Considering Cross Cultural Issues in Attachment Therapy

1. Considering Cross Cultural Issues in Attachment Therapy Maria Tatzmann MSW, LICSW Maria Marino and Associates www.mariamarinoassociates.com

2. Objectives • 1- Understand attachment • 2- Cultural underpinning of family structures • 3- Identify the most common causes and effects of disorganize attachment and their prevalence in minority populations • 4- Identify possible interventions when working with mothers and their children in your practice

3. Concept of attachment • How does it work, why is it important? • What can go wrong? • What do we see in our practice?

4. What is attachment Attachment is a reciprocal process by which an emotional connection develops between an infant and his/her primary caregiver . Healthy attachment occur when the infant experiences the primary caregiver as consistently providing emotional essentials such as touch, movement, eye contact and smiles .

7. Why is it important • The quality of the attachment becomes the scaffolding for the development of trust or mistrust, sense of self and the concept of mastery. It shapes how the child relates to the world throughout life, the quality of his relations, and his ability to develop as a well adjusted adult. • Caregiver becomes a regulating partner

8. What influences attachment: Physical, Mental Health Mother/Child Temperament Tuning Trauma effects Exposure to violence Antisocial learned behavior Dulling of emotions

9. Attachment affects: Brain Development Relations Stimulation Exposure. Regulation Emotions How do I deal with to my feelings From satiated/aroused d/sad/glad/shamed

10. 1-Secure attachment • Consistent emotionally responsive caregiving results in a secure attachment. • Infant learns to use the caregiver to be comforted, to manage arousal, to learn self regulation and self soothing • They develop a balanced strategy of attachment and exploration. • Resolution of fear. • Secure base of exploration. • Flexible regulation of behavior, attention and emotion

11. 2-Insecure attachment Tuning and temperament dissonance. Insensitive, inconsistent, overly rigid caregiving often results in insecure attachment. The infant is able to be comforted by the parent/caretaker in an indirect manner. Learns to manage arousal by maladaptive strategies Insecure attachment is classified as: Avoidant/dismissive: Minimizing strategy to maintain closeness, minimizes distress, restrained explorations. Resistant/ preoccupied: Maximize strategy to maintain closeness, maximizes distress, maintain vigilance.

12. 3- Disorganized attachment The inability of the child to be comforted by the caretaker. Unable to manage arousal, achieve self regulation or self soothing

13. IF : • If the child experiences the caregiver as non-responsive he/she might in turn respond by being clingy. • If the child experiences the caregiver as over-reactive he/she might in turn respond by being avoidant. • If the child experiences the caregiver as rejecting he/she might in turn respond by being afraid, sad, feeling persistently aroused

14. What can go wrong • If this process is non existent or disrupted, the child may not develop the secure base necessary to support future healthy development. • Disruptive factors may include indifferent caregivers, invasive or painful medical procedures, sudden traumatic separation from mother ( hospitalization, incarceration etc.) neglect, sexual or physical abuse,, prenatal alcohol or drug exposure.

16. Other issues of concern: • Parent’s mental health issues, substance abuse • Chaotic environment • Unresolved trauma • Domestic violence • War and the effects of war

17. Attachment within a cultural context • Cultural values and attachment issues • What adults teach children without noticing it.

18. Families within a Culture • Type 1 • Traditional Family: Recent immigrants, little socialization, language difficulties. • Type 2 • Transitional Family: Role duality ( mothers are wage earners, children speak English), generational issues are more prominent. • Type 3 • Bicultural Family: Everyone speaks English. Parents speak their own language, children might speak but understand. • Type 4 • Integrated Family: Family adjust to cultural mores of the community they live in.

19. What is a family • Definition of family and of who is the care taker of a child is an extremely culturally bound concept. • Nuclear • Single parent • Tribal • Extended by blood or by • ritual

20. What does a parent hope for her/his children • A common answer is the hope that they grow healthy and well adjusted. • Across cultures this takes a very different meaning • Honor ancestors • Defend the family honor • Provide for elders • Have many children • Bring pride to family, tribe, village, nation. • College degree, good job • Be happy

21. How adults teach values to their children • Identity is a concept passed on from adults to children. Individuality, cooperation, common good, responsibility for self, for others • What do we call adults? Who do we listen to? • Differences from when we were a village.

22. What adults teach children • In many groups who we feed is the definition of family. • Who is responsible for the child if parents are absent? • How we honor or care for elders, parents, ancestors.

23. What children learn • How do I please my parents? • What is my place in society? • Who will take care of me? • What is expected of me? • How do I honor my teachings? • How do I become an adult? A parent?

24. Interventions in children’s mental health within a cultural context • Who are our clients? • Why is it important and how do we find out? • How did they get here? • Family history. Immigration history, What needs to happen to achieve a positive outcome

25. Whose problem is it? What brings them to your door • The school • The neighbors • My sister What do Mom or Dad or both think? Is there a problem? Who is affected by the problem? Who is the client?

26. Who is the client? • In working with young children, and their families the DSM V does not provide an accurate description of symptoms to achieve an effective treatment plan. • The need to assess the relation is vital to the effectiveness of the intervention. • DC 0-3 provides you with a diagnosis of the relation. It becomes the map for your treatment plan and intervention.

27. A thorough family history • Children live within the context of a family. Unless you know the family you cannot be effective. • Be aware that in many groups stories relate to actual events. Do not question the logic of the stories. Ponder the need to tell you. • Learn to ask the questions. If we don’t ask, they wont tell us.

29. Questions we often do not ask • Where Mom and Dad were born? • Where were their parents born? • What do they know about their ancestors? • What did they learned about parenting from their families ( ghosts and angels in the nursery) • History of substance abuse, sexual abuse, domestic violence, war, immigration, trauma. • Consider the issue of specific historical trauma on certain populations.

30. Generational issues • Intergenerational conflict • In law conflict • Marital difficulties • Hostile dependent relation with sponsor • Role reversal, inadequate communication, split loyalties

31. Immigrations issues • Family migration and relocation history • Pre-migration experience • Migration experience • Impact of migration on the individual and family cycle

32. Degree of loss and traumatic experience • Losses: • Significant family and friends • Material losses • Loss of community support • Spiritual community • Physical trauma • Psychological trauma

33. Cultural shock Adjustment problems • Language,, housing, transportation, employment , child care, racism • Different rates of acculturation of family members • Community stigma • Availability of support system

34. Work and Financial Stress • Downward mobility • Status inconsistency • Long working hours • Language difficulties • Racism at work • Rural vs. urban living

35. Physical health and medication history • Degree of somatization • Medical history of patient and family • Western medicine vs. traditional healers • Family concept of mental illness, help seeking behavior and treatment expectations. • Symptoms • Causes • Relationship to post traumatic behavior

37. Concurrent work with mom and child • Be aware you are treating Mom as well as the relation. • Mom’s experience as a child as well as her experience of being mothered are the silent script in the relation. • Identify the ghosts, concentrate on the angels. • As Mom becomes better at dealing with her own issues her child will become better at using the relation to meet his/her needs.

38. Working with Ghosts and Angels • Ghosts in the Nursery. ( Selma Freiberg) • We learn to be parents from the experience of being parented. • Angels in the Nursery. ( Liebermann) • Identify those moments or people in Mom’s past that parented her well. The “angels” that helped overcome negative experiences .

39. Parting thoughts