Breaking the cycle: a clinical example of disrupting an insecure attachment system. (Practice).

Attachment theory has increasingly become a primary clinical focus as mental health counselors cope with the repercussions of an insecure attachment style. Mental health counselors working with emotionally impaired children face severe behavioral challenges, and approaching these challenges from an attachment systems perspective allows the mental health counselor to address the child's treatment issues on a variety of levels. This article provides a brief overview of current attachment literature, an argument in favor of using attachment theory based on the possible consequences of insecure attachment, and then provides an example of treating an emotionally impaired teen from an attachment perspective.

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Working with emotionally impaired children in foster care provides many clinical challenges. However a clinical implication sometimes overlooked is the effect of attachment style on the ability of a child to function in the foster home. Traditional behavioral approaches address the behavior but may miss the importance the child places on maintaining his or her attachment system. The purpose of this article is to provide mental health counselors with a clinical example in which an attachment theory approach proved useful and contributed to successful treatment of a young adolescent client. A clear understanding of the attachment system aids in clarifying the treatment approach as well as attachment's possible effects on development, since the development of possible psychiatric disorders derived from insecure attachment patterns could persist into adulthood.

ATTACHMENT THEORY REVIEW

Attachment theory contains many factors, including a biological or behavioral component, an emotional or psychodynamic component, and a social or systemic component that addresses issues of communication and interpersonal interaction. From a biological perspective, an infant arrives preprogrammed to develop in a socially co-operative way. The child responds, learns, and becomes attached to the aspect of the environment that will ensure survival (Lewis & Volkmar, 1990). Pain, fatigue, and fear in general activate the attachment response, which protects the child from predators (Bowlby, 1988). Attachment is the behavior of attaining or maintaining proximity to some other clearly identified individual who is conceived as better able to cope with the world. Attachment acts as an environmental homeostasis, allowing the child to tolerate distance and understand accessibility by using sophisticated methods of communication to maintain contact with the attachment figure.

The psychodynamic aspect comes into play when a child senses a discrepancy between desired availability and current circumstances. The child strives to reduce the discrepancy by internalizing an image of the primary caregiver, thereby developing object constancy and tolerating separation (Kobak & Cole, 1994). Attachment then influences how the child perceives the parent and the environment based on the child's internal representation of others, eliciting the environment to act in a way that perpetuates the child's internal attachment model (van Ijzendoorn & Zwart-Woudstra, 1995). For example, a child who experienced rejection will expect rejection from others. The child proceeds to exhibit behaviors often viewed as hostile and aggressive, which in turn causes the environment to reject the child. Attachment patterns become a self-fulfilling prophecy, trapping the child in a circle of despair. The more the child tries to attach, the more rejection the child receives.

The emotional basis of attachment is based on an affectionate, specific, and discriminating tie that one person forms to another person (Lewis & Volkmar, 1990). However, children will exhibit attachment behavior toward any stable adult available. While children prefer the primary caregiver, the biological need for attachment allows the child to chose a stranger as the attachment figure in order to survive (Bowlby, 1988).

The systemic nature of attachment involves the communication patterns the child develops as a result of the early interpersonal experiences. As the child develops an internal working model of the attachment figure, the constant feedback loop derived from the attachment behavior maintains the system. The child strives to reduce stress brought on by separation, and the behavior forms an action loop that regulates appraisals of attachment figure's responses (Kobak & Cole, 1994). The child also builds an internal self model that reflects the image the parents' project, which in turns determines communication and behavior patterns and styles with others in the environment (Bowlby, 1988).

Attachment theorists divide attachment style into four categories based on scientific observation (Ainsworth, 1992). Secure attachment implies successful negotiation between the child's needs and the appropriate response of the caregiver. The other three attachment styles, collectively referred to as insecure attachment, may occur as part of normal development, but the intensity of the insecure attachment puts a child at risk for clinical pathology. Anxious-avoidant attachment occurs when the child cannot rely on the attachment figure and expects rejection. Anxious ambivalent attachment occurs when the attachment figure responds in an aloof manner. Disorganized attachment occurs when a child lacks a consistent attachment model and randomly chooses attachment methods to get needs met. As the child ages, threats of abandonment create intense anxiety (Bowlby, 1988).

POSSIBLE CLINICAL IMPLICATIONS OF INSECURE ATTACHMENT STYLES

Persons with insecure styles seem more at risk for serious psychiatric disorders, though insecure attachment per se does not seem to be linked, in a deterministic way, to serious psychiatric difficulties. One important identified risk factor is loss or trauma, especially if linked to the primary attachment figure. "Unresolved attachment organizations in adulthood are believed to reflect a history in which the attachment system and the organizational capacities of the individual were overwhelmed in response to a major loss or trauma at some previous point and have not subsequently become reorganized in a correct fashion" (Allen, Hauser & Borman-Spurrell, 1996, p. 255). These researchers found that adults with dismissing attachment patterns reported significantly more criminal behavior than securely attached adults reported. From a developmental perspective, attachment style could interfere with the successful negotiations of developmental tasks, making a child more susceptible to encountering difficulty when trying to resolve these tasks (Rosenstein & Horowitz, 1996). For example, a child with an insecure attachment might struggle to achieve a sense of initiative or industry, resulting in a sense of guilt and inferiority. These difficulties would then compound the child's sense of insecurity, and perpetuate the insecure attachment style as the child attempts to overcome these feelings with either angry or needy behavior.

An insecure attachment style may also compound learning difficulties for cognitively disabled children, who have less protective factors and resources to overcome the stress of an insecure attachment (Rosenstein & Horowitz, 1996). The resulting attachment-related disorder may cause unfounded fear, unfounded guilt, and trauma. Children with a disorganized attachment have no coherent strategy to respond to separation or reunion (Rosenstein & Horowitz). As the child ages, insecure attachment styles may contribute to both developmental and cognitive functions. Salzman, Salzman, & Wolfson (1997) noted a link between ambivalent attachment and hyperactivity. They also stated that insecure interpersonal strategies used as young children maintain in adulthood, keeping a chronic insecure attachment system alive. Insecure attachment is also linked to an increase in trait anxiety, based on the amount of support or restriction the parents employ, which ultimately effects cognitive function (Cobham, Dadds, & Spence, 1999).

With insecure attachment patterns or an attachment disorder children develop the inability to form secure attachments and react in a hostile, rejecting manner with their environment. Children who develop severe attachment disorders often exhibit destructive or dangerous behavior, constantly testing adults to determine if their internalized model will repeat itself (Samuels, 1995). Such children demand to be fed or hugged, then immediately pull away, rejecting before the rejection comes. The children also self-denigrate themselves, believing the parents projected image of themselves as unworthy of healthy attachment.

Chronic insecure attachment could also contribute to cognitive consequences. As children enter adolescence, their cognitive abilities dramatically increase. Teens with a history of secure attachment have more cognitive flexibility based on their ability to revise their models of themselves and their parents (Kobak & Cole, 1994). Securely attached teens can coordinate attention, feelings, behavior, and cognition while maintaining access to the parent. However, a teen with a history of insecure attachment cannot readily adjust or revise the internal models, since the teen remains focused on achieving better attachment. This inability to revise and adapt to new situations decreases cognitive function and effects formal operations development (Kobak & Cole). Similarly, insecure attachments may limit or bias new attachment information. Teens with insecure attachments create a deactivation strategy to cope with the attachment problem, or the teen must constantly monitor the parent, which restricts the teen from developing skills to cognitively step outside the attachment process. Both strategies limit the development of introspection and insight (Kobak & Cole). To develop strong cognitive and emotional skills, the child must be capable of coordinating these processes and have the freedom to experiment and tolerate doubt. Children whose attachment style involves a circle of rejection or who become hypervigilant and clingy cannot tolerate this doubt, for fear of losing the attachment (Kobak & Cole). A securely attached teen, however, usually becomes a securely attached adult, capable of outside perspective taking and able to display empathy for others. (van Ijzendoorn & Zwart-Woudstra, 1995).

The intensity of the emotion associated with attachment helps predict later problem behavior. A successful attachment allows for security, whereas anxiety and jealousy develop from poor attachments, as does anger, grief, and depression (Bowlby, 1988). When the attachment process is disrupted, as in the case of adopted or foster children, each new loss and reattachment can result in aggression, and can threaten the stabilization of object constancy for a very young child (Samuels, 1995). Foster care or adopted children have the added complication of multiple placements, requiring them to attach to several different caregivers, sometimes in short periods of time. These multiple placements exacerbate the loss of the initial attachment figure and compound the negative consequences of earlier adverse experiences (Eagle, 1994). "Research suggests that it is not separation and loss per se that predict negative outcomes, but the adverse contexts (e.g. family dysfunction and maltreatment) in which separation and loss often occur, and the biological factors or later experiences associated with those contexts" (Eagle, p. 421).

The attachment is further complicated as the child must attempt to attach to another caregiver whose attachment style varies from his or her own. Meanwhile, the child also retains the attachment dynamic from their family of origin. The child struggles to meet attachment needs, but the resulting competition between an already internalized image of a parent and the images of a new caregiver can cause severe emotional distress.

CASE STUDY

The following is a case study of a 12-year-old African-American male who exhibited behavior related to an attachment disorder. This case study will demonstrate the efficacy of using attachment theory to treat behavioral disorders.

John X (pseudonym) lived in foster care in a large urban setting. He is the third oldest of seven children. John entered foster care 9 years ago after police found John and his siblings living in an unsafe environment. The home had no bathroom facilities and little food or heat. The police placed his mother in jail for several months for medical neglect of a younger sibling, and John went to live with his brother's paternal grandmother. John's father is deceased. John then entered foster care after the paternal grandmother's son allegedly sexually abused all three boys. He entered his latest foster home 4 years ago.

John's mother has a history of substance abuse, depression, and developmental delay. While she remained close to all her children, she clearly favored her oldest son and found John ingratiating. For example, he would hug her tightly, and she would push him away. When asked to spend more time one-on-one with Job. n, she made excuses to avoid him. John often appeared weepy after family visits and spoke about wanting to return to his mother's care.

When first placed in his current foster home, John exhibited a severe emotional and developmental delay. He rocked when upset, hid his face in his hands, and played with toys much younger than his age level. He appeared socially delayed as well, refusing to interact with peers and refusing to leave his brothers. He exhibited poor public social skills, poor table manners, and an inability to read normal social cues. To get attention, he would often scream "excuse me" or just scream in a high pitched voice.

His behavior in the foster home had been consistently troublesome. John often made statements like "you hate me" or "I'll never see you again." He perseverated on topics that increased his negative relationship with adults such as demanding a birthday present months before his birthday. He seemed unable to redirect himself and showed poor impulse control by threatening to jump out a car or jump out of a window. This impulsivity also manifested itself in his inability to make decisions. He did not respond to questions in a definitive manner, changing his response every few seconds, which increased the likelihood of a negative response from his caregiver. The ongoing threats to physically harm himself resulted in a 3-week in-patient psychiatric hospitalization. When John returned to his foster home, his acting out increased.

Based on his history and behavior, John appeared to have developed an anxious-avoidant attachment style. His birth mother failed to meet his biological needs consistently, since her depression and resulting neglect likely contributed to John crying inconsolably. As a result, his emotional needs remained unmet. He internalized a representation of the caregiver as distant and unavailable or rejecting, and internalized an image of self as unworthy and unlovable. John would draw adults into his system by demanding attention. His attention-getting methods prompted adults to repel him, which fortified his belief that no one would meet his needs.

All treatment took place in the foster home but involved coordination with an out-patient mental health counselor that John saw weekly, through a community mental health agency to monitor his medication. The initial focus of treatment involved decreasing his negative behavior and compensating for his developmental delay, because his acting out jeopardized his placement in the foster home. However, across time, the relevance of John's attachment style and its influence on his other problems became apparent as he developed an increasingly negative pattern of interaction with the foster parent, Ms. Jones (pseudonym), and his in-home mental health counselor. Every intervention Ms. Jones tried resulted in reinforcing the anxious-avoidant attachment style. Ms. Jones would try behavior modification plans that failed immediately, because John would act out and never earn the reward. Every attempt to help him decrease his impulsivity or improve behavior resulted in a constant loss of privilege, which exacerbated his belief of a rejecting world.

Therapy then began to focus on improving the attachment relationship and removing the behavior-reward contingency plan already established. The first intervention involved addressing the emotional and safety aspects of attachment, by giving John positive interactions regardless of his behavior and allowing him to make his own decisions, despite the dubious nature of these decisions. In this way, natural consequences could take the place of adult imposed discipline. This treatment included going for car rides, getting a meal, or seeing a movie. Because John had trouble making decisions and viewed limit setting as a personal rejection, the therapy focus moved to helping him determine his own limits, within reason. During an outing to a movie for his birthday, he ordered all the food he wanted; and rather than imposing restrictions on his intake, the mental health counselor allowed John to determine when he was full. His response to this intervention was mixed. Although John tried to eat all the food he ordered, he did acknowledge when he was full and stopped eating. However, he struggled with the prolonged positive attention and escalated his acting out, by threatening to jump out of the car. Later he stated he had "too much fun," apparently unsure how to handle positive, nonrejecting attention.

Efforts to help the foster parent cope with John and decrease his acting out proved difficult. Ms. Jones did not want to stop giving the negative attention and could not follow through on positive interactions without insisting that John earn the behavior. She also found behavioral plans useless due to their lack of success, and complained about the time investment needed to implement them.

The next intervention then needed to break the current communication attachment pattern, while allowing John to internalize a new model of self as worthwhile and a new model of other as nonrejecting. This intervention also had to respect Ms. Jones' time constraints and address her need to confront John's troubling behavior. The mental health counselor developed a simple behavior modification plan that involved giving John a check for all inappropriate behaviors and a star for appropriate behavior. Ms. Jones kept a journal and drew the checks and stars as he earned them. At the start of the intervention, the mental health counselor and foster parent informed John that his allowance would increase to $10.00 per week. In order to receive his allowance, he needed to earn more stars then checks each week, but the number of checks and stars were irrelevant. For example, if he earned 17 checks and 18 stars, he still earned his allowance. The mental health counselor then strongly urged the foster parent to give John a check for poor behavior, but not make any verbal statement to him. However, when John earned a star, the mental health counselor asked the foster parent to provide a lot of positive verbal feedback and initiate positive physical contact, including hugs. This intervention allowed for immediate consequences without repeating the current negative communication attachment pattern and for immediate praise, which allowed John to internalize a model of other as available and a model of self as worthy. The foster parent engaged in the treatment plan and ensured that John received more stars than checks each week. After one week, he appeared calmer and showed increased impulse control, exhibiting the ability to stop himself in the middle of a behavior, apologize, and then correct the error. Ms. Jones would give him an immediate star for fixing his behavior, further increasing John's investment in the plan.

The weekly therapy session involved giving John positive feedback focusing on a continued positive interaction, including helping John improve his schoolwork. After three weeks of the intervention, the mental health counselor could spend 10 minutes reviewing math or writing, while John held his attention to the subject. He continued to seek attention and engage in negative behavior patterns, but had taken small steps toward taking more responsibility for his behavior. Five weeks later, John's grades improved dramatically and he began to appropriately negotiate for rewards.

CONCLUSION

This case study shows a small example of how addressing behavioral problems from an attachment perspective may help decrease acting out. Understanding the delicate balance between ingrained attachment patterns and the child's desire to meet attachment needs helps mental health counselors develop interventions aimed at changing the attachment pattern. Although the behavior theory approach failed to help John, disrupting his negative attachment behavior allowed him to begin to rebuild his internalized view of himself and his caregivers. Mental health counselors working with children in the foster care system usually become overwhelmed with the behavior problems presented and struggle with sorting out where to begin treatment. This case study demonstrated a different starting point, approaching the attachment style as a means to decrease acting out. Hopefully, in the process, the child can experience a positive relationship with a caregiver and begin rewriting the internal script that often prevents successful placements.

REFERENCES

Ainsworth, M. (1992). A consideration of social referencing in the context of attachment theory and research. In S. Feinman (Ed.), Social referencing and the social construction of reality in infancy (pp. 349-367). New York: Plenum.

Allen, J. R, Hauser, S. T., & Borman-Spurrell, E. (1996). Attachment theory as a framework for understanding sequelae of severe adolescent psychopathology: An 11-year follow-up study. Journal of Consulting and Clinical Psychology, 64, 254-263.

Bowlby, J. (1988). A secure base. London: Routledge.

Cobham, V. E., Dadds, M. R., & Spence, S. H. (1999). Anxious children and their parents: What do they expect? Journal of Clinical Child Psychology, 28, 220-221.

Eagle, R. S. (1994). The separation experience of children in long term care. American Journal of Orthopsychiatry, 64, 421-434.

Kobak, R., & Cole, H. (1994). Attachment and meta-monitoring: Implications for adolescent autonomy and psychopathology. In D. Cicchetti, S. L. Toth, & et al. (Eds.), Disorders and dysfunctions of the self (pp. 267-297). Rochester, NY: University of Rochester Press.

Lewis, M., & Volkmar, F. R. (1990). Clinical aspects of child and adolescent development (3rd ed.). Philadelphia: Lea & Febiger.

Rosenstein, D. S., & Horowitz, H. A. (1996). Adolescent attachment and psychopathology. Journal of Consulting and Clinical Psychology 64, 244-253.

Rosenstein, D. S., Horowitz, H. A., & Durand, V. M. (1990). Severe behavior problems. New York: The Guilford Press.

Salzman, J. P., Salzman, C., & Wolfson, A. N. (1997). Relationship of childhood abuse and maternal attachment to the development of borderline personality disorder. In M. C. Zanarini (Ed.), Role of sexual abuse in the etiology of borderline personality disorder. (pp. 71-91). Washington DC: American Psychiatric Association.

Samuels, S. C. (1995). Helping foster children to mourn past relationships. The Psychoanalytic Study of the Child, 50, 308-326.

van Ijzendoorn, M. H., & Zwart-Woudstra, H. A. (1995). Adolescents' attachment representations and moral reasoning. The Journal of Genetic Psychology, 156, 359-372.

Sheri Pickover is an instructor and doctoral candidate with Oakland University, Rochester, MI. E-mail: [e-mail]