Attachment-based therapy

Attachment-based therapy applies to interventions or approaches based on attachment theory, originated by John Bowlby. These range from individual therapeutic approaches to public health programs to interventions specifically designed for foster carers. Although attachment theory has become a major scientific theory of socioemotional development with one of the broadest, deepest research lines in modern psychology, attachment theory has, until recently, been less clinically applied than theories with far less empirical support. This may be partly due to lack of attention paid to clinical application by Bowlby himself and partly due to broader meanings of the word 'attachment' used amongst practitioners. It may also be partly due to the mistaken association of attachment theory with the pseudo-scientific interventions misleadingly known as attachment therapy. The approaches set out below are examples of recent clinical applications of attachment theory by mainstream attachment theorists and clinicians and are aimed at infants or children who have developed or are at risk of developing less desirable, insecure attachment styles or an attachment disorder. Attachment-based therapy applies to interventions or approaches based on attachment theory, originated by John Bowlby. These range from individual therapeutic approaches to public health programs to interventions specifically designed for foster carers. Although attachment theory has become a major scientific theory of socioemotional development with one of the broadest, deepest research lines in modern psychology, attachment theory has, until recently, been less clinically applied than theories with far less empirical support. This may be partly due to lack of attention paid to clinical application by Bowlby himself and partly due to broader meanings of the word 'attachment' used amongst practitioners. It may also be partly due to the mistaken association of attachment theory with the pseudo-scientific interventions misleadingly known as attachment therapy. The approaches set out below are examples of recent clinical applications of attachment theory by mainstream attachment theorists and clinicians and are aimed at infants or children who have developed or are at risk of developing less desirable, insecure attachment styles or an attachment disorder. Child–Parent Psychotherapy (CPP) is an intervention designed to treat the relationship between children ages 0–5 and their caregivers after exposure to trauma or in high risk situations. This intervention was developed in part from infant-parent psychotherapy, a psychoanalytic approach to treating disturbed infant-parent relationships based on the theory that disturbances are manifestations of unresolved conflicts in the parent’s past relationships. This broader idea is represented as “ghosts in the nursery”, indicating the continued presence of earlier caregiving generations Infant–parent psychotherapy was expanded by Alicia Lieberman and colleagues into child–parent psychotherapy, a manualized intervention for impoverished and traumatized families with children under the age of 5. In addition to the focus on the parents early relationships the intervention also addresses current life stresses and cultural values. CPP incorporates attachment theory by considering how attachment bonds are formed between child and caregiver. CPP considers how traumatic experiences may influence attachment bonds and how caregiver’s sensitivity may influence the infant’s behaviors.;) CPP also incorporates developmental theories by considering the influences of risk factors and treatment on biological, psychological, social, and cultural development of both the child and caregiver. The 'patient' is the infant–caregiver relationship. The main goal of CPP treatment is to support the parent-child relationship in order to strengthen cognitive, social, behavioral, and psychological functioning. CPP is delivered in one 1-1.5-hour session per week for a year, with both the child and the caregiver/s. In treatment, the child and caregiver are introduced to the formulation triangle. The triangle helps the child and caregiver to visualize how experiences influence behaviors and feelings and how CPP treatment will target those behaviors and feelings to in turn change experiences. CPP treatment encourages joint play, physical contact, and communication between the child and caregiver. The therapist serves to guide treatment, interpret thoughts and behaviors, and emotionally support the child and caregiver. CPP is supported by five randomized trials showing efficacy in increasing attachment security, maternal empathy and goal-corrected partnerships. The trials also showed a reduction in avoidance, resistance and anger. The trials were conducted with low income groups, maltreating families, families with depressed mothers and families where children were exposed to domestic violence. Training for CPP is conducted through the Early Trauma Treatment Network, a division of the Substance Abuse and Mental Health Services Administration’s National Child Traumatic Stress Network (NCTSN). CPP training lasts 18 months. This is a parent education and psychotherapy intervention developed by Glen Cooper, Kent Hoffman, Robert Marvin, and Bert Powell designed to shift problematic or 'at risk' patterns of attachment – caregiving interactions to a more appropriate developmental pathway. It is stated that it is explicitly based on contemporary attachment and congruent developmental theories. Its core constructs are Ainsworth’s ideas of a Secure Base and a Haven of Safety (Ainsworth et al. 1978). The aim of the protocol is to present these ideas to the parents in a user-friendly, common-sense fashion that they can understand both cognitively and emotionally. This is done with a graphic representation of a circle, emphasizing the necessary balance between a child's need for exploring independence and seeking comfort from a caregiver. At the top of the circle, there is the depiction of the caregiver's support of the child's autonomy and mastery in navigating the world independently. The caregivers acts as a secure base for the child rely on and look towards as a source of guidance. The circle continues onto the bottom half where the caregivers' play the role as comforting the child when in need or protection or warmth. If parents are balanced on both sides of the circle, they resemble parent-child relationships that are secure and organized. If there is not a balance, there is a limited circle of security, placing restrictions on the parent-child relationships. These limited circles yield insecure, disorganized parent-child attachments. The protocol has so far been aimed at and tested on preschoolers up to the age of 4 years. The main goal of the intervention is to help caregivers become 'Bigger, Stronger, Wiser, and Kinder'. This phrase has served as the tagline for Circle of Security, highlighting the main tenets of the intervention. These goals can be summarized in these key aims: Its four core principles are: that the quality of the child parent attachment plays a significant role in the life trajectory of the child; that lasting change results from parents changing their caregiving patterns rather than by learning techniques to manage their child's behaviors; that parents relationship capacities are best enhanced if they themselves are operating within a secure base relationship; and that interventions designed to enhance the quality of child–parent attachments will be especially effective if they are focused on the caregiver and based on the strengths and difficulties of each caregiver/child dyad. The intervention puts a focus on the primary caregiver and the child. There is an initial assessment which utilizes the 'Strange Situation' procedure, (Ainsworth 1978), observations, a videotaped interview using the Parent Development Interview (Aber et al. 1989) and the Adult Attachment Interview (George et al. 1984) and caregiver questionnaires regarding the child. The child's attachment pattern is classified using either Ainsworth or the PAC (Preschool Attachment Classification System). The therapy is then 'individualized' according to each dyad’s attachment/caregiver pattern. The program consist of 20 weekly sessions that last 75 minutes. Sessions are in groups with no more than 6 parent-child dyads. The small group setting allows caregivers to observe and learn from their peers as well as maintain an individualized treatment plan. The actual therapy consists of video feedback vignettes and psycho-educational and therapeutic discussions. Caregivers learn, understand and then practice observational and inferential skills regarding their children's attachment behaviors and their own caregiving responses. To capitalize on this user-friendly system in the intervention, therapists developed the 'shark music' tool. During the video feedback clips, intense music (shark music) is played when there is problematic behavior exhibited by the caregiver or child. The music is meant to noticeably point out triggering behavior for the caregivers of the group to witness. Not all caregivers view certain behaviors as problematic, so this makes it clear for them to see what is okay and not okay.