ATTACHMENT RELATED TRAUMA AND EMDR Patterns of Insecure

ATTACHMENT RELATED TRAUMA AND EMDR Patterns of Insecure Attachment Sandi Richman

ATTACHMENT

ATTACHMENT CLASSIFICATION Adult attachment classification can be an important aspect of case formulation Attachment literature suggests in the context of the AIP model that patterns of attachment shaped in early caregiver experiences influence all later adaptive and maladaptive coping responses Daniel Siegel (2010) : The best predictor of a child’s security of attachment is how his/her parents made sense of their own childhood experiences

LIFE STORIES By asking certain kinds of autobiographical questions, we can discover how people have made sense of their past Each individual’s life story is defined by : The way we feel about the past Our understanding of why people behaved as they did The impact of those events on our development into adulthood This internal narrative may be limiting an individual in the present.

LIFE STORIES Parents who had a rough childhood and were unable to make sense of what happened would be likely to pass on that harshness to their own children who would in turn pass on this legacy to the next generation Parents who had a tough time in childhood but did make sense of those experiences were found to have children who were securely attached to them : they had stopped handing down the family legacy of insecure attachment

LIFE STORIES When taking a history, how an adult tells his or her story can be revealing Securely attached people acknowledge both positive and negative aspects of family experiences Securely attached people can give a coherent account of their past and how they came to be who they are as adults In contrast, people who had challenging childhood experiences often have a life narrative that is incoherent

LIFE STORIES We can change our lives by developing a “coherent” narrative even if we did not start out with one Through EMDR treatment, and the AIP model, our clients who had difficult experiences early in life find a way to make sense of how those experiences have affected them and their current responses Through analysis of questioning in the Adult Attachment Interview, the AAI questions reveal an ‘adult state of mind’ with respect to attachment A child’s attachment behaviour in childhood predicted the type of narrative developed as an adult

CORRESPONDENCE OF ADULT AND CHILD ATTACHMENT ADULT NARRATIVE INFANT STRANGE SITUATION BEHAVIOUR Secure Dismissing Avoidant Preoccupied Ambivalent Unresolved/Dis- Disorganised/Dis- organised oriented

SECURE NARRATIVE My Dad struggled to get a job and support us. He was irritable and often shouted at us. I didn’t feel close to him but my Mom helped me to understand how painful his situation was for us all. As I got older I felt sympathy for him, got over my anger and had a much closer relationship with him. It is easy for me to become emotionally close to others. I am comfortable depending on others and having others depend on me. I don’t worry about being alone or having others not accept me.

DISMISSING NARRATIVE My childhood was fine. My Dad was an accountant and my mother was an excellent normal mother. I had a normal childhood. In answer to specific questions, answers with ‘I don’t remember’ (cannot give details) I am comfortable without close emotional relationships. I like being on my own. It is very important for me to feel independent and self-sufficient, and I prefer not to depend on others or have others depend on me. Or ‘my parents were excellent parents. What’s all this got to do with the RTA? ’

PREOCCUPIED NARRATIVE My father was mad. He didn’t like me. He’d always say ‘don’t ever talk to me that way again’. And Mummy never said ‘don’t’ to him. (Talking as if parents were actually present). I want emotionally close relationships, but I find it difficult to trust others completely, or to depend on them. I worry that I will be hurt if I allow myself to become too close to others.

PREOCCUPIED NARRATIVE OR I want to be completely emotionally intimate with others, but I often find that others are reluctant to get as close as I would like. I am not comfortable being without close relationships, but I sometimes worry that others don’t value me as much as I value them. I find it intolerable when people let me down.

UNRESOLVED/DISORGANISED NARRATIVE At times I fall apart, so I can’t depend on myself. My child drives me crazy. I flip out whenever he gets upset. I feel like I m falling apart when he resists me. I feel like I become at first frightened and frozen, and then I’m afraid something will snap and I’ll scream or worse, I’ll hit him. I feel like I am losing my mind. Sometimes I just get stuck and I’m unable to move.

UNRESOLVED/DISORGANISED NARRATIVE My Dad was scary. If I didn’t eat all my food he would scream at me and banish me to my room. Sometimes he would hit me with his belt. His face was very frightening when he was like that. Then later, he would come to my room and get into my bed and hold me and tell me he loved me. And I felt very good and safe in his arms.

DAVID WALLIN, 2007 Secure/Autonomous Attachment Free to connect, explore and reflect Avoidant/Dismissive Attachment Not-so-splendid isolation Ambivalent/Preoccupied Attachment No room for a mind of one’s own Disorganised/Unresolved Attachment Scars of trauma and loss

DIANA FOSHA, 2000 Secure Attachment Affective competence Feeling and dealing (while relating) Capable of auto- and interactive regulation ‘I’m OK’

DIANA FOSHA, 2000 Insecure Dismissive (Avoidant) Attachment Not Feeling but Dealing ‘Goes on automatic’, eradicating feelings in order to cope. Less capable of interactive regulation I’m FINE, Really!’

DIANA FOSHA, 2000 Insecure Preoccupied (Ambivalent/Resistant) Attachment Feeling but Not Dealing Being overwhelmed with feeling and unable to cope Capable of interactive regulation but not easily soothed Less capable of auto-regulation ‘I’m dying, help!’

DIANA FOSHA, 2000 Disorganised Not Attachment Feeling and Not Dealing Alternates between hyper- and hypoaroual Not capable of auto- or interactive regulation ‘I’m not sure’

ATTACHMENT CATEGORIES Research on attachment offers a powerful tool But, each person is a one-of-a-kind Honouring uniqueness is essential But when we can ‘name it we can tame it’!

POSSIBLE PROBLEMS CREATED BY ATTACHMENT PATTERNS IN EMDR PROTOCOL

HISTORY TAKING : CLIENT’S COMMUNICATION SECURE clients communicate Truthfully and succinctly while remaining relevant Talk thoughtfully and with vivid affect Are capable, even when absorbed in strong feeling, of staying connected Are mindful of the purpose of history taking Therapist feels connected with client and optimistic about treatment

HISTORY TAKING DISMISSIVE Have clients : a hard time being coherent and collaborative Have trouble being truthful, often failing to support, and may contradict, what they assert Are over succinct ‘Don’t remember’ attachment-related experiences or needs for connection

HISTORY TAKING DISMISSIVE Often clients have little to say about the difficulties that bring them to therapy The past does not influence the present Don’t need others for anything Often come to therapy because partner thinks they have a problem Cannot describe any situation from before turning, say, 15

HISTORY TAKING DISMISSIVE Express clients : discomfort with history-taking Therapist feels frustrated as taking a history feel like pulling teeth and case conceptualisation becomes very difficult

HISTORY TAKING PREOCCUPIED May clients : be truthful but are rarely succinct When asked about family patterns, they seem to unravel and become tangential May start to describe past situation and slip into what happened last week Can easily become emotional and overwhelmed during history taking

HISTORY TAKING PREOCCUPIED Become clients: preoccupied during history taking Suddenly the adult tone shifts into a desperately unhappy forlorn little boy Therapist feels swamped by client’s emotional responses during history taking

HISTORY TAKING DISORGANISED : May clients, during history taking demonstrate sudden changes in speech Or fall silent for 2 minutes in mid-sentence and then continue on an unrelated topic May give extreme attention to details surrounding loss Indicate that a deceased individual is simultaneously dead and alive

HISTORY TAKING DISORGANISED clients May place the timing of an event, i. e. death, at several widely separated periods May indicate that they were responsible for the loss where no material cause is present May claim to have been absent at time of a traumatic event and then a bit later claim to have been present May describe an extremely traumatic event in flat tone and eerie detachment, when 5 minutes previously the client had been engaged and emotionally available

HISTORY TAKING DISORGANISED Therapist client feels fragmented and unable to get a clear picture of client’s history Case conceptualisation becomes a challenge! Creating a relationship in which the client can feel safe becomes a lengthy and fraught process

PREPARATION PHASE SECURE Can clients : engage in the Safe Place exercise with ease Generally do not need resource installation exercises as they are resilient enough Can collaboratively select targets for EMDR processing with therapist

PREPARATION PHASE DISMISSIVE Generally clients : reject Safe Place and RDI exercises Cannot self soothe Don’t allow anything ‘good’ to come their way from therapist SP and RDI can lead to internal physiological distress or client reports no observable response

PREPARATION PHASE DISMISSIVE Are clients either devaluing of resource work Or idealising Or controlling Target selection is thwarted by the client ‘not remembering’ any disturbance from the past Therapist works hard to identify possible memories for targeting which are rejected as not eliciting any emotion by the client

PREPARATION PHASE PREOCCUPIED clients Can work with Safe Place and RDI But choose a Safe Place with someone else looking after them May become overwhelmed with sadness in their SP (I never got to feel this sense of security with my mother) Target selection becomes a challenge as too many memories of insecurity and cannot choose a touchstone event Present and past become entangled in target selection

PREPARATION PHASE DISORGANISED Require clients lengthy preparation Could easily dissociate whilst doing the SP and RDI exercises If one ego states becomes relaxed in the SP, sabotaging or frightened parts could be in conflict RDI with unprepared ego states could also lead to conflict with other ego states

PREPARATION PHASE DISORGANISED find clients target selection a huge challenge Identifying certain targeted memories could destabilise ego states which are using denial as a way of coping Targets may also be relevant to one ego state and completely irrelevant to another ego state

ASSESSMENT PHASE SECURE Have clients little or no problem with identifying the different elements comprising the basic protocol Are completely able to collaboratively identify the elements of the disturbing event with therapist

ASSESSMENT PHASE DISMISSIVE May clients thwart therapist’s attempts to find a positive cognition Similarly, the negative cognition never quite captures the feeling state No negative cognition is ‘good enough’ As these clients ‘dismiss’ emotion, no NC will be acceptable, given that the NC is elicited to access the emotion inherent in the event

ASSESSMENT PHASE DISMISSIVE Identifying clients the elements of the Assessment Phase and basic protocol could become a power struggle with the client PC may be given a VOC of 7 Wording used to elicit the NC could be a source of conflict and opposition Therapist could end up feeling quite beleaguered Body sensation completely dismissed

ASSESSMENT PHASE PREOCCUPIED Could clients find it hard to settle on one NC and one PC NC may spark a distressing feeling state, reassociating the client to the traumatic event too intensely leading to activation of dissociative defences Identifying the NC may be interpreted by client as therapist abandoning them SUDs are often 20+ !

ASSESSMENT PHASE DISORGANISED Identifying clients the baseline information in the Assessment Phase can trigger dissociation Elements of Assessment Phase for one target may be very different for different ego states Could go into a trance or become terrified

PROCESSING SECURE Can clients usually process distressing material, thoughtfully, with appropriate emotions and physical sensations, making adaptive links Need limited intervention from therapist in the form of therapeutic interweaves to reach adaptive resolution

PROCESSING DISMISSIVE clients May struggle to get into a mindful state Answer ‘nothing’ to therapist’s question ; What do you notice now? Or ‘I’m just watching your fingers go back and forth’ Need to be told exactly what they are ‘supposed’ to do ‘I’m wondering if this is working ‘Isn’t your arm getting tired? ’ ‘This seems like a waste of time’

PROCESSING DISMISSIVE If clients they access emotion, dismiss it : ‘well, isn’t that normal? ’ ‘No I’m not doing well, I never have’ Feedback very limited and brief Therapist not sure the material is processing SUDs do not decrease as little emotion is processed

PROCESSING PREOCCUPIED Need clients constant reassurance and comfort of closeness Have chronically incomplete sessions Often get stuck with high levels of emotion which does not resolve Move from one distressing incident/memory to the next without making adaptive links High emotion may be a way of getting therapist to intervene to take care of them

PROCESSING PREOCCUPIED May clients process in a very detailed, tangential and fragmented way Channels can slip from past to present with little coherence Can become overwhelmed and helpless without resolution, and little adaptive response to cognitive interweaves offered by therapist Endless processing with little resolution

PROCESSING DISORGANISED Processing clients is just that, disorganised Primary, secondary and tertiary dissociation to be expected Therapist needs to work very hard to keep the client connected to present safety Expect dissociation, projective identification and counter-transference

EMDR / AIP MODEL EMDR is so much more than an evidencedbased treatment for PTSD. The AIP Model explains why. Research and particularly ‘practice based’ research indicates that EMDR brings about symptom relief in a great number of distressing conditions EMDR not only brings about ‘state’ changes but also ‘trait’ changes

AIP and INTERNAL WORKING MODEL AIP has much in common with Bowlby’s Internal Working Model Both assert that early experiences drive perceptions and responses later in life Bowlby stated that the child’s early experiences with attachment figures determined the child’s Internal Working Model, i. e. core beliefs about self, others and the world

DIAGNOSIS : ATTACHMENT No all-encompassing diagnosis for adults affected by severe attachment-related trauma Attachment disorganization in adults is identified by disorientation, poor logic and extreme behavioural effects related to caregiver abuse or major loss ‘Complex Trauma’ is not a formal diagnosis But outlines the complexity and severity of symptoms in adults suffering from chronic abuse by attachment figures

HYPOTHESIS? Can EMDR treatment focussing on early attachment-related trauma change the attachment status in the affected adult or child? If EMDR can successfully reprocess maladaptively stored distressing memories and create new adaptive associations in the brain, then targeting early attachment-related memories with EMDR should have a positive impact on the individual’s Internal Working Model

HYPOTHESIS Thus, improvement of attachment status through EMDR treatment should help adult clients to function more adaptively in relationships and respond more sensitively to their children

WESSELMANN & POTTER (2009) 3 case studies illustrating pre- and post- EMDR adult attachment status as measured by the AAI (Adult Attachment Interview) All 3 categorised with an insecure or disorganized attachment status at pre-treatment Mood anxiety symptoms related to problems in current marital and family relationships Received 10 – 15 EMDR sessions utilising all 8 phases Following EMDR treatment, all made positive changes in attachment status

MADRID (2007) Describes a method of using EMDR to repair maternal-infant bonding failures Case of a mother of a 5 year old girl who reported only negative emotions re her experience of being a mother : ‘She drains me, she’s a pest’ Early negative bonding experiences identified Standard EMDR protocol used to desensitize and process these experiences Mother reported only positive feelings towards daughter

CASE : ANNIE 30 year old woman with extreme anxiety about 8 month old baby. Worries about the baby stopping breathing, that the baby will die and it will be her fault. Feels she is a terrible mother. She has found the last 8 months ‘too much’ and at times wishes she was not around. After 5 EMDR sessions says : “I am so much more positive now and have gained a much clearer sense of who I am, and importantly of how my interactions with the world are shaped. I know I’m an OK mom, I’m a good enough partner, and if I think I’m not, I really know why I think this. I feel so good about sharing my daughter’s ups and downs with her and just being there for her in a way I never thought was possible” Sent a picture of baby with card saying “We are both doing very well these days!”

EFFECTIVENESS OF EMDR ON ATTACHMENT SECURITY Recent studies provide preliminary evidence that clients who lack adequate emotional regulation skills and social supports can, with support and preparation, and EMDR treatment : Resolve attachment injuries Improve attachment status Improve emotional stability Improve present day relationships

EFFECTIVENESS OF EMDR ON ATTACHMENT SECURITY More randomized controlled studies are needed to evaluate changes following EMDR in adults and children who have experienced early relational trauma Wesselman (2012) indicates that more research is needed to examine effects of EMDR on Attachment status Relationship stability Emotional regulation, self-concept, beliefs and expectations And Interpersonal behaviours and functioning

EFFECTIVENESS OF EMDR ON ATTACHMENT SECURITY Wesselman : “If continued research finds EMDR an effective method for improving attachment status, it seems reasonable to expect that change in attachment status in parents may increase attachment security and organization in their children. ”

CASE : ADAM 2 nd of 4 children When 3 sent with sister and brother to live with grandmother in Glasgow as parents couldn’t cope 8 years taken with sister and brother to London (not told where going) to a home for boys and girls Suffered physical, verbal and sexual abuse Doesn’t feel much about his experience and ‘just got on with it’ Became a successful lawyer Has difficulty in relationships with women. Started a new relationship and really wants to make this one last

ADAM Abandoned by parents Attached to grandmother but she abandoned the children by sending them to a home Avoidant/dismissive attachment style Secondary and some tertiary dissociation Has black rages with women Target : Rejection by teenage son NC : I’m invisible Floatback : Waiting (over 3 hours) for father to collect him and brother and Kings Cross Station 11 years

ADAM Incredulity ……. Just waiting Ø Waiting. Looking at that boy. How strange they look. Dressed in horrible thick short trousers and grey scratchy shirts and big badly fitting boots Ø They look hopeless. No life about them Therapist : ‘Sitting in this chair, the adult you are today, can you just look at that child’ Ø Yes Therapist : ‘Just see this child, just notice whatever you see (BLS) Ø I can’t look at that child. Pathetic! Therapist : ‘What’s good about not looking at that child? ’ Ø

ADAM I don’t have to see his fear, I don’t want to see his fear (BLS) Ø Well, I can look at him now’ Therapist : ‘When you look at the child, can you see the child’s feelings? ’ Ø He doesn’t have feelings, he’s not looking at me. (BLS) Ø He’s not looking, not communicating (BLS) Ø He’s not anxious to connect at all, he’s just closed (BLS) Ø

ADAM Ø Not anxious at all if he is collected or not, so what (BLS) So what. Voice is distant, a monotone Therapist asks the client to come back to the room (CIPOS) (BLS) ‘Come back to the room, We’ll get back to that boy at the station is a minute. But right now come back out of it to the room’ (BLS, bringing him back into therapy room) ‘OK, when you’re ready, close your eyes and just be drawn back to the boy at the station again. But let yourself be sure to stay partly here. Just look at that child, that boy, just see and notice whatever you see (BLS) Ø I feel irritated with him, I can’t understand why he does not ask someone, find out what’s happening (BLS)

ADAM Feeling twitchy Therapist invites client to come back to present safety, then back to the child. ‘Just look at that child. Is there anything that you know as an adult, that would be helpful to that child? ’ Ø (long pause) I don’t know, I don’t know how to comfort him, to get in. I can’t look at him. Therapist : ‘What’s good about not looking at him? ’ Ø I can’t bear his loneliness, his hopelessness (BLS) Ø I feel sad for that boy …. (becomes a bit tearful) (BLS) Ø

ADAM Therapist : When you see this child, if you could go back in time, the man you are today, and go to that boy and tell him something that would help him with his sadness, something you know that he doesn’t know, that would really help him, what would you say to him? ’ Ø I could tell him he deserves better. That he will be OK (BLS) Therapist : Do you think that boy has it rough? ’ Ø Yes, yes, I do think he has it rough (BLS) Therapist: When you look at this boy, how do you feel about him when you think of this? ’ Ø I feel sad for him because he has no-one taking care of him (BLS)

ADAM He has good reason to feel frightened, even angry (BLS) Ø I would never treat my boy, my son like that (BLS) Tearful. In this way, therapist assists the client in strengthening the part of the self that is oriented to present reality, and then assists that present-oriented ego state in witnessing the painful affect held in a dissociated child ego state. Often the affect within a child ego state has never been compassionately observed, either by another person, or by another part of the self within the personality system Ø