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Used by permission
Permission given by
Robert Marvin, Ph.D.—Director
The Mary D. Ainsworth Child-Parent Attachment Clinic
University of Virginia Medical Center
Please do not make copies of this document
without first receiving permission from the author
Editorial comments by the Foundation are shown in italics
Preamble
The following excerpt was taken from the
narrative of a grant proposal submitted to the Foundation by Robert
Marvin, Ph.D., in support of the Circle of Security Project. Frederick
Leonhardt, the Foundation's president, in reviewing this grant request,
was impressed by the information this narrative contained on
taking a cautious stance towards treatment
modalities that go by such names as “Rebirthing,”
“Rage Reduction,” “Attachment Therapy,” or “Holding Therapy.” The
president felt that this narrative contained information that should be
readily available to the general public. The president asked Dr. Marvin
for permission to place this information on the Foundation's web site as
a web document. Dr. Marvin graciously gave his permission for the
Foundation to do so. The Foundation extends it's thanks to Dr. Marvin
for sharing this information with the general public. For more on these types of treatment modalities, please see the
book “Attachment Therapy on Trial” by Jean Mercer and her colleagues
(please see the reference list in the RESOURCES area). The FHL
Foundation ascribes to the Bowlby-Ainsworth theory of attachment, and,
as such, uses this theoretical orientation as a backdrop when evaluating
grant requests and proposals.
THE NEED FOR THEORY-DRIVEN, RESEARCH-BASED
ATTACHMENT THERAPIES FOR PRESCHOOL CHILDREN
Robert S. Marvin, Ph.D., Director
The Mary D. Ainsworth Child-Parent Attachment Clinic
University of Virginia Medical Center
rsm8j@virginia.edu
Introduction
The preschool period, between the ages of 18 or 20 months and about 5
years, is an especially important period in the development of
children’s attachment relationships, and their relationship skills
generally. Having consolidated their differential attachment(s) during
infancy, it is during this latter period that they begin increasingly to
organize their use of their attachment figures as Secure Bases and
Havens of Safety on the basis of inferences they draw about their
attachment figures’ internal states, and their emerging abilities to
negotiate and compromise (e.g., Bowlby, 1969/82, Chap. 17; Marvin, 1977;
Marvin & Britner, 1999). Between their third and fourth birthdays, for
example, children become able to think about their mothers’ thoughts,
feelings, and desires, are able to differentiate mother’s mental states
from their own, and in a purposeful way are able to construct and
interact on the basis of joint goals and plans with their mothers
(Marvin & Greenberg, 1982). Bowlby (1969/82) labeled this fourth phase
in the development of attachment the “goal-corrected partnership.” This
set of developmental and relationship skills have, over the past 30
years, been labeled variously as perspective-taking (e.g., Flavell,
1985), “theory of mind” (e.g., Wellman, 1990), and more recently
“mentalization” (e.g., Fonagy, Gergely, Jurist, & Target, 2002).
In the field of attachment research, this mentalizing activity has
received most attention in the context of the caregiver’s mentalizing
rather than the child’s. This is not too inappropriate, because of the
crucial roles that the caregiver’s thoughts, feelings, and behavior
toward the child play in the pattern and security of the child’s
attachment (Bretherton & Munholland, 1999; Main & Hesse, 1990).
Ainsworth herself (e.g., Ainsworth, Blehar, Waters & Wall, 1978)
insisted that a caregiver’s ability to use the child’s cues to make
accurate inferences about his or her internal state and needs is a
crucial component of “maternal sensitivity.” And certainly the preschool
child’s ability to make accurate inferences about mother’s internal
states—the child’s mentalizing about the
caregiver—is based in large part on the quality, accuracy, and patterns
of the caregiver’s mentalizing in relationship with the child. This
suggests that intervening in high-risk or problematic
caregiver-preschool child attachments should include a significant focus
on improving the parent’s inferences about the child (and herself!), in
order to improve the attachment interactions between the two of them—with
those attachment interactions themselves now being organized so
extensively in terms of sometimes-different-sometimes-shared goals,
plans, and feelings.
There is also increasing evidence from attachment research that
individual differences in patterns of attachment-caregiving interactions
tend, during the preschool years as well as during infancy, to be shared
by parent and child in the form of a reciprocal behavioral “dance” (see
Ainsworth et al., 1978; Cassidy, 1999; Cassidy & Marvin, 1992; Britner,
Marvin & Pianta, in press). Each child and caregiver pattern can be
identified reliably in terms of specific organizations of behaviors and
of internal working models of both partners. At least four distinct
dyadic patterns have been identified for older toddlers and preschool
children (e.g., Cassidy & Marvin, 1992; Boris et. al., 2004): Secure;
Insecure-Avoidant, Insecure-Ambivalent (Resistant); Disorganized
Role-reversed; and Disorganized Insecure-Other (a group consisting of
especially problematic patterns reflecting severe and chronic trauma,
deprivation, neglect, and other forms of maltreatment).
Attachment Interventions
While there are a number of early intervention projects being developed
and tested that focus on the security of attachment-caregiving
relationships in high-risk parents and their infants (e.g., (Berlin, Ziv,
Amaya-Jackson, & Greenberg, in press; Lieberman, Weston, & Pawl (1991);
Van den Boom, 1995), there are very few evidence-based programs that are
focused on older toddlers and preschool children. Unfortunately, those
programs for preschoolers and older children that do exist tend to take
one or a few ideas from attachment theory and research, incorporate them
in an oversimplified manner into another, usually incompatible,
theoretical framework, and apply the resulting programs without
adequately testing their effectiveness.
Specifically, these programs, some of which are known as Rebirthing,
Rage Reduction, Attachment, or Holding Therapy, and referred to in this
article as “the holding therapies,” have been published privately, in
edited books, and on the Internet (e.g., Cline & Fay, 1990; Levy &
Orlans, 1998; Thomas, 1997; c.f., Mercer, Sarner, & Rosa, 2003). The
designers of these programs draw from Bowlby’s theory a focus on the
importance during infancy of close bodily contact, security, and trust
in the child’s attachment figure. However, these “holding therapies”
tend to have taken those constructs and integrated them, without
appropriate rules of theory construction, into intervention models based
either: a) on a distorted version of the classical psychoanalytic theory
of regression (Rebirthing and Rage Reduction therapies); and/or on
behaviorism and principles of behavior modification designed to reduce
or eliminate undesirable behaviors (Attachment and Holding therapies).
Clearly, these are not really attachment theory-based interventions, and
they are not appropriately evidence-based.
Characteristics of the holding therapies have led to the proliferation
of interventions that, while they are administered by therapists with
the best of intentions, are at worst abusive and potentially
life-threatening (e.g., the Evergreen Rage Reduction program), and at
best are neither based on attachment theory, nor are empirically tested
regarding treatment effectiveness (the less radical versions of “Holding
Therapy”). Unfortunately, many of these programs claim to be based on
the Bowlby-Ainsworth theory of attachment, and there are literally
thousands of therapists in communities around the U.S., Canada, Europe,
and Australia who use them in their daily practice. In defense of these
therapists, it should also be noted that until very recently there have
been few if any evidence-based interventions for preschool and older
children, truly developed from attachment research, available to them.
Interventions that are evidence-based and derived from attachment theory
will have many differences from the holding therapies. Three that are
especially pertinent to evidence-based practice are:
1. Holding therapies tend to use a diagnostic system that is
non-standardized, non-validated, and not able to differentiate among the
many psychological disorders found in childhood. In contrast, attachment
research-based interventions should utilize a “diagnostic” system that
is based specifically on thought and behavior patterns from attachment
theory and research, and on research in other areas of parent-child
interaction and relationships. This system should be scientifically and
clinically reliable and validated. It should be sufficiently limited in
scope both to identify specific attachment problems, and at the same
time to differentiate these problems from other childhood and
relationship difficulties as well as from formal diagnostic groups such
as ADHD, Oppositional Defiant Disorder, Conduct Disorder, Bi-Polar
Disorder, and other disorders so often inappropriately associated in
clinical practice with “Attachment Disorders.”
2. Holding therapies tend to direct the intervention to the child him or
herself. In contrast, all attachment research-based interventions with
which we are familiar, including the Circle of Security (described
below), are designed to impact the child’s attachment pattern indirectly
by directly focusing on caregiver patterns of behavior and thinking.
This practice follows directly from Ainsworth’s focus on caregiver
sensitivity to the child’s cues as perhaps the major variable in
predicting security of attachment.
3. Holding therapies tend to view the behavior- and emotion-regulation
problems of children with attachment difficulties as unacceptable
behaviors, and often make inferences about negative intent on the part
of the child. Most holding therapies attempt to eliminate or extinguish
these intentions and behaviors through consistent, strong, and often
negative, consequences that are based either on aversive behaviors
toward the child, or on temporary separation, or interruption of the
interaction, between the child and caregiver. In contrast, interventions
based on attachment theory are likely to view the behavior- and
emotion-regulation problems associated with attachment difficulties as
patterns of thinking and behavior that are both an understandable
adaptation to the child’s unique developmental and relationship history,
and are reflections of the child’s inability, at the moment, adequately
to self-regulate his or her affect and behavior. Even if the child is
acting in an aggressive, controlling manner, attachment-based
interventions will, in most but not all situations, view the child as
anxious, vulnerable, “in over his head,” out of control, and needing the
parent’s empathy, soothing, and management.
The Circle of Security (COS) Intervention Protocol
To our knowledge the only standardized, attachment theory-based protocol
designed to intervene in the attachment-caregiving relationships of both
toddlers and preschool children is the “Circle of Security” protocol.
This is a protocol developed by Kent Hoffman, Bert Powell, and Glen
Cooper of the Marycliff Institute, Spokane, WA, and this author. The
following is an abbreviated outline; the reader is urged to read Marvin,
Cooper, Hoffman & Powell (2002), and Cooper, Hoffman, Powell & Marvin
(in press) for more detailed presentations of the protocol.
The protocol uses established attachment research procedures to diagnose
and design a specific, individualized, treatment goal for each dyad. The
actual intervention process, a 20-session weekly group-based protocol,
is also derived from attachment theory and research, with specific
exercises to: help the parent be more reflective about her child and
herself; develop a practical, “user-friendly” understanding of
attachment theory; and become more accurate and empathic in reading the
child’s cues and miscues. The specific intervention protocol is based on
video-review of the caregiver’s interactions with her young child in
order to help her reflect accurately on those interactions. The
video-review is also used to “trigger” a co-reflective process between
therapist and caregiver about the caregiver’s own attachment-history,
about how that history is related to the feelings experienced in
challenging interactions with the child, and about how the caregiver’s
reactions to his or her own painful and confusing feelings in
attachment-caregiving interactions can interfere with the strong desire
to be sensitively responsive to the child. Finally, by assessing the
pattern of attachment-caregiving interactions again immediately
post-intervention—as well as one year
later—we can scientifically evaluate the effectiveness of the protocol.
The Circle of Security protocol received the Year 2000 Washington State
Council for Prevention of Child Abuse and Neglect: Governor’s Award for
“Innovations in Prevention.” In 2003 it was placed on the DHHS list of
“promising” intervention protocols. Versions of the protocol are
currently being used in Spokane, WA; Virginia; New Orleans, LA:
Washington, D.C.; and the women’s prison system in Baltimore, MD.
Studies of the effectiveness of different versions of the protocol are
currently in progress.
References
Ainsworth, M. D. S., Blehar, M., Waters, E., & Wall, S. (1978). Patterns
of attachment. Hillsdale, NJ: Erlbaum.
Berlin, L.J., Ziv, Y., Amaya-Jackson, L. M., & Greenberg, M. T. (in
press). Enhancing early
attachments: Theory, research, intervention, and policy. New York:
Guilford Press.
Boris, N., Hinshaw-Fuselier, S., Smyke, A., Scheeringa, M., Heller, S.,
& Zeanah, C. (2004).
Comparing Criteria for Attachment Disorders: Establishing Reliability
and Validity in
High-Risk Samples. J . Am. Acad. Child & Adolescent Psychiatry, 43:5,
568-577.
Bowlby, J. (1969/1982). Attachment and loss. Vol. I: Attachment (2nd
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(Eds.), Handbook of
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Britner, P, Marvin, R, & Pianta, R. (In press). Parental Caregiving
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