Psychiatry & Psychotherapy Podcast - Therapeutic Alliance Part 6: Attachment Types and Application

Episode Date: December 12, 2019

Therapy is an intensely focused relationship that involves acceptance, trust, unconditional positive regard, hope, attunement, tolerance, and mending empathic strains and ruptures. There is also emotional contagion between a therapist and patient, with transference and countertransference. On this week's episode, I talk about how attachment theory can be a powerful predictor in helping someone move forward past trauma and develop attachment to their therapist in a healthy and therapeutic way. By listening to this episode, you can earn 1 Psychiatry CME Credits. Link to blog. Link to YouTube video.

Hello and welcome to the Psychiatry and Psychotherapy Podcast. I'm here to talk about getting rid of burnout, increasing job satisfaction, and feeling like an expert in what you do. One thing that created a lot of burnout and angst for me was trying to get continued medical education right at the last minute. So why not join the CME membership and do CMEE while listening to this podcast? Go to Psychiatrypodcast.com. Sign up, sign in, take the test, and the certification is email to you in seconds.

All right, welcome back to the podcast. Today I'm going to be going through attachment. therapy and how to utilize it in the work that we do in psychotherapy and psychiatry and building a therapeutic alliance. And so here we go. The basics of attachment. I'm going to talk about that first. Attachment in infants is primarily a process of proximity seeking to an identified attachment figure in situations of perceived distress or alarm for the primary purpose of connection. And so you have this child, you know, especially the first couple years of life, and they're seeking proximity to attachment figures,

especially when there's some sort of distress or alarm or something scary, for the purpose of connection. And so one of the main drivers of infants in the midst of their development is actually to seek out connection. And so attachment patterns that form early on lead to expectations or anticipations of how future relationships will unfold. And one of the great videos that I look at with Resonance for this is the Stillface Experiment. And if you have not seen the Stillface Experiment yet, maybe pause or watch it, watch it later today.

And think about how it reflects upon attachment. I actually put a video on my YouTube of the Stillface Experiment and on my Instagram and where I'm going through my analysis of it. And basically, the mother is playing with his infant and then is told to have a still face. And the infant who's about a year and a half years of age is trying to interact with the mother. At first, in a playful way, you know, pointing and giggling and doing all the things that normally would engage play in sort of a connected mode, right, laughing and giggling. And then the infant gets distressed as the mother. still face continues. The mother doesn't make any, you know, expressions. And the infant gets into more of an anger, you know, or a fight and flight place where the, you know, the child screeches and

bites himself even. And, and then the child goes into more of a shutdown, you know, which polyvagal theory, we would say it's more of the dorsal vagal, unmyelated space of, you know, looking away, dissociating, disconnecting. you know, although there aren't specific ways to look at the dorsal Vegas and, you know, and measure it physiologically, this is sometimes a helpful theory to sort of understand, you know, dissociation, right? So there's multiple things going on

in a dissociative experience. And it can happen from this profound disconnection and it can be very jarring and it can make you feel numb or disconnected or nauseous or some people feel faint So as this attachment distress progresses, it goes from, you know, this playful place, this place of connection, to this place of fight and flight, to this place of this shutdown. And then when the mother reengages and looks at the child, the child smiles and starts mirroring the mother once again. And this is connection mode, right? And, you know, it's what I'm just going to go on a little rant right now.

My rant is there's a lot of bad parenting advice that talks about attachment. This is attachment parenting. Okay. And so they talk about attachment parenting as if, you know, attachment parenting is, you know, carrying the baby or co-sleeping, you know, doing these things that may be important but they don't really align with what Bolby and Ainsworth and the attachment research really says what is attachment type of work? Attachment type of work is mirroring of emotions, empathy. Attachment work is playing, playfulness, you know, connecting.

And the still face experiment is a perfect image of that, right, where you have this mother who's able to engage her child in play. and then the child goes through phases of disconnection, right? And so attachment is often, you know, more about security. And can you help me in the midst of my distress? One of the adult attachment interview questions, actually, is where do you go? What do you do or what did you do when you were a child and you were distressed?

did you go to your room under your bed and suck your thumb and smell your lovey? Did you go to your mother? Did you go to your father? And then how did your father or mother help you in the midst of that? So if you're a parent, the correct answer is if your child is distressed and they come to you, you pick them up, you comfort them, you put words to their distress. and you pause and just sit with them sometimes. And then the distress fades and they go out and they play again.

So attachment is a regulator of emotional experience. And so when a child has that attachment with you, it regulates their emotions. So they don't go into that fight and flight in that shutdown, they can stay in a playful place. Your primary attachment figures early on in your life become an internal working model of how you understand relationships and connection. Okay, so this is like the past experiences integrate into you.

In object relations theory, they say that they become like an object or a part of you, and there's emotions that flow to that object and away from that object, and it's like it gets internalized. You know, if your primary attachment figure was always critical, then you will feel a part of yourself that is very critical towards everything you do. Further, when you meet new people like a therapist, you may not feel criticalness from them in the session, although sometimes that happens as well.

But then when you leave, you may fear that they are critical of you. Okay. So now what's happening is that past internal working model of that relationship and how attached that detachment was is getting put on other people. And that's transference. And if you're a therapist, that's called countertransference.

So let's get more into attachment. There's these, there's infants, then they seek proximity, they seek sensitivity, they seek protection, consistency. Adults may respond, right, by touching them in a positive way, you know, giving them that comfort, soothing, holding, reciprocating, softening their voice maybe if someone's upset. And ideally this creates a co-participation and an equilibrium. and there's this synchronicity that goes on where there's a modulating of respirations.

The infant will mirror the adults. There's muscle tone will soften as the infant becomes comforted. Heart rate will slow down and there'll be more, you know, respiratory sinus arrhythmia, which is where the heart rate kind of moves up and down in a nice sinusoidal pattern. Blood pressure will be.

be calmed, temperature will be more regulated. There will be a mixture of gazing at the comforting attachment figure, but then averting it sometimes. And that's good as well, right? So it's not like it needs to be always like gazing. Okay. Therapy is an attachment relationship, whether it's a bad attachment or a good attachment. There is an attachment relationship going on. It's like you're giving someone one intense attention. And that intense attention really does facilitate you becoming an attachment figure in their life. Ideally, you have a sense of acceptance. There's trust, there's unconditional positive regard towards them and their struggles. And you also have hope for them. you are attuning to their emotional states,

to their situations that they're going through and seeking to understand in part what they're going through. I say in part because we'll never truly fully understand, but we can more closely approximate someone's situation. We try to work through empathic strains and ruptures. And, you know, it's not unusual for patients to have strong feelings, negative feelings, towards their therapist. And so, ideally, we notice that and we draw it out and we have them put words to it.

And then we empathize with the distress of having those negative feelings towards us. And that becomes attachment healing. Okay. So there's this sort of mutual regulation of feelings in this diet. It's not just one way, right? An infant from a young age will learn how to participate in this attachment relationship. This is a two-way attunement. And one of the things that leads to attachment distress is when the infant becomes the one that's caretaking for the adult.

and I think it can happen from the very beginning. You know, from the very beginning, the infant can be the one that is regulating the adult. And that can be unhealthy, you know. It's good for the adult to be the adult. There can be emotional contagion, you know, you can feel very acutely what your patients are feeling. And that can be distressing it. times. And I would say you also need attachments outside of your patients where you are getting some of those distressing thoughts or feelings regulated. So, you know, seeking supervision is so,

so important in therapy. So there's this collaborative alliance, this working relationship, this therapeutic alliance that we've talked about quite a bit. And attachment and the primacy of attachment in that, it's just so central. Attachment may intensify moments of emotional engagement. Like if you're just meeting someone that's a stranger, sometimes you can share with them things in a way that you couldn't share with someone who you have an attachment with. like you'll see people sharing things about their life with strangers sometimes in an airplane that they won't tell their own kids, you know, because it's like there isn't all of those

attachment strains that have occurred over time. You know, ideally in a relationship, we don't have years and years of attachment strains and experiences of shame that you felt from, you know, someone. But in a relationship where the relationship where the relationship, there is that stuff and there is that sort of baggage. It can be really hard to have real conversations. And that's what happens a lot of time in marriages. It's like there's a lot of those strains.

It's like they're not just arguing about food or like they're not just arguing about, you know, what color of the carpet should be. There's all these attachment sort of things underneath. So the attachment relationship with the patient, helps regulate emotions and anxiety. And it's interesting that what I found is that when you're able to establish that good attachment, in the session, their emotional world should be regulated. They should calm down.

They should eventually maybe feel some gratitude or some positive emotions. Just within, you know, 20 to 40 minutes of really listening, you'll see a shift. we watch a lot of videos in the residency I'm at low maledite residency and I watch videos once a week with the residents as a group of their therapy sessions and you can see a shift at some point in the session where the patient calms down and often patients will come in with heightened anxiety and emotions and then they'll calm down in the process so the attachment relationship in therapy is often implicit, meaning that it's sometimes unconsciously there. It's not like, it's not like there's not like there's always words that have been put to it. Okay. It's intersubjective,

inner subjective as in like you have a subjectivity, they have a subjectivity. So it's the place, it's that third place, right? Not the third place, like Starbucks. Starbucks wants to be the third place between, you know, home and work. They want to be that place where you work out. That's not what I'm talking about. It's, you have your subjectivity. The patient has their subjectivity. And, you know, by subjectivity, I mean emotions, thoughts, dreams, passions, beliefs. And then between you guys, there's this sort of third. It's the creation of that interpersonal space between you and that other person. That is the attachment. Or that speaks to the quality of the attachment. Attachment is largely right brain to right brain.

Okay. So think about the left brain, Broca's area, Warnikis area. This is, you know, Broca's is where we're speaking. Warnikis is we're receiving words. Okay. Before you're able to make words, you're forming attachments with your parents. And so attachment largely is nonverbal. Okay. And so that's why I say it's right brain to right brain. It's before words, what is there? There's emotions. And there's a regulation, a co-regulation of those emotions back and forth. And now this is extending to the therapist's patient relationship. And so some of the emotions that will be felt that the patient is feeling about you are things that they are not even putting words to, but they may be distressing, like shame. if a patient was always shamed by their parents, they may feel as if you are shaming them, even if with your best intentions you're not,

or you didn't say anything that was explicitly shaming. They may feel that shame, and they may not know why. They may not be able to, it's like they're feeling it, and then they're putting words to it secondarily. And your words can actually be soothing to the distress. of how distressing that might be for the patient to feel that acute sense of shame,

you know, that I am bad, that I am doing something wrong. Okay. So attachment communication are critical to the development of this structural right brain neurobiological system involved in processing emotion, modulating, stress, self-regulation, and thereby functional origin of the bodily based implicit self. What does that mean? That means that as attachment is formed over the first couple years of life, there is an internal, it gets internalized.

And therefore, this is why attachment is the solution to a lot of patients to stress. if a patient is having difficulty modulating their stress, processing their emotion, self-regulating, this can come out in all sorts of ways, self-harm, cutting, it can come out in binging, purging, it can come out in self-destructive behavior, you know, and it can come out in drug use, alcohol use. Often, the attachment is formed or not formed. And in this session, we're going to go through the different types of attachment. and what we know about those. So a little bit on the historical piece,

there was Conrad Lorenz who talked about imprinting, imprinting of attachment in geese, how you could get a geese to follow whatever was there when the geese came out so they could follow a human around if the human was the one given the attachment needs. There was Fairbairn who talked about object seeking, how we are object-seeking creatures, object being coming from object-relations theory, and it meaning that we are looking for people, things, to attach to, not objects,

not physical objects. And then there was Harry Stack Sullivan talked about the importance of this empathic linkage, and John Bolby, who talked about the internalization of a secure base and the exploration and security and self-enhancement. And the importance of in attachment, exploration is actually one of those things, curiosity and exploration. And then you had Ainsworth, who developed the strange situation procedure, you know. You leave a child in a room with some toys, the mother steps out, and then the mother comes back in. And how does that child interact with the mother when the mother comes back in?

you had Maine who talked about disorganized attachment so Ainsworth talked about kind of like there was the three and then Maine came around and talked about disorganized attachment quite a bit and then James Robertson talked about the protest despair detachment responses to separation and Dan Siegel has talked a lot about attachment you know two minds in resonant energy and information flowing between self and the other. So I'm not going to go too much into the history. I'll bring it out a little bit as we continue through this. But let's talk about the mother and the infant

in a self-regulating and mutually interacting system. In the attachment system, there's oxytocin that is being generated. And this is generated in pregnancy and nursing and helps the mother bond to the child, helps the child attached to the mother. It promotes trust, relaxation, desire for closeness. The child is seeking closeness, you know, through visually seeing the attachment figure through bodily touch, especially when they're experiencing anxiety, such as separation from the mother, encounters with threatening or unfamiliar situations, encounters with strange people,

experiences of physical pain and feeling overwhelmed by fantasies or nightmares. When you look at the mother infant sort of attachment, there's this sensitivity and attachment quality that you can assess. You know, does the attachment figure attuned to the child signals and interpret them correctly and attend to them promptly and appropriately? you know there's there's both an emphasis in our culture on empathy but then there's also i think a large failure of empathy we like to talk about it a lot i'm not sure we do it as well as we talk about it um i'll get more into that maybe later so in these internal working models as the attachment

gets internalized into the brain. The interactions with the attachment figure in the child over time develop these sort of constant models for how attachment will take place. Over time, it becomes a preferred attachment strategy of relating. How do you greet each other? How do you connect with each other? How do you engage each other in play?

How does your, how does you, if you have kids, How do your son or daughter, you know, how do they elicit connection from you? You know, mine sometimes will cling on to my legs, you know, when I'm walking through the door, they will give hugs, you know, they'll want to wrestle, they'll tell me they want to wrestle, they'll tell me why they want to go jump on the trampoline, that way they want to go in the chakouzy. So there's these internal working models for how connection is going to take place. I think it's really important to emphasize the exploratory system. So this originates in opposing motivations with the attachment system,

but exist in a state of interdependence. So the exploratory system is actually part of the attachment system. So when I'm assessing a child's attachment with their parent, how well are they able to leave their parent and go explore? So secure attachment is preconditioned. for the infant's ability to explore his environment and experience himself as an agent and a self-effective individual. From seven to eight months, the infant's crawling, and the mother must allow this exploration while setting limits on it as well, but also be available as a secure base for

emotional refueling. And so you'll see the child explore and then come back to the mother and then explore and come back to the mother. And this is part of attachment. So attachment is not always cleaning and not always just reflecting each other or playing right with the child. There's also part of attachment which is allowing the child the freedom to explore.

And think about this as well, this sort of exploration. How does this relate to therapy? You know, well, you know, as a patient feels more secure in their attachment with the therapist. Maybe they're able to explore some of their giftedness. Maybe some of their passions in life. They're able to kind of like just venture out and try out new things.

You know, maybe they feel secure enough to take a risk. I often have patients who, after a while, they want to leave from being like a manager to being like a business owner. And they take risks. and then venture out and, you know, take steps towards creating some of those goals, those lifetime goals, right? Okay. So the goal-directed partnership is there, right?

It occurs when the child is able to pay attention to maternal goals and not just his own. So, you know, our kids learning that our goals are important of cleaning up the house, right? So, okay, let's make this fun as well. Let's count the toys as they go into the toy bin. So we'll sometimes do that. And we'll have a little competition who can put the most toys in the toy bin. But in this goal-directed partnership, each partner is communicating their goals that are emotionally important to them and attend to the other partner's interests as well. And so this is important.

Like when you're planning your day, sometimes I'll plan my day with my kids. My kids are right now three and five. And so we'll write a list of things that they want to do. Okay. And then I'll write a list in there of the things that I want to do. I want to clean the house. You know, at the end of the day, I want them to be a part of that. I don't want to just be stuck with it all by myself.

And so writing out our goals. Okay. When you think about attachment, think also about epigenetics. So epigenetics is, how the genes, you know, wrap up and unwrap to express what's in the genes. And through epigenetic phenomenon, our genes can close in certain areas and open up in certain areas. So an example of epigenetics is the cortisol level of the infant brain is significantly influenced by the mother-child interaction. So cortisol and the sensitivity of the cortisol receptors will change if the,

they've been through a series of traumatic events that have not been attuned to or not been sort of processed through trauma affects brain structures so for example victims of childhood abuse and neglect exhibit in adulthood you know differences in their brains they have a different size of their hippocampus corpus callosum and amygdala in comparison at non-abuse controls and the more the child finds herself or himself in a state of hyper arousal and dissociation, the more traumatic experiences will result in neuropsychiatric symptoms along the lines of PTSD. So the orbital frontal cortex, which controls integrations of different things, modulation of affect, matures as we grow older, actually up until,

the age of 30. There's still pruning and there's still development of the frontal lobe. So if you're in your 20s and you're listening to this and you're very impulsive still, keep working on your impulsivity and your brain will continue to grow and develop. The trauma and infancy as well may influence this maturation of the orbital frontal cortex, right? The integration of affect, the modulation. There's this right brain nonverbal hemisphere that we talked about before that develops through attachment and affect regulation.

And it may be affected by early childhood trauma. And we know that people with things like borderline per size order or chronic trauma and childhood have differences in their amygdala and in their ability to regulate affect. So there's also this sensitivity. there's this capacity for empathy which influences attachment right so the capacity to identify the intentions

motivations thoughts and feelings of another person you know through mere neurons we can feel other people's stuff we can pick up a little bit of what's going on in their brain and so this capacity allows for responding

consoling caregiving and it can lead to a secure attachment. If you don't know the intentions, motivations, thoughts, or feelings of another person, it's going to be really hard to attach to them. And so this is where I get excited about, you know, learning how to read body language or learning how to read micro expressions, learning how to see other people, right? I think it's very important to be able to leave your own frame of reference, your own experience.

into another person's experience. It leads to a more secure attachment, more ability to play and explore, and less anxiety and irritation in your interactions. So infants with less sensitive mothers show more anxiety, irritation, and aggression. And if you videotape interactions and then debrief with the parents later,

this led to increased sensitivity compared to controls, who idealized their own behavior, behaviors and overestimated their sensitivity to their child's signals. So it's very, it's very normal to overestimate your own sensitivity to your child. So like watch, observe, put the phone down, put the computer away, be present. It's, it's really hard to pay attention to someone else's intentions, motivation, thoughts, feelings, if you're constantly being interrupted.

And I say that, by the way, for myself as well. I am not perfect in this by any means. Although I do spend quite a bit of quality time with my children, jumping on the trampoline, in the jacuzzi, having fun. But there are times where I'm distracted. And so I'm not just pointing the finger at other people and saying that I don't struggle maybe myself. Okay.

So an infant with a fearful mother during pregnancy have more frequent problems with self-regulation than other infants and more behavioral problems in preschool. So if you remember the episode I did with Kelly Ravinius on that sort of early parenting, postpartum depression, anxiety, OCD, those types of things, they're so important to treat because they influence the attachment. you know and i'll sometimes see a very anxious mother with a child and the child would be clinging to the mother and not exploring um exploring is met with fear and anxiety you know and so um it's so important to do your own work as well if you are high anxiety okay there's another word called reflective function which is a strong predictor of a child's attachment style, four times more likely to be secure if you have a very good reflective function.

So the process is very intersubjective. The child gets to know the caregiver's mind as the caregiver endeavors to understand and contain the mental state of the child. The child internalizes the caregiver's representation of the child, as an intentional being, mentalizing, desiring, believing. So this can be put in Winnicott's words of giving back to the baby, the baby's own self. And this does not happen if the child will not conceive of thinking in terms of the physical reality rather than the mental states.

This is some of Fornegut's work. Okay. this another way, reflective function. So are you able to give back to the child what is going on in their own experience? So one way that I do this in a very simple way is I use simple words to describe emotions. And I did it from a very early age. So because I can use microexpression to read anger or fear or pain, you know, and it's sometimes very obvious, right? if your child comes to you and they're crying, you're in pain. You're in pain. You're experiencing

pain. You're linking together a verbal representation with their emotional and physical experience of pain. Or you're angry. You're frustrated. You're frustrated. You're angry. It's helpful to internalize a word with what they're feeling. Right. So you're giving back to them their own self. or pleasure, you know, wow, you really enjoy putting glitter on things. We should get more glitter. You really enjoy it. Creating was really enjoyable this morning. We did glitter Christmas trees.

And I'll post it on my Instagram if you want to take a look. But it was actually very artistic. My daughter did it. It was very beautiful. We put glue on a page and she put glitter on it. And it was a lot of fun. and she told me that she wants to glitter her whole room. And I said, okay, let's do it.

Let's get some glitter. Let's get some glue. And we'll paint it on your walls. And she was like, maybe just pictures for now, Daddy. I don't know if I'm ready for that. So there's the exploration. There's progressive exploration. That's a good example of progressive exploration.

So it's like, okay, there's this big thing that she's a big goal. Okay, let's take small steps towards that. Let's do a lot more small work. and then we can build up and do a big work like a mural. So there's an association between a child's attachment quality and the parents' behavior and representations. So mothers who during the pre-verbal years, you know, zero to one,

translate their child's nonverbal signals into words and affective states, will lead to more of a secure attachment. so that the child will feel acknowledged and heard and understood and the emotions will not be just floating around but will be consolidated into words but also soothed right the infant will feel felt infants feel their affective states are understood in the context of an empathic verbalization as they take a note of the tone, melody, rhythm, pitch. So even when it's in that pre-verbal state, it's so important to put words to it

because it's like it's not just the words, it's the tone, the melody, the rhythm, the prosody. Okay. So in the adult attachment interview, which Mary Mayne and Goldwyn put together, there's four types. So the first one is secure or free autonomous. But I'm going to go with secure.

And when the adult is describing their early childhood, they will describe their parenting situations as loving, caring, and comforting. So when they were being parented, they will describe that this took place. They're able to talk in a detailed and thoughtful way about what happened. there's a high level of self-reflectiveness. There's also a group of people who have what's called an earned secure attachment style in which they can report negative experiences coherently due to later experiences with important attachment figures like through psychotherapy.

So people can get secondarily into a secure place through that and it's called an earned secure. The second type is dismissing in which they'll have few memories of their childhood. So you'll have this adult that will be describing their childhood. They'll have few memories. They just won't have very many memories. They ascribe little importance to attachments in their lives. They develop more of an avoidant attachment style as children,

which leads to this sort of avoidant adult attachment style or dismissing attachment style. my experience is that these people want to connect with other people. There's a large amount of fear and they try to avoid attachments. Or because of the fear, attachments are not usually soothing like a secure attachment. So these people may be a little bit more harder to connect with for the average person, right? they may be a little bit more standoffish. When things get stressful and they're in relationship with you, they may move away. And that may be a way of them coping.

So chasing them too much might actually be even more distressing. So early on, they self-regulated by being alone internally. So some of these people have a rich, fantasy life early on in their childhood and even into their adulthood and this and or if not an internal fantasy world maybe an external the things that they um sort of ruminate or spend a lot of time thinking about are more like ideas and um things that are a little bit distant from people the second type of the insecure attachment styles is the preoccupied or um the anxious. So this would be an anxious attachment style child that develops into this type of person

as an adult. And when you ask them about their childhood, they may have a plethora of details, entanglements, contradictory statements. The degree that the interviewee does not recognize the contradictions in their own statements is remarkable. So they may be telling you things that contradict each other. And yet, they don't make sense to the person. Okay. And then they develop this sort of anxious attachment style that then gets played out into their adult relationships.

So maybe they connect very, very quickly with someone, but then they have a mixture of emotions that come with that. So it's like they have, they, they have a hard time being away from someone maybe or they have they have a large amount of anxiety when they're distant from someone they don't feel loved they don't feel cared for so it's not like they're in a secure place with their attachment and the the fourth type is the unresolved so this is from the disorganized attachment style of children as an adult they'll describe the unresolved attachment style with many statements characteristics

characterized by disorganization or disorientation. For example, borderline personality disorder patients may have speech, thought, process, and descriptions of emotional, affective experiences that tend to break down and have like, sort of more of a dissociated, disorganized place. So it's like instead of being angry, they'll feel numb or disconnected. And they're more likely to have experienced trauma, extreme loss, maltreatment, and abuse. And the disorganized attachment specifically is it's a tough, it's a tough one to both have as a person,

but also to be in relationship with because there's no organized way of reconfirmed, connecting. So the therapist may feel the great turmoil that comes with the attachment. So these people may not have experienced a good attachment figure all the way to the time that they come and they're with you as their patient. Or they may have experienced some very sort of thwarted attachment figures in boyfriends, maybe they got some good stuff, but some bad stuff or in different leaders that they were under. I think they're seeking a strong attachment. And when they find it, they will be very faithful in wanting to continue to come back because it's part of what they're needing. They're needing this.

So there is a 70% correspondence between parental attachment style and child attachment classification and 75% if just secure and insecure attachment categories. So often the child will pick up the parent's attachment style. Okay. So I'm going to go back through the four attachment types in more detail now. and in this one study there was an 80% congruence between 12 months and 6 years of life in attachment style. So at 12 months they were able to predict

what they were experiencing at 6 years of life. And then in late into adolescence, longitudinal studies show a strong leak between maternal attachment style and what develops eventually in the child. So let's say you have a 6-year-old in your life, like, oh my gosh, this is probably an insecurely attached child. Like, what do I do?

The first thing you could, the most beneficial thing you could do is get your own therapy and develop your own security in your attachment style. Now, interestingly, if you look at what types of therapies lead to a stronger attachment, there are studies that look at transfer and focus therapy and mentalization based therapy. and they show an increased in the reflective function. But not in DBT, dialectical behavioral therapy. It doesn't, you know, it has improvement in mood, but it doesn't change the fundamental attachment system.

I will send you those studies. I'll put them in the resource library. And what this means is that the attachment that you form as a therapist with the client, both transfer service therapy and mentalization-based therapy is really focused on this attachment that you have with the client. We're looking at the interpersonal. We're looking at their emotions towards you that get elicited. That's the type of therapy that is going to be helpful for them,

the type of therapy that we're going to be describing in this series, the Therapeutical Alliance series. So secure attachments. The parents are sensitive and loving. They soothe the child when he cries, keep them warm, protected fed. The psychoanalyst mentor that I have Dr. Tar says, you cannot overly spoil a child in the first two years of life. If they're distressed, soothe them. If they're hungry, feed them. And the mothers that lead to a secure attachment have a sensitivity.

They're attuned to the infant's signals with attentiveness. They're not internally or externally preoccupied with their own needs and well-being. They appropriately interpret and decipher the meanings the child has, you know, the meanings of, you know, am I hungry? Do I have illness? Do I have pain? Do I have boredom? Do I have overstimulation? Do I have a dirty diaper?

They're not interpreting needs as a result. of their own needs or by projection of these needs onto the child. So it's quite easy to project our own experience on other people. It's a lot harder to have the sensitivity to feel and do another person's experience. They respond appropriately with the correct amount of nourishment, soothing to the child. There's not over-stimilization or under-stimilization. So for example, in this BB study at four months, they were able to predict secure or disorganized attachment.

At four months, they videotaped mothers interacting with children. And there would be these scenes in which the mothers, the child obviously wanted distance. The child was looking away, trying to get away from the mother. And the mother looms in further and further. It's this picture of not reading the infant's cues that leads to this disorganized attachment style.

there's also prompt responses from the parents that does not cause intolerable frustration of the child and so the child develops confidence that others will be helpful when appealed to becomes increasingly self-reliant becomes bold and exploration becomes cooperative with others is sympathetic and helpful to others distress and can tolerate and integrate negative experiences and emotions. In the strange situation, what happens? So you leave the child in the room, the mother steps out, then the mother steps back in the room. In a normal, secure attachment child, how does the child respond? The child follows the mother to the door, calls for her name, many finally cry and show distress,

Then they react with happiness when the mother returns. Reach out for her arms. Want to be consoled. Sometimes there's a little bit of crying. They seek physical contact. Then they become calm and they return to play. That return to play is actually, you know, it may be a minute or two minutes.

It's, you know, there's distress, but then the return to play is actually pretty quick. If you have a secure attachment, it may protect against psychopathology later, in life, also pain. It also may protect against traumatic experiences. So when we looked at this one study of Beebe, Patriot's BB at four months, the diet looked like this.

Okay, this was the secure attachment diet at four months. The mother anticipated the child's emotions, mirrored the child. the child anticipated the mother a little bit too and they were following each other's feelings up and down and they resonated with each other the mother noticed the cues of the child did the child need space did the child need more comfort the mother knew

how to read the child the mother smiled when the infant smiled looked concerned when the infant smiled looked concerned when the infant looked sad. And that was able to predict secure attachment at one year of life in this strange situation. So about 50 to 60% of kids in various longitudinal studies

have a secure attachment style. So that's secure attachment. Now an anxious attachment, anxious, ambivalent, which later becomes, the preoccupied, I don't know, I like to consider it all anxious attachment. It just makes it simpler to me. The parent, what do we know about the parents of the anxious attachment-style child? They respond to the child's attachment behavior tardily and unwillingly

and regarded it as a nuisance. Sometimes they're overly suffocating or they have their own anxiety. the child is apprehensive that his caregiver will be missing or unhelpful when he needs her so is reluctant to leave her side so this child will sometimes hover the child may be unwillingly and anxiously obedient, unconcerned about the troubles of others because they're sort of internally preoccupied, maintain contact with the attachment figure, have a heightening expression of fear, or anger. And in the same way that the adult continues his or her internal conflict with early

caregivers. So this pattern is repeated. In the strange situation, so you leave the child in the room, the mother leaves, the child demonstrated the greatest degree of distress upon separation, crying intensely. And when the mother returns, it takes a much longer time to console. and then the mother picks up the child and the child wants physical contact and closeness but it's also sometimes aggressive kicking hitting pushing turning away so you can imagine how that's distressing for the mother as well and about 10 to 20 percent in longitudinal studies

of kids have this the third type is the avoidant attachment so let's go over the avoidant So in the avoidant attachment, the parent actively rejects the child. So the parent is rejecting the cues for closeness, rejecting the cues for desire for comfort. And so the child avoidance competes with a desire to be near. They sometimes have an angry behavior. At age six, they do not talk about their emotions involving attachment or they are overwhelmed. So they have a hard time coming up with solutions to the separating solutions shown in images. At age 10, they mentioned negative feelings less often.

And we're very reserved during the interview when emotionally laid in subjects touching on their own feelings were brought up. And they also reduced their own frustrating experiences by cutting off their anger and distress. They kind of like stuff their emotions down. Okay. They negate their emotions, they reject them, but they're still there. In the strange situation, when the mother leaves them, they display little protest and display no clear attachment behavior. They continue to play, but with less curiosity or persistence.

And when their mother returns, they do not ask to be taken up in the mother's arm. So they also show that although when they come back in the room, they may not look distressed, they have higher levels of cortisol than is securely attached or anxiously attached child. So they're distressed, but they're isolating. They continue to play when the mother comes back in the room, but they're distressed. This can be up around 30 to 40 percent in various longitudinal studies. And finally, the fourth attachment style, which is the disorganized attachment. So this is about 15% of healthy children born term to parents under low levels of social stress.

So psychological risk factors include poverty, violence, poor living conditions. They also increase the mother's risk of having hostile and helpless behavior. towards the child. Okay. So not only is it difficult, it's like, not only is it being influenced by the dyad, but it also influences the mother

and makes parenting more distressful. So what are some of the commonalities of the parents of children who have disorganized attachment? The parents have experienced traumas such as loss, separation, maltreatment, and abuse and carry these experiences into the, their relationship with their child.

Working through the trauma can help these parents. And so doing their own work can be so important. Mothers who have children with disorganized attachment will be both a safe emotional haven and a source of fear and threat because the mother will behave aggressively or frightening, frighten the child. and often attachment situations overwhelm the mother, and the mother will like dissociate in those moments. So there's this pervasive pattern in the parents

of extremely inadequate, insufficient, and contradictory responses when the infant needs closeness, protection. And the longer the duration of the deprivation for this child, for example, under institutional conditions, may lead to increased symptoms of ADHD and attachment disorders. So now let's look at the child with the disorganized attachment and what might be some of the risk factors. We know that prematurity, peritivintricular lucal malaysia,

like brain bleeds can increase the risk, postnatal hypoglycemia, early abuse, deprivation. Some of this is biologically, some of the, some of the biological things can make it harder to connect with this infant, right? Like brainbleeds can lead to increased risk of disorganized attachment. Up to 80% of kids

who have been neglected, mistreated, or abused exhibit disorganized behavior such as trans-like states, frightening behavior, and this kind of stereotypical motor behavior and contradictory behavioral patterns. So there is this group of kids who are exhibiting these like trans-like

or disorganized or dissociative states. They can have effective lapses in addition to motor agitation, throwing themselves on the floor and rage, not a limit-setting result-in-tentrum. This is not a limit-setting. setting a tantrum. So, you know, this is not just a child who doesn't like your limits and is having a tantrum. This is a strong inability to regulate. They can often be rejected by peers, leading to

aggressive behavior, which is met by attempts to structure and control, such as hiding the need for attachment relationships. They're often rejected by their peers, leading to aggressive behaviors, which is met by attempts to structure and control such behaviors, like hiding the need for attachment relationships. So in the strange situation, there was no coherent way of reconnecting with the mother in these children. They may have ran towards their mother, stopped short halfway, and then ran away. Sometimes they had repetitive stereotyped behavior and movement patterns.

as if the attachment system had been activated but could not be expressed in clear behavioral strategies. So they didn't have a cohesive way of reconnecting. This was seen, remember, as early as 12 months of life when they did these things. We know there's some unique biology in these patients or people. The dopamine receptor D4 gene, DRD4, polymorphism increased risk of disorganized attachment tenfold.

Studies have showed a correlation between disorganized attachment in ADHD and between dopaminergic abnormalities in ADHD. Disorganized attachment is frequently associated with aggressive behavior in preschool children and elementary school children. And there's this polymorphism of a promoter region of a serotonin transporter gene, which more frequently exhibited disorganized attachment only if the mother responded with insensitivity towards them. I really like Beatrice Beebe's work on this,

and she did this study at the four months when they looked at the mother interacting with the child at four months. And as the infants grew distressed, the mother did not sense or acknowledge their distress in a way that was connecting. And there was this sort of back and forth that went on, which showed that the mother wasn't really observing or attuning or able to calm the child. Infant was distressed. Mother was surprised.

Infant was distressed. Mother put on a smile. Infant looked at them. Mother looked away. Infant looked away. Mother loomed in at them. So there was this mismatch of the back and forth. And interestingly, like there are moments of therapy when we watch this on video that you can see the disconnection.

And you can see this in a micro moment as very similar to what goes on over and over again at the four months of age that leads to this disorganized attachment. The infant may be saying something like, this is a quote from Beatrice PB. I'm so upset you're not helping me. I'm smiling at you and whimpering. You don't see, I want love for you. When I'm upset, you smile or close up and look away. You make me feel worse. I feel confused about what I feel and about what you feel.

I can't predict you. I don't know what's going on. What am I supposed to do? I feel helpless to affect you. I feel helpless to help myself. I feel frantic. The mother shows generally a lack of empathy and a failure to register the internal states of the child. The mother has unresolved fears and is often disorganized or dissociated themselves.

So I will put in the show notes these pictures from Beatrice Beebe's book. And I really would recommend her book on attachment if you can't find it. shoot me a DM and I'll share it with you. It was monumental in me understanding things like borderline personality disorder. Because if you have disorganized attachment style, it predicts that later on in adolescence, you will have higher amounts of dissociation. And that dissociation is what is so common with people with borderline personality disorder.

They get stuck in that dissociation. Okay, now I'm going to go through how to translate this into therapy and kind of summarize it. So we want to be emotionally attuned to the moment-to-moment changes of emotion. We watch for the patient's cues of distress and we try to attune to it and empathize with the distress. We help them put words to their emotions. We foster emotional expression in regards to attachment issues. we look at the attachments of their life, their attachment with us, and we put words to that. We talk about that.

We function as a reliable secure base in which the patient can engage in problem solving. We try flexibility in handling the closeness and the distance and interactions with patients. We empathize with the distress of how the distance may be difficult. and we facilitate a joint examination, awareness, and discussion of the therapeutic relationship and its vicissitudes. So we may look at the relationship and the complexities of the relationship that we have with them. We may serve as a model for dealing with frustrations, intense, disruptive emotions, and engage with unwavering commitment.

We encourage patients to think about what attachment strategies he or she is using and dealing with the therapist and in dealing with other important relationships. How do they regain connection, right? And we help patients put into words concerns about separateness, separation, stranger anxieties, and we want them to feel safe and secure. And if they feel less safe and secure, then we want them to put words to that. And we empathize with the distress that might be there and not feeling as secure as they would want to. We look for small moments of loneliness that they may feel in sessions with us. And we want them to put words to that. We also want them to talk about moments where they don't feel lonely, where they feel more connected.

Okay. So this is the end of this session. I hope this has been helpful for you. I would I would love to hear your thoughts if you have any I'll be posting on my Instagram social media about this episode

I respond to every comment or at least I try to and I'll put these notes in the resource library if you want I would go there, check them out watch the still face experiment on my Instagram and my analysis of it

and I really hope this has been helpful for you I think this is building on something really important to me. You know, I get, I get messages from you guys that this stuff is helping you connect better with your clients. And if I can do that, then I'm being successful. And that makes me really excited. So I will leave it there.