Introduction
Supporting Security is a 12-session intervention for groups of parents, designed to promote healthier, more secure attachment relationships between parents and infants. . Feeling secure about your primary attachments when you are a baby is associated with having a better life in many ways. Supporting Security teaches parents how important it is for babies and toddlers to feel secure, helps parents recognize when babies and toddlers are not feeling secure and helps them find ways to improve interactions so that their children feel more secure. In developing Supporting Security we focused on research findings associated with insecure attachment. These are found more often in at-risk parent-infant dyads but are not uncommon in the general population. Thus Supporting Security can be helpful to higher risk families as well as those in the general population.
In order to make Supporting Security available to many families we organized it so that we could train leaders such as nurses, family home visitors, etc to lead groups of parents with young babies. We wanted to make it acceptable/accessible to parents from many different cultures and communities. Thus we have leaders who are already in their communities and can help us adapt the intervention so that it is compatible with community traditions and values as well as with the findings of Attachment Theory. Supporting Security is adapted to each new community when we carry out the training. We learn from the new leaders as much as they learn from us.
The group sessions are highly structured so that leaders with little experience are able to learn how to run these sessions easily; training takes from three to five days plus supervision over the course of one to two sets of group sessions. The supervision can be done by teleconference so that our reach is extended widely. Each group is run by two leaders who provide support to each other as well as being more attentive to the members of the group.
Theory and techniques in supporting security
Attachment Theory
Supporting Security addresses a number of factors that have been associated with insecure attachment. Insecure attachment has been associated with:
- insensitive responses from caregivers (i.e. responses that do not recognize a baby’s signals of feeling insecure and do not quickly and effectively reduce feelings of insecurity (Ainsworth, et al , 1978).
- disorganized attachment (Main and Solomon, 1986, 1990) and that in turn has been associated with parental behaviours that frighten or confuse babies (Lyons-Ruth et al 1999).
Therapies Integrated into Supporting Security
The immediate goal of the intervention is to teach parents to recognize infants’ “cries for help” more quickly and accurately, and to respond effectively. Several schools of therapy were considered and influenced the shape of this intervention.
1. Psychoanalysis and Psychodynamic Psychotherapy
Attachment theory arose out of psychoanalytic theory (Bowlby, 1969-1980) and has been developed within the field of developmental and clinical psychology. Infant observation has been the fundamental instrument for advances in our understanding of child development. In Supporting Security we teach parents how to observe and give them practice in observing their babies.
Fonagy and Target (1997) described reflective functioning and its association with attachment theory. Reflective functioning is the capacity to envision mental states in oneself and others; to reflect on what one is thinking, feeling, etc. and what another person might have in her/his mind. Better reflective functioning in parents is associated with secure attachment status in infants. A parent who can reflect on her infant’s behaviour, intentions, feelings and wishes is more likely to read his communications accurately. Thus she will more effectively identify the baby’s expressions of insecurity. Parents who can reflect on their own reactions are more likely to be able to contain the frustrations (and other negative feelings) that are inevitable when rearing children. These parents are also more able to overcome the difficulties and traumas they may have endured themselves as infants and young children. All of these characteristics enable parents to help their babies feel more secure.
To support the development of reflective functioning, we encourage parents to consider points of view that differ from their own (coming from other parents or group leaders and most importantly, from their own infants). Parents are encouraged to wonder about the behaviours, intentions and communications in their own infants. They are encouraged to reconsider conclusions they have drawn from previous experiences. As parents wonder about or reflect on their impressions and responses, they are likely to become more accurately sensitive and contingently responsive to their infants. Note that this is much more than an intellectual or purely cognitive change. If a parent accurately perceives her infant’s need for reassurance, she will be emotionally motivated to respond to increase the baby’s feeling of security. This is part of the biological root of attachment theory that Bowlby described.
It is also important for group leaders to be able to reflect on their experiences and those of the others in the group. This enables leaders to respond supportively to each other and to the group members as well as to the babies. Leaders must be able to consider and reflect on the experiences of all the others in the group. This is particularly relevant when a group member is challenging the group or one of the group leaders. There may be times when a baby’s behaviour interferes with the group’s activity or the goals a leader has for the group. There may be times when a parent’s responses to a baby are less than ideal or cause concern. Leaders must be able to consider and reflect on the experiences and intentions of the baby, the parent, the other members of the group and the other leader as they respond. For example consider a crying baby whose mother seems to be irritated with the baby as he does not settle down. The group cannot focus on its activity. The leader must provide leadership to the group. This includes demonstrating awareness of the baby’s distress and of the mother’s distress. It is likely that the mother wants to settle her baby and is becoming anxious about disrupting the group. She may feel ashamed, feel like a failure, that she cannot settle her baby more quickly. She may begin to see the baby as her enemy, someone who is making her look bad. As the mother becomes more stressed, the baby is likely to feel more insecure. The leader must empathize with the mother, the baby and the group in order to find a solution that advances the understanding and experience of security for all. Sometimes reassuring the mother that she can take her time relieves her stress enough to let her soothe her baby. Sometimes accompanying her outside the group to settle the baby may be needed. Other solutions may be suggested or thought of by the leaders or other members of the group. Any solution must include helping mother soothe the baby – this is a priority. At the same time the leader, or her partner, can discuss the attachment perspective of what is going on.
2. Parent Training
The structure of group sessions for Supporting Security has been informed by the approach used in Parent Training interventions. Parent Training approaches are used when children and youth present with problems of aggressive behaviours. Widespread empirical support for Parent Training interventions has been found, with medium to large effect sizes, generalization to home and community settings, maintenance of improvement, and high levels of consumer satisfaction (Chambless & Ollendick, 2002; Kazdin & Weisz, 1998; Weersing & Weisz, 2002). Group sessions include opportunities for learning and practicing both in the group setting and at home. These characteristics are also part of Supporting Security, although there is more emphasis on self awareness and on relational systems in the latter.
In Supporting Security we focus on insecurity rather than aggression and we are dealing with parents of much younger children. Our purpose is to improve parental sensitivity to infants’ signals and communications about insecurity and to enable parents to respond in ways that are likely to increase infants’ feeling secure. Thus we create opportunities for parents to observe their babies together and we encourage them to do the same at home.
3. Psychoeducation
Psychoeducation is a large part of Supporting Security. We teach parents about attachment theory and about infant and child development with the understanding that an educated parent is more likely to recognize, understand and respond to a child’s distress accurately.
4. Group therapy
Meta-analyses of treatment outcome research provide considerable evidence that group therapy benefits children, adolescents and adults (for an extensive review see, Bednar & Kaul, 1994; Kazdin, 2000; Weisz, Weiss, Han, Granger, & Morton, 1995). Yalom (1995) devised an inventory of 11 curative factors that contribute to the power of group therapy’s in effecting change. Among these factors are universality, imparting of information, imitative behaviour, and group cohesiveness, characteristics built into Supporting Security.
Supporting Security is designed for groups of parent and can include both individual parents and couples. It is desirable for both parents to attend whenever possible. Individuals such as grandmothers, close friends, etc. who provide support to a parent can accompany that parent to group sessions. The degree to which a parent can feel supported in the group by the presence of these supportive individuals must be balanced against changes in group membership, which tend to cause uncertainty and distraction in the group as a whole. We encourage anyone who attends, to attend regularly.
Leaders seek to make the group a supportive, interesting and enjoyable experience for parents. We want parents to feel secure within the group. That feeling of security will help them be reflective and help them learn. For some parents, this may be an unusual experience – they may feel threatened in their lives more often than they feel secure. The feeling of security may act as a motivator, encouraging them to attend group meetings. The group should function to maximize peer support and create an environment in which different and perhaps even opposite points of view can be voiced within an emotionally positive and tolerant atmosphere. There is also evidence that when mothers have supportive relationships with other mothers their babies are more likely to feel secure (Huth-Bocks et al, 2004).
Unlike group interventions that evoke abreactive responses (venting) and thus intense feelings, the purpose of this intervention is to provide support for members, convey information and create opportunities to reflect. Thus leaders work to minimize intense affect in the members. This also reduces challenges to group organization and cohesion for inexperienced leaders.
5. Problem Solving Therapy
Providing parents with strategies and solutions to problems is likely to help parents reduce their anxiety and stress not only when their babies are distressed, but at other times in the day too. There is evidence that when parents feel more stressed on a day-to-day basis, their babies feel more insecure (Easterbrooks and Graham, 1999). We think this could happen in two ways. Parents who are stressed are more likely to evoke insecurity in their infants; i.e. these parents are more likely to manifest FR behaviours (Lyons-Ruth, 1999). They are also likely to have difficulty being sensitive to their babies’ signals and responding effectively.
Nezu & Nezu (2001) describe a problem-solving model for depression that highlights the moderating nature of problem solving ability. Problem Solving Therapy (PST) involves training individuals in five major processes: problem orientation, problem definition and formulation, generation of alternatives, decision making, and solution implementation and verification.
In Supporting Security we help parents use a problem solving framework to address a number of day-to-day challenges they may face. We encourage them to think together and individually, in the group meetings and later when doing their homework, about the sorts of problems they are confronted with when taking care of young babies. We help them rehearse ways of dealing with those problems. Our expectation is that they will become able to apply the technique when faced with real problems away from the group meetings.
6. Mindfulness training
Mindfulness-based interventions have been found to be associated with better outcomes in a number of different disorders: anxiety disorders, depression, borderline personality disorder, pain-associated disorders, etc. (Baer, 2003). Mindfulness is described as paying attention to the present experience in a non-judgemental way on a moment-to-moment basis (Baer, 2003; Kabat-Zinn, 1994). We have included this practice as a way of helping caregivers learn to pay attention to and recognize their babies’ signals as well as their own internal reactions. These are components of reflective functioning and of sensitive responsiveness. Mindfulness is also associated with stress relief (Kabat-Zinn, 1992). We expect it to support reflective functioning and to reduce stress, to complement and facilitate the problem-solving formula referred to above.
Group sessions
Each session lasts two hours and includes a regular schedule of checking in, discussing homework assignments, teaching, a group activity in which members practice what has been the subject of the teaching and finally home work is assigned for the next week which is once again an opportunity to practice the teaching. Teaching topics include attachment theory, infant emotional and cognitive development, infants’ perceptions in relationships, parental self-regulation, problem solving, parental anxiety, depression and anger, violence in the family and the neighbourhood, and choosing alternative caregivers. The focus of all topics is repeatedly brought back to its relevance to attachment and feelings of security.
Leaders contact each group member once between each group session.
Outcomes and plans
We have conducted three feasibility studies, two in a challenged neighbourhood in Toronto and one on an isolated aboriginal reserve in northern Ontario.
These demonstrated:
1. we were able to train leaders to run groups adherent to the manual.
2. leaders could engage and retain mothers with babies up to one year of age in the course of 12 sessions
3. participants benefited from the intervention in the directions we predicted although numbers were too small for statistical significance.
We have trained leaders in five northern Ontario aboriginal communities and are conducting a randomized control outcome study.
Groups have been running in five separate sites for several years in Israel, where the concept of this intervention first arose, thanks to Ravit Nisan who translated the original manual into Hebrew.
Funding for Supporting Security has been provided by Health Canada, First Nations and Inuit Branch and by Save the Children Canada.
References
Ainsworth, M.D.S., Blehar, M.C., Waters, E. and Wall, S. (1978). Patterns of Attachment. Hillsdale, NJ: Lawrence Erlbaum.
Baer, R.A. (2003). Mindfulness training as a clinical intervention: a conceptual and empirical review. Clinical Psychology: Science and Practice, 10:125-143.
Bednar, R.L., & Kaul, T.J. (1994). Experiential group research: Can the canon fire? In A.E. Bergin, & S.L. Garfield (Eds.), Handbook of psychotherapy and behavioral change 4th Edition (pp. 631-663), Canada: John Wiley & Sons, Inc.
Bowlby, J. (1969-1982). Attachment and Loss: Vol. 1: Attachment. Vol. 2 – Separation; Anxiety and Danger; Vol. 3 – Loss ; sadness and depression. New York: Basic Books.
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Fonagy, P., Target, M. (1997). Attachment and reflective function: their role in self-organization. Development & Psychopathology. 9(4):679-700.
Huth-Bocks, A.C., Levendosky, A.A., Bogat, G.A., von Eye, A. (2004). The impact of maternal characteristics and contextual variables on infant-mother attachment. Child Development, 75(2): 480-496.
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Main, M., & Solomon, J. (1986). Discovery of an insecure, disorganized/disoriented attachment pattern; Procedures, findings and implications for the classification of behavior. In M. Yogman & T. B. Brazelton (Eds.) Affective Development in Infancy. Norwood, NJ: Ablex.
Nezu, A.M., & Nezu, C.M. (2001). Problem solving therapy. Journal of Psychotherapy Integration, 11(2): 187-205.
Webster-Stratton, C. (2001). The Incredible Years: Parents, Teachers and Children Videotape Series Leaders Guide Basic Program. Seattle, WA: Incredible Years.
Weersing, V. R. & Weisz, J. R. (2002). Mechanisms of action in youth psychotherapy. Journal of Child Psychology and Psychiatry, 43/1, 3-29.
Weisz, J.R., Weiss, B., Han, S.S. and Granger, D.A. & Morton, T. (1995). Effects of psychotherapy with children and adolescents revisited: A meta-analysis of treatment outcome studies. Psychological Bulletin, 117, 450-468.
Yalom, I. D. (1995). The theory and practice of group psychotherapy Fourth Edition. New York: Basic Books.
Authors
Wittenberg, Jean-Victor P., MD
The Hospital for Sick Children,
Toronto, Canada
