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Treatment Assumptions

The training in all settings is based upon the following assumptions.

  1. Learning (including therapeutic change) occurs from within a secure base relationship.
  2. The quality of the parent/child attachment, which is amenable to change, plays a significant role in the life trajectory of the child.
  3. Interventions need to be based on a differential diagnosis that is informed by research-based theory.
  4. Lasting change comes from parents developing specific relationship capacities rather than learning techniques to manage behaviors. The capacities needed for a secure relationship include:
    • Observational skills informed by a coherent model of children’s developmental needs,
    • Reflective functioning and the ability to enter into reflective dialogue,
    • The ability to engage with children in the regulation of their emotions,
    • Empathy.

Following is a description of these assumptions.

Secure Base Relationship

John Bowlby concluded that the most dangerous event for baby mammals, including humans, is separation from a protective adult. Conversely, Bowlby recognized the need for exploration as being essential to survival. His hypothesis was that when children feel safe and secure, their attachment system terminates, and their exploratory system engages. This allows for both optimal safety and the mastery of necessary skills. However, when children feel threatened, exposed, criticized, or vulnerable to attack, their exploratory system terminates and their attachment system is activated.
The reciprocal relationship between seeking protection and developing new capacities presents a challenge for children and adults alike. This dilemma occurs because there exist a strong evolutionary advantage for seeking protection, when needed, to override all other systems, thereby becoming the only system active. In other words, people cannot adequately learn and defend themselves at the same time. When parents, especially high-risk parents who are often under social and legal scrutiny, take the risk of placing their caregiving approach under a magnifying glass their attachment needs (for protection and comfort) are often activated. This inevitably results in their need to take a defensive posture. Therefore, it is essential to provide a secure base environment to help terminate their attachment system. Only then can they be open to developing new capacities. This requires that parents view the facilitator as a kind, respectful, interested, caring, and concerned person capable of providing sufficient protection to allow needed safety, thus allowing them to calm their defenses in order to take in new experiences.

Parent/Child Attachment

Early intervention programs for at-risk parent/infant dyads are using increasingly refined procedures for defining goals, as well as for developing intervention protocols and methods for identifying change. There is an increasing emphasis on developing interventions that are focused on, in the words of Kathryn Barnard, “…specific challenges in the caregiving environment, and on specific opportunities to make a positive difference in the development of children and parents.” Barnard specifically emphasizes that promoting secure attachments between young children and their parents should be a focus of early intervention.

It is now well established that during the period beginning at birth and continuing through the end of the preschool years, the quality of the child’s attachment is related to concrete, definable parental capacities, caregiving behavior patterns, and internal working models. In turn, the quality of infant and preschool child-attachment status can be used to identify increased risk for future emotion-regulation struggles, behavior difficulties, and relationship problems as well as future academic difficulties. This is especially true in high-risk populations.

Recent longitudinal studies (birth to adulthood) at the University of Minnesota have found that secure attachment has served as a protective factor for children whose families have experienced high levels of stressful life events. In comparing competent children with less competent children from highly stressed families, researchers found that a history of early attachment-related competence proved to be a major protective factor against the adverse effects of stressful life events. The “early history of competence” was characterized by a secure attachment at twelve and eighteen months.

There is increasing evidence that an insecure attachment during infancy, especially one that is “disorganized,” is an important component of the cumulative risk factors on a developmental pathway toward maladaptive child outcomes. These outcomes are related to social competence with peers and teachers, impulse control, conduct disorders, anxiety, depression, dissociative disorders, and other psychiatric and legal problems.

Allan Sroufe, concludes that “Overall, longitudinal findings have indicated that the early attachment relationship provides an important foundation for later development and that a secure attachment may serve as a protective factor against the negative impact of various adversities and risk factors. Our findings and those of other investigators are quite compelling and suggest that efforts aimed at promoting a secure attachment may prevent various forms of problems among children in high-risk circumstances.”

Differential Diagnosis

Over the past decade, the procedures and findings from attachment research have begun to be applied in the context of clinical assessment and intervention with infant/preschooler-parent dyads at risk. The primary limitation is that the details of the interventions are not individualized to the specific attachment-caregiving pattern of each dyad. While it is almost certain that some individualization takes place as the intervention unfolds, what is needed at this point is an organized, published, differential system of assessment-treatment protocols. Without a systematic protocol, the likelihood that a specific intervention could be ineffective (or worse, counterproductive) is greatly increased.

The following examples of misattuned interventions are common, within the context of the four basic attachment strategies (Secure/Secure, Dismissing/Avoidant, Preoccupied/Ambivalent, and Unresolved/Disorganized):
Caregivers with a Dismissing/Avoidant pattern often “over focus” on the child’s exploration to avoid activation of the child’s attachment behavior (e.g., distress regarding an impending separation or at the time of reunion). During a video review session, this parent might view him or herself on videotape distracting the young child toward exploration in order to discourage distress. If the facilitator mistakenly further encourages this parent’s support for exploration, an insecure attachment strategy could become further entrenched. On the other hand, focusing on a moment when this same parent appears hurt by the child’s avoidance, or when the parent and child share a moment of delighted, mutual gaze, could present an opportunity for important discussion and change.

In the case of a Preoccupied parent with a Resistant/Ambivalent child, the moment to focus on might be just the opposite, (i.e., a moment on the videotape when the child engages in competent, independent exploration when not distressed.)
In addition, caregivers with an Unresolved/Disorganized pattern often look to the child to help them regulate their affect. These parents frequently describe themselves as helpless to protect their children from threats and danger, and their caregiving often contains themes of inadequacy, helplessness, and/or losing control. Such a parent will repeatedly describe her/his child as “bossy,” “too much for me to handle,” or alternately, as a “best friend” and caretaker of the parent (i.e. “My little man takes care of his mommy.” Sadly, we even see such projections onto the child in parents of newborns.) This tends to give rise to children who appear “over-bright” and “competent,” when in fact disorganized children are actually frightened regarding the lack of structure in the relationship and thus desperately seeking to provide some measure of order.

Even so, it is common for a therapist, without access to a working differential diagnosis, to mistakenly consider the child’s exaggerated competence to be a positive sign (“Oh look at how active he gets in bringing you all of those toys,” or “Isn’t it nice to see how much he likes to offer you comfort?”). Such an intervention further encourages the Unresolved/Disorganized parent’s passivity under the guise of admiring the child’s “capacity.” Hence, a severely insecure attachment strategy might become more deeply embedded in both parent and child.

However, a clinician or family coordinator, given a working model of the key indicators regarding disorganization, can consider another kind of intervention. Hence a therapist’s focus on a moment when this same Unresolved/Disorganized parent momentarily takes charge, while simultaneously observing how the child suddenly settles into her/his lap for several seconds, could present a needed opportunity for important discussion and change (“Did you see, just then, when you seemed more clear and firm with your voice, your daughter stopped pulling away and started to cuddle with you?”).

Hence, a working knowledge of differential diagnosis can take much of the guesswork out of how to approach treatment with each particular caregiving strategy (see grid on page 6). Rather than having to intuit or guess what might be useful with a particular parent/child dyad, a well-developed knowledge of differential diagnosis can provide specificity in the choice of interventions. When confronted with a troubled caregiver and her/his troubled child and when given only a short time to impact their family dysfunction, having access to a systematic understanding of their particular dynamics can be most beneficial.

Thus, what is needed is a system for differentially identifying each child’s attachment pattern and his or her parent’s caregiving pattern, followed by a specific treatment protocol assigned to that dyadic pattern. Such a protocol helps eliminate the potential problems of a “one size fits all” approach to intervention. It is our belief that a careful elaboration and dissemination of this differential assessment-intervention protocol would allow more standardization in the training of service providers and implementation of their services, as well as the replication of the success we have come to know in our current work. (On the following page, please find our “Differential Table: Problem Areas/Specific Events and Behaviors Requiring Intervention.”)

Differential Table: Problem Areas/Specific Events and Behaviors Requiring Intervention

Dismissing/
Avoidant

Preoccupied/
Ambivalent

Unresolved/
Disorganized

Caregiver Affect
Tendancy to be either flat or over bright
Smooth affect only during child’s exploration and play
Dismissing of child’s requests for affection
Dismission of child’s negative affect

Caregiver Affect
Immature/babyish quality
Dramatic facial/vocal expression
Seeks to convince/plead with child when negative affect emerges

Caregiver Affect
Passive affect
Tendency toward abrupt affect change in a way that is unpredictable or frightening to the child
Seem inability to acknowledge affective requests from child

Gaze
Little gaze
Brief looks

Gaze
Direct and long
Avert, eye-roll, or sharp glance

Gaze
Fearful
Abrupt shifts: disinterested/harsh

Exploration & Play
Competency (rather than enjoyment) becomes theme
Play sessions become quiz sessions

Exploration & Play
Caregiver seeks to keep child focused upon proximity
Willingness to accept/normalize misbehavior

Exploration & Play
Passive role
Allows child to organize both play and caregiver
Intermittent aggression on part of caregiver

Departures
Leaves quickly, with little or no explanation
Dismissing of child’s concerns and feelings
No preparation
No affection

Departures
Premature focus on departures
Drawn-out, conflicted leave taking
Lies or bribes
Phony affect

Departures
Uncertain, timid during leave taking
Insensitive departure
Confusing/double messages given concerning departure

Child’s Dilemma
“To get close is to be rejected; to truly separate (in areas beyond performance) is to be rejected.”

Child’s Dilemma
“To be close is to feel smothered; to separate is to feel abandoned.”

Child’s Dilemma
“The source of my support is also the source of my danger.”

Working Alliance Centers Upon
Therapist’s commitment to empathy, understanding and willingness to build a relationship with caregiver

Working Alliance Centers Upon
Therapist’s commitment to caregiver’s competence and consistency with child

Working Alliance Centers Upon
Therapist’s commitment to caregiver’s well-being via building structure, providing predictable interest and availability, clear communication and willingness to support resolution

Treatment Themes
Support attunement and positive experience of need between caregiver and child, (e.g. mutual gaze, sincerity of affect, attending to child’s feelings, turn-taking, willingness to negotiate, matching of child’s temp, clarity of speech, etc.)

Treatment Themes
Support hierarchy and competence of caretaker with child (e.g. willingness to take charge, focus on tasks, clarity and firmness of purpose, interest in child’s exploration and separate experience, frankness, clarity and directness of speech, etc.)

Treatment Themes
Support structure building, consistency, availability and attunement between caregiver and child, (e.g. attending to child’s feelings, smooth shift in parent’s affect, recognition of child’s tempo, focus on tasks and their completion, etc.)

Relationship Capacities
The Circle of Security™ Project helps develop the following relationship capacities:

Observational Skills and the Circle of Security™

Attachment theory provides a framework to comprehend children’s fundamental relationship needs. The Circle of Security™ is a user-friendly map that we developed to teach attachment theory to parents. The following is a summary of our introduction:

  • When children feel safe, their exploratory system or innate curiosity is activated and they need support (either verbally or non-verbally) for exploration;
  • As they are exploring, sometimes they need their parents to watch over them, sometimes they need help, and sometimes they need their parents to enjoy with them;
  • When they have explored long enough, (or if they get tired or anxious, or find themselves in an unsafe situation) they need their parents to welcome them back. When they return, they need their parents to comfort, protect, delight in, and/or organize their feelings. We focus on the last piece because for many of the parents it is a new idea that children need help organizing their internal experience as well as the external environment.
  • When the attachment system is terminated, children are ready to start the circle again.

Much of our training with parents (and therapists) entails helping them develop the observational skills to differentiate between exploration and attachment systems; it also involves differentiating among the specific needs within each system. With a clear understanding of attachment theory and enhanced observational skills, parents (and therapists) can sharpen their responses to further promote secure attachment.

Reflective Functioning

We do not learn from our experience, we learn from standing back and reflecting on our experience. Our program teaches parents to reflect on their experience by utilizing video review and reflective dialogue. When we first engage parents in reflecting on their experience (or the experience of their children) it is not unusual for them to reply, “No one has every asked me that before.” Because video review is, by its very nature, reflective, the weekly utilization of increasingly specified review supports and enhances the parents’ competence for reflective functioning. As the group continues, we often see a dramatic increase in their capacity for reflection. Current attachment research shows a direct correlation between a caregiver’s capacity for reflective functioning and the security of her/his children.

Emotional Regulation

Many theorists are currently focusing on the essential role of emotional regulation in the health of individuals and relationships. Much of psychotherapy and psychopharmacology are designed to help patients contain emotional experience within a manageable range. Regulation of affect is not an innate capacity, but rather a capacity learned in infancy through a relationship with a primary caregiver. For many parents the idea that children need help learning to regulate their experience is new information. Through the course of the group, parents learn to identify, acknowledge, and bring language to their children’s emotional experience. This process teaches children that emotions are a useful source of information rather than something they need to hide or be punished for feeling. Through this process of working with their children’s emotional experience, parents in the group increase their own capacity for emotion regulation.

Empathy

Our experience is that as parents gain experience utilizing the Circle of Security™ as a map, improve their observational skills, enter into reflective dialogue, contain their own affect as they attend to their children’s need for affect regulation, we see a shift from defensive process to more empathy for their children. Typically, this “empathic shift,” is a movement away from focusing on children’s behavior to focusing on: 1) the relationship in general and 2) specific emotional needs. Our repeated experience shows that when parents attend to relational/emotional needs, the necessary changes in behavior follow. To be sure, a healthy relationship requires parents to be “bigger and stronger” (set limits, take a position of hierarchy, and have high standards and expectations of children’s behavior [see p 41]) as well as be “wiser and kind.” However, behavior is like a finger pointing to the moon. If parents focus primarily on the finger (conduct), they will miss the moon (the centrality of the underlying relationship). When parents stabilize the relationship by responding with wisdom, appropriate hierarchy, and empathy, their children are then free to engage in a satisfying relationship and act appropriately.
© Cooper, Hoffman, Marvin, & Powell – 2000