Mechanisms of Change: Relationships that Work for Adults and Children

Adapted by Ellaine B. Miller, Ph.D.

From presentation byMargaret Keiley, Ed.D, LMFT

Auburn University, AL

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Getting to Know Each Other

Challenging Provider Issues Make me Feel Like???

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What’s Your Style?

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Theoretical UnderpinningsAttachment Theory

Affect TheoryChange Theory

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Attachment TheoryWhat is Attachment? Why does attachment exist?

Survival mechanismTo maintain the proximity with a caregiver,

especially in a stressful situationGoal is to reduce arousal and reinstate a

sense of felt securityTo provide a “secure base” from which to

explore

What about attachment and caregivers?

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Attachment Styles•Secure Warm, available, and responsive caregiver

•Ambivalent-insecure Inconsistent caregiver

•Avoidant-insecure Emotionally unavailable or rejecting caregiver

•Disorganized Intrusive, abusive caregiver

Insecure attachment styles interfere with a person’s ability to regulate affect and to explore his/her world

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Internal Working ModelsWorking models of the world

Who attachment figures are and how one might expect them to respond

Working models of the self How acceptable or unacceptable one is in the eyes of

attachment figures

These internal working models of how attachment relationships operate predispose individuals to habitual forms of engagement with others, including the regulation of affect

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Internal Working Models (Cont.) Secure: Self is worthy and competent; world and

others seen as safe and trustworthy

Anxious: Self is unworthy; world and others seen as undependable and rejecting

Avoidant: Self is unlovable, incompetent, never good enough; the world and others are seen as untrustworthy and never satisfied

Disorganized: No organized internal working models

Last three attachment IWMs are driven by FEAR of: Rejection, Incompetence, Caregiver

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Affect TheoryWhat is affect? Information about our experience and desire

How is affect regulated?Affect regulation involves tolerance,

awareness, expression, and control of the physiological, behavioral, and experiential aspects of affect

Affect regulation is first co-constructed as part of the attachment process in infancy

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We need access to the information that is contained in affect in order to make decisions about what we want & how we want get what we want. So it must be regulated.

Link between Affect & AttachmentSecure individuals are able to flexibly manage their emotions and their distance from others in conflictual interactions

Ambivalently (Anxiously) attached individuals tend to heighten distress and anger as well as pursue in conflictural interactions

•Avoidantly attached individuals tend to restrict the communication of anger and distress and withdraw from conflictual interactions

Disorganized individuals have no organized attachment strategies or affect regulation strategies: Sometimes pursue and heighten distress, sometimes withdraw and restrict expression

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Examples of the Links between Affect & Attachment•Secure

Overtly/Hidden: express vulnerable feelings

•Ambivalent Overtly: nagging, angry criticism, and pursuit Hidden: fear of rejection or sadness about

disconnection

•Avoidant Overtly: stonewalling, withdrawing, or flat affectHidden: anger, hurt, sadness, and fear of

incompetence

•Disorganized Overtly: stonewalling, withdrawing, flat affect,

pursuit, angerHidden: terror, terror, terror

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Summary MAP: Attachment Positions and AffectsSecure: Flexibility in movement toward and

away from the other and tolerance of own and others’ affect (not afraid of feelings)

Ambivalent: Pursue, show distress, hide sadness and fear

Avoidant: Withdraw, show little distress, hide anger, fear, and sadness

Disorganized: No organized position, vulnerability always hidden, terrified

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Physiology of AffectThe regulation of emotional arousal is the key

factor in determining the nature and form of close relationships. (Porges’ Polyvagal Theory and Gray’s Motivational Theory)

Emotional arousal gets our attention. THEN

We are able to calm ourselves, attend to what is in front of us and respond appropriately. We can regulate the arousal in order to keep it in the tolerable zone (SECURE)

Or we move into a highly aroused panic mode that is not cognitively controlled. The result is we revert to a habitual mode of interaction, either fighting (rage, AMBIVALENT/ANXIOUS) or fleeing (fear, AVOIDANT)

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High Arousal (Red Zone)When you are highly aroused and in a

panic mode, you CANNOT engage your brain to make decisions

You go directly into a habitual mode of response without thinking:

Flight, Fight, or Freeze

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Central Nervous System

Autonomic Nervous System

Sympathetic Nervous System

Motivational Functioning

Parasympathetic Nervous System

Regulatory Functioning

Reward System: Behavioral Activation

System

(BAS)

(Dopamine System)

Punishment System:

Behavioral Inhibition System

(BIS)

(Serotonin System)

Vagal Complex:

Vagus Nerve, Dorsal Motor Nucleus, Nucleus Ambiguous

Vagal Tone:

Emotional Trait

Vagal Reactivity or

Vagal “Brake”:

Emotional State

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Vagal Tone (VT): Heart Rate Variability

• High VT: Heart rate variability high: Easier to regulate reactivity appropriately; emotional & communication flexibility

Associated with better child, adult outcomes

• Low VT: Heart rate variability low: Harder to regulate reactivity appropriately; emotional inflexibility and communication difficulties

Associated with both externalizing and internalizing problems

Aggression – anger, rageDepression – sadnessAnxiety – fear, panic

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Vagal Reactivity (VR): RSA Reactivity

This vagal “brake” regulates heart rate increases and decreases to deal with environmental demands

VR facilitates effective coping with challenges by allocating cognitive and motivational resources

VR reflects intra-individual shifts in levels of fear and anger

Moderate VR: Optimal engagement, prepare to respondExcessive VR: Emotional lability

Vagal tone stabilizes by age 1, but vagal reactivity is somewhat amenable to alteration and change

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Porges’ Polyvagal Theory (PNS): Regulatory Functioning

Influences on the Heart:Vegetative Vagus – Deceleration of heart rate

associated with orienting (older, reptilian brain)

Smart Vagus – After orienting Decision Point: One of two decisions (mammalian brain)1. Attend to and engage: Sustained attention and further deceleration of heart rate

2. Fight-Flight: Rage-Panic: Excessive acceleration of heart rate and enlist SNS

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Change is HardWhy?What can we do about it?

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Stages of ChangePrecontemplationContemplationPreparation/DeterminationAction/WillpowerMaintenanceRelapse

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Mechanisms of Change1st order : De-escalation2nd order : Permanent Change

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Mechanism of Change• Low Arousal (First Order Change)

Cognitive change – Reframe allows for awareness of initial internal working models (Emotional and Cognitive changes)

Behavioral changes – De-escalation of cycles

• High Arousal (Second Order Change) Repeated in-session Change of CyclesConsolidation of change of relationship

cycles (out-of-session change)

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Low Arousal: 1st Order ChangeDe-Escalation of Cycles with ReframeThe trainer reframes providers’ overt

feelings and behaviors to illuminate their vulnerable feelings, attachment desires and positions, and the consequences of their behaviors

The results of reframing are:Cognitive changeInternal working models change (Emotional and Cognitive changes)Behavioral changes – De-escalation of cycles 24

High Arousal: 2nd Order Change

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Training Visit Interventions and Directives The trainer directs the provider to respond in a different way.

To express his/her vulnerable feelings to the other, that is to ask directly for what she or he wants

Or to help him/her to hear, understand, and respond to this expression of vulnerable feelings and attachment needs

This directive RAISES the AROUSAL LEVEL of the participants

Over time, the participants learn to take new positions with each other and that helps to reorganize their interactional patterns

Evoking High Arousal Only evoke the vulnerable feelings of

the providerFearSadnessIncompetence/Anger of the withdrawer

Do not evoke the overt or defensive feelingsRage, AngerShameEmbarrassment

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Q&ADo we think we know what our own

attachment style is?Do we have an idea of what our providers’

attachment styles are?Having and idea about our own and others’

styles can help us engage with others in a more positive and productive way.

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Engaging Providers

Types of ProvidersWhat are the characteristics of the providers

you are involved with?Can we create profiles?

Styles of EngagementHow do we relate to or engage in meaningful

conversation with each type?Is this a one-size fits all approach?Do we need different approaches?

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Process of Change in Training/Mentoring

1. Engagement2. Assessment3. 1st Order Change: Reframe4. 2nd Order Change: Directives5. Consolidation

Engagement Strategies

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Empathy

Validation & Normalization

Heightening Vulnerable Feelings

The Use of Metaphors & Stories

AssessmentWhat is assessed?

Attachment positionsOvert and vulnerable feelings related to

positionsInteractional cycles and consequences

We assess these things by tracking and reflecting the interactional cycles and the consequences

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1st Order Change -- REFRAMEAddress negative feelings (yours and

provider’s)Change the scriptStop the cycle

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2nd order change -- DIRECTIVES Change the cycleStopThinkRespond differentlyPractice, practice, practiceNeeds to hold up under stress

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Practicing StrategiesApplying the theoriesRole play

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SummaryAttachment styleAffect/vagal toneChange is hardCultureFamily of originPresent situationsHistoryTrust

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