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Lucy: [00:00:10] Hey there, podcast listeners. It's Lucy here. I hope everyone's well today. I'm excited to be remote co-hosting this episode on Attachment theory. Hopefully this audio quality is sufficient despite this remote recording. We have two new guests with us today. Firstly, I will introduce Chase Thompson, a PGY2 psychiatry resident who will be co-hosting with me. Fun fact I actually met Chase on an emergency psych call shift at CAMH. And basically we plan to collaborate on the episode and and here we are. So, Chase, can you just tell us a little bit about yourself and any of your interests?
Chase: [00:00:54] Hi, my name is Chase. I'm a PGY2 in psychiatry here at the University of Toronto. I'm originally from Calgary and moved to Toronto for psychiatry residency. Recently, I became interested in attachment theory after doing some work with our guest, Dr. Diane Phillip, and I'm excited to explore that a little bit further today.
Lucy: [00:01:16] Thanks for that Chase. And our expert today is Dr. Diane Phillip, who is a child and adolescent psychiatrist at the SickKids Centre for Community Mental Health in Toronto. And she's also assistant professor at the University of Toronto. So she's developed a family therapy method called Reflective Family Play, which is a model of therapy which aims to improve parent child dynamics and more specifically, attachment. She currently practices reflective family play and also teaches this method locally and internationally.
Dr. Diane: [00:01:49] I'm really excited to be here today talking with you guys about attachment theory.
Lucy: [00:01:53] All right. Awesome. So today we will be exploring a key foundational concept in psychiatry, which really informs a great deal of what we do in the scope of formulation and psychotherapy. This is such a backbone framework in theory, and I think having this understanding will also set us up well for future episodes on different psychotherapeutic modalities and other areas of psychiatry. So I hope I mean, our hope is to sort of cover the following learning objectives. It's kind of loaded, but we will do our best. So firstly, we will define attachment and attachment theory. I think that this would be a great place to start. Then we will review some of the history of attachment theory and how the field developed. We'll touch on the evolutionary basis and the functional role of attachment in infants. We will also review some of the neurobiological perspectives of attachment. Well, of course, look at the different types of attachment and attachment disorders and how infant attachment is assessed. And hopefully we'll will also have a little bit of time to also explore how adult attachment is assessed and how attachment disorders impact adult relationships and child rearing. So that's a lot. So I think we should get started. So why don't we explore this first question. So what is attachment? Is it a noun? Is it a verb? What is attachment? What does attachment theory?
Dr. Diane: [00:03:32] Sure. And it is confusing because there's the English language that uses the word attachment to mean a whole bunch of things. And there's pop culture that has come to adopt attachment theory and kind of morph it in ways that it never was intended for. So in its purest sense, when we talk about attachment, we're talking about a specific bond that an infant or child has towards their primary care giver or primary care givers. And so I should also specify that this particular bond has to do with when the child is feeling insecure, threatened, unwell in distress, and they seek security or they seek comfort or protection. So it's a drive to seek comfort or protection with a primary care giver.
Chase: [00:04:24] Thank you, Diane. And attachment, it's it seems to be kind of this specific phenomenon that has been observed. And I'm just wondering where the first observations of this behaviour in infants came about and how it became a recognizable phenomenon with within psychiatry and psychology.
Dr. Diane: [00:04:45] So there. In the history that we tend to talk about. And the first is john bowlby, who was trained in psychology. He was and went on into medicine and became a psychiatrist and a psychoanalyst. And he observed children and observed. Okay children who were in more challenging and marginalized situations and started to develop this theory also influenced by mythologist Konrad Lorenz, who was observing other species actually. And so he came up with this idea of attachment and that this idea of infants and children seeking security from a primary caregiver. And he saw this really as a primary human drive, just like the drive for food and sustenance or the drive for sex and procreation. And his theory was also that which we often forget, is that infants and children seek security from their attachment figures in times of distress. They're then free to explore their environment. And so there actually he talked about two poles for attachment, the pull of security and comfort seeking when the attachment system is what we call activated. And so they're activated to try to find a secure base. And then they are able to explore when they're on the other pole, the other end of the continuum, they're able to then explore their environment. And so that's that's Bowlby stuff in a nutshell. And then we flip over to somebody else, a colleague of his, Mary Ainsworth, who is actually studying mothers and babies in Uganda and getting some of her own ideas around attachment behaviour and attachment security seeking in infants in that setting. And she came back and created this laboratory setting called The Strange Situation, where she actually created a model or a paradigm where we have been able to measure or define or categories infants and toddlers into categories of attachment. And we can talk, I'm sure we will more about those categories as we go forward in this discussion.
Lucy: [00:07:09] Yeah, thank you for that. I mean, it's so interesting. I mean, that's why I kind of asked about is attachment sort of like a verb. I mean, it kind of seems like an impulse, like a basic instinct for survival. And that's where I kind of see this strong sort of evolutionary basis for attachment.
Dr. Diane: [00:07:27] Absolutely. And it makes sense from an evolutionary perspective. And certainly Bowlby spoke about this and others have, too, that it makes evolutionary sense that we're not the largest or the strongest, but perhaps we're the smartest species on the planet. And these kind of prosocial behaviours that we have our ability to communicate and our ability to signal our distress and get comfort from our parents is a key thing that perhaps put us at a survival advantage from an evolutionary perspective. And so, yeah, it's this biological drive within us that may have been selected for as something that increase the probability of the infant surviving infancy because infants, infant mortality rates historically have been extremely high. So if you are an infant that is able to let your caregiver know, hey, there's a problem, I'm not well and there's something threatening happening to me, this is scary. And then your caregiver picks you up and you are soothed and comforted by that. Well, that's also rewarding for the caregiver. It's a really clear communication pattern that has a nice cycle to it for the for the parent and the child.
Lucy: [00:08:46] Yeah, for sure. Like, I feel like a lot of this overlaps with what I've been learning through the trauma therapy program and women's college, where I'm doing an elective. You know, I think everyone knows about, you know, fight or flight as, you know, survival responses. But I've also learned about attach, cry and also freezing. But like attach cry. I forgot that that's sort of like it's definitely a protective measure as a means for survival. So that kind of maps on to what you've been saying. I guess next, what I'm kind of wondering about is exactly like when does attachment develop? Like does it begin in the womb? I guess more so curious about how attachment develops?
Dr. Diane: [00:09:29] We believe it develops sort of over the course of the first six months of life. It's starting to develop. And then by when it became measurable in this this laboratory setting that Mary Ainsworth developed was around 12 to 18 months when she created this thing called the Strange Situation. But we believe it's developing all along through the first year of life. And there have been others who have actually done modified strange situations with much younger infants and seen kind of the precursors of some of the attachment behaviours. But it isn't until a child is 12 to 18 months old that they're able to either crawl or even walk and so give a really clear indication of their attachment behaviours. So I don't know if it's okay for me to digress a little bit and talk about the strange situation.
Lucy: [00:10:20] Yeah, please digress.
Dr. Diane: [00:10:23] So this is the thing that Mary Ainsworth developed, which was in the lab with infants and their mothers at that time who and the infants were 12 to 18 months old, and it's this increasingly stressful situation. So these were just community volunteers, mother baby dyads, and they brought them into the lab and they came in and they played with some toys. It was a new playroom situation for the infant. And then at a certain point, this friendly but unknown other woman comes into the room and at first she's not interacting with the baby. She then starts to interact with the baby and then they get the mother to leave and the baby is left alone with the stranger. Then a stranger leaves and the mother comes back. And with these increasing levels of stress, the baby obviously reacts to, or most babies react to the stressful situation. And then what ends up happening in the classic strange situation is everybody's left him or her. And then the mother returns and the behaviour of the baby on the return of the mother is then coded by independent coders in a way that can then categorise the baby. So a majority of the babies, somewhere around 65%, let's say, will do this thing where they they make a beeline to the mother. And that's why, as I mentioned before, you kind of want a baby that can crawl or walk so that they can make this beeline towards the mother and sort of letting the mother know I'm in distress, pick me up. Mom scoops the baby up, and within a relatively short period of time, the baby settles to the point that they are able to return to play, although there's usually this sort of guarded play for the next couple of minutes and then full rapprochement of the relationship to more back to baseline and those that what I just described that sort of distress beeline soothing bit guarded and then back to baseline is what we describe as. As a secure pattern in an infant or preschooler. And then there are these two different insecure patterns that we see, which is still considered attachment behaviour, but it's considered insecure, avoidant or insecure, ambivalent, resistant. And about 15 to 25% of babies will be insecure avoidant. And what their behaviour looks like is Mom comes back in the room after we've had lots of comings and goings of the stranger and the mom and the baby's now been left alone and mom comes back in the room and baby kind of sees them. First of all, baby doesn't show as much distress.
Dr. Diane: [00:13:07] Outwardly Baby sees mom and seems pretty calm when Mom returns and we don't have that same distress kind of pattern with these insecure, avoidant babies that are still attached. But in this kind of avoidant of big dramatic displays of distress and then the insecure, ambivalent resistant babies, which is about 10 to 15% of babies in these studies, have more of a pick me up, put me down, stay distressed much longer kind of pattern compared to the secure babies. And then there was this fourth category called Insecure, Disorganised, and these babies were categorised as disorganised because their behaviours looked disorganised. We now recognise their behaviours as quite organised, but not they're more atypical and they are more not in the service. They don't seem to be as coherent with the idea of getting proximity. They the child may freeze the some of them may crawl backwards. They do bizarre things that don't seem to have that same goal of trying to get closer. So I should come back to the kids that are insecure but attached. Sorry, they're all attached but insecure attachment styles of avoidant and ambivalent resistant. Those babies have learned a strategy. All of the babies have learned strategies for maintaining proximity to the caregiver.
Dr. Diane: [00:14:39] In particular, these these first three categories that I described, the secure ones and the two insecure ones, these are strategies that they have learned through the course of that first year of life to maintain proximity to their caregiver. Because, remember, the goal here is to stay safe and this biological drive, to stay safe, to stay close to the caregiver so that the caregiver can protect me and comfort me and deal with any distress that I might have. So if I've learned that my caregiver kind of the best way to keep my caregiver near me is to be is is to signal I'm in distress, I'm unhappy. I've developed what we call this internal working model that my caregiver is going to be there for me to comfort me when I'm in distress. But I may have a different internal working model that my caregiver kind of doesn't want me to make such a big fuss. So I'm not going to make such a big fuss because that's the best way to keep my caregiver around. That's the avoidant strategy, and the ambivalent resistant one is more sort of a push pull kind of relationship with the caregiver. But I'm going to pause there because I think I've talked a lot and maybe have some questions.
Chase: [00:15:53] Yeah. So that's an interesting point about the infant wanting to keep their caregiver around as much as possible. I guess that sort of implies that parents respond differently to their infant's distress cues. And I'm wondering. Parental style that would lead to an infant developing an avoidant attachment style, and then also maybe an ambivalent or preoccupied style. And maybe you could describe what types of behaviours would lead to that.
Dr. Diane: [00:16:22] Absolutely. So we know from research that actually the parents attachment style and that's a whole different discussion that you may or may not have already had with somebody else on this podcast. But parents attachment style or adult attachment style can be categorised into very similar categories. And so parents who have a secure attachment style tend to have what we call good reflective capacity. So they have a good sense of how they're feeling, but they also have a good sense of how their infant is feeling as distinct from them. And they can flexibly consider a number of hypotheses about what might be going on for this infant. Oh, maybe he's not feeling well. Maybe she's cutting a new tooth. Maybe they are feeling scared because we're in a new situation. Maybe they've got gas. So they come up with a they have what we call cognitive flexibility around what might be going on for their infant. And that cognitive flexibility allows them to really pay attention to the infant's cues and respond in a sensitive and attuned manner. The parents who are who have insecure infants typically are parents who have an insecure attachment style themselves, and they have less of that good reflective capacity and less of that cognitive flexibility. So for them, the infant cries and they might think, why is he doing this again to to bother me or and that's the only only understanding they have of their child's behaviour is that they're just doing this to bug me or, you know, she's just she doesn't actually have a problem. She's just a drama queen. And that's the only explanation that parent has of what's going on for the child. They're not able to come up with a bunch of different hypotheses and so they respond insensitively or in a less attuned manner. And that comes from their own inheritance of of an attachment pattern that they have perhaps with their own primary caregivers.
Chase: [00:18:35] Yeah. So it sounds like what you're talking about, in a sense, it's the attachment style of the parent is kind of passed down from parent to child in the way that they're able to discern what's going on in their own infant and Attune provide some sense of attunement to their own infant's needs. I guess I'm wondering in that in the disorganised infant, it sounds like the infant doesn't really have an organiser consistent approach to the caregiver and what kind of behaviours from the caregiver would lead to that sort of style?
Dr. Diane: [00:19:11] Yeah, they're a very interesting group and probably a group that is way overrepresented in my clinical population and what we know from work of folks like Dr. Karlen Lyons Ruth, who actually took the same strange situation and looked at parental behaviours on that reunion moment and in particular looked at these, these disorganised infants, is that those parents were frightened or frightening. So you can imagine that you're in distress, you're an infant and you're in distress and you look to your parent to help you with your distress and your parent either appears frightened by your behaviour or frightening. Neither of those responses from your caregiver are going to help you feel contained in your distress. And so those infants are the ones that have a more disorganised pattern. There. Typically in these dyads, there's a history of some sort of unresolved trauma or loss in the in the parent or the caregiver who who gets distressed by their child's distress.
Lucy: [00:20:34] So thank you for taking us through each of these different types of attachment styles. And I guess I wonder about like, you know, do these attachment styles, are they sort of like fixed? Or is it possible to learn a new attachment style? And I guess I'm thinking about orphans or or children who are who go from one foster home to another. I guess is it possible to learn a new attachment style? And I guess when is it best to kind of learn a new attachment style during childhood? Or is there a specific age range in which it's it's sort of optimal to teach a child a new attachment style?
Dr. Diane: [00:21:19] So obviously we're very interested in this because we have this population often of infants who have gone through pretty, pretty high risk situations when they were quite young and supposed to be forming these attachment relationships and. I guess there are two. The good news is all hope is not lost. And the bad news is, yeah, these it can profoundly impact you and set you up for a higher likelihood of psychopathology and just poor outcomes in general, both in terms of health, academic and mental health outcomes if you've had this rough start to life. So the earlier a child is the adoption studies where the kids were in, particularly in deprived orphanages back in the nineties, there was a lot of research on those those kids. The earlier the child is adopted, the better, the better the orphanage situation was, i.e. that there were primary care givers instead of a rotating random array of caregivers, the better the outcome. But there's actually been more recent research on adoption and that you looking at particularly actually doing these adult attachment interviews with adoptive parents around the time of adoption and looking at outcomes in the kids and securely attached adoptive parents have a much higher likelihood of having even later adoption kids end up with a secure attachment and better outcomes than parents, where in particular the mother has an insecure attachment. And the worst case scenario is when both parents have an insecure attachment. So yeah, all hope is not lost in a good foster home or a good adoption. There is some very promising, not a ton of data, but some promising data that you can shift the attachment relationship or the attachment outcome for the child. So that's that's one area of data. And the other area of data is treatment. So you can also do work with kids who are in problematic attachment dyads but have not been removed from their home or adopted out. And treatment can also shift an infant or a child towards greater security.
Chase: [00:23:51] So it sounds like, you know, even infants who are in a more marginalised home at the beginning can shift their attachment style to from maybe insecure to secure what do parents, adoptive parents or even just parents in general, what do they actually do with their infants to create a secure attachment? And how is that actually what does specifically that look like in terms of the parent child interaction?
Dr. Diane: [00:24:23] Right. So in the adoption population, if you've got a parent who's already got a secure attachment, they have these models of internal working models in their mind of what relationships should look like. They have good reflective capacity, meaning they have a good sense of this is what I'm feeling, this is how I'm reacting and this is how I imagine my child is feeling and how my child is reacting to me in this moment. And maybe I'm going to. And they're able to adjust and sensitively attune their behaviour not 100% of the time, because that'd be just weird to be 100% of the time attuned to what somebody else needs because we're not psychic. It's more that they have a sense and they're able to keep doing that. That dance of attunement, where they're, they're shifting their behaviour to meet the needs of their child. And through that relationship, this child who's come from a more high risk background, who's been adopted into this family with securely attached parents, is going to to shift their internal working model of what relationships should look like so that rather than adults being frightening or frightened all the time and unpredictable and erratic or withdrawn and unavailable, they they now have multiple instances where these securely attached parents are responding in this much more predictable, much more sensitive and much more attuned way.
Dr. Diane: [00:25:53] So that that would be the the good enough foster home or the the good enough adoptive parents. And the data is looking like part of it is a securely attached parent can can help shift that child in treatment. It looks a little bit different because you're taking the parent who perhaps has their own insecure attachment and you're working with them in in in the relationship with their child and trying to help them to shift from what I was describing earlier, this cognitive rigidity. So the work with those kind of parents is to help them broaden their understanding of why else might your child be having a tantrum when you. Make him stop playing his video game and come to the table, or when you move too quickly and decide to transition him to a new activity that has nothing to do with devices and you start helping them. Then consider what else might be going on for their child as opposed to this one hypothesis that they have.
Lucy: [00:27:00] You've been speaking a lot about, you know, I guess, how you would respond to a patient or to a parent maybe in the scope of the work that you do. So I'm kind of wondering about the type of therapy that you specialise in and how attachment informs the way that you do that form of therapy. And how might you respond to parents with with approaches that might be informed from their own attachment styles?
Dr. Diane: [00:27:29] So at our centre we do a therapy called Watch, Wave and Wonder, which there was an RCT that looked at attachment security actually pre and post treatment, and it was found to shift the infant and preschoolers attachment towards greater security. But there are lots of attachment based therapies that do similar work. So Areal Slate has this program called Minding the Baby and the folks in some folks in the UK, Anthony Bateman and Peter Fonagy have mentalization based therapy and all of these therapies are sort of geared towards helping people who struggle with being able to view to people who struggle with being being able to keep the mind of somebody else in mind with being attuned and sensitive with that people who struggle with that cognitive flexibility and have very rigid ideas about why others behave the way they behave, or or no interest or curiosity about why others behave the way behave. So people with more avoidant attachment styles who tend to have infants, who have avoidant attachment styles, they're less curious about the minds of others and don't really take them into consideration. And that can be problematic too. So when you're working with the parents, it's actually all of these different types of therapies. We we think about the parents attachment style quite a bit because that tells us how they're going to approach their child. And so if they have cognitive rigidity or no curiosity about what's going on in the mind of others or no ability to even imagine, imagine what might be going on or motivating their infant going on in the mind of their infant or motivating their infant to behave the way they behave.
Dr. Diane: [00:29:24] The work is in trying to help them consider other possibilities. And in the infant and pre-school population, we really use play quite a bit, whether we're more directive and behavioural in our approach or whether we're more exploratory. An insight oriented play actually usually forms a significant portion of each session in the infant pre-school population and the idea is through play, you're able to help the parent become more sensitive and attuned and thinking about what might be going on for their infant as somebody separate and different than themselves. Who who's impacted by your behaviour and plays a very non-threatening way to work with parents. But they're often able to generalise from these play moments to other moments in their life that are not so non-threatening. And the other thing that happens typically we do watch wait and wonder interaction guidance, some mentalization based work and reflective family play, all of which have this play component and then discussion about the play. And while it's supposed to be play most of the time, some of the time kids have tantrums, kids have challenging moments with their parents. Kids refuse to play with their parents. Well, what do you think might be going on for your child right now and start getting them to exercise that reflective capacity muscle that there isn't just one thing or nothing that motivates us. There are lots of things that could be going on that that can explain a child's behaviour.
Lucy: [00:31:04] You know, I guess you've already talked about, you know, parents with different attachment styles themselves, and this makes me kind of wonder about the trajectory from each of these attachment styles. What does it look like when there is no intervention? And, you know, they these types of attachment styles persist into adulthood. How does it affect their interpersonal relationships or how do they how does it affect their work? And I'm wondering, without intervention, how these attachment styles manifest in adulthood.
Dr. Diane: [00:31:35] So there's a lot of evidence that children who have a secure attachment when they're infants or preschoolers are going to go on to have much more positive social and emotional competence. I think I mentioned they're just it's kind of a win win situation when you have a a good working model of what relationships could look like, that people can be trusted that when you're in distress, somebody is going to comfort you. You it has a good outcome for lots of different measures that have been looked at from cognitive functioning, physical health and mental health. And the inverse is the case for children with insecure attachments. They're more at risk for negative outcomes. It doesn't mean you're actually going to have a negative outcome, but they are more at risk for those negative outcomes. And then those who have the disorganised attachment style are at much greater risk for psychopathology.
Chase: [00:32:35] I guess going back to what you've talked about briefly in terms of adults who have a secure attachment style, are able to foster that sort of secure attachment with their infant who may go on to become securely attached in general. Is there any sort of other psychopathology which would get in the way of a parent developing that attachment with their child outside of their own attachment style?
Dr. Diane: [00:33:08] Sure, absolutely. If the parent is psychotic or abusing drugs, then their ability to be sensitive and attuned is going to be problematic, even if they're super stressed. And I do actually worry about parental use of devices and its impact on attachment, because parents who are on their devices when they're with their children are can't be attuned and sensitively responding. And there's actually a lot of very concerning data coming out of a number of sites, looking at parental use of devices and increase likelihood of children acting out, increased likelihood of the child actually getting a device to use to but increased likelihood of problematic interactions as parental device use just in naturalistic studies. Actually one coming out of Ann Arbour, where they were just observing parents and kids and the children were more likely to get into trouble if they were if the parents were using devices more. So I do worry about that too. But coming back to your question, Chase, about psychopathology for sure, substance abuse, psychosis, severe depression, where the parent can't really pull it together to be attuned and might actually appear frightening to the child is going to have an impact. There's also a goodness of fit. So there has been a lot of research on temperament, which is kind of the wiring of the child and how easily they can be soothed and how calm they are and how easily they adjust to a schedule and new situations which seems to be biologically driven.
Dr. Diane: [00:34:57] The problem with the with temperament research is it's it's questionnaire based and where you're giving the questionnaire to the parents to describe their child. So it's a bit relational. So you have to take that with a grain of salt. But what I take from it is this idea of goodness of fit. So if you have a child who is temperamentally really challenging, not sleeping well, not settling easily, not easy to soothe and you're secure, but maybe not the most secure because secure attachment, again, is on a continuum. You might not be the best fit for that child, and you may respond in such a way that is not as sensitive or attuned because it's not a great fit because the child is a little bit more challenging. That being said, you can have a child who's temperamentally really easygoing and you put them in the wrong situation. They're going to end up insecurely attached because they're not getting their needs met because all infants and children are going to have needs, even the most easygoing ones.
Lucy: [00:35:57] And that's great. I mean, I think we've talked a lot about different, different types of attachment. And I guess in an extreme sort of case, I'm also curious about detachment or what happens to a child that does not attach to an attachment figure.
Dr. Diane: [00:36:12] It's extremely rare and it's in these rare situations. So most children attach because it's a survival thing, right? It's just whether they attach securely or insecurely and even the disorganised ones, one can construe them as having an attachment, a bond as well with the caregiver. Despite the maltreatment or bizarre behaviour of the caregiver, children who are removed from the situation, if if they had a good enough attachment with the primary caregiver that they lost, they may suffer, they will suffer and they may be more prone to things like depression and they may show lots of signs of distress, but they have a template for what an attachment relationship should look like. And they have a work internal working model that adults can be trusted and lost, but they can be trusted. And so they're much more likely to be able to form a new attachment with a good enough attachment figure. The ones that have had, you know, very deprived situations, either from the children that were studied from the 1990s where they were in in orphanages that were overpopulated with rotating roster of caregivers and no sense of primary caregiver or children who are in and out of problematic foster homes and high risk situations. Those children are very disorganised and they would be that that small subset of the population. And those are the ones where we know from some limited data, but promising that good enough foster placement as opposed to bad foster placement or good enough attachment. Adoption, adoption. Adoptive families where the parents have secure attachment and it's a stable environment, can have a corrective influence and shift the child towards something that's approximating security or even to security.
Chase: [00:38:17] It sounds like attachment in a broad sense is an individual's first sort of internal working model of someone else. I'm wondering, like, does this map onto what we think of as like empathy or even just the way we think about others? It almost sounds as if if you can't sort of develop that first primary attachment with a caregiver, that it sort of impedes you the rest of your life in terms of creating an attachment with other people. Is that fair to say, or is that a little bit too abstract?
Dr. Diane: [00:38:55] Well, it's fair to say that, like your earliest attachment relationships do set the template for what your expectation is in relationships. And I know there's Mickalene and Florian have looked at romantic relationships. I believe that's the folks that have done that and and correlating it with your attachment style as well. So yeah, it has a profound impact and it can be you can have corrective experiences through adoption, through an important relationship with a loved one or a teacher or through psychotherapy where you can shift, shift that template and get a new, more corrective experience. But yeah, it has this profound impact. But there was something else that you said that made me think of something else which has now slipped my mind about attachment.
Chase: [00:39:53] I was just commenting whether it might does it map onto what we think of as a sort of cognitive empathy or empathy?
Dr. Diane: [00:39:59] Right. Right. So empathy and empathy is in there. But to me, empathy and correct me if you disagree, but to me, empathy is sort of feeling for somebody else. And I think that in the. Attachment literature. We're talking about something even bigger than that, which is it's feeling like having a sense of what somebody else is feeling. But it's also in the context of my relationship with that person. So knowing that my behaviour, how I'm feeling affects my behaviour, which then affects how somebody else feels, which then affects how they behave. So yeah, like empathy to me is wow, I really get how so-and-so is feeling. But mentalization, which is another term that we use in the attachment literature, or my reflective capacity or my ability to internalise what somebody else is feeling or what I'm feeling is about also the relationship. I'm not sure if that makes sense, but it goes beyond empathy. Not only can I empathise or figure out what that person is feeling, but I also am aware that I maybe created some of that and that if I change how I'm behaving, which may mean me needing to figure out how I'm feeling, then I can shift the whole relationship.
Chase: [00:41:19] Right? And that whole process seems to kind of necessitate a really high level of emotional intelligence. And I wonder if. I'm not sure if this is known, but is there some sort of component of emotional intelligence or sort of social intelligence that plays into whether people are good at developing attachments with their infant? Because it seems like sort of a complicated process that could be quite difficult if you if you aren't able to really pick up what your infant is needing and being able to develop all these models. It sounds like a complicated process.
Dr. Diane: [00:42:02] It sounds complicated, but I'm not a I don't know how to. I'm not a psychologist, so I don't want to speak to stuff that is out of my area of expertise in terms of measuring emotional intelligence. But it is something that has been studied with people of varying intelligence. And it's it's not something that's necessarily so I'm making it sound much more conscious and explicit, but it's more on an implicit level that the parent can consider, Oh, maybe his diapers wet or maybe she's cutting a tooth or maybe she's cranky because she didn't get enough sleep or it's a new situation. Like, you don't have to be that super smart to take those things into consideration. You have to be curious, open to the possibility that there might be multiple reasons why the child why a child is in distress. But I don't know that you have to be super clever or anything like that.
Chase: [00:43:07] I think that that is clarified because I think the laying it out is something that's sort of implicit or something that kind of naturally happens in human child rearing makes it, I think, a bit more understandable because, you know, when we do kind of talk about it in an intellectualised sense, it does sound like a very complicated process, but it is something that every Parents is kind of capable of in a natural sense, like they can learn to do these things without being a highly emotionally intelligent individual is kind of the sense that I'm getting from you.
Dr. Diane: [00:43:44] Right. And like, you can get people who are very intelligent, who have no curiosity, and I'll have parents will say, well, why do you think he chose to do X, Y or Z? And the parents, like, I have no idea. And that sort of that an avoidant kind of lack of curiosity about the mind of somebody else and a shutting down of of feelings around in particular distressful behaviour, distressing behaviours, and then the more preoccupied ambivalent attachment system the parent might is more likely to say, well he, you know, he's they'll have this very rigid idea of the my child did this to just piss me off and can't I mean I said this earlier just they can't entertain the possibility that there are multiple, multiple, multiple options and often more than one thing that might be going on. And again, it doesn't have to be that complicated and you don't have to be that smart to think it could be one of a few things that might be causing the child to be in distress.
Lucy: [00:44:53] I'm just kind of also curious about what you mentioned around the implications of attachment in romantic relationships. And I'm wondering if you work with couples and parents and you're kind of noticing two different attachment styles between the parents and and how you manage that or or how you explore that within the scope of therapy.
Dr. Diane: [00:45:12] Right. So reflective family play, this approach that we developed at our centre where we took some of the mentalization based therapy and said, Hey, we don't have something for this for a whole family and to work on couples stuff. It was explicitly developed in order to try to work on couple co-parenting issues and some of these differences in parenting styles. And for sure you can have parents who have different attachment styles and children will actually attach differently to the two different parents based on that. And that can create some of the conflict in our relationship around co-parenting. And so, I mean, often in co-parenting, a lot of the work we do is just sort of identifying and labelling these differences and then looking for ways to find complementarity. And instead of saying this is this is a problem and it's a difference that's insurmountable to rather say, hey, let's capitalise on each of your strengths and your differences to find some sort of complementary way of co-parenting this child or these children. But I'm not sure I answered your question. Lucy.
Lucy: [00:46:22] No, that's great. I mean, I guess I was just thinking about my couples therapy case right now and how I could apply some of this theory into kind of managing these two with the couple that I'm working with two vastly different ways forms of attachment and ways of relating to each other. And I guess I was just curious about that and how it would help me with my specific situation.
Dr. Diane: [00:46:48] For sure. And I sometimes call talk about the match made in hell, which is typically the kind of preoccupied, maybe borderline mom or wife and the female part of the partnership, if it's a heterosexual couple. And then the dismissing avoidant or maybe even slightly autistic male in the partnership. And I think of that as a match made in hell where she just keeps up regulating and upping the ante in her pre-occupied way to try to keep him engaged. And he keeps avoiding and dismissing and escaping. And it can be very frustrating to see. And again, naming that as a difference is half the work and getting them to recognise that they have this difference. And at our site we do adult attachment interviews with both parents and so that helps us understand where that behaviour, that attachment style comes from. And then we can talk about whether you have this template of X, Y and Z and you have this alternate template of showers and, and that can be challenging for the two of you. Let's talk about that.
Lucy: [00:48:00] Thanks, Diane Chase, do you do you have a final question?
Chase: [00:48:03] I do. I just just wanted to put it out there because I know at the beginning, Diane, you mentioned that attachment is really become kind of the purview of popular culture. And in some sense, like I've seen multiple books about it, podcasts mainly out of California about it. I'm wondering like, what do you think are the most common misconceptions you see out there regarding attachment? And is there anything you'd like to kind of dispel for us before we close here?
Dr. Diane: [00:48:35] I think my top peeves are that when people sort of use attachment and bond or relationship interchangeably and say things like they've got a great attachment because they were playing so nicely together in the waiting room, attachment. The attachment relationship is not about facilitative behaviour, so it's not about their ability to play. They might be able to play really well together and then the child gets distressed and the parent freaks out or is unavailable to the child. So attachment is again, that thing that you do when you're in distress and it's not the same as loving and playing and feeding and all those other great things and teaching great things that parents need to do to help their children survive and thrive. But they're different. And then I the other issue is like confusing attachment to literally needing to be inseparable from the child and having the child attach to at all times and not being able to kind of set clear limits and boundaries. One of the things children need to learn how to do is how to manage their own distress. And one of the ways parents help children learn to manage their own distress is by responding in an attuned and sensitive way. But I said earlier that you wouldn't want a parent who is 100% attuned because that doesn't really leave the child any breathing room to to actually live with some distress and learn how to manage their distress for themselves. And I have one colleague who talks about benign neglect and that that children sometimes need a little bit of benign neglect. They need to learn how to self-soothe a little bit. Obviously, this is not something we recommend in situations where there's a history of trauma or disorganised attachment or even avoidant attachment. But this idea that children need to always be sensitively dealt with and be literally with their parents constantly and attached to them constantly is is a misuse of the terminology. Attachment theory is really about what is what do you do when a child is distressed. So if a child and that whole thing coming back full circle to what Bowlby said, which was there's two poles to the whole thing. So if the child's attachment system is activated, they need to seek that primary care giver. But if the attachment system is not activated, then they should be free to explore their environment. And being able to explore your environment is the other pole of attach the attachment continuum.
Chase: [00:51:10] It sounds like what you just spoke about kind of maps onto the concept of being a good enough parent, one who is attuned to their child sufficiently, but also gives them that space where there might be periods of distress that the child does have to learn to deal with in some sense.
Dr. Diane: [00:51:27] Yeah, you were really paying attention, Chasee When we were talking about this stuff.
Chase: [00:51:33] That's right.
Lucy: [00:51:35] This is excellent. I mean, I think we've all definitely expanded. I mean, at least Chase and I am speaking for me specifically around expanding on some of these concepts of around attachment that we sort of, at least for me, have kind of always thought of it in a very sort of solid, specific way and now have a much more sort of elaborate way of thinking about it. And thank you for also dispelling some of those misconceptions about attachment. And I think this also will kind of better inform the way that we approach patients with different attachment styles, and it may alter the way that we were able to engage with them in therapy, but also sort of in a clinical and sort of assessment sort of context. I guess just to wrap things up. Dr. Philip, I always sort of ask the expert if there's any sort of words of wisdom or any advice or any thoughts about attachment or psychiatry in general that you'd like to share with our audience, which composed of young learners.
Dr. Diane: [00:52:34] I think I love attachment theory. I think it's this profound piece of psychological theory that has influenced the last 30 odd years of mental health thinking. And so I recommend that trainees in psychiatry consider learning more about it and maybe even learning about the adult attachment interview if you're more of an adult psychiatry person, because I think it's it's a great clinical tool and there are folks who've written about using the adult attachment interview clinically because it's a laboratory thing to and so it's not something you need to go and get training in because that's like an 18 month conversion process and religious conversion process to learn how to to become a coder for the AEI, but rather there's lots of stuff now, lots of people writing about how to use the adult attachment interview, the A.I. clinically. So I think it's just so useful to have that lens when you're thinking about shifting people, people's. Psychosocial experience through psychotherapy. And I, I really love the work of the group in the UK that does mentalization based treatment, and I think I would recommend reading some of phonics and dating and stuff.
Lucy: [00:54:23] Thanks. So thanks, Diane, for your expertise and Chase for joining me. And stay tuned, guys. We'll have another episode for you shortly. Bye.
Chase: [00:54:44] PsychEd is a resident driven initiative led by residents at the University of Toronto. We are affiliated with the Department of Psychiatry at the University of Toronto, as well as the Canadian Psychiatric Association. The views endorsed in this episode are not intended to represent the views of either organisation. This episode was produced and hosted by Lucy Chen and Chase Thompson. This episode was audio edited by Alex Raben. Our theme song is Working Solutions by All of Music. A very special thanks to our incredible guest, Dr. Diane Philip, for serving as our expert on this episode. You can contact us at the psychedpodcast@gmail.com or visit us at psychedpodcast.org, As always, thank you so much for listening.