Автор: Мирон Шкробут від 8-02-2019, 11:23, переглянули: 11

УДК: 159.922.7
Corie Schoeneberg, EdS
Olya Zaporozhets, PhD
Regent University


Abstract. Attachment is a critical process developed in early childhood between a parent and child. Across the lifespan, attachment patterns serve as one’s relational template and way of viewing the world. The characteristic features of each type of attachment (secure, avoidant, ambivalent, and disorganized) are discussed along with attachment’s far-reaching implications psychosocially and neurologically. Child-parent relationship therapy (CPRT) is an evidenced-based therapeutic intervention designed to enrich and support the emotional connection and relational attunement between a parent and child, suitable for cases of children with attachment needs. The principles and format of CPRT are presented with a summary of therapy outcomes research.
Keywords: child parent relationship therapy, attachment, children’s mental health, play therapy

Анотація. Емоційна прихильність - це важливий процес, який започатковується у ранньому дитинстві між батьками та дитиною. Через життєвий цикл шаблони прихильності служать своєрідним шаблоном відносин і способом погляду на світ. Висвітлюються характерні особливості кожного типу прихильності (безпечна, уникаюча, амбівалентна та дезорганізована) разом із довготривалими психосоціальними та неврологічними наслідками. Терапія відносин між дітьми та батьками (Child-parent relationship therapy - CPRT) – це терапевтичний підхід, який має сильну доказову базу, та показаний для збагачення та підтримки емоційного зв'язку та налаштування стосунків між батьками та дитиною, включаючи випадки, де у дітей гостро виражені потреби у формуванні здорових форм прихильності. Принципи та формат CPRT представлені з узагальненням результатів дослідження цього терапевтичного підходу.
Ключові слова: терапія відносин між дітьми та батьками, CPRT, прихильність, дитяче психічне здоров'я, ігрова терапія

Аннотация. Привязанность - это важный процесс, который развивается в раннем детстве между родителем и ребенком. На протяжении всей жизни шаблоны привязанности служат в качестве реляционного шаблона и способа понимания мира. Обсуждаются характерные особенности каждого типа привязанности (безопасный, избегающий, амбивалентный и дезорганизованный), наряду с далекоидущими психосоциальными и неврологическими последствиями. Терапия взаимоотношений между родителями и детьми (CPRT) – это терапевтическое вмешательство, которое имеет сильную доказательную базу, и предназначено для обогащения и поддержания эмоционального связи и налаживания отношений между родителями и ребенком, включая случаи где у детей остро выражены потребности в формировании здоровых форм привязанности. Представлены принципы и формат CPRT с резюме исследований результатов терапии.
Ключевые слова: терапия отношений между родителями и родителями, CPRT, привязанность, детское психическое здоровье, игровая терапия

Formulation of the problem
Around the developmental age of 7 to 9 months during infancy, children begin the process of attachment and bonding, which can be conceptualized as the organization of behaviors and the process by which a child relates to his or her preferred caregiver through physical proximity and emotional connectedness in order to receive comfort, nurturance, support, and safety [5]. Attachment is a highly crucial psychological milestone which is forged through the relationship between a child and caregiver. The pioneering work of Bowlby (1982) [7] regarding this early childhood process has led to the inclusion of attachment principles in the psychosocial understanding of children and its implications in mental health and behavior [13]. Research indicates that attachment development is an experiential process, not biologically based, and an established attachment style reflects the patterns of communication that exists between a parent and child [42]. Fundamentally, an individual’s beliefs about emotional connectedness, confidence in relationships, and sense of personal self-worth are reflective of early childhood experiences and one’s model of attachment (Frederick & Goddard, 2008). The relational patterns created within this earliest parent-child context often become the lens through which a child views the world from the cradle to the grave.
On the most adaptive end of the spectrum, a ‘secure’ attachment is relational style characterized by a child’s feelings of safety, trust in the parent’s availability, and reassurance from the parent during moments of distress. A child who holds a secure attachment with a parent or caregiver has developed this attachment style through consistent, loving, and emotionally attuned parenting practices. A positive, secure attachment between parent and child has been shown to serve as the foundational platform for many critical psychosocial and cognitive aspects across the lifespan. Securely attached children demonstrate a heightened ability to explore and engage in activities that promote wellbeing, personal growth, resiliency, and positive relationships [31; 42]. However, when the relationship between a parent and infant is characterized by ongoing stress, fear, neglect, or non-availability, children will subsequently develop an attachment style that can be broadly categorized as avoidant, insecure, ambivalent, or disorganized (Bowlby, 1982) [8]. D.Siegel [42] describes children living in an emotionally impoverished relationship with their parent as individuals who often develop an avoidant attachment style, which can be predictive of later difficulties in peer relationships and understanding of self. Alternatively, infants who experience non-contingent communication from a parent may emerge with an insecure attachment style. If a parent is inconsistently available for contingent communication, an ambivalent attachment style may also emerge. These types of attachment may later lead to anxiety in social situations.
D.Siegel [42] further adds that while the avoidant, insecure, and ambivalent attachment styles can pose as deficits in psychosocial aspects across the lifespan, the disorganized attachment style presents as the most consequential. Characteristics of a disorganized attachment style include the infant’s experience of the parent as a source of terror or alarm, as the child find him or herself in the constant paradox of needing to seek out the parent for comfort while also wanting to avoid and hide from the stress and terror that the parent presents. There is no solution for this infant’s dilemma, and the stress of this experience takes a toll. Disorganized attachment style is frequently associated with dissociative coping skills, which is also linked with poor consciousness, emotion, and memory. These children are at risk for feeling fragmented due to dissociation, experiencing social difficulties, and developing post-traumatic stress and other disorders [21; 32; 42] . Disorganized attachment typically arises within the context of child abuse or neglect, persistent parental conflict or domestic violence, significant separation from parents, and foster or institutional care [18]. These experiences are typically referred to as early childhood adversity or complex trauma. Events such as these that are synchronous with attachment development during the first three years of life should always be considered within the developmental context [39].
The impacts of attachment are far reaching and expand into many domains, including social, emotional, cognitive, and neurological. In severe cases of childhood maltreatment and disorganized attachment, children may become violent or aggressive, which may later evolve into personality disorders such as antisocial personality, narcissistic personality, or borderline personality [3]. Longitudinal studies show that individuals from these adverse backgrounds with non-secure attachment styles are at greater risk for anxiety (2.0 times the average), depression (3.4 times the average), drug abuse (3.8 times the average), alcohol abuse (2.5 times the average), and antisocial behavior (4.3 times the average) [33]. Additionally, chronic childhood maltreatment has been linked with problems in self-regulation, interpersonal functioning, somatization, affect regulation, maladaptive coping skills, behavior, self-concept, and executive functioning skills, such as attention [3].
Read et al. (2014) further reports meta-analysis which indicates that childhood adversity significantly increases the likelihood of psychosis in adulthood. The traumagenic neurodevelopmental model [39] proposes that an individual’s heightened sensitivity to stress and the neurological changes that have occurred in the brain as a result of trauma can create vulnerabilities for the development of schizophrenia later in life. In fact, the authors suggest that neurological consequences of adverse experiences in childhood may account for an estimated 33% of the adult cases of schizophrenia. Ultimately, neurological research indicates that it is not simply exposure to adverse experiences that can leave lasting change, but from a developmental perspective, it is equally critical when these adverse experiences occur [37]. The experiences during the child’s first years of life become the neurological road maps across the lifespan with attachment serving as the primary medium for understanding one’s world. In short, the quality of caregiving during infancy and toddlerhood directly affects the developing architecture of the brain (Doyle & Cicchetti, 2017).
Problems created from disrupted attachment or non-secure attachment styles range significantly in scope. For some children with mild attachment deficits, they may present minimal challenges within intimate relationships. For other children who have been exposed to tremendous childhood abuse or neglect, consequences may result in the development of the Reactive Attachment Disorder (RAD) as described by the Diagnostic Statistical Manual (DSM 5) (American Psychiatric Association, 2015) or International Classification of Diseases and Related Health Problems (ICD-10) (World Health Organization, 1992). The occurrence of this disorder is rare in reasonable caregiving environments, and cases of RAD are not reported outside of situations in which very serious neglect has occurred [5].
Apart from childhood abuse and neglect, disruptions in attachment may also occur with more normative life events. Due to a familial crisis or a need for foster care, children who are moved from caregiver to caregiver without a consistent and enduring attachment figure may also experience significant challenges in their attachment process. Likewise, children who experience the death of their preferred attachment figure or who spend significant lengths of time away from the attachment figure during early childhood may develop complicated or non-secure attachment styles as a response to these stressors. Adoptive parents of older children and military families recovering from lengthy deployment cycles also report challenges in the parent-child relationship that are consequential from circumstances outside the family’s control [13; 23].
The clinical practice parameters outlined by Boris and Zeanah (2005) for the treatment of RAD and associated attachment problems identify a number of recommendations for mental health professionals. In situations of childhood abuse and neglect, maltreated children should be assessed for developmental delays, including speech and language deficits, and untreated medical ailments, which are common comorbid conditions. Mental health professionals are further recommended to advocate for the provision of an emotionally available attachment figure. Clinicians are highly encouraged to focus on the assessment of the caregiver’s attitude and perceptions towards the child. The central therapeutic goal should be focused on the facilitation of positive, nurturing interactions between the caregiver and child. Interventions that involve noncontingent physical restraint or coercion, such as “therapeutic holding” or reattachment through “rebirthing therapy”, are strongly discouraged and have been associated with serious harm, including death [5].
The Purpose: The purpose of this article is to discuss the importance of secure attachment formation between a parent and child. Child-parent relationship therapy (CPRT) is discussed as a therapeutic approach that helps to strengthen parent-child emotional connection. CPRT principles, format, and outcome research are given further overview.
Basic presentation of the material
Child-Parent Relationship Therapy (CPRT)
Child-Parent Relationship Therapy (CPRT) [29] is an evidenced-based, manualized treatment approach designed to facilitate emotional connection and positive interaction between a child and caregiver. CPRT represents a conjunctive intervention built from the theoretical foundations of the group-based, interactive parent-training framework of filial therapy [22] and the Rogerian qualities found in child-centered play therapy [2]. Filial therapy emerged from Moustakas’ (1959) beliefs that children flourish and are best able to adapt, change, and grow within the safe, trusting, and accepting environment created by their parents. In this type of relational context, children are able to positively explore their thoughts and feelings and developmentally flourish. In the 1960’s, Bernard and Louise Guerney took these foundational concepts to create the filial therapy model in which parents are interactively taught and provided with experiences to increase healthy communication with their child and foster the child’s feelings of self-worth [22].
In play therapy, children are understood developmentally, and the mental health professional abides to the concept that children communicate and express themselves more easily and most naturally through the language of play rather than through verbal exchange [2; 28]. The play therapy approach in counseling can be explained most simply as «toys are used like words, and play is the language» [28, 12]. While there are many theoretical models within play therapy, a child-centered play therapy approach parallels the humanistic philosophies of Carl Rogers about how change occurs within the individual. A child-centered play therapy orientation ascribes to the principle that children are inherently capable of positive self-direction in psycho-emotional healing, allowing for a non-directive methodology. The child-centered play therapist’s central goal is to provide a therapeutic environment that promotes the child’s natural communication of play in order for the child to express personal thoughts and feelings within the therapeutic child-counselor relationship, and it is this expression and acceptance of self that serves as the central curative intervention and agent for change in the child’s life.
Bridging these ideas together, CPRT [26] utilizes a manualized protocol for a therapy group of six to eight parents that meet for 2 hours at a time over the course of 10 weeks. During group meetings, parents are taught basic child-centered play therapy skills, which they then apply with their child during a weekly parent-facilitated play session. These play sessions are supervised by the group facilitator, and parents are instructed to video record all of the play sessions for feedback in regards to the application of their play therapy skills and dispositions towards the child. The primary goal of the parent-child play session is to foster empathetic, emotionally attuned reactions and dispositions from the parent to the child. Enriched communication and relational connectedness often results in improved child’s self-regulation, social behaviors, empathy towards others, and positive family functioning [16; 26; 30; 44].
In addition to basic play therapy skills, parents are also taught parenting skills that are applicable in everyday situations. For example, the CPRT curriculum helps parents to make questions into statements regarding their child’s feelings and needs, remain calm when their child’s problematic behavior intensifies, use statements of encouragement rather than praise, and utilize positive limit setting and disciplinary choice giving. These aspects of the CPRT curriculum were identified as some of the most helpful elements of the therapy by parents [6].
CPRT represents a well-research modality with positive outcomes presented across diverse populations. With more than 40 studies investigating CPRT effectiveness involving over 1,000 participants, CPRT demonstrates moderate to large treatment effects on reducing children’s behavior problems, increasing parental empathy, and decreasing parental stress (Bratton, Landreth, & Lin, 2010) [11]. Research indicates that counseling outcomes are significantly more positive when parents are involved in the therapeutic process [12; 27; 29], making CPRT a highly relevant treatment approach for a range of presenting problems. CPRT has been found to be effective with significant results for adoptive families of children with attachment problems[14], military families struggling with negative impacts of deployment separations [23], single parent families [9], cross-culturally with Israeli families in high stress situations [25], families of diverse cultures [20; 47], families who have witnessed or experienced domestic violence, non-offending parents with children who have been sexually abused [45], families seeking an increase in healthy family functioning [15], and with parents of children experiencing chronic illness [19], learning disabilities [24], high functioning autism [43] emotional disabilities [41] and other behavioral and emotional problems, ranging from normal to severe [25; 35]. Despite the varied presenting concerns bringing families to CPRT, «Promoting secure attachment relationships between parents and children is at the heart of this approach» [13, 329].
In addition to its therapeutic efficacy, CPRT is an adaptive, flexible model suitable for the family cultural setting and values. While CPRT does not ascribe to any particular faith or spiritual belief system, Bornsheuer-Boswell, Garza, and Watts (2013) found that many parents desire mental health interventions that are compatible with their value system. For families in which spirituality is a central value, CPRT offers a platform where this multicultural aspect can be easily infused [6]. Because of the group format and its efficiency in teaching parents therapeutic dispositions and skills, this model is also extremely relevant in situations where a client-case load is large and financial resources are limited.
Clinical Applications of CPRT in Attachment Work
CPRT has been manualized in a user-friendly format for group facilitators [10]. Group facilitators are mental health professionals trained in play therapy, group work, and the concepts of CPRT. CPRT manual provides goals and outline for each group session as well as all the necessary handouts and accompanying CD-ROM with supplemental materials. Each group session is generally structured around two goals: (a) psychoeducation for parents and (b) the facilitation of parent play therapy skills and dispositions. These goals are applicable to a broad scope of problems of the relationship between a parent and child, aiming to enhance secure attachment patterns.
Psychoeducation. Parents are presented with concepts that can be incorporated into their daily parenting practices. They discuss three key metaphorical ideas. The first one is of ‘focusing on the donut not the hole’ [10]. This metaphor is intended to spark discussion around a parent’s perspective in choosing to focus on a child’s strengths rather than problematic behavior. When parents are able to view their child’s strengths and conceptualize problematic behavior as a way for the child to meet a certain need, parents then are more likely to exhibit empathy, patience, and understanding for their child.
The second key metaphorical concept is linked to the image of a ‘thermostat’ and ‘thermometer’. It is explained that the thermometer mirrors what is happening in the environment, as compared to the thermostat, which is able to change the environment itself. The idea is paralleled to a parent’s response or reaction to a child’s problematic behavior. Parents are taught to discuss the following concepts linked with the metaphor:
«Learn to RESPOND (reflect) rather than REACT. The child’s feeling are not your feelings and needn’t escalate with him/her. When your child’s feeling and behaviors escalate, you can learn to respond in a helpful way, rather than simply reacting and allowing your feelings and behaviors to escalate, too. Remember: In-control parents are thermostats; out-of-control parents are thermometers.» [10].
The third key idea rests on the need of relational recovery between the parent and child. Group facilitators emphasize the importance in a parent’s ability to recognize when he/she has made a mistake and initiate relational repair and change with the child. The defining idea for parents is that parenting mistakes may not be as important as how the parent addresses a mistake with their child [10]. Parents are encouraged to seek forgiveness from their child, be willing to admit mistakes, and model relational repair for their children. This concept normalizes imperfection in parents and creates a new norm for families in learning how to apologize and reconnect after an emotional break.
Play Therapy Skills and Dispositions. Parents are taught basic play therapy skills and dispositions that are utilized for weekly special parent-child play times. Parents are encouraged to make reflective responses that convey an attitude of ‘being with’ the child. These dispositions, non-verbal messages, and verbal statements ultimately communicate ‘I am here; I hear you; I understand; and I care’ [10]. These messages are compared to unhelpful messages, such as ‘I always agree with you; I must make you happy; and I will solve your problems’. Parents are encouraged to discuss and explore the rationale behind these types of messages and reflect upon their own parenting posturing.
Additionally, specifically for the parent/child special play time each week, parents are taught the basic play therapy skills of tracking and reflecting of feelings, thoughts, needs, and wishes in a relationally enhancing manner that avoids questioning. Parents practice in the group to identify feelings and create reflective responses. The group also spends significant time discussing play therapy, how play therapy (also referred to as ‘special play time’) between the parent and child is beneficial, and the materials needed for this process, including toy supplies and videoing technology. The overall goals and objectives for the parent-child play therapy experience include:
1. «To allow the child- through the medium of play- to communicate thoughts, needs, and feelings to his parent, and for the parent to communicate that understanding back to the child.
2. Through feeling accepted, understood, and valued- for the child to experience more positive feelings of self-respect, self-worth, confidence, and competence- and ultimately develop self-control, responsibility for actions, and learn to get needs met in appropriate ways.
3. To strengthen the parent-child relationship and foster a sense of trust, security, and closeness for both parent and child.
4. To increase the level of playfulness and enjoyment between parent and child.» [10, p. 12]
As the group progresses, more time is dedicated to parents taking turns presenting a video recorded play therapy session with his or her child, and the group facilitator offers additional supervision, feedback, insight, and parent training. While the video recording presentation process initially creates anxiety for many parents, they quickly discover the benefits of the facilitator’s modeling of strength-building and normalizing play therapy skills and ‘being with’ attitudes. Paralleling the attachment relationship between parent and child, group facilitators model trust-building, a strengths-based perspective, unconditional positive regard, and acceptance of the parents even with imperfections.
The development of positive, secure attachment between parent and child is a critical platform on which the child is able to grow and feel empowered to engage the world with confidence and safety. When the attachment process is disrupted due to parenting practices or circumstances outside of a family’s control, mental health services and therapeutic interventions can be extremely valuable in restoring a child’s sense of safety and connection with a trusted caregiver. CPRT provides an exceptional model to address the needs of attachment during childhood as it attends specifically to the parent-child dyad and equips parents and caregivers with positive parenting skills that will endure long after counseling services end. CPRT represents a therapeutic intervention highly applicable and beneficial for bringing children and their parents back to a place of positive connectedness and relational attunement.

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