Developing a secure base in family intervention: using the adult attachment projective system to assess attachment in family relationships.

Families are core to human well-being. Therapeutic intervention may be needed in the context of family disruptions. Attachment theory conceptualizes parents as the secure base and safe haven that support children's optimal development. Parents who have experienced their own attachment difficulties or traumas may not provide quality caregiving necessary for balanced secure parent-child attachment relationships. Following Bowlby's original thinking (1988), an attachment approach to family intervention views the therapist as a secure base that enables families to explore individual and system problems to restore equilibrium. Attachment informed therapy uses attachment theory to understand family functioning. However, the unavailability of valid economical assessment for examining attachment representations has constricted the practical utility of attachment theory in family therapy beyond applications of general concepts. This chapter describes the Adult Attachment Projective Pictures System (AAP) and explores its use as an efficient manner for assessing attachment representations within families that allows therapists to understand problematic interactions, disabling defensive processes, make predictions concerning negative patterns, and create targets for change and restorative intervention. Consolidating three decades of attachment and caregiving system research, we describe how distinct patterns of AAP responses for each adult attachment group map onto expected parenting and family system expectations and behaviors to provide a concise and informative framework. In addition to the traditional adult attachment patterns (Secure, Dismissing, Preoccupied, Unresolved), we describe for the first time expectations for two additional forms of incomplete pathological mourning (Failed Mourning and Preoccupied with Personal Suffering) that have been overlooked in the field.

A Novel Think Tank Program to Promote Innovation and Strategic Planning in Ophthalmic Surgery.

BACKGROUND: Continuous quality improvement is a pillar of all surgical groups. Innovation is a critical aspect to continuously improve, but traditional staff retreats have several disadvantages which limit their utility in identifying needs and developing innovative solutions. To address these challenges, we designed the novel Think Tank Program to spur innovation and strategic planning for an academic ophthalmology department including the Kellogg Eye Center 6 operating rooms. METHODS: The Think Tank program is a structured seven-phase program for faculty in small teams to identify, innovate, and implement meaningful change. Participants brainstormed problems and possible solutions to those problems, formed teams, acquired data, and implemented meaningful change in clinical care, research, education, and administration. RESULTS: The program generated 19 novel proposals and significant faculty engagement and discussion in improving the department. A case example of improving the operating room (OR) utilization resulted in improved OR utilization from 63.8% to 74.6% over a 3 month period before and after implementation. It also resulted in a reduction of cancelled or rescheduled surgeries within 2 weeks or surgery from 29.8% to 15.2%. This resulted in an estimated positive financial margin of over $141,000 to the institution in addition to improvement in patient, surgeon, and staff satisfaction with the quality of care. CONCLUSIONS: Engaged faculty, critical data analysis, and value proposition analysis with data-driven metrics and accountability can result in a significant increase in OR utilization and reduction in surgical cancellations. Think Tank serves as a model transformative program to assist practices and institutions to best fulfill their mission while actively engaging and retaining their members.

Early childhood attachment stability and change: a meta-analysis.

Examining degrees of stability in attachment throughout early childhood is important for understanding developmental pathways and for informing intervention. Updating and building upon all prior meta-analyses, this study aimed to determine levels of stability in all forms of attachment classifications across early childhood. Attachment stability was assessed between three developmental epochs within early childhood: infancy, toddlerhood, and preschool/early school. To ensure data homogeneity, only studies that assessed attachment with methods based on the strange situation procedure were included. Results indicate moderate levels of stability at both the four-way (secure, avoidant, resistant, and disorganised; κ = 0.23) and secure/insecure (r = 0.28) levels of assessment. Meta-regression analysis indicated security to be the most stable attachment organisation. This study also found evidence for publication bias, highlighting a preference for the publication of significant findings.

Antenatal caregiving representations and perinatal behavior in mothers with severe lifetime psychopathology.

Psychopathology poses a risk for optimal parenting. The current study explored antenatal caregiving representations as markers for later risk of nonoptimal maternal behavior among mothers with severe mental illness. Sixty-five mothers diagnosed with psychosis, bipolar disorder, depression (psychopathology group), and nonclinical controls participated in a longitudinal study from pregnancy to 16 weeks after birth. Mental health diagnoses and caregiving representations were assessed during pregnancy. Maternal behavior was assessed during the 5-min recovery phase of the still-face paradigm at 16 weeks. Mothers with psychopathology reported significantly higher levels of "heightened" caregiving representations (i.e., separation anxiety from the child) than did controls. The only significant diagnostic group difference in perinatal maternal behavior was that mothers diagnosed with depression exhibited more overriding-intrusive behavior than did nonclinical control mothers. Regression modeling results showed that antenatal caregiving representations of "role reversal" predicted significantly lower levels of sensitivity and higher levels of overriding-intrusive behavior independent of the effect of psychopathology. The findings can be interpreted in the context of representational transformation to motherhood during pregnancy. The results provide preliminary evidence for the potential of a new questionnaire measure of caregiving representations as a screening instrument for antenatal representational risk.

La sicopatología presenta un riesgo para la crianza óptima. El presente estudio exploró las representaciones antenatales de la prestación de cuidado como señales para un posterior riesgo de conducta materna no óptima entre madres con una enfermedad mental severa. Sesenta y cinco madres con diagnosis de sicosis, trastorno bipolar, depresión (grupo de sicopatología), así como madres en el grupo control no clínico participaron en un estudio longitudinal desde el embarazo hasta 16 semanas después del nacimiento. Se evaluaron los diagnósticos de salud mental y las representaciones de la prestación de cuidado durante el embarazo. La conducta materna fue evaluada durante la fase de cinco minutos de recuperación del paradigma de la Cara Inmóvil a las 16 semanas. Las madres con sicopatología reportaron niveles significativamente más altos de representaciones "agudizadas" de la prestación de cuidado (v.g. ansiedad de estar separadas de su niño) que las madres del grupo de control. La única significativa diferencia de grupo de diagnóstico en cuanto a la conducta materna perinatal fue que las madres con diagnosis de depresión presentaron una conducta predominantemente más intrusa que las madres del grupo de control no clínico. Los resultados del uso de modelos de regresión mostraron que las representaciones antenatales de la prestación de cuidado en cuanto al 'cambio de roles' predijeron niveles significativamente más bajos de sensibilidad y niveles más altos de conductas predominantemente intrusas, independiente del efecto de la sicopatología. Se pueden interpretar los resultados en el contexto de la transformación de representación hacia la maternidad durante el embarazo. Los resultados aportan evidencia preliminar para la posibilidad de una nueva medida de cuestionario sobre las representaciones de la prestación de cuidado como instrumento de detección del riesgo de la representación antenatal.

La psychopathologie pose un risque pour le parentage optimal. Cette étude a exploré les représentations de soin anténatal en tant que marqueurs de risque ultérieur de comportement maternel non-optimal chez les mères atteintes d'une maladie mentale sérieuse. Soixante-cinq mères ayant été diagnostiquées avec une psychose, un trouble maniaco-dépressif, une dépression (groupe psychopathologie) et des contrôles non-cliniques ont participé à une étude longitudinale de la grossesse à 16 semaines après la naissance. Les diagnostics de santé mentale et les représentations de soin ont été évaluées durant la grossesse. Le comportement maternel a été évalué durant la phase de récupération de cinq minutes du paradigme de Visage Immobile à 16 semaines. Les mères avec une psychopathologie ont fait état de niveaux bien plus élevés de représentations 'accrues' de soin (anxiété de séparation d'avec l'enfant) que les contrôles. La seule différence importante de diagnostic de groupe dans le comportement maternel périnatal était que les mères diagnostiquées avec une dépression ont fait preuve de plus de comportement prépondérant-intrusif que les mères du groupe de contrôle non-clinique. Les résultats du modèle de régression ont montré que les représentations anténatales de soin de 'l'inversion des rôles' ont prédit des niveaux de sensibilité bien plus bas et des niveaux de comportement prépondérant-intrusif bien plus élevés quel que soit l'effet de la psychopathologie. Les résultats peuvent être interprétés dans le contexte de la transformation représentationnelle de la maternité durant la grossesse. Les résultats offrent des preuves préliminaires quant au potentiel d'un nouveau questionnaire comme mesure de représentations de soin en tant qu'instrument de dépistage du risque représentationnel anténatal.

Antenatal caregiving representations among expectant mothers with severe mental illness: a cross-sectional study.

Objective: The study explores predictors of antenatal caregiving representations among mothers with a history of severe mental illness (SMI). Background: Attachment research has demonstrated that multifactorial assessment of antenatal caregiving representations predicts later maternal behaviour and child attachment. However, the field lacks research among clinical groups. Knowledge of factors influencing caregiving representations during pregnancy can contribute to our understanding of caregiving risk among SMI-mothers and inform intervention decisions. Method: The current study is a cross-sectional subsample of the WARM study. Participants were 65 Danish or Scottish pregnant women with a history of either schizophrenia, bipolar disorder, moderate-severe depression, or non-clinical controls. Caregiving representations, adverse childhood experiences, social support and current symptom severity were assessed during pregnancy. Results: Symptom severity was associated with more non-optimal caregiving representations expecting less parental enjoyment, more difficulties separating from the child, and more feelings of caregiving helplessness. Lack of social support and adverse childhood experiences served as independent predictors of caregiving representations. Parental mental illness during own childhood predicted role reversed expectations. Conclusion: Antenatal caregiving representations can be assessed with a time-efficient self-report measure that assesses caregiving as a multidimensional construct. Prenatal treatment planning should target individual difficulties in undertaking transformation of the caregiving system.

Adult attachment and birth experience: importance of a secure base and safe haven during childbirth.

OBJECTIVE: Examine connections between mothers' adult attachment and subjective birth experience in the context of parity and mode of delivery. BACKGROUND: Research has established a clear connection between adult attachment and birth experience. This study extended previous research with an in-depth self-report attachment measure examining different dimensions of mothers' attachment representations and their relation to subjective birth experience.  Interactions between mode of delivery and parity were also considered. Method: Participants were 257 mothers who gave birth 4 days to 12 months prior to the study. Mothers' mean age was 30.5 years, 61% primiparas, and 26% delivered by caesarean.  Participants completed an online survey with the Birth Experience Questionnaire, the Reciprocal Attachment Questionnaire, and demographic information. RESULTS: Hierarchical moderated regression analyses showed direct effects from adult attachment dimensions to mothers' subjective birth experiences, specifically perceived availability, feared loss, separation protest, angry withdrawal, and compulsive careseeking. Interactions emerged for parity and/or mode of delivery for overall subjective birth experience, perceived control, perceived social support, and satisfaction. CONCLUSION: Adult attachment representations related to subjective birth experience, indicating that attachment figures serve as secure bases and safe havens for mothers during childbirth. These results have implications for practitioners and provide direction for future research.

UNDERSTANDING THE CONNECTION BETWEEN ATTACHMENT TRAUMA AND MATERNAL SELF-EFFICACY IN DEPRESSED MOTHERS.

Maternal self-efficacy predicts sensitive and responsive caregiving. Low maternal self-efficacy is associated with a higher incidence of postpartum depression. Maternal self-efficacy and postpartum depression can both be buffered by social support. Maternal self-efficacy and postpartum depression have both been linked independently, albeit in separate studies, to the experience of violent trauma, childhood maltreatment, and spousal abuse. This study proposed a model in which postpartum depression mediates the relation between attachment trauma and maternal self-efficacy, with emotional support as a moderator. Participants were 278 first-time mothers of infants under 14 months. Cross-sectional data were collected online. Mothers completed questionnaires on attachment trauma, maternal self-efficacy, postpartum depression, and emotional support. A moderated mediation model was tested in a structural equation modeling framework using Mplus' estimate of indirect effects. Postpartum depression fully mediated the relation between trauma and maternal self-efficacy. Emotional support moderated only the pathway between postpartum depression and maternal self-efficacy. Attachment trauma's implications for maternal self-efficacy should be understood in the context of overall mental health. Mothers at the greatest risk for low maternal self-efficacy related to attachment trauma also are those suffering from postpartum depression. Emotional support buffered mothers from postpartum depression, though, which has implications for intervention and future research.

Ideal Parent Figure method in the treatment of complex posttraumatic stress disorder related to childhood trauma: a pilot study.

Background: There is a consensus within the trauma field for the necessity of a three-phase treatment programme for complex posttraumatic stress disorder (CPTSD). This pilot study focuses on the stabilisation phase, the goal of which is the development of psychological resources and the reduction of disabling symptoms. Objective: To test the efficacy of the Ideal Parent Figure (IPF) method as a stabilization treatment for CPTSD patients with a history of childhood trauma. Method: The sample was comprised of 17 adults with a history of childhood trauma concomitant with CPTSD symptoms consulting at a clinic in France. Participants enrolled in a 5-week psychotherapy programme based on the IPF method, a semi-structured visualization programme designed to treat attachment disturbances. Measures of DESNOS symptoms, psychological symptoms, quality of life, and adult attachment were administered pre- and posttreatment as well as at 8-month follow-up. Results: A significant decrease in symptom severity and attachment traumatization and a significant increase in quality of life were found, both with medium-to-large effect sizes. The 8-month follow-up assessment showed outcome stability. Conclusions: These results suggest that treating attachment disturbances directly with an approach akin to the Ideal Parent Figure method may lead to fast and stable improvement for individuals with CPTSD.

Planteamiento: Existe consenso dentro del campo del trauma sobre la necesidad de un programa de tratamiento de tres fases para el trastorno por estrés postraumático complejo (TEPTC). Este estudio piloto se centra en la fase de estabilización, cuyo objetivo es el desarrollo de recursos psicológicos y la reducción de síntomas incapacitantes. Objetivo: evaluar la eficacia del método de la figura parental ideal (IPF, siglas en inglés de Ideal Parent Figure) como tratamiento de estabilización para pacientes con TEPTC con antecedentes de trauma infantil. Método: La muestra estaba compuesta por 17 adultos con antecedentes de trauma infantil concomitante con síntomas de TEPTC que fueron a consulta en una clínica en Francia. Los participantes se inscribieron en un programa de psicoterapia de 5 semanas basado en el método IPF, un programa de visualización semiestructurado diseñado para tratar las alteraciones del apego. Se administraron mediciones de síntomas de DESNOS, síntomas psicológicos, calidad de vida y apego adulto antes y después del tratamiento, así como en un seguimiento a los 8 meses. Resultados: Se encontró una disminución significativa en la gravedad de los síntomas y la traumatización por apego, y un aumento significativo en la calidad de vida, ambos con tamaños de efecto de mediano a grande. La evaluación de seguimiento a los 8 meses mostró estabilidad en los resultados. Conclusiones: Estos resultados sugieren que el tratamiento de los trastornos de apego directamente con un enfoque similar al método de la figura parental ideal puede conducir a una mejoría rápida y estable para las personas con TEPTC.

The European General Data Protection Regulation: challenges and considerations for iPSC researchers and biobanks.

Increasingly, human induced pluripotent stem cells (iPSC) and their associated genetic and clinical information are being used in a wide range of applications, with large biobanks being established to support and increase their scientific use. The new European General Data Protection Regulations, which comes into effect in 2018, will have implications for biobanks that generate, store and allow research access to iPSC. This paper describes some of the challenges that iPSC biobanks face and suggests some points for the development of appropriate governance structures to address these new requirements. These suggestions also have implications for iPSC research in general.

Rapid establishment of the European Bank for induced Pluripotent Stem Cells (EBiSC) - the Hot Start experience.

A fast track "Hot Start" process was implemented to launch the European Bank for Induced Pluripotent Stem Cells (EBiSC) to provide early release of a range of established control and disease linked human induced pluripotent stem cell (hiPSC) lines. Established practice amongst consortium members was surveyed to arrive at harmonised and publically accessible Standard Operations Procedures (SOPs) for tissue procurement, bio-sample tracking, iPSC expansion, cryopreservation, qualification and distribution to the research community. These were implemented to create a quality managed foundational collection of lines and associated data made available for distribution. Here we report on the successful outcome of this experience and work flow for banking and facilitating access to an otherwise disparate European resource, with lessons to benefit the international research community. ETOC: The report focuses on the EBiSC experience of rapidly establishing an operational capacity to procure, bank and distribute a foundational collection of established hiPSC lines. It validates the feasibility and defines the challenges of harnessing and integrating the capability and productivity of centres across Europe using commonly available resources currently in the field.

Assessing Attachment Representations in Adolescents: Discriminant Validation of the Adult Attachment Projective Picture System.

The contribution of attachment to human development and clinical risk is well established for children and adults, yet there is relatively limited knowledge about attachment in adolescence due to the poor availability of construct valid measures. The Adult Attachment Projective Picture System (AAP) is a reliable and valid instrument to assess adult attachment status. This study examines for the first time the discriminant validity of the AAP in adolescents. In our sample of 79 teenagers between 15 and 18 years, 42 % were classified as secure, 34 % as insecure-dismissing, 13 % as insecure-preoccupied and 11 % as unresolved. The results demonstrated discriminant validity for using the AAP in that age group, with no associations between attachment classifications and verbal intelligence, social desirability, story length or sociodemographic variables. These results poise the AAP to be used in clinical intervention and large-scale research investigating normative and atypical developmental correlates and sequelae of attachment, including psychopathology in adolescence.

A Reaction Time Experiment on Adult Attachment: The Development of a Measure for Neurophysiological Settings.

In the last few decades, there has been an increase of experimental research on automatic unconscious processes concerning the evaluation of the self and others. Previous research investigated implicit aspects of romantic attachment using self-report measures as explicit instruments for assessing attachment style. There is a lack of experimental procedures feasible for neurobiological settings. We developed a reaction time (RT) experiment using a narrative attachment measure with an implicit nature and were interested to capture automatic processes, when the individuals' attachment system is activated. We aimed to combine attachment methodology with knowledge from implicit measures by using a decision RT paradigm. This should serve as a means to capture implicit aspects of attachment. This experiment evaluated participants' response to prototypic attachment sentences in association with their own attachment classification, measured with the Adult Attachment Projective Picture System (AAP). First the AAP was administered as the standardized interview procedure to 30 healthy participants, which were classified into a secure or insecure group. In the following experimental session, both experimenter and participants were blind with respect to classifications. One hundred twenty eight prototypically secure or insecure sentences related to the eight pictures of the AAP were presented to the participants. Their response and RTs were recorded. Based on the response (accept, reject) a continuous security scale was defined. Both the AAP classification and security scale were related to the RTs. Differentiated study hypotheses were confirmed for insecure sentences, which were accepted faster by participants from the insecure attachment group (or with lower security scale), and rejected faster by participants from secure attachment group (or with higher security scale). The elaborating unconscious processes were more activated by insecure sentences with potential attachment conflicts. The introduced paradigm is able to contribute to an experimental approach in attachment research. The RT analysis with the narrative procedure might be of interest for a broader variety of questions in experimental and neurophysiological settings to capture unconscious processes in association with internal working models of attachment. An electrophysiological model based on preliminary research is proposed for assessing the preconscious neuronal network related to secure or insecure attachment representations.

The Attachment Doll Play Assessment: Predictive Validity with Concurrent Mother-Child Interaction and Maternal Caregiving Representations.

Attachment is central to the development of children's regulatory processes. It has been associated with developmental and psychiatric health across the life span, especially emotional and behavioral regulation of negative affect when stressed (Schore, 2001; Schore and Schore, 2008). Assessment of attachment patterns provides a critical frame for understanding emerging developmental competencies and formulating treatment and intervention. Play-based attachment assessments provide access to representational models of attachment, which are regarded in attachment theory as the central organizing mechanisms associated with stability or change (Bowlby, 1969/1982; Bretherton and Munholland, 2008). The Attachment Doll Play Assessment (ADPA, George and Solomon, 1990-2016; Solomon et al., 1995) is a prominent established representational attachment measure for children aged early latency through childhood. This study examines the predictive validity of the ADPA to caregiving accessibility and responsiveness assessed from mother-child interaction and maternal representation. Sixty nine mothers and their 5-7-year-old children participated in this study. Mother-child interaction was observed during a pre-separation dyadic interaction task. Caregiving representations were rated from the Caregiving Interview (George and Solomon, 1988/1993/2005/2007). Child security with mother was associated with positive dyadic interaction and flexibly integrated maternal caregiving representations. Child controlling/disorganized attachments were significantly associated with problematic dyadic interaction and dysregulated-helpless maternal caregiving representations. The clinical implications and the use of the ADPA in clinical and educational settings are discussed.

Neural Response during the Activation of the Attachment System in Patients with Borderline Personality Disorder: An fMRI Study.

Individuals with borderline personality disorder (BPD) are characterized by emotional instability, impaired emotion regulation and unresolved attachment patterns associated with abusive childhood experiences. We investigated the neural response during the activation of the attachment system in BPD patients compared to healthy controls using functional magnetic resonance imaging (fMRI). Eleven female patients with BPD without posttraumatic stress disorder (PTSD) and 17 healthy female controls matched for age and education were telling stories in the scanner in response to the Adult Attachment Projective Picture System (AAP), an eight-picture set assessment of adult attachment. The picture set includes theoretically-derived attachment scenes, such as separation, death, threat and potential abuse. The picture presentation order is designed to gradually increase the activation of the attachment system. Each picture stimulus was presented for 2 min. Analyses examine group differences in attachment classifications and neural activation patterns over the course of the task. Unresolved attachment was associated with increasing amygdala activation over the course of the attachment task in patients as well as controls. Unresolved controls, but not patients, showed activation in the right dorsolateral prefrontal cortex (DLPFC) and the rostral cingulate zone (RCZ). We interpret this as a neural signature of BPD patients' inability to exert top-down control under conditions of attachment distress. These findings point to possible neural mechanisms for underlying affective dysregulation in BPD in the context of attachment trauma and fear.

Birth and motherhood: childbirth experience and mothers' perceptions of themselves and their babies.

Childbirth is a major experience in a woman's life, but the relation between childbirth experiences and later mother-infant outcomes has been understudied. This study examined the relation between mode of delivery and subjective birth experience (e.g., perception of control, social support during labor and delivery), and mothers' descriptions of their babies and their maternal self-esteem, both powerful predictors of maternal caregiving behavior. This study had three questions: (a) Do mode of delivery and subjective birth experience predict mothers' descriptions of their babies and maternal self-esteem? (b) Are the effects of mode of delivery on mothers' descriptions and maternal self-esteem mediated by subjective birth experience? (c) Does infant age moderate any of these pathways? The sample consisted of 269 mothers of full-term, healthy infants who gave birth in the year prior to the study. Mode of delivery showed a direct effect on how mothers describe their babies, but not maternal self-esteem, which was not mediated by subjective birth experience. Subjective birth experience had direct effects on both outcomes. Infant age did not moderate any of these pathways. Results point to the subjective aspects of childbirth as important components of women's experience of labor and delivery. Implications are discussed.

Anorexia and attachment: dysregulated defense and pathological mourning.

The role of defensive exclusion (Deactivation and Segregated Systems) in the development of early relationships and related to subsequent manifestations of symptoms of eating disorders was assessed using the Adult Attachment Projective Picture System (AAP). Fifty-one DSM-IV diagnosed women with anorexia participated in the study. Anorexic patients were primarily classified as dismissing or unresolved. Quantitative and qualitative analyses of defensive exclusion were carried out. Results showed potential benefits of using the AAP defense exclusion coding system, in addition to the main attachment classifications, in order to better understand the developmental issues involved in anorexia. Discussion concerned the processes, such as pathological mourning, that may underlie the associations between dismissing and unresolved attachment and anorexia. Implications for developmental research and clinical nosology are discussed.

Use of the adult attachment projective picture system in psychodynamic psychotherapy with a severely traumatized patient.

The following case study is presented to facilitate an understanding of how the attachment information evident from Adult Attachment Projective Picture System (AAP) assessment can be integrated into a psychodynamic perspective in making therapeutic recommendations that integrate an attachment perspective. The Adult Attachment Projective Picture System (AAP) is a valid representational measure of internal representations of attachment based on the analysis of a set of free response picture stimuli designed to systematically activate the attachment system (George and West, 2012). The AAP provides a fruitful diagnostic tool for psychodynamic-oriented clinicians to identify attachment-based deficits and resources for an individual patient in therapy. This paper considers the use of the AAP with a traumatized patient in an inpatient setting and uses a case study to illustrate the components of the AAP that are particularly relevant to a psychodynamic conceptualization. The paper discusses also attachment-based recommendations for intervention.