Dr Angela Busuttil Head of Psychology in Physical and Occupational Health Sussex Partnership NHS UK

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1 Dr Angela Busuttil Head of Psychology in Physical and Occupational Health Sussex Partnership NHS UK Richmond Foundation Malta October 2012

2 Definitions Overview of attachment theory and its developments Attachment theory and personality disorder Implications for therapeutic relationships

3 "enduring patterns of inner experience and behaviour" that are sufficiently rigid to bring a person into repeated conflict with the social and occupational environment. DSM-IV specifies that these dysfunctional patterns must be regarded as nonconforming or deviant by the person's culture, and cause significant emotional pain and/or difficulties in relationships and occupational performance. In addition, the patient usually sees the disorder as being consistent with his or her self-image (ego-syntonic) and may blame others for his or her social, educational, or work-related problems.

4 DSM-IV -three clusters based on symptom similarities: Cluster A (paranoid, schizoid, schizotypal): Patients appear odd or eccentric to others. Cluster B (antisocial, borderline, histrionic, narcissistic): Patients appear overly emotional, unstable, or self-dramatizing to others. Cluster C (avoidant, dependent, obsessive-compulsive): Patients appear tense and anxiety-ridden to others.

5 Attachment- Fahlberg 94 "an affectionate bond between two individuals that endures through space and time and serves to join them emotionally Involves the study of human relationships, especially early, formative relationships; early work by John Bowlby & Mary Ainsworth developed our understanding

6 Work developed from ethnology Asserts there is a biological imperative for infants to form attachments; attachment behaviours seen in other animal species Viewed as crucial to survival

7 Propensity to form intimate emotional bonds. Bowlby (1969) argued that we have a biological need to seek and maintain contact with others: an impulse to maintain closeness, to restore it if impaired, and to seek out a particular person if we are distressed. Role of endogenous opiates Attachment behaviours exhibited to facilitate attachment: smiling, crying, clinging, following, approaching, etc. These behaviours have an adaptive survival function - all serve to keep the child close to the carer Quality of early attachment relationships link to emotional functioning throughout life. This process begins in infancy, but continues throughout life. Language, cognitive and moral development related to the quality of early attachment relationships.

8 Through the relationship, infant develops working models or cognitive frameworks about the accessibility of the CG as well as their own ability to elicit having their needs met from others From early attachments, an internal working model develops which acts as a template for other relationships. Attachment behaviour continues throughout life, and develops from immature dependence on caregivers to mature dependence on friends and partners.

9 Internal Working Model- Self An evolving schema of how children view themselves based on their role in the attachment relationship Internal Working Modelothers From the IWM of the caregiver a broader base of expectations about others and the world develop Set of beliefs about one s worthiness as a person and one s competence develops

10 Secure Attachments play happily when care-giver present, protest. when they leave, go to them for comfort on their return. show some wariness of strangers; choose their care-giver for comfort when upset. They have a base that is stable, but also acts as a springboard to the wider social world. Long-term resilience associated with opportunity to develop secure attachment to at least one person. Insecure Attachments may show one of four patterns: avoidant ambivalent disorganised anxious preoccupation. Children who have been abused or neglected are more likely to show insecure patterns of attachment. And Insecure patterns of attachment more common in PD and other mental health issues

11 Avoidant Children little distress at separation, avoid contact with the AF on return and appear not to discriminate markedly in their behaviour between stranger and the AF Disorganised Demonstrated in a mixed reactions and contradictory behaviour patterns: e.g. gazing away whilst being held. May appear confused, unable to appear comforted by the AF. Anxious Ambivalent Pattern of insecure attachment, characterised by an anxiety about and preoccupation with the availability of the carer.

12 Secure attachment associated with responsive CG responding appropriately to child's needs and TEMPERAMENT Attachment patterns are therefore influenced by the interaction between the child (affected by his or her temperament) and the adult ( also their temperament). The early pattern of attachment acts as a template (IWM) for later relationships but it is the encounter of confirmatory experiences of the IWM that contribute to their persistence.

13 Bowlby (1973) present cognitive or behavioural structures determine what is perceived and what is ignored, how a situation is construed and what plan of action is likely to be constructed Current structures moreover determine what sorts of person and situation are sought after...an individual comes to influence the selection of their own environment and the wheel comes full circle

14 Operation of assimilative feedforward mechanisms (Lyddon 1993, Mahoney 1991) New experiences are constrained to fit into existing cognitive constructions and can be inflexible to new information. Securely attached individuals have self-system that is flexible, more open to learning (feedback) and change.

15 Positive (low) MODEL OF SELF dependence Negative (high) Positive (low) MODEL OF OTHER avoidance Negative (high) SECURE Comfortable with intimacy and autonomy DISMISSING Dismissing of intimate relationships, counter dependant PREOCCUPIED Preoccupied with relationships FEARFUL Fearful of intimacy and socially avoidant

16 Holmes- mentalising is seeing yourself from the outside and others from the inside. Attachment affects ability to make and use mental representations of your own and other people's emotional states Fonagy and Bateman

17 Developing ability to independently observe the self is the product of a secure attachment. If feedback to children is either missing or inaccurate, children are unable to fully develop the capacity to mentalise, they do not learn how to understand their own thoughts, feelings, and motivations; nor those of others Mentalisation is necessary in good personal relationships and in PD may be impaired Mentalisation is assumed to be an important coping skill that is necessary for effective emotion regulation. Difficulties with emotional regulation are one of the four primary characteristics of all personality disorders.

18 Caregivers who meet children's needs for protection and comfort provide effective and appropriate soothing responses. When caregivers model these effective soothing responses, this enables children to learn how to calm and soothe themselves. Through predictable responsive caring children learn to regulate their own emotions internalising within themselves selfsoothing, comforting coping strategies that previously took place in the space between caregiver and child.

19 When CG is rejecting, inconsistent in response to children's needs, does not model soothing, then children do not experience caregivers as soothing and safe, or predicatable. Mental representations of relationships likely to be unsafe and insecure (i.e., insecure attachment). Maltreatment results in an insecure attachment style leading to confusion in relationships with caregivers and authority figures. Child anticipates abuse and is therefore cautious or avoidant but there is simultaneously a biological drive to seek attachment and support.

20 Involves: A great part of the right hemisphere. Broca s area and part of the supra orbital area of the braincrucial in empathy with others. Partly mediated by: endogenous opiates and oxytocin dopamine and serotonin mirror neurons (activated by performing and observing actions and by feeling and observing emotions) At birth baby s brain has 50 trillion synapses; by age 3 1,000 trillion. During that time, new synapses are formed and hard wired whilst unused ones are pruned. Impact of attachment on development marked

21 experience can either positively or negatively influence the maturation of brain structure, and therefore, the psychological development of the infant. This developmental psychoneurobiological model clearly suggests direct links between secure attachment, development of efficient right brain regulatory functions, and adaptive infant mental health, as well as between traumatic attachment, inefficient right brain regulatory function, and maladaptive infant mental health. Schore 2001

22 Attachment Theory In relation to PD: Interrelated deficits associated with BPD and other PD include: Impulsiveness Emotion regulation Relationship problems Identity formation

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24 Complex Relationship between Adverse Childhood Experiences and PD Insecure attachment style and distorted IWM representations of self-and-others do not constitute disorders in-and-of themselves but when combined with other biological and environmental risk factors such as abuse, they may contribute to the development of a personality disorder. Exposure increases likelihood that a personality disorder may occur but not all neglected/abused children develop personality disorders.

25 Multiple risk factors (both genetic and environment) are likely to be involved. Suggests various protective factors may limit the damage. Access to social support appears to serve this protective function (Johnson, Bromley, & McGeoch, 2005) Abused/emotionally neglected children tend to have better outcomes when they have access to nurturing and supportive relationships with secondary caregivers

26 Interface between attachment problems and later trauma impersonal trauma interpersonal trauma attachment trauma nonhuman agent human agent attachment figure Jon Allen

27 Attachment and Therapy provides the patient with a secure base from which he can explore the various unhappy and painful aspects of his life, past and present, many of which he finds it difficult or perhaps impossible to think about and reconsider without a trusted companion to provide support, encouragement, sympathy, and, on occasion, guidance. Bowlby What good therapists do with their patients is analogous to what successful parents do with their children What is the therapeutic alliance if not an attachment bond? Jeremy Holmes (2001)