1. THE USE AND MISUSE OF ATTACHMENT DR MAX DAVIE CONVENOR, PMHA 15 TH SEPTEMBER 2015

2. Attachment behaviour allows the infant to draw others towards them at moments of need or distress (Fonagy et al., 1995). A biological system for coping with threat, not active when no threat is perceived WHAT IS ATTACHMENT?

3. a reasonably firm expectation of feeling protected and safe, which in turn allows them to explore their world more confidently. WHAT ARE WE AIMING FOR?

4. WHAT CAN GO WRONG? PART 1 OF 3 Degree of responsiveness to separation Avoidant Resistant Secure

5. Organised Vs Disorganised WHAT CAN GO WRONG? PART 2 OF 3

6. Reactive Attachment Disorder Lack of attachment behaviours Extreme maltreatment Rare Disinhibited Social Engagement Disorder Lack of inhibition Decreasing link to maltreatment Neurodevelopmental, rare WHAT CAN GO WRONG? PART 3 OF 3

7. Secure organised attachment Insecure organised attachment Disorganised Attachment Attachment Disorder CLASSIFICATIONS AND TERMINOLOGY Attachment Difficulties Attachment problems No place for ‘disordered attachment’

8. Abnormal caregiving Disturbed attachment Negative internal working models Poor outcomes Questions: What kind of abnormal caregiving? Can patterns be altered? Does altering patterns/ models result in better outcomes? CLINICAL SIGNIFICANCE- THE NARRATIVE

9. ABNORMAL CAREGIVING AND ATTACHMENT PATTERN Lack of sensitivity Insecure attachment Abuse/ neglect Disorganised attachment Extreme abuse RAD Good evidence for link in infancy, poor for significance Good evidence for link, moderate for significance Good evidence for link, Good for significance

10. Insecure and disorganised lumped together Video feedback effective but not available Link to broader function unclear THERAPEUTIC EFFECTIVENESS

11. Lifespan Behaviour Responses Narratives Non-threat “Attachment theory also describes the ways in which individuals handle their most intimate relationships with their parents, children and life- partners” ATTACHMENT CREEP

12. Disorganised attachment as an indicator of impact of abuse Attachment security as a part of a formulation with other factors Recognising RAD and DSED and referring PERSONAL VIEW- WHAT IS IMPORTANT

13. Inappropriate therapies WHAT’S THE HARM?

14. Blame Shame Denial Disengagement WHAT’S THE HARM?

15. Narrow vision Assumption of harmful parenting Confirmation bias WHAT’S THE HARM?

16. Missed diagnosis  ADHD  SpLD  Anxiety  PTSD  Depression  Ongoing abuse WHAT’S THE HARM?

17. Therapeutic nihilism? WHAT’S THE HARM?

18. SUMMARY An important process not a unifying theory Evidence base clearest in infancy for increasing sensitivity, but dissipates rapidly outside this Insecure and disorganised attachment quite distinct Can lead professionals down blind alleys.

19. Question what is meant by “attachment X” Ask what therapeutic intervention this leads to. Resist closing down of other avenues MY PERSONAL ADVICE

20. Critical thinking is important!! FINAL MESSAGE

21. A small plug PMHA winter meeting 28-29 January 2016 Highgate house LAC, impact of maternal abuse, diagnostic controversies, Public Mental Health Pmha-uk.org for details