Attachment Narrative Therapy: Applications and Developments 3031127447, 9783031127441

Table of contents :
Contents
Notes on Contributors
List of Figures
List of Tables
Introduction to the Book
1: Attachment Narrative Therapy
Hostages to our Past or Agents of our Lives?
Representational Systems and Choice
Corrective and Replicative Intentions
Don’t Blame the Parents: Reflecting on Responsibility and Influence
ANT: A Communicational Approach
Formulation in ANT: An Ecological Model
The Parenting System: Views of the Child
The Therapeutic Process in ANT
Co-creating a Secure Base
Greg
Tara
Processes of Exploration and Fostering Changes
References
2: Towards a Secure Exploration of Attachment and Shame Using Attachment Narrative Therapy
Introduction
What Is Shame?
Attachment Narrative Therapy and Shame
Integrating Internal Working Models and Dispositional Representations
From Attachment-Based Therapy to Attachment Narrative Therapy
Two Examples of the Use of Attachment Narrative Therapy in Clinical Practice
Farah’s Story: “I Want to Be a Good Mother”
Stage 1: Establishing Trust and Creating a Secure Base
Navigating Shame and Repairing Unintentional Shaming
Cultural Aspects
Stage 2: Exploring the Problems
Identifying Key Relational Moments of Shame
From the Semantic to the Visual: Tracking Circularities
Traumatic Memory from the Past (Figs. 2.1 and 2.2)
Memory Is Triggered Implicitly in the Present (Figs. 2.3 and 2.4)
Stage 3: Exploring Alternative Narratives, Alternative Contexts and Fostering Change
Reframing the Event
Understanding the Wider Family Context
Exploring Patterns of Comforting
Exploring Hypothetical Future-Oriented Attachment Narratives
Connell’s Story: “You are so Strong, My Boy”
Stage 1: Establishing Trust and Creating a Secure Base
Navigating Embarrassment and Avoiding Shame
Organisation of Narratives
Attachment-Focused Timeline
Stage 2: Exploring the Problems
Identifying Key Traumatic Events
Traumatic Memories from the Past (Figs. 2.6 and 2.7)
Memories are Triggered Implicitly in the Present (Figs. 2.8 and 2.9)
Stage 3: Exploring Alternative Narratives, Alternative Contexts and Fostering Change
Reframing the Events
The Wider Family Context
Exploring Patterns of Comforting and Hypothetical Future-Oriented Attachment Narratives
Conclusion
References
3: Supporting Parents of Children with an Intellectual Disability Using Attachment Narrative Therapy
Introduction
Setting the Context
Personal and Professional Connections
Formulation and Intervention in Child ID Settings
Circularities
Exploring the Family Genogram
Triangulation
Developmental Needs and the Family Life Cycle
Attachment-Informed Timelines
Cultural Narratives of ID and Internal Working Models
Corrective and Replicative Scripts
Building a Secure Base
Activities for Readers
Case Study: Intergenerational Attachment Patterns and Corrective/Replicative Scripts
Conclusion
References
4: Taking an Insider Position to Working with Family Conflict, Violence and Domestic Abuse: Contributions from Attachment Narrative Therapy
Introduction
Insider/Outsider Positions in Organisations
ANT
Clinical Practice Example
Uncertainty and Risk: The Production of ‘Risk Objects’
Developing Services that Respond to Domestic Violence and Abuse
Organisational Practice Examples
Development of a Consultation System
Recording Practices
Group Supervision
Conclusion
References
5: Working Systemically with Family Violence and Attachment Dilemmas
Setting the Scene
Our Systemic Safety Methodology for Safe Relationship Therapy Practice
The Management of Risk of Future Violence
The Assessment of the Risk of Future Violence
Responsibility for Behaviour that Harms Others and Responsibility for Safety
Collaborative Practices
Safety Planning: An Attachment Narrative Approach
Internal Triggers for Dangerous Arousal
External Triggers for Dangerous Arousal
Family Members’ Resources
Predicting and Preventing Violent Escalations
In Conclusion
References
6: SAFE, a Manualised Version of Attachment Narrative Therapy Designed for Families of Children with an Autism Diagnosis
The Secure Base
Exploration and Intervention
Tracking Family Patterns
Sculpts
The Area of Special Interest
Self-Autism Mapping (SAM)
Reflecting Conversations
Maintaining
Some Final Thoughts
References
7: Self-Harm: Moving from Dyads to Triads
Introduction
Setting the Context: Service Settings, Personal and Professional Orientations, and Ethos
Triadic Processes and ANT
Formulation of Self-Harm with the ANT Approach
Corrective and Replicative Scripts and Intentions
Case Example
Katie and Her Family
ANT Formulation: Current and Trans-Generational Processes
The Layers of Attachment: Dispositional Representations
Developing a Secure Base as the Foundation for the ANT Approach: Co-constructing a Therapeutic Relationship
The Triangle as a Therapeutic and Supervisory Tool: Two Case Examples
Phoebe: Caught Between Parents and Between Home and Hospital
Case Example: “A Huge Penny Dropped on My head”
Discussion
References
8: Fostering Home–School Relationships: SAFE with Schools (SwiS)
Development of SwiS
Aims of SwiS
Theoretical Base
Structure of SwiS
Summary of the SwiS Programme
Day 1
Introductions
Overview of the Orientation of SwiS
Sharing Understandings of Autism
A Systemic–Relational Perspective: Positive and Problematic Cycles
Video Consultation Activity
Day 2
Meltdowns and Shutdowns
Externalising
Attachment Theory
Child’s Relationship with the Home–School System
The Children’s Worlds: Narratives of Autism
SAM: Self-Autism Mapping
Keeping Connected
Discussion
References
9: Long-Term Supervision in Post-Qualification Systemic Psychotherapy: An Attachment Narrative Approach
Introduction: Positioning and Context
Co-creating Safety: The Secure Base in Supervision
ANT and Long-Term Supervision
Growth, Development and Evolution
Exploration, Illumination and the Way Forward
Colleagues as Friends, and Friends as Colleagues: The Construction of Safety
Safety–Trust–Protection
References
10: Setting Up an ANT-Based Systemic Family Therapy Clinic: Experiences, Recommendations and Extensions
Introduction
What Is Attachment Narrative Therapy?
The Need for a Specialist ANT: Systemic Family Therapy Clinic
A Child-Friendly Approach: Multi-sensory
Guidelines for Setting up a Systemic Clinic Informed by the ANT Framework
Referral Criteria
Staff Skills and Qualifications
Supervision
Experience of Setting Up an ANT Clinic
Conversations in Preparation: Key Players
The Structure of the ANT Clinic
Pre-Session
Session (Part 1)
The Intersession/Reflecting Team Conversation
Session (Part 2)
Outline Placeholder
Similar to the pre-session, the post-session discussion takes about 20 to 30 minutes. Again at the beginning stages, we would suggest planning for a 30-minute post-session. The team shares what they have ‘learnt’ about the family, how the emerging form
Discussion
References
11: Bereavement Attachment Narrative Therapy (BANT): An ANT Approach to Working with Grief
Introduction
Jenny and Alison
Narrative Indicators of Dismissing Strategies
Indicators in Narrative of Preoccupying Strategies
Dawn and Her Family
References
Index

Citation preview

PALGRAVE TEXTS IN COUNSELLING AND PSYCHOTHERAPY Series Editors: Arlene Vetere · Rudi Dallos

Attachment Narrative Therapy Applications and Developments

Edited by Rudi Dallos

Palgrave Texts in Counselling and Psychotherapy

Series Editors Arlene Vetere Family Therapy and Systemic Practice VID Specialized University Oslo, Norway Rudi Dallos Clinical Psychology Plymouth University Plymouth, UK

This series introduces readers to the theory and practice of counselling and psychotherapy across a wide range of topical issues. Ideal for both trainees and practitioners, the books will appeal to anyone wishing to use counselling and psychotherapeutic skills and will be particularly relevant to workers in health, education, social work and related settings. The books in this series emphasise an integrative orientation weaving together a variety of models including, psychodynamic, attachment, trauma, narrative and systemic ideas. The books are written in an accessible and readable style with a focus on practice. Each text offers theoretical background and guidance for practice, with creative use of clinical examples. Arlene Vetere, Professor of Family Therapy and Systemic Practice at VID Specialized University, Oslo, Norway. Rudi Dallos, Emeritus Professor, Dept. of Clinical Psychology, University of Plymouth, UK.

Rudi Dallos Editor

Attachment Narrative Therapy Applications and Developments

Editor Rudi Dallos Clinical Psychology University of Plymouth Plymouth, UK

ISSN 2662-9127     ISSN 2662-9135 (electronic) Palgrave Texts in Counselling and Psychotherapy ISBN 978-3-031-12744-1    ISBN 978-3-031-12745-8 (eBook) https://doi.org/10.1007/978-3-031-12745-8 © The Editor(s) (if applicable) and The Author(s), under exclusive licence to Springer Nature Switzerland AG 2022 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Credits: Sergey Ryumin This Palgrave Macmillan imprint is published by the registered company Springer Nature Switzerland AG. The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Contents

1 Attachment Narrative Therapy  1 Rudi Dallos 2 Towards  a Secure Exploration of Attachment and Shame Using Attachment Narrative Therapy 33 Myriam Laplanche 3 Supporting  Parents of Children with an Intellectual Disability Using Attachment Narrative Therapy 65 Mark Hudson 4 Taking  an Insider Position to Working with Family Conflict, Violence and Domestic Abuse: Contributions from Attachment Narrative Therapy 95 Rebecca Infanti-Milne, Richard McKenny, and Lee Walton 5 Working  Systemically with Family Violence and Attachment Dilemmas121 Arlene Vetere

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6 SAFE,  a Manualised Version of Attachment Narrative Therapy Designed for Families of Children with an Autism Diagnosis139 Rebecca Stancer 7 Self-Harm:  Moving from Dyads to Triads161 Ramón Karamat Ali and Rudi Dallos 8 Fostering  Home–School Relationships: SAFE with Schools (SwiS)195 Tara Vassallo 9 Long-Term  Supervision in Post-­Qualification Systemic Psychotherapy: An Attachment Narrative Approach229 Arlene Vetere, Rebecca Infanti-Milne, Lee Walton, and Richard McKenny 10 Setting  Up an ANT-Based Systemic Family Therapy Clinic: Experiences, Recommendations and Extensions247 Ramón Karamat Ali 11 Bereavement  Attachment Narrative Therapy (BANT): An ANT Approach to Working with Grief275 Jacqui Stedmon and Rudi Dallos I ndex305

Notes on Contributors

Rudi Dallos is Emeritus Professor of Clinical Psychology at the University of Plymouth. He has worked as a family therapist and clinical psychologist for over 40 years. He has engaged in research and publications and has written a number of books, including Don’t Blame the Parents (2019), Formulation in Psychology and Psychotherapy (2013) and An Introduction to Family Therapy (2010). Mark Hudson  completed his undergraduate degree in Psychology at the University of Leicester, UK, before studying Clinical Psychology at the University of Birmingham and University of Sheffield, UK. He is a practising clinical psychologist and Assistant Professor of Clinical Psychology at the University of Nottingham, UK. After qualifying, he initially worked in an in-patient assessment unit for children with moderate-severe intellectual disabilities (ID), before moving to work in both a community child and adolescent mental health service and a specialist community team for children with ID. He has a particular interest in attachment and systemic family therapy, and has published on the use of these approaches in people with autism and ID. He works for an autism charity, providing specialist assessments to families where a child has developmental difficulties.

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Notes on Contributors

Rebecca Infanti-MIlne  is a social worker and systemic psychotherapist, and works part-time as Systemic Lead for London Borough of Hackney and part-time with Lee Walton and Richard McKenny. She has a special interest in working with couples who have used and experienced domestic violence. She teaches and trains on working with violence, using dialogical approaches in social care. Ramón Karamat Ali  is a family therapist and supervisorwho works with adolescents pre­senting with complex mental health problems and their families. He also uses ANT in his private practice as a systemic supervisor and as a couple therapist working with relationships in distress. He is the Research Lead on the MSc in Family and Systemic Psychotherapy in Manchester where he is also the Course Lead on the Systemic Supervision Course. He has trained counsellors, therapists and psychologists in the Netherlands and South Africa. Myriam Laplanche  is a psychotherapist and supervisor in private practice in London, working mainly with individual clients. After originally qualifying as a lawyer in France, she trained as an attachment-­based psychotherapist at the Bowlby Centre in London. She came to write this chapter through her work in a supervision group led by Rudi Dallos. She has a strong interest in the transmission of attachment patterns within families and through wider cultural influences. Richard McKenny is a social worker, systemic psychotherapist and supervisor, working mainly with organisations to develop services for families through consultation, supervision and clinical practice. He has a special interest in working with couples who have used and experienced domestic violence. He teaches and trains on working with violence, using dialogical approaches in social care. Rebecca Stancer  is a developmental psychologist, family therapist and Associate Professor of Early Childhood at the University of Plymouth. She is also co-designer of the SAFE intervention and has a longstanding research interest in support for autistic children and their families. She has produced a range of related publications and headed a feasibility

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study to explore the family experience of SAFE in NHS settings in the southwest of the UK. Jacqui Stedmon is Director of Clinical Psychology Training at the University of Plymouth. She is a family therapist who has developed Jeremiah’s Journey, a bereavement service for children in Plymouth, Devon, UK. She has published widely on family therapy, bereavement and clinical formulation, and has authored the book Reflective Practice in Psychotherapy and Counselling (2009). Tara Vassallo  is a lecturer and early career researcher in child development and education at the University of Plymouth. Her background is in psychology and her main research interest is autism, with a focus on systemic practice and family systems. She has worked closely with the autistic community for more than 15 years, in the UK and previously in Australia, both professionally and in a voluntary capacity as an autism ally and family advocate. Her doctoral research centres on the development of the systemic attachment-based intervention ‘SAFE with Schools’ (SwiS), exploring its application within education, and focusing on the relationships of parents and teachers and the child they share. Tara lives with her family in Devon, UK. Arlene Vetere  is Professor Emeritus of Family Therapy and Systemic Practice at VID Specialized University, Oslo, Norway. She is a clinical psychologist and systemic psychotherapist and supervisor, registered in the UK, where she resides. Lee Walton  is a social worker, systemic psychotherapist and supervisor, working mainly with organisations to develop services for families through consultation, supervision and clinical practice. He has a special interest in working with couples who have used and experienced domestic violence.He teaches and trains on working with violence, using dialogical approaches in social care.

List of Figures

Fig. 1.1 Fig. 1.2 Fig. 1.3 Fig. 1.4 Fig. 1.5 Fig. 2.1 Fig. 2.2 Fig. 2.3 Fig. 2.4 Fig. 2.5 Fig. 2.6 Fig. 2.7 Fig. 2.8 Fig. 2.9 Fig. 3.1 Fig. 3.2 Fig. 3.3 Fig. 4.1

Communication and attachment ANT, an ecological model Matching attachment strategies and fostering change Process of exploration and fostering change Tracking a circular pattern in a family Farah circularity 1 Farah circularity 2 Farah circularity 3 Farah circularity 4 Connell’s timeline Connell’s circularity 1 Connell’s circularity 2 Connell’s circularity 3 Connell’s circularity 4 A circularity showing a repeating pattern of interaction surrounding a child’s soiling A genogram showing the family context of an isolated young man with severe ID The impact of negative social discourses on the internal working models of parents and children with ID Tracking and mapping an incident of violence between Anton and Jade

13 14 20 27 28 45 45 46 47 53 55 56 57 57 71 73 79 103 xi

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List of Figures

Fig. 4.2

ANT model of children’s social care responses to domestic violence and abuse referrals, incorporating Vetere and Cooper’s (2001) ‘risk, responsibility, collaboration’ framework Fig. 4.3 A strange loop process in the supervision of domestic violence and abuse Fig. 6.1 Circle of Security (adapted) Fig. 6.2 Tracking a family process Fig. 6.3 Self/Autism Mapping (SAM) graphic Fig. 7.1 ANT—Triadic formulation of attachment in a family Fig. 7.2 Interactional Attachment Cycle around adolescent self-harm Fig. 7.3 Genogram of Katie and her family Fig. 7.4 Tracking current family dynamics: An attachment circularity Fig. 7.5 Trans-generational family patterns of attachment strategies Fig. 7.6 Phoebe’s relationships with her parents and hospital Fig. 7.7 Escalating distance between hospital and home Fig. 7.8 Genogram of Rabia and her family Fig. 7.9 Initial triangle of the family triad (drawn on the white board by the therapist) Fig. 7.10 Illustration to the family of distance between mother and daughter and a closeness between maternal grandmother and granddaughter (white board) Fig. 7.11 Illustration to the family of the closeness of granddaughter to her grandmother to the exclusion of her mother (whiteboard) Fig. 8.1 Triadic process Fig. 8.2 Attempted solutions and escalation of problems Fig. 8.3 Tracking: Slowing things down; exploring positive and negative cycles Fig. 8.4 Example of a Circle of Security discussion Fig. 8.5 Circle of Security (extended) Fig. 8.6 Self-Autism Mapping – SAM Fig. 9.1 Triangle of family, supervisor and supervisee relationships Fig. 9.2 Attachment strategies of supervisors and relationship with the couple Fig. 11.1 Jenny and Alison: Putting a brave face on the loss

107 109 145 150 154 166 169 171 175 176 182 182 184 186 186 187 205 212 213 217 218 219 233 242 279

List of Tables

Table 1.1 Representational systems: the layers of attachment Table 2.1 Therapeutic approaches and attachment styles Table 3.1 Examples of questions adapted from the AAI (adapted from McKenzie et al., 2020)

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Introduction to the Book

It was over 20 years ago that I first started to develop the integration of approaches drawing on systemic therapy, attachment theory, and narrative theory and therapy. I had started to notice that many clinicians were employing their own idiosyncratic integrations of therapeutic models. These integrations often appeared to be pragmatic rather than bound by theoretical purity in their integrations. For example, I noticed that people could combine intra-psychic approaches, such as cognitive behavioural therapy or psychodynamic orientations, with systemic work. During the same period I was also writing about formulation and likewise it was clear that formulation could be combined from different models in a theoretically coherent manner or pragmatically. I had also been inspired by the work of Harry Procter (Procter and Winter, 2020) in his conceptual integration of personal construct theory and systemic therapy. However, many clinicians were combining approaches drawn from intra-psychic approaches with systemic therapy. These positions constitute a conceptual divide and potential schism. Systemic therapy and intra-psychic therapies hold contrasting understandings about the causation and treatment of problems, locating them respectively as relational as opposed to within the person. However, as I became increasingly aware of the impact of trauma and trans-­generational patterns of attachment difficulties in my clinical work I wondered about how attachment theory could also be woven into xv

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systemic and narrative approaches. This seemed to constitute a theoretical dilemma in that until that point I had understood attachment theory as constituting a deterministic and largely intra-psychic model. This is a good example of how we can make assumptions about an approach based on what others tell us about it, which I found to be quite different to what Bowlby had actually said in his writings. In fact, it turns out that attachment theory is in a sense a misnomer because it is not one theory but in itself an integrative model. It utilises systemic theory as fundamental to understanding attachment as a behavioural and relational system. It incorporates cognition and narrative in its idea of the ‘working model’ and psychodynamic conceptualisations in its idea of the working model as actively filtering our experiences in terms of defensive processes. As I have developed Attachment Narrative Theory (ANT) over the last 20 years we have held many training events and clinical supervisions where we have outlined it and discussed its applications. At each of these hundreds of workshops, I have learnt something new from the responses of the clinicians attending. They have shown us how the approach is inevitably adapted and moulded in their own work in different clinical areas. It is hoped that we have been able to weave in some of the richness and excitement resulting from these reactions. It also became evident that the time is now right to give a platform to the creative and inspirational way these colleagues were utilising ANT in their own work.

It has therefore been a pleasure to develop this edited compilation of the creative ways in which the ideas have been carried forward. Running through the chapters is the ‘golden thread’ inspired by Bowlby of the need to create with individuals, families and organisations a sense of safety or ‘secure base’ to prepare the ground for the possibility of positive changes. Jacqui Stedmon’s chapter on bereavement reminds us that separation and loss are central aspects of the human experience and of the development of attachment theory. John Bowlby described the loss of people we love through death or the ending of relationships due to separation or divorce as similar to the experience of a bereavement. The chapters include applications where the work is largely conducted with individual clients, as in Myriam Laplanche’s chapter on working with issues of shame. Though the work is typically with individuals, Myriam employs a systemic trans-generational formulation to understand and explore with her clients the nature of their experiences. Mark Hudson

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illustrates how ANT has been applied in the context of working with children with a diagnosis of a learning difficulty and their families. He describes the complex attachment needs that the children typically display and the need to consider the attachment dynamics of their families. Working with children displaying complex neurodevelopmental challenges is also the focus of the chapters by Rebecca Stancer and Tara Vassallo. Rebecca describes how ANT has been developed into a manualised approach for work with families where a child has a diagnosis of autism. Though this development was prompted by the demands for mutualisation as a requirement of a research trial, she describes how it offered unexpected benefits for the families and clinicians who delivered it. She goes on to describe how this application also offers a significant contribution towards building a research evidence base on the benefits of ANT. Ramón Karamat Ali describes his application of ANT in the context of high risk in working with children and young people who are engaging in self-­harming behaviours. In particular, he offers an important illustration of how ANT has included an extension of attachment theory from a dyadic to a triadic focus on attachment relationships. The importance of thinking about triads is continued in chapters by Arlene Vetere on violence in families and long-term supervision. Both chapters emphasise how creating a secure base is a continuing and enduring aspect of clinical work and supervision. Where violence and abuse has occurred, the reality and pervading sense of danger can shape the experience of not only families but also the organisations involved in working with them. Rebecca Infanti-Milne, Lee Walton and Richard McKenny’s chapter on working in the context of domestic violence describes how their task is to manage not only danger and fear in the couple and family relationships but also the anxieties experienced by professionals involved with them. Finally, Tara Vassallo’s chapter advances this organisational focus by illustrating how ANT has been developed to look at relationships between families and schools. Observing children with a diagnosis of autism and their families, she develops a triadic framework to show how a child can become entangled in the emotional dynamics between the home and school settings. Finally, the chapters inspired me to write the introductory chapter outlining the developments of the conceptual basis of ANT. As the chapters

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I hope illustrate, a significant development of ANT is that it offers a way of using attachment theory alongside narrative and systemic perspectives to offer a model which recognises that we are shaped by but not hostages to our attachment histories. We are also able to make decisions and choices about our futures and alter the trans-generational patterns that shape us. This offers a hopeful approach which recognises that facilitating positive change can be demanding, but also that within an ANT approach it can sometimes also occur rapidly when we are able to facilitate a sense of safety and security for the systems of attachment dynamics and accompanying narratives. We hope that you will enjoy the chapters and yourself continue to develop and elaborate the ANT approach within your own personal integration of ideas and techniques. Procter, H., & Winter, D. A. (2020). Personal and relational construct psychotherapy. Palgrave Macmillan.

1 Attachment Narrative Therapy Rudi Dallos

When we were first articulating the Attachment Narrative Therapy (ANT) approach, John Byng-Hall added a note of caution regarding promoting another ‘brand’ of therapy. This was helpful advice, and the aim is not to promote another brand but to propose an integration of a mixture of theoretical concepts and clinical approaches that might be helpful in guiding our work with people and their families. This is similar to ‘attachment theory’, which is also an integrative mixture of different theoretical approaches to an understanding of child development and the emergence of problems. Attachment Theory was not specifically conceived of as a clinical method but as formulating the development of attachment connections in families. It was based on an integration of ideas from systems theory, evolutionary biology, cognitive neuro-science, ethology and psychodynamic theory. Bowlby (2005) managed this integration so well that sometimes it is not recognised that attachment theory is made up of these component parts. Likewise, ANT includes these R. Dallos (*) Clinical Psychology, University of Plymouth, Plymouth, UK e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 R. Dallos (ed.), Attachment Narrative Therapy, Palgrave Texts in Counselling and Psychotherapy, https://doi.org/10.1007/978-3-031-12745-8_1

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R. Dallos

components with the addition of constructivist and social constructionist perspectives and their use in the narrative therapies. We are attempting something quite ambitious theoretically in this integration of ideas. But perhaps what most clearly captures our approach is a recognition that it is not just us ‘professionals’ who are attempting this task but also the families we work with. Ideas from psychology and psychiatry, such as unconscious feelings, parenting styles, theory of mind, attachment bonds and systemic processes, have entered popular consciousness. When we meet with families they are using these concepts sometimes following considerable research and sometimes through hearing about them in the media and from friends, family members and so on. These ideas are combined with a wide canvas of ideas from science, philosophy, popular culture, and the history of ideas within our own families and communities. These coalesce into stories that we develop but also that are drawn from wider cultural themes, for example stories of redemption, futile love, heroic suffering, tragedy, rising from the ashes, betrayal and enlightenment. Perhaps whatever psychological theories we develop, these stories provide the theatre of life within which they make sense to us. For example, the attachment style of dismissing perhaps chimes with the story of the quiet but silent, long-suffering hero preoccupied with the unpredictable, volatile, moody artist. Though drawing these connections here may seem fanciful, we need to reflect on how we communicate our theories to our clients. If we do not try to think about how they connect to culturally shared stories we risk them appearing irrelevant or as being rather dry scientific concepts that we employ to do things to people rather than with them. Back in the 1960s systemic family therapy appeared to offer a radical new approach to formulating and treating clinical problems. Amongst its core assumptions was that problems do not simply reside ‘within’ people but can be understood as a product of relationships between people. This was an exciting and provocative idea in the context of the primary treatments at the time with a focus on the individual metal processes as behaviours. Also there was the ascendency of medical models of treatment involving psychotropic medications. Initially this new way of thinking, for example that ‘depression’ was not a thing within us but related to types of interactions in families, suggested a model of causation not just

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a form of treatment (Dallos & Draper, 2015). I remember being excited by both features of systemic thinking: that it offered a new way of treating problems and of understanding the causes of problems. This seemed to herald an alternative to medical diagnosis and systems such as The Diagnostic and Statistical Manual of Mental Disorders and the International Classification of Diseases, which were not based on psychological theories of causation, nor did they offer clear guides for interventions (Jackson, 1957; Timimi, 2014). There was of course already a significant anti-­ psychiatry movement which critiqued the medical models but seemed rather vague in terms of what might replace them (Szasz, 1960). Systemic theory of the development of problems in families appeared to provide some specific answers to aetiology and also for treatment. These were exciting times and we observed that our work with families helped alleviate problems which sometimes had been very resistant to change by other clinical approaches. But over time I also came to reflect on my own experiences of working systemically with families and also on the families’ own experiences. For example the use of live supervision was powerful in being able to draw on the experience of colleagues to guide work with a family, but at times I felt anxious and warry of being judged by colleagues. Likewise, we were aware that families could trigger reminders and emotions from our own family experiences—‘counter transferences’. Though we touched on looking at our feelings and reflecting on how safe we felt, this was rather peripheral to the excitement of the discussions of systemic theory, of mapping circularities, strategic interventions, reframing, circular questioning and so on. Also I came to reflect more on what the experience was like for families. We had to explain and request permission for recording of sessions, live supervision, meeting the team and so on before a session. Families could express some apprehension about these aspects, but often it seemed we eventually settled reasonably comfortably into working this way. It appeared that most families could see the advantage of ‘two or more heads are better than one’. Some nagging thoughts and feelings started to form over the years and especially for a period of time when I was specialising in work in an eating disorder unit. Working exclusively with families where anorexia or bulimia was the presenting problem, I was struck by some patterns in dynamics, including what felt like a high level of anxiety about attending

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family therapy and about their internal dynamics. At the same time I became drawn to attachment theory and Bowlby’s (2005) ideas about therapy because they offered a secure base for people to be able to think about their relationships and difficulties: For not only young children, it is now clear, but human beings of all ages are found to be at their happiest and to be able to deploy their talents to best advantage when they are confident that, standing behind them are one or more trusted persons who will come to their aid should difficulties arise. The person trusted provides a secure base from which his (or her) companion can operate. Bowlby (1973)

This quote from Bowlby captures the core of ANT. Firstly, it connects with the central finding in psychotherapy research that the most important prerequisite for any form of therapy is the therapeutic relationship. Though we may cherish our preferred techniques, these are likely to be ineffective if we do not have a positive and trusting relationship with our families (Bordin, 1979). Bowlby (2005) suggested that the therapist become like a parent for the family or like a transitional attachment figure who offers a sense of security. This was also seen as analogous to the base of security that a parent offers for a child. For example, a toddler at their first day at a playgroup is likely to cling to their parent while they watch the other children play. After a while she may pluck up some courage and with her mother’s encouragement might venture over and play with a toy. She will repeatedly look to see if her mother is watching, and her mother will smile back and encourage her and welcome her back, for example if frightened by another child. The process might start again and this gradual development of risk-taking can be seen as analogous to what happens in therapy. In my experience, many if not most people I have worked with have not had this experience of being watched over and cared for. So, this becomes a new and precious relationship. The quote also includes the remark that we are “able to deploy our talents to best advantage”. This coincides with psychological evidence about stress and anxiety and contemporary neuroscience to indicate that our mental functioning, for example our ability to reflect and problem- solve, is most effective when our arousal is at a comfortable optimal level as opposed to

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heightened due to fear. Again, for most therapies a vital component is that people are able to engage in reflection and increase their ability to understand themselves and others. The outline of ANT has been offered in several publications including two books, Attachment Narrative Therapy (Dallos, 2006) and Working Systemically with Attachment Narratives (Dallos & Vetere, 2021, 2nd edn.), alongside various journal publications. The following will be a summary of some of the core features and especially some tensions and pointers for developments within the approach.

Hostages to our Past or Agents of our Lives? Bowlby’s initial intention in developing attachment theory and its related research was to demonstrate that when children experience adversities in their childhood this can have long-lasting effects. More specifically, that a central aspect of adversities was a breaking of their sense of safety and connection with their attachment figures. At the time the evidence of the negative consequences was based on observations of how children acted in distressed ways, sometimes being destructive to themselves or others. More recently, evidence is also accumulating that adverse early experiences of attachment disruptions also lead to changes in brain functioning, including the development of neural connectivity and organisation of the brain regions, such as speech and higher executive functions involved in problem-solving. One the one hand, this adds to a deterministic view of attachment theory with the important caveat from neuroscience that the brains of infants also show great plasticity and ability to adapt and overcome disruptions. The bulk of attachment theory-based research, however, suggests that early experiences shape our personalities and vulnerabilities to various types of problems. The core concept relating to this in attachment theory has been ‘security’ vs ‘insecurity’ to denote the two major orientations of attachment development (Ainsworth et al., 2015). Crittenden et al. (2021) have argued against this nosology and instead suggest that we develop forms of adaptations that are attempts to respond to dangers, and the adaptations that occur early in development and in response to severe dangers are seen as highly influential and

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lead to automatic strategies in later life which can be problematic. Traumas are not a different form of reaction but lie at the extreme end of a continuum of adaptations which disrupt the basic self-protective attachment responses.

Representational Systems and Choice Bowlby (1969) had been interested in developing what he came to regard as somewhat speculative conceptualisations of unconscious processes in psycho- dynamic theory. He turned to the developing field of cognitive neuroscience and drew on the idea of representational systems to develop a model of attachment experiences being represented at multiple levels in terms of memories and problem-solving strategies (Table 1.1). All the representational systems relate to choice in that they are seen as dispositional guides to action in the future. Further, this indicates that our narratives are composed of all of these layers—emotions, sensory material (images, smells, sounds), semantics (the words, concepts and causal explanations that we employ) and episodes (the stories of events we tell and the reflective mentalisations we have about how and why things have developed). The latter importantly includes ideas about what we have learnt from our experiences, how they have shaped us, and what our intentions are for the future, including what we plan to do differently or repeat from what we have experienced. In the narrative therapies, there is frequent reference to ‘thickening’ narratives but the concept of representation systems clarifies what this might include. A coherent story is one that includes information from all of the representational levels; we need to be able to use all of these layers of information or meanings about our life. For example, recognising my own emotions or visual aspects of situations may be important in avoiding or developing plans for how to deal with dangerous situations. Conversely, if we rely excessively on emotions and sensory information to the exclusion of semantic information we may miss out on having understandings of events and the ability to predict the causal linkages between events. Contemporary neuroscience has added to our understanding of attachment and narrating. When exposed to high levels of danger and experience of fear we are activated to respond rapidly and

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Table 1.1  Representational systems: the layers of attachment

Nonverbal

PROCEDURAL : how we do things, emotional reactions to others

Verbal

SEMANTIC : cognition, beliefs, attitudes

SENSORY: visual images, smell, touch, sounds

EPISODIC : narratives, stories INTEGRATIVE: reflection, meta-cognition, on-going monitoring of our speech and thought.

automatically. Under calmer circumstances we are able to appraise and reflect on the dangers and can formulate plans or stories about how to manage them in the future (De Kolk, 2014; Damasio, 2001). For children who grow up in circumstances where such calm reflection is not possible it is likely that their stories stay reactive; they see themselves as passive victims of events or as angrily reacting with rage and fear.

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Corrective and Replicative Intentions Attachment research, though employing these fascinating conceptualisations, has tended until recently to focus less on the content of the story of people’s lives revealed in the Adult Attachment Interview (AAI) and more on employing a structured form of discourse analysis to reveal the dominant self-protective strategies that the narrative reveals. An important development has been offered by John Byng-Hall (1995) to suggest that we can also see attachment narratives from an existential perspective. We also develop ‘intentions’ based on what we have learnt from our attachment experiences and, in particular, intentions about what we wish to repeat (replicative scripts) and what we wish to change (corrective scripts). Predominantly, our intention to change things, for example to be a different kind of parent, partner or sibling, is a conscious semantic representation, whereas we may more implicitly find ourselves replicating aspects of what we have learnt in an embodied way. These two sets of representations can sometimes run alongside each other in contradiction or dissociation, so we find ourselves, despite our best intentions, acting in ways that we have vowed to ourselves and others that we would avoid (Dallos, 2019). This recognition that our narratives contain this juxtaposition of conscious intentions and choice with the potential conflict of implicit representations is a core element of the ANT approach. We suggest that our emphasis on intentions and choice also offers an important contrast to other therapeutic models that employ attachment theory (Dallos, 2019). The issues focus on what is seen to be the role of consciousness and intentions in this picture. For ANT this is the central contribution of a narrative perspective. We not only live our lives but we give meanings to what has happened to us, and one of the most significant ways that we develop these meanings is in the form of stories or narratives (McAdams, 1993; Reiss, 1980; Bruner, 2004). But our stories are not simply descriptions of what has happened to us but serve to guide the choices we make. The narrative therapies suggest that if we are able to re-write these stories we hold about our lives we are also able to have different lives, to be able to change. In contrast, when we hold stories that are full of problems—problem saturated—these stories serve to impede or freeze our ability make choices in

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our lives (White & Epston, 1990; Anderson and Goolishian, 1988). Further, within our stories we position ourselves in different possible ways, for example as observers of our lives—passively spectating on what is being done to us or as active agents or authors who are constructing and shaping our lives. The emphasis on narrative and families as engaged in continual communications and dialogues whereby meanings are constructed has become central to contemporary family therapy (Bertrando, 2018; Paolo and Lini, 2021; White and Epston, 1990). Associated with this is the constructivist view that although we make choices, these are contingent on the actions and choices of people we are involved with in our families. So we are like authors who are continually re-writing the plot of a book but also writing it as a team with our family members and others. This is arguably a simplistic way of presenting the positions of attachment theory and contemporary family therapy. But it may nevertheless also capture some of the tensions between them and the reluctance of many family therapists to engage with attachment theory. ANT suggests that there is some potential for integration and reconciliation of these positions. Others have gone some way to doing this as well, notably McAdams (1993), who is a dominant narrative theorist and researcher and makes a connection with our early experiences and attachments regarding the tome of the narratives we develop: While some life stories exude optimism and hope, others are couched in the language of mistrust… the infant who experiences the secure and trusting attachment bond with the caregiver moves through childhood and beyond with faith in the goodness of the world and hope for the future…. (in contrast) A pessimistic narrative suggests … that the world is capricious and unpredictable… and stories are bound to have unhappy endings. McAdams (1993, p. 47)

These two different narrative tones imply quite different choices of action in our lives. Having faith in the goodness of the world means we are likely to approach people and situations with a positive orientation and a willingness to explore and experiment to take risks. In contrast, a tone of mistrust is likely to lower our expectations, promote withdrawal from the world and others, and perhaps lead us to choose like-minded

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mistrusting people to associate with. Because our stories predispose us in how we approach and act towards others it is likely that they will have self-fulfilling effects. There can then be a momentum of the stories to gather experience that consolidates our view of the world. This connection between narrative tone and attachment offers a way of bridging the idea of people as making choices based on their narratives, but also how these narratives are in themselves shaped by our experiences. In attachment theory the progression from early embodied experiences to mental representations has been discussed in terms of internal working models and more recently with reference to neuroscience as dispositional representations (Damasio, 2001; Crittenden et al., 2021).

 on’t Blame the Parents: Reflecting D on Responsibility and Influence In applying Bowlby’s quote for our thinking about therapy it is evident that it is vital for people in therapy to feel safe and able to trust. But how does this square with some of the core findings from attachment theory that the child’s emotional state and capacity to cope with challenges are shaped by the early interactions with their parents? This is also a key theme for ANT in that we have developed a number of techniques that allow a collaborative exploration of these influences we have had on our children. It is also our experience that parents are already engaged in thinking about what their role has been in the formation of their own and their children’s difficulties. Where these concerns have existed alongside little assistance from services for them and deterioration of the situation, they are more likely to turn away from these distressing thoughts about their role in the problems. Instead they may orient towards trying to suppress these and adopting medical explanations, such as that their child has an ‘illness’ (Dallos, 2019). ANT tries to offer ways of helping families feel safe at the same time as exploring with them in a collaborative and non- blaming way how their dynamics may be related to their problems.

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Similarly, early systemic therapies were concerned with identifying what kinds of family dynamics were casually related to the emergence of different forms of clinical presentations the field has turned away from in this endeavour. There were a variety of reasons for this but a major one was that families could experience feeling blamed for causing different kinds of problems in their children. This was not generally the intention of the early pioneers, though some put things quite sharply: I no longer believe in individuals; rather, I think of scapegoats, sent out by their families-of-origin to do battle with their new spouse over whose family they will recreate. Carl Whitaker

Examples of other theories of causation included the double-bind theory of schizophrenia (Bateson et  al., 1963), ‘refrigerator mother’ and autism, and conflict detouring in relation to anorexia (Minchin et al.). Though these theories were revised—for example, double-bind theory was developed as a triadic phenomenon which did not blame mothers— they continue to be seen as family blaming, perhaps resulting in the lack of research into family dynamics and development of problems. Systemic family therapy is based in a position of neutrality and a recognition of mutual influence in families but nevertheless there was increasing concern not to appear blaming. At the same time it was argued, especially by feminist-oriented family therapists, that families are not made up of individuals with equal power and that abuses can and do occur. This was perhaps most evident in forensic presentations where, for example, parents are clearly held responsible. They may be punished for inflicting violence or sexual abuse on their children and children may be removed from them if there is evidence of gross physical neglect. Understandably, systemic therapists have largely chosen not to engage in questions of causation but instead have taken a more pragmatic stance on how to promote positive changes in families (Dallos & Draper, 2015; De Shazer et al., 1986; White and Epston, 1990). Unfortunately, this has resulted in stagnation in the field in terms of our understandings of the nature of problems and family dynamics, and in turn we lack a model of causation to assist in the development of interventions.

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ANT: A Communicational Approach Bowlby described attachment as a goal-directed self-correcting system and employed the analogy of feedback systems seen in biological and mechanical systems. The goal in an attachment system is to ensure adequate protection from danger and an adequate sense of safety and security. The core premise of systemic theory is that the self-corrective processes operate on the basis of feedback, which consists of communication between the parts of a system (Jackson, 1957; Bateson, et al., 1963). Communication occurs continuously at different levels: non-verbally between members of families, and also between families, schools and so on. An early dictum in systemic theory was that it is ‘impossible not to communicate’ (Watzlawick et al., 1967) in a relationship; for example, silence can be an extremely powerful form of communication, as can non-verbal communications such as the ways we look, act, breath and move. These processes of communication alternate between being conscious and unconscious. For example, I may not be aware of how stroking my beard or tapping my fingers might be experienced as communicating something about my inner feelings or our relationship. Likewise, attachment needs involve communications; for example, an infant expresses her distress by crying, and waving her arms and legs to gain the attention of her parent. The parent responds to these communications in various ways, imitating her, ignoring her, trying to comfort, engaging in play and so on (see Figs. 1.1 and 1.2). The responses become internalised by the child as a sense of themselves and their relationship with their parent. This linkage between the external dynamics in the family system and the emerging internal world of the infant was central to our interest in early systemic theory and therapy. This is a representation of the child–parent dyad but this itself is located within wider systems of the family and also within implicit (embodied) and explicit beliefs about what kind of family we are: emotionally reserved, demonstrative, caring and so on. Though attachment theory focuses on what happens in the early stages of a child’s life, this process of communication about our feelings and needs occurs continually. For example, in Claire’s family when her mother

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CHILD communicates Attachment needs…. Internal representation Of the parent

FAMILY attachment belief system

PARENT communicates Responds to child

….

Internal representation Of the child

Fig. 1.1  Communication and attachment

cried in family therapy, as she did very frequently, no one responded by asking how she was, looking at her, touching her or offering a tissue to wipe her eyes. Her distress was triggered by talking about her own childhood and memories of emotional neglect from her depressed mother. But in affect her experience of being left alone with her distress was being repeated ‘now’ in the session. It can be very tempting as the therapist in such a situation to offer the comfort that is not being offered or the empathy that is not being communicated. However, family members are also being influenced by a variety of other contexts. First, there are ideas about the nature and cause of problems and also about what therapy is and how they are expected to behave in therapy. For example, many families will be influenced by pervasive medical discourses and so perhaps see Claire’s mother as ‘having depression’, which means it is an illness that they cannot do much about. They may also regard therapy as coming to

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R. Dallos COMMUNICATION: moving between implicit and explicit communication and meaning making

NARRATIVES: shared stories, cultural values, Media , Religion SYSTEMIC Parentchild, family, extended family, teachers, friends..

ATTACHMENT child - needs, for safety biology, brain

Mental Health services, Social Care, School Systems, religious organisations

Family’s development over TIME – family and individual life cycle

Fig. 1.2  ANT, an ecological model

be ‘fixed’ and so expect the therapist to look after them and manage the situation. Some families have had a relationship with social services over many generations and the communications and responses to each other’s requests for care are shaped by this, so they feel helpless and powerless in the face of problems. The solution becomes to bring in a professional to fix them.

Formulation in ANT: An Ecological Model A criticism of many developmental models including attachment theory is that they are limited to focusing in a linear way on the development of

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the child within the immediate family setting (Bronfenbrenner, 1979; Farnflield  and Holmes, 2014). ANT adopts a multi-level or ecological perspective in that the child and family are seen as immersed in multiple layers of influence, for example school, community and the wider cultural contexts. The understanding of the development of difficulties and the map for intervention in ANT draws on the idea of multiple levels of influence. At the individual and biological level we can understand the child’s need for safety and connection with their parents and reciprocally the parents’ needs to connect with their child. We then view this in terms of the family dynamics including relationships between the parents and the child, siblings, extended family, neighbours, school and friends, and thirdly in terms of the wider cultural contexts. The first two layers are immediate in that they involve physical interactions between people. The cultural level is more proximal in that it consists of the transmission of ideas and beliefs through various forms of language, media representations and so on. However, it does also involve direct contact, for example, with mental health services whose organisation and ways of responding to children and families embody certain discourses and beliefs, for example eligibility for service and support and what consequences occur, such as diagnosis and provision of medications. These layers of influence are also seen as moving across times, and different needs and demands for adaptation occur across the family’s life cycle but also in terms of changes in cultural contexts, a prime example being the changes prompted by the Covid pandemic. In practice, in ANT we move between these levels with families; for example, with a family genogram we explore the relationships between the children, parents and extended family. The focus can be on the nature of the attachment relationships between them, and how safety, intimacy and comfort was provided. It is also possible to draw in ideas about historical concepts regarding parenting, expectations of children and parents’ roles, and how these may have changed historically. Likewise, we use sculpting to explore relationships between different family members but also between the family and extended family, school, professional services and so on. The exploration of the difficulties and of the resources available to the family continues between the layers of influence. At the

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centre, the attachment relationships that occur through childhood are seen as becoming held in embodied forms that provide attachment orientations or dispositional representations. They can be seen to have a stability but are also being continually reshaped by family interactions and also by wider contexts. For example, in terms of crises such as wars, natural disasters and epidemics, the nature of families’ lives and in turn the attachment representations in each family member will in turn be influenced and altered. As Bowlby emphasises, attachment is a continuing process of adaption in a relational system and not just ‘inside’ individuals.

The Parenting System: Views of the Child Ainsworth’s work had shown that children develop differing attachment patterns, and the primary research format for exploring this was the Strange Situation procedure. It is now well documented that infants display difference in response to the anxiety generated by the separations involved in the procedure. What is less clear is why and how these patterns develop. Ainsworth had suggested that these are shaped by the way that parents respond to their child’s attachment needs. In particular, she suggested the idea of ‘maternal; sensitivity’ and ‘control’ as vital aspects. However, measuring these has not been straightforward not least since it is difficult to study interactions over an extended period of time between an infant and its mother and unethical to deliberately cause a distressing relationship to see how sensitively a parent responds. Attachment theory suggests that we parent our children in terms of how we were parented ourselves. It is suggested that this transmission is through our internal working models. For example, Fonagy and Target (1998) found that the attachment styles of expectant mothers in the AAI are predictive of the patterns of how their infants will be attached to them two or so years after birth. This is not to suggest that we are simply blind victims of the patterns that we have acquired from our childhoods, but rather that we hold these experiences in our narratives about ourselves and others. The experiences are held in terms of how we see others and ourselves, what we

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expect emotionally from others, and how worthy we feel ourselves to be of love and affection. Though fascinating and important, this still only offered a correlational finding: that the parent’s AAI and the child’s level of attachment security are related. It does not tell us much specific detail about how our parenting influences our children’s development. One of the core discoveries of systemic family therapy has been that although a child may have been identified as presenting the ‘problem’, this is embedded in the wider family relationships. We also frequently hear that a parent may feel despondent about their child, feel a victim of their actions, feel hopeless to be able to influence or control their behavior, or see them as an adversary or alternatively as a friend and even as protective of them. The child holds a set of meanings for the parent, and we often see how these meanings have developed from the parent’s own childhood experiences. A number of attachment theorists (George & Salomon, 1996; Crittenden, 2008; Grey & Farnfield, 2017) have been exploring further the nature of the meanings that a child holds for a parent and how these relate to the parent’s own attachment history and in turn come to shape their relationship with their child. In particular, the Meaning of the Child approach (Grey & Farnfield, 2017) helps to integrate a narrative and attachment approach in offering an analysis of how the relationship between a parent and a child develops to form into a narrative which is made up of implicit and explicit representations. Below is an example of our research and application of ANT in the context of families with a child diagnosed with autism. The two examples below illustrate stark differences between a sense of anger—the child as an adversary (Sandra)—and dependency on their child (Pamela): Pamela: They get all upset and then he’d come back down, when [CWA has] calmed down and be like I feel really bad, … and they don’t want to be my friend anymore.

Pamela had learnt as a child to try to remove herself emotionally from her parents’ conflicts and an emotionally unpredictable and frightening mother and to rely on herself. Now as a mother herself she wants to

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appear non-threatening to her children and to have a warm and mutually rewarding relationship with them. When, as is inevitable at times, her children are difficult, she experiences this as a rejection, withdraws from them, and becomes like the lonely child that she was rather than a parent to them. In contrast, Sandra, rather than withdrawing, expresses her anger towards her children: You either leave him alone and don’t go near him or he’s just in your face talking a load of crap…. you’ve just got to come to terms with, … that’s the way they are.

Sandra was adopted and always felt like an outsider. She described that various children with traumatic backgrounds were fostered and she developed some difficult behaviours to elicit their care, to which her parents responded instead by angrily shaming and punishing her. Her child appears to provoke memories of being shamed by her parents for her ‘demanding’ behaviours despite Sandra wishing to be different and less punitive as a parent. She states her wish to accept her son: ‘you’ve just got to come to terms with…’ but reveals her anger by saying he is ‘in your face talking a load of crap…’. Both Sandra and Pamela told stories of childhoods which had various forms of difficulty and trauma. Each developed ways of coping with these experiences which represented their self-protective attachment strategies. Pamela appeared to learn that it was best to minimise her feelings and try to suppress her need for affection and care, and with her child these feelings of rejection can re-surface so that she now feels abandoned by her own child. In effect, a reversed role appears to have developed so that she has become childlike in needing the friendship of her child who has become her parents. In contrast, for Sandra her child evokes angry feelings that she was unable to articulate to her parents but now emerge as anger towards her child. In this case he presents as an irritating adversary. ANT draws on this form of analysis of the profile of meanings regarding the current relationships in people’s families. Further, like Pamela and Sandra, we add that people are also attempting to change and make some different choices about what they want in their current families. Pamela

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wants to be available, reliable and protective of her children, but her need to be different also brings in the risk that she may feel hurt and abandoned if this does not appear to work. Likewise, though more angry with her son, Sandra does allow him to talk and does not want to silence him the way she was silenced.

The Therapeutic Process in ANT ANT attempts to integrate two fundamental features of its ecological model: What is held by family members in an embodied form and is being communicated between them in implicit ways and their explicit beliefs about the nature of their relationships and emotional needs. The early implicit experiences construct our self-protective strategies and our narrative tone. They also embody how people approach the therapeutic meeting (see Fig. 1.3). Some families approach therapy with a sense of defensiveness and wariness at having to remember and confront difficult and painful feelings in contrast a sense of feelings boiling over and needed to be expressed forcefully and emotionally in the session. These broadly represent the dismissing and the preoccupied attachment orientations. In families and couples there may be a mixture of orientations and we may need to adapt to each one in turn. It can be helpful to inquire from each family member how they feel about coming for therapy and what they are expecting. In some cases there is relative agreement that ‘it would be uncomfortable’, and people differ on the extent of their agreement with this shared view. ANT essentially consists of four phases of therapy which are interwoven: • • • •

Co-creating a Secure Base Processes of Exploration Fostering Changes Maintaining the Therapeutic Relationship

In all of these stages the guiding focus is on enabling family members to feel safe and to be able to trust the therapeutic process. This does not mean that there will not ruptures and difficult moments, but being able

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ATTACHMENT STRATEGY

ACKNOWLEDGE/ VALIDATE: match emotion verbally and on-verbally

DISMISSING

Focus, on actions, facts. Accept avoidance of emotions Encourage

FOSTERING CHANGE

Exploration of feelings, expression of EMOTIONS

PRE-OCCUPIED

Acknowledge emotions. Validate expression of feelings Encourage focus on events, sequences, causes, COGNITION

Fig. 1.3  Matching attachment strategies and fostering change

to negotiate these and gain a sense of confidence that problems and rifts can be repaired is key to the process. Key also to this is that both positive and negative feelings and experiences are noted. There are parallels, for example, in the solution-focused therapies in that the starting point is a focus on successes and exceptions to the problems. Likewise, ANT utilises the idea that a recognition of family successes is likely to generate a positive emotional arousal, which offers a strong starting point for moving on to solve more difficult problems. The emotional glow of our positive intentions and successes being noted provides the fuel for becoming open to exploration and also to initiate new solutions. It can also mean that after the sessions have ended the family is able to retain and hold in mind what went on and what they learnt and how they felt. This provides new positive memories and experiences of success that they can call upon in the future to resolve problems.

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Co-creating a Secure Base Helping to foster a sense of safety and security is a feature shared by most therapies. It includes welcoming families in a warm manner, adopting a non-blaming position, taking an interest in them as people not just problems, and showing empathy in relation to their distress. However, we suggest that adapting to the family’s attachment orientation is a key feature of this and is shared by many therapies. Sometimes it is referred to as helping some families to ‘warm’ up and others to ‘cool down’. Obviously we cannot make an immediate assessment of their attachment orientations unless we have already done, for example, an Adult Attachment Interview with them. But we can listen out for the characteristics of the way they start to talk about themselves and their difficulties. For some families their tone can be almost apologetic for coming to bother us with their problems and they may display very little emotion, minimise their problems and be inclined to blame themselves. Others rapidly demonstrate their emotional distress, how significant the problems are and identify people and services who they regards as being to blame.

Greg In talking about the difficulties he was experiencing in being a parent to his son who now had a diagnosis of autism Greg also described his own childhood, which suggested he had not had much experience of warmth and comforting: Normally as I said my mom was the primary caregiver so like if we were upset or hurt we will probably go to her but to be honest I can’t remember that many times …. it would have been my mum that I would have gone to crying um but yeah it sort of it as I say this sort of like there’s, there’s sort of whilst I said primary caregiver that’s only because they were around my mum was around more ….

For Greg his memories of comforting are vague and hypothetical. Rather than seeing that possibly his struggles to connect emotionally

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with his son with autism and his other children might be related to his own parents’ lack of affection towards, him he was reluctant to suggest any hint of accusation or blame towards them. The therapeutic task is not to make him blame his parents but to see that without recognising that he may have had a lack of an emotional model on which to base is parenting he may be unduly hard on himself. This appeared to be consistent with him displaying symptoms of depression. Part of a therapeutic orientation to help him develop a more coherent narrative would be to access information about feelings. More generally, for people with a dismissing style and living in emotionally avoidant patterns, it may be helpful to broadly adopt a more experiential orientation, using role-play, suggesting enactments or demonstrations of emotional process, asking empathetic questions (how others might be feeling) and using internalised other interviewing (Tomm, 1988). There can be an emphasis on exploring the emotional issues, such as how conflict is managed and how caring and comforting is given and received. The aim is to help them to develop narratives that incorporate feelings and emotion and do not involve such a shutdown of sensory and episodic memory systems. In contrast, encouraging an expression of cognitions aims to assist people to gain some distance from the immediacy of their feelings and the potential to be unhelpfully overwhelmed by emotion, such as fear and shame, and to be able to reflect on and develop narratives that can locate experiences in causal and temporal connections. In the extract below, Tara frequently in her story of her childhood was overcome by memories of her own vulnerabilities and also became preoccupied with her parents’ faults. For example, some play with her father is remembered as painful and uncomfortable excessive ‘tickling’.

Tara My mum she would get into an arguments another parents, always doing that I couldn’t get away from it… she was very anxious all the time….we had two cats… wanted cats to stay in my room, wasn’t allowed… mum was very anxious and angry in the morning… always operating at a high level of anxiety, hard to be around that… my dad was the same…

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I was upset, distressed quite a lot, at my birthday party I got so anxious about my dress… I became so anxious I couldn’t go, I had a sort of breakdown… both parents were trying to be consoling but they didn’t understand why I was so inconsolable about it… I don’t have strong memories of being touched….mum is not very tactile and I remember my dad tickling me until I couldn’t breathe…. Don’t know if you have ever experienced it but… So I felt sick, tickling can actually be painful…. For people with a more preoccupied attachment style the emphasis in therapy is on strengthening semantic processes. This can include a variety of structured therapeutic approaches, such as the use of genograms and life storylines that ask people to locate key events in their lives in terms of time and place. This can help to build more temporal order in their stories so that they are less disconnected in terms of timing of events. Tracking circularities and mapping cycles of beliefs and actions can help to foster causal and temporal relations between events in their narratives. Also, questions can be asked that encourage semantic descriptions about how other people see events, their own beliefs and cognitions, and circular questions can be asked that attempt to identify patterns of responding in their systems (Dallos & Draper, 2015). This process of accommodation, or shaping of our therapeutic style and response to people’s attachment patterns, may occur outside our awareness and may be shaped by our own preferred attachment orientations. Tara appears to become overwhelmed with negative thoughts about her parents and also becomes distracted and attempts to involve the interviewer by asking if he had similarly experienced such ‘unpleasant tickling’. Such an account can generate a sense of feeling emotionally overwhelmed, perhaps similar to how she felt overwhelmed by her mother’s anxiety. It can also fuel an urge in us to wish to introduce a more balanced and less relentlessly critical portrayal of her parents. If our own attachment orientation is dismissive we may start to feel overwhelmed by her account, and a typical response, in interviews which resemble Tara’s, is to seek to introduce a calmer and more balanced narrative. This of course can sometimes be therapeutically helpful but there can be a risk that if we do this inadvertently we do not quite recognise Tara’s pattern since we have merged her narrative with our own. Consequently, we may find it harder to recognise the attachment strategy that is fuelling her

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difficulties. Moreover, Tara offering suggestions about seeing her parents in more positive ways can be met with an unproductive further listing of their failings. Greg, in contrast inspires strong feelings in us of wanting to help him to express what he feels, to help him move beyond this painful defence. However, the emotional processes can be very powerful and we can become caught up in unhelpfully engaging with such patterns. For example, without noticing it we may become over-rational and lacking in affect in a session with Greg. In fact, it is quite easy to start to think that things are quite alright, ‘there is no problem at all and no need to worry!’ Or, to start feeling overly animated and emotional or chaotic and out of control with Tara. This framework is not meant to be a rigid prescription for our responses. We suggest that there may be times when it is important to validate both Greg’s and Tara’s styles and not engender anxiety by deliberately or inadvertently challenging their self-protective attachment strategies. However, a recognition of these styles can help us to be more flexible and creative in assisting them to develop fuller and clearer, more coherent narratives about their lives and relationships. In the following chapters we develop these ideas further, by looking at their applications in diverse settings and relationships. These excerpts highlight how we can tell our stories from an attachment position or adaptation that involves dismissing our emotions, our need for others and expectations of care. Typically, since expectations of care from others are dismissed or minimised there is either an absence of holding others to account or blame for what has happened to us, or in some cases a sort of looking at events through rose-tinted glasses to make things look positive. In contrast, people may tell their story with a preoccupation with emotion, a focus on past hurt, grievances, anger, fear, or a sense of betrayal at how we have been unfairly treated. Often thinking about the future is short-circuited by an emphasis on resolving these grievance before it is seen as possible to move forward. The narrative theories and therapies stress a social constructionist perspective that there are no truths. Different stories are possible but attachment theory adds substance to this by revealing that one important way that stories differ is how they are shaped by the characteristic ways we have learnt to adapt to

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the emotional circumstances in which we developed (Crittenden et al., 2011). Our starting point is the view that the stories that we create about our lives are a key component in how we live and how we develop problems and difficulties in our relationships. We create narratives about what has happened to us in our lives and these help shape how we think of our past and importantly how we view and embark on the future. The ANT approach focuses on an important set of stories that we develop about our connections, namely our emotional and sexually intimate relationships, our attachments with others, such as our parents and children, and our dependencies, experiences and expectations of trust in our relationships. Attachment theory emphasises that we have a fundamental need, which appears to be based on an evolutionary survival instinct, to engage in intimate relationships fueled by our need, starting in infancy, to seek safety and protection with our parents/carers when faced with threats of danger, loss and adversity. These early interactions between the parent and the child produce the experiences that form the material of our developing narratives about ourselves and others. These early experiences subsequently come to be shaped into broader narratives and sets of expectations that we generalise to other relationships outside our families. However, narratives are not a passive recording of the past but constitute an active process of continual construction, reconstruction and review. We tell our stories to others and their questions, reactions, comments, additions, revisions and corrections serve to reshape our stories with each telling. As we tell our stories, even when we muse to ourselves, powerful feelings are evoked, which shape how and when we tell our stories—for example, who we tell, what we leave out, forget or defend ourselves from remembering, alter, adjust and edit, and, of course, why we tell. We may also alter our stories according to who we are telling and thus how safe we feel we are to be honest, straightforward, open and able to access our memories. Our framework approach therefore shares much with the narrative therapies in our emphasis on working with people’s narratives and relationships to foster change, liberation and release from their interpersonal problems. However, we add an emphasis on the emotional content of people’s stories, and as yet untried experiences, such as trauma, and in particular on how they manage their feelings and

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attachments, for example how they comfort themselves and others in times of anxiety, distress and difficulties. We are interested in how children learn to narrate their experiences and what assists them in developing the skills for open, consistent and coherent communication of their emotional experiences. In addition, we focus on the process of the telling of the narratives to consider what types of self-protective strategies or defences people are employing as painful, uncomfortable and anxietyprovoking memories are evoked in the telling. This shares some similarities with psychodynamic models in recognising the need to elicit both what is explicit and also what is implicit—what we find harder to articulate. This does not involve adopting an ‘expert’ position of knowing better than the families we see but rather finding ways to help them to articulate the more hidden, subjugated aspects of their emotional experiences in their relationships and the self-protective strategies that they may have been employing. Central to this is the creation of a context of safety and trust for families that can help such material to be accessed, illuminated, expanded, expressed and processed.

Processes of Exploration and Fostering Changes In the ANT approach there is not a linear progression from talking about the difficulties to an exploration of deep underlying attachment problems (see Figs.  1.4 and 1.5). In the therapeutic process there is typically a movement between talking about past childhood difficulties and traumas, alongside current circumstances and family dynamics. This may be related to families’ attachment orientations; for example, for families with preoccupied patterns there can be a rush of information about emotions, conflicts and childhood experiences, mixed in with current problems. In other more dismissing family orientations there can be a focus on the symptoms with little enthusiasm for exploring possible emotional influences from childhood. Rather than a linear process this can be represented as a circular process. Exploration and intervention can go hand in hand because the oscillation between these different areas can result in continuing negative arousal,

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FAMILY PROBLEMS, presenting problems

EMOTIONAL DYNAMICS IN THE FAMILY

CHILDHOOD EVENTS AND TRAUMAS

EXTENDED FAMILY and OTHER SYSTEMS

Fig. 1.4  Process of exploration and fostering change

sense of helplessness and confusion for both the family and the therapist. Ruth

Ruth, a mother of two young boys, described how both her boys (9 and 5 years of age) were becoming violent towards her and she was struggling to manage them. She was extremely psychologically aware and had previously engaged in parenting programs and various forms of counselling and psychotherapy. She rapidly offered the formulation that the boys’ anger may have been linked to them being caught up in the continuing post-separation conflict between their father and herself. She also described that her ex-husband was continually complaining and bad-­ mouthing her to her sons when they stayed with him, despite her asking him not to. She was also trying to be understanding and described his traumatic family background, as well as her own difficult childhood experiences of being parented. Rather than needing to pursue deeper attachment-related information, this was immediately presented. However, as the session progressed it was apparent that it was not helping

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younger brother has oLder brother's toy.... argument GIve older boy a cuddle

mother adds more explanaon about inappropriatenes of violence

Ruth intervene, give toy to older brother and get him to leave the room with her

Younger brother grabs the toy

fight ensue, older brother kicks door into mum and she is hit by him

Older brother calms down a bit mother explains not ok to hit

Fig. 1.5  Tracking a circular pattern in a family

her develop effective ways of dealing with her sons’ violence. We have found that in such cases of too much peripheral information it can be helpful to slow down and focus on the most immediate problems and explore them using attachment-based tracking of a specific incident. As we mapped this cycle Ruth started to feel less helpless and less of a failure as a mother and to recognise that much of what she had done worked (see Fig. 1.5). However, it had involved her being hurt and she was wary of this happening again. We considered some alternatives. One was that she could have taken the toy from her younger son and given it to the older one and removed him from his older brother’s room. She

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agreed that this might have calmed the older boy but would have made the younger one furious and that possibly his temper was worse and she confided that he had been excluded from school three times in the last two months for aggression. This led to a discussion of how she was between a ‘rock and a hard place’ and that possibly it would be more manageable the next time this happened to deal with the younger child. Of course this was not the sole focus of the session, but detailed attention to patterns of actions and escalating feelings can provide a starting point. This focus on helping her to contemplate some different solutions for managing her boys’ anger took place alongside discussion of her own past, her relationship with the boys’ father and so on. She described her own mother as unpredictable, controlling and anxious and her father as absent. Possibly for a therapeutic relationship it was helpful to be able to help create a secure base for her which was reliable, non-controlling and calm. These are generally positive qualities but it is important in the exploration and change facilitation to not become overly directive. A feature of ANT is also to invite families to continue exploration and experimentation between sessions so that they gain confidence in exploring problems using these tools from ANT. The chapter on the SAFE manualised version of ANT will offer further descriptions of this.

References Ainsworth, M. D. S., Blehar, M. C., Waters, E., & Wall, S. N. (2015). Patterns of attachment: A psychological study of the strange situation. Psychology Press. Anderson, H., & Gollishan, H. A. (1988). Human systems as linguistic systems: Preliminary and evolving ideas about the implications for clinical theory. Family Process, 27, 371–394. Bateson, G., Jackson, D. D., Haley, J., & Weakland, J. H. (1963). A note on the double bind- 1962. Family Process, 2(1), 154–161. Bertrando, P. (2018). The dialogical therapist: Dialogue in systemic practice. Routledge. Bertrando, P., & Lini, C. (2021). Towards a systemic-dialogical model of therapy. Human Systems: Therapy Culture and Attachments, 1(1), 15–28. https:// doi.org/10.1177/26344041211003853

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Bordin, E. (1979). The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy, Theory, Research and Practice, 16, 252–260. Bowlby, J. (1969). Attachment and loss v. 3 (Vol. 1). Random House. Bowlby, J. (1973). Attachment and loss, vol. 2: Separation, anxiety and anger. Hogarth. Bowlby, J. (2005). A secure base: Clinical applications of attachment theory (Vol. 393). Taylor & Francis. Bronfenbrenner, U. (1979). The Ecology of Human Development. MA: Harvard University Press. Bruner, J. (2004). Life as narrative. Social Research: An International Quarterly, 71(3), 691–710. Byng-Hall, J. (1995). Rewriting family scripts. Guilford Press. Crittenden, P. M. (2008). Raising parents: Attachment, parenting, and child safety. Willan Publishers. Crittenden, P. M., & Landini, A. (2011). Assessing adult attachment: A dynamicmaturational approach to discourse analysis. WW Norton & Company. Crittenden, P.  M., Landini, A., & Spieker, S.  J. (2021). Staying alive: Self-­ protective strategies, Neurodevelopment, & Traumatic Danger. Human Systems. Dallos, R. (2006). Attachment narrative therapy. McGraw Hill. Dallos, R., & Draper, R. (2015). An Introduction to Family Therapy. McGrawHill, Maidenhead. Dallos, R., & Vetere, A. (2021). Systemic Therapy and Attachment Narratives. Taylor Francis. Damasio, A. R. (2001). Reflections on the neurobiology of emotion and feeling. The foundations of cognitive science (pp. 99–108). Clarendon Press. De Shazer, S., Berg, I. K., Lipchik, E. V. E., Nunnally, E., Molnar, A., Gingerich, W., & Weiner-Davis, M. (1986). Brief therapy: Focused solution development. Family Process, 25(2), 207–221. Farnfield, S., & Holmes, P. (Eds.) (2014). The Routledge Handbook of Attachment. London and New York: Routledge. George, C., & Salomon, J. (1996). Representational models of relationships. Infant Mental Health Journal, 17(3), 198–216. Grey, B., & Farnfield, S. (2017). The meaning of the child interview: A new procedure for assessing and understanding parent–child relationships of ‘at-­ risk’ families. Clinical Child Psychology and Psychiatry, 22(2), 204–218. Grey, B. and Farnflied, S.(2017) The Meaning of the Child Interview (MotC). Journal of Children’s Services. 12.(1) 16–31

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Jackson, D. (1957). The question of family homeostasis. Psychiatry Quarterly Supplement, 31, 79–99. McAdams, D. P. (1993). The stories we live by: Personal myths and the making of the self. Guilford Press. Fonagy, P., & Target, M. (1998). Mentalization and the changing aims of child psychoanalysis. Psychoanalytic Dialogues, 8(1), 87–114. https://doi. org/10.1080/10481889809539235 Szasz, T. S. (1960). The myth of mental illness. American Psychologist, 15(2), 113. Timimi, S. (2014). No more psychiatric labels: Why formal psychiatric diagnostic systems should be abolished. International Journal of Clinical and Health Psychology, 14(3), 208–215. Tomm, K. (1988). Interventive interviewing: Part 3. Intending to ask circular, strategic or reflexive questions. Family Process, 27(1), 1–17. Van der Kolk, B. (2014). The body keeps the score: Mind, brain and body in the transformation. Front Psychol, 12, 704974. Watzlawick, P., Beavin, J., & Jackson, D. (1967). Pragmatics of human communication. Norton. White, M., & Epston, D. (1990). Narrative means to therapeutic ends. Norton.

2 Towards a Secure Exploration of Attachment and Shame Using Attachment Narrative Therapy Myriam Laplanche

Heaven knows we need never be ashamed of our tears, for they are rain upon the blinding dust of earth, overlying our hard hearts. I was better after I had cried, than before—more sorry, more aware of my own ingratitude, more gentle. Charles Dickens, Great Expectations Shame is a soul eating emotion. Carl Gustav Jung

Introduction There are two concepts that I am going to bring together in this chapter: Attachment Narrative Therapy (ANT) and chronic shame. I will be sharing my experience of using ANT while working in private practice with clients whose attachment bonds have been disrupted by unresolved chronic shame.

M. Laplanche (*) London, UK © The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 R. Dallos (ed.), Attachment Narrative Therapy, Palgrave Texts in Counselling and Psychotherapy, https://doi.org/10.1007/978-3-031-12745-8_2

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Although ANT was initially developed to work with families, it includes and takes an interest in the personal experience of family members and lends itself to working with individuals in both short- and long-term therapy.

What Is Shame? The importance of shame is often underestimated, despite it being a key emotion of socialisation and therefore a powerful organiser of the human experience (Sanderson, 2015). Allan Schore (1994) teaches us that young infants can feel shame and that, as parents carry out the task of protecting and socialising their children, shame is present in early attachment experiences. Shame ranges from a mild, fleeting sense of embarrassment or self-questioning to unconscious deep-seated chronic feelings of shame. Healthy, fleeting shame is at play in everyday human interactions; it encourages pro-social behaviours and the development of empathy and compassion. However, persistent, deeply felt shame, also called chronic shame, can severely affect the capacity to make and maintain attachment bonds. Shame is inherently relational, and our experience of it will often stem from our earliest sense of ourselves in relation to others. It is buried deep in our psyche and can become pervasive to the point of invisibility, even to ourselves. Judith Jordan (1997, p. 147) gives the following definition of chronic shame: “…shame is most importantly a sense of unworthiness to be in connection, a deep sense of unlovability…. There is a loss of the sense of empathic possibility, others are not experienced as empathic, and the capacity for self-empathy is lost”. This is important information to keep in mind when working with shame-prone clients because, in therapy, they may have no expectation that they will be listened to with empathy. Patricia A. De Young (2015) gives a definition which is both relational and informed by attachment theory (p.  18): “Shame is the experience of one’s felt sense of disintegrating in relation to a dysregulating other”. She continues (p. 21): All of it has something to do with needing something intensely from somebody important and something going wrong with the interaction…If the sequence is repeated often enough in my experience to become an expect-

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able experience, I will have a core propensity to feel shame whenever I have strong feelings, need emotional connection, or feel something is wrong in an interpersonal interaction.

With this definition, shameful feelings are part of the fabric of insecure attachment strategies.

Attachment Narrative Therapy and Shame In 2015, I joined an ANT supervision group led by Rudi Dallos and, over several years, we discussed many cases and found that certain factors were essential for a successful outcome from the therapy. The main one is the need for a secure base, that is, a base from which clients can explore and take risks and to which they can return to feel safe and contained (Bowlby, 1988; Holmes, 2001). Coming to therapy and talking involves a huge risk. By telling our stories, we may for the first time face the reality of what has happened in our life and in our family. We no longer have access to our dismissing strategies of blocking or denying distress. Recalling distressing memories may flood the room with anxiety both for the client and also the therapist, for whom some memories of being shamed may also be provoked. These feelings of shame need to be acknowledged and regulated. Therefore, co-creating a secure base will involve taking time to establish trust and co-create safe patterns of exploration. “An ANT approach recognizes the strong emotions that are quickly evoked and tries to weave together and establish a pattern whereby the discussion can alternate between discussion with a structured, semantic focus and one with an emotional one” (Dallos, 2006, p. 148). Clients will be scrutinising therapists to decide what they can reveal and when. In shame-prone contexts, unintentional shaming by the therapist is likely to occur, and when disconnects happen, therapists will aim to repair the rupture. ANT offers a wide range of lenses and angles through which implicit patterns and explicit behaviours can be observed. I like the metaphor of a camera with a powerful zoom and a wide angle. This zooming in and out and changing positions and angles facilitates the safe exploration of

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attachment and shame because it helps regulate the balance between feelings and cognitive processes. A very wide lens will catch the client’s cultural genogram, the “pride and shame issues…aspects of a culture that are sanctioned as distinctively negative or positive” (Hardy & Laszloffy, 1995, p. 229). Focusing in, it is equally important to understand emotional ways of relating within a family’s belief system, that is, “a family’s way of knowing and understanding its world” (Burnham, 1986, p. 21); a narrower lens will focus on how these patterns developed into internal working models of relating to others for each member of the family and particularly my client (Bowlby, 1969, 1988); and finally, adopting different positions within the family will explain how patterns may be repeated in new relationships as well as transmitted through the generations. ANT underlines the importance of understanding attachment bonds within the wider system in which the individual operates, not merely within the limited dyadic positions of parent and child or caregiver and careseeker. This enables the focus of attention to shift away from who cares for whom. Instead, the focus is on how secure attachment can be best nurtured in a specific family context. Again, this contextual perspective is especially important in shame-prone families because no single individual carries the blame as every behaviour makes sense as an attachment strategy within that family.

Integrating Internal Working Models and Dispositional Representations A further significant aspect of ANT is the integration of our understanding of internal working models with the concept of “dispositional representations” (Crittenden, 1997). As Rudi Dallos (2019, p. 65) reminds us: Bowlby drew on the emerging field of cognitive science to offer a model of the developmental pathway of how early experiences are stored (Tulving, 1972). These may operate both consciously and unconsciously to shape our experience and choices of actions, sometimes outside of our conscious

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awareness. This concept has been elaborated by Crittenden to suggest that our memories which are also the bases of our actions, feelings and choices, are stored in terms of five major levels. Two of these are forms of non-verbal memories: procedural and sensory and three are forms of verbal memories: semantic, episodic and integrative.

For use in clinical practice, these levels of representation are simplified. A way of making this technical language accessible is to use the following terms: feeling, thinking, talking and doing. When we observe patterns with clients, for example by using circularities or circular questions, we keep in mind these four levels of representation. ANT facilitates working fluidly across several levels of representation because it integrates three theoretical frameworks: attachment theory, systemic thinking and narrative therapy. Attachment theory is more focused on affect and affect regulation (feeling and talking), whilst the systemic and narrative approaches pay more attention to actions, ideas, attitudes and beliefs (thinking and doing). We know that shame is a particularly complex feeling state that can be easily missed because it makes an individual want to hide. By having these different levels of representation in mind, we are more likely to catch and recognise what is happening around shame in the client’s internal world.

F rom Attachment-Based Therapy to Attachment Narrative Therapy My first psychotherapy training was at The Bowlby Centre, where I learnt about attachment theory. I was taught that attachment theory is an evolutionary and ethological theory that explains, in a codified systematic fashion, the need for human children to attach to their caregivers for their physical and emotional development, and ultimately for their survival. The type of attachment that is likely to be formed between the child and the caregiver depends on the sensitivity and responsiveness of the caregiver to the child’s needs. The child will adapt to the caregiver’s

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responses and recognisable patterns of interaction will develop over time. These patterns of interaction, and related expectations, are internalised in childhood and teenagerhood and will influence our representation of the self, our expectations of others and our behaviours, together with our feelings and thoughts in later relationships throughout life. With this model in mind, my early work was based on the belief that change would happen through the therapeutic relationship, primarily because the therapist was attuned and responsive to the client’s attachment needs in a way the client had not experienced before. Through the repeated positive experience of having the client’s attachment needs met, clients and therapists create new patterns of interaction that become the template for more secure attachment strategies and create a new internal working model for the client. Although I still believe this is a crucial part of the therapeutic process, ANT adds other useful components to the therapeutic process. The clinical tools typically used in systemic settings, such as tracking circularities, mapping the self in relation to attachment figures, sculpting, genograms and timelines, are all drawn by the client and therefore put the client in charge of the material being looked at. Looking together at emerging patterns, client and therapist become co-observers of the system (Campbell, 2000). This allows for more flexibility and creativity as clients can play with, and explore, the roles ascribed in the family. Observing the wider context through the lens of attachment, via genograms, means that patterns of interaction and transmission are not located in one individual. Systemic thinking is also conducive to acknowledging interdependence and the impact that each part of the system has on another part of the system. Each family system comes with a set of expectations, beliefs and rules, both visible and invisible, that influences the roles and behaviours adopted by each member of this specific family. The perspective is no longer who looks after whom in the dyad but who looks after whom in the wider system. What are the beliefs in the family? What is the dominant discourse about who looks after whom?

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 wo Examples of the Use of Attachment T Narrative Therapy in Clinical Practice For clarity purposes, in the following two clinical cases the work has been presented in stages. The first stage is to create a secure base to explore from and come back to. The second stage is where the problems are being identified and explored. The initial formulation is being made through an attachment narrative perspective and starts by identifying the dominant attachment pattern for each client and “whether their style is to organize in terms of a dismissive strategy: dismissing emotions and emphasizing cognition or a preoccupied strategy: dismissing cognition and emphasizing emotions” (Dallos, 2006, p. 128). Then the clinical work expands to explore how the dominant pattern is being maintained and possibly transmitted through the generations. So key emotional relational moments illustrating attachment strategies are being chosen as particularly illustrative. The third stage is where alternative attachment narratives are being explored; those already in place can be reflected upon, as well as hypothetical future-orientated narratives. Throughout the process, the choice of therapeutic tools is led by their likelihood to encourage expression of feelings or cognitive processes. Table 2.1 (Dallos, 2006, p. 129) is a useful guide. The first clinical example, Farah’s story, illustrates the use of ANT to explore the trans-generational transmission of an anxious-preoccupied Table 2.1  Therapeutic approaches and attachment styles Dismissive

Preoccupied

Encouraging expression of feelings Enactment Role-play Reflective functioning questions Internalised other interviewing Exploring areas of conflict Managing conflict Caring and comforting

Encouraging cognitive process Genograms Lifestory lines Tracking circularities Mapping beliefs, actions and cycles Scaling questions Circular questions Shared family beliefs

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attachment strategy that had been internalised following early relational trauma. The second example, Connell’s story, illustrates the use of ANT with an avoidant-dismissive strategy that had been internalised following repeated periods of separation from attachment figures in childhood. For confidentiality purposes, these cases are composites of set in a fictional background.

Farah’s Story: “I Want to Be a Good Mother” Farah is a joyful and warm young woman who lives with her husband Sami, their two-year-old son, Aayan, and their six-month-old daughter, Hana. The couple moved to the United Kingdom from Azerbaijan one year after getting married, when Sami was offered a senior post in his field. Farah also works full time as a researcher and lecturer. The couple’s grandparents were family friends and Farah and Sami met through cousins. There was no courtship as both Farah and Sami wanted to follow religious principles. They are both committed to the success of their family life and Sami has also started therapy. Farah’s faith is particularly important to her and has given her guidance and strength throughout her life. She is the youngest of six children and she was the only female child in her family. She grew up in a privileged setting and, in early childhood, was mainly looked after by nannies. Her upbringing was strict and even punitive at times. The family’s social life was mainly with relatives and Farah spent many meals and religious festivals with her grandparents, her aunts and her numerous cousins. With so many potential caregivers present in Farah’s life, I asked attachment-informed circular questions to orientate myself in Farah’s family of origin (Singh & Dutta, 2010). Who looked after you when you were growing up? Who comforted you when you were hurt? I also asked which aspects of her upbringing she wanted to replicate for her own son and which things she wanted to do differently. Through this exploration, replicative and corrective scripts could be acknowledged (Byng-Hall, 1985; Dallos, 2019). Farah decided to come to therapy when she moved to London because she was worried about not being a good parent. She felt she was giving

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too much attention to her new-born daughter and not enough to her son. She could see that her relationship with her son had changed since the birth of her daughter. She noticed that she had less patience with him than previously. She became angry with him over small things and this worried her. She often asked herself if her son loved her husband more than he loved her and she needed reassurance from her husband that this was not the case. Farah’s attachment organisation tended towards a preoccupied pattern of behaviour. Farah was on high alert about her lovability. Her strategy in trying to manage this was to rigidly monitor levels of closeness to her husband and to her son and the level of closeness between the two of them. When she felt her demands for closeness were not being met, she became very anxious and could hear herself becoming critical. Having had a mother who was relentlessly critical, she had a clear positive intention to act differently but could not always live up to her own expectations. Understanding how “… conscious intentions may conflict with or be distorted  by unconscious attachment scripts…” (Dallos, 2019, p.  135) has been at the core of our reflections during supervision. In Farah’s case, we came to understand that seemingly benign interactions with a close attachment figure could easily evoke a high arousal at an implicit memory-processing level. Her preoccupied attachment pattern of behaviour feared humiliation, in the form of rejection, and this activated her fear system. In this highly generalised state of fear, she could no longer have access to her cognitive functions and make sense of what was happening. She could not easily discriminate whether behaviours were intentionally rejecting or not.

Stage 1: Establishing Trust and Creating a Secure Base Navigating Shame and Repairing Unintentional Shaming In the early sessions, Farah really wanted to tell me numerous stories about her childhood, stories about her relationship with her parents and the place she had in her family. Most of the vignettes indicated that her parents had employed elements of both controlling and unresponsive

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caregiving with her (Grey & Farnfield, 2017). This mixture of control and unavailability from parents appeared to have promoted a sense of her relational world as having been generally unsafe and unpredictable when she was growing up. It was helpful for us to revisit early traumatic moments and share her sadness and concern about being “the bad one” in her family. As the therapy was not time-limited, we had time to bear witness to what had happened to her. Farah’s story had a preoccupied orientation in that she expressed a range of criticisms, complaints and negative memories regarding her parents, especially her mother. For example, she suggested that her appropriate wish for closeness to her mother had been systematically rebuffed. She had not been able to share her deepest wounds with anyone for fear of being at best dismissed or, at worst, punished. Being the only female child in the family and the youngest, she had been treated differently from her brothers and her developmentally appropriate wish for autonomy had often been perceived as socially unacceptable by family members. She had found solace in her studying. The emotional atmosphere, when her brothers were at home, was one of constant banter where she would be targeted for being a “nerd”. Her preoccupation in the present  with her brothers’ wrongdoings in the past kept her angry. This anger prevented her from using a wider lens and from looking back at the family system from an adult’s perspective. It is important to first meet the client where she is at now, then witness what has happened and connect with the emotions and sense of injustice expressed in preoccupied narratives  such as this. My demonstration of understanding of her stories and validation of her feelings contributed to establishing trust and building a secure base. Validating her feelings also lowered her anxiety. These early sessions were also a good time to introduce ‘cooler’ and more semantic content to allow her to step away from her emotions and complaints to reflect more broadly in lay terms about attachment strategies. I gave her a copy of the Circle of Security diagram and included some psychoeducation around key concepts to underpin our understanding of what was happening.

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Cultural Aspects In telling me these stories, Farah was also taking a huge risk. She revealed traumatic vignettes that she had never disclosed, and this felt exposing. Putting these into words made them feel real, and potentially shameful. These were feelings I could relate to from my own therapeutic journey. Sometimes we managed to navigate around a difficult moment without unintentional shaming occurring. Together we could adopt an empathic stance to observe. And sometimes we could not. The moments of disconnect happened when I misread Farah’s attempts to connect with me and therefore ignored them. I then, unintentionally, became the dysregulating other. Fortunately, she was able to tell me when this occurred, and I would listen and apologise. In this way, we managed to repair these ruptures as we proceeded. These moments also happened when I misunderstood the family culture and made assumptions based on my own culture (Singh, 2009; Singh & Dutta, 2010). Farah was always happy to give me more context and slowly I learnt about the hierarchical structure and patterns of relating in her social context together with the richness of her culture and religion (Falicov, 1995). In this exploration, Farah described many positive exchanges of solidarity and warmth between friends and family members and these were to become helpful positive templates.

Stage 2: Exploring the Problems Identifying Key Relational Moments of Shame With clients who have suffered relational trauma, the attachment narrative seems to be encoded in one or more traumatic memories that resurface again and again. Often, the most useful intervention to explore these difficult moments is to map patterns of interactions between family members (Dallos & Vetere, 2009). Mapping out these traumatic memories in parallel to current interactions allows for more integration of feelings and thoughts to increase reflective functioning.

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In quite a few stories that Farah related to me, the scenarios played out were familiar and she used the same words: the adjective “naïve”, the leitmotiv “I am such a loser”, and the expression “throwing yourself at people”. Therefore, I suggested that we observe more closely two episodic memories involving these, one in the past and one in the present, where a similar narrative was being played out.

From the Semantic to the Visual: Tracking Circularities For a client such as Farah, with a preoccupied attachment strategy, recalling a vignette can heighten their emotional response and dysregulate their affect. Through our reflective stance in supervision, we have seen that tracking and mapping circularities can be helpful because the process of drawing slows down the client’s dysregulated narrative. Heightened arousal and anxiety decrease as client and therapist engage together in reconstructing, in a slow and structured minute-by-minute manner, a pattern of interaction. This changes the roles assumed in the room as patient and therapist are now both observers of the interaction (Campbell & Groenbaek, 2006). Farah’s first memory, when she was a child, is mapped out in Figs. 2.1 and 2.2. Her second memory, in a different role as an adult, is mapped out in Figs. 2.3 and 2.4.

Traumatic Memory from the Past (Figs. 2.1 and 2.2) Farah is 11, and she has spent a lovely morning at a good friend’s house. They have been discussing what they have bought for their respective mothers for Mother’s Day. Her mother has seemed worried lately and perpetually angry with her. Farah has saved all her pocket money for a month to buy her mother an expensive brooch. Her mother’s reaction to Farah’s gift is to scold her for spending too much money and being “so naïve”. This was representative of Farah’s appropriate attachment behaviour being met by a hostile reaction. As this

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Mother is feeling anxious and preoccupied Farah is furious with her mother and shuns her for days

Farah says, "Happy Mother's Day"

Farah feels hurt and shame and hides in her bedroom.

Mother says, "You are so naive, you throw yourself at people"

Mother opens the gi not smiling

Farah feels anxious Mother says, "Silly girl, this is too expensive"

Fig. 2.1  Farah circularity 1

Aachment behaviour expressed as anger quickly followed by detachment

Caregiver is preoccupied and anxious

Aachment behaviour. Careseeker expresses wish for closeness.

Careseeker is flooded by shame. Need to disconnect

Aachment behaviour is misunderst ood and not met

Rupture in the aachment bond

Fig. 2.2  Farah circularity 2

Wish for closeness is met with an hosle reacon

Careseeker is feeling anxious

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was repeated throughout her childhood, it became a blueprint for one of Farah’s Internal Working Models. Her wish for emotional connection was implicitly experienced as being wrong because she was made to feel shame for it.

Memory Is Triggered Implicitly in the Present (Figs. 2.3 and 2.4) Farah and Aayan are at the park. They have come for a playdate with one of Aayan’s friends from nursery. Farah is feeling anxious and speaking with the friend’s mother. When Aayan runs towards a third child to give him a hug, he is ignored by the child. Aayan then looks at his mother for reassurance. He is feeling confused but not upset. Farah is triggered and flooded with anxiety and shame. She cannot reassure him, and she looks away, feeling worried that he is like her: naïve and throwing himself at people.

Farah is feeling anxious and preoccupied Farah looks away, feeling anxious. She thinks "I am a bad mother"

Aayan is feeling happy and runs towards a friend, also a toddler, to give him a kiss

Implicit memory is triggered. Farah thinks: "He is a loser like me"

The friend ignores Aayan and carries on playing Aayan looks at his Mum. He is confused but not upset

Fig. 2.3  Farah circularity 3

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Farah as a caregiver is feeling preoccupied and anxious Rupture in the attachment bond

Attachment behaviour. Child expresses appropriate wish for closeness

Caregiver cannot respond to the child attachment needs

Wish for closeness is not reponded to. Small rupture

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Implicit memory is triggered Caregiver is flooded by anxiety

Fig. 2.4  Farah circularity 4

With Farah’s collaboration, we used coloured pens to revisit these circularities, wondering what each person is thinking, feeling, saying and doing. Farah could see for herself some similarities between these two situations, although in each she was in a different position in the attachment system. She expressed the wish to do things differently with her son but did not know how to react. She wanted Aayan to be loved and feel loved but was not sure how to achieve this. In her words, “If he throws himself at people, he will get hurt”. Farah’s functional wish to be close to her mother had been met with hostile reactions which had made her feel shame. Over time, this pattern of interaction had led to Farah feeling a preoccupying intense shame each time she wanted closeness and her need was not met. Therefore, by identification, she had felt overwhelmed when her little boy expressed an appropriate wish for closeness with the other child and had been ignored.

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 tage 3: Exploring Alternative Narratives, Alternative Contexts S and Fostering Change Reframing the Event We discussed different possible ways to interpret what happened that day in the park. One plausible explanation was that her son was social and happy and the fact that he was running towards another child was something to be celebrated. It showed that his expectations of others were positive, and it was a sign of inner security. This observation had a significant effect on Farah; she had never thought of it like that. This turned out to be a turning point in her understanding of her son’s attachment patterns.

Understanding the Wider Family Context The risk from expressing care and affection fitted also in the wider discourse among the women in her family of origin. In Farah’s family, it is considered wrong for a woman to be too attached to her husband, especially at the start of their marriage. In such a context, escalations of either preoccupied or dismissing attachment patterns are likely. On the one hand, there can be a dismissing pattern of attempting to suppress the need for emotional connection and withdrawing into functional and distant relationships. On the other, it can lead to a preoccupying sense of abandonment, anxiety and need for connections. The latter was Farah’s dominant pattern and she was determined that her child would not experience the same feelings of emotional abandonment. In the patriarchal hierarchy at play in her family of origin, a woman would be in a vulnerable position negotiating her rights and financial security. An exploration of her genogram showed how, over a few generations, divorce and separation in her family had left women in a vulnerable position. In this context, her mother’s response and use of shame could be better understood and seen as protective of her wellbeing. This helped Farah not to feel quite so much a victim and angry and resentful about her mother. Exploring her husband’s family dynamics, however, was a different picture. Strong attachment between newlyweds was perceived as

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functional and encouraged and there was no obvious difference of expectations between genders.

Exploring Patterns of Comforting We also explored who was comforting whom in the family, using attachment-­based circular questions. When you are upset as an adult who do you go to? When your husband is upset, who does he go to? When your son is upset, who does he go to for comfort? How do you comfort him? Farah had an entrenched belief that she was not good enough at comforting her son and that both her husband and her son’s nanny were better at it. This belief needed reframing as it could lead to increased feelings of shame followed by a deactivating strategy towards her son. In ANT, an important way in which change happens is to explore unique outcomes, as they represent an already existing change in the narrative. In this case, I asked Farah to think of at least one example when she could comfort her son. In fact, Farah could give quite a few instances where she had done this. We chose an occasion when her son had very slightly hurt himself after climbing up a tree, despite her saying “No”. I asked Farah to think about all the steps she had taken to comfort her son. Again, this exercise allowed us to make several levels of representation explicit by tracking what she had felt, thought, said and done. Through a reflexive stance these same steps of feeling, thinking, saying and doing were thought about in relation to her son. Farah had responded in a balanced manner by first reassuring her son and attending to his feeling state and then stating again that climbing trees was dangerous. More importantly, this gave Farah a renewed confidence in her ability to look after her son and a strong wish to stay connected to him.

Exploring Hypothetical Future-Oriented Attachment Narratives During our discussions in supervision, we have found that there may be a disconnect between a client’s conscious corrective intentions and the

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repetition of an implicit replicative script, which can lead to a sense of shame or even despair in a client. In Don’t Blame the Parents (2019), Rudi Dallos writes (p. 135): The idea of a double sense of failure captures the central message of this book. For many parents with whom I have worked, this seems to be an untenable idea, and part of the dilemma is that even if parents become aware that this is a possibility, it may be very hard for them to alter their attachment response patterns. This is especially the case when their attachment scripts and corrective intentions are driven by powerful traumatic states. It is as if the trauma from their childhood has been abusive twice over: once as part of their own childhood and now again despite their best intentions.

In Farah’s case, her continuous sense of failure resulted in her withdrawing from attempting to understand her son as she became overwhelmed by her sense of failure. This not only meant that she risked not engaging with her child but also that she could not recognise times that she had been able to be the good reflective mother she wanted to be. Therefore, wondering with her about positive interactions was helpful in allowing her sense of feeling good enough to emerge and override the preoccupying sense of failure that narrowed her focus down to herself rather than her child. Farah was genuinely interested in her son’s feeling state. Focusing on two vignettes, she reported with affection how proud Aayan had been to “introduce” his baby sister to his nursery friends, and she had praised him for this. On another occasion, he had been jittery and upset whilst she was breastfeeding but, after she had praised his patience, he calmed down. From this safe space, we wondered more generally about the place of praising between all members of the family, including between her and her husband, widening the angle again. In parallel, we could explore the positive intentions that Farah had for her children’s relationship and how these could be fostered. Over a period of 18 months in therapy, Farah became more aware of her inner monologue of emotionally aroused self-criticism. She also noticed how this spilled over into her criticism towards her loved ones, which echoed the criticisms she had received from her mother and

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brothers. In parallel, she recognised moments of emotional connection with her son and daughter. Allowing space for safe self-reflection improved her relationships with all of her close family members and with her nanny. This was evident in the warmth with which she spoke about them in sessions, often praising them appropriately.

Connell’s Story: “You are so Strong, My Boy” It was Connell’s father who contacted me on his behalf. I received an email with a coherent narrative giving me background information about his son’s situation. Connell had contacted his parents explaining that he was having “some kind of breakdown” and needed to come back home from university. His father and I then spoke very briefly over the phone and agreed that, if he felt able to, it would be good for Connell, who was 19, to contact me directly. Connell phoned me that very same afternoon. There was a feeling of urgency in this first contact and it was clear that his father was worried about Connell.

Stage 1: Establishing Trust and Creating a Secure Base Navigating Embarrassment and Avoiding Shame In the initial consultation, Connell was presenting as withdrawn. His answers to my questions were short and even monosyllabic. I could see he was on the verge of crying and could feel his wish to keep it all in. I shared some of my observations and feelings with him. This led to a surge in emotion which Connell immediately apologised for. This was Connell’s first experience of therapy and it was new for him to feel tearful in the presence of someone he had never met before. Creating a secure base with Connell involved allowing him to feel emotional in my presence and easing the embarrassment that he felt because of it. I normalised it by acknowledging that opening up in front of a stranger was an unusual situation and that for most people it brought up strong feelings. Whenever given the opportunity, I would normalise situations for Connell as being

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part of human experience and certainly a normal part of therapy. To help him get closer to his feelings, I gently acknowledged when feelings arose and together we would try to give the feeling a name and Connell would give it a rating, thus weaving cognitive processes into emotional reactions. Between sessions, he used a phone app to keep track of his low moods. By looking at his phone, he could recall what he had been doing or thinking about each day that week and together we would shape a story in tiny fragments, gradually moving from a place of unsafe uncertainty towards safer uncertainty (Mason, 1993).

Organisation of Narratives The quality of Connell’s speech during our first meeting was a mirror of what had happened in Connell’s life recently. He had tried to keep it all in and at bay but eventually this avoidant-dismissive strategy broke down and he started feeling overwhelmed. Articulating to another person experiences that we have tried to forget makes them feel more real, and the defences acquired through an avoidant-dismissive attachment strategy are threatened. Clients may have to face the unbearable reality of what has actually happened. Connell’s speech was stilted and there was a lot he could not remember. The amount of his recent history that was relegated outside of his consciousness was indicative of how much he had relied on this strategy in the last few months (George et  al., 1985). It became clearer later in the therapy that this attachment pattern had developed at an earlier time in his life.

Attachment-Focused Timeline Mapping Connell’s experience on a timeline (Dallos, 2006; Dallos & Vetere, 2009) over the last 12 months was helpful because he could see for himself how much he had gone through (see Fig. 2.5). Suggesting that these experiences be rated based on how distressing they had been, on a scale of one to ten, was equally helpful in Connell organising his narrative whilst keeping an explorative stance of uncertainty (Mason, 1993).

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September Moving to Uni Break up with girlfriend. Rated 5

October Flatmate's suicide/ start drinking regularly. Rated 6

November isolated drinking increases/ training. Let down by his friend. Rated 6

January isolated drinking increases and training

February drinking increases /use of recreaonal drugs. Asthmac symptoms

End of February. Asthma aack. Hospitalizaon. Rated 8

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March returns home

Fig. 2.5  Connell’s timeline

Connell had gone to university the previous year and, away from home, had tried his best to manage his feelings despite a series of adverse experiences. Having been diagnosed with severe asthma when he was a young infant, he was housed in special accommodation for students with special needs. Two of the students he lived with had a history of psychosis and tragically one of them committed suicide during the first term. Connell’s response was to go to the gym every day and exercise almost compulsively. One of Connell’s acquaintances from school was on the same campus and Connell had hoped he could get close to him and his flat mates and fully live the students’ experience he had looked forward to. His hopes were crushed as his friend regularly forgot to include him in his plans. Connell felt disappointed and isolated. He started going out anyway, drinking excessively. He found himself in a vicious circle of working out at the gym extensively during the day and going out at night, steadily increasing his use of alcohol to try to recapture feeling inebriated and slightly numb. These strategies eventually stopped working. He was feeling low and started withdrawing. Connell did not talk to anyone at university about what was going on for him because, he told me, going out with fellow students was all about “having some fun and taking the piss, really”. Connell decided to break up with his girlfriend, who had moved to a different university town, as in his own words, “I didn’t want to be a burden and use her as a crutch”. By the middle of the academic year, Connell was tired and could not concentrate enough to be on top of

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his studying. He had a severe asthma attack which required hospitalisation. This was the tipping point. With strong encouragement from his now ex-girlfriend, he decided to talk to his father, and they agreed he should come back home. We revisited this timeline from an attachment perspective. Developmentally, Connell was going through a phase where he and his contemporaries were exploring being away from home and experiencing more autonomy. Connell had a strong narrative that university was supposed to be fun and he felt like a failure for not living up to his expectations. He also felt ashamed for being physically and emotionally vulnerable – ‘weak’ was the word he used. He also thought that, as he was now living away from home, he should be “strong” and “sort himself out”. His awareness of all the events that had occurred and had made him feel vulnerable had been pushed away from his conscious and emotional experience. He had used two main strategies to do this: going to the gym to make himself strong and using alcohol and drugs to numb his feelings.

Stage 2: Exploring the Problems Identifying Key Traumatic Events As the therapy evolved, Connell spoke more and more about his childhood experiences. Asthma had been a prominent feature in his early life. He had spent prolonged periods of time in hospital throughout his childhood. My initial hypothesis was that Connell had learnt to become selfreliant in early childhood and rigidly applied this strategy in the present. Again, we drew a timeline of key events, both positive and negative, that had happened to Connell since birth. Among these episodic traumatic memories, two came back in the form of flashbacks and Connell gave them a rating of 9 and 8 out of 10 respectively, in how distressing he had found these vignettes. This was a good place to start our exploration and map out these two traumatic episodic memories.

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Traumatic Memories from the Past (Figs. 2.6 and 2.7) In the first incident, Connell is 10  years old and is seeing his parents’ extremely distressed faces looking at him on a stretcher seconds before falling into a coma and being taken to hospital. This is the most severe asthma attack he has had. When he woke up from his coma after a few days, he was disorientated, scared and lonely. When his parents arrived to visit him (they were staying in a hotel nearby), they were so pleased to see him awake that he did not want to upset them by asking for more information. His father looked at him and said: “You are strong, my boy”. In a second memory, three months later, Connell is asking hospital staff to wait for his mother to be by his bedside before putting a canula in his hand. His hands are blue with bruises and he has become phobic of this intervention. The hospital staff wait for a short while but then refuse his request. Connell feels alone and scared.

Connell waking up from coma: I need you I am scared. Rupture in the attachment bond. Deactivating strategy

Parents are staying in nearby hotel worrying. They are not in the room when he wakes up.

Connell thinks "I don't want to upset you, I need to be strong for you".

Connell is thinking: You are absent.

Dad's words of reassurance are: "You are strong, my boy".

Fig. 2.6  Connell’s circularity 1

Parents are back at the hospital. They are feeling relieved.

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Rupture in the attachment bond Deactivating strategy

Connell: I have become phobic of needles. I need reassurance.

Mother is supposed to be visiting but has not yet arrived.

Connell: I turn to hospital staff for help. My request is not answered. First rupture

Connell: You are back and I do not want to upset you more.

Mother is back, she was stuck in traffic and feels annoyed about it.

Connell: I need my mother and she is not here. Second rupture

Fig. 2.7  Connell’s circularity 2

Memories are Triggered Implicitly in the Present (Figs. 2.8 and 2.9) Overtime, as is often the case in these circumstances, Connell developed a narrative where he felt responsible for the hardship his family was going through. He verbalised that “it was his fault, and his family would be better off if it was not for him”. He could not separate himself from the condition he suffered with and this distortion was never addressed between himself and his parents and siblings.In the present, as his parents and siblings were also feeling some distress when recalling this scary period, it triggered painful feelings for Connell and reinforced his script. One such occasion was his 20th birthday. On this joyful day, his father made a speech for their guests praising his son for the man he had become. On recalling Connell’s younger years, his father suddenly broke down in tears when saying “I thought that maybe Connell would not be here on his 20th birthday”. Connell had felt upset by what had happened on that day. It took him back to earlier times in his life when he saw his parents’

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Connell is looking at his father talk about him. Connell thinks "It's my fault"

Father is joyful.

Connell feels distressed and embarrased. Dad had to leave.

Father remembers a traumatic memory. Flashback Connell sees his father's distress and his father leave.

Father is overwhelm ed and stops midspeech.

Fig. 2.8  Connell’s circularity 3

Rupture in the attachment bond. Deactivating strategy

Caregiver is feeling calm even joyful Painful memory is triggered for caregiver

Implicit memory is triggered. Careseeker is flooded with anxiety and shame

Caregiver is overwhelm ed by emotion

Careseeker sees caregiver's distress

Fig. 2.9  Connell’s circularity 4

Caregiver withdraws Deactivating strategy

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distress. This was an opportunity to draw parallels between attachment interactions in the past and in the present and encourage reflective functioning. Connell’s sense of being “flawed” and not wanting to “bother” others was generalised, and he was reluctant to communicate openly about his condition outside of the family. He would not mention it to his friends and would tend to hide it when his breathing became difficult. It is possible that, at an implicit level, finding himself in a situation at university where he was alone and disorientated whilst physically separated from his family led him to use the rigid attachment strategies he had to use in childhood in hospital. This made him vulnerable to repeating events where, ignoring the physical symptoms in his body, he was potentially more at risk of an asthma attack.

 tage 3: Exploring Alternative Narratives, Alternative Contexts S and Fostering Change Reframing the Events Together with Connell we discussed different ways to look at his parents’ reaction when he was on the stretcher on his way to hospital. In that moment, his parents had presumably felt really scared about the severity of the attack and that was all he could remember. I introduced some psychoeducation and shared with Connell my understanding of the brain’s and nervous system’s response to danger. As our fear system’s main function is to keep us and our loved ones safe, his parents’ prompt reaction, immediately raising the alarm, calling the ambulance and showing their distress, had kept him safe. There is safety in raising the alarm and showing distress. This also meant that, in that moment, they could not reassure Connell, which is what he needed. And due to him then falling into a coma, the opportunity was lost to give him this reassurance on the way to the hospital. Connell was interested in understanding the brain’s functions and did his own research to read more about the subject and look at the event through a new lens.

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Seeing his parents’ highly distressed response to his own distress, at a few key traumatic moments, had made Connell believe that his physical and emotional distress had caused this reaction and made him feel inappropriately responsible for what his family was going through. His father’s emotional reaction at his birthday could also be revisited through an attachment lens. It was true that his parents and siblings did still get emotional when thinking about difficult moments. It was also a sign of their attachment to him. We explored with Connell what happened just after his father had to stop his speech. Connell did not see what happened, but his father came back, and the party carried on with everyone having a great time. It was therefore plausible that another family member or friend had comforted him.

The Wider Family Context Connell’s family had done incredibly well, given the circumstances. There had always been ongoing family solidarity to ensure that Connell and his siblings were looked after. His mother and his maternal grandmother had visited him every single day in hospital and his father came as often as he could. His paternal grandparents regularly looked after his siblings to give his parents a chance to come and visit. However, due to his extensive stays in hospital, there was a lot that Connell missed, particularly in observing patterns of comforting in the family. By the time he was back home, what Connell experienced was his parents wanting to put it all back behind them and enjoy some normality in their family life.

 xploring Patterns of Comforting and Hypothetical Future-Oriented E Attachment Narratives We explored together who Connell would hypothetically be more likely to open up to when he was distressed. He thought he was more likely to reach out to his father. We also tried to imagine how his father might

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respond if he showed him some distress. Interestingly, Connell mentioned that his father would be fine with this. His father did cry openly in front of his family and encouraged his children to express their feelings and cry. And when this happened, they gave each other a hug. It was good to pause and note that opening up and crying was not linked to any sense of embarrassment in his father’s mind. From this safe place we did think together about the different ways in which one can find comfort. Connell was reticent to open up about all of his problems to his friends. This was wise, and we discuss the importance of reciprocity and balance. Opening up and finding that they could not respond as he wished was always going to be a risk of finding that your needs are overwhelming. However, Connell did take a few risks with school friends and they responded with empathy. He slowly reconnected with them and became part of their friendship group, and they even went on holiday together. At home, Connell also took a few risks by discussing his worries about university with his sister who was able to provide sound advice. Looking towards the future, going to the gym and training was the strategy that Connell wanted to keep using the most as it made him feel good, in control and strong. We started imagining additional habits and connections that could make returning to university safer. Due to the COVID-19 pandemic, events did not unfold as expected. Connell did not move back into his university accommodation as most of his course transferred online. He decided to carry on with the therapy and we continued exploring ways to keep him connected and safe. After one year of treatment, Connell’s mood had improved dramatically, and he felt better equipped not only to make a success of his year at university but also more generally for the future. He perceived his condition as something he could manage well, with the help of his father when needed. He remained close to his sister who continued helping him navigate university challenges. Although I was working only with Connell, he was able to share some of our discussions at home and this opened up the communication within the family.

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Conclusion The cases above demonstrate that the ANT model can be effective in one-­ to-­one therapy with clients whose attachment bonds have been disrupted by chronic shame. It is important when using the ANT approach in individual work to proceed cautiously in terms of moving to exploration of family relational dynamics and trans-generational process. If we proceed too quickly some clients may be reluctant to explore trans-generational patterns in their wider family of origin because they do not see the relevance of it. Others can be reluctant to explore their family system because they are attached to their status and position as the innocent child in the family. It is important to create a sense of safety and trust, perhaps all the more so in the context of working with powerful feelings of shame. However, creating a place for self-reflection can take time and can be frustrating for those clients who want solutions and quicker fixes. Frequently, when clients feel safe they give permission or invite the therapist to start to explore trans-generational or family dynamics by mentioning these in the conversation. The ANT model offers therapists and clients an extensive theoretical framework and clinical opportunities to foster exploration and change. Traditionally, attachment theory tends to focus on danger and the anxiety it creates, as well as anger, sadness and hope as part of the mourning process. The ANT model, by drawing upon both attachment theory and systemic thinking, facilitates the exploration of the full colour palette of emotional experiences, including shame but also remorse, regret, jealousy and ambivalence, for example. By focusing on positive intentions and unique outcomes alongside implicit attachment scripts, ANT has a firmly non-blaming stance. Using its unique combination of clinical tools, clients and therapists can collaboratively observe patterns of relating and ranges of emotions and can co-create complex narratives to allow improved ways to relate to the self and to others.

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3 Supporting Parents of Children with an Intellectual Disability Using Attachment Narrative Therapy Mark Hudson

Introduction The chapter will focus on my experience of using Attachment Narrative Therapy (ANT) with children who have an intellectual disability (ID) and their families. It will draw upon case material to illustrate recurring themes that have arisen from my clinical work, including the importance of attuning to parents/carers, helping them to understand and respond to their child’s developmental needs, and exploring the relationship between parents’ attachment histories and the demands placed on them by the caregiving role. Frequently encountered issues in ID services, such as unresolved grief around diagnosis and the impact of the disability on parents’ hopes for their child, will be explored using an ANT lens. Particular attention will also be paid to the significance of working with multiple health and social care systems, in order to provide a ‘secure

M. Hudson (*) University of Nottingham, Nottingham, UK e-mail: [email protected] © The Author(s), under exclusive license to Springer Nature Switzerland AG 2022 R. Dallos (ed.), Attachment Narrative Therapy, Palgrave Texts in Counselling and Psychotherapy, https://doi.org/10.1007/978-3-031-12745-8_3

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professional base’ for the family. To highlight these themes, processes commonly employed in ANT will be described, including the use of attachment-informed timelines and genograms, circularities and questions from the Adult Attachment Interview (AAI). Please note that the names of clients and some of their details have been changed to preserve anonymity.

Setting the Context Families will recognise that a child is delayed in their development at different stages, and therefore contact with professionals occurs at various points over the course of the life cycle. Some parents become aware early on that their baby is not developing as expected, and may find out about a genetic condition linked to intellectual disability (ID) through early blood tests, scans or genetic testing. For others, there may be complications following a traumatic birth or other intrauterine insult that impacts brain development. This can occur due to the mother being exposed to a range of environmental or biological risks, such as infection, domestic violence, drugs/alcohol or toxins, such as lead (Parker et al., 2010). In yet other families, where children may be raised in contexts where parents are affected by their own trauma, adversity and poor living conditions, mild ID can arise as a result of neglect (Buchanan & Oliver, 1977). Not all parents learn of their child’s diagnosis in the early years, however, and the child may later be referred to a paediatrician, educational psychologist or Child and Adolescent Mental Health Services (CAMHS), due to concerns around academic progression, emotional regulation or behavioural problems. Definitions of intellectual disability vary between the main classification systems; however, they share three aspects: a significant impairment in intellectual functioning (IQ