Articles
How the Adult Attachment Interview can Inform Marschak Interaction Method
Feedback and Theraplay Treatment
Karen Buckwalter, MSW, LCSW, Certified Theraplay Trainer/Supervisor
Director of Program Strategy, Chaddock, Quincy, IL
A child enveloped in a particular style or relatedness learns its special intricacies and particular rhythms, as he distills a string of instances in the simpler tenets they exemplify. As he does so, he arrives at an intuitive knowledge of love that forever evades consciousness.” -A General Theory of Love
Attachment theory and attachment-based play are two foundational pillars upon which the Theraplay model is built. Theraplay assumes that a parent’s involvement in their child’s Theraplay sessions is an essential part of the child’s progress in treatment. The focus of Theraplay treatment is the parent-child relationship with one of the primary goals giving parents new positive and healthy ways of interacting with their child. (Booth & Jernberg, 2010)
Some parents, despite the therapist’s most enthusiastic efforts, have difficulty being playful and attuned to their child in the ways the Theraplay model requires. The Adult Attachment Interview (AAI; George, Kaplan, & Main 1996) gives the Theraplay therapist significant insight into the internal world of the parent helping the therapist to understand why a parent may be behaving in certain ways in the Theraplay sessions. This information also sets the stage for MIM feedback to illuminate how the parent’s past impacts the parent’s ability to attach to their own child. Thus, the AAI may help explain why some parents may become “stuck” in treatment and are unable to “get into the mind of their child.” An understanding of the “parent’s state of mind with regard to attachment” can also help the therapist predict what challenges may come up in treatment and allows the opportunity to tailor treatment in effective ways. (Bick & Dozier, 2008)
The Adult Attachment Interview protocol was developed in the early 1980’s, along with an accompanying system for scoring and classification. The questions that comprise the interview are masterfully designed to “surprise the unconscious” and as a result the therapist is able to unearth information about the parent’s“state of mind with regard to attachment” that often would not have been shared with the therapist by traditional clinical interviews and assessments (Hesse, 1999). The AAI may be scored and interpreted by a professional trained for the task, or it may still offer useful insights without the time and expense of hiring a reliable coder for scoring. If the AAI is to be scored and classified, the interview is recorded and transcribed verbatim and the transcript is then scored by a person certified as a reliable coder (Hesse, 1999).
Unfortunately this process can be both cost and time prohibitive for the average therapist who is not using the AAI for research. Yet much can be gained from using the interview without scoring if the therapist attains sufficient understanding of the coding system to be able to recognize some of the major themes of the interview responses.
Training for learning to code the AAI requires the therapist to attend a two week AAI scoring course. This course outlines the coding system, offering the therapist a heightened sensitivity to various defensive strategies that may emerge in the interview. Another less time consuming option would be to attend a workshop about the AAI (Lifespan Learning Institute offers such workshops and has an extensive CD collection of lectures about the AAI available at www.lifespanlearn.org) Independent reading and study are additional options for learning about the AAI. The text Clinical Applications of the Adult Attachment Interview (Steele & Steele, 2008) offers an excellent overview of many ways the AAI can be used in clinical practice, and Attachment In Psychotherapy (Wallin, 2007) outlines various ways for a therapist to alter his/her clinical approach based on the client’s “state of mind with regard to attachment.” Parenting from the Inside Out (Daniel Siegel, 2003) is a helpful book to share with parents and caregivers as they explore how their own history of being parented impacts their current parenting style.
Below is a brief modified list of the AAI questions (Hesse, 1999). Please note that this is a brief prècis of the AAI protocol taken from George, Kaplan, and Main (1996) The AAI cannot be conducted on the basis of this abbreviated version which omits several questions as well as critical follow-up probes. The full protocol, together with extensive directions for administration, can be obtained by writing Professor Mary Main, Department of Psychology, University of California at Berkeley, CA 94720. It is also available at: http://www.psychology.sunysb.edu/attachment/measures/content/aai_interview.pdf
However, the questions listed below can be very helpful for use in non research-related clinical settings particularly early in treatment (Wallin, 2007)
Introduction of interview:
I’m going to be interviewing you about your childhood experiences, and how those experiences may have affected your adult personality. So, I’d like to ask you about your early relationship with your family, and what you think about the way it might have affected you. We’ll focus mainly on your childhood, but later we’ll get on to your adolescence and then to what’s going on right now. This interview often takes about an hour, but it could be anywhere between 45 minutes and an hour and a half.
1. Could you start by helping me get oriented to your early family situation, and where you lived and so on? If you could tell me where you were born, whether you moved around much, what your family did at various times for a living?
2. I’d like you to try to describe your relationship with your parents as a young child… if you could start from as far back as you can remember?
3/4. Can you give me five adjectives or words that reflect your relationship with your mother/father during childhood? I’ll write them down and when we have all five I’ll ask you to tell me what memories or experiences led you to choose each one.
5. Now I wonder if you could tell me, to which parent did you feel the closest, and why?
6. When you were upset as a child, what would you do, and what would happen? Could you give me some specific incidents when you were upset emotionally? Physically hurt? Ill?
7. What is the first time you remember being separated from your parents?
8. Did you ever feel rejected as a young child? Why do you think your parent did those things – do you think he/she realized he/she was rejecting you?
9. Were your parents ever threatening with you in any way --- maybe for discipline, or even jokingly?
10. In general, how do you think your overall experiences with your parents have affected your adult personality?
11. Why do you think your parents behaved as they did during your childhood?
12. Were there any other adults with whom you were close, like parents, as a child?
13. Did you experience the loss of a parent or other close loved one while you were a young child or as an adult?
14. Were there many changes in your relationship with your parents after childhood
15. What is your relationship with your parents like currently?
Hesse (1996) emphasized that the interview questions demand that the interviewee engage in simultaneous tasks which include producing and reflecting on memories related to early attachment experience while also maintaining coherent discourse with the interviewer. The fact that their interview moves along at a fairly rapid pace while asking questions that demand careful reflection allows numerous opportunities for the interviewee to contradict themselves and lose coherence in various ways. The speaker’s ability or lack thereof to maintain coherence allows the AAI transcript to be judged into several different categories which are summarized below (Hesse, 1999):
Secure/Autonomous (F)
Coherent collaborative discourse. Valuing of attachment but seems objective regarding any particular event/relationship. The adjectives that are given to describe each parent are well supported by examples given.
Dismissing (Ds)
Not coherent. Dismissing of attachment related experiences and relationships. Normalizing (“excellent, very normal mother”), with generalized representations of history unsupported or actively contradicted by episodes recounted. Transcripts tend to be excessively brief.
Preoccupied (E)
Not coherent. Preoccupied with or by past attachment relationship or experiences, speakers appear angry, passive or fearful. Sentences are often grammatically entangled or filled with vague usages (“dadadada,” “and that”). Transcripts are often excessively long.
Unresolved/Disorganized (U)
During discussions of loss or abuse individual shows striking lapse in the monitoring of reasoning or discourse. For example the individual may briefly indicate a belief that a dead person is still alive in the physical sense, or that this person was killed by a childhood thought. The speaker will ordinarily otherwise fit Ds, E, or F categories
In looking at the distribution of the above AAI classifications in samples of non-clinical mothers, Bakermans-Kranenburg & van IJzendoorn, (2009) found the majority of mothers were classified as securely attached (58%) with 23% of the mothers being classified as insecure-dismissing and 19% as preoccupied. In addition, some 18% of the non-clinical mothers displayed unresolved attachment representations. The importance of this for clinicians who are working with children with attachment difficulties and their caregivers is the strong correlation between a parent’s AAI classification and the classification of their child in the Strange Situation. Dozier, Chase-Stovall, Albus and Bates (2001) in one of the first studies to look at the connections between foster mothers attachment state of mind in the AAI and infant attachment as assessed by the Strange Situation, found a remarkable association. There was a 72% match between a foster care mother’s state of mind and child attachment. In the article the authors propose that foster children may organize their attachment around the emotional availability of their foster parents. (Steele, Hodges, Kaniuk, Steele, Hillman, Asquith, 2008). This idea is central for therapists who are working with foster and adoptive parents using Theraplay. The Theraplay model’s success rests upon the parent’s ability to engage in attachment-promotingbehaviors with their foster or adoptive child.
Setting early Theraplay sessions up for success:
Early Theraplay sessions are diagnostic regarding both the parent and the child. Based on initial case assessment and responses in the MIM, it is not uncommon for therapists to expect a child to act one way in Theraplay sessions even though they end up presenting in a quite different way. For example, children we may expect to be resistant in Theraplay sometimes seem to “soak up” the Theraplay experience like a sponge. Others surprise us with their staunch rejection of nurture or intense efforts to control all aspects of the session. Neither response may have been anticipated based on the MIM assessment.
This element of surprise in how children respond during initial Theraplay sessions can also be true for parents. Few Theraplay therapists can say they have not experienced a Theraplay session where a parent they expected to be nurturing and engaging was incapable of connecting their child in a playful, attuned manner. Use of the AAI early in treatment can give therapists useful information about what may be blocking a parent from being the “therapeutic” parent they need to be to address their specific child’s needs. It also assists the therapist in knowing more specifically how they may need to work with a parent prior to the parent joining the Theraplay session. The task for the Theraplay therapist in engaging a parent can be approacheddifferently based on the parent’s “state of mind with regard to attachment” (Main, Goldwyn, & Hesse, 2003) The parent’s state of mind helps the therapist identify specific ways to help parents alter their view of parenting as well as assess how open the parents are to change. Information produced by the AAI allows the therapist to shape treatment strategies and approaches in ways that are most helpful for individuals (Bick and Dozier, 2008).
Use of the AAI for MIM Feedback and Theraplay Treatment Case Discussion:
Case Discussion #1
What follows is an example of how a parent responded to the AAI question, and the implications of that answer for therapy:
When you were upset as a child what would you do?
One mother I worked with answered this question by explaining she would go to her room andtry to stay out of everyone’s way. Throughout the AAI interview she shared memories of her fears of a volatile father and her efforts to be a good girl at all times to avoid upsetting him. Her young adopted son was intensely hyperactive, loud and at times aggressive. The more active he became in the MIM the more passive she became. An understanding of the mother’s history from the AAI allowed me to make the connection, in the MIM feedback session, between her early coping skill of “hiding” from her father and her more recent behavior of “hiding” from her son. Information gained from the AAI allowed me to have a deeper level of empathy for the mother when discussing how hard it was for her, based on her history and how she had to survive as a young girl, to have a son who could so readily become aggressive. These insights may also have helped the mother learn to be strong, firm and confident in the face of her son’s often challenging and difficult behavior. This mother was provided an opportunity, while watching the Theraplay therapist, to see a different way of interacting with her son than the negative pattern she was living out. With Theraplay I eventually coached the parent in these new behaviors with the child in an environment of nurturing care and support. By making statements such as, “I am going to check with your Mom about that,” or “Mom you know best, what do you think we should play next?”, I began to build this mother’s confidence that she can give her child what he needs and remain strong and steady in spite of his resistance to accepting appropriate guidance and structure from her. I became the secure base this parent may not have had in childhood and this allowed her to try out new behaviors and new ways of parenting.
Case Discussion #2
Another case example is a father who responded to the same AAI question:
“When you were upset as a child what would you do?”
He stated, “Being upset was not permitted in my house.” In the MIM feedback sessions with this father I saw the father becoming increasingly frustrated with his child’s escalating anger regarding a task. I exploredwith this father how foreign and at times uncomfortable it must be for him to be parenting a child who is so easily upset and argumentative when he himself was raised in an environment where no one was allowed to be upset. By being able to link the past to the present and explore the “ghosts” that are impacting his current relationship with his child, this father will be able to be more reflective and less reactive in responding to his child. (Fraiberg, Adelson & Shapiro 1975)
Case Discussion #3:
Typical parent burn-out versus ghosts in the treatment room
I was recently working with a family with a child adopted internationally. It was notable in the first three Theraplay sessions that the adoptive mother seemed to be withholding affection and was emotionally distant from this child. I wondered if this behavior from the mother is a result of being so overwhelmed and burned out by this child’s difficult behaviors or if perhaps the mother behaved in this manner in other relationships as well. Did the mother enter the relationship witha Dismissing style of attachment or was this learned behavior on her part the result of earnestly trying to parent a child who is so rejecting of her? With these questions in mind, I decided to conduct an AAI interview with the mother. When the transcript was coded, she was placed in the Secure-autonomous category. Part of what this classification means is that she had a great deal of positive experience from her own childhood to draw upon as an adult. Therefore,treatment could be less focused on looking for unresolved issues in the mother’s childhood and more focused on things like psycho-education, support and self-care. It also meant that this mother would be likely to respond swiftly to these interventions as compared to parents in an insecure or unresolved category; such individuals would likely require more involved therapeutic intervention.
The way in which parents tell the story of their lives and how coherent they are in sharing their early life experiences is the best predictor of how their children will become attached to them (Siegel, 2003). As Theraplay therapists, working within an attachment-based model of treatment, use of the Adult Attachment Interview can be powerful complimentary tool to our work with parents and their children by giving us a glimpse into the inner world of parents and helping us stand by them to confront any ghosts from their past.
References:
Bakermans-Kranenburg, M.J. & van IJzendoorn, M.H. (2009). The first 10,000 Adult Attachment Interviews: distributions of adult attachment representations in clinical and non-clinical groups. Attachment and Human Development 11(3) 223-263.
Bick, J. & Dozier, M. (2008) “Helping foster parent’s change: the role of parental state of mind” in H. Steele and M. Steele (Eds) Clinical Applications of the Adult Attachment Interview. New York: Guilford.
Booth, P., & Jernberg, A., Theraplay: Helping Parents and Children Build Better Relationships Through Attachment-Based Play, San Francisco: Jossey-Bass.
Dozier, M., Chase-Stocal, K., Albus, K., & Bates, B. (2001). Attachment for infants in foster care: the role of caregiver state of mind. Child Development 72(5) 1467-1477.
Fraiberg, F., Adelson, E., & Shapiro, V. (1975). Ghosts in the nursery: a psychoanalytic approach the problems of impaired infant-mother relationships. Journal of the American Academy of Child Psychiatry, 14(3) 387-421.
George, C., Kaplan, N., & Main, M. (1996). Attachment Interview for Adults (3rd ed.). Unpublished Manuscript, University of California, Berkley.
Hesse, E. (1996). Discourse, memory and the Adult Attachment Interview: A note with emphasis on the emerging cannot classify category. Infant Mental Health Journal, 17, 4-11.
Hesse, E. (1999) “The adult attachment interview: historical and current perspectives” In J. Cassidy and P. Shaver (Eds) Handbook of Attachment: Theory, Research and Clinical Applications. New York: Guilford.
Lewis, T., Armini, F., Lannon, R., (2000) A General Theory of Love, New York: Vintage Books
Siegel, D. (2003) Parenting from the Inside Out, New York: Jeremy P. Tarcher/Putnam.
Steele, M., Hodges, J., Kanuck, J., Steele, H., Hillman, S., Asquith, K., (2008) “Forecasting outcomes in previously maltreated children: the use of the AAI in a longitudinal adoption study” in H. Steele and M. Steele (Eds) Clinical Applications of the Adult Attachment Interview. New York: Guilford
Wallin, D. (2007) Attachment in Psychotherapy, New York: Guilford
