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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Serie: Wiley Series in Clinical Psychology
- Sprache: Englisch
Attachment in Intellectual and Developmental Disability
“Skillfully introduced and edited by Helen Fletcher and her colleagues, this long-needed collection of excellent chapters on attachment and disability reveals the vast wellspring of resilience that persons with disability possess – or can be helped to achieve. Readers will discover how best to support a family member, client or friend with a ‘disability’. A definitive resource for multiple disciplines, this book is surely required reading for all those working in the health professions aimed at addressing the needs of those with severe physical, mental or emotional impairments.”
Professor Howard Steele, New School for Social Research
“This informative, comprehensive text is unique, and is destined to become an invaluable national and international resource on attachment issues in the field of intellectual and developmental disabilities. Given the breadth and depth of this book, practitioners can use it both as a guide in practice and as a resource for research purposes. Both the editors and contributors are to be congratulated for introducing attachment theory to a wider audience, who will all, I am sure, appreciate the centrality and importance of this theoretical framework to their everyday practice.”
Professor Bob Gates, University of West London
This title in The Wiley Series in Clinical Psychology is the first to explore the role of attachment theory in understanding and helping children and adults with intellectual and developmental disabilities (IDD). There is a growing evidence base of interventions for IDD underpinned by attachment theory, including direct intervention and the application of attachment theory to understand the interactions and relationships that occur between individuals with IDD and those who support them.
Attachment in Intellectual and Developmental Disability brings together leading clinicians and researchers to present and integrate cutting-edge models and approaches that have previously been accessible only to specialists. They discuss the role of attachment theory in clinical practice when working across the lifespan of people with IDD, the theoretical basis of attachment difficulties, and how these difficulties are presented. They also discuss practical approaches to assessment and intervention, using clear case studies to illustrate the applications of attachment theory to clinical work.
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Seitenzahl: 517
Veröffentlichungsjahr: 2016
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Table of Contents
COVER
TITLE PAGE
ABOUT THE CONTRIBUTORS
FOREWORD
REFERENCE
ACKNOWLEDGEMENTS
Chapter 1: INTRODUCTION
AIMS OF THE BOOK
CURRENT CONTEXT OF ID SERVICES IN THE UK
CONTENT OF THE BOOK
LANGUAGE AND TERMINOLOGY
HOW TO USE THIS BOOK
Chapter 2: AN OVERVIEW OF ATTACHMENT THEORY
DEVELOPMENT OF ATTACHMENT THEORY
INTERGENERATIONAL ATTACHMENT
ATTACHMENT AND CULTURE
CRITICISMS OF ATTACHMENT
PAST AND PROXIMAL LOSSES
DEVELOPMENTS IN NEUROSCIENCE
ATTACHMENT-BASED INTERVENTIONS
SUMMARY
ACKNOWLEDGEMENTS
REFERENCES
Chapter 3: ATTACHMENT RELATIONSHIPS BETWEEN PARENTS AND THEIR CHILDREN
BECOMING A PARENT AND ANTENATAL SCREENING
RECEIVING A DIAGNOSIS
ATTACHMENT THEORY AND REACTION TO DIAGNOSIS
MODELS OF FAMILY GRIEVING
PARENTS’ CAREGIVING ABILITIES
CONNECTIONS BETWEEN EARLY BEGINNINGS AND LATER CHALLENGES
FAMILIES WHICH PRESENT WITH ONGOING COMPLAINTS
SUMMARY
RECOMMENDATIONS FOR PRACTICE
FINAL THOUGHTS
REFERENCES
Chapter 4: ASSESSING ATTACHMENT RELATIONSHIPS IN PEOPLE WITH INTELLECTUAL DISABILITIES
INTRODUCTION
ASSESSMENT OF ATTACHMENT IN CHILDREN
ASSESSMENT OF ATTACHMENT IN ADULTS
CHALLENGES IN THE ASSESSMENT OF ATTACHMENT IN PEOPLE WITH INTELLECTUAL DISABILITIES
ATTACHMENT MEASURES DEVELOPED FOR PEOPLE WITH INTELLECTUAL DISABILITIES
STRENGTHS AND LIMITATIONS OF AVAILABLE MEASURES
AN ATTACHMENT TOOLKIT
CONCLUSIONS
REFERENCES
Chapter 5: AUTISM SPECTRUM DISORDER AND ATTACHMENT
INTRODUCTION
THE IMPORTANCE OF ATTACHMENT IN PSYCHOLOGICAL WELLBEING
EARLY SOCIAL DEVELOPMENT AND AUTISM SPECTRUM DISORDER
ATTACHMENT AS A PSYCHOLOGICAL CONSTRUCT IN ASD
ASSESSMENT OF ATTACHMENT IN CHILDREN AND ADULTS KNOWN TO HAVE ASD
ASD AND ATTACHMENT IN CLINICAL PRACTICE
CONCLUSION
REFERENCES
Chapter 6: MAINTAINING THE BOND
IMPORTANT CONSIDERATIONS IN CASES OF CHALLENGING BEHAVIOUR
A MODEL FOR WORKING WITHIN AN ATTACHMENT THEORY FRAMEWORK
REFERENCES
Chapter 7: PSYCHOTHERAPY AND ATTACHMENT DYNAMICS IN PEOPLE WITH INTELLECTUAL DISABILITIES
INTRODUCTION
THE RANGE OF APPROACHES
INDIVIDUAL THERAPY FOR PEOPLE WITH MORE SEVERE DISABILITIES
FEATURES OF THE THERAPY
EXAMPLES OF ISSUES AND HOW THEY ARE WORKED WITH
TRAUMA-INFORMED CARE – THE NECESSARY ELEMENTS
ASSESSMENT FOR ATTACHMENT-BASED PSYCHOTHERAPY
KEY FACTORS IN INTERVENTIONS FOR PEOPLE WITH MORE SEVERE INTELLECTUAL DISABILITIES
WAYS OF WORKING: STAGES OF EMOTIONAL DEVELOPMENT
CONCLUSION
REFERENCES
Chapter 8: ADULT ATTACHMENT AND CARE STAFF FUNCTIONING
THE ATTACHMENT THEORETICAL PERSPECTIVE
ADULT ATTACHMENT AND PROFESSIONAL CARE
ADULT ATTACHMENT AND STAFF MANAGEMENT
ADULT ATTACHMENT AND PROFESSIONAL RISK AND RESILIENCE
CONCLUSIONS
REFERENCES
Chapter 9: HAVE A HEART
SETTING THE SCENE
IMPLICATIONS FOR LATER LIFE
INCREASING EMOTIONAL SECURITY AND DEVELOPMENT THROUGH STAFF SUPPORT
SHARING IDEAS AND FORMULATIONS WITH STAFF TEAMS
WORKING THROUGH THERAPY
SAFE EMOTIONAL WORKING
HELPING SERVICE SYSTEMS TO UNDERSTAND THE WORK
CONCLUSION
REFERENCES
Chapter 10: ATTACHMENT TRAUMA AND PATHOLOGICAL MOURNING IN ADULTS WITH INTELLECTUAL DISABILITIES
WHAT IS ATTACHMENT TRAUMA?
ATTACHMENT TRAUMA AND INTELLECTUAL DISABILITIES
USING THE ADULT ATTACHMENT PROJECTIVE PICTURE SYSTEM TO ASSESS PATHOLOGICAL MOURNING
THE CURRENT STUDY: ATTACHMENT TRAUMA AND PATHOLOGICAL MOURNING IN ADULTS WITH INTELLECTUAL DISABILITIES
CONCLUSIONS
IMPLICATIONS FOR RESEARCH AND PRACTICE
RECOMMENDATIONS FOR CLINICAL PRACTICE
REFERENCES
Chapter 11: ATTACHMENT, PERSONALITY DISORDER AND OFFENDING
ATTACHMENT AND PERSONALITY DISORDER
ATTACHMENT AND BORDERLINE PERSONALITY DISORDER
ATTACHMENT AND ANTISOCIAL PERSONALITY DISORDER
ATTACHMENT AND EMOTIONAL REGULATION
DEVELOPMENTAL ADVERSITY LEADING TO ATTACHMENT PROBLEMS FOR PEOPLE WITH IDD
MEASUREMENT OF ATTACHMENT IN PEOPLE WITH IDD
ATTACHMENT AND EMOTION FOR PEOPLE WITH IDD
PERSONALITY DISORDER, EMOTION AND ATTACHMENT IN PEOPLE WITH IDD
CLINICAL IMPLICATIONS
CONCLUSION
REFERENCES
Chapter 12: GETTING INTIMATE
INTRODUCTION
DEVELOPMENT OF INTIMATE RELATIONSHIPS
ATTACHMENT AND ROMANTIC RELATIONSHIPS
ATTACHMENT AND THE PARENTING RELATIONSHIP
CONCLUSION
REFERENCES
INDEX
END USER LICENSE AGREEMENT
List of Tables
Chapter 02
Table 2.1 Phases of protest, despair and detachment, see Kobak and Madsen (2008)
Chapter 04
Table 4.1 Attachment scales
Chapter 06
Table 6.1 A process of working with challenging behaviour referrals with an integrated positive behavioural/attachment approach
Chapter 09
Table 9.1 Summary of elements of ‘good enough’ emotionally nurturing care
Table 9.2 Summary of elements in an emotionally nurturing therapeutic relationship
List of Illustrations
Chapter 08
Figure 8.1 Mean proportions of responsiveness by interaction recording during baseline and intervention period for care staff in the three attachment categories.
Chapter 10
Figure 10.1 The
Bench
attachment scene from the Adult Attachment Projective Picture System.
Figure 10.2 The
Corner
attachment scene from the Adult Attachment Projective Picture System.
Guide
Cover
Table of Contents
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Wiley Series in
CLINICAL PSYCHOLOGY
Adrian Wells (Series Advisor)
School of Psychological Sciences, University of Manchester, UK
For other titles in this series please visit www.wiley.com/go/cs
ATTACHMENT IN INTELLECTUAL AND DEVELOPMENTAL DISABILITY
A Clinician's Guide to Practice and Research
Edited by Helen K. Fletcher, Andrea Flood and Dougal Julian Hare
ABOUT THE CONTRIBUTORS
Myooran Canagaratnam has worked as a Consultant Child and Adolescent Psychiatrist in the Lifespan ASD and Learning Disability Service at The Tavistock Clinic, London, UK since 2011. He is the Child and Adolescent Psychiatry Academic Programme Director and Lead for Undergraduate Medical Education at the Tavistock. He is particularly interested in the contribution of biological, psychological and social factors to the presentation of developmental conditions across the lifespan, the role of attachment in social and emotional development and the broad range of psychotherapeutic interventions which can help support individuals with these conditions and their families.
Jennifer Clegg is Honorary Associate Professor at the University of Nottingham, UK. Prior to retiring in 2015, she was a Consultant Clinical Psychologist and qualified family therapist working for Nottinghamshire Healthcare NHS Trust. She has espoused a relational approach to research and practice in ID throughout her career, publishing both empirical and case-study articles on attachment. A recently concluded longitudinal research project with a cohort of school leavers critically examined concepts framing ID policy and practice such as Inclusion and Adulthood. She also writes on the history and ethics of clinical practice. Jennifer provided clinical support to an acute Assessment and Treatment Service for adults with ID and mental health problems or challenging behaviour and their families, alongside nursing and other colleagues. For eight years, this service used Jacques Heijkoop’s Discovery Awareness, a Dutch relationship-building method grounded in developmental psychology, with considerable success.
J. Clasien de Schipper is Assistant Professor for Clinical Child and Family Studies at VU University, Amsterdam and is a member of the Academic Workplace on Child Abuse and Neglect. Her research focus is on attachment, attachment disturbances, challenging behaviour, child abuse and trauma, mechanisms of change in intervention and specific and non-specific treatment factors. She was trained in observing attachment behaviour by Dr Robert Marvin, Dr Elisabeth Carlson, Dr Alan Sroufe, Dr Sarah Mangelsdorf, Dr Jolien Zevalkink, Dr Neil Boris and Dr Jim Elicker. She has carried out research on attachment behaviour in daycare centres, group care for young people with intellectual disabilities, foster families and children exposed to inter-parental violence or sexual abuse.
Caroline Finlay graduated from the University of Dundee, Scotland, UK in 2013. Following this she completed a masters degree studying Psychology Therapies in Primary Care. During this time she became interested in learning disabilities and currently works in a learning disability and challenging behaviour service.
Helen K. Fletcher is a Chartered Clinical Psychologist specializing in working with people with intellectual disabilities. She has over twelve years of experience working with children and adults with ID within the NHS in Community, Inpatient and Tier 4 Specialist Teams including The Tavistock Centre, London, UK. Helen completed her training at University College London, undertaking research on attachment and ID which was supervised by Professor Howard Steele. Her particular interest is the relationship between attachment and parents’ reactions to their child’s diagnosis of ID. She has presented on this topic at National Psychology Conferences. Helen is a Visiting Tutor for the Oxford Institute of Clinical Psychology Training and joint module organizer for the teaching on intellectual disabilities and older people. She has extensive experience of reviewing and marking academic submissions through her role as Examiner for the Oxford Doctoral Course in Clinical Psychology.
Andrea Flood is a Chartered Clinical Psychologist with extensive experience of working with children and adults with intellectual disabilities and their families in both NHS and social care settings. She currently works as a Clinical Teacher on the Doctorate in Clinical Psychology Programme at Liverpool University, UK. Her clinical experience includes both diagnostic assessment and post-diagnostic support for children and young people with ASD. This fostered an interest in the clinical implications of attachment theory in this field. She is also involved in developing supported living services for individuals with ID who have been living in out-of-area placements. Andrea is a co-author of the Manchester Attachment Scale – Third party observational measure (MAST).
Pat Frankish has many years of experience working therapeutically with people with disabilities. Her interest stems from an early life in close contact with long-stay hospital patients. She was aware of their attachment difficulties as a child and has worked hard to redress the balance of their emotional lives and needs. Her doctoral research established a measurement tool for levels of emotional development and consequent attachment needs. She has worked in all levels of security, including high, has been President of the British Psychological Society and now has her own independent business after retiring from the NHS. She provides training for all levels of staff from how to provide a therapeutic environment on a day-to-day basis, through to how to be a Disability Psychotherapist.
Deanna J. Gallichan (née Mason) is a Consultant Clinical Psychologist with the Community Learning Disabilities Team in Plymouth, UK. She has worked with people with intellectual disabilities since qualifying in 2006 from the University of Exeter. Prior to clinical training she completed a PhD at the University of Birmingham. She has additional training in family therapy and systemic practice. Deanna has a particular interest in attachment theory, using it to inform her clinical formulations and interventions with individuals and families, and in consultation with staff teams. She is trained in the use of the Adult Attachment Projective (AAP), and is a certified reliable AAP judge. She has published research with Carol George exploring the use of the AAP to measure attachment state of mind in adults with intellectual disabilities.
Carol George is Professor of Psychology at Mills College, California, USA. She received her doctorate in developmental psychology at the University of California, Berkeley. She is considered an international expert in attachment across the lifespan. She has authored numerous research articles, book chapters and books on adult and child attachment and caregiving, including Attachment Disorganization (1999), Disorganized Attachment and Caregiving (2011) and The Adult Attachment Projective Picture System. Carol has been at the forefront of developing attachment assessments for children and adults, including the Attachment Doll Play Projective Assessment, the Caregiving Interview, the Adult Attachment Interview and the Adult Attachment Projective Picture System. She teaches courses in development, infancy and attachment, co-directs a master's degree programme in infant mental health, trains and consults on the application of attachment assessment in research and clinical settings and is on the Editorial Board of Attachment and Human Development.
Dougal Julian Hare is a Chartered Clinical Psychologist with a quarter of a century of experience in working with people with intellectual and developmental disabilities, particularly those on the autistic spectrum. Following studies at Durham and London, UK, he undertook his clinical training at the University of Leeds and has worked as a Consultant Clinical Psychologist in the NHS and in the charitable and private sectors. He is currently Reader in Clinical Psychology at Cardiff University where he is the research director for the South Wales Clinical Psychology training programme. Dougal has published extensively in the field of intellectual disabilities, with a particular focus on behavioural phenotypes, movement and sleep disorders and attachment. He has also been an editor for Autism and the Journal of Applied Research in Intellectual Disabilities.
Sabina Kef is an Assistant Professor in the Department of Educational and Family Studies at the VU University in Amsterdam, The Netherlands. As a senior researcher she is supervising several national and longitudinal projects on social relations, social support, psychosocial development, job satisfaction, social participation and parenting of families of persons with intellectual or visual disabilities. Furthermore, she is involved as a coach in a masterclass called ‘Scientific research for professionals working in the field of support for persons with disabilities’. She is a board member of different national committees for research, journals/newsletters, societal projects and policy initiatives for parents of persons with disabilities.
Hazel Lewis is a Trainee Clinical Psychologist at the University of Liverpool, UK. Prior to training, she worked with adults with severe and enduring mental health problems at Guild Lodge Secure Services as an Assistant Psychologist. She later trained as a Psychological Wellbeing Practitioner within Wigan IAPT Primary Care service. Influenced by her experiences of working with service users with interpersonal difficulties who often struggle to form relationships, she has an interest in attachment and challenging behaviour.
William R. Lindsay is Professor of Learning Disabilities at the University of Abertay, Dundee, Scotland, UK and Honorary Professor at Deakin University, Melbourne, Australia. He has published over 350 research articles and book chapters, published five books and given many presentations and workshops on cognitive therapy and the assessment and treatment of offenders with intellectual disability. He has always been a working clinician and his current research and clinical interests are in dynamic risk assessment, sex offenders, personality disorder, alcohol-related violence and CBT, all in relation to intellectual and developmental disability.
Sandra Miller is a speciality doctor in Learning Disability. She originally qualified from Dundee University, Scotland, UK, in 1985 and thereafter trained and worked in General Practice. She has worked both in psychiatry and in hospital medicine throughout her career. Her interests include systemic working, attachment and resilience.
Victoria Penketh is a Chartered Clinical Psychologist specializing in working with people with mental health, attachment and forensic needs. Victoria completed her Clinical Psychology training at the University of Manchester, UK. She undertook research on attachment leading to the development of the Manchester Attachment Scale – Third party observational measure (MAST). Other research interests include mother–infant interactions that promote a secure attachment for mothers living with psychosis. She has over eleven years’ experience of working with children, adolescents and adults with complex needs and intellectual disabilities. She is currently working within an inpatient service to increase access to psychological therapies and promote the assessment, formulation and treatment of attachment needs.
Ewan Perry qualified as a Clinical Psychologist from the University of Manchester, UK, in 2009. He works with adults with intellectual disabilities in Manchester as part of a multi-disciplinary community team. Ewan has developed an interest in working with people on the autism spectrum and he currently leads on the development of the Autism Spectrum Disorder care pathway for the service. In his clinical work, he integrates interpersonal and psychodynamic ideas, systemic approaches and positive behaviour support in an attempt to address the emotional and behavioural needs of his clients. He has been involved in the selection and teaching of Trainee Clinical Psychologists and provides regular clinical placements to trainees in the hope that he can inspire them to consider working within the varied, challenging and rewarding field of intellectual disability.
Carlo Schuengel is Full Professor and Leader of the Section of Clinical Child and Family Studies and Associate Dean for research at the Faculty of Behavioural and Movement Sciences of VU University, The Netherlands. He is also a member of the executive committee of EAMHID and Associate Editor of Child Development, a leading scientific journal. From 1999 he has directed the research programme on Challenges in Childrearing Relationships. During this period, he has engaged with multiple large organizations that provide care and support for people with intellectual disabilities to forge long-term partnerships for practice-based research. He has been an advisor for 20 dissertations, many of which are in the field of intellectual disabilities. His research, published in over 100 journal articles and book chapters and well-cited, spans topics from attachment, parenting, maltreatment and intervention, to social development and mental health. His theoretical and methodological approach to research and practice has been shaped, to a large extent, by attachment theoretical research.
Amanda Shackleton is a Clinical Psychologist with many years of experience working with people with intellectual disabilities in the NHS, UK. She has always worked primarily with people showing distressed or challenging behaviours. Her interest in psychotherapy and attachment ideas began after seeking to address the limits of behavioural approaches. Completing four years of training in Disability Psychotherapy has profoundly changed her clinical practice. She currently works in independent practice utilizing psychotherapy and attachment ideas within a service which supports people with intellectual disabilities and forensic issues. Amanda regularly delivers training around Disability Psychotherapy to a range of audiences.
Nancy Sheppard trained at the University of East London, UK, in 1996 and has been working in the field of intellectual disabilities since. She worked as a Consultant Clinical Psychologist within the original Learning Disabilities service at The Tavistock Clinic, London, offering psychodynamic and attachment-based work to children and adults and their families. During this time, Nancy took up a significant training role, offering teaching and support to staff at all levels. Nancy has been keen to make psychodynamic thinking and models of attachment accessible to staff working with people with intellectual disabilities, contributing to Sally Hodges’ book Psychodynamic Counselling for People with Learning Disabilities (2003) and chapters in Simpson and Miller's Unexpected Gains (2004). Previously Head of CAMHS Psychology at The Tavistock Clinic, she currently manages the CAMHS team in the Camden integrated service for children with disabilities and is a Trustee and Training Committee member of The Institute of Psychotherapy and Disability.
Allan Skelly is Consultant Clinical Psychologist within the National Health Service in Tyneside, UK. He has published research into the effectiveness of psychological and multi-disciplinary interventions in community and inpatient settings; the effectiveness of group and individual psychodynamic therapy in people with intellectual disabilities; the process of change in psychodynamic phenomena within therapy; and the role of attachment narrative style in therapy. More recently, he has advocated for the incorporation of attachment theory into the practice of Positive Behaviour Support in the UK, both as a risk factor and a construct of outcome. Allan is currently Honorary Secretary of the Faculty for People with Intellectual Disabilities within the British Psychological Society.
Lesley Steptoe currently works in the Forensic Service for offenders with intellectual disability in NHS Tayside, UK. She gained her PhD at the University of Abertay, Dundee, investigating attachment issues in offenders with intellectual disability. Similar to her research interests, on which she has published extensively, her clinical interests include risk assessment, sexual offending, personality disorder and quality of life.
Samantha Walker is a Senior Clinical Psychologist, who has experience of working with children and adults with intellectual disabilities and their families in both NHS and social care settings. She currently works independently for Socrates Clinical Psychology in Huddersfield, UK. Her clinical experience includes the assessment of autism and differential diagnosis around attachment, and post-diagnostic support to children and adults. She also works within the expert witness arena for family and criminal courts. Her interest in attachment theory began whilst completing her doctoral thesis in the area of attachment assessment with people who have an intellectual disability. Her research provided the foundation for the development of the Manchester Attachment Scale – Third party observational measure (MAST), of which she is a co-author.
FOREWORD
When John Bowlby died in 1990 at the age of 83, he had already seen the proofs of his last book Charles Darwin: A New Life, which was published after his death. It is not often we have the chance to experience a genius writing about a genius and Bowlby accesses the emotional losses and joys of Darwin in a way that sheds insight without demeaning any of Darwin’s brilliance. Indeed, looking at attachment, loss and somatizing in Darwin through the prism of Bowlby’s own clinical and theoretical contributions adds to our knowledge of both men.
As well as all the other connections between these two men, who both created paradigm shifts, there is one that is particularly apposite for this seminal book. Both men had the experience of intellectual disability in their families (Darwin’s son and Bowlby’s grandson) and both men loved the family member with a disability. Indeed, in the early days of The Tavistock Clinic Mental Handicap Workshop (the correct terminology at that time), both John Bowlby and his daughter told me with great pride that he had diagnosed the disability before other doctors had and that because of all the love and family support, the child had exceeded all expectations.
Intellectual disability can create such loss and exclusion that it feels warming that the father of attachment theory was not part of such processes. Attachment theory has allowed us to find a way of evaluating social and emotional richesse, hope, risks, forensic concerns, safeguarding issues and generational transmission. It has engendered internationally accepted research tools that have meaning for the emotional health of each country. It is a lifesaving body of theory and practice.
This book, the first to formally, academically, clinically and theoretically extend the applications of attachment theory to the population of those with intellectual disability who are excluded from so much mainstream research, is a fitting quarter-century tribute (post Bowlby’s death) to the continuing and deepening legacy of his work.
Children and adults with intellectual disability face a different world to many of their peers. Cognitive and emotional capacities can be significantly impacted on by disability, which then requires rethinking of provision and research tools. Dependency needs, extra losses and lack of emotional and sexual fulfilment impinge on and affect the nature of attachment processes and relationships. These issues have not been explored adequately. The impact on care staff of different attachment patterns in this field also requires further attention to avoid the damaging dissociative defence of looking at behaviour only to avoid the pain of emotional meaning.
Whilst disability psychotherapists in the UK mention attachment and remain connected under the umbrella of the Institute for Psychotherapy and Disability (e.g. Blackman, Corbett, Frankish, Hollins, Kahr, Sheppard and Sinason), attachment has not been the core of the work. There has been a growing need for a book that finally privileges the subject and its applications across different clinical populations within the Intellectual Disability field. Attachment patterns, assessment, children, families, services, forensic populations, autism and challenging behaviour all come under helpful and knowledgeable scrutiny.
Helen Fletcher, Andrea Flood and Dougal Julian Hare are to be congratulated for righting this omission in such a positive, rigorous and informative way. Together with their fine selection of senior contributors they have extended the attachment map, and this book is a crucial addition to the field.
John Bowlby was a profoundly honourable man who followed his clinical and academic understanding even when it led to unpopular fields. He was ahead of his time in realizing the importance of secure, consistent relationships and the impact of loss on children. As a psychoanalytic historian and clinician speaking at the Bowlby Centre's 25th Anniversary Conference in honour of John Bowlby, Professor Brett Kahr spoke of the towering impact of the man and his legacy whilst pointing out a final evaluation of his work was not yet complete. Indeed, it is still too early to appreciate properly the internationally accumulating legacy left by Bowlby. However, an important book like this raises a warm glow of attachment in the disability field and spreads a major legacy in a deeply successful way.
Valerie Sinason PhD MACP M. Inst. Psychoanal., FIPD is President of the Institute of Psychotherapy and Disability
REFERENCE
Bowlby, J. (1990)
Charles Darwin: A New Life
. New York: Norton & Company Inc.
ACKNOWLEDGEMENTS
We would like to thank all the authors who have contributed to this book and worked so hard on their chapters, in addition to their full work lives and other commitments. Book editing and writing chapters is a time-consuming business and we would like to thank our families for their support, patience and encouragement over the two years of working on the book.
Helen would like to give thanks to Rob, Sue and Keith for helping look after the girls to free up essential blocks of time for book writing. Special thanks to Rob for his support and encouragement and for being so patient during the long nights of work as the book deadline approached. To Sophie and Chloe, who have taught Helen most about attachment theory in real life, this book is dedicated to them with special love. Thank you also to Andrea and Dougal for sharing the journey of book editing, which has been so stimulating and challenging.
Dougal would like to thank Liza Dysch for her help with copy-editing and proof-reading various chapters, Adrian Wells for his support of this book from its inception, his co-editors for their patience and hard work in seeing this project to completion and, of course, Jayne Bromhall. He would like to dedicate this book to his dad, Kenneth Geoffrey Hare, who was one of the pioneer clinical psychologists in the UK before a distinguished career as an educational psychologist in West Cumbria.
Andrea would like to thank Bret for all his support, encouragement and continued dedication to sharing equally the important task of nurturing their amazing daughters. She would also like to thank Ruby and Alexa, for the joy they bring every day, and bringing meaning to much of what is written about in this book. This book is dedicated to them all with love and appreciation. Thanks go to Helen and Dougal for their perseverance and wisdom, with particular gratitude to Helen for the time she committed when the rest of the country was asleep. Finally, a special thank you goes to Elaine Thomson, who provided inspiration, knowledge and mentorship at the very beginning of Andrea’s journey, and whose influence has been profound and long-lasting.
Many people have supported us by reading drafts of the chapters, giving incredible feedback which helped to shape and improve the chapters. Helen would like to thank the following people for their time and assistance in reading and commenting on her chapters: Louise Acker, Amy Critoph, Kate Ferrara, Sue, Keith and Claire Fletcher, Rob Fletcher-Dallas, Barbara Hurtado, Lynne Jones, Marielle Lord, Sophie Mills, Catherine Naysmith, Laura Sanchez-Horneros, Nancy Sheppard and George Young. A special thanks to Deanna Gallichan for her time and assistance in reading, commenting on and shaping up the chapters.
Various professionals from Wiley have supported us throughout the writing and editing of the book. Thank you to Darren Reed for supporting us with the development of the book proposal and for overseeing the book. Also thanks to Roshna Mohan, Karen Shield, Amy Minshull and Aneetta Antony for answering our questions and guiding us in the process when needed. We would like to acknowledge Helen Heyes for her copy editing work and Dr Laurence Errington for his Indexing skills.
Finally and most importantly, we would like to thank the people with intellectual and developmental disabilities and their support networks who have inspired us to work in an attachment-informed way and allowed us to share part of their lives with them.
Chapter 1INTRODUCTION
Dougal Julian Hare1, Helen K. Fletcher2 and Andrea Flood3
1South Wales D. Clin. Psy. Programme, Cardiff University, UK
2Bucks Community Learning Disabilities Team, Southern Health NHS Foundation Trust, High Wycombe, Buckinghamshire, UK
3University of Liverpool, Liverpool, UK
There is nothing more practical than a good theory.
Kurt Lewin (1952)
AIMS OF THE BOOK
This book has been written by clinicians and researchers to tell the story of their experiences of applying attachment theory to their work with children and adults with Intellectual and Developmental Disabilities. Although attachment theory is well established in psychological and therapeutic work in mainstream populations, it remains a developing area of research and practice for those working with people with Intellectual Disabilities (ID). This book outlines the challenges of researching attachment in ID populations, provides a careful review of the available literature and discusses the implications for clinical work. The content draws on the extensive clinical experience of the contributors and presents a guide to offering attachment-informed clinical assessment, formulation and intervention to people with ID in various clinical settings.
Attachment theory is not aligned to any one clinical approach and can be integrated into the full range of psychological interventions: from Behavioural to Psychoanalytic, Systemic to Cognitive Behavioural Therapy. As a universal developmental theory it is also relevant to people from every country and culture, although, of course, different family contexts will create natural variations in the way children are raised. This book uses case studies taken from clinical practice (although adapted in order to make them anonymous) to give detailed examples of how attachment behaviours may present in clinical work, and ways to understand and reduce distress related to attachment trauma and losses. Although many of the cases are drawn from clinicians working in the National Health Service (NHS) in the United Kingdom, they have been chosen to illustrate common difficulties which confront people with ID, their families and paid carers, wherever they are living.
We are sure that many clinicians are working with people with ID using aspects of attachment theory, possibly naming it as such or using other language to describe it. We hope that this book will build upon their excellent work and confirm the theoretical rationale behind their ways of working. For people in training who are new to working with people with ID, we hope this book will give them ideas on how to work in a truly person-centred, ethical way, looking at people's enduring relationships and the challenges people with ID and their families and carers may face.
The idea for the book emerged in email correspondence following the IASSIDD and DCP Faculty for ID Advancing Practice event, held in 2011 in Manchester in the UK. Carlo Schuengel delivered a keynote speech on Attachment and ID and there were other stimulating presentations focusing on attachment in ID. Following this, a small group of people came together to form a collaborative network with a shared interest in research and clinical work using attachment theory in ID settings. The idea of writing a book together was welcomed instantly by the group.
As the editors of this book, we hope that you will find it an interesting and practical guide to using attachment theory to improve the lives of people with ID. We wanted to unpick and demystify some of the more technical parts of attachment theory so as to help clinicians to feel confident in talking about and using such ideas. We also wanted readers to see real examples of how attachment theory has informed work in different settings and services and to be able to take away practical ideas to use in their work without having to do any further training or go on a particular course.
Books such as this cannot, of course, be written solely on the basis of enthusiasm and goodwill. We have to engage with the ongoing issue within clinical psychology of what constitutes ‘evidence’. This presents particular difficulties in the field of ID, where there are many challenges to using the well-established research methods that are used to explore models of distress and approaches to intervention in mainstream populations. Randomized controlled trials are rarely used in ID research, perhaps due to difficulties in gathering a suitably large and homogenous group of research participants. However, the apparent lack of ‘evidence’ in ID populations more generally may reflect not only the challenges in research design, but also a more widespread disinterest and dismissal of important issues for people with ID. This could be related to issues of stigma and disempowerment of people with ID, particularly for those whose communication difficulties mean their ‘voices’ may not be heard without others advocating for them. Within this book, the contributors have drawn upon a wide range of evidence including clinical trials and outcome studies, single-case studies, experimental research, innovative approaches such as Q methodology and practice-based evidence. The latter is vital in supporting the all-important ‘how to’ element that is emphasized throughout this book.
CURRENT CONTEXT OF ID SERVICES IN THE UK
There has been much talk of the need for compassionate care in the light of the abuse perpetrated upon people with ID at the Winterbourne View care home in Gloucestershire, UK, which was brought to light in 2011. The shocking images filmed by the BBC Panorama TV programme during an undercover investigation were a stark reminder that many people with intellectual disabilities still lack safe and nurturing places to live. It was evident right from the beginning of this chain of events that there was a culture of callous indifference and cruelty alongside a fear of speaking out or ‘whistleblowing’ in order to protect those vulnerable people who were being abused. Following investigation of these horrific crimes, senior figures in the UK have turned their attention to fundamental failures in the commissioning and delivery of services, particularly when individuals with ID are experiencing a period of acute distress or crisis. There is a commitment to enable individuals supported in out-of-area services to return ‘home’, the development of pooled budgets at a local level and an increasing emphasis on the importance of people with ID being legitimate partners in the change process.
Unfortunately, progress has been slow. Important work has been done to change inspection and regulatory systems and attempts made to improve skills and boost empathy in direct care staff, however many barriers remain. Notably, there has been little attention given to the very complex issue of the nature and quality of the relationships between people requiring support and those who provide this. It is precisely here that attachment theory has so much to offer in terms of both understanding and improving such relationships to the benefit of all parties in ID services. Therefore, whilst attachment theory cannot overcome the systemic barriers to the wholesale change in culture that is required, we think that the current book, with its over-riding emphasis on practice, is both timely and imperative with relevance across a range of settings and services.
I’ve learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel.
Maya Angelou
CONTENT OF THE BOOK
In Chapter 2, Helen Fletcher and Deanna Gallichan summarize the theoretical basis for attachment theory, describing the milestones that have occurred in understanding parent–child relationships and their role in long-term psychological functioning. This chapter is intended to set the scene for the remaining chapters in the book, so that readers without any prior knowledge of attachment theory can become familiar with basic elements and key concepts of the model. This is followed by a further chapter by Helen Fletcher in which the impact of having a child with a disability is explored from the perspective of the parents, with particular reference to both early attachment relationships and later presentations in a clinical setting. Chapter 4 by Sam Walker, Victoria Penketh, Hazel Lewis and Dougal Hare reviews the assessment of attachment in people with ID in clinical practice, with an emphasis on the validity and feasibility of available techniques, and presents a clinical ‘toolkit’ to this end. In the fifth chapter, Ewan Perry and Andrea Flood examine the oft-problematic issue of attachment and autism spectrum disorder (ASD), with an emphasis on the importance of primary attachment relationships for the psychological wellbeing of individuals with ASD and useful recommendations for applying attachment theory in adults with ASD. Chapter 6 by Allan Skelly examines the value and utility of using attachment theory when working with people whose behaviour challenges services. He highlights the risk of services minimizing the importance of a person’s life history and personhood through focusing primarily on challenging behaviours. The chapter presents a detailed ‘worked-through’ case example, which illustrates how clinical outcomes can be improved by ensuring attachment theory is at the heart of interventions such as positive behavioural support. In the seventh chapter, Pat Frankish presents a distillation of her extensive psychotherapeutic work with people with intellectual disabilities. She describes the necessary focus on attachment dynamics and the onus placed on the therapist to provide a ‘secure base’ within a validating and often long-term therapeutic relationship.
In Chapter 8, Carlo Schuengel, Jennifer Clegg, J. Clasien de Schipper and Sabina Kef write about the vitally important topic of attachment relationships between care staff and people with intellectual disabilities. Their chapter presents the results of recent research on professional caregivers and the impact of their mental representations of attachment on the quality of interaction with their clients. They provide a practical overview of the human resources necessary for offering good quality care, including issues of carer selection, training and supervision. In the ninth chapter, Amanda Shackleton draws upon and develops Pat Frankish’s work to understand how the attachment experiences of people with intellectual disabilities can affect their emotional development and how such issues can be worked with in clinical practice via assessment and appropriate intervention tailored to their emotional stage of development. Central to this work is engineering secure attachments and emotional safety by working via staff teams and through individual therapy. Deanna Gallichan and Carol George then discuss their work using the Adult Attachment Projective with adults with ID, through the lens of attachment trauma. They focus on experiences of abuse including the common experience of bullying, and discuss the ways in which these threats can be compounded by helplessness and lack of adequate protection by caregivers. In Chapter 11, Lesley Steptoe, Bill Lindsay, Caroline Finlay and Sandra Miller examine the relationship between attachment experiences, emotional regulation and the subsequent development and presentation of personality disorder in offenders with ID. This chapter draws on their extensive experience of working with this population in secure clinical settings. In the final chapter, Nancy Sheppard and Myooran Canagaratnam examine how attachment influences close and intimate relationships for people with ID undergoing therapy at The Tavistock Clinic, London. They explore a variety of such relationships including attachment relationships between parents and adult children, sibling relationships, friendships, romantic relationships and relationships between parents with ID and their children.
LANGUAGE AND TERMINOLOGY
We decided to use the term Intellectual Disabilities (ID) throughout the book as this language is being used increasingly internationally to refer to individuals who are described as having ‘Learning Disabilities’, ‘Global Developmental Delay’ and, historically, ‘Mental Retardation’. Of course, language and terminology is forever changing and the people we work with (who are given such labels and diagnoses) are rarely empowered to choose the terminology used by clinicians and researchers. Each author has used different language to describe their attachment-informed work and therefore there are slight differences in the terminology used throughout, reflecting the contributors’ individual perspectives and writing styles.
HOW TO USE THIS BOOK
We have edited the book in order to provide the necessary theoretical and practical resources for using attachment theory in everyday clinical practice with people with ID. To this end, each chapter has been written as a stand-alone chapter with the necessary cross-referencing to enable the reader to read as much or as little of the book as desired without too much overlap among chapters. The various chapters use clinical case examples both to illustrate theoretical issues and to provide practical ideas for using attachment theory in clinical work. When appropriate and possible, these examples are supplemented by a clinical toolkit of assessments and procedures.
It is important that the ideas and practices described in this book are utilized within a broader framework of good practice in clinical psychology and psychotherapy. This, of course, includes our normal practice of working under the Human Rights Act (1998), the Mental Capacity Act (2005) and the Mental Health Act (2007) in the UK. In addition to this, it is necessary to work collaboratively and sensitively with both the person with ID and those who support them, in order to develop a meaningful formulation that integrates historical information, current contingencies and systemic influences. In particular, when working with behaviours described as ‘challenging’ that place people at risk of harm, it is necessary to ensure both an effective risk management strategy and robust mechanisms to provide emotional support for families and staff before addressing the possible role of historical factors. With these in place, an assessment of psychological functioning and presenting needs, taking into account relational histories and attachment dynamics, can be undertaken. In particular, when working with staff teams and families, it is important to be mindful that they may be feeling ‘stuck’ with a problem that they feel they cannot influence and may have experienced previous professional input as chaotic, unhelpful or disempowering. Such situations often suggest, or even demand, the use of attachment theory, but it is vital that ideas and approaches are introduced and presented in a comprehensible and practical manner.
To conclude this introduction, we would ask that you read this book with the stance that, as clinicians, our theoretical interest must never be merely academic, for the aim of our work is primarily to relieve distress and promote the wellbeing of other people. Moreover, to do this effectively, we must recognize that none of us, whether described as having an intellectual disability or as neurotypical, are wholly autonomous individuals, and that people need people.
Piglet sidled up to Pooh from behind. ‘Pooh?’ he whispered.
‘Yes, Piglet?’
‘Nothing,’ said Piglet, taking Pooh's hand. ‘I just wanted to be sure of you.’
A.A. Milne
Chapter 2AN OVERVIEW OF ATTACHMENT THEORY: BOWLBY AND BEYOND
Helen K. Fletcher1 and Deanna J. Gallichan2
1Bucks Community Learning Disabilities Team, Southern Health NHS Foundation Trust, High Wycombe, Buckinghamshire, UK
2Community Learning Disabilities Team, Plymouth Community Healthcare CIC, Plymouth, UK
Attachment theory describes one of the most simple and basic requirements of all animals: that of protection and survival of their young. Although it was originally thought to be a physical mechanism, Bowlby (1969) argued the importance of both emotional and physical aspects of attachment relationships. Attachment theory has been comprehensively written about and researched over the past 40 years and continues to be regarded as a central concept in psychology and psychotherapy. This is because it offers a structure through which to study and understand the development of people’s enduring emotional connections with their primary carers and a template with which to consider their later interactions and relationships with others. In addition to this, there is now a convincing amount of research connecting psychological distress in adulthood with difficulties and traumas in early attachment relationships (Dozier, Stovall-McClough and Albus, 2008; Mikulincer and Shaver, 2012). This has stimulated the development of a variety of therapeutic interventions which aim to promote better quality attachment relationships between children and their carers or to help older children and adults to understand the impact their early relationships have had on their emotional functioning, personality and behaviours.
Although Bowlby’s work did not focus on families with intellectual disabilities (ID), clinicians have long applied attachment theory to help understand the needs of individuals with ID and the difficulties resulting from problems in their early attachment relationships. The psychological difficulties that have been observed in people with a history of insecure attachment (Main, Kaplan and Cassidy, 1985) or mistreatment from parents (Main and Hesse, 1990) are of central importance to people with ID. This is because people with ID are at increased risk of having difficulties in their attachment relationships as well as being more likely to have experienced physical and emotional abuse from others (Van IJzendoorn et al., 1992; Wright, 2013).
The aim of this chapter is to provide an introduction to attachment theory and its clinical applications to set the scene for the rest of the book. It will include:
An overview of attachment theory as described by Bowlby;
A description of the work carried out by Mary Ainsworth, Mary Main and Pat Crittenden in developing classifications of attachment and expanding upon Bowlby’s attachment theory;
A discussion of contemporary neuroscience related to attachment theory;
An overview of therapeutic work regarding attachment theory in non-ID populations.
Throughout the chapter there will be discussion of the application of attachment theory and mainstream interventions to individuals with ID. A case example will also be used to help explain and illustrate the application of attachment theory within ID populations.
DEVELOPMENT OF ATTACHMENT THEORY
John Bowlby’s interest in attachment relationships developed whilst he was working in a home for ‘maladjusted boys’ shortly after graduating from university. During this time he worked with two boys with very different responses to being separated from their mothers. One behaved in a remote, affectionless way with a tendency to isolate himself, whilst the other boy followed Bowlby around constantly. Bowlby noted that similar patterns of behaviour were observed in adults with emotional difficulties, who presented as either clinging and demanding or as having difficulty forming emotional connections with others. This led him to hypothesize that early relationships and separations had a significant impact on later development of personality and psychological problems.
Bowlby became strongly influenced by the observations of his colleague James Robertson, who was studying the reactions of children who were separated from their mothers during periods of hospitalization. Bowlby reported that children responded to their mother’s absence with a ‘powerful sense of loss and anger’ (Bowlby, 1969, p. xiii) and when reunited, reacted either by clinging intensely to their mother or rejecting her and appearing detached. This typical pattern of protest, despair and detachment (see Table 2.1) seen in children older than six months of age led Bowlby to develop his theory of attachment, stating that ‘the young child’s hunger for his mother’s love and presence is as great as his hunger for food’ (Bowlby, 1969, p. xiii). This marked a move away from the views of contemporary psychoanalysts and social learning theorists, which held that children’s bonds with their mothers were developed primarily through the mother feeding them (Cassidy, 2008). Bowlby drew upon ethological studies by Lorenz (1935) and Harlow (1958) which demonstrated that both geese and rhesus monkeys developed attachments to ‘mothers’ that did not feed them but which gave comfort. Bowlby formulated a principle that in order for a person to have good mental health, the child needs to experience a ‘warm, intimate and continuous relationship with his mother (or permanent mother substitute) in which both find satisfaction and enjoyment’ (Bowlby, 1973, p. 11).
Table 2.1 Phases of protest, despair and detachment, see Kobak and Madsen (2008)
Protest
Began as parent prepared to leave. Characterized by intense distress (e.g. crying, screaming, anger, pounding the door, shaking the cot). Lasted from a few hours up to a week. Child appeared to retain hope that their mother would return. Attempts by other adults to soothe the child unsuccessful; some children actively rejecting other caregivers. Crying may subside but return at bedtime or during the night. Dominant emotions: fear, anger, distress.
Despair
Physical movements diminished, child withdrew or disengaged. Behaviour indicated hopelessness that parent would return. Likened to deep mourning, as though the child interpreted the separation as loss (Bowlby, 1973). Withdrawal often misinterpreted as recovery. Hostile behaviour could increase over time. Dominant emotion: sadness.
Detachment
Child actively turned attention to environment. No longer rejecting alternative caregivers; sociable with peers. Apathetic when mother returned, some treating her like a stranger. Detachment alternated with clinging and fear that she would leave again. Following reunion, children would exhibit fear if nursery workers visited their home. Dominant emotions: appearing emotionally numb alternating with fear.
Bowlby’s work on separation significantly shaped policies and led to important changes in the way children are looked after within hospitals, child care and systems of fostering and adoption in the UK (Rutter, 2008). Children’s services are now aware of the importance of maintaining as much contact as possible between children and their primary caregivers. Where children are removed from their birth families, they are placed within family home environments wherever possible and supported to develop attachment relationships with new carers. This is a significant shift from the historic model of placing children in orphanages and children’s homes with a small number of staff looking after large numbers of children. Although these changes have taken place in non-ID groups and in the care of children, we still see that in ID services children and adults are often in placements with high turnover of staff, where there is poor continuity of care and limited opportunities for developing secure relationships (see Chapters 7 and 9 for further discussion).
Behavioural Systems
Bowlby’s (1969) development of attachment theory was based upon evolutionary theory and ethology. He proposed that attachment behaviours are organized within a ‘behavioural system’ which promotes proximity between children and their mothers in response to real or perceived threats, in order to help them to survive. When activated, the child’s attachment behavioural system acts to achieve the goal of proximity to the attachment figure in the most effective way it knows how. Babies may cry or hold their arms out, whilst older children may crawl, run or call out to their parent. As soon as the goal of proximity to the attachment figure is achieved, the child feels safe and their attachment behavioural system is deactivated.
Crucial to Bowlby’s theory was the idea that the attachment behavioural system works in concert with several other behavioural systems to ensure survival of the species. These include the fear, exploratory, sociable/affiliative and caregiving behavioural systems. Thus, a child who feels fearful when approached by a stranger will use attachment behaviour to get closer to their attachment figure (e.g. holding out their arms to be picked up). Should the attachment figure be unavailable, the child faces not only the fear of the unfamiliar situation, but also the anxiety of not being able to access their source of protection and comfort (see Kobak and Madsen, 2008). As the attachment behavioural system is not thought to be contingent on pleasure, children will develop attachments to their parents even if they are not meeting their physiological needs or are behaving in abusive ways (Bowlby, 1956).
The parent’s caregiving system evokes a biological, pre-programmed urge to care for and protect their child. When the caregiving system is activated, the parent is maintaining proximity and closeness to their child, providing a safe haven or secure base for them; for example, seeing their toddler climbing on a chair, a parent will move closer, allowing them to explore but remaining ready to catch them should they slip. This means that the child’s attachment system can be deactivated as long as they do not perceive any threats, freeing them to explore. A child will only explore their surroundings comfortably, or seek friendships with peers, if they feel confident in the availability of their attachment figure, should they need them (see Cassidy, 2008 for further discussion on behavioural systems). However, if a parent’s caregiving system is deactivated, then the attachment system may need to become activated, for example if a parent suddenly leaves the room. It is thought that this is why being left can be disturbing to a child and can lead to attachment behaviours such as protest and despair.
Bowlby (1969) hypothesized that the development of a secure attachment relationship is dependent on a smooth interaction between the parents’ caregiving behaviours and the child’s attachment behaviours. In favourable conditions, it is assumed that children form secure relationships with their mothers and other important figures which serve a protective function.
Internal Working Models
Bowlby’s approach to the unconscious, termed ‘internal working models’ (IWM), departed from his background in psychoanalysis, and was influenced by information processing, cognitive psychology and neurophysiology (Bowlby, 1980). He proposed that as children grow older, and less in need of direct physical proximity and protection from their caregivers, attachment relationships are increasingly governed by IWMs of attachment. These begin developing towards the end of the first year of life and develop rapidly during the second and third years, alongside the development of language and motor skills. The child’s day-to-day experiences with their caregiver were thought to give the child a working model of ‘who his attachment figures are, where they may be found and how they may be expected to respond’ (Bowlby, 1973, p. 203).
Bowlby (1973) wrote that a key concern for an individual with regards to their internal working model of their ‘self’ is whether they are acceptable to their attachment figures or not. An internal working model of self as being valued, accepted and competent will be developed in the context of an internal working model of ‘other’ being emotionally available and protective when needed and supportive of the individual’s exploration. Parents who are unresponsive and unavailable or rejecting in their patterns of responses will be connected to internal working models of self as unacceptable, devalued and incompetent.
