a secure attachment model of care: meeting the needs of women with mental health problems and...

EditorialA secure attachment model of care: meeting the needs of women with mental health problems and antisocial behaviour

Copyright © 2006 John Wiley & Sons, Ltd 16: 3–10 (2006)

Criminal Behaviour and Mental Health16: 3–10 (2006) Published online in Wiley InterScience (www.interscience.wiley.com) DOI: 10.1002/cbm.56

MIRANDA BARBER1, JACQUELINE SHORT2, JENIFER CLARKE-MOORE2, MARGARET LOUGHER1, PHILIP HUCKLE1 AND TIM AMOS3, 1Llanarth Court Psychiatric Hospital, Llanarth, Raglan, Usk, UK, 2formerly Llanarth Court Psychiatric Hospital, 3University of Bristol, Bristol, UK

Introduction

Women still constitute a minority group within the criminal justice system and specialist health services for offender patients but, in the UK at least, the size of this group is growing. There is widespread concern that the healthcare needs of such women are not adequately met, in part just because there are very few of them amongst relatively large numbers of men, and in part because of the related possibility that their specific needs may have been missed. Women who need secure hospital services have commonly experienced longstanding and extreme relationship difficulties. These interpersonal problems have not only generally contributed to the entry of these women into secure environments but also are often re-enacted in the new environment, creating toxicity in the system of care around them. This, in turn, results in the women being detained for lengthy periods, or finding themselves being moved repeatedly from one service to another.

For England and Wales, the Department of Health (DoH) responded to such concerns with a general review of women’s mental health care and provided resultant guidance for services (DoH, 2002). The review highlighted the paucity of published research on models of care specific to the needs of women. Nevertheless, implementation guidance (DoH, 2003) proposed a whole-systems approach as essential. Such holistic, multidisciplinary work requires a shared vision and understanding founded in relationships, but multidisciplinary teams often struggle even to establish a common language. How might such barriers to effective care be overcome? A

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Copyright © 2006 John Wiley & Sons, Ltd 16: 3–10 (2006)DOI: 10.1002/cbm

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A well-established theoretical model that has been developed to consider an individual’s significant relationships and their ongoing impact on functioning is Bowlby’s theory of attachment (Bowlby, 1969, 1973). This theory proposes that if an individual’s primary caregivers are generally available during his or her childhood and adolescence, sensitive to his or her signals and consistently respon-sive, then that person develops confidence that supportive care is accessible. These expectations are what is meant by a ‘secure base’, which allows both exploration of the environment and ease of soothing when distressed. In contrast, when care is unpredictable and highly conflictual, then an anxious attachment relationship occurs. This can disrupt the individual’s core beliefs about self and others, creating a vulnerability to expectations that others will not be able to contain that individual’s emotional needs successfully. A belief that she/he is not worthy of care follows.

Attachment theory also proposes that an individual will experience anxiety in response to the threat of, or actual, separation from an attachment figure. Examination of the background histories of many patients in secure services often brings to light instances in which the individual has experienced extremes of separation or threatened abandonment from significant others, e.g. suicide or threats of suicide by a parent. Not only do threats of abandonment create intense anxiety but they also arouse anger, often of an intense degree. Extreme forms of punishment also create attachment difficulties as not only is the individual faced with threats to her/his attachment figure’s availability, but the attachment figure is also a source of danger.

Styles of attachment

The importance of the concept and theory of attachment is that once these principles are grasped there is less difficulty in understanding the interac-tional behaviours evidenced by women in secure institutions. Patients will react to clinical staff (or prison staff in prisons) based on their attachment history.

Those with a dismissing style may find it difficult to engage therapeutically, as they invest their energies in avoiding thinking about difficult and painful feelings. This is often interpreted by staff as failure to engage but is often based on early childhood experiences of fractured or traumatic relationships. The same early attachment difficulties can also be demonstrated by excessive reliance on mind-altering substances, such as illicit drugs, or medication, prescribed ‘as neces-sary’ rather than on a regular basis. In contrast, those with anxious ambivalent attachment styles tend to have an attachment system that is chronically hyper-activated. Attachment relationships to staff and other patients are often unstable, with rapid changes of mood and behaviour. The patient’s frantic attempts to seek proximity and emotional fusion with carers can lead to her/him being seen by

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clinical teams as demanding and emotionally draining. Individuals with this attachment style can also present with high levels of hostile, self-destructive and challenging behaviour, as a way both of engaging a caregiver’s attention and of expressing anger and distress at perceived abandonment.

Once dysfunctional attachment patterns are established they are repeated, and become more entrenched and more likely to operate outside of conscious awareness. Patients will interact with others based on unconscious expectations and assumptions built from earlier relationships. This is complicated by the fact that staff do not come themselves as a ‘blank slate’, and will have their own attachment styles. Adshead (2002) expands on resulting interactions and their consequences, including splitting in the staff teams.

Such entrenched patterns of relating might lead to pessimism, but there is increasing evidence that dysfunctional attachment patterns can be altered through the experience of emotional support. A consistent, containing relation-ship will, over repeated interactions, challenge previous expectations and beliefs about relationships. As women feel more secure within the therapeutic milieu they become more able to signal their needs directly and clearly, and approach for help in more socially conventional ways. They also begin to develop a secure

Table 1: Styles of attachment

Developmental Insecure attachment Example of Attachmentprocess strategy behaviour which may classification be evidenced

Care is chaotic, Maintain proximity Emotional lability Anxious/ inconsistent, and closeness to the Threats/actual self- ambivalent neglectful or rejecting Caregiver destructive behaviour Maximize the expression in response to staff of attachment member being awayMajor losses behaviour Punish from work the caregiver for non-responsivenessThreats of abandonment Cut off expression of Reluctance to engage Anxious/ used as control attachment behaviour with care team avoidant Emotionally over- controlledCaregivers behave in Approach/avoidance Dissociation – Disorganized frightening or conflict disruptions in incoherent ways orientation to the towards the child environment and failure to integrate various aspects of emotional and cognitive experiences

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sense of themselves as deserving of attention and support. A healthy therapeutic alliance may then follow, allowing the person to engage in other therapeutic work, designed to promote insight, conflict resolution and adaptive, integrated functioning.

Practical application of the model

Attachment theory may be useful as a model of care in secure services, but operationalizing theory into integrated care and treatment, from the preadmis-sion stage through to discharge and follow-up, poses a substantial challenge. We have found taking the following staged approach to be helpful.

Stage 1: Establishing a secure base

A whole-systems approach is paramount. Each clinical discipline brings its own unique knowledge and skills, but it is essential that there is shared ownership of the secure attachment model of care. Staff must feel validated and respected by one another, in order to feel consistently contained and supported by the system. It is only when staff have established a secure base for themselves within the service that they are able to create a secure base for patients. It helps if only staff with a genuine interest in working with women, and who have the ability for reflective practice, are recruited.

Prior to admission, a fully comprehensive, multidisciplinary pre-admission assessment is completed. Use of data from multiple sources – presenting patient, significant others and official records – can help identify previous patterns of attachment and thus prepare for potential future disturbances.

When previous attachment patterns had been severely disrupted, a core nursing team is allocated to work alongside the primary nurse, to reduce the intensity of damaging re-enactments. The core team has an in-depth knowledge of the patient, and works collaboratively to support each member in maintaining consistent availability and a consistent and empathic response, and boundary maintenance. This assists tolerance of the toxicity of the patient’s interpersonal dynamics.

On admission, each patient is likely to be in crisis. Her presenting mental state is likely to be unstable but then, potentially, exacerbated by the transitional changes including new relationships and alterations in environment, routines and expectations. At this point, the primary task is to stabilize mental state and estab-lish a more secure relational base with the patient. Availability and responsiveness of clinical staff are important but quality of the interactions is even more so. Staff have to be active in providing secure base support. In this process they need to be interested and open to detecting and acknowledging distress, notwithstanding the confused, even perverse way in which it may be communicated. It helps if the staff



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response is timely and manifestly cooperative. Figure 1 attempts to summarize this, with the secure relational base at this stage provided by the core nursing team. This core team provides a buffer zone around the patient, and the role of others in the team is principally to support and advise the core team.

Stage 2: Maintaining a secure base and supporting recovery

Commitment by both qualified and unqualified staff to attend group reflective practice is imperative to the implementation of this model. Such space to focus

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members in support of the model

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Figure 1: Relationship between the patient’s attachment status and the role of the care team within secure services on admission

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on understanding the patient’s internal world, how past traumas can be re-enacted, and on acknowledging its impact on each staff mentor (Watts and Morgan, 199�) helps to counter malignant alienation. The process of reflection also assists with effective risk assessment/management, and helps the team to work proactively, rather than reactively. Figure 2 shows the shift in type of activity then possible within the model’s framework.

Stage 3: Maintenance of the secure base through discharge and follow-up

The need to maintain relational security to manage longer term risk of harm to self or others becomes particularly apparent at the stage of discharge and after-care. As the secure base becomes more internalized within the patient, she becomes empowered to function more independently, and her self-esteem and confidence increase. However, perversely, this may be complicated by the stability of the patient’s mental health and emotional well-being, which may lead to an underestimation of the level of emotional support required to sustain progress.

The capacity of women in secure services to manage issues related to their risk is dependent on a variety of factors. In further research, hypotheses based on the attachment model could be tested. Those with more disrupted and inco-herent attachment patterns, for example, may be at particular risk of reverting

Offence-related work

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Figure 2: Relationship between the patient’s developing secure attachment and the role of the care team within secure services during inpatient intervention



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to previous, more maladaptive attachment strategies at times of transition, when they experience actual or threatened separations from significant caregivers. For these patients, success may be more significantly related to levels of relational security provided by a placement and care team, than to the level of physical or procedural security of a so-called secure unit.

Figure 3 shows the patient’s expanded capacity for internalized security and the removal of the buffer zone but with ongoing professional and lay support to encourage continuing resolution and rehabilitation.

Conclusions

The behaviours of women in secure services are frequently described as chaotic and ‘non-understandable’. Attachment theory provides an explanation and a practical model of care, and partly meets the need outlined in the DoH review and guidance for supportable models of care. We have shown the feasibility of this approach in an all-female medium secure hospital unit. Next steps must be to evaluate its efficacy and cost-effectiveness, addressing the diverse presentations and psychopathologies demonstrated by these women. The theoretical framework assists in the understanding of the relevance of early, disrupted attachments that are subsequently re-enacted, and informs the development of clinical interven-tions that are meaningful both to the individual women and to the clinical team working with them.

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Figure 3: Relationship between the patient’s developing secure attachment and the role of the care team within secure services prior to discharge

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References

Adshead G (2002) Three degrees of security: attachment and forensic institutions. Criminal Behaviour and Mental Health 12(2): 31–�5.

Bowlby J (1969) Attachment. In Attachment and Loss, Vol. 1 (2nd edn 19�2). London: Hogarth Press; New York: Basic Books; Harmandsworth: Penguin.

Bowlby J (1973) Separation: anxiety and anger. In Attachment and Loss, Vol. 2. London: Hogarth Press; New York: Basic Books; Harmandsworth: Penguin.

Department of Health (2002) Women’s Health: Into the Mainstream. Strategic Development of Mental Health Care for Women. London: DoH.

Department of Health (2003) Mainstreaming Gender and Women’s Mental Health: Implementation Guidance. London: DoH.

Watts D, Morgan G (199�) Malignant alienation: dangers for patients who are hard to like. British Journal of Psychiatry 16�: 11–15.

Address correspondence to: Dr Miranda Barber, BSc DClinPsy, Forensic Clinical Psychologist, Llanarth Court Psychiatric Hospital, Llanarth, Raglan, Usk NP15 2YD, UK. Email: [email protected]

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