Tuesday, 1 June 2010

A Secure Base, a Safe Haven - Supported caregiving to children with disorganized attachment

Substitute caregivers may be the most valuable resource for children whose lives are blighted by extremes of abuse and neglect and the failure of primary carers to provide warmth, safety and comfort. Caregivers who think and work therapeutically offer a therapeutic alliance with the child to support their recovery from the failure of their earlier experiences. These children are invariably troubled and vulnerable. They are often identified as needing therapeutic help and may even be fortunate enough access therapy. But therapy is happening in a context: the where and the how of the child’s daily living. This paper focuses on how we support caregivers in the emotional labour of therapeutic living.
Attachment theory reframes the child’s disturbing behaviour as having meaning for the child. Models of therapeutic care developed from attachment theory require that we consider the impact of the child’s disturbing social relatedness on caregiving adults. Theories of adult attachment can provide a model to support caregivers.
Exposure to warm, consistent and reliable caregiving can change children’s expectations both of close adults and of themselves, but in order to support reliable and consistent caregiving we must understand what caregivers find difficult. They are living with uncertainty and risk, and they need training, support and consultancy that develop therapeutic practice and hold onto the powerful and disturbing emotional experiences inherent in the work.
Caregivers are more secure with a clear task, and we should therefore be clear what that task is. Attachment theory is a theory of developmental pathways; early experiences are probabilistic, not deterministic. We all bring our relationship history with us, and subsequent development builds upon as well as transforms what preceded.
As children recover, caregivers will see them initiate safe-haven and secure-base behaviours in appropriate ways. The child is living in the here and now, and recovery does not mean tortuous exploration of early trauma, but the acquiring of “earned security” though gaining a coherent account of their attachment history, so that they are able to look for and accept support, develop a stronger sense of identity and belonging, and possess healthier self-esteem.
Providing secure base experiences is an integral aspect of therapeutic caregiving; the child can explore the world around, and return knowing that they will be welcomed, physically and emotionally nourished, comforted and reassured. Secure base experiences are reliably provided within a planned environment, a holistic approach to living that provides a backdrop which supports therapy. Through predictable and consistent attitudes and responses a planned environment promotes the child’s organization of mental representation of others: caregivers are a safe haven at times of stress and distress, and a secure base from which to explore the social world in the here and now. In order to survive this troubling work, caregivers need to feel secure, but they are parenting under pressure. Where is their safe haven?
Attachment is a relationship played out across time and contexts with a particular partner. During the first years of life, infants learn to deal with stressful circumstances and negative emotions in an organized manner through the shared intersubjectivities and contingent responses of their attachment figure. At the heart of attachment are two competing drives, the drive to explore and the drive to keep close to the attachment figure for safety (proximity). The attachment system operates as a feedback loop. When the attachment figure is near and sensitively responsive to the child, the child feels loved, valued and effective. They are joyful and sociable and are able to elicit the proximity of the caregiver. However, it is in separation that we seen the working of attachment. When the caregiver is not present, the child feels some separation distress, compounded by threat or danger. The child’s attachment behaviours are activated, from visual monitoring to intense protest and searching. These behaviours exist to bring about the attachment figure’s return, and if this happens to an optimal level, the child learns to feel secure within this relationship. However, when the attachment figure does not return or is unpredictable in returning, the child develops an insecure or anxious attachment, either resisting comforting or learning to avoid the need to be comforted.
From the second year onwards, infants begin to represent the world to themselves in symbolic form. Based on experience, the child represents themself, the attachment figure and the relationship as an Internal Working Model (IWM) with emotional and cognitive components. Although the IWM exists outside consciousness, it guides the child’s actions and enables the developing child to predict the behavioural responses of the attachment figure to their attachment behaviours, allowing them to plan an appropriate response. This process of anticipation and response promotes attachment organization: the development of a repeatable strategy that allows maximum proximity to and security from the attachment figure. Over time, this IWM functions as a kind of filter and predictor for other relationships.
By observing infant and attachment figure separation and reunion, three categories of organized attachment have been identified (see, for example Ainsworth & Bell, 1970). These are: Secure, Anxious-Avoidant and Anxious-Ambivalent (also known as Anxious-Resistant). Anxiously attached children show some anxiety over separation but still demonstrate an organized response. However, a group of children show an unpredictable and disorganized pattern of responses to separation and reunion, and are categorized as Disorganized.
Disorganized attachment is strongly related to early trauma. The sudden, uncontrollable breaking of affectional bonds is traumatic. The child is unable to deactivate their attachment system. The attachment figure is the source of fear, the child is caught between incompatible behaviours: flight and proximity seeking, and is unable to develop a repeatable, consistent strategy to meet their need to be safe and to be comforted. Caught in this approach-avoidance dilemma, they are left with a feeling of fright without solution (Main & Cassidy 1990). They cannot predict danger, and are dazed, confused and apprehensive, without a coherent system for dealing with separation.
Disorganized attachment is not uncommon, but is more widespread in families with low social economic status. Van Ijzendoorn et al (1999) suggest that as many as 15 – 25% of children have disorganized attachment, but this rises to 43% in families with substance abuse and 48% in maltreating families. This, along with observational data, suggests that many children within the care system have a disorganized pattern of attachment.
Although attachment patterns not immutable, disorganized attachment is highly stable over time (Weinfield et al, 2004), and is influential in a child’s maladaptive developmental pathway. The longer an outlying pathway is explored, the less likely a return to centrality, and the child becomes caught in a series of self-fulfilling prophecies of self-loathing and rejection.

By age six, some children with disorganized attachment attempt to resolve the paradox of a frightened/frightening attachment figure by developing a brittle overlay of behavioural organization. Whilst still lacking any underlying organized mental representation, these children adopt either controlling-punitive or controlling-overbright caregiving behaviours (Solomon, et al, 1995). As the child attempts to regulate their emotions by controlling the source of fear through “role reversal” with the attachment figure, caregivers can feel punished, controlled and overwhelmed, and their very integrity can feel threatened.
In thinking about how caregivers can be adequately supported for this onslaught, we make use of the model of adult attachment expounded in the Adult Attachment Interview (George, Kaplan & Main, 1984) and relate this to important psychodynamic concept: transference-counter transference. The child’s maladaptive coping strategies exert pressure on adult carers that is comparable to the parental “role reversal” identified by Lyons-Ruth (2004, 2007). A strong pressure is exerted on caregivers to adjust to these controlling behaviours by becoming hostile-helpless, hostile-self referential, or helpless-fearful.
In order to survive feelings of helplessness in the face of the child’s distress, caregivers protect themselves from feeling negative about themselves either by becoming negative about the child (“this child is impossible”) or from becoming negative about the child by becoming negative about themselves (“I’m not up to the job”). The ability to seek and accept support are secure traits, but they may diminish under the child’s increasing pressure on the adult’s own attachment security. Without a safe haven, caregivers cannot remain autonomous and secure, and are squeezed toward being dismissive, becoming critical and punitive towards the child, or toward becoming entangled, being either indulgent or neglectful.
Utilizing George, Kaplan & Main’s (1984) model of adult attachment styles is not intended as a clinical investigation into caregiver’s attachment. It is a reflective, iterative process of support and personal development through which organizations, and those placed to support caregivers, provide a safe haven as part of their support and development role. Caregivers need support from trusted others, and should be encouraged to recognize that it’s OK to need help. A safe haven support model reflects individual experiences and is attuned to the caregiver’s needs. Exploring how the caregiver experiences the child develops a coherent account of their thoughts and feelings. Caregivers who feel they are becoming dismissive need help to unravel the link between the child’s early trauma and their troubling behaviour in the here and now. Whereas caregivers who become entangled need support to move beyond the powerful feelings of distress engendered as the child rejects them.
In providing this support we use an explanation of attachment and reflective questions to help establish these connections. This process is iterative. Equipped with insight into our own attachment needs and the unmet needs of the child, the questions “What am I thinking and feeling?” and “Why am I thinking and feeling this?” can be approached again. Caregiver and supporter reflect on what the pressure on their own feelings of security tells them about the child’s inner world. This process reduces reactivity to the disorganized child’s maladaptive coping and allows caregiving to resist retaliating to the child’s controlling-punitive adjustment, and to remain consistent and predictable, promoting the child’s internal representation of the caregiver as a secure base.
Caregivers are the probably greatest resource for recovery for children with disorganized attachment. Their hard “emotional labour” requires effective support. Within a holistic therapeutic environment we have consistently found that thinking about and reflecting on the adult attachment style and needs of caregivers and those who support them utilizes this resource in endlessly creative and effective ways.

George, Kaplan & Main, (1984), cited in, Prior, V. & Glaser, D. (2006). Understanding Attachment and Attachment Disorders: theory, evidence and practice. London: Jessica Kingsley.
Lyons-Ruth, K., Melnick, S., Patrick, M. & Hobson, R.P. (2007). A controlled study of Hostile-Helpless states of mind among borderline and dysthymic women. Attachment & Human Development. 9(1), 1-16.
Lyons-Ruth, K. & Spielman, E. (2004) Disorganized infant attachment strategies and helpless-fearful profiles of parenting: integrating attachment research with clinical intervention. Infant Mental Health Journal. 25(4), 318–335.
Main, M. & Cassidy J. (1988). Categories of Response to Reunion With the Parent at Age 6: Predictable From Infant Attachment Classifications and Stable Over a 1-Month Period. Developmental Psychology 24(3), 415-426.
Solomon, J., George. C., & De Jong. A. (1995). Children classified as controlling at age six: evidence of disorganized representational strategies and aggression at home and at school. Development and Psychopathology, 7, 447 -464.
Taylor, C. (2010). A Practical Guide to Caring for Children and Adolescents with Attachment Difficulties. London and Philadelphia: Jessica Kingsley Publishers.
van Ijzendoorn, M.H., Schuengel, C. & Bakers-Kranenberg, M.J. (1999). Disorganized attachment in early childhood: Meta-analysis of precursors, concomitants, and sequelae, Development and Psychopathology 11, 225-246.
Weinfield, N. S., Whaley, G. J. L & Egeland, B. (2004). Continuity, discontinuity, and coherence in attachment from infancy to late adolescence: Sequelae of organization and disorganization. Attachment & Human Development. 6(1) 73 – 97.

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