The Neurobiology of Attachment Focused Therapy

Enhancing Connection & Trust in the Treatment of Children &

Adolescents (Norton Series on Interpersonal Neurobiology)

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 The Norton Series on Interpersonal Neurobiology
Louis Cozolino, PhD, Series Editor
Allan N. Schore, PhD, Series Editor, 2007–2014
Daniel J. Siegel, MD, Founding Editor

The field of mental health is in a tremendously exciting period of

growth and conceptual reorganization. Independent findings from a
variety of scientific endeavors are converging in an interdisciplinary
view of the mind and mental well-being. An interpersonal
neurobiology of human development enables us to understand that the
structure and function of the mind and brain are shaped by
experiences, especially those involving emotional relationships.

The Norton Series on Interpersonal Neurobiology provides cutting-

edge, multidisciplinary views that further our understanding of the
complex neurobiology of the human mind. By drawing on a wide
range of traditionally independent fields of research—such as
neurobiology, genetics, memory, attachment, complex systems,
anthropology, and evolutionary psychology—these texts offer mental
health professionals a review and synthesis of scientific findings often
inaccessible to clinicians. The books advance our understanding of
human experience by finding the unity of knowledge, or consilience,
that emerges with the translation of findings from numerous domains
of study into a common language and conceptual framework. The
series integrates the best of modern science with the healing art of
psychotherapy.
The Neurobiology of Attachment-
Focused Therapy

Enhancing Connection and Trust in the

Treatment of Children and Adolescents

Jonathan Baylin and Daniel Hughes

W. W. Norton & Company

Independent Publishers Since 1923
New York • London
A Norton Professional Book
For Youngblood and Tyree and the yet unborn to B. and A., the future —
Jonathan Baylin

For the Members of the DDPI Community —Daniel Hughes

 Contents

Preface
Introduction
1 Good Care and Poor Care: The Neurodynamics of Attachment and
Caregiving
2 Blocked Trust: Stress and Early Brain Development
3 Blocked Care: The Parenting Brain and the Role of the Caregiver
4 Attachment-Focused Treatment: The Core Processes of Change
5 Trust-Building in Parent–Child Dyads
6 Practicing Openness: Awakening Trust and Engagement with Relational
Processing and Fear Extinction
7 Healing Stories: Prosody, Integrative Narratives, and Co-Creation of
Meaning
8 Playing in Safety: Strengthening Attachment Bonds with Delight and
Co-Regulation of Affect
9 Treating Blocked Care: Guidelines for Working with Parents
10 Therapeutic Presence: Brain-Based Approaches to Staying Open and
Engaged with Caregivers and Children
11 Expanding the Model: Mindfulness, EMDR, Neurofeedback, and More
References
Acknowledgments

Index
 Preface

Three Layers of Transparency

The screen door is partially open
to allow for the cat to come in
and go out at his leisure
This space opens to the outside air
and my arm could easily reach through
to that freshness
The screen door, in a more reserved and veiled way,
also allows the cool morning air
to pass through to the inside
Further to the left of the screen is the glass sliding door
a hard clear shell that, too, allows light to pass through
but clearly defines inside and outside,
Three layers of transparency,
three ways of being
There are times I am glass
when I allow things in and peer out at the world
but remain separate and distinctly myself
At times I am the screen
permeable, allowing light and air to pass through from
either side
with only a skin of protection
when trust has begun to deepen with ones I love
And the open space, that’s what I long to be
when all barriers have dissolved
when the air inside is no different than the air outside
and I am free to roam fearlessly in all the spaces
When compassion for myself floods into the open space of
compassion for all
—Eric Baylin, August 2015

Stephanie and Chad were quite happy with their life together in a peaceful
suburb on the outskirts of St. Louis. They had two remarkable teen girls
who seemed to defy the rumors that the teen years would be rocky, good
careers that were satisfying and provided for their needs and more, and
strong extended families—what more could they ask for? They felt they had
more to give and more room in their family for a child who needed a home.
After many discussions with their daughters, friends, and a social worker,
they chose to adopt, and within a year welcomed nine-year old Mark into
their home. He had a very difficult history but seemed to be doing well in
his latest foster home and they had confidence—supported by their social
worker—that they could provide Mark with the home he needed.
Within four or five months, they began to have doubts. They had been
patient with Mark’s forgetfulness about the rules and few chores he was
assigned. They knew he needed time to adjust, but after the first few weeks
when he seemed to show a forced cheerfulness, he seemed chronically
unhappy. He did not seem to enjoy things they did for him or with him. Nor
did he ask for their help when he couldn’t do something or when he made a
mistake. Instead, he would lie about his mistakes and become irritated when
they doubted him. Gradually his irritation became anger and his anger
became severe, marked with threats and running to his room and refusing to
talk.
Stephanie and Chad sought psychological treatment and spoke with a
counselor while Mark saw his own therapist. After another four or five
months, their doubts increased. The therapist said that Mark needed time,
but his behavior was only getting worse at home and at school. What
bothered them the most was what Mark said to them. Often he said that he
hated them, he didn’t want to live with them, they weren’t his parents and
never would be. When they gave him consequences for his behavior, he
would threaten to pay them back and then he did. Things in their home
disappeared or were broken. The hardest was when Mark started to treat
their daughters as badly as he treated them.
A year after Mark entered their home, they barely remembered the family
they used to have, the family they wanted to share with him. They bickered
with each other and spent more time away from home. They now
experienced little laughter or joy. Stephanie and Chad were convinced that
they had made a horrible mistake in adopting Mark. They felt trapped. They
had long since stopped feeling love for him. He was a duty, a job. What had
happened?
After receiving good care from Stephanie and Chad for a year, Mark still
did not trust them. If anything, he trusted them less, finding more reasons
each day to justify never trusting them. As the weeks and months passed
and their irritation increased, he became more convinced that they were not
trustworthy. What would it take for Mark to move from mistrust to trust?
Whatever it was, it was now less likely to happen because Stephanie and
Chad began to stop caring. If good care was not helping, poor care was not
likely to do so. It was now a perfect storm. Mark came to his adoptive
family with blocked trust, and nothing that his adoptive parents, social
worker, or therapist could do enabled him to begin to trust. Stephanie and
Chad were now in blocked care. Even if Mark were somehow able to take a
tentative step toward beginning to trust, they were not likely to see it or
respond to it. Their primary response was defensiveness. They were
protecting their hearts from the pain of enduring his anger and rejection for
months and months.
This book is written for people like Mark, Stephanie, and Chad. If trust is
to develop and care is to be restored, we have to know what is preventing
the development of trust in the first place when a child is living in an
environment of good care for a long period of time. What do abuse and
neglect do to the development of children’s brains that makes it so difficult
for them to trust adults who are so different from those who hurt them? We
have to know what we—both parents and professionals—might do to
encourage the development of such trust.
The Neurobiology of Attachment-Focused
Therapy
 Introduction

If we are to protect young children from harm … we will have to

value more and give response to what children bring to human
life—the eager spirit of their joyful projects beyond their seeking
to survive.”
—Colywn Trevarthen (2013, p. 203)

How can therapists and caregivers help maltreated children recover what
they were born with: the potential to experience the safety, comfort, and joy
of having trustworthy, loving adults in their lives? This is the topic of this
book. The authors have been collaborating for a number of years now about
the treatment of maltreated children and their caregivers. Both experienced
psychologists, we’re committed to helping these children learn to trust
caregivers and helping caregivers be the “trust builders” these children
need. Our shared project is developing a science-based model of
attachment-focused therapy that links clinical interventions to the
underlying biobehavioral processes of trust, mistrust, and trust-building.
Our approach is embedded in the growing field of interpersonal
neurobiology (IPNB) (Siegel, 2012; Schore, 2013), a clinical model that
seeks to inform psychotherapy with the exploding knowledge from social
neuroscience. In particular, we draw from (1) research showing how early
exposure to poor care tunes the child’s brain for living defensively (Perry et
al., 1995; Cushing & Kramer, 2005; Roth et al., 2006; Beach et al., 2010;
Tottenham, 2012; Meaney, 2013) and (2) research showing that later in life,
“enriched” social experiences can retune the brain and support a
biobehavioral shift from mistrust to trust, reawakening and strengthening
the child’s capacity for social engagement (Branchi, Francia, & Alleva,
2004; Weaver, Meaney, & Szyf, 2006; Curley et al., 2009; Dozier, Meade,
& Bernard, 2014; Humphreys et al., 2015; Moretti et al., 2015).
Our earlier work on the development of a brain-based model of
caregiving led to the book Brain-Based Parenting (Hughes & Baylin,
2012), in which we focused mostly on the neurodynamics of parenting,
introducing the concept of blocked parental care, or simply blocked care. In
this book, we turn our attention to children who are forced by poor care to
develop what we call blocked trust: the suppression of inherent relational
needs for comfort and companionship to survive neglect and abuse. How do
infants, who are not aware of learning anything, learn to trust and mistrust
adults? Once young children develop blocked trust, is this learned
defensiveness reversible? Can their blocked potential for trusting in the care
of a trustworthy adult be reawakened after years of living defensively? Can
these children learn to feel the social emotions—separation pain, remorse,
empathy, joy of connection—that they had to suppress to be asocial earlier
in life? If so, how do they make this journey from mistrust to trust, and
what needs to happen in their relationships with caring adults to facilitate
this shift? How do their caregivers avoid the risk of blocked care from
repeated experiences of being mindlessly mistrusted and manage somehow
to sustain their compassion for these complicated hurt children? How can
caregivers, therapists, and other adults send strong, consistent messages of
safety and approachability deep into those mistrusting brains where safety
and danger are first detected?
Children develop blocked trust in response to frightening and painful
relational experiences with adults. Neuroscientific research reveals that
these experiences sensitize a neural “alarm system” (Liddell et al., 2005)
called the mid-brain defense system, laying the foundation for chronic
defensiveness, the core of blocked trust. At the same time, maltreatment
suppresses the development of the child’s “social engagement system”
(Porges, 2011), the brain system that would normally be activated and
strengthened by good care. Maltreatment triggers chemical reactions in
children’s brains that decrease subjective suffering from the pain of
rejection and abuse (Lanius, Paulsen, & Corrigan, 2014) while enabling
them to remain vigilant and defensive around uncaring caregivers. This
combination of pain suppression and chronic, mindless defensiveness is at
the heart of the deep emotional disengagement and mistrust we see in these
children. Treatment for blocked trust has to target the mid-brain alarm
system, disarm it, and remove the blockage that keeps the child from
feeling the need for care and comfort from adults. To accomplish this,
children need to have comforting, enjoyable experiences with adults,
experiences that can awaken their brains to experience the safety they have
never known. They need to hear the caring voices, see the shining eyes, and
feel the loving touch of people who somehow manage to keep caring deeply
about them in the face of their mistrust.

Dyadic Developmental Psychotherapy: A Brain-

Based and Attachment-Focused Model
Dyadic developmental psychotherapy (DDP) is a model of treatment that is
squarely focused on providing the kind of safe, trustworthy experiences
with adults that can facilitate this brain-shifting process and help children
with blocked trust move from chronic defensiveness toward open
engagement (Hughes, 2006; 2007; 2011). DDP targets the heart of blocked
trust: the social brain switch where the implicit process of appraising safety
and danger begins. In this brain circuit, we use crude sensory information
such as facial expressions to appraise trustworthiness at a preconscious
level faster than we can be aware that we are appraising anything. This is
where attachment-focused therapy needs to work; this, as Sebern Fisher
(2014) so powerfully puts it, is the “epicenter” of the chronic defensiveness
at the heart of blocked trust and developmental trauma. Crucially, the DDP
therapist embraces the child’s defensiveness, putting connection before
correction, knowing that the child had to develop this core relational
strategy to survive poor care. This radical acceptance of the child’s mistrust
(which can feel like hugging a porcupine) is essential to the process of
helping a mistrusting child begin to trust.
 Maltreated children who have never felt safe with caregivers need to
experience safety on at least three basic levels: (1) safety to feel the pain of
disconnection and to seek comfort from a trustworthy adult; (2) safety to
engage a caregiver in positive, playful, rewarding interactions; and (3)
safety to share inner experiences and enter an intersubjective relationship
with a trusted adult. These are the three levels of safety children need to
recover from blocked trust and the suppression of attachment needs.
In DDP, change is driven by relational and emotion-focused processes
that work from the bottom up, creating new positive experiences with
caregivers, and from the top down, promoting new meaning making and the
development of more coherent narratives as the child awakens to the reality
of being in a safe, trustworthy environment. The relational processes used
in DDP are similar to the trust-building processes parents use with young
children to develop secure attachments, processes that are now known to
buffer the child’s defense system and foster healthy brain development
(Tottenham, Hare, & Casey, 2009). The DDP therapist uses relational skills
to help caregivers and mistrusting children revive the suppressed reciprocal
processes of attachment and caregiving that were absent in the child’s
earlier relationships with adults. DDP helps caregivers and therapists
function as trust builders by being in the “right” mind to send safety
messages deep into that hypersensitized defense circuit and switch on the
social engagement system.
When a child’s alarm system is off, and the social engagement system is
switched on, the child can begin to use the higher brain regions, especially
the prefrontal cortex, that have to be activated to support the new learning
to make the journey from mistrust to trust. We link the processes of DDP to
the neurobiological processes of reversal learning, fear extinction, memory
reconsolidation, reflection, and reappraisal, which depend on the awakening
of the prefrontal regions. These processes enable mistrusting children to
start learning from experiences with adults and gradually change their
minds and their behavior based on new experiences, something they are not
able to do as long as their brains remain in the shut-down state of blocked
trust. Using such processes as PACE (playfulness, acceptance, curiosity,
empathy), follow-lead-follow, co-regulation of affect, storytelling, co-
creation of meaning, emotional state induction, affective/reflective
dialogue, and relational repair, the DDP therapist establishes a rhythm of
reciprocal nonverbal communication with the child. Then she blends this
nonverbal engagement with words congruent with the traumatic events of
the past, while remaining socially engaged with PACE, enabling the child to
participate in this dialogue without defensiveness. This allows the child to
experience care differently and start creating new meanings for past
traumatic events, moving toward developing a coherent autobiographical
narrative. PACE constitutes a therapeutic mind-set or “attitude” that helps
ensure adults will send messages of approachability and trustworthiness
into the child’s brain, helping prevent the mutual mistrust scenario that
often develops between mistrusting children and adults. The attitude of
PACE is the opposite of an adult’s frequently defensive approach toward
these children.
By concentrating on the main agenda of creating a safe connection with
the mistrusting child, the therapist learns in real time, constantly monitoring
the child’s feedback, how to engage the child. Once some level of
engagement is attained—what we call engagement light—the therapist
concentrates on extending and deepening this dyadic connection while
modeling the engagement process for caregivers and coaching them in
becoming messengers of safety and trustability for the child. The therapist
uses the engagement to help the child travel emotionally from a shut-down
state to a state perhaps of light playfulness, toward a state of sadness, with
the goal of helping the child safely remove the neurobiological block from
the separation distress system that is a core component of attachment. This
in turn enables the child to start feeling the need for care and seeking
comfort from an adult who is ready, willing, and able to provide it—an
adult who is not in blocked care.
DDP includes intensive work with caregivers to enhance their capacity to
sustain a caring state of mind toward the child. In brain terms, this involves
helping caregivers strengthen the brain circuitry that enables them to “keep
their lids on” and regulate their emotions and actions when faced with
oppositional behavior and defensiveness. By helping the adults learn to rise
above their “low-road” instinctive feelings of rejection, DDP helps
caregivers provide the enriched kind of care that is needed to undo the
damaging effects of earlier exposure to adults who didn’t (for whatever
reason) rise above their own defensive needs to be trustworthy caregivers
for these children.
 Here is what lies ahead. In Chapter 1, we discuss the new science of
attachment and caregiving and how children learn to trust sensitive
caregivers and experience the comfort and joy of deep connections. In
Chapter 2, we present the concept of blocked trust, developing a brain-
based model of how poor care forces children to adopt a style of living that
combines heightened defenses with suppression of “social emotions.” In
Chapter 3, we turn to the caregiver side of the dyad, revisiting the concept
of blocked care we introduced in Brain-Based Parenting to emphasize the
importance of working with parents on an emotional level to help them
become trust builders for their children.
In Chapter 4, we introduce the four R’s of change—reversal,
reconsolidation, reflection, and reappraisal—tying the neuroscience of
change to attachment-focused treatment. We describe how enriched care
facilitates the learning process by disarming the child’s defense system and
awakening the higher regions of the child’s brain suppressed by chronic
mistrust. Beginning in Chapter 5, we describe specific processes used in
DDP to promote positive change in parent–child relationships. Here we
introduce PACE, follow-lead-follow, affective-reflective dialogue, co-
regulation of affect and co-creation of meaning, interactive repair, and
emotional state induction processes as core brain-based change-promoting
processes in DDP.
Chapter 6 presents the concepts of awakenings and engagement practice,
the twin processes of helping children start to recover their suppressed,
underdeveloped capacity for feeling the need for care and helping them “do
the reps” of social engagement with therapists and parents. We describe in
detail the process involving the co-regulation of affect and introduce the
important process of state induction as the therapist helps the child reenter
forbidden emotional states, especially sadness, to activate the all-important
experience of the need for comfort from a caregiver. This discussion
emphasizes the crucial process of helping the parent/child dyad revive the
call and response process that got derailed when the child had to learn to
suppress his attachment needs earlier in life.
In Chapter 7, we further define the process of affective-reflective
dialogue presented in Chapter 5 and describe the healing power of
storytelling and story voice to promote change. We present the neuroscience
behind the power of stories to move us and the importance of the emotional