptions of 1) whether the caregiver is judged
responsive, and 2) whether the self is judged worthy of such response
(Bowlby, 1973, p. 204). This model is based on the child’s
experiences with the caregiver. Once formed, by about age 3, these
expectations tend to persist as largely unconscious perceptions
and remain relatively unchanged throughout life—unless directly
identified, resolved, and revised.
Early attachment related trauma can have the most devastating
effects on the developing child because of the often lasting effects
on the child’s developing capacity for emotional and self
–regulation (van der Kolk, Pelcovitz, Roth, and Mandel,
1996). However, advances in neuroscience and attachment research
provide reason for hope. The expanding body of research now conceptualizes
attachment as an “…ongoing process that becomes organized
and reorganized at each stage of development in keeping with new
maturational and experiential opportunities” (Greenspan
and Lieberman, 1988, p. 415). Moreover, advances in neuroscience
are powerfully demonstrating that “human connections create
neuronal connections” (Siegel, 1999), such that relationships
are critical in organizing and reorganizing the child’s
developing brain. “Attachment relationships may serve to
create the central foundation from which the mind develops”
(Siegel, 1999, p. 68). Thus, attachment theory is increasingly
viewed as a regulatory theory (Schore, 2001), with critical implications
for both emotional- and self-regulation capacities throughout
life.
The process of healing attachment disorders appears to involve
several critical components. Different approaches to attachment
therapy may conceptualize and/or prioritize these steps in different
ways. However, there seems to be a growing consensus among attachment
clinicians that these represent fundamental components of the
therapeutic process. One involves the revision of the distorted
internal working models and chaotic narratives (Osofsky, 1993).
The second involves resolution of the child’s chronic patterns
of avoidance of emotional and physical closeness. This is evident
when the child can accept both verbal and nonverbal components
of such closeness. For example, the child becomes more comfortable
with nurturing touch. Touch is important because of its effects
in activating brain systems involved in the regulation of stress
responses (Panksepp, 2001). Additionally, the child becomes more
comfortable with eye contact for closeness, as this facilitates
synchronized face-to-face communication to support the kind of
resonance necessary for attunement and arousal regulation (Schore,
2001). The third involves utilizing the improved attachment relationship
as the support for enhanced self regulation across all domains
(e.g., affect, cognition, behavior).Implications
from Research on the Neurobiology of Trauma
Human beings have multiple memory systems including both explicit
and implicit forms (Tulving, 1985). Explicit memory systems involve
conscious learning that the individual can recall and discuss.
Explicit memory includes both semantic (factual) and episodic
(autobiographical) memories. Explicit memory systems, dependent
on the hippocampus, do not begin to mature until the 3rd year
of life (Perner and Ruffman, 1995).
Implicit
memory systems involve more unconscious patterns of “procedural
learning” that include emotional responses, behavioral patterns,
skill sets, and mental models. Implicit memory systems, which
depend on subcortical parts of the brain including the amygdala,
are functional from birth (LeDoux, 1996). Experiences of attunement
or misattunement are stored as implicit memories and become the
mental models of attachment (Siegel, 1999).
Therefore,
more traditional talk therapies, which elicit more explicit memories,
may not be able to fully access a child’s model of attachment.
Further, a young child’s explicit memory of early trauma
may also be limited. However, the implicit memory systems may
store a number of sensory-motor memories related to the both trauma
and attachment.
When
the parent is the source of a child’s fear, as in cases
of maltreatment or “relational trauma” (Schore, 2001),
the child cannot utilize the parent as a source of soothing or
comforting. Thus the child becomes overwhelmed by both the fearful
behavior of the parent and the child’s perceived lack of
security in response to the fear. This overwhelming experience
of fear is inherently disorganizing for the young child (Main
and Hesse, 1990). These patterns of affective misattunement may
also become ingrained in implicit memory and alter the developing
structure of the nervous system, leaving the child vulnerable
to heightened physiological reactivity (Amini, Lewis, and Lannon,
1996).
When
extreme stress is prolonged or chronic, there are biochemical
changes in the brain that have effects on behavioral and emotional
responses (Cozolino, 2002). Research has demonstrated dysregulated
fear is often a consequence of experiences of prolonged fear absent
resolution (LeDoux, 1996). Dysregulated fear can generate the
aggressive and controlling behaviors evident in disorganized attachment
and attachment disorders (Solomon and George, 1999). Effective
management of fear reactions has long been the focus of the intervention
known as exposure and desensitization (to be addressed in a section
below).
Attachment-related
trauma, occurring early in a child’s life, can have very
specific effects on the child’s development and subsequent
functioning. When a child experiences early, preverbal trauma,
the child is deprived of the ability to use language to organize
the experience at a conscious level or integrate necessary neural
structures (Siegel, 1999). This has several important implications:
First, the child is left with the automatic, unconscious conditioned
fear reactions (LeDoux, 1993), whose origins lack a sense of time
or context. Second, the effects of trauma interfere with cortical
systems of integration of memory into coherent and conscious narrative
(Siegel, 1996; Main, 1995, Fonagy, 1996).
However, a carefully guided, well-regulated attachment relationship
can help revise these emotional structures. This is the goal of
attachment-focused therapy. Indeed, advances in neuroscience are
showing that successful therapeutic techniques can help recognize
and alter non-integrated or dysregulated neural networks, thereby
promoting better psychological functioning (Cozolino, 2002).
Implications
from Trauma Therapy
Children with histories of significant attachment-related trauma
struggle with the dual aspects of this unique trauma. They suffered
both the maltreatment itself and, often more significantly, the
loss of the caregiver as a “secure base” (Ainsworth,
1982; Bowlby, 1988). The abuse or neglect may evoke fear or even
terror, as well as physical distress or pain in the child. Second,
the abuse or neglect precludes or disrupts the development of
the secure attachment necessary for the development of the capacity
to modulate arousal (van der Kolk and Fisler, 1994). The regulation
of arousal and emotion is increasingly seen as a critical developmental
process with far-reaching implications on mental health (Schore,
2001a).
“Recovery
can take place only within the context of relationships; it cannot
occur in isolation. In renewed connections with other people,
the survivor recreates the psychological faculties that were damaged
and deformed by the traumatic experience” (Herman, 1992).
For children, the potent crucible for healing is the parent-child
relationship, not the therapeutic relationship with a therapist.
In attachment therapy, the therapist works as a catalyst for and
facilitator of healthy attachment between the child and parent.
In therapy for trauma related experiences, “there is general
consensus that the cornerstone of treatment involves helping the
individual re-experience the trauma and its meaning in affectively
tolerable doses in the context of a safe environment” (Pynoos,
1990). The process of helping children re-experience the trauma
depends on the child’s level of functioning and accessibility
to treatment.
Traumatized children with less severe degrees of such exclusion
can and do respond to more traditional forms of psychotherapy
in which they are gradually able to access and accept the support
of another. But what of the child who continues to actively (even
aggressively) resist all efforts (both therapeutic and parental)
of comfort and nurture, and whose behavior presents continual
threat of harm to self or others? It is these children who most
need therapeutic intervention, yet steadfastly resist. The result
is that these children typically end up on escalating medication
regiments that provide chemical restraint and/or in institutional
settings for containment/restraint of their behavior. In these
cases, there is frequently little or no resolution of the underlying
cause of the behavior, resulting in the often dangerous escalation
of dangerous behaviors to self and/or others.
Attachment therapy seeks to provide an alternative approach where
possible and prudent. Attachment therapy attempts to identify
and resolve the underlying cause of the behavior, when the etiology
is viewed as emanating from the early caregiving experiences.
This resolution is dependent upon the dual process of identifying
and reworking early maladaptive beliefs while providing a context
of behavioral practice that involves the new caregiver. For children
who experienced early relational trauma from profound neglect
or maltreatment, the context of an emotionally intimate relationship
becomes the critical crucible for healing. Yet, for these children,
physical and emotional proximity are often themselves triggers
for past traumatic memories. Recognizing this process, the attachment
therapist purposefully utilizes positions and techniques that
create emotional and physical proximity. The goal is to achieve
systematic desensitization of the cues that elicit the child’s
defensive responses, so that the child can begin to experience
a sense of safety in the present. But this exposure must be done
in a manner that provides “affectively tolerable doses in
the context of a safe environment” (Pynoos, 1990). Attachment
therapy seeks to provide exposure in manageable doses to ensure
that the conditioned emotional responses do not overwhelm the
child’s coping. This requires that the child is educated
and prepared about the process; that the child and parent together
explicitly contract to work on painful material; and that safeguards
are in place to ensure the child’s safety in the process.
These safeguards must begin with a thorough clinical assessment
to determine history, functioning, resources, and diagnosis, as
well as to rule-out other comorbid conditions that may impede
effective processing of such emotionally painful material (e.g.,
psychotic or pre-psychotic functioning; sensory integration difficulties;
etc.). The safeguards then must include the continued reinforcement
of present conditions of safety to actively counteract distorted
cognitive beliefs emanating from the prior experiences of maltreatment—that
is, to continually draw the boundary between the past and the
present (e.g., provision of the experience of “disparity”,
Briere, 2002). Another critical safeguard is the active encouragement
and process of contracting and recontracting, throughout the therapy
as means of identifying, addressing, and remaining sensitive to
the defenses that arise in the process. Other safeguards are discussed
in the Professional Practice Manual of ATTACh (2002).
Briere
(2002) has offered a comprehensive model for trauma resolution
for working with adults who experienced severe childhood maltreatment.
His integrated model is informative for attachment therapy for
children who are survivors of such maltreatment. This model indicates
the importance of the therapist’s attention to balancing
exploration of traumatic material with consolidation of the client’s
coping resources; active management of the client’s level
of activation; assessment and development of the client’s
skills for coping; and the provision of safety and support before
more direct work on traumatic memories is attempted. The direct
work on trauma is accomplished through a combined process of gradual
exposure to traumatic material; activation of conditioned emotional
responses; active disconfirmation of fear by the provision of
tangible safety (e.g., providing “disparity”); followed
by emotional and cognitive processing. The goal is to help the
client develop a coherent narrative to both make sense of what
happened and feel an increased sense of control, so the earlier
defenses of avoidance and dissociation are no longer necessary.
Implications
from Developments in Psychodynamic Therapies
Children with significant disorders of attachment have often failed
to benefit from more traditional child therapy techniques. Often
their early experiences of profound maltreatment affected their
personality development in ways that precluded their ability to
form and utilize a therapeutic relationship as an agent of change.
What has evolved over 30 some years of attachment-focused treatment
parallels evolutions within the field of psychodynamic therapy.
In psychodynamic therapy, there has been a gradual awareness that
traditional forms of therapy, which require the client to form
and utilize a strong working alliance with the therapist, are
most effective with higher functioning clients. Clients whose
basic character structure is organized around more primitive defenses
and who lack the ability to form the same kind of therapeutic
working alliance need modified approaches to therapy (McWilliams,
1992).
Early psychoanalytic theory embraced the idea of abreaction developed
by Breuer and Freud (1958). Abreaction referred to the process
of reexperiencing the origins of early traumatic memories along
with a discharge of uncovered emotions. Such breakthroughs of
defensive processes were considered to be therapeutic in resolving
pathologic symptoms. Psychodynamic theories have primarily focused
on “the pathogenic nature of repressed or disavowed affect”
(Greenberg and Safran, 1989).
More traditional forms of psychoanalytic therapy shifted away
from the use of abreaction and catharsis toward greater focus
on interpretation and insight. Current theory has questioned the
necessity of abreaction for resolution of trauma. One area in
which catharsis has been especially criticized is in the discharge
of the emotion of anger. Research in social psychology has shown
that there is little benefit from expression of anger; indeed,
in such cases there is often a concomitant increase in aggression
(Lewis and Bucher, 1992). However, other researchers have challenged
these findings when considering clinical implications of catharsis
(Scheff, 1979; Pierce, Nichols, and DuBrin, 1983; Kosmicki and
Glickauf-Hughes, 1997). For example, in clinical contexts, catharsis
can be helpful, if it meets the following criteria: it is handled
in a safe, therapeutic manner; is an active process; and involves
some form of cognitive processing.
There is ongoing debate about the usefulness of abreaction in
clinical work. However, there is some level of agreement that
a distinction needs to be made between abreaction that facilitates
integration versus disintegration (Rothschild,2000). Abreaction
that results in disintegration occurs when the level of arousal
overwhelms the resources for coping, so that retraumatization
and decompensation follow. Conversely, abreaction that promotes
integration is carefully modulated to the individual’s resources
and, moreover, facilitates emotional expression necessary for
reprocessing traumatic material. The benefit of this latter form
of abreaction is accepted by many in the trauma field. Indeed,
“repeated emotional release during nondissociated exposure
to painful memories is likely to pair the traumatic stimuli to
the relatively positive internal states associated with emotional
release” (Briere, 2002, p. 196).
Attachment therapy seeks to provide a safe container for emotional
expression. For children with histories of cumulative relational
trauma, their chronic reliance on strategies of avoidance and
disconnection in order to survive extreme distress has resulted
in a lack of a capacity to regulate their emotional experience.
First, sensitive attunement is used to help the child begin to
identify his/her emotional experience. The safety provided by
this sensitive attunement facilitates the child’s experience
and expression of emotion, so there is less need to rely on the
earlier avoidant strategies. Part of the safety is that the child
is not left alone in overwhelming states of negative emotion.
Instead, a corrective experience of “interactive repair”
is provided (Tronick, 1989). Interactive repair occurs when the
caregiver actively helps the child transition back to a positive
affective state. This teaches the child that negative emotions
can be tolerated and survived. When the caregiver’s attempt
at nurturance and safe containment activates the child’s
conditioned fear response, the caregiver actively facilitates
the child’s transition to a positive affective state through
soothing, reassurance, and encouragement. This “interactive
repair” provides a potent experience of “disparity”
(Briere, 2002) so that the child can begin to experience the primary
relationship as one of safety and emotional assistance. “Disparity
is not just the absence of danger, however—in the best circumstances,
it is the presence of positive phenomena that are the antithetic
to danger” (Briere, 2002, p. 195).
The release of negative emotions is only the beginning of emotional
expressivity sought in attachment therapy. Attachment is promoted
when the caregiver and child can develop a reciprocal capacity
for resonating pleasure in their interaction (Demos, 1984). Attachment
therapy often seeks to provide concrete experiences of nurturance
that allow regressive dependency needs to be met by a sensitive
caregiver in the present. In this way, the “traumatically
thwarted infantile needs are therapeutically remobilized and delivered
into the present” (Stark, 1994). This provides yet another
confirmation for the child that his/her needs can be met within
the context of this new (or rehabilitated) relationship with the
caregiver.
In order for emotional expression to be effective in therapy,
it is essential that therapists create a strong therapeutic alliance
with the client. This helps promote the client’s sense of
feeling accepted, safe, and supported, so that exploration is
possible (Greenberg and Safran, 1989).
Implications
from Developments in Cognitive-Behavioral Approaches to Desensitization
Developments within the field of cognitive-behavioral therapy,
specifically as relate to exposure and desensitization, offer
another important parallel to the evolution of techniques used
within the field of attachment therapy. Cognitive-behavioral approaches
to treatment “are a rational amalgam of diverse yet interrelated
strategies for providing new learning experiences that involve
enactive procedures and a cognitive analysis” (Kendall and
Braswell, 1993, p. 1). Such treatment seeks to create opportunities
to behaviorally practice solutions within a framework of identifying
and addressing one’s maladaptive cognitive processes.
Exposure is a cognitive-behavioral intervention that is used to
increase a client’s level of arousal when the client’s
avoidance strategies have become maladaptive. “Arousal can
be created either by confronting (the client) with those aspects
of experience, behavior, and sensation that are being avoided
or preventing the exercise of usual coping strategies…Exposure
to avoided experience necessitates that (the client) reorganize
conceptual systems and respond differently” (Beutler and
Clarkin, 1990, p. 273). For the fear response to be changed, a
specific sequence of intervention must occur. The fear memory
must be activated and then coupled with information that contradicts
or refutes it so that a new memory can be formed (Foa, Steketee,
and Rothbaum, 1998). Successful processing or integrating of the
new information is necessary for successful recovery.
For conditioned emotional responses to traumatic memories to be
extinguished, they must be challenged by a new experience that
provides true disparity (Briere, 2002). The most powerful context
of disparity for a traumatized child occurs when those limiting,
distorted beliefs of the negative internal working model can be
sensitively challenged in an environment that provides demonstrable
attunement and protection by a committed, compassionate caregiver
in the face of the child’s fears, rage, and self-loathing.
However,
since extreme distress impedes the process of maintaining attention
and may increase defensive responses, the level of arousal must
be managed effectively. That is why exposure therapy utilizes
strategies such as attention to somatic sensations, focused breathing,
and cognitive reprocessing, which are essential components to
effective management of exposure.
All models of psychotherapy are “devoted to managing the
level of patient arousal or distress to keep those experiences
within a range that is conducive to effective work” (Arkowitz
and Hannah, 1991). If the arousal level is optimal, it will facilitate
disconfirmation of distorted beliefs, cognitive change, and hopefully,
even self-observation. When there is “too little arousal
to maintain productive levels of motivation…the induction
of arousal may be necessary in order to effectively promote change”
(Beutler and Clarkin, 1990, p. 274). The therapist must ascertain
“what is avoided” and “how it is avoided”.
If the level of arousal is too great, the child can be overwhelmed
with negative affect. The result can be the reinforcement of the
need for avoidance and dissociation or further fragmentation and
disorganization. It is the therapist’s responsibility to
balance the demands for safety and processing.
The technique of exposure has long been used in cognitive-behavioral
approaches to trauma work. Exposure is the activation of fearful
arousal, coupled with active fear reduction techniques. The goal
was to promote the ability to stay calm even when confronted with
anxiety-provoking cues. The most accepted theory of the mechanism
for systematic desensitization is counter-conditioning (Wolpe,
1958). In counter-conditioning, the individual is taught a competing
response called reciprocal inhibition since the new response inhibits
other problem states such as fear.
Early forms of exposure therapy for desensitization were very
confrontive and distressing. Exposure therapy initially focused
on helping the client elicit and then habituate to high levels
of fearful arousal. The objective of this process was to help
the client challenge limiting beliefs that he/she could not cope
with the frightening stimulus. Contemporary forms of exposure
therapy now encompass more of a mastery approach. Indeed, guided
mastery has been shown to produce more effective results than
stimulus exposure treatment (Williams, 1990). These approaches
use the “safety-signal perspective” (Rachman, 1980)
to deemphasize the level of anxiety aroused during exposure, while
actively supporting the client’s sense of mastery. Emphasis
is now on acquisition of a sense of control over perceived unpredictable
and uncontrollable events, with a change in the escape or avoidance
behavior.
Early forms of attachment therapy, like early forms of desensitization,
were more confrontational and distressing. But like exposure therapy,
attachment therapy continues to evolve. Attachment therapy relates
to the process of desensitization in several ways. The resolution
of disordered attachment is dependent upon the dual process of
identifying and reworking early maladaptive beliefs within a context
of behavioral practice that involves the new (or newly rehabilitated
) caregiver. However, the special challenge is that the child
with this kind of disorder typically manifests a high level of
defensive exclusion of attachment-related behavior, representation,
and affect. Traditional forms of talk therapy are unlikely to
evoke and access these excluded components. Indeed, these children
are often very fearful of and therefore avoid any cues that might
evoke these components. In attachment disorders, the “what
is avoided” is the physical and emotional closeness with
a caregiver; the “how it is avoided” is through the
processes of deactivation, disconnection, and aggression.
Therefore
the use of touch and physical holding in attachment therapy is
utilized to create a context that facilitates access to these
defensively excluded components. First, physical closeness of
the head in the parent’s lap, coupled with encouraged eye
contact, recreates a sense of dependency and vulnerability in
the child. It is these feelings and the fears they induce that
are often so heavily defended against in attachment disorders.
But more importantly, the protective lap of the new (or newly
rehabilitated) caregiver provides a physical experience of safety
and comfort that can powerfully counter the potent sensori-motor
memories of the early deprivation and maltreatment. Thus, safety
is provided in a relational context that was originally associated
with fear. Memories or representations of early experiences of
attunement versus maltreatment are acquired in the preverbal,
sensorimotor period and therefore are most resistant to change
(Koback and Sceery, 1988). That is why verbal interventions alone
are usually less effective with this type of early, preverbal
traumatic memory.
The
objective is to decondition the automatic fear reactions associated
with emotional intimacy. This deconditioning helps facilitate
the reintegration of emotional and behavioral experiences that
were defended against in the processes of deactivation and disconnection
of the attachment system. As this deconditioning occurs, the child
is able to behaviorally practice reciprocal emotional interaction
with the caregiver and accept nurturing care. This process occurs
within the context of the relationship with the caregiver. The
reciprocal inhibition is accomplished when the child can be physically
and emotionally close with the parent (the former trigger for
avoidance and dissociation), yet now experience a sense of safety
and comfort.
It is not just talked about or imagined, as might occur in more
traditional talk therapies. It is experienced and reinforced.
Such in vivo desensitization has proven to be more effective than
fantasy for several reasons (Watson and Tharp, 1972). First, the
actual behavior change is important. Second, the imagined scenes
are not as complete and realistic. Third, the objective is not
just a decrease in fear, but more importantly, an increase in
effective coping.
Such
deconditioning presents special challenges in working with children
who have disorders of attachment. Disorders of attachment more
typically derive from experiences of cumulative, severe trauma.
Children manage this type of trauma through defensive strategies
of numbing and dissociation (Terr, 1991). This leads to the above
discussed deactivation and disconnection of the attachment system
when the trauma occurs within the caregiving relationship. Further,
severe trauma before the age of 4 results in limited cognitive
recall and an inability to relate current symptoms to the early
trauma (Perry, 2000). Thus, the child, due to the very nature
of the disorder, is unable to competently give informed consent.
This is not an unusual occurrence with children given their limited
cognitive abilities. Parents typically act on the child’s
behalf to give consent. The concern here is that the intrusive
techniques not be re-traumatizing for the child. In order to best
accomplish this, there needs to be extensive preparation and contracting
involving the child and parents. Contracting with the child involves
(1) careful identification of the implications of the child’s
behaviors without treatment; (2) the current caregiver’s
commitment to the child; and (3) the commitment to safety for
all through the process. Parents give consent for intrusive medical
interventions to save the child’s life. The implications
for treating attachment disorders are the emotional equivalent
of saving a child’s life. The developmental trajectory of
untreated attachment disorders can be severe personality disorders
with significant functional impairment perpetuating the cycle
of maltreatment with their children, spend years of their life
incarcerated, and/or failing to be safe and contributing members
of society (APA, 1994).
Exposure
can be direct (e.g., conscious self access to explicit memories)
or indirect (e.g., implicit, meaning that the traumatic memory
is activated within the relationship itself) (Briere, 2002). Where
trauma therapy would focus on direct exposure to the traumatic
memory, attachment therapy works initially utilizing indirect
exposure. That is, the relationship itself activates the conditioned
emotional response. Until the triggers associated with the context
of the relationship itself are identified and resolved, the child
does not have access to a haven of safety so needed for trauma
work. Since attachment is formed in implicit memory systems (Tulving,
1985) as preverbal, sensori-motor templates of interaction (Koback
and Sceery, 1988), conditioned emotional reactions to attachment
are more unconscious and therefore difficult to change through
conscious, verbal interventions.
Another
issue concerns the nature of the therapeutic relationship itself.
In more traditional forms of therapy, “the therapist must
ensure that the strength of the relationship is always sufficient
to help the patient through the resistance and arousal that characteristically
accompany directive and intrusive interventions” (Beutler
and Clarking, 1990). The fundamental problem in disorders of attachment
is the child’s profound inability to form that kind of trusting
relationship. Indeed, these children typically have defeated numerous
caregivers and therapists prior to getting to the point of referral
to a therapist who specializes in treatment of attachment disorders.
Therefore, the diagnosis of an attachment disorder presumes the
motivational force behind the child’s extreme issues of
control is to maintain the level of deactivation and disconnection.
The child’s need for control generates a profound need to
resist the therapist’s (or parent’s) influence. It
is in clinical situations such as this that defiance-based paradoxical
interventions have their most desirable effects among clients
who exhibit such high levels of interpersonal resistance (Shoham-Salomon,
Avner, and Zevlodever, 1988; Beutler and Clarkin, 1991). Such
defiance-based paradoxical interventions may include prescribing
the symptom, as well as magnifying or exaggerating the symptom.
Both
of these processes can be present in attachment therapy utilizing
physical holding. For example, the child’s defensive strategies
of deactivation, disconnection, and aggression may be explicitly
identified as a response to the caregiver seeking emotional connection
with the child. The roots of this defensive strategy are also
explicitly identified (e.g., as survival strategies for past experience)
but challenged against current reality. When the caregiver then
makes a nurturing overture toward the child (e.g., verbally expressing
caring about the child, encouraging eye contact, touching the
child, etc.), the child’s defensive strategies are then
met with reassurance and calm. The caregiver perseveres to prove
that the defensive strategies that have defeated others in the
past will no longer work to keep this caregiver away. If the child
escalates into strategies of aggression, the child can be safely
contained so that he/she is not able to hurt or drive others away.
Such containment is coupled with active reassurance, protection
and guidance to disconfirm old, distorted beliefs. Nurturing containment
through the use of physical holding, coupled with verbal reassurance
and explanations, is recognized as a critical function of healthy
parenting, especially for young (or developmentally young) children
(Brazelton, 1992).
In
spite of the effectiveness of such defiance-based paradoxical
interventions, their use requires special safety precautions.
Most significantly, “the therapist should be aware of the
potential for abuse in these procedures” (Beutler and Clarkin,
1991, p. 277). Most importantly, the therapist must be able to
congruently demonstrate positive feelings toward the child throughout
the intervention (e.g., signs of annoyance or irritation are counter-therapeutic
and increase the risk for abuse). Other safety precautions include
adequate training and preparation of all participants as well
as the guidelines outlined in the Practice Manual for ATTACh.
Finally, the therapist must be able to provide a developmentally
appropriate rationale for the child. This needs to integrate the
behavioral practice component with the process of identifying
and resolving the maladaptive cognitive processes inherent in
the formation and maintenance of the defensive strategies and
distorted beliefs that underlie disorders of attachment.
Summary
Attachment therapy attempts to provide a corrective emotional
experience of empathic attunement, coupled with specifically enriched
experiences (e.g., resonating positive emotional exchanges; provision
of tangible nurturing; sensori-motor experiences of safety and
comfort with the parent, to challenge the early experiences of
maltreatment or abandonment that contributed to the distorted
internal working model; assistance in developing a coherent narrative,
etc.). In this way, attachment therapy is viewed as a developmentally
focused set of interventions aimed at remediating the developmental
effects of early trauma and/or deprivation. These experiences
are believed to “enhance the growth of neurons and the integration
of neural networks” (Cozolino, 2002) necessary to resolve
early trauma, revise relational schemas, and remediate developmental
deficits. Cozolino further states that growth and integration
in this process are enhanced by:
1.
The establishment of a safe and trusting relationship.
2.
Gaining new information and experiences across the domains of
cognition, emotion,
sensation, and behavior.
3.
The simultaneous or alternating activation of neural networks
that are inadequately
integrated or dissociated.
4.
Moderate levels of stress or emotional arousal alternating with
periods of calm and
safety (to develop skills in affect regulation).
5.
The integration of conceptual knowledge with emotional and bodily
experience through
narratives that are co-constructed with the therapist (and parent).
6.
Developing a method of processing and organizing new experiences
so as to continue
ongoing growth and integration outside of therapy.
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________________________________________________________________________
1Clinical
Director, Upper Bay Counseling & Support Services; Adjunct
Professor, Institute for Graduate Clinical Psychology, Widener
University.
2Note:
The author appreciates the valuable contributions made by Bill
Goble, Ph.D., Todd Nichols M.A., Denise Lacher, M.A., Lark Eshelman,
Ph.D., and others in revisions of this paper.
