Attachment 30 th November 2012 Dr Helen Brotherton

Attachment

30th November 2012Dr Helen Brotherton

Session Outline• Historical perspectives on Attachment Theory-

the work of Bowlby & others• DVD- Early research studies of Attachment• Importance of ‘Bonding’ and Infant Mental

Health• Update on Contemporary Attachment Theory• Disruptions in Childhood Attachment• Research on links between early attachment and

later mental health difficulties• DVD- Clinic illustrations of attachment & bonding

How Attachment theory fits in

• Initial Group Exercise

"What does the term attachment mean to people? What words, phrases, concepts, understandings etc .......”

“What’s your understanding of Attachment Theory? ….”

Historical Perspectives on Attachment Theory

• From 1910 onwards, 2 theories were dominant in understanding a child’s tie to its mother:-– Psychoanalytic theory; and– Social learning theory

• These theories both emphasized that a relationship developed when the mother feeds the infant -> leading to a pleasurable relationship when hunger is satisfied

• These theories were described as ‘secondary drive dependency theories’ by Bowlby

‘Secondary drive dependency’ Theories of Attachment

• Cupboard love theories, as they became known, were therefore dominant

• The rationale being:- we attach to our mother because she feeds us (Dollard, Millar, Freud etc).

• Primary drive is food -> leading to a Secondary drive for attachment.

Evidence against ‘Cupboard Love Theories’

• Bowlby noticed evidence from animal studies challenged previously held notions

• Lorenz noted infant geese attached to parents who did not feed them:- therefore, imprinting seemed to occur during a critical period due to exposure

Evidence against ‘Cupboard Love Theories’

• Harlow observed infant rhesus monkeys• The studies found that, in times of stress,

monkeys preferred a more comforting cloth-covered ‘mother’ figure to feed them, rather than the wire-mesh ‘mother

• Evidence also grew to show that human infants became attached to people who did not feed them

• So Bowlby (1980) noted:-“if the secondary drive dependency theory was inadequate, what was the alternative?”

Attachment Theory - the contribution of Bowlby

• Bowlby - British child psychiatrist, part of the psychoanalytic community, training when object-relations (Kleinian) theories were dominant

• Supervised and analyzed by Melanie Klein, but differences began emerging between him and others in the psychodynamic community

• Bowlby’s view led his to be ignored by the psychoanalytic community & only considered relevant in recent years (ie Fonagy, Holmes etc)

Attachment Theory - Differences between Bowlby &

Analysts• Bowlby’s work evolved from observing the

impact of WWII & working in a home for maladjusted boys - the impact of separations, losses and disruptions in close relationships

• The answer came when Bowlby considered the child’s actual experience with its primary attachment figures - he considered this to be the “bedrock of psychic structure” (Lemma, 2003)

Bowlby’s Theory of Attachment

• Bowlby developed an ethological theory, which suggested that:-“the infant attachment bond is an instinctually guidedbehavioural system that has functioned throughouthuman evolution to protect the infant from danger”

• With this evolutionary based theory, fear of strangers and other threats to survival is innate

Bowlby’s Theory of Attachment• Bowlby considered that infants preferred a

principal attachment figure for comfort and security = ‘monotropy’

• This monotropy theory has gained support, but some researchers remain critical

• Some writers report ‘attached’ and ‘unattached’ infants and Bowlby thought that without attachment, we get affectionless psychopathy

• Others have considered there to be no such thing as ‘no attachment’

DVD- Exploring Early Attachment Research

‘Attachment’ DVD– Look at Harlow’s early research studies– Thinking about the ethics of the research, both with

historical & contemporary perspectives– Think about what information we can gain today from

this research, in terms of the:-• Importance of attachment to the primary caregiver• The impact of neglect• How this research may relate to well-known cases

of childhood maltreatment, neglect, and disrupted attachments in humans

Bowlby’s Theory of Attachment• Bowlby- recognized importance of environment,

contexts, circumstances, relationships and interactions in a way not previously considered

• Emotional development was recognized as as important as physical development

• Events/interactions that disrupted the important interaction with attachment figures were seen as crucial to emotional development

• Further work focusing on emotional development was conducted by Ainsworth, Main, Lyons-Ruth

Bowlby’s Theory of Attachment• Attachment behaviours, such as smiling &

vocalizing, are signalling behaviours which alert mother to child’s interest & bring her to the child

• Others, ie crying, are aversive, but bring mother->child and signal something needs terminating

• Bowlby believed the attachment process is assisted by Fixed Action Patterns, which are instinctive and biological

• Fixed Action Patterns are complex behaviours which can aid attachment formation, including grasping, crying and smiling (Ainsworth)

Bowlby (cont)

Attachment behaviours– clinging– using mother as a secure base to explore– signalling to mother to ensure her proximity– different behaviours are used with different

types of attachment

So Attachment is about….

• …the ability of individuals to use attachment figures as a secure base from which to explore and

• …a safe haven in times of fear, distress or danger

• …the extent to which caregiver responses are:

• Reciprocal • Sensitive (accurate interpretation of signal)• Consistent• Offer comfort, calm & enable feelings of safety

Schafter’s Theory of Attachment: Separation Anxiety

• Shafter’s work particularly looked at attachment and separation reactions

• Three stages of attachment, generally presented as:-– 6/52-3/12 - attach to anyone– 3-8/12 - knows strangers are different but not scared

of them– 8+/12 - separation and stranger anxiety– From 3 years, develop trust in mother’s permanence

and can move away from them

Ainsworth: Separation Anxiety/Protest

• Ainsworth, colleague of Bowlby, did pioneering naturalistic observations of mothers and infants

• She developed the ‘Strange Situation’ assessment, studying parent-infant reactions

• Study = parents in lab setting are separated then reunited with their 12-14month-olds

Ainsworth: Separation Anxiety/Protest

• Ainsworth (& Main later) developed three main types of attachment A, B & C (plus later type D- disorganised)

• Intra and cross cultural differences and children can move between groups

• Key is mother’s sensitivity to needs

‘Strange Situation’ results - Responses to Separation

• Type A- Insecure Avoidant (20%)- little bond with mother, not too upset by separation, but hates being alone so comforted by stranger, whilst actively avoids seeking contact with parent

• Type B- Securely attached (60%)- distressed by parent leaving but seeks parent and can easily be consoled on return

• Type C- Insecure Ambivalent (20%)- little security in bond initially, when separated becomes very distressed, difficulty being soothed on reunion

Contemporary Attachment Theory

• Attachment Relationship can be defined by:- i) proximity seeking to preferred figure; ii) the secure-base effect; and iii) separation protest (Weiss, 1982)

• Attachment categories/styles:- – i) Secure (2/3; 60%); – ii) Insecure avoidant (1/5; 20%); – iii) Insecure ambivalent (1/6; 15%); and – iv) Disorganized (1/20; 5%)

The Importance of the Very Early Life - Infant Mental Health• Attachment theorists emphasize the

impact of very early bonding experiences, as well as later childhood events

• In terms of development, Bowlby considered that the 1st year is a ‘sensitive period’, but the critical period for attachment may be up to 3 years

The Importance of Infant Mental Health 0-12 months

Pregnancy, birth and ‘bonding’- during these processes, parents experience

negative & positive feelings, from distress and anxiety to intense happiness

- when baby is born, he/she is also at the mercy of such extreme feelings

- ‘bonding’ is the development of a deep relationship, through painful experiences as well as good times

Infant Mental Health 0-12 months

First few days- babies have distinct personalities and

different responses to the trauma of birth- early stages can feel ‘messy’ both

emotionally & physically for parents- parents can be struggling to live up to

ideals- getting to know the baby and developing a

relationship is the primary task

Infant Mental Health 0-12 months

The first 6 weeks- both parents and babies can feel at their

most vulnerable and terrified- babies will be feeling bewildered and lost,

and life feels chaotic, frightening and without boundaries

- the parents’ moods affect the baby and the baby’s moods affects the parents

Infant Mental Health 0-12 months

Three to six months- importance of feeding -> highlights babies’

individual temperaments & personalities- baby begins to separate from mother &

already uses play to make sense of feelings

- parents’ and baby’s emotions are closely entwined- each is intensely affected by the other

Infant Mental Health 0-12 months

Six to Twelve months- baby begins to integrate his/her feelings and

thoughts, creating a more coherent view of the self and others

- life is full of emotional extremes for baby- baby’s emotional development depends on

his/her parents’ ability to bear frustration and to allow themselves & baby to be human

Infant Mental Health -> Attachment theory and BondingAttachment theory focuses on …- how loss and separation need to be

continually, and frequently, negotiated in the 1st year of life, with weaning, parental return to work etc

- how babies need to experience being fully known and ‘held in mind’ for the child to feel integrated, secure and understood

- the impact of normal disruptions and the importance of 'good enough' parenting ….

Are Attachment Strategies constant from infant to adult?

Different perspectives…1) Two Models of Attachment stability/instability:-

i)existing representations are revised/updated with new experiences- early styles ‘overwritten’ii) representations from 1yr are preserved & continue to influence behaviour thru life [Fraley]

2) Client’s ‘constant attitude’ (Reich) -> one attachment style? Category? (AAI)

3) Repertoire of attachment styles? -> Dimensions rather than discrete categories? (Holmes, 2001)

Contemporary Attachment Theory

Four main findings from Attachment Theory:-1) Universality hypothesis- in all cultures, human

infants become attached to 1+ specific caregivers2) Normality hypothesis- secure attachment is

numerically & physiologically normal (70%)3) Sensitivity hypothesis- attachment security is

dependent on sensitive & responsive caregiving4) Competence hypothesis- differences in

attachment security lead to differences in social competence [Van Ijzendoorm & Sagi, 1999]

Contemporary Attachment Theory

Holmes (2001) added three further hypotheses:-5) Continuity hypothesis- childhood attachment

patterns significant impact on relationship skills & mental representations in adulthood

6) Mentalization hypothesis- secure attachment leads to capacity to reflect on self & others’ states of mind (mentalization)

7) Narrative competence hypothesis- childhood secure attachment is reflected in how adults’ talk about their lives, past, relationships & related pain

Contemporary Attachment Theory

Early attachment factors leading to patterns:-• i) Secure - parents-children play, ‘good enough’

parenting, child can express negative emotions• ii) Insecure avoidant - parent rejects child’s

contact/ emotions -> child withdraws• iii) Insecure ambivalent - emotionally

inconsistent parent,‘parentified child’• iv) Disorganized - parent doesn’t have child in

mind, attachment figure may be maltreating child

Contemporary Attachment Theory

Implications in Adult life/relationships:-• i) Secure - working model of self as worthy of

care, autonomous, regulates negative emotion• ii) Insecure avoidant - dismisses rels,

compulsive self-reliance, shuts down to avoid distress

• iii) Insecure ambivalent - clinging/ neediness, self worth low, hyper-vigilance to distress

• iv) Disorganized - chaotic, fear of intimacy, expects rejection (approach/avoidance conflict)

Disruptions in Childhood/Early Attachment

Group Exercise:-– What may we actually mean by childhood/

early attachment disruptions? – What events, circumstances, relationship

patterns etc do you think we would be looking for, in the histories our child or adult patients with insecure or disorganized attachments?

– How may disrupted attachments present?

Disrupted Attachment Presentations

• Spitz- breaking attachment in first few years leads to depression with physical and mental deterioration (studied privation in institutions)

Short term separation– Bowlby considered a universal

pattern of reactions to short-term separation ->

Protest -> despair ->detachment

Disrupted Attachments: Risk Factors to Babies/Infants

Negative risk factors to attachment & bonding in infants [the bad news…]

• Difficulties with pregnancy, labour & birth• Child’s developmental difficulties• Parents’ mental health problems -> post-natal

depression, past abuse histories• Domestic violence & other forms of abuse • Single parenthood, teenage parenthood and

poor social support• Child’s temperament

Disrupted Attachments: Risk Factors to Babies/Infants

Negative risk factors for babies [more bad news..] • Gerhardt (2004) ‘Why love matters’ book

”quality of the relationship between parent and child influences both the biochemistry and the structure of the brain” (p.211)

• The baby’s nervous system is more vulnerable early on -> very early experiences are crucial

• Early experiences of affection, nurturing and attachment impact on both emotional & cognitive development -> early brain developments continue to have an impact in later life

Disrupted Attachments: Risk Factors to Children

Most disruptive if:– 7-36/12 old– boy– poor language– have pre-existing behavioural problems– initial bond was poor– no previous history of separations – only one attachment

Disrupted Attachments: Risk Factors to Children

Negative risk factors [more bad news ….] • All forms of abuse can cause disruptions to the

security and attachment of a child:- physical, sexual and emotional abuse.

• Neglect has interestingly been found to have some of the most profound effects - are inconsistent attachments better than no attachments at all?

• This research influences current policy to try and keep families together, despite their difficulties

Impact of long term disruptions

• Most common is death and divorce• Contexts around death and divorce can lead

to more or less traumatic responses

Long term disruption• Can lead in children to:-

– separation anxiety– psychosomatic reactions– aggressive and demanding behaviour– clinging or detachment from other attachments

Disruptions in Childhood/Early Attachment- the Research

a) Loss- incl actual loss & prolonged absences,eg parental illness, death, family disruptions leading

to foster/care placements circumstances/• caregiving before & after the loss are also criticalb) Stressful Events- incl marital conflict, divorce,

parental illness/dysfunction, parent-child conflict• affect attachment when child perceives threat to

the attachment bond or caregiver availability• an insecure child defensively distorts signals/

strategies, perceiving a threat

Disruptions in Childhood/Early Attachment- the Research

c) Abuse & Trauma- incl sexual, physical or emotional abuse, and neglect

• abuse impacts on child’s attachment style, both as trauma and context in which abuse occurs

• nature of the abuse/abuser is important• ‘perverse paradox’ of abuse [Holmes]- vicious

circle where adult carer is both attachment figure child turns to for protection and is the main source of threat child needs protection from-

• More frightened/in pain child becomes, the more they cling to the perpetrator

Disruptions in Childhood/Early Attachment- the Research

d) Quality of caregiving- inadequate caregiving’s been linked to all forms of later psychopathology

• Perceived threats to carer availability incl:- – prolonged absence * emotional disengagement– rejection * harsh discipline *neglect [most sig?]– inadequate control * over-protection– unresponsiveness *physical inaccessibility– disrupted communication – witnessing violence/suicide

Disruptions in Childhood/Early Attachment- the Research

Most importantly, it is not just disruptions per se that influence attachment responses…..

But cognitive appraisals/perception of threat following separation/loss-> these develop into ‘Internal Working Models’ of adult attachment

A child’s attachment responses will therefore be based on:-

• i) Intrapersonal processes- IWM; strategies• ii) Interpersonal processes- sensitivity; positive

parenting; open communication

Positive Factors for Infant and Child Attachment

The Good news for infants ….• Mothers mis-attune with their babies more times

than they attune (about 70%) - human beings are therefore very forgiving & resilient (60-70% ‘securely’ attached)

• ‘Angels in the nursery’ - One secure figure may be enough, even if parental bonding is poor

• Child’s temperament • Resilience and normal pathology!

Links between Early Attachment & Adult mental health difficultiesHolmes- thought about obvious links between adult

psychological reactions and attachment styles:-• Sadness- if an attachment bond is severed• Depression- if there are threats to status in a

group• Anger or Anxiety- if an attachment bond is under

threat; Phobias- excessive fears of attack• Mania- has a triumphant/delusional sense that

attachment bonds can be dispensed with• BPD- where minor threats to attachment bond are

experienced as devastating

Research on links between early attachment and later AMHConclusions from research:-• “Attachment-related events, such as loss and

abuse, lead to modifications in these internal representations and affect a child’s strategies for processing thoughts and feelings.”

• Therefore, they become “more vulnerable to psychopathology” [Handbook of Attachment]

• But, are Holmes’ predictions of associations between particular attachment styles and development of specific disorders borne out in research findings?

Research on links between early attachment and later AMHResearch• Evidence looking at linking infants’

behavioural strategies to psychopathology in adulthood is limited

• More research is available looking at links between attachment-related events in childhood and later psychopathology/ mental health conditions

Research on links between early attachment and later AMH• Extensive, but complicated body of research• Some longitudinal studies look specifically at

attachment-> childhood/adolescent/adult psychopathology, ie– Minnesota Parent-child project– Lyons-Ruth et al

• Key attachment researchers to consider are:- Ainsworth; Main; Sroufe; Egeland; Cassidy; Lyons-Ruth; Crittenden; Fonagy etc

Research on links between attachment strategies and AMH

Insecure defensive strategies [Main, Holmes etc]:-

• a) ‘Minimizing strategies’[‘deactivating’]- defensively turning attention away from distress= develop limited access to own feeling-> predispose child to externalizing disorders

• b) ‘Maximizing strategies’[‘hyperactivating’]- defensively turning attention towards own distress= unable to accurately appraise threats-> predispose child to internalizing disorders

Research Conclusions

• Findings re: Attachment states of mind show some consistencies & inconsistencies

• Classification system has changed over time & comorbidity is difficult to assess

• Overall though, psychiatric disturbance is nearly always linked to insecure states, unresolved states and disorganized patterns are over-represented

Summary of links between Attachment and Mental Health

• Mood Disorders- linked to all 3 attachment types• Bipolar Disorder- under-researched• Anxiety Disorders- ‘preoccupied’ (ie insecure

ambivalent) but also ‘unresolved to trauma’• Eating Disorders- predominantly insecure, mixed

categories depending on classification• Schizophrenia- high proportion of ‘dismissing’ (ie

insecure avoidant) but difficult to assess• BPD- v strong links with ‘disorganized’ categories• Antisocial PD- ‘unresolved’ & ‘dismissing’

DVD- Exploring attachment links to AMH difficulties

Cases of mothers with PND….– Mothers’ attachment patterns have been shown to be

correlated to their baby’s patterns‘Help me love my baby’ DVD– Look at the mirroring between mother & child– Think about how the mother’s early attachment

disruptions may have impacted on her attachment style and her later development of post-natal depression

– Think about the mothers’ narratives attachment strategies, both in her early life and now in adulthood

– Think about the infant’s attachment strategies, both at 6 months and at 16 months- why these styles?