Tuesday, 1 June 2010

The Relationship Between Therapy and a Therapeutic Approach

I manage a small therapeutic unit. The children/young people present a range of social and emotional difficulties: self harm, risk-taking, problematic and conflicted relationships. It is not uncommon to find “therapeutic” homes that provide therapy, however, we consider ourselves to be “therapeutic” for two reasons. First, we have a track record of good outcomes for young people that arise from their supported recovery from traumatic experiences of abuse and/or neglect. Second, we adopt a therapeutic approach. I am sure that for some young people to recover, therapy is helpful, even essential, but I suspect it is often not sufficient. Working with very trouble kids, I’ve come to understand that what is required in many cases is an over-all, therapeutic approach.

Individual therapy is an important aspect of an over-all therapeutic approach, but the two are not synonymous. From the perspective of Attachment Theory, children who experience sub-optimal parenting develop an insecure and anxious attachment. Without a secure attachment the child does not have a secure base to explore their social world, and they develop an Internal Working Model (IWM) of themselves as unwanted and ineffective in the world, with a corresponding IWM of the attachment figure as unreliable, hostile and interfering. In early development, the attachment pattern is a property of the relationship between the child and the attachment figure, but as the child develops, the attachment security becomes increasingly a property of the child. The anxiously attached child’s IWM predicts that relationships will fail and sets up a kind of “self-fulfilling prophecy” where the child’s inability to find safety in a caring relationship undermines the caregiver’s ability to provide the supportive parenting the child requires.

The first task, then, in the therapeutic approach is to provide secure base experiences that promote recovery from the anxious and insecure attachment experiences. Without a secure base (which in a secure attachment is internalized as the child’s IWM) the child cannot explore their experiences in the here and now. Within a planned therapeutic environment the consistent and attuned provision of secure base experiences develops a therapeutic alliance between the child and their caregivers, which over time promotes the child’s ability to further explore relationships. Further, establishing a secure base is a necessary pre-requisite of making the move to engaging in individual therapy.

Individual therapy is not a “silver bullet” to recovery from insecure attachment. Indeed, Bolwby specifically stated that the idea of attachment therapy is at odds with attachment theory. Recovery happens in relationships; the continual and predictable provision of secure base experiences promotes the cognitive restructuring of the IWM and the development of “earned security” that provides the bedrock for autonomy and healthy psychological functioning.

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