Dr. Daniel Hughes, a well published psychologist who specializes in attachment, has written a practical handbook for clinicians looking to learn how to conduct attachment-focused family therapy (AAFP). Specifically designed to help foster and adoptive families of children with signs of developmental trauma and attachment disturbances, AAFP was originally developed under the name Dyadic Developmental Psychotherapy (DDP).
The book starts off with an overview of attachment theory for those who are new to the world of attachment. Key concepts in the treatment approach include: 1) Intersubjectivity; 2) Affective-Reflective Dialogue; 3) PACE; 4) Repair of the Attachment Relationship; and, 5) Therapist as Attachment Figure.
Intersubjectivity is how the therapist can help the patient regulate his/her affect by matching the patients’ affect. For therapists trained to be always calm and neutral, this may feel unnatural. Interestingly enough however, it is what most of us do naturally in conversation with others, e.g. when listening to a friend or co-worker tell a story, we naturally match their affect.
Affective-reflective dialogue is a technique whereby the therapist helps the patient integrate the affective (i.e. emotional) meaning of an event with the “cognitive understanding of the event.” Integration of the affective-reflective is important, because when dialogue is reflective only, it tends to be ‘intellectualization’, and when dialogue is affective only, it is catharsis. For those familiar with cognitive behavior therapy (CBT), it is somewhat similar to helping clients see the the link between feelings and thoughts, and vice-versa.
PACE is the therapist’s attitude of being “playful” (i.e. being optimistic, humour when appropriate); and having “acceptance” (i.e. being validating/accepting of the patient’s experience without judgment), “curiosity” (i.e. showing non-judgmental interest and curiosity in the patient’s experience) and “empathy” (for the therapist to convey his/her experience of the patient). Although PACE is an attitude that the therapist employs throughout the therapy, it is really the same natural attitude that healthy parents would normally have with their children.
Whereas many clinicians naturally feel disappointed when there are breaks in the attachment relationship with their clients, Dr. Hughes views these breaks as inevitable, and in fact, welcomes breaks as an opportunity to resolve the break, thereby strengthening the relationship.
One of the challenges in working with overwhelmed parents is that standard psychoeducational, directive or advice-based interventions fail, because parents are simply too overwhelmed. In other words, parents may need to feel cared for themselves, before they can care for their children. The solution to this dilemma is to ensure that the therapist can be an attachment figure for the parents, by first connecting, accepting, validating and empathizing with the parent. A parent that feels cared for, will have their ‘parenting circuits’ reactivated and recharged so that they can then care for their child.
As a workbook, various techniques are used to make the content more visually appealing, and easier to learn. The format for each chapter is similar, starting off with a brief overview of the chapter material. There are extensive examples of session dialogue throughout, which greatly helps the learner in knowing what to say during therapy. Each chapter finishes with a quiz. Finally, the workbook includes a DVD with a sample therapy session.
I thoroughly enjoyed this book, and using its principles has greatly enriched my psychotherapeutic armamentarium, and it has enabled me to have breakthroughs with families in situations where I have previously been stuck and struggling. Regardless of the mental health issue, strengthening a patient’s attachments is helpful and in many cases, that will be sufficient. In other cases, additional, specialized techniques and medications may still be required, but outcome is always improved with strong attachments. In summary, I would highly recommend the Attachment-Focused Workbook for all clinicians and trainees working with children and youth.
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