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| Volume 1, Issue 1, 2007 | |||
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Attachment-Based Intervention with Prepubertal Children: The Impact of Parent, Child, and Therapist Mental Representations on Intervention Points of Entry |
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Geoff Goodman, Long Island University, ggoodman@liu.edu |
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Abstract Prepubertal children (defined here as children ages 5 to 12) are often referred by parents, school officials, and pediatricians for intervention services. The symptoms that these referred children experience are often of sufficient frequency, intensity, and duration to meet formal criteria for one or multiple childhood diagnoses contained in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association [APA], 2000). Perhaps the most troubling symptoms a prepubertal child can experience are aggression and depression. Familial, interpersonal, and individual risk factors have been identified to account for childhood aggression (Katsurada & Sugawara, 2000; Warrick-Swansen, 1999) and depression (Gazelle & Ladd, 2003; National Institute of Mental Health, 2000; Williams & Harper, 1979). Although parental hostility and depression are known risk factors for childhood aggression and depression (Brent et al., 2002; Katsurada & Sugawara, 2000; Lyons-Ruth, Easterbrooks, & Cibelli, 1997; Pfeffer, Conte, Plutchik, & Jerrett, 1979; Warrick-Swansen, 1999), the literature is indecisive about which variables might mediate their influence, and which interventions might work with which parents and children. In this article, I will discuss the design and implementation of attachment-based intervention with prepubertal children who experience significant psychiatric dysfunction such as aggression and depression. I will discuss two areas: 1) potential intervention points of entry based on attachment theory, and 2) the impact of parent, child, and therapist characteristics, notably mental representations, on the potential intervention points of entry being targeted. Attachment theory has evolved from a theory of infant socioemotional development first proposed by Bowlby (1958, 1982) into a grand blueprint for early clinical intervention in the mother-infant relationship (Bakermans-Kranenburg, van IJzendoorn, & Juffer, 2003; Berlin, Ziv, Amaya-Jackson, & Greenberg, 2005; Bowlby, 1988, 1989; Egeland, Weinfield, Bosquet, & Cheng, 2000; Lieberman & Zeanah, 1999; Stern, 1995; Stern-Bruschweiler & Stern, 1989; van IJzendoorn, Juffer, & Duyvesteyn, 1995). Attachment theory has even been used to understand the intricacies of clinical intervention with adults (Bosquet & Egeland, 2001; Diamond et al., 1999; Dozier, 1990, 2003; Dozier, Cue, & Barnett, 1994; Dozier & Sepulveda, 2004; Dozier, Stevenson, Lee, & Velligan, 1991; Fonagy et al., 1996; Horowitz, Rosenberg, & Bartholomew, 1996; Korfmacher, Adam, Ogawa, & Egeland, 1997; Slade, 1999; Tyrrell, Dozier, Teague, & Fallot, 1999). Unfortunately, in spite of these impressive efforts, virtually nothing has been written about clinical intervention with prepubertal children from an attachment theory perspective. Greenberg (1999) attributed the lack of research in this period of development to a “measurement roadblock” (p. 486); that is to say, assessments of attachment are only beginning to be validated for this age range (see also Solomon & George, 1999b). In a recently published volume (Kerns & Richardson, 2005) that seeks to rectify this omission in the attachment literature by focusing exclusively on prepubertal childhood, Mayseless (2005) follows Waters and Cummings (2000) in suggesting that this paucity of literature reflects the relative lack of theoretical attention Bowlby (1977, 1988) paid to any developmental period beyond the preschool years. While such a volume is desperately needed for attachment theory to close what I would call the “prepubertal childhood gap”, none of its 12 chapters addresses clinical intervention for children from this developmental period. Thus, attachment-based intervention with prepubertal children needs to be designed and implemented to reduce their increasing levels of aggression and depression and other forms of psychopathology. Potential Intervention Points of Entry Based on Attachment Theory Perhaps the central question asked by attachment researchers who have both studied and designed attachment-based early intervention programs for mothers and infants is, “Where should one intervene to improve the infant’s attachment security?” Regardless of the researcher, two answers always seem to be offered: either 1) at the level of maternal mental representation, or 2) at the level of maternal behavior. For example, although published 10 years apart, both van IJzendoorn et al. (1995, p. 227) and Berlin (2005, p. 4) present almost identical models of attachment transmission that predict that 1) maternal mental representation of her attachment relationship to her parents influences 2) maternal behavior, especially sensitivity and contingent responsiveness, which in turn influences the infant’s attachment security. This developmental pathway simultaneously privileges the quality of the mother-infant relationship as the bedrock foundation of infant attachment security and later socioemotional adaptation (Weinfield, Sroufe, Egeland, & Carlson, 1999) and illustrates the means by which the quality of attachment is believed to be transmitted intergenerationally. All attachment-based early intervention programs seem to focus exclusively on the maternal mental representations or behavior as the agents of change. One group of researchers explained that “as an adult, the caregiver has more degrees of freedom in changing patterns of attachment-caregiving interactions than does the child” (Cooper, Hoffman, Powell, & Marvin, 2005, p. 141). This top-down approach to understanding the origins of infant attachment security has become a core tenet of attachment theory (Sroufe, 1985). The mother is believed to be providing emotional “training” to the infant “through her behavioral and emotional reactions to her baby [which] is thought to build the child’s working model of attachment, and thus lays the foundation for the expectations the child has concerning his or her relationship with the mother” (Cassidy et al., 2005, p. 38). The mechanism of maternal sensitivity as the mediator between the maternal mental representation of her own childhood attachment experiences and the infant’s attachment security has been questioned, however (De Wolff & van IJzendoorn, 1997). This transmission gap (van IJzendoorn, 1995) has been explained in several ways: inadequate assessment of maternal sensitivity, need for greater focus on constructs related to but not identical with sensitivity (e.g., reflective functioning, secure-base provision), inadequate theory, and infant temperament (Berlin, 2005; Cassidy et al., 2005; Goodman, 2002; Slade, Grienenberger, Bernbach, Levy, & Locker, 2005). As the child becomes older, however, his or her mental representation of the relationship with the parents becomes increasingly resistant to change, as past interactional experiences become habitual, expected, and reliable forecasters of future caregiver behavior (Bowlby, 1980; Bretherton, 1985; Main, Kaplan, & Cassidy, 1985). Thus, when considering attachment-based intervention for children beyond the preschool years, does the assumption of a caregiver-focused intervention still apply? An attachment-based model for understanding potential intervention points of entry for prepubertal children is presented in Figure 1. This model includes the two traditional intervention points of entry (A and D) as well as five other points of entry either recently targeted (B and C) or not targeted at all (E, F, and G) in current attachment-based early intervention programs. Each of these points of entry will be discussed.
Intervention Point of Entry A Intervention point of entry A--the parents’ mental representations (also known as internal working models) of their attachment relationships with their own parents--has been traditionally targeted by attachment-based early intervention programs (e.g., Benoit, Madigan, Lecce, Shea, & Goldberg, 2001; Carter, Osofsky, & Hann, 1991; Cicchetti, Toth, & Rogosch, 1999; Cohen et al., 1999; Cramer et al., 1990; Egeland & Erickson, 1993; Erickson, Korfmacher, & Egeland, 1992; Heinicke et al., 1999; Heinicke et al., 2000; Heinicke, Fineman, Ponce, & Guthrie, 2001; Lieberman, Weston, & Pawl, 1991). Most proponents of this intervention point of entry cite Fraiberg and her colleagues (Fraiberg, Adelson, & Shapiro, 1975) as the inspiration behind the modification of parents’ mental representations. The theory behind this approach is that parents’ mental representations are haunted by the ghosts of the past--unintegrated memories of painful interactions with their own parents during early childhood that never got resolved. These unintegrated memories often have an unintentional impact on the parents’ own parenting behavior, often in the context of those same kinds of interactions that first produced the unintegrated memories. Let us take for example a mother who as a toddler was scolded and spanked by her own mother whenever she urinated in a new diaper. Now, the mother scolds and spanks her own daughter whenever she urinates in a new diaper. The mother has no idea why she behaves in this manner toward her daughter in this context. This behavior, however, is interfering with the daughter’s sense of security in her mother’s protectiveness and comfort. The daughter now becomes frightened whenever the mother approaches to change her diaper. Or perhaps the daughter attempts to retain her urine or feces because she has associated her mother’s anger with her own urination and defecation. The daughter thus develops a symptom. These unintegrated memories of the mother’s painful interactions with her own mother are the ghosts that need to be exorcised, or at least confronted and metabolized, by working with the mother on her mental representation of her relationship with her own parents. According to the theory, if the mother can remember and work through (Freud, 1914) these memories rather than repeat them in her own caregiving, then she will become a more sensitive caregiver, even in those contexts in which she had provided insensitive caregiving. This enhanced sensitivity will result in the child’s development of a more secure mental representation of his or her relationship with the parents, which has been previously associated with a wide range of desirable socioemotional outcomes (Weinfield et al., 1999). In considering the socioemotional needs of prepubertal children, however, it is an empirical question whether this approach alone can modify the developmental trajectory already set in motion by countless previous interactions with the parents. If through intervention a parent can resolve ancient conflicts from childhood relationships with his or her own parents, would the resulting changes in caregiving behavior have the same impact on the prepubertal child’s mental representation that it might have had on this structure at an earlier developmental period? As mentioned earlier, Bowlby (1980) suggested that mental representations become increasingly resistant to change. Expectations of specific parental responses to the child’s behavior--particularly during moments of distress when the child’s attachment system is activated (separation, injury, illness, fear, or punishment)--gradually move from the realm of episodic memory into the realm of semantic or procedural memory (Main & Goldwyn, 1994). Stern (1985) referred to this process as “representations of interactions that have become generalized” (RIGs). This process continues throughout childhood, like slow-drying cement, into adulthood, when personality organization is considered stable and classifiable (Kernberg, 1986, 1996). Perhaps beyond the preschool years the child’s attachment security cannot be changed solely through the intervention point of entry of the parents’ mental representations of the relationships with their own parents. Other points of entry—including the child as the subject of intervention—need to be considered. Intervention Point of Entry D Intervention point of entry D—the parents’ behavior toward the child—has also been traditionally targeted by attachment-based early intervention programs (e.g., Anisfeld, Casper, Nozyce, & Cunningham, 1990; Barnett, Blignault, Holmes, Payne, & Parker, 1987; Dozier, Dozier, & Manni, 2002; Dozier, Lindhiem, & Ackerman, 2005; Lyons-Ruth, Connell, Grunebaum, & Botein, 1990; Spieker, Nelson, DeKlyen, & Staerkel, 2005; van den Boom, 1994, 1995). The theory behind this approach is that mothers can become more sensitive and contingently responsive to the infant’s attachment-relevant cues and thus enhance the infant’s attachment security—without having to bother with modifying the parents’ mental representations of the relationships with their own parents. In other words, intervention at this point of entry “will be successful in promoting secure attachments...without the need to alter the caregiver state of mind [mental representation]” (Dozier et al., 2005, p. 189). The general method used to circumvent the parents’ mental representations is “to help caregivers override what may be their own natural response to turn away from a distressed infant” (Dozier et al., 2005, p. 179). Another technique used is to train the parent to “become more focused in the interaction with the child by monitoring the child’s behavior (as was practiced in the intervention), and thereby diminish...dissociative processes in the presence of the child” (van IJzendoorn, Bakermans-Kranenburg, & Juffer, 2005, p. 304). Let us take again our example of the toddler who is retaining her urine out of fear of her mother’s reaction. Helping the mother to focus on her insensitive behavior during diaper-changing episodes can provide her with the opportunity of “overriding” her impulse to scold and spank her daughter as she was scolded and spanked as a child during those same situations. In considering again the socioemotional needs of prepubertal children, however, it is an empirical question whether sensitivity training alone can modify the developmental trajectory already set in motion by countless previous interactions with the parents. Assuming that the mother can indeed modify her behavior in the context of diaper changing through this behavioral approach, would these modifications have the same impact on the prepubertal child’s mental representation that they might have had at an earlier developmental period? A mother severely restricts her 9-year-old son’s mobility in their quiet neighborhood. In response, he defies her restriction and fails to return after 15 minutes. As the mother becomes increasingly punitive toward her son, in defiance he extends the time spent in the neighborhood to dangerously long intervals, and now ventures outside the neighborhood. A sensitivity intervention targeting the mother by the time the child reaches his 11th birthday might work for her, but it might not do anything to modify his defiant behavior. Sensitivity training could improve the mother’s sensitivity in one developmental period, but might not generalize to later developmental periods (van IJzendoorn et al., 2005). As mentioned earlier, other points of entry--including the child as the subject of intervention--need to be considered. Intervention Points of Entry B and C Intervention points of entry B and C will be considered together. These approaches have only recently been targeted by attachment-based early intervention programs (e.g., Cooper et al., 2005; Cooper & Murray, 1997; Grienenberger, Kelly, & Slade, 2005; Heinicke et al., 1999; Heinecke et al., 2000; Slade, Sadler, & Mayes, 2005). The theory behind these approaches is that mothers can become more sensitive and contingently responsive to the infant’s attachment-relevant cues and thus enhance the infant’s attachment security through modifying their mental representations of the relationships with their infants and increasing their reflective functioning related to their caregiving behavior. After the publication of Main et al.’s (1985) landmark article that introduced an innovative approach to the assessment of mental representation of attachment, attachment researchers began to identify other representational structures that could be measured. One of these representational structures was the parent’s mental representation of the relationship with the infant. Four groups of researchers have developed instruments that assess this construct (for a review, see Goodman, 2002; see also Goodman, 2005). Attachment researchers have begun to recognize the importance of these more proximal mental representations to the parents’ behavior than the more distal mental representations of the parents’ childhood attachment relationships. To the extent that the therapist can help the parent modify his or her mental representation of the relationship with the infant, then the consequent caregiving behavior can be similarly modified. Related to the parents’ mental representations of the relationship with the infant is the process of reflective functioning, first identified by Fonagy and his colleagues (Fonagy, Steele, Moran, Steele, & Higgit, 1991) and subsequently discussed as a potential intervention point of entry by others (Cooper et al., 2005; Heinicke et al., 1999; Heinicke et al., 2000; Slade et al., 2005; Truman, Levy, & Mayes, in press). The origins of this concept can be traced back to cognitive theory’s metacognitive knowledge (Flavell, Green, & Flavell, 1986) and psychoanalytic theory’s observing ego (Freud, 1933). Fonagy et al. (1996) defined reflective functioning as the person’s “capacity to understand mental states [of self and other] and their readiness to contemplate these in a coherent manner” (p. 24). Their rating scale based on this concept “assesses the clarity of an individual’s representation of the mental states of others as well as of their own mental states” (p. 24). Elsewhere, Fonagy and Target (2000) described reflective functioning as “the capacity to make use of an awareness of their own and other people’s thoughts and feelings” (p. 72). Reflective functioning has been shown to be negatively associated with parental psychopathology (eating disorders and borderline personality disorder) and mediates the influence of parental mental representations on their children’s attachment security (Cooper et al., 2005; Fonagy, Gergely, Jurist, & Target, 2002; Fonagy et al., 1996; Grienenberger et al., 2005; Slade et al., 2005). Thus, helping the parent to develop this reflective functioning could in turn modify his or her behavior toward the child and thereby change the child’s expectations of comfort and protection from the parent. These two intervention points of entry (B and C) pose certain advantages over the traditional points of entry (A and D). The therapist can focus on increasing the parents’ awareness of and making meaning out of the infant’s internal states and intentions, in other words, to speak for the baby (Carter et al., 1991; Fraiberg et al., 1975). For example, the therapist says to the mother, “Look how he turns and reaches up to you when he sees me. I bet he’s telling you that he wants to feel safe when an unfamiliar person is around and that you’re just the person who can pick him up and make him feel safe!” The other aspect of this work is to increase the awareness of the parent’s own internal states and intentions in response to the infant’s internal states and intentions. A mother’s discomfort with her son’s bids for contact, and the message that her discomfort might convey to him, would be explored. This work directly influences the parents’ mental representations of the relationship with the child, without necessarily activating the anxiety and resistance commonly associated with conjuring the ghosts of the childhood caregivers. In other words intervening at points of entry B and C obviates the necessity of modifying the parents’ mental representations of the relationships with their own parents (point of entry A). At the same time, modifying the parents’ mental representations of their relationship with the child stands a better chance of generalizing the parents’ sensitivity and contingent responsiveness to a variety of developmental periods than sensitivity training alone, conducted during a single developmental period (point of entry D). At later periods of development such as prepubescence, however, the child’s mental representation of the relationship with the parents has already been formed. The child is now behaving in accordance with this complex mental organization that includes historically-derived expectations of parental behavior in attachment-relevant situations as well as defensive processes that serve to ward off discomfort when attachment security is not forthcoming (Goodman, 2002). As mentioned earlier, intervening at any of the four parental intervention points of entry (A-D) might modify parental sensitivity but not necessarily the prepubertal child’s mental representation or behavior. Intervention Points of Entry E and F Intervention points of entry E and F will be considered together. Notably, these approaches have not been targeted by attachment-based early intervention programs, probably because these programs have been traditionally focused on mother-infant and mother-toddler dyads (see Bakermans-Kranenburg et al., 2003; Berlin et al., 2005; Egeland et al., 2000; Lieberman & Zeanah, 1999; van IJzendoorn et al., 1995). Working directly with an infant or toddler on modifying his or her mental representation of the relationship with the parents would be at best a dubious endeavor. Bowlby (1988), Silverman (2001), and Slade (1999) have written with clarity and insight about how to apply attachment theory to clinical work with adults, but little systematic work has been published regarding clinical work specifically with prepubertal children from an attachment theory perspective (but see Goodman, 2002). In spite of the paucity of clinical application to children from this developmental period, the basic concepts identified by Slade (1999) as central to attachment-based clinical work with adults--transference, countertransference, defensive processes, and affect regulation--closely resemble the clinical concepts used in clinical work with prepubertal children carried out by therapists who espouse more traditional clinical perspectives (e.g., Altman, Briggs, Frankel, Gensler, & Pantone, 2002; Lanyado & Horne, 1999; Pine, 1985; Spiegel, 1989). The clinical distinctiveness of attachment theory underscored by Bowlby (1988) and Slade (1999) lay in the recognition that the therapist represents an attachment figure—a secure base from which a person can explore the depths of his or her wishes and disappointments and to which the person can return for safety and solace when this exploration becomes overwhelming. The pattern of attachment that the person might form with the therapist might resemble the pattern of attachment that the person formed with the first attachment figures, the parents. The theory behind this approach is that modifying the mental representation of the relationship with the parents will directly modify the person’s behaviors and improve a wide range of socioemotional outcomes. The prepubertal child might defend against wishes for closeness and emotional intimacy by minimizing the importance of the therapist and the therapeutic relationship out of fear of rejection or unavailability, just when the child might need the therapist most such as moments of distress or emotional vulnerability. The child might be demonstrating to the therapist in the transference just how he or she defended against expectations of rejection in the parental relationships. The therapist’s countertransference reaction might consist of feeling rejected or unacknowledged by the child and a resultant urge to disregard the child without recognizing the underlying need for connection. A different prepubertal child might also express neediness directly to the therapist by clinging at the end of sessions, refusing to leave the therapist’s office, calling or e-mailing the therapist between sessions, or more seriously, threatening to hurt himself or herself when the therapist announces an upcoming vacation. The child might be demonstrating to the therapist in the transference expectations of feeling overwhelmed and confused in response to the unpredictability in the parental relationships. The therapist’s countertransference reaction might consist of feeling overwhelmed and confused by the child’s emotional dysregulation and a resultant urge to abandon the child and take more vacations without recognizing the underlying need for containment. A third prepubertal child might also express bitter disappointment or even terror at never having experienced his or her attachment needs gratified by trashing the therapist’s office, making threats of harm against the therapist or self, or actually assaulting the therapist or self during sessions. The child might actually enjoy the experience of inflicting pain, which simultaneously disguises deeply buried, split-off needs for personal safety and emotional wholeness. The therapist’s countertransference reaction might consist of wanting to beat the child to a pulp, or of wanting to banish the child to a disliked colleague without recognizing the underlying needs for connection as well as containment. Related to the child’s mental representation of the relationship with the parents (point of entry E) is the process of the child’s reflective functioning (point of entry F). Fonagy and Target (1997, 2000) have offered some ideas about how to modify reflective functioning in the prepubertal child. First, the child needs to learn how to observe his or her own emotional states, which takes place by helping him or her to label specific emotions, identify conscious and unconscious links between these emotional states and their behaviors, and notice moment-to-moment changes in the child’s internal states within the therapy sessions. Second, pretend play between the therapist and child allows for the sharing of internal states between both parties and a shared understanding of a world that is considered neither real nor fantasy--a potential space (Winnicott, 1971) both discovered and created by the child. This potential space is populated by a common set of objects symbolically held in the minds of both parties. The varieties of play and the challenges of playfulness facilitate the development of reflective functioning in the prepubertal child. In older children, this playfulness can take place in the potential space of discourse. Third, paying close attention to the transferential relationship offers what Fonagy and Target consider “the most effective route towards acquiring mentalizing [reflective] capacity” (Fonagy & Target, 2000, p. 87). The authors point out, however, that the nonreflective child transfers repudiated self-representations, not parental mental representations. The therapist works in the here and now, using interpretations to place emotions in a context of sequential mental experiences. In so doing, the child begins to “find himself [or herself] in the mind of the therapist as a thinking and feeling being” (p. 88). This process is believed to enhance the child’s emotional regulation and impulse control, which in turn is believed to modify behavior. Intervention Point of Entry G Attachment-based early intervention programs, again because of the limited age range of the child participants, have not targeted intervention point of entry G—the child’s behavior. We know that infants’ and toddlers’ behavior cannot be directly modified to improve socioemotional functioning. Behavioral and cognitive-behavioral therapists, however, tend to work directly with the prepubertal child on behavior modification, which usually also includes work with the parents and family (e.g., Graham, 1998; Greene, 1998; Reid, Patterson, & Snyder, 2002; Watson & Gresham, 1998). Although working directly with the prepubertal child to modify behavior has its advocates, all psychoanalytic theories, including attachment theory, presuppose a mind that mediates behavior and its functions. A child’s behavior can be directly modified; however, without uncovering the meanings of this behavior and the purposes it serves in the child’s mental organization, the likelihood that the behavior modification will generalize across socioemotional contexts and developmental periods is reduced. Moreover, attachment theory is fundamentally a theory about the formation of relationships and their role in affect regulation. It would make sense to use a form of therapy that focuses on the relationship between therapist and child as the curative agent in affect regulation rather than behavior modification. The child’s behavior also reciprocally influences the parents’ mental representations of the child, which in turn influences the parents’ behavior toward the child in a feedback loop (see Figure 1). Therapists who intervene at point of entry G need to understand and anticipate the impact of the child’s behavioral changes on the parents’ mental representations and on their own behavior. One would expect that changes in the parents’ mental representations would lag behind the child’s behavioral changes because the parental expectations that comprise these mental representations have developed over time and become resistant to change. Moreover, other factors such as birth order, physical appearance, physical health, gender, and personality and intellectual attributes unrelated to the child’s behavior influence these parental expectations. For all these reasons, parental changes made at the representational level—without direct intervention at point of entry C—will naturally take time to observe. Generally, relationship-focused therapies (e.g., McWilliams, 1999) hold promise for restructuring the representational landscape that influences the child’s thoughts and feelings about the self and others as well as the child’s behaviors. Attachment-based intervention that focuses on these relationships--either with the parents in reality or with the therapist as a psychical representative of the parents or the child himself or herself--can work toward resolving the underlying affect dysregulation and conflict related to attachment insecurity, fear of emotional closeness, and mistrust. This intensive and challenging work needs to occur to establish a sense of internal and external security. A therapist treating a prepubertal child from an attachment theory perspective would therefore more likely consider intervention points of entry E and F for conducting an attachment-based intervention, or consider combining all three child intervention points of entry (E-G) in a multi-pronged approach that might also include the parental intervention points of entry (A-D). The most effective attachment-based intervention with prepubertal children would ideally consider addressing all intervention points of entry (A-G). The Impact of Parent, Child, and Therapist Characteristics on Intervention Points of Entry Theoretical preferences often influence the selection of intervention points of entry in attempting to improve the socioemotional functioning of the prepubertal child. The success of the intervention can be empirically tested through rigorous execution of the intervention protocol and the evaluation of the outcomes to be modified. Intervention evaluators ask two questions when evaluating an intervention: 1) does the intervention modify the outcomes targeted by the therapist, and 2) which intervention points of entry are targeted most effectively for which parents and children? As discussed earlier, attachment-based early intervention programs usually target maternal sensitivity and infant attachment security as outcomes to be modified. More recent intervention strategies focus on maternal reflective functioning and maternal mental representations of the relationship with the child. Attachment-based intervention programs with the prepubertal child, however, need to emphasize other outcomes such as the regulation of severely dysregulated affects (found notably in aggression and depression reviewed earlier), frustration tolerance and self-inhibition, autonomy, social competence, self-esteem, intellectual functioning, and academic achievement. Erikson (1950) identified industry versus inferiority as the prevailing psychosocial crisis of this developmental period, with competence as the successful outcome and inferiority as the failed outcome. Thus, intervention outcomes need to target psychological domains that encompass this particular psychosocial developmental period. The intervention points of entry to be selected and outcomes to be modified depend on the psychological characteristics of the parents and child as well as the therapist. The effectiveness of an attachment-based intervention program depends on the extent to which these characteristics either facilitate or interfere with the implementation of the intervention. The intellectual functioning of both the parents and child should influence the selection of the intervention points of entry as well as outcomes to be targeted for modification. For example, some psychoanalysts (e.g., Clarkin, Yeomans, & Kernberg, 1999; Kernberg, Selzer, Koenigsberg, Carr, & Appelbaum, 1989) recommend insight-oriented therapy only to patients assessed as having average or higher intellectual functioning, while referring the rest to cognitive-behavioral therapy such as dialectical behavior therapy (Linehan, 1993). It is believed that patients assessed as having higher intellectual functioning are more likely than others to have the capacity to engage in the kind of abstract reasoning and symbolic thinking required of this kind of clinical work. Reflecting on the effectiveness of their intervention program that targets the improvement of reflective functioning in low-income, high-risk, first-time mothers, Slade and her colleagues (Slade et al., 2005) commented that reflective functioning “is linked to executive capacities such as planning and reasoning that are part and parcel of higher cortical functioning” (p. 171). In mothers assessed as having intellectual functioning in the borderline range, “we have at times had so much difficulty just getting them to hold onto an idea, let alone link it to other mental or objective phenomena, that we have had to lower our goals and expectations significantly” (p. 171). One could therefore question whether the authors’ selection of mothers’ reflective functioning as the primary intervention point of entry (B) was appropriate for everyone, given the serious intellectual limitations of some of the mothers. The same caution would apply to the intellectually limited prepubertal child. A more behavioral intervention approach might therefore be indicated. The severity of psychopathology present in the parents and child should also influence the selection of the intervention points of entry as well as outcomes to be targeted for modification. For example, Slade and her colleagues (Slade et al., 2005) identified severe psychopathology (notably, posttraumatic stress disorder [PTSD] and borderline personality disorder) among at least 40% of the mothers enrolled in their attachment-based early intervention program. Because of the underlying personality disorganization, these mothers experienced particular difficulty with acquiring reflective functioning. The therapist’s tending to the daily chaos and upheaval in these mothers’ lives “must be accomplished alongside cultivation of the mothers’ awareness of their babies’ needs and intentions” (p. 172). Poverty, social deprivation, community violence, and the resultant sense of powerlessness could also be considered barriers to the acquisition of reflective functioning. It appears that severe psychopathology, like low intellectual functioning, might pose formidable obstacles to the exploration of mental representations or the acquisition of reflective functioning in both parents and the prepubertal child. Thus, a more behavioral intervention approach might be indicated for this population as well. Yet others believe that a more intensive, psychodynamic intervention approach in which mental representations are explored and modified is especially indicated, while behavioral interventions are contraindicated. For example, in a discussion of the four principles that underlay their attachment-based early intervention program, Cooper and his colleagues (Cooper et al., 2005) suggest that teaching parents concrete behavior management techniques may be limited by a parent’s problematic history and the resulting tendency to experience strong negative emotion (which may evoke defensive behavior) in response to particular signals from her or his child. Although a parent may cognitively learn about more sensitive responses, there may in fact be no increased likelihood of the parent applying those new responses when emotionally aroused by the child’s signals. Our assumption is that applying these changes in a lasting manner requires changes in the parent’s internal working models [mental representations], which are partially regulated by emotional reactions. (pp. 131, 132) In parents who experience “strong negative emotion”--a DSM-IV (APA, 2000) criterion of borderline personality disorder--or acute emotional arousal--a DSM-IV criterion of PTSD--perhaps the only interventions that have any likelihood of modifying the prepubertal child’s socioemotional outcomes target those points of entry that focus on parent and child mental representations or reflective functioning (A-C, E, F). Other studies (Egeland et al., 2000; Olds, 2005; Spieker et al., 2005) concur that intensive attachment-based early intervention programs can be more effective with more psychiatrically compromised mothers than with those less compromised. Considering the prepubertal child diagnosed with serious emotional disturbance, it has been empirically demonstrated that a more intensive, relationship-focused intervention approach is more effective than less intensive approaches (Fonagy & Target, 1996; Target & Fonagy, 1994a, 1994b). These children seem to respond less favorably to less intensive approaches, while less emotionally disturbed children respond equally well regardless of intervention intensity (frequency and duration of intervention). In fact, in a retrospective study of 763 child cases, less intensive approaches resulted in negative outcomes for almost 60% of the children with serious emotional disturbance, but positive outcomes for over 80% of the less emotionally disturbed children. These findings suggest that the selection of intervention point of entry might be more consequential for parents and children with serious emotional disturbance than for parents and children simply at risk for serious emotional disturbance. Parent and Child Mental Representations The quality of the mental representations of both parents and prepubertal child should also influence the selection of the intervention points of entry as well as outcomes to be targeted for modification. Insecure and disorganized mental representations of relationships with parents or children produce general vulnerabilities to psychopathology whose manifestations depend on ego resources, support systems, and later life circumstances (Bowlby, 1980, 1988, 1989; Rutter, 1985, 1987; Sroufe, 1988; Sroufe & Rutter, 1984). A large body of evidence now supports the hypothesis that the levels of security and disorganization of these mental representations carry varying levels of risk for later psychopathology across the lifespan (e.g., Carlson, 1998; Greenberg, 1999; Lyons-Ruth, Easterbrooks, & Cibelli, 1997; Lyons-Ruth & Jacobvitz, 1999; Solomon & George, 1999a; van IJzendoorn, Schuengel, & Bakermans-Kranenburg, 1999; Weinfield et al., 1999). Thus, attachment-based intervention programs need to take into account the quality of these mental representations as a design feature to maximize their effectiveness. The effectiveness of these intervention programs often depends on formulating intervention strategies that focus on the specific vulnerabilities associated with specific patterns of mental representation. For example, Cooper and his colleagues (Cooper et al., 2005; see also Dozier & Sepulveda, 2004) hypothesized that parents with insecure mental representations of their relationships with their own parents can feel either 1) less comfortable with their child’s need for exploration, independence, and autonomy, or 2) less comfortable with their child’s need for closeness, protection, and comfort. Parents in the first category might feel that their child is too independent and does not need them. The child, acting in accordance with the parents’ fears, might miscue the parents by acting needy or distressed at the prospect of moving away to explore, even when he or she might be experiencing such a need. Conversely, parents in the second category might feel that their child is too clingy and dependent. The child, also acting in accordance with the parents’ fears, might miscue the parents by acting self-sufficient or precociously autonomous, even when he or she might be experiencing a need for comfort. Such compromises enable both parents and child to gratify the attachment needs of the child while simultaneously protecting both parties against mutual discomfort elicited by closeness or separation. A third category of parents have mental representations that make them prone to engaging in frightening or frightened behaviors during moments when the child’s attachment system is activated, creating an approach/avoidance conflict in which the child must protect himself or herself from the presumed source of protection, the caregiver (Main & Hesse, 1990). The child responds by acting confused, disoriented, frightened, or listless. By age 6, however, the child organizes these responses into controlling-punitive (in which the child seeks to humiliate the parent) or controlling-overbright/caregiving (in which the child seeks to take care of the parent) behavioral patterns (Main & Cassidy, 1988). This apparent reversal of parent-child roles serves to protect both parties from unspeakable dread while simultaneously providing some pretense of a secure base for the child. These three parent categories can then be used to design intervention strategies individually suited to the parents’ needs based on their quality of mental representation. For example, an attachment-based intervention program targeting point of entry C might use videotaped feedback of a parent-child interaction to focus on a moment when the child needed comfort based on the situation but has miscued by moving away--in accordance with what the child perceives to be the parent’s expectation. Helping the parent to interpret the miscue (defensive process), interpret the underlying need that the child is disguising with the miscue, and respond to the underlying need rather than the miscue, will ultimately modify the parents’ mental representations of their relationship with the child and resultant behavior toward the child (Cooper et al., 2005). Similarly, the therapist can use videotaped feedback to focus on a moment when the child needed to express autonomy based on the situation but has miscued by seeking proximity, or when the child needed to feel safe but became listless because of a frightening parental behavior. Exploring the complex web of parent-child interactions, based on prior knowledge of the parent’s pattern of mental representation, can deepen the parent’s understanding of the child and result in a modified mental representation of the relationship with him or her. In considering the phase-specific psychological tasks that the prepubertal child must accomplish (Erikson, 1950), the inevitable transition from the world of home to the world of school and peers places increased stress on the attachment system and produces changes in the goal-corrected partnership (Bowlby, 1982)--what Mayseless (2005) referred to as a “shift in responsibility between child and parent for monitoring and maintaining the availability and accessibility of the caregiver” (p. 10). It is plausible to suggest that these phase-specific tasks could differentially affect parent-child dyads, depending on the nature of the compromises both parties reached in infancy and toddlerhood. Specifically, parents who expressed discomfort during these earlier developmental periods with the child’s need for exploration and autonomy, and children who miscue the parents by signaling for comfort when no such comfort is necessary, will traverse the developmental period of prepubertal childhood with greater upheaval than those parents and children who seek to deny a need for closeness, comfort, or protection. Attachment-based intervention programs that serve the needs of the prepubertal child and his or her parents need to consider the nature of the psychological stresses stimulated by this developmental period. An apparent absence of psychological stresses during this developmental period, however, does not mean that children of parents who tend to avoid or dismiss their needs for comfort and security present with a low risk for future psychopathology. Perhaps these children will encounter emotional difficulties during a later developmental period such as young adulthood, when the developmental crisis to be overcome is intimacy versus isolation (Erikson, 1950). These children might appear relatively well adjusted during prepubertal childhood because they separate easily from parents, make acquaintances easily, and demonstrate an eagerness to explore their environment; however, difficulties might arise during young adulthood because they fear making an intimate emotional connection with another person in a love relationship. This failure could result in a retreat into isolation or a pattern of indiscriminate superficiality in relationships (Goodman, 2002). Attachment-based intervention programs need to adjust their intervention protocols to accommodate the specific vulnerabilities of parents and children in consideration of their defensive processes (compromises) and developmental tasks to be accomplished. Intervention outcome studies (Bakermans-Kranenburg, Juffer, & van IJzendoorn, 1998; Bosquet & Egeland, 2001; Korfmacher, Adam, Ogawa, & Egeland, 1997; Routh, Hill, Steele, Elliott, & Dewey, 1995) suggest that the quality of parents’ mental representations of their relationships with their own parents not only poses specific challenges to therapists’ individualized intervention strategies (see earlier) but also predicts outcome success as measured by mothers’ quality of intervention participation, sensitivity, hostility, and intrusiveness, and child’s positive relationship with the mother and self-reliance. In a high-risk sample (Bosquet & Egeland, 2001), mothers with preoccupied mental representations (discomfort with separation and exploration) who received the attachment-based intervention demonstrated greater improvement than their counterparts in the control group, while mothers with other patterns of mental representation did not seem to benefit. In a low-risk sample (Bakermans-Kranenburg et al., 1998), preoccupied mothers benefited more than mothers with dismissing mental representations (discomfort with closeness and connection) when the intervention included both video feedback and discussions about childhood attachment experiences, while dismissing mothers benefited more than preoccupied mothers when the intervention included only video feedback. In a high-risk sample (Korfmacher et al., 1997), mothers with unresolved mental representations (frightening or frightened responses to attachment needs) more likely had a crisis orientation to intervention than other mothers, while dismissing mothers had a more disengaged involvement with intervention than other mothers. In the only study to predict the differential impact of a parent management-training course on the child from the quality of the mothers’ mental representations (Routh et al., 1995), children of mothers with unresolved mental representations demonstrated less behavior change than children of other mothers. As a whole, this small but formidable body of research challenges intervention designers to take into account parents’ individual mental representations and their differential impact on intervention participation and outcome when selecting an intervention point of entry to target and a set of outcomes to modify. For example, the Bakermans-Kranenburg et al. (1998) study suggests that intervention point of entry A (parents’ mental representations of their relationships with their own parents) might prove more successful at producing parental sensitivity for preoccupied parents than for parents with other patterns of mental representation, while intervention point of entry D (parents’ behavior toward the child) might prove more successful for dismissing parents than for other parents. Clearly, more research needs to be conducted to account for the differential impact of various attachment-based intervention programs on parent and child socioemotional outcomes based on this representational information. Specifically, individual intervention points of entry need to be systematically tested on parents with varying patterns of mental representation to determine which points of entry are most effective at modifying which outcomes for which patterns of mental representation. A new line of research could also be inaugurated in which prepubertal children’s mental representations could be assessed for their differential impact on intervention effectiveness. This research, in combination with ongoing research investigating the differential impact of parents’ mental representations on child outcomes (Bosquet & Egeland, 2001; Routh et al., 1995), could provide a more comprehensive assessment of the selection of intervention points of entry as well as modifiable outcomes for both parent and child. A potential hypothesis would be that parents and children with mental representations that produce discomfort with exploration and autonomy might require intervention at points of entry A and E, whereas parents and children with mental representations that produce discomfort with closeness and connection might require intervention at points of entry D and G. These parent and child characteristics also need to be considered in the context of other parent and child characteristics discussed earlier such as intellectual functioning and level of psychopathology to create an attachment-based intervention program uniquely suited to the needs of the dyad. For example, my own data (Goodman, Sapp, Stroh, & Valdez, 2005) suggest that a prepubertal child’s chaotic, confused mental representation mediates the influence of the mother’s performance impairment (one factor of depression) on the child’s aggression. If the child’s aggression is targeted as the outcome to be modified, then the intervention needs to focus on the mother’s depression but especially the child’s mental representation. Methadone-maintained mothers’ quality of communication with their toddlers was mediated by the quality of infant attachment (Goodman, Hans, & Bernstein, 2005). A transactional model of development (Sameroff, 1975) predicts that modifications in the child will produce modifications in the mother, which in turn will produce further modifications in the child. Modifications in a child’s attachment security might produce a favorable modification in the parents’ mental representations and in turn greater emotional responsiveness from the parents (see Figure 1; van IJzendoorn et al., 1995; van IJzendoorn et al., 2005). Therapist Mental Representations A final psychological characteristic also needs to be considered. The quality of the therapist’s mental representation of the relationships with his or her own parents should influence the selection of dyads to whom the therapist is assigned for intervention, which in turn should influence the selection of the intervention points of entry as well as the outcomes to be targeted for modification. It is already known that the therapist’s expertise and professional credentials influence mother and infant outcomes (Olds, 2005). The therapist’s mental representation, however, can also influence an intervention program’s effectiveness. Dozier and her colleagues (Dozier, 2003; Dozier et al., 1994; Tyrrell et al., 1999) are the only group of researchers to have explored this issue in depth. According to their findings, the quality of the therapist’s mental representation, and the correspondence between the therapist’s mental representation and the adult patient’s mental representation (no work has been published with child patients), partially determine the therapist’s competence and intervention’s effectiveness. Specifically, therapists with more secure mental representations of their relationships with their parents were more likely to attend and respond to the patient’s underlying needs better than therapists with more insecure mental representations (discomfort with autonomy or closeness; Dozier et al., 1994). Therapists with mental representations that reflected discomfort with closeness, paired with patients with mental representations that reflected discomfort with autonomy, tended to have a better working alliance and patients with higher global life satisfaction and higher global assessment of functioning, than therapists and patients with matching mental representations. Conversely, therapists and patients mismatched in the other direction also tended to have a better working alliance and patients with higher global life satisfaction and higher global assessment of functioning, than therapists and patients with matching mental representations (Tyrrell et al., 1999). Dozier (2003) interpreted these results to mean that intervention is most effective when the therapist provides a “gentle challenge” (p. 254) to the patient. Therapists with more secure mental representations tended to provide more challenging interventions than therapists with more insecure mental representations. These interventions also seemed individualized to the patient’s particular discomfort: more psychologically oriented interventions were provided to patients with mental representations that reflected discomfort with closeness, while more independence-promoting interventions were provided to patients with mental representations that reflected discomfort with autonomy. According to Dozier’s hypothesis, therapists with more secure mental representations seem more likely to provide a gentle challenge to their patients, a key ingredient to intervention-program effectiveness. Dozier further suggested that therapists whose mental representations do not match their patients’ mental representations also tend to provide a gentle challenge as a function of the representational differences that naturally exist between them. Although the therapeutic technique of confrontation has been an enduring staple of some forms of psychodynamic psychotherapy (e.g., Clarkin et al., 1999; Kernberg et al., 1989), Dozier’s findings seem open to alternative interpretations. One such interpretation originates from an understanding of attachment theory as a theory of affect regulation (Kobak & Sceery, 1988). Patients need both affect containment--the metabolization and organization of chaotic, overwhelming affects (Bion, 1962, 1967)--and affect tolerance--permission to experience and express unpleasant, repressed affects (Fraiberg et al., 1975). It is plausible to suggest that some patients--generally those who experience discomfort with autonomy and exploration--need particular assistance with affect containment, while other patients--generally those who experience discomfort with closeness and connection--need particular assistance with affect tolerance. Therapist-patient mismatches might be particularly effective because the therapist, by virtue of his or her own pattern of affect regulation, is providing an intervention needed by the patient. When the therapist-patient mental representations match, however, the therapist is providing either affect containment for the patient whose affects are already over-controlled, or affect tolerance for the patient whose affects are already under-controlled. This quality of the therapist’s mental representation could therefore be used to enhance the effectiveness of an attachment-based intervention program by systematically mismatching therapists and parents prior to the beginning of the intervention. Therapist-parent mismatches would probably be most important to arrange with attachment-based intervention programs that have selected the parents’ or child’s mental representations as the points of entry (A, C, E). Modification of these points of entry relies on an emphasis on working through affects associated with the discussion of significant others in attachment-relevant situations. Representational matching also needs to be considered between the therapist and prepubertal child, although no research is available that suggests its potential to improve intervention-program effectiveness. The groundbreaking work of Dozier and her colleagues, however, offers no insight into the third category of parents mentioned earlier: those whose mental representations make them prone to engaging in frightening or frightened behaviors during moments when the child’s attachment system is activated, creating an approach/avoidance conflict in which the child must protect himself or herself from the presumed source of protection, the caregiver. Which therapist mental representation would be most effective with this kind of parent? A high degree of overlap has been demonstrated between persons whose mental representations reflect discomfort with autonomy and exploration and persons whose mental representations make them prone to engaging in frightening or frightened behaviors (Adam, Sheldon-Keller, & West, 1996; Fonagy et al., 1996; Pianta, Egeland, & Adam, 1996). Thus, a therapist whose mental representation makes him or her skilled at containing affect might be most effective with this kind of parent. A prepubertal child who engages in such behaviors poses specific challenges to any attachment-based intervention program. Owing to the disorganized nature of their mental representations (Solomon, George, & De Jong, 1995), these children could become increasingly frightened by potential attachment figures such as the therapist, who is offering them the opportunity to experience a secure, trusting relationship with them. Cognitive-behavioral interventions with these children that focus on intervention point of entry G have been suggested (Green & Goldwyn, 2002), yet there is no evidence that such treatments are effective with these children. It is my belief that attachment-based intervention programs that focus on relationships--either with the parents themselves or with the therapist as a psychical representative of them--can work toward resolving the underlying affect dysregulation and conflict related to parental dread, mortal vulnerability, utter helplessness, rage, and despondency. This intensive and challenging work needs to occur to establish a sense of internal and external security and thus remove some of the precipitants of their aggression and depression, which have been interpreted as desperate attempts at engaging an emotionally unresponsive or unprotective parent (Adam, 1994; Goodman, 2002; Goodman, Gerstadt, Pfeffer, Stroh, & Valdez, 2007; Goodman & Pfeffer, 1998).
As prepubertal children with disorganized
mental representations enter adolescence—a developmental
period that coincides with an increased opportunity to carry
out these symptoms’ lethal forms—it is critical that they
have had the opportunity to experience a trusting
relationship with an attachment figure that has the
potential to modify their frightening representations of
relationships with others. We believe that those therapists
most highly qualified to conduct an attachment-based
intervention with such parents and children have already
engaged in their own process of self-exploration with a
senior therapist—a secure base—who facilitated a process of
reflective functioning and aided in restoring an integrated,
coherent mental representation that can then serve as a
reliable guide in the chaotic cauldron of these therapeutic
relationships. Indeed, Freud’s prescription that would-be
analysts undergo their own personal analysis to increase
their understanding of their own mental lives and thus the
mental lives of their patients seems as relevant to
therapists in the 21st century as it did in 1912. The author gratefully acknowledges the assistance of Clovia Ng (clovia@cngraphics.com) in reproducing Figure 1 in Adobe Illustrator, and Marcia Miller, Chief Librarian at Weill Medical College of Cornell University--Westchester Division, in locating and obtaining reference materials. References
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