Attachment and Metacognition : Converting Attachment Theory Into Attachment Practice

1. Attachment and Metacognition: Converting Attachment Theory Into Attachment Practice

2. Jodie was a 24 year old woman who was referred for counselling by her GP because of “depression, anxiety, possible panic attacks, and unresolved grief over her parents’ divorce”. The divorce happened at a crucial time in Jodie’s adolescence. She was 16 and in year 11 at school. Her mother moved out of the home abruptly, began night-clubbing and making up for her lost youth. Jodie’s father became depressed and withdrawn. Her two older sisters had either moved out of home or were on their way to moving out. Jodie floundered at school and became quite depressed. After a period of time, Jodie started having what she called “fits”. She described how out of the blue her body would develop a tingling sensation and numbness, and she would find herself unable to move or talk. Various medical specialists were unable to find a physical cause for these episodes and alternative health practitioners were unhelpful.  After high school, Jodie had a series of service-related jobs. At the time of the referral, Jodie had a new boyfriend who was quite seriously committed to her. She continued to have a fractious relationship with her family. Her mother kept up her exuberant lifestyle and her father moved on to a new marriage. Both seemed preoccupied by their new lives. When she had contact with them, Jodie felt pressured and used. For example, her mother kept a dubious tally of all her financial contributions to Jodie’s living and educational expenses since the break up and often used this as a means of leveraging favours or money from Jodie. Jodie still lived in the family home, waiting for her parents to make a decision about selling it and settling property.

3. INTERNAL WORKING MODEL • An “internal working model” contains our expectations for how current and future relationships will unfold, and for how we will experience ourselves and others in that relationship. • These are symbolic or representational “blue-prints” that determine how we perceive, edit, and interpret our relationship experiences. • Because these “blue-prints” shape our response to others, they also shape the actual relationship dynamics, and so become self-reinforcing.

4. EARNED SECURITY

5. Correspondence between SS and AAI Categories Strange Situation Adult Attachment Inventory • Secure • Avoidant • Ambivalent • Disorganised • Autonomous/Free • Dismissing/Avoidant • Preoccupied/Enmeshed • Unresolved for loss or trauma

6. Secure Attachment Style – Autonomous/Free Comfortable in relationship settings. Readily contribute to interdependent relationships as a springboard for engaging in the wider world. Less distressed by interpersonal conflict. Able to engage in productive, task-oriented conflict. Less preoccupied with the need to elicit positive regard from others or the need to avoid closeness with others.  Generally able to access attachment figures for connectivity, soothing and intimacy

7. MetacognitionMain 1991 Reflective Function (Fonagy and colleaugues 1997) Mentalization

8. Mentalizing The act of reflecting on one’s own mental representations of self and other (and associated feelings); AND – at the same time – being able to reflect upon the other person’s mental representations, feelings, and intentions. (benign intentions) Moreover, it involves perceiving the connection between one’s mental state and that of the other person. INTENTIONAL STANCE

9. Mindreading • Theory of Mind • Mindfulness • Mindsight

10. Facets of Mentalizing Facet Aspect • Content of mental states • Level Of representations • Object • Time Frame • Scope • Needs, desires, feelings, thoughts, hallucinations, intentions • Explicit (narrative) to implicit(intuitive) • Self Vs Other • Past,present, future • From narrow (eg. present mental state) to more broad (eg. autobiographical context)

11. Research • RF and Mentalizing Capacity has a higher correlation with mental health outcomes than AAI categories (Fonagyet,al 2006) • Mentalizing capacity of parent is more accurate than their AAI category in predicting security in their children (Slade) • Secure attachment is conducive to children’s mentalizing capacity BUT contingent mentalizing responsiveness by parents is key (Meins et al. 2001) • Inaccurate maternal mentalizing is associated with high levels of psychopathology (Sharp et,al 2007) • Greater mentalizing ability in parents is associated with lower physiological arousal and greater emotion-regulation in their children (Gottman and colleagues, 1996) • Parents who use disciplinary strategies that focus on mental states results in enhanced mentalizing capacity in their children (Sabbagh and Callanan 1998) • Mentalization capacity in children correlates with ability to tolerate negative affect (Dunn and Brown 2001)

12. Features of Good Mentalizing

13. Failures in Mentalization(Fonagy et.al 2008) Psychic Equivalence Mode World=Mind, ideas are too “real” constructs are not distinguished from external reality that they represent eg. dreams, flashbacks, paranoid delusions Pretend Mode ideas are not real enough authentic feelings do not accompany thoughts Feelings and thoughts are role-played can make wild assumptions about mental states of others, “hypermentalizing” “destructively inaccurate mentalizing” Teleological Mode Mental states are compulsively acted out Only actions and their tangible effects count eg. self harm, violence

14. What constitutes an Attachment Perspective for enhancing Metacognition in Psychotherapy?

15. Regarding symptoms as imbedded in the client’s attachment system Appreciating the primacy of emotions and their relationship with the clients attachment system. A concern with providing a secure base context in and out of therapy.

16. The Problem as part of the Client’s Attachment System

17. Describing the Self – Other Representation that is meaningfully connected to the presenting symptoms/difficulties • Ask yourself: How does the client experience themselves in relation to others? • Identify who does what to whom and the associated affect. • How is this internalised self-other representation manifest in their outer life? • How might their representations of self/others influence and be influenced by current relationships? • How does this internalized self-other representation manifest themselves in relation to you, the therapist?

18. The Primacy of Emotions Le Doux (1996) – emotions are free standing phenomena Damasio (1994) – emotions organise cognitions not visa versa Schore – emotions can be implicit and explicit, they can be consciously or unconsciously experienced - arousal and tolerance of emotional states is necessary to access pre-cognitive, implicit memories and to allow cognitive elaboration Fonagy and colleagues – emotions are intentional – they have a purpose related to one’s attachment system

19. 3 goals of working with emotions • 1) to explore constructs of self and other which are seen as best accessed in the context of emotional arousal • 2) to promote opportunities for experiencing interpersonal affect regulation • 3) to promote the client’s ability to self-regulate through re-appraisal of their affective experience.

20. Mentalized Affectivity • Elliot Jurist’s 2005 3 part process • Identifying Affects - naming - distinguishing 2) Processing Affects - modulating - refining 3) Expressing Affects - outward expression - inward expression

21. Optimal Conditions for Secure Attachment – CRADLE TO GRAVE • Prompt responsiveness to distress, Non-Intrusiveness, Interactional Synchrony, Warmth • Mid-Range Tracking of Child’s Affect (Beebe and Lachman 2002) • Contingent and Marked Mirroring • Containment – understand the cause of distress - do not join in their distress - recognise their intentional stance • Mirroring Meta-Cognitive Capacity • Intersubjectivity • Repeated cycles of attunement, misattunement, and reattunement (Schore 2008) • REPAIR –GOTTMAN and couples

22. Jodie was a 24 year old woman who was referred for counselling by her GP because of “depression, anxiety, possible panic attacks, and unresolved grief over her parents’ divorce”. The divorce happened at a crucial time in Jodie’s adolescence. She was 16 and in year 11 at school. Her mother moved out of the home abruptly, began night-clubbing and making up for her lost youth. Jodie’s father became depressed and withdrawn. Her two older sisters had either moved out of home or were on their way to moving out. Jodie floundered at school and became quite depressed. After a period of time, Jodie started having what she called “fits”. She described how out of the blue her body would develop a tingling sensation and numbness, and she would find herself unable to move or talk. Various medical specialists were unable to find a physical cause for these episodes and alternative health practitioners were unhelpful.  After high school, Jodie had a series of service-related jobs. At the time of the referral, Jodie had a new boyfriend who was quite seriously committed to her. She continued to have a fractious relationship with her family. Her mother kept up her exuberant lifestyle and her father moved on to a new marriage. Both seemed preoccupied by their new lives. When she had contact with them, Jodie felt pressured and used. For example, her mother kept a dubious tally of all her financial contributions to Jodie’s living and educational expenses since the break up and often used this as a means of leveraging favours or money from Jodie. Jodie still lived in the family home, waiting for her parents to make a decision about selling it and settling property.

23. Interventions that Enhance Mentalizing Capacity • An inquisitive, “not knowing” stance • Exploring interactions and self-experiences from multiple perspectives • Validating their experience before offering alternate perspectives • Letting client know what you are thinking and inviting them to correct it • Two hands

24. Interventions that Enhance Mentalizing Capacity • Identify a break in mentalizing • Rewind to a moment before the break • Explore the current emotional context (client-therapist dynamic?) • Make contrary moves When they are overly introspective, invite them to consider another mind When they are excessively focussed on others, invite them to focus on his or her own mind

25. Jon Allen: Some people need to feel more about their thinking. Some people need to think more about their feelings.

26. INTERLOCKING VULNERABILITIES Surface Behaviour & Non-Verbals Surface Behaviour & Non-Verbals Underlying Feelings & Vulnerabilities Underlying Feelings & Vulnerabilities

27. Rodney (Jodie’s boyfiend) is from India of Punjabi origin. One Friday afternoon he came home from a long day’s work hoping to see Jodie and spend the evening with her. He home to find Jodie dressed up to go to the Pub and meet a girlfriend. • Rodney started criticising her tight jeans and make-up. • Jodie tried to reassure him that she was just have a drink or two with her friend and then would be home after that. • Rodney began sulking and cut-off from her. • Jodie took herself off to the bathroom and locked herself in. She became numb in her body and unable to speak. Rodney came to speak to her, asking her to let him in. Jodie found herself unable to move or to speak to him. • Rodney alternated between calling Jodie childish and pleading with her not to be upset with him.

28. Some Old Time Family Therapy Favourites • Circular Questions • Triadic Questions   • Other-Oriented Questions   • More or Less Questions • Imagined-Other Questions   • Reflexive Questions   • Difference Questions

29. TISSUE BOX

30. Jodie –Mentalized Affectivity 1 • During one session, Jodie related her annoyance at her family members not accepting her new boyfriend because of his Indian ethnicity. As she spoke about her sister’s racism, Jodie went quiet and looked down at the floor. She moved her hands in short, agitated movements. • Therapist: What are you experiencing right now, Jodie? • Jodie: (After a long pause). I don’t know. I guess I feel really frustrated. How could they talk about Rodney like that? • Therapist: What feeling do you think you are having as we talk about this? (mentalizing affect) • Jodie: I’m not sure. Pissed off maybe? • Therapist: Would it be fair to say that you are feeling anger? (Jurist’s, 2005, identifying) • Jodie: Yeah. Yes that’s right. I’m really pissed off!! • Therapist: (Wanting to help Jodie to explore and articulate this feeling further.) Where in your body do you think this feeling is strongest? (Jurist’s, 2005, modulating and expressing emotion)

31. Jodie –Mentalized Affectivity 2 • The therapist leads Jodie to scan her body and then to focus on the muscles around her throat (Wallin’s, 2007, working with “implicitly” with feelings). • Therapist: So your anger seems to be heaviest around your throat? Is that where your muscles are most tense? • Jodie: Yes. (Her voice is raspy and parched) • Therapist: I notice your voice is very strained at the moment. I’m wondering if those muscles around your throat are trying to hold back your voice? I wonder what your voice would say if those muscles just let it out without holding back? (Jurist’s, 2005, modulating and expressing the affect) • Jodie: It wouldn’t be very nice? I don’t think people would like it. • Therapist: Maybe you might say something others don’t want to hear? (mentalizing self and other constructions in the midst of aroused emotions) • Jodie: No…they definitely wouldn’t want to hear it. • Therapist: What’s it like to have to hold back what you are thinking and feeling because others won’t like it – or – even worse, not like you? • Jodie: It feels impossible. It feels like I’ve got all this anger that I can’t have.

32. Jodie Epilogue One • Fits and Expectations • The Developmental Thread • Crystallization at 16

33. Jodie Epilogue Two • The Tradeoff • Saying “No” • The beginning of RAGE • Holding both mental states in mind (boyfriend)