Sunday, 6 June 2010

The Residential Task (Part 1)

Although developmental difficulties can be recovered from in nurturing social relationships, children with attachment difficulties display a range of problematic behaviours. Some of these behaviours are the child’s still immature attempts to have their primary needs met, some are learnt in a history of broken, breaking and disrupted relationships: the child’s internal disturbances act out in the world, which finds them disturbing and disturbed, and so frequently responding to them from bewilderment or anger, and sometimes fear or hostility; responses that confirm the child self-other belief that they are worthless and unwanted and others are rejecting and hostile. However, attachment behaviour are an intrinsic aspect of human nature, and the expression of attachment behaviours later in life is neither regrettable nor regressive, as it is often labelled, but is a result of the individual attempting to find a secure base with an available attachment figure.

The developmental niche
The environment in which a child grows up greatly influences their development. There are many influences in this environment, but in their early years their caregivers’ beliefs, values and ways of caring are the most significant. As the child develops and explores, peer relationships become increasingly influential. They are also influenced by teachers, relatives’, and activities in the community and greater society. These influences can be thought of providing a developmental niche that is different for each child. However, development is not a one-way process; when exploring their world the child is both influenced by it and an influence upon it.

A child thrives the developmental niche is a good fit to the needs of the child, but if there is a poor fit between the child’s needs and their developmental niche, it is stressful for all concerned, the child is like “a square peg” forced into “a round hole”. The child will develop behaviours that provide ways of coping with these pressures, behaviours which may further d=reduce the goodness of fit. In extreme cases a child’s healthy development can be significantly impaired.

Attachment is a relationship played out across time and contexts with a particular partner. Attachment resolves two competing drives: to explore and to be safe. These drives are reconciled by through the proximity, the sensitive responsiveness and the availability of the attachment figure. When this is “good enough”, a secure relationship develops, in which both child and attachment figure find satisfaction. A primary caregiver who is predictable and sensitively responsive engenders in the child feeling of trust and security. The relationship becomes as secure base for exploration and a safe haven at times of danger, and so most infants learn to deal with stressful circumstances and negative emotions in an organized manner. However, when caregiving is not “good enough”, the child can become anxious that their need for comfort and safety will not be met. Although the child may feel insecure, they are still able to organize their thinking and feeling about the attachment figure in a manner in which these unmet needs are partially resolved.

Disorganized attachment
However, a primary caregiver who is frightening and unpredictable leaves the child with an unsolvable dilemma: “do I approach or do I avoid (for comfort and safety)”. Traumatized by severe neglect and/or abuse, such a child is left with fear without a solution; they are unable to organize their internal world in a way that can be relied upon to have attachment needs met.

By age six, these children are beginning to organize their behaviour in ways that controls this approach-avoidance dilemma. Whilst they remain unable to form an organized mental representation of the attachment figure, they may acquire a brittle layer of coping skills. In order to control the fear that is intertwined with the attachment figure the child may create a kind of role-reversal, beginning to control and dominate the attachment figure through controlling and punitive behaviours. Punitive-controlling behaviours seek to keep the attachment figure from occupying the role of the carer, as it is too frightening to let the helpless/hostile carer be in control. The child begins to be hostile, aggressive and directive towards the attachment figure. Interactions are intended to humiliate them into submission, or aggressively control the attachment figure. The child takes responsibility for their own care and protection and never seeks adult advice, guidance or protection. They generalize these controlling behaviours onto other adults.

Whilst some children are unable to develop even these brittle coping skills and remain disorganized and unresolved, others become controlling overbright-caregiving, taking on the role of parenting and controlling their parents. Overbright-caregiving behaviours develop when the attachment figure’s needs, vulnerabilities and dependencies take precedence over the child’s. The child is frightened by the adult’s helplessness and cannot find an attachment strategy to increase security. As a way of attempting to engage the attachment figure, the child begins to act like a parent towards the adult, who responds by emphasising their own dependence on the child’s precocious qualities. The child directs the parent’s interaction in a helpful, positive manner, and is excessively cheery, polite and helpful. They are orientated to protect the parent. The child’s needs are suppressed and remain beneath the child’s petrified surface, erupting as rage or panic when the child is under pressure.

Faced with these attempts at control, parents can feel hostile and helpless, overwhelmed and that their very integrity is threatened. Under such threat, caregivers need to defend themselves, and caught in the child’s hostility, can feel either that the child is impossible or that they are not up to the job of caring for them.

Two systems in the human brain that seem to be closely linked are the attachment system and the area of the brain that allows us to think about other people’s mental states. The ability to carry out this process, called mentalizing, is reduced when the attachment system is activated by a threat. In evolutionary terms this makes sense. Under threat, to think about your own danger and signal for safety through proximity kept early humans alive. If the mental state of eh other was thought about, that may seem more important than the threat. Child with highly anxious attachments are frequently hyper-vigilant, and hyper-aroused; states that are accompanied by reduced capacity to consider the mental states of others.

Although often overlooked, a powerful intervention to promote recovery is organized at the level of the caregiving system. This can be thought of as operating at two levels: the psycho-social environment and individual parenting style.

The psycho-social environment needs to sooth arousal and support and enable exploration. This requires consistency and predictability, but also requires that over restriction is guarded against: the planned environment promotes safety and exploration. Caregivers can manage the child’s arousal level by adjusting the elements of structure and challenge, as if pulling levers in response to the child’s needs.

Parenting style is a product of beliefs and values interacting with experience. Some of our core beliefs and assumptions may be hidden from our immediate gaze. Although therapeutic work has a mystique around it, we should not underestimate the work done by carers who have intimate knowledge of the child. They may be the child’s most valuable resource.
Therapeutic parenting supports therapy, but also attempts to diminish intensity of the memories, emotions, bodily sensations, thoughts by allowing the child to revise memories of past trauma in a safe environment. Progress is likely to be slow, the child can remain stuck in their familiar ways and it takes time to learn to trust being dependent yet safe. But, recovery happens in relationships with others who are attentive and sensitive to the child’s performance, and provide helpful and encouraging response to difficulties and success.

Therapeutic parenting requires adults who are appropriately mindful of their own needs, and are able to set and maintain boundaries. The child’s recovery requires that they can set and high expectations for now and future development, and that these expectations are accompanied by good explanation of expectations, boundaries, actions and choices. These two elements of therapeutic parenting are bound together by authentic, unconditional warmth. The child can explore the world around, and return knowing that they will be welcomed, physically and emotionally nourished, comforted and reassured.

Supporting and enabling
Therapeutic work requires explicit expectations and clear explanations (against a backdrop of authentic warmth). The consequences of actions need to be well understood and made explicit, and individuals n to be (or become) responsible for their own actions. Left to their own devices, the child may not be able to make progress, so it is our task to make explicit how we will support and enable progress. The child’s primitive coping places us under a huge pressure that we will at times inevitably be defended against, either rejecting the child for their behaviour or feeling overwhelmed by their pain.

Supporting caregivers
Caregivers carry the burden of the emotional labour of the work, and to promote recovery they too need supporting and enabling. Support needs to be matched to their needs. The bleak terror of the child’s inner world can leave us uncertain and defended. Like the recovering child, the caregiver needs to know there is nothing so terrible it cannot be talked about.

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