Prevention of Insecure Disorganized Attachment: and maybe the Ambivalent and Avoidant as well

Irene Harwood, MSW, Ph.D., Psy. D.

While writing my psychoanalytic thesis on Trauma, Attachment and Neurobiology many questions arose for me about how the different individuals responded to their particular trauma. I wondered how different attachment configurations and caretakers responsivity would have affected their ability to respond and deal with the trauma differently.

After many years of attending Beatrice Beebe's presentations I started applying what I have learned from her, other infant researchers, and attachment specialists in my practice. I started working with pregnant and new mothers before and after they gave birth. As someone working intersubjectively in individual and group for many years, I also wanted to focus on the first dyad in life in a group setting (Harwood, 1986, 1995, 1998) with the focus on prevention of the intergenerational transmission of trauma.

Through my UCLA appointment, I was able find a community setting to develop a prevention program for pregnant and new mothers called PIDA - Prevention of Insecure Disorganized Attachment. All of these women were from the Spanish speaking community and had undergone some form of trauma. Trauma literature suggests that without intervention, trauma gets transmitted through several generations. Thus, while continuing my regular practice I also wanted to reach into the community, give back, and try to make a difference.

To summarize some findings from trauma literature: adults who have suffered severe trauma, especially as young children, are likely to develop unresolved insecure disorganized attachment styles as manifested by 1) introversion, 2) unassertiveness, 3) feelings of exploitation, 4) self-consciousness and lack of self confidence, 5) more negative than positive feelings about themselves, 6) signs and symptoms of anxiety, depression, hostility and violence, 7) self defeating behavior and greater reporting of physical illness, and 8) fluctuations between interpersonal neediness and withdrawing (Shaver & Clark, 1994). They are also likely to suffer from posttraumatic stress disorder and dissociation (van der Kolk, et al., 1985, 1996). Victims of trauma tend to either reenact their own experience of trauma with their own children or others or never move out of experiencing themselves as victims. In the latter situation, they are unable to leave abusive and violent relationships and therefore also expose their own offspring to the intergenerational transmission of trauma. In my practice, both in psychoanalytic and psychotherapy cases, I also have become aware how traumatized individuals often reenact what has been done to them when the trauma has been disassociated.

The trauma, attachment, infant research, and neurobiology literature (Beebe, 2000, 2003; Fonagy, 1996, 2000, 2001: Heinicke et al., 1999, 2001; Jaffe at., al, 2001; Main, 2000: Pally, 2003, Tronick, 2004, Schore, 2003a, b) suggest that patterns of attachment develop by the end of the fourth month of life and are consolidated by the end of the first year. Most synaptic connections are immature at birth and are open to be shaped by experience. If infants are not responded to in an affectively attuned manner, many of their brain cells in the orbital frontal cortex are thought to die by the end of the first year of life. In addition, if these infants are also traumatized, they are likely to develop an insecure disorganized attachment. These same infants are in danger of not developing the capacity for understanding the state of another from facial impressions, the basis of empathy.

In the last three years, I have started and conducted two groups for pregnant and new mothers. From the first group, I learned that in order to make an impact one should start with pregnant women at least during their last trimester. From both of these groups I learned that psycho-educational methods must be supplemented with specific metaphors that each mother can relate to in order not to do to her infant what has been done to her.

These groups need to go through several phases:

The first phase of the group is psycho-educational. It provides information about infant development and facilitates for the new mothers the sharing of their experiences. It is also the stage where the ambiance of safety, confidentiality and trust is established.

In the second phase, as the babies are born and brought into group, the mothers can start applying what they have learned in the psycho educational stage as well as reworking what has been stored in their own body memories from their own first years of life. At four months, a specific attachment - secure; insecure ambivalent, insecure avoidant or insecure disorganized starts forming and, if not disrupted, will consolidate at age one. It is also during the first four months of the baby's life that intervention and facilitation for a secure attachment has to take place. This is the prime time for prevention of negative establishing patterns between mothers and babies.

An example of an intervention with a depressed mother and baby

Supporting Beebe (2003) and Lachmann's (2004) observations that one way that babies cope with the depressed mother is by imitating her affect, in our first group, baby Beth, at three months, closely watched her mother's sad and unsmiling face. She looked continuously sad just like her mother.

Since mothers are pleased when I show interest in their babies and pick them up, I knew an intervention was timely. I extended my arms and invited Beth into them. After picking her up, I waited until Beth established eye contact with me and then I started gently, but barely, smiling at her. As she responded, and we took turns, I increased the width of my smile and the sparkle in my eyes, similarly to Beebe's (2003) interventions demonstrated in her research videos. I slightly increased my affect as I spoke softly to her, attending to vocal rhythm. Beth responded with a full, pleased, and related smile.

After having established a joyous dyadic regulation with Beth, I noticed that her mother was now looking at her daughter with full interest and attention. I quickly placed Beth, who by now had a full smile on her face, into her mother's lap. Her mother, Silvia, had not yet, to my observation and her admission, received such a response from her daughter, but, seeing a smile on her daughter's face, she was able to shift from her own depressive feelings and return a delighted smile to Beth. Quite pleased with what I was able to accomplish, I whispered my newly discovered mantra: "My mama's smile is the most beautiful mirror in the world." A "heightened affective moment" was born (Beebe, 2003).

Silvia could not stop smiling at her baby and Beth was delightfully smiling back. The group joined in by validating with smiles and great warmth this newly established connection between mother and child. I had confidence, at that point, that this was the beginning of ongoing, positive, affective dyadic regulation and a secure attachment relationship for Silvia and Beth, unless disrupted by a significant trauma. Indeed, this warm affective dance continued between Silvia and her daughter during the next few group sessions. During her fourth and fifth months, Beth was also able to respond to the different mothers' interest, words and smiles and sit happily in their laps for a considerable time. After a while, she would turn toward her mother, stretch out her arms and Silvia would happily pick her up. Beth would put her hand on her mother's breast, a form of self-regulation, and at times turn towards Silvia's breast and vocalize her needs. There was a relaxed sense of "being at home base." At this early time, babies can establish differing intersubjective dyadic regulations and differing attachment configurations with different people, all encoded in implicit memory.

Group interactions

In the second stage of these groups, when a mother is having difficulties, she is encouraged by the example of others to talk about her feelings. The other mothers in the group also have a chance to sympathize and empathize. Thus, each mother does not feel so unique in her response. I also specifically encourage observation of their babies during the week and ask them to bring in for discussion the observed new psycho-emotional and physical developments.

Since it is difficult for each mother to observe herself and her baby in the dyad, I ask a different mother in the group to describe what she observes about the baby across from her, including the gaze, vocalization, body tone, hand gestures, touch, ongoing regulation, de-regulation, rupture and repair, and hightened affective moments. I then ask for any other observations from the entire group. Throughout I validate attunement and responsiveness by each mother to others, to her own baby, and to participating in the group.

I ask the group what the baby is trying to communicate, when I see reaction to impingement. Not being caught up in their own mind-body set, mothers who cannot see something with their own baby, often can see it demonstrated by another mother and baby. Even mothers who dissociate at times can observe and tune-in to others. It takes some mothers once, and others many, many times, to change how they approach their own babies. Even with awareness, during times of stress, the previously traumatized mother unconsciously and automatically reenacts her own traumatizations.

Teaching Mentalization through empathic metaphors

It is at the times that an impingement or lack of attunement, or blaming of the baby occurred that I learned how to utilize metaphors to help the mothers start attuning to the self-state or communication of their infant. For Fonagy, mentalization is the ability to attune to the mental state of the infant.

Thus, when I observe a miss-attunement to the communication that the baby is offering, or when the mother is enacting something that has nothing to do with the baby's needs, I try to find an equivalent metaphor that the mother(s) can relate to from past experience. It is when I give an example of a situation that the mother can identify with and find some humor in, that I find that she can start empathizing with her baby's state of mind.

For example, if a mother is trying to feed the baby and the baby is gaze averting, I ask (tongue-in-cheek) something like: "Let's see how many of you have been in a situation when you went to your mother-in-law's and you were not hungry, but she insisted that you eat what she made and tried putting it in your mouth? How did it feel?" The response was a hearty laugh. From this point on, most of the mothers would offer food, rather than insist that the child eat. When a mother forgets and insists that a child eat, another mother might laugh and say: "Remember mother-in-law."

Thus, more and more, I became aware that helping mothers acquire the capacity to mentalize through such psycho-educational means as modeling and describing what the babies appear to be expressing by their gaze, vocalizations, affects, hand gestures, touch and body postures were not as effective as utilizing empathic metaphors.

In another situation, baby Beth, 7 months, was sitting happily exploring and playing with colorful toys. The mothers were having light refreshments. All of a sudden, Silvia, for no apparent reason, picked up her daughter without warning and placed her on her back. Beth protested this impingement by crying loudly. Silvia complained to everyone: "Look, she is again making war!" I wondered aloud if we could imagine Beth's experience. I asked the women: "Imagine someone more than twice your size, while you are enjoying your refreshments, picking you up without warning from your sitting position and laying you down on the floor. How would you feel?" Most of them, in a chorus, including Silvia, responded, "We would make war, too!"

I have also utilized metaphors and empathic introspection to help the mothers move out from their baby's face and space, when they were smothering their babies with kisses or overwhelming with tickling, and failing to attend to their babies' nonverbal communication. I asked them to imagine, or remember, how they feel when they are in the midst of something important and pleasant and are interrupted by their husbands' kissing and tickling them in a manner that soon becomes overwhelming. The description of such a scenario brought knowing smiles and laughter as well.

In essence, I learned how to help these mothers mentalize their babies' subjective experiences by first empathically immersing myself in experiences that they could imagine or may have experienced, and then playfully, through the use of metaphor, translate these for them. As we know, we unconsciously repeat with others what has been done to us. People who have experienced traumatic impingements tend to unconsciously repeat those experiences with others. By being empathically playful with the mothers, I encourage the beginning of self-reflection between their own memories and experiences and those of their babies.

In the Prevention of Insecure Disorganized Attachment (PIDA) groups, with the start of each group, we are beginning the process of breaking the intergenerational transmission of trauma.

References

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