Attachment Theory

Based on the work of John Bowlby and Mary Ainsworth, Attachment Theory states that early experiences with primary caretakers during infancy provide a “working model [of oneself] and others” (Broderick & Blewitt, 2006). It is also worth noting that the concept of attachment, as described here does not pertain to a specific set of observable behaviors. Instead attachment is a system of beliefs that sure the purpose of an emotional bond known as “proximity maintenance…[in addition to a] safe haven…

[and]…secure base” (Broderick & Blewitt, 2006, p125) with which to interact with one’s world Instead have profound effects throughout one’s lifetime. It is for this reason, an individual’s early attachment experiences have profound affects that last a lifetime.  It is in the early social interactions with primary caregivers during infancy that we first learn trust others and develops a capacity for emotional regulation. Mary Ainsworth’s research utilized a measure called the “strange situation test” (Broderick & Blewitt, 2006, p126). Based on her observations four types of attachment styles have been observed. Babies with secure attachments show distressed when separated with a caregiver and are easily comforted upon her return so they are able to return to their play activities (Broderick & Blewit, 2006; Ingram, 2012).   Anxious-Ambivalent attachments, like securely attached babies are distressed when their caregiver leaves. However, when they return, they are more anger and resistant to their caregivers attempts to provide comfort (Broderick & Blewit, 2006; Ingram, 2012). Infants with Avoidant Attachments do not cry when separated from their caregiver and ignore them when they return in the room (Broderick & Blewit, 2006; Ingram, 2012).   Finally Disorganized Attachments are seen in an infant’s tendency to avoid a caregiver when they approach while seeking them out if stressed (Broderick & Blewit, 2006; Ingram, 2012).

Goals for Attachment Interventions

A primary goal of attachment theories, regardless of one’s developmental stage is the consistent availability and access to an attachment figure (Cassidy & Shaver 1999). However it is important to note that an individual’s “assessment of availability” (Cassidy & Shaver, 1999, p39). changes throughout life. For example, during infancy availability is equated to physical proximity and consistent responsiveness from a primary caregiver. As we mature, the perception of availability pertains to communication and the cognitive appraisal of responsibility to relationship and emotional needs (Cassidy & Shaver, 1999).

For purposes of intervention in order to address disruptions in attachments it is important to assess the individual’s “current appraisal (Cassidy & Shafer, 1999, p39) of their attachment. As a current working model that influence’s one’s relationships, this construct varies and changes in response to relationship experiences throughout life (Cassidy & Shafer, 1999, p39). Intervention goals vary in accordance with: (1) an individual’s current relationship experiences and (2) their developmentally relevant methods of assessment of an attachment figures availability and inherent trustworthiness. Overall, goals center around the disruptions in present attachments and their long-term consequences for a relationship (Cassidy & Shafer, 1999).

Attachment Theory Interventions

One example of a Parent-Child Attachment Intervention is the “Steps Toward Effective Enjoyable (STEEP) Program” (Cassidy & Shafer, 1999, p565).   The primary interventional goal for this program is to address a mother’s “working model of attachment by focusing on her feelings, attitudes and representations of the mother-child relationship” (Cassidy & Shafer, 1999, p565).   Involving regular home visits staring around the later trimesters of a woman’s pregnancy and into early infancy. It takes a proactive approach. Participants include those who are at greater risk for parenting issues based on prior history. Individual and group sessions allow the individual to alter their beliefs about self and relation to others in order to prevent repeat experiences of old family history.

Attachment Interventions for adults in individual psychotherapy can include, for example the work of Mary Main who describes three types of parental attachments towards children: “autonomous, dismissing and preoccupied” (Cassidy & Shafer, 1999, p565). Interventions utilized in Mary Main’s approach include metacognitive exercises that ask individuals to consider the working models and belief systems guiding their parental efforts. “Reflective functioning” (Cassidy & Shafer, 1999, p581), is an example of another intervention that involves reviewing life events and evaluating it from everyone’s perspective. Finally, interventions can also be aimed at allowing mothers to develop an understanding of their mental state and a child’s needs (Cassidy & Shafer, 1999).

Attachment Assessments

One convenient example of attachment assessments in early infancy, includes the work of Mary Ainsworth, as described earlier. With this in mind, they involve analysis of child-parent interactions and the stability of observable behaviors over time. As individual’s progress assessments such as “The Cassidy-Marvin System” (Cassidy & Shafer, 1999, p297), are useful. This assessment involves categories of attachment styles similar to Ainsworth’s but for individuals in early child and more diverse display of behavioral responses (Cassidy & Shafer, 1999). Attachment assessments for adolescents and adults, according to the Handbook of Attachment (Cassidy & Shafer, 1999), include a series of narrative interviews. The main goal in this respect is to examine the mental constructs they utilize in current relationships and behavioral responses to these preconceptions (Cassidy & Shafer, 1999).

FINAL QUESTION: “Would a goal of therapy be to increase healthy forms of attachment? Is this possible?” In a nutshell, based on this book review and overview of interventions/assessments/goals I believe it is possible to work on attachments.   An overview of my own attachment history and my husband, shows how fundamentally important this personal construct is in all relationships throughout one’s lifetime. I also believe, in this respect, that addressing it is a worthwhile and fruitful endeavor. One ideal example of the possibility of change is my own husband. His mother was an alcoholic, who died in her forties. Married 8 times in her life, she wasn’t a source of stability for him. Additionally, my husband’s father was never around. Despite this history, and after taking time to address these issues in his own life, he is an amazing husband and wonderful father. He is motivated to create the family he never had. Therefore, I would love to address this issue in my future practice.

References

Broderick, P. C., & Blewitt, P. (2006). The life span: Human development for helping professionals. Boston MA: Pearson.
Cassidy, J & Shaver P.R. (1999). Handbook of Attachment. New York: The Guilford Press.
Ingram, B.L. (2012). Clinical Case Formulations: Matching the Integrative Treatment Plan to the Client. (2nd ed.). Hoboken, NJ: Wiley.

 

 

 

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Treatment Plan

Overview of Process

“The treatment plan is the road map that a patient will follow on his or her journey through treatment….Treatment planning begins as soon as the initial assessments are completed…[and] is a never-ending stream of therapeutic plans and interventions, (Perkinson, et al, 2009, p. 75).” Each agency requires will require atreatment plan for clients and have a specified deadline for completion. It is eventually included as a part of the client’s permanent record and becomes a map for the services provided.

How to Define Problems.

Ingram (2012) defines clinical case formulation as “a conceptual scheme that organizes, explains, or makes sense of large amounts of data and influences the treatment decisions, (p. 3).” The first step to defining the problem is gathering data from the client, significant others, clinical records, and one’s own clinical judgment. This information can allow us to develop a problem list, which we can utilzie to develop diagnoses that can indicate potential treatment targets (Ingram. 2012).

BASIC SID….

Ingram (2012) describes the problem identification process as involving two key tasks: defining “the presenting problem…[and developing a] comprehensive problem list” (p43). The BASIC SID comprehensive problem framework involves assessing the following areas: “behavior, affect, sensation, imagery, cognitive, spiritual, interpersonal, [and medical]” (p43). Developed by Arnold Lazarus in the 1980’s, this assessment method allows a holistic assessment of clients, without the influence of theoretical conceptualization in the process (Ingram, 2012).

Standards for Defining Problems

  1. Problems are define solvable goals for treatment.
  2. Problem titles define to the client’s real-world problems & current functioning.
  3. Problems are written clearly and tailored to the client’s specific situation.
  4. Problems do not pertain to theoretical concepts & clinical hypothesis.
  5. Problem’s reflect the client’s value system & not therapist’s.
  6. The problem list is complete & comprehensive

How to Define goals

Every problem listed requires a treatment goal to resolve the issue. Success of therapy is measured in terms of evidence of progress toward the goal. They also provide a guideline for treatment planning and criteria for when to terminate therapy. There are four standards for defining goals:

  1. There should be a logical connection between the outcome goal and the problem title.
  2. The goals should be theoretically neutral.
  3. The goals should be realistic, measurable, and attainable.

Standards for Writing a Treatment Plan

  1. Focused on resolving problems and achieving goals.
  2. The plan is logically related to the clinical hypotheses & data gathered.
  3. The plan pertains to knowledge of clinical research.
  4. It is strategically clear problem -> evidence -> goal -> objective -> intervention.
  5. The plan pertains to the client’s specific situation
  6. The plan is appropriate given situational constraints, (insurance, treatment setting, etc).
  7. The plan addresses legal & ethical issues.
  8. The plan utilizes referrals and community resources.

Essential Elements of a Treatment Plan

The Problem List

img_3082The problem list reflects problems that need to be addressed during the treatment process. “The problems must be specific, [and provide] a brief clinical statement of a condition of the patient that needs treatment, (Perkinson, 2009, p. 76).” Since the problems are abstract concepts by themselves, treatment plans list evidence of signs and symptoms for every problem listed.

Developing Goals

“Once you have generated a problem list, you need to ask yourself what the patient needs to do to restore normal functioning, (Perkinson, 2009, p. 77).”

Difference between goals and objectives

  1. GOALS define what you hope to achieve in therapy with the client.
  2. OBJECTIVE: Define what the client will do to achieve this outcome
  3. GOAL = TREATMENT
  4. OBJECTIVES = STRATEGY

How to write them…

img_3083“A goal is a brief clinical statement of the condition you expect to change in the client…You must state state what you intend to accomplish in general terms, and then specify the condition of the patient that will result from treatment. All goals will label a set of behaviors that you want to elicity in the patient, Goals should be more than the elimination of pathology. They should be directed toward learning…(Perkinson, 2009, p. 77).”

Treatment Objectives

img_0429After listing problems and goals, you list objectives.  Objectives are list specific skills that the patient will exercise in order to achieve a goal.  “It is a concrete behavior that you can see, hear, smeel, taste or feel…[and] must be stated clearly so that anyone would know when he or she saw it.

Defining Interventions

Interventions follow objectives.  “Interventions are what you do to help the patient complete the objective…they are also measurable and objectives…There should be at least one intervention for every objective.  The person responsible for the intervention should be listed.

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Avoiding Errors

For successful case formulation to occur, it is essential that the resulting treatment plan matches the client’s specific needs (Ingram, 2012). Our textbook also lists three common errors associated with matching a treatment plan with the client’s specific needs.   The first of these errors involves developing a case formulation without adequate data to support underlying hypotheses (Ingram, 2012). In order to avoid this error, I believe it will help to complete the “three-column worksheet” (Ingram, 2012, p88), described in our text. Another useful preventative for this mistake is to make sure your data is complete. The second error mentioned in our textbook involves the presence of data that contradicts a case hypothesis (Ingram, 2012). As Ingram, (2012), mentions it is essential that a therapist enter the data-gathering process without a predefined orientation (p89).   I would surmise, that doing so would color a therapist’s understanding of the client’s situation. The final case formulation error mentioned in our textbook involves failing to address a key issue in the client’s case.   If a wealth of data exists in support of a specific case hypothesis, it would be a disservice on the part of our client’s to overlook this issue.   One step therapists can take to prevent this might involve carefully reviewing information from the database after the initial interview process. A second step a therapist can take, might involve a consultation with a co-worker or supervisor.

Sample Treatment Plan

Attached is a copy of a treatment plan I created for a class.  It doesn’t refer to an actual client and is purely a hypothetical and acdemic exercise.  Keep in mind, it is my first attempt… 🙂

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References

Ingram, B.L. (2012). Clinical Case Foundations: Matching the Integrate Treatment Plan to the Client. (2nd. Ed.). Hoboken, NJ: Wiley.
Perkinson, R. R., & Jongsma Jr, A. E. (2009). The addiction treatment planner (Vol. 254). John Wiley & Sons. Retrieved from: http://www.sagepub.com/sites/default/files/upm-binaries/18970_Chapter_5.pdf

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