capa part 2 school years attachment 6-11 years

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CAPAPart2ConsolidatePart1UnderstandandcodeC5-6UnderstandandcodequasiautisticUnderstandandcodeA3UnderstandandcodeA8imitationArousalinTypeAandCUnderstandandcodeforUtrandUlDifferentiatingUtrA+fromC+UnderstandandcodeforDepressionmodifierUnderstandandcodeforifnainA+modifierMentalising

School years attachment 6-11 years In Type C cognitive development enables greater deception C5-6 DMM – in adolescence sexual maturity and less reliance on adults for protection A5-6 DMM – adulthood cortical integration A7-8 and C7-8 A8 imitation clearly present in the school years

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A Dynamic-Maturational Model of Patterns of Attachment in Infancy

Integrated Cognition Affect

pre- compulsive

Avoidant

Comfortable B3

Reserved B1-2 B4-5

Reactive

A1-2

A+

C1-2 Resistant/

Passive

A/C

pre- coercive

C+

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A Dynamic-Maturational Model of Patterns of Attachment in the Preschool Years

False Positive Affect

Integrated True Cognition True Negative Affect

Compulsively Caregiving/ Compliant

A1-2

A3-4

Comfortable B3

Reserved B1-2 B4-5

Reactive

C3-4

C1-2 Threatening/

Disarming

Aggressive/ Feigned Helpless

A/C

Inhibited/ Socially facile

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A Dynamic-Maturational Model of Patterns of Attachment in School Age


Integrated True Information True Cognition True Negative

Affect

False Cognition


A1-2

A3-4

Comfortable B3

Reserved B1-2 B4-5

Reactive

C5-6

C3-4

C1-2 Threatening/

Disarming


Punitive/ Seductive

A/C


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A Dynamic-Maturational Model of Patterns of Attachment in Adolescence



Affect

False Cognition

Compulsively Promiscuous/ Self-Reliant

Comfortable B3

Reserved B1-2 B4-5

Reactive

A5-6

C5-6

C3-4

C1-2 Threatening/

Disarming


Punitive/ Seductive


A1-2

A3-4 A/C

Dis

tort

ed C

ogni

tion

Distorted A

ffect


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A Dynamic-Maturational Model of Patterns of Attachment in Adulthood


Delusional Idealization/

Externally Assembled

Self


Comfortable B3

Reserved B1-2 B4-5

Reactive

A1-2

A3-4

A7-8

A5-6

C7-8

C5-6

C3-4

C1-2 Threatening/

Disarming


Punitive/ Seductive

Menacing/ Paranoid

AC Psychopathy

A/C

True Cognition True Negative Affect

False Positive Affect False Cognition

Integrated False Information

Integrated True Information

Dis

tort

ed C

ogni

tion

Distorted A

ffect


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Coding: pre-school v school-years Pre-school 3- 6 years School years 6 – 11

Developmentally stems are perfect for their ZPD

Can understand the purpose of the stories

Coding less dependent on discourse than social engagement signals and arousal

Discourse becomes very important – need to know DMM-AAI discourse analysis

Theory of mind not developed to point of covert deception

Greater deception

Strategies B, A1-4, C1-5 Increase in strategy – A8 (A5,6) C5-8; absence of quasi autistic

Ages 3 and 5 (entry to year 1) bring reorganisation –making coding difficult

Developmentally more stable (latency period?)

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C5 C6

Dismissesvulnerability–ofselfandother

Inhibits/concealsanger

Obsessedwithrevenge Obsessedwithrescue

Seesselfasvictim

Deceptive–hidesownintentionsuntilclearwhattheotherpersonwilldo

Risktakingbehaviour–risktoself(C6)andtoselfandothers(C5)

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Difference between C1-2 & C 3-4

C1-2 C3-4Lackofcooperationcovert–e.g.offtopicbutgenerallysociablewiththeinterviewer

Overtoropenstrugglewiththeinterviewer–i.e.thestrategyisactedoutwiththeinterviewerintheroom

Lowlevelofviolenceinstories Cartoonviolence(C3)

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Difference between C3-4 & C 5-6

C3-4 C5-6Hotaffect(C3)Helpless(C4) Coolermorecontrolledaffect

Overtstruggle Deception

Menace,sadism,sex(C5)Risktoselfinthestoriesorintheroomwiththeinterviewere.g.puttingfingerincroc’smouthsoit‘hurts’(C6)

ImitationA8•  Themostcompletefalseself•  Denialoftraumaticexperience•  Shame

•  HypothesisedtobeproductoffailureofA3-4strategiesand/ormultiple(2-3+)movesinthecaresystem

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Coding for A8 •  Dramatic run on stories with GTO & FPA

•  The child takes all the parts and does all the voices – so it’s like watching a play

•  Often involves borrowed (American!) accents from films / TV

•  May copy mannerisms / accent of the interviewer

•  Stories often very long and boring (because there is no self story)

•  The stories do have negative affect but dismiss the consequences

•  The child may pause as s/he makes up the next bit

•  Comments like “that was a long one” or “this is a hard one”.

•  Denial of traumatic events

•  May involve morality tales as to how things should be / what happens when bad children misbehave

•  Child’s arousal often plummets in between stories.

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Difference between A8 and Type B •  Type A discourse •  FPA • Expressed negative affect which is borrowed or distanced

from the self or where the effects are denied. • A phoney canned quality to the delivery •  Frequently have evidence for Utr

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Mulberry Bush Study Using 8 way distribution of patterns

(A3-4/A+; A5-6; A8, C2-4; C5-6; C7-8; A/C and QA) At entry most common pattern was A8 (32% n=16) At FU (2 years later) it was A/C (28% with A8 2nd @ 22%) Most stable patterns across 2 years were A8 and C5-6 50% of children in both patterns had the same pattern at follow up) (X2 (42, N=50) =70.405, exact p=.003).

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Imitation In the DMM the externally assembled self (A8) is not seen as strategic until adulthood BUT: “Imitation is not a skill babies learn – it is an ability they are born with. An infant's ability to imitate simple actions, such as sticking out her tongue, comes from the same part of the brain that allows young children to develop empathy. http://www.parentingcounts.org/parent-handouts/information-for-parents-imitation.pdf

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A7 delusional idealisation

• A7 extremely rare in school aged children’s stems • Developmentally they do not have the cognitive distance

from childhood to organise it.

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Unresolvedtrauma:BIGquestions:1.  Howtointerpretviolenceinchildren’sstories2.  HowtousethestemstoaccuratelyscreenforPTSD/

developmentaltrauma.

3.  Howtodistinguish ‘normative’(usuallyTypeC)violencefromPTSD/unresolvedtrauma.

4.  Howtoidentifyhiddenordismissedformsoftrauma

5.  Howtodefineandidentifydissociation

6.  DistinguishbetweenUtrA+andC+

7.  Whatarethecommonalities&differencesbetweenA+&C+reUtr?

8.  WhatISA/C?

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Thesis

•  All endangered children organise a defensive strategy

•  We call these DMM attachment Types A and C

•  These strategies are formed in infancy and moulded by later trauma

•  Type A & C organise around trauma in different ways

•  Type A organise around inhibition and ‘freeze’ (PSN)

•  Type C organise around flight or fight or cling (SNS)

•  Unresolved trauma is a breakdown of strategy and requires different

intervention according to Type A or C

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Attachment

• Attachment strategies function to protect the self

•  i.e. behaviour is organised around a self protective

strategy

•  Insecure – anxious attachment strategies are functional

and on their own do not indicate ‘pathology’

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Steve Farnfield February 2018 !

Attachmentinvolvessocialengagementsignals

18/02/18 ! 21 Steve Farnfield February 2018 !18/02/18 ! 22

Steve Farnfield February 2018 !18/02/18 ! 23 Steve Farnfield February 2018 !18/02/18 ! 24

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Steve Farnfield February 2018 !18/02/18 ! 25 Steve Farnfield February 2018 !

Synchronypromotesselfregulationandmentalising

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Steve Farnfield February 2018 !18/02/18 ! 27 Steve Farnfield February 2018 !

TraumaBREAKDOWN IN SOCIAL ENGAGEMENT

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Steve Farnfield February 2018 !

Trauma

18/02/18 ! 29 Steve Farnfield February 2018 !

Trauma

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In essence trauma appears to be an experience of:

• Aloneness

• Solitude

• Shame

I.e. absence of social engagement

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Isolation is traumatic

Stephen Porges

Isolation is traumatic Stephen Porges

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What is trauma?

•  A bad thing happening to the self, self substitute (sibling) or attachment figure.

•  The nature of the bad thing should be such as to

raise severe doubts as to the safety, integrity and

even survival of the self.

•  The bad thing may be a one off or repeated event.

•  Traumatic acts perpetrated by attachment figures

tend to be more damaging children than things done

by outsiders.

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What is trauma?

•  Feelings are evoked in the present which are tied to / associated with bad things that happened in the past

•  This includes both the original traumatic experience and the subsequent ‘flash backs’/defences.

•  The child behaves as if the bad thing were happening now and uses behaviour, including displays or inhibition of affect, that he feels are self protective even though they may not function to protect him.

•  This produces a temporary breakdown in social engagement – flight/fight/freeze

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Post traumatic stress – preschool-children

The American Diagnostic and Statistical Manual of Mental

Disorders (DSM 5 : APA, 2013) introduced a new set of

PTSD criteria for preschool children based on symptoms of:

•  intrusion

•  avoidance

•  increased arousal.

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PTSD

These broadly overlap with the basic ‘attachment’ defences

of preoccupation, dismissal and hyper arousal or

disorganisation.

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DSM5 – PTSD adults

There are now four clusters of symptoms:

•  intrusion

•  avoidance

•  negative alterations in cognitions and mood

•  alterations in arousal and reactivity

(Types C, A, Dp & D)

Together with a clinical subtype - dissociation

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Borderline personality disorder BPD is commonly associated (comorbid) with PTSD

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Utr

• A breakdown in A and C strategies (Crittenden)

• Breakdown in social engagement

• Self protection over rides social engagement

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DMM - Unresolved loss and trauma

• Ul and Utr temporary derail a functional strategy when

current events evoke responses to previous loss or

trauma often at a physiological level

• Once arousal is lowered and the threat passes the self

can organise strategically until the next time …

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Dismissed loss or trauma Crittenden (2002)

•  Information which might predict a recurrence of the danger is discarded

•  The impact of events is minimized, blocked or otherwise inhibited

•  Mental pain may be somatised

•  Over attribution to the role of the self in causing the event

•  In some cases, rather than blocking or repressing feelings, the relationship was, in fact, only superficial or the ‘trauma’ was never encoded by the brain when the incident occurred.

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Preoccupied loss or trauma Crittenden (2002)

•  Information which is unnecessary for the prediction of a

recurrence of the danger is retained;

•  Recall of the event is emotionally intense and floods both

the present and predictions about the future so that the

person, irrationally, believes it will happen again

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Of particular importance are reversals:

• Preoccupation/fabulation in a Type A strategy

•  Inhibition/minimization in a Type C+ strategy.

• Both are evidence that the usual coping strategies have

failed to meet the challenge of the evoked trauma.

•  This may be the basis for PTSD (Crittenden).

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Hyper vigilance.

• Danger is everywhere in present time

• Strategies break down

•  The child cannot regulate their arousal

• Disorganised

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Infancy – dissociation predates trauma?

•  Van Der Kolk and de Zulueta see dissociation as

the essence of trauma

•  Van Der Kolk (2015: 121) – dissociation predates

any trauma. It comes from very unresponsive or

mis-attuned parenting in the first 2 years of life

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Terr (1991)

Type 1 Unanticipated single event

Clear memory of the event, repetition, avoidance, and

hyper alertness

Type 2 Long standing, repeated exposure

Massive denials, psychic numbings, self-anessas and

personality problems

Lack of a coherent narrative (developmental trauma)

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Developmental Trauma disorder (Van Der Kolk)

1.  Pervasive pattern of dysregulation

2.  Problems with attention and concentration

3.  Difficulty getting along with self and others

4.  Shifts from tantrums & panic to detachment, flatness &

dissociation (Van Der Kolk, 2015: 158)

Rejected by DSM 5 but included in ICD-11 as complex PTSD

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ICD-11 - complex or developmental PTSD

6 clusters of symptoms

3 PTSD 1.  Re-experiencing 2.  Avoiding 3.  Hypervigilance

Plus 3 disturbances of self organisation 4.  Emotional dysregulation 5.  Interpersonal difficulties 6.  Negative self concept

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Study of 165 Danish psychiatric outpatients

36% diagnosed with Complex PTSD compared with 8%

PTSD Møller L, Augsburger M, Elklit A, Søgaard U, Simonsen E. (2020) Traumatic experiences, ICD‐11 PTSD, ICD‐11 complex PTSD, and the overlap with ICD‐10 diagnoses. Acta Psychiatr Scand 2020: 1–11

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Developmental Trauma

DMM - A 3-8 & C 3-8 are organised responses to developmental

trauma

ABCD – most infants in D organise to A3 or C3 in the school years

A few remain in D

Only D predicts serious problems in later psycho-social functioning

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Rethinking trauma

•  In many cases infant D is likely a precursor of Utr

so drop it

• Most of the work on PTSD fits Terr Type 1

• Terr Type 2 describes developmental trauma

• U Trauma in B likely Type 1

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Trauma

BREAKDOWN IN SOCIAL ENGAGEMENT

Attachment Social engagement1. Behavioural signals2. Representations

Sensory integration

Self regulation rather than interpersonal regulation or social engagement

1. Physical disability2. Learning disability3. Trauma

Unresolved traumaSelf protection rather than social engagement

Disrupts attachment strategy

DMM modifiers

Intrusions forbidden negative affectSomatic signsDepression

May have a chronic effect on the functioning of the strategy

ReorganisationDisorientation

Assessment

!X 52

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Codingfortraumainchildren’sstories

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Unresolved / disorganised markers in the MSSB/Anna Freud systems

These groups identified a number of categories which are

generally taken as strong indicators of unresolved trauma

or disorganisation.

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Disorganisation

They are biased towards preoccupation:

•  catastrophic fantasy

• magical/omnipotent responses

•  bizarre/atypical responses,

•  figures dead or thrown away without comment,

•  abandonment / kidnap and sexual material.

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Coding violence/catastrophic fantasy

•  If we simply code content we will end up with a large

number of children who tell violent stories

• Some of these will be typical kids

• What matters is the gap between playing & reality (Winnicott).

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CAPA - cartoon violence C3

•  C3 is a form of social engagement

•  The child is in control of the story

•  It functions to take control of the airwaves and maintain the

attention of the interviewer

•  The child does not always know what he is going to say next (Gazzanaga’s interpreter).

•  Has similarities with Utr Preoccupied but in Utr(p) the child is controlled by the story theme (stuck play)

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Rethinking trauma Type C+

•  Type C5-8 a lot of traumatic experience is subsumed into

the strategy: menace, sadism, paranoia

•  I.e. they meet the danger head on by either 1. attack 2.

feigning vulnerability in order to neutralise the aggressor.

•  This is highly strategic - so much so that it is hard to

decide at times at what point strategy has failed and we

are looking at trauma.

• When Cs lose strategy SNS fight/flight

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Type C Organisation around danger - fight:

•  Deception

•  Attack

•  Dismiss other’s feelings

•  Other’s responsible

•  Humiliation

•  Perceive self as victim & blameless

•  Identify with the aggressor

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Type C organisation around danger - fight:

Threatening

Aggressive

Obsessed with revenge

Menace Crittenden

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Type C organisation around danger - cling:

Deception

Exaggerate or feign vulnerability

Dismiss other’s feelings

Other’s responsible

Humiliation

Assume role of the victim

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Type C organisation around danger - flight/cling:

Disarming

Feigned helpless

Obsessed with rescue / seductive

Paranoia

(Crittenden)

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Breakdown of strategy - Type C

• Dissociation – loss of the split of part of the self

(anger/vulnerability)

•  Loss of control

• Sadism

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Attachment Type C5/7

•  Possibly the precursor to sociopathy / antisocial personality disorder

•  Attachment figures have signalled comfort only to abuse the child

•  Everyone is now potentially dangerous

•  Humiliation

•  Sexual sadism (form of comfort disorder?)

•  Sensory integration appears normative

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Utr preoccupied in a Type C+ story This is difficult to determine because we are looking at fabulation in a fabulated narrative!

•  There is evidence for a Type C+ strategy

•  The child becomes controlled by aspects of the story (the Utr); it

becomes a story that has to be told - stuck play.

•  There is a recurring theme(s) suggesting trauma (e.g. hiding repeatedly;

wet beds)

•  The Utr passages occur in some stories only

•  Rather than functioning to control the interviewer (Type C+) the child

seems possessed by the story (stuck play)

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Rethinking trauma Type A+

•  Type A+ use self protective strategies which involve

hiding, numbing, avoiding, placating powerful people.

• When these strategies fail they lose control, flip into high

states of anxiety (INAs). Once in an INA they find it hard

to calm down. Indeed well meaning adults may only

prolong it.

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Type A - organisation around danger:

Freeze

Dissociation

Inhibit negative own feelings

Self responsible

Shame

Placate the aggressor (deception)

Identify with the victim

Depression

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Type A - organisation around danger:

Compulsive caretaking inhibit desire for comfort

Compulsive compliance inhibit anger + comfort

Self reliance inhibit desire social relations

Trauma bond DV

False self

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Breakdown of strategy - Type A

•  Intrusion of forbidden negative affect

•  Anger Rage

•  Comfort seeking Sexual assault

•  The person is out of their own control

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Intrusions of forbidden negative affect

A modifier

INAs!

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Intrusions of forbidden negative affect in a Type A+ strategy – INAs!

•  Clear evidence of a Type A+ strategy

•  Very high arousal which cannot be contained by the child/ adult

•  Outbursts of rage, fear or desire for comfort (sexualised)

•  These outbursts may be brief, prolonged or intermittent.

•  They are not preoccupied (suggesting an A/C) because they

are not strategic; ie the child/adult does not disarm or even

notice what she is doing. Like a character in a mediaeval play

she IS rage.

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Coding Utr •  Concerning themes across stories – e.g. wet beds, people looking down at

dead people

•  Preoccupied stories in Type A+ which are told with flat affect. In effect P with the content but Ds re affect.

•  Hyper-vigilance – e.g. starting at noises outside, suddenly looking at the door, asking the interviewer if someone is coming in.

•  Weird or bizarre content

•  Content that feels chillingly real (often told with flat affect)

•  Somatic expression of bodily pain

•  Dissociation

•  Depression

•  Inability to use the interviewer or therapist for relief

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Preoccupied trauma in a Type A+ story •  Here the trauma runs counter to the strategy

•  There is clear evidence for a Type A(+) strategy in other stems •  Obvious high arousal (in a child who may have appeared inhibited) •  The child becomes controlled by aspects of the story (the Utr

preoccupied); it becomes a story that has to be told •  There is a recurring theme(s) suggesting trauma (e.g. hiding repeatedly;

children keep going to bed) •  Type C markers around certain themes/stories; i.e. no closure, off topic,

escalation of problems •  The Utr passages occur in some stories only •  They do not function to shock the interviewer •  Fabulation which is drained of affect - suggesting depression. in A+

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Therapy

“There is a general consensus that either end of the physiological arousal spectrum (i.e. states of hyper-arousal or dissociation) hinders the processing of traumatic or difficult experiences and that there is a desired ‘window of tolerance’ that a child must move within for therapeutic effect. ” (Prichard, 2016)

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Theoretically, dynamic play occurs when three elements are present:

1. An active play circuitry,

2. A perception of safety

3. A supportive relationship.

This is the type of play a play therapist hopes to facilitate. In dynamic play the child is in an optimal state of physiological and psychological arousal, that best facilitates the reworking and integration of trauma, without triggering defensive fight, flight or freeze reactions.

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Stuck or toxic post-traumatic play

Some types of play do not aid in the re-working of trauma

This play has been called stuck play (Goodyear-Brown, 2010) or

stagnant post-traumatic play (Gil, 2006).

In stuck play children tend to be unaware of the presence of the

therapist. This play also lacks imagination, joy, spontaneity and

variety and fails to bring relief (Gil, 2006; Levine & Kline, 2007).

It can be re-traumatising

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Dynamic post traumatic play

Alternatively, dynamic post-traumatic play allows

for the re-working of trauma and is characterised

by visible affect, variety, creativity, imagination,

symbolism, joy and relief and an acknowledgement

of and interaction with the therapist (Gil, 2006).

This is re-integrative and regulatory.

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Dynamic post traumatic play

•  The child can use the interviewer or therapist as a

means of seeking meaning and emotional relief

• Eye contact

• Moderate arousal

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Gil 2017

Appendix

Checklist for Posttraumatic PlayChild’s Name Date of Session Session No.

Dynamic Posttraumatic Play Toxic Posttraumatic PlayAffect variable Affect constricted/flat

Seeks interactions with clinician Play is focused and isolated

Available for emotional connection Unavailable for emotional connect

Breath fluid Breath shallow/holds breath

Physical movement is fluid Physical tension

Evidence of release No evidence of release

Focused investment in play Rigid interaction with play

Story starts/ends differently Story starts/ends unvaried

Story has new information/ characters

Story is repetitive, without change

Presence of new themes Thematic material remains fixed

Play occurs in different locations in room

Play must be presented in the same place

Adaptive outcomes emerge No new outcomes emerge

Rigidity loosens over time Play remains rigid

New characters are added/deleted No new characters are introduced

Role playing emerges Play still: No role playing (maybe play stagnant?)

Child’s voice is given to story characters

Child’s voice is not present

Temporary increase of symptoms Symptoms increase and stabilize

At-home behavior improves At-home behavior deteriorates

From Posttraumatic Play in Children: What Clinicians Need to Know by Eliana Gil. Copy-right © 2017 The Guilford Press. Permission to photocopy this material is granted to pur-chasers of this book for personal use or use with individual clients (see copyright page for details).

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DMM Modifiers

Have a more pervasive / permanent effect on a person’s strategy

• Depression

• Disorientation •  Intrusions of forbidden negative affect

• Expressed somatic signs • Reorganisation

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Depression – a modifier Crittenden (2002)

•  Used in a restricted sense and is not intended as a proxy psychiatric diagnosis

•  The person values love relationships but gives clear indications that restoration of same is hopeless

•  Indication that previous strategies (such as dismissal or preoccupation) no longer work

•  Perception of the self as an object with no control over their life

•  Intense, sad affect

•  Futility.

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Coding Dp or partial [Dp] •  Lack of eye contact or interest/connection with the interviewer.

•  An inability to use the interviewer for relief

•  Lack of self agency; i.e. the inability of the characters to make anything happen and an acceptance of the same

•  A sense of stuckness and/or futility in the stories and/or the child

•  Lack of play/exploration

•  Low arousal including slumped body posture; yawning; sighing

•  Sadness

•  Zoning out

•  Repetitive, rhythmic actions, such as repeatedly tapping a figure on the table or dropping figures down the chimney of the dolls house. This may sometimes appear to be self soothing.

•  Repetition of words that do not motivate action ‘sad’ or cancel each other out ‘angry’ and ‘sad’.

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Affect (Crittenden)

• Arousal, changed body state (feelings), motivates

action

•  Comfort → continuing activity

•  Anger → aggression

•  Fear → escape

•  Desire for comfort → affectionate approach

•  Tiredness → no action

•  Sadness → no action

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Intensity, Arousal, & Affect (Crittenden)

• Mania & Pain • Sexual arousal •  Fear • Anger • Desire for comfort • Alert & comfortable • Bored •  Tired • Sleep • Depressed • Unconscious

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Intensity, Arousal, & Affect: Normative (Crittenden)

• Anger • Desire for comfort • Alert & comfortable • Bored • Tired

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Intensity, Arousal, & Affect: Severe Pathology (Crittenden)

• Mania & Pain • Sexual arousal • Fear •  •  •  •  • Sleep • Depressed • Unconscious

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Management of arousal in A+ B and C+ Type A Type B Type C The self is responsible Co-regulate with adult Others are responsible

so use a struggle to regulate self

Hide negative feelings; project sense everything is all right, nothing to see here, I am boring & of no interest

Make feelings explicit and seek shared understanding

Split off unmanageable/unwanted feelings, get the adult to experience them

Risk of depression/ mania; ina’s; ‘sexual arousal’, self harm.

Boredom, anger; greater tolerance of self than A or C.

Boredom; sadism; ‘sexual arousal’, risk taking behaviour,

Isolation is traumatic

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Do not assume high arousal = C

• Both A and C patterns are anxious insecure

• Children in A try to hide anxiety

• Children in C display negative affect

• Only C3 is obviously aroused

• ALL As look aroused albeit while trying to conceal it

•  In the Mulberry Bush study there was a significant

association between a diagnosis of anxiety disorder and

Type A but not C

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Arousal in C+

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Arousal in Type A+

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Differentiating A+ from C+ Type A+ Type C+

Relationship with the I

Please, comply, placate Struggle

Arousal Rely on self for regulation; see arousal scale

Use the I to regulate the self; see arousal scale

Discourse GTO; absence inhibit neg. affect – check A8

ROS; C5-8 deception, false cognition

Mentalising External reference, concrete

Preoccupied, internal

Modifiers IfNA only in A+, Dp more likely

Dp less likely

Utrauma Both show stuck or dynamic post traumatic play

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False A in Type C •  In the AAI idealising one parent in order to trash or blame

the other. •  In stems: The stems are coded Type C including the

relationship with the interviewer but in between stories the child is very co-operative and polite.

• At set up and first few stories the relationship with the I looks A or even B but then settles into clear Type C5-6 – basically the child is ‘holding fire’ until s/he has got the measure of the I and the task

• Written as [A] e.g. [A] C5

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StemsratedA/C

Alternating A and C strategies

A and C strategies are used independently and switched

around according the level of perceived threat

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The rating of A/C requires the following:

• The interview is codable and contains markers that

have been met with before and are covered elsewhere in the manual

• The child’s stories and behaviour are not adequately

described using a single type A, B or C notation

• Type A and C markers are clearly evident at different

parts of the exercise

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In addition:

•  The coder should form a hypothesis as to the function of

the A and C strategies.

• E.g. A when very anxious, C when less so

•  This may be seen in terms of a response to a particular

story or stories or to the interviewer at different parts of

the exercise.

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Dissociation

Some interviews appear to contain A and C behaviours which do not appear to function strategically.

Parts of the interview appear chaotic and ‘uncodable’

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Symptoms of Complex PTSD linked to disorganised attachment (de Zulueta)

•  Impaired affect modulation

• Dissociative symptoms

•  Somatic complaints

•  Feeling constantly threatened

•  Self destructive/ impulsive behaviour often re-enacting the

trauma

•  ie shame > dissociation > violence

•  ie Vietnam veteran and anniversary

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Fear without Solution and Structural Dissociation (de Zulueta) •  The infant’s psychobiological response to such states comprises 2

possible response patterns:

•  1. ‘Fight-flight’ response mediated by the sympathetic system. This blocks

the reflective symbolic processing with the result that traumatic experiences

are stored in sensory, somatic, behavioural and affective states.

•  2. If ‘fight-flight response is not possible, a parasympathetic dominant state

takes over and the infant ‘freezes’ in order to conserve energy, feign death

and foster survival.

•  Vocalisation is inhibited.

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Structural dissociation around the‘fulcrum’of the traumatic attachment (de Zulueta)

• Children in fear of their care-giver’s hatred and violence will:

•  Need to maintain their attachment to their desperately needed caregiver:

the resulting Traumatic attachment’ increases with rejection and

fear.

•  Resort to splitting ie creating different representations of themselves

and their caregiver resulting in a lack of self continuity in relation to the

other as in BPD (Fonagy and Target,1997) ie multiple IWMs.

•  The Traumatic Attachment provides the fulcrum for ‘structural

dissociation’ to take place and maintains it.

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Clinical signs of structural and other forms of dissociation (de Zulueta)

•  The phenomenon of dissociation should no longer be

ignored in our understanding of such phenomena as:

•  Inexplicable shifts in affect

•  Discontinuities in train of thought.

•  Changes in facial appearance, speech and mannerisms.

•  Apparently inexplicable behaviour

•  Somatic dissociative phenomena: eg swollen eyelids

•  The ‘incoherence’ in the “unresolved” text of the AAI

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Dealing with dissociation (de Zulueta)

•  Its management requires a good attachment relation in therapy and techniques to reduce its frequency and intensity.

• Shame is important in eliciting dissociation

• Grounding techniques for dissociation: spicy tea bags and flower oils. Aim when dealing with trauma is to maintain ‘one foot in the past and one in the present’.

• Tape recordings of session or video.

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Dissociation

Some Type C+ stems are coded dissociative [A] C5+. This

does not refer to pseudo compliance (which is strategic) but

stems where the child enacts or depicts sadistic or angry

themes consistent with Type C5/7 but then relates to the

interviewer as if nothing had happened.

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A Dynamic-Maturational Model of Patterns of Attachment in Infancy

Integrated Cognition Affect

pre- compulsive

Avoidant

Comfortable B3

Reserved B1-2 B4-5

Reactive

A1-2

A+

C1-2 Resistant/

Passive

A/C

pre- coercive

C+

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A Dynamic-Maturational Model of Patterns of Attachment in the Preschool Years


Integrated True Cognition True Negative Affect


A1-2

A3-4

Comfortable B3

Reserved B1-2 B4-5

Reactive

C3-4

C1-2 Threatening/

Disarming


A/C


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A Dynamic-Maturational Model of Patterns of Attachment in School Age



Affect

False Cognition


A1-2

A3-4

Comfortable B3

Reserved B1-2 B4-5

Reactive

C5-6

C3-4

C1-2 Threatening/

Disarming


Punitive/ Seductive

A/C


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A Dynamic-Maturational Model of Patterns of Attachment in Adolescence



Affect

False Cognition


Comfortable B3

Reserved B1-2 B4-5

Reactive

A5-6

C5-6

C3-4

C1-2 Threatening/

Disarming


Punitive/ Seductive


A1-2

A3-4 A/C

Dis

tort

ed C

ogni

tion

Distorted A

ffect


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A Dynamic-Maturational Model of Patterns of Attachment in Adulthood


Delusional Idealization/

Externally Assembled

Self


Comfortable B3

Reserved B1-2 B4-5

Reactive

A1-2

A3-4

A7-8

A5-6

C7-8

C5-6

C3-4

C1-2 Threatening/

Disarming


Punitive/ Seductive

Menacing/ Paranoid

AC Psychopathy

A/C

True Cognition True Negative Affect

False Positive Affect False Cognition

Integrated False Information

Integrated True Information

Dis

tort

ed C

ogni

tion

Distorted A

ffect


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Expressed somatic signs – a modifier

•  Often ordinary behaviours that occur to excess

• E.g. sniffing, coughing, ticks, yawning …

•  They represent the conflict between what is known or

suspected and what one is permitted to know or say

•  Family secrets

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DMM – AAI Disorientation – a modifier

•  Problem with source memory

• Sources of information over attributed to the self

• Subject cannot organise around either self (Type C) or

other (Type A) perspective but flip flops from one to the

other

• Always coded Type A/C or AC

•  Very rare in stems

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Coding for reorganisation •  The child is co-operative with the interviewer and can make sustained

use of the interviewer to manage arousal and find solutions to the stories.

•  Good eye contact with the interviewer.

•  The discourse has A or C markers but there is some evidence of change - e.g. other’s perspective in a Type C and self perspective/openness to negative affect in Type A.

•  Humour.

•  Moderate arousal.

•  Stories end on a benign note

•  High levels of mentalising.

•  Depression may be part of reorganisation for some children

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Reorganisation – a modifier

•  From an insecure pattern towards B

• Result of maturation – 2 & 5 years and puberty/

adolescence

•  Therapy, love relationships, safer conditions and time

itself

• Adults become “earned Bs”.

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IO Insecure other •  Evidence of A and C discourse

•  Moderate swings in arousal

•  The ability to make some use of the interviewer

•  Benign story endings in the last stories (rather than starting in a

self regulated way but losing regulation as the stress goes up).

•  Balanced stories that have flat affect.

•  Dynamic post traumatic play not stuck play.

•  Spikes of mentalising.

•  The start of reorganisation

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Quasi autistic

Disappears in the school years

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CAPA stability over 2 years Mulberry Bush study •  For 8 way attachment ICC = .609 with 95% confidence interval = .29 - .79

p=<.001 (moderate stability)

•  Four way - 64% (70% including CC) of the children stayed in the same pattern (A, C, A/C or QA), 26% of children showed a shift to or from A/C (mainly between A and A/C) while 10% of changes were discrepant (ie change from A to C or vice versa)

•  The ABC+D Manchester Child Attachment Story Task (MCAST) found 76.5% of ABC categories (71% for insecure) and 69% of D remained stable over a median 5.5 month period (Green et al. 2000).

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Change in attachment strategy Least susceptible to change was Type C (83%) followed by Type A (70%) then A/C (43%). At follow up the most common pattern was A/C. This is the most complex pattern and one usually associated with high levels of threat. However it is possible children used A/C to manage two types of environment – care at the Bush and home.

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Modifiers • The modifiers produced stronger correlations with both parental characteristics (substance abuse and mental illness) and child diagnoses (depression, anxiety and attachment disorders, ADHD) than attachment strategies.

• This supports the theory that attachment is an organised response to danger whereas the modifiers identify breakdowns in strategy – experiences attachment cannot manage. Put another way the modifiers are an indicator of pathology whereas attachment is akin to social engagement and resilience.

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•  Dp modifier correlates with diagnosis of depression

•  100% correlation between QA and NOFT

•  Significant association between anxiety disorder and a

Type A attachment at entry and follow up

•  23% of the variance in unresolved loss or trauma at entry

was accounted for by having a mother who substance

abused in pregnancy.

•  The persistence of unresolved loss or trauma was associated

with having a mother aged 19 or younger at birth or a parent

with a mental illness in the first year of life, accounting for 15%

and 29% of the variance respectively.

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• Unresolved loss of family correlated with a diagnosis of

attachment disorder.

• Unresolved loss of family also correlated with self-harm

and diagnoses of depression and anxiety disorder.

• Children who self-harmed (n=9) were in Type C or QA at

entry and follow up. It seems that self-harm has a different

function for each of these attachment patterns: eliciting

attention in Type C and sensory relief in QA with the latter

being a non-social engagement / non attachment issue.

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INAs • Most significant at entry is the association between INAs and changing placement. This fits the theory that INAs are explosions of rage or (sexualised) desire for comfort that are out of the child’s control (Crittenden 2008/2016) and seem likely contributors to placement breakdown or decisions to move the child.

• This is an important finding as INAs may prove an important predictor of placement breakdown.

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Story themes • On the results of this study the risk of false positives or Type 1 errors for physical abuse, neglect, domestic violence and loss of birth family appears to be low but the ability to capture a large percentage of a particular abuse category is equally low with a high probability ofType 2 errors.

• The correspondence of particular play themes between entry and follow up was poor indicating play themes using the narrative story stem procedure are labile.

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What correlated with change in attachment, play and resolution of trauma and loss?

Improvement 44% of children

No change 28% of children

Deterioration 28% of children

Diagnosis of attachment disorder Not having a statement A mother aged 20+ at time of birth Entering with Type A8 attachment [Psychotherapy]

Diagnosis of depression On medication at entry Entering with Type A3-6 attachment Type C attachment Twice weekly therapy

Diagnosis of ADHD Mother substance abused in the first year To a lesser degree mothers substance abuse in pregnancy Parental mental illness in the first year A mother aged 19 or less at time of birth Entering with Type A3-6 attachment On medication at entry

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• May 22 Megan • May 28 Max •  June 5 Sis •  June 8 Zoom seminar 3 – 5pm •  June 12 Yael •  June 19 Tyrone •  June 26 Gemma •  July 3 Chloe _+ transcript Alan •  July 10 Hugo + Zoom seminar 3 – 5pm

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capa part 2 school years attachment 6-11 years

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