Monday, June 6, 2016

Adult Attachment Assessment

Chapter Four
Adult Attachment Assessment
            If the intention of therapy is to change parent behavior in order to increase the child’s sense of safety and security, to help them attune to their child and demonstrate it, then understanding what drives the parent is essential to treatment.  Identifying the parent’s attachment style, understanding their trauma history, and joining in their parenting journey are the keys for me in helping parents help their children heal and grow.  Reviewing clients’ trauma history and attachment styles also provides context for helping couples and individuals in their relationships whether the issues are communication, finances, and intimacy or grief, mental illness, and substance use.  Certainly some issues are best and most quickly addressed with present focused cognitive-behavioral and future focused solution focused treatment.  But when working with children no one can ignore the impact of early attachment, developmental history, and parenting style to their overall health and functioning.  And when working with parents no one can ignore the impact of the way they were parented and their ideas about parenting.  Every time I have ignored by better judgment and moved ahead with parent-child treatment without investigating the parents’ history and relationship style, the issues have stalled any progress.
            Using Mary Main’s Adult Attachment Interview as a guide, while certainly not trained or following the protocol, I use a brief set of structured questions that help reveal for me and the client some of the roots of the challenges they have in parenting and relationships in general.  The format, order, and tempo of the interview are important.  They allow the answers to come unfiltered and unprocessed revealing often unconscious beliefs, feelings, and thoughts that drive present behavior.  I say slowly with no additional explanation, “Please give me three adjectives that describe your childhood.”  Then, I ask for an experience that goes with each of those adjectives, and I wait.  I do not explain the question or give examples.  Then, I ask the client to describe how their relationship with, first, their mother, and then their father developed from infancy to adulthood and how it may have changed along the way.  The follow up question here is, “Did you ever feel separate or rejected by your parent?”  Then, “Was there anyone else to whom you felt close; an older sibling, aunt, uncle, grandparent or family friend?”  After these questions, I ask about the person’s journey to parenthood with some set-up.  “From an early age, and for both boy and girls, we usually have ideas about if, when, how we might become parents and what kind of parent we will be.”  Then I acknowledge that the reality of parenting rarely matches our ideal and ask, “What are your parenting challenges?  What do you find most difficult about parenting, or parenting this specific child?”  Finally, I ask how the client parent best learns, that is, how I may coach or support them.  This has to do with the parent’s learning style; audio, visual, or kinetic.  “Some people like to read and do, watch and do, or learn by doing.”  This exchange usually takes 10 to 15 minutes per parent.
I conduct the interview with clients in individual sessions and with couples together.  Sometimes couples may be hearing this material for the first time in this way, and sometimes one partner will prompt the other with an example.  While it may be more accurate to do this interview individually with each member of a couple, the interview is so brief that it does not seem to make much difference.  Neither does it seem to make much difference if one or the other partner goes first, giving the other a head start thinking about their answers.  It feels more valuable if the client answers, “off the top of their head”, or “what comes to mind first”, but it is also helpful for partners to hear the other’s answers.  This self-disclosure and self-reflection often leads to some surprising insights and the beginning of empathy and understanding, which is the whole point. 
            In terms of interpreting the information from this brief interview, I am listening as much to the depth and tone as to the content and coherence of the answers.  The first answer adjectives may include happy, fun, adventurous or sad, lonely, and poor.  Based on the adult attachment styles identified by Mary Main, these descriptors are not as important as what comes next.  If the examples of childhood experiences are consistent with the adjectives it demonstrates some coherence in the person’s understanding of their life story.  For example, a lonely childhood in which parents were divorced or absent makes sense, describing it as happy with no further detail does not.  I have heard parents describe a painful childhood in which parents were clearly abusive.  This does not necessarily predict adult relationship problems.  One client reported a happy childhood but with no memories before the age of six.  The partner reminded the client that they were ill as a child spending a lot of time in the hospital.  The parent seemed disconnected from their own suffering.  The couple was asked to care for a boy with anxious attachment, the result of inconsistent care by parents with drug addiction, and a teenage girl with avoidant attachment, the result of multiple foster care placements.  The boy was very needy and demanding.  The girl seemed independent and wanted nothing to do with adults.  One can see that the mother with the dismissive adult attachment style, who could not feel empathy for herself, would have difficulty feeling for these children.  You might predict that the mother would find the boy annoying and needing of medication or another placement.  On the other hand, she would be unlikely to see the need to reach out to the teenager until it was too late.  In the first session, she was most concerned about how to decorate their rooms before their arrival.  In contrast another parent reported a sad childhood in which his parents were addicted to alcohol nearly causing a divorce and lots of conflict in the family.  The parents subsequently achieved sobriety, the parents and children became closer in adolescence, and the client used therapy to process his childhood.  This earned security gave him the ability to be reflective about his own experiences, and his wife’s, and thus more likely to be able to be responsive to their children’s feelings.  Next, the questions about relationships with parents and times of rejection reveal whether the parent experienced acceptance and empathy from their parents, and thus have the ability to provide it to their children.  If the parent experienced repair of a disconnection with their parent they are more capable of repairing the inevitable disconnections with their children.  A parent once described an abusive childhood at the hands of her father who she had cut out of her life.  It was not the fact that the breach had not be repaired but that the wounds were still very raw, a preoccupied adult attachment style, that made it difficult for this parent to tolerate a child with a disorganized attachment style, his neediness and anger, without taking it personally.  To be sure developing secure attachment requires both the anxiety of need and satisfying the need, the rupture and repair of relationship.  This is what Daniel Siegel (2013) describes as “the dance of attunement”.  In the parent-child relationship, the parent leads the dance and has the responsibility to correct the missteps; disconnections can lead to stronger connections if parents have the self-awareness and self-control to make the necessary adjustments.  Parents do it all the time when they hear a baby cry and through trial and error find what sooths the infant.
The idea here is that no one gets through life unscathed, without experiences of separation, pain, or trauma.  A secure adult attachment style does not mean the parent had a perfect childhood but that they have made sense if not peace with it and so is better able to take responsibility for their triggers when they arise with their children.   Children will “push our buttons”, but they did not put them there, our parents did.  Knowing where our buttons are, and taking care to heal them on our own and take care of ourselves, is essential to mindful parenting.  Also, especially in adoption, children have attachment styles that are the result of previous caregivers and experiences, with strange coping behaviors like lying, stealing, and aggression.  Adoptive parents can “take themselves off the hook” for creating some of the behaviors, but make the commitment to care for the child.  Healing is in their hands.  Children do not choose to be abused, and they do not choose to be adopted.  Their misbehaviors, intentional as they may seem, are not choices but their attempts to cope with their own triggers.  Often the child’s trigger is the parent themselves, especially the safe, nurturing parent.  This is what Bruce Perry describes as “relational PTSD”.  The child has difficulty accepting and believing in loving parenting.  So, understanding the parents’ triggers is as important as understanding the child’s.
I do not use this interview to determine the parents’ adult attachment styles.  That would be unethical, unnecessary, and not particularly helpful.  Instead, what is helpful is identifying the parents’ triggers so I can notice them and help them manage them in present-day interactions with their children.  Is it any wonder that a parent raised by a father with an alcohol problem finds his son’s impulsive behavior so difficult to deal with?  The father’s automatic response is to raise his voice or leave like he did to avoid conflict with his father, both of which disconnect him from his child who needs him close and calm.  Knowing this helps him change his reaction to a more effective response.  One mother whose adopted son was so anxious that he would not let her go to the bathroom without banging on the door and who once drove away leaving her child at home realized that she used to run away and hide anytime her critical father demanded she do more work on the farm.  Knowing this helped her stay and tolerate her discomfort until her son was comfortable that she would not leave him.   I keep and refer back to this information often throughout the therapeutic process.  Daniel Siegel provides excellent questions for parental self-reflection (2003, p. 133), and I often suggest his entire book, Parenting from the Inside Out, as homework for parents, in addition to a class based on it.
Parents’ hopes and dreams about having children, their motivations and reasons for becoming parents, often explain their actions and emotions in facing current challenges.  Again, whether we decide to have children or not, to give birth or adopt, and there is huge social pressure do so, each of us has fantasized about the kind of child we would have.  Even if for a fleeting moment, we have considered “our” child.  Sometimes, that fantasy is fully developed.  We decide the gender, we picture hair color, we pick the clothes, the school, the career.  Nobody dreams of having a child with challenges.  Sometimes, we choose not to parent and a child with challenges shows up anyway.  Unplanned pregnancies and grandparents raising grandchildren are two examples.  And, the contrast between our expectations and reality often cause conflict, grief and loss.  We experience pain and sadness when our children are in pain and we cannot help them, or what we are doing does not seem to be working the way we want.  As Kubler-Ross taught us, grief and loss is part of life, a process to be identified and addressed.  The last stage she identified, acceptance, is better stated as readjustment.  We do not get over loss, we get used to it.  We incorporate it into the story of our lives.  Grief and loss is a central issue in adoption.  Particularly, in adoption, if parents have spent years trying to give birth or considering adoption, they have also spent more time developing a picture of their “ideal child”.  Usually, adoptive parents are even asked their preferences as to gender, age, and ethnicity, as if ordering at a drive-through restaurant.  Even if their “real” child matches their preferences, he or she is not, cannot be, that “ideal child”.  Not even birth children match up.  Each child surprises their parent with their uniqueness, their collection of abilities, personality, and temperament.  It is the discrepancy between the ideal and the real that causes the pain.  The real child exists.  The ideal child never did, except in our minds.  Until we grieve, yes bury, the ideal child, it is very difficult to accept the real one.  And acceptance is the beginning of attachment and healing.  As therapists we are loss managers, we run the funeral home.  Acknowledging this and guiding clients through it is part of the treatment plan.  Creating rituals can be helpful as an intervention.
In terms of choosing interventions it is very helpful to know the client’s learning style.  As therapists our shelves are full of books explaining symptoms and diagnoses, exercises and interventions.  We learn in different ways, too.  A client who can read about their situation brings so much knowledge and understanding into the session for work.  There may be little teaching or psycho-education that needs to be done.  Some clients take in everything we say and benefit from our explanations and examples.  Others really need not just our demonstration of a technique but our coaching in trying it themselves, whether it is using “I statements”, tone of voice, or playing with their children.  A favorite time was when two beautiful, smart, funny twin boys decided they did not want to follow their mother’s instructions to shake my hand and walk out of my office.  A loud tantrum ensued, two hours of overturning chairs, dumping the contents of an ottoman, taking the wheels off a table.  When their mother pleaded or placated, they cried louder, “You’re ruining my life!  Let us leave.”  They could have walked out at any time, they never did.  When I got quiet, and coached the mother to stay calm, the chairs went upright, the puppets went back in the box, and the wheels went back on the table with perfect cooperation and skill.  Stress created the tantrum, they were testing whether they could trust their mother to hold her ground.  Quiet calm created the safety they needed to put their thinking caps back on, and a friendly handshake sealed the deal.