Running head: INTEGRATING ATTACHMENT IN AN ADOPTED CHILD INTEGRATING ATTACHMENT PROCESSES IN AN ADOPTED CHILD WITH LIFESPAN INTEGRATION THERAPY: A HERMENUTIC SINGLE CASE EFFICACY DESIGN by CARLEE E. LEWIS A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS in THE FACULTY OF GRADUATE STUDIES Master of Arts in Counselling Psychology We accept this thesis as conforming to the required standard …………………………………………………….. Janelle Kwee, Psy.D., Thesis Supervisor …………………………………………………….. Marvin McDonald, Ph.D., Second Reader …………………………………………………….. Joanne Crandall, Ph.D., External Examiner TRINITY WESTERN UNIVERSITY September 13, 2017 © Carlee Lewis INTEGRATING ATTACHMENT IN AN ADOPTED CHILD ii ABSTRACT Insecure and disorganized parent-child attachment in middle childhood is considered by many psychologists as irreversible and unchangeable. However, psychopathology in this stage of development is often tied to attachment disruptions, especially experienced in adopted children. A newly researched therapy, Lifespan Integration (LI), is meant to address attachment processes in both children and adults, thus helping to reduce psychopathology outcomes associated with disrupted attachment. In this study, the efficacy of Lifespan Integration for addressing attachment processes with adopted children in middle childhood was investigated. A Hermeneutic Single Case Efficacy Design (Elliott, 2002, 2015) was used to gather quantitative and qualitative data from an adoptive parent-child dyad who were experiencing Lifespan Integration therapy (LI) for the first time. The research participant, a 12-year-old male, received 10 sessions of weekly LI therapy sessions, and data was collected before, during, and after the therapy process. The adoptive mother was present throughout therapy and used as a resource in facilitating a more secure attachment. Client change and the contribution of LI to client change were argued by expert case developers, and adjudicated by three experts, who concluded that change occurred and that this change was due to LI Therapy. Changes in internal attachment processes and the attachment bond between the parent and child of this dyad were observed. This case provides evidence that attachment disruptions can be repaired in middle childhood and that attachment processes can be targets in interventions beyond early childhood. Keywords: Attachment Processes, Adoption, Middle Childhood, Lifespan Integration, HSCED, Psychotherapy Outcome Research, Evidence-based Treatment, Case Study INTEGRATING ATTACHMENT IN AN ADOPTED CHILD iii TABLE OF CONTENTS ABSTRACT .................................................................................................................................... ii TABLE OF CONTENTS ............................................................................................................... iii LIST OF TABLES ....................................................................................................................... viii LIST OF FIGURES ..................................................................................................................... viii ACKNOWLEDGEMENTS ........................................................................................................... ix CHAPTER 1: Introduction ............................................................................................................. 1 CHAPTER 2: Literature Review .................................................................................................... 4 Attachment Processes .................................................................................................................. 4 Emotional processes ................................................................................................................. 5 Relational processes ................................................................................................................. 6 Insecure Attachment ................................................................................................................. 8 Disorganized attachment .......................................................................................................... 9 Attachment and Psychopathology ............................................................................................. 10 Insecurity and disorganization ............................................................................................... 11 Adopted children .................................................................................................................... 12 Middle childhood ................................................................................................................... 14 Intervention gap...................................................................................................................... 15 A Possible Solution: Lifespan Integration ................................................................................. 16 Neural integration and attachment ......................................................................................... 18 LI with children ...................................................................................................................... 19 INTEGRATING ATTACHMENT IN AN ADOPTED CHILD iv Conclusion and rationale ........................................................................................................... 21 CHAPTER 3: Method ................................................................................................................... 23 Design ........................................................................................................................................ 23 Paradigm................................................................................................................................. 23 Participants ................................................................................................................................ 25 Recruitment ............................................................................................................................ 26 Research teams and judges ..................................................................................................... 27 Data Collection Procedure ......................................................................................................... 28 Measures .................................................................................................................................... 29 Parenting Styles and Dimensions Questionnaire (PSDQ)...................................................... 29 Simplified Personal Questionnaire (PQ). ............................................................................... 30 Helpful Aspects of Therapy (HAT). ...................................................................................... 30 Therapy notes and video observations ................................................................................... 31 Change Interview ................................................................................................................... 31 Parenting Relationship Questionnaire (PRQ). ....................................................................... 32 Behavioral Assessment System for Children (BASC-2)........................................................ 32 Child attachment measures..................................................................................................... 33 Data Analysis, Case Development, and Adjudication ............................................................... 34 Rich Case Record ................................................................................................................... 34 Affirmative and skeptic cases ................................................................................................ 34 INTEGRATING ATTACHMENT IN AN ADOPTED CHILD v Adjudication ........................................................................................................................... 36 Rigour and Quality .................................................................................................................... 37 CHAPTER 4: Outcomes ............................................................................................................... 38 Rich Case Record ...................................................................................................................... 38 Contextual factors .................................................................................................................. 38 Quantitative outcome data. ..................................................................................................... 40 Qualitative outcome data. ....................................................................................................... 44 Case Development and Adjudication ........................................................................................ 49 Affirmative brief .................................................................................................................... 49 Skeptic brief. .......................................................................................................................... 50 Affirmative rebuttal ................................................................................................................ 50 Skeptic rebuttal ....................................................................................................................... 51 Adjudication ........................................................................................................................... 51 CHAPTER 5: Discussion.............................................................................................................. 56 Reflections on LI and HSCED .................................................................................................. 56 Client change .......................................................................................................................... 56 Therapeutic processes ............................................................................................................ 57 Timeline ................................................................................................................................. 57 Baby doll attunement protocol ............................................................................................... 58 Common factors ..................................................................................................................... 59 INTEGRATING ATTACHMENT IN AN ADOPTED CHILD vi Attachment factors. ................................................................................................................ 59 Therapeutic considerations and future directions................................................................... 60 Future LI research directions.................................................................................................. 62 HSCED implementation and enhancement ............................................................................ 62 Child Friendly ........................................................................................................................ 63 Research team and adjudicators ............................................................................................. 64 Limitations and Future Directions for HSCED. ..................................................................... 65 Reflections on Attachment ........................................................................................................ 67 Assessment of attachment ...................................................................................................... 67 Consideration of attachment and psychopathology ............................................................... 68 Attachment-focused interventions.......................................................................................... 69 Future research and application.............................................................................................. 71 Conclusion ................................................................................................................................. 72 REFERENCES ............................................................................................................................. 74 APPENDIX A: Agreement to Participate ..................................................................................... 84 APPENDIX B: Parenting Styles and Dimensions Questionnaire................................................. 88 APPENDIX C: Personal Questionnaires ...................................................................................... 89 APPENDIX D: HAT Forms ......................................................................................................... 91 APPENDIX E: TSNQ Form ......................................................................................................... 94 APPENDIX F: Change Interview Forms ...................................................................................... 96 APPENDIX G: Kerns Security Scale ......................................................................................... 103 INTEGRATING ATTACHMENT IN AN ADOPTED CHILD vii APPENDIX H: Rich Case Record .............................................................................................. 106 APPENDIX I: Case Development .............................................................................................. 149 APPENDIX J: Adjudicator A Response Form ........................................................................... 155 APPENDIX K: Adjudicator B Response Form .......................................................................... 159 APPENDIX L: Adjudicator C Response Form .......................................................................... 161 INTEGRATING ATTACHMENT IN AN ADOPTED CHILD LIST OF TABLES Table 1. Jaydee’s Post-therapy Change List and Ratings…………………………….…..46 Table 2. Jaydee’s Follow-up Change List and Ratings……………………………….…..46 Table 3. Jaydee’s Mother’s Post-therapy Change List and Ratings………………….…..47 Table 4. Jaydee’s Mother’s Follow-up Change List and Ratings…………………….…..48 Table 5. Adjudicators’ Scores for Change…………………………………………….….52 LIST OF FIGURES Figure 1. Tracking of Jaydee’s PQ mean throughout therapy……………………………43 Figure 2. Tracking of Parent PQ mean throughout therapy………………………………44 viii INTEGRATING ATTACHMENT IN AN ADOPTED CHILD ACKNOWLEDGEMENTS There are many people who provided the academic, emotional, and physical support needed to complete this project. I would like to extend my gratitude to Jaydee and his mother, whose willingness to be vulnerable allowed me to collect such rich data. I am especially thankful to Janelle and Cathy for introducing me to Lifespan Integration therapy for children; Mac and Chris for their direct and indirect guidance in the HSCED method; and for all others who assisted in various stages of the research, particularly Andria, Meghan, Bart, Lynne, Danielle, Sharon, Vanessa, and Neeta. This project would not be complete without you. ix INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 1 CHAPTER 1: Introduction Of all the factors contributing to a child’s development, none have received greater attention in the literature than the parent-child relationship, as first outlined in Bowlby’s attachment theory (1969). Attachment, an emotional bond present from birth, is widely recognized as a factor that greatly contributes to emotional, social, and neurological development. Many attachment theorists and researchers have given the impression that children become “stuck” in their insecure or disorganized pattern of attachment internalized in early childhood, if such a pattern is present. Due to such a premise, most psychological interventions are aimed at managing the subsequent social, emotional, and behavioural problems that manifest in middle childhood and beyond. Alternative interventions must be focused on the developmental socioemotional functions of attachment and its neurological basis to directly target insecure attachment patterns and resulting consequences. Attachment theory, especially as represented in current research, becomes an integrative perspective for many developmental problems to be addressed in therapy. Developmental psychopathology emphasizes studying childhood disorders and problems as a process in context, with multiple events shaping development (Cicchetti, 2006; Mash & Wolfe, 2013). Attachment itself influences development in multiple ways, interacting with and encompassing the key developmental influences of neural plasticity, emotion regulation, temperament, goodness of fit, social learning and cognition, and family dynamics. Schore’s (2003) work in understanding the neurological underpinnings of the parent-child attachment supports the claim that early relationships shape brain development. Attachment theory is considered a regulatory theory by Schore and many others, as the primary caregiver’s responsiveness to children’s emotional displays and corresponding needs helps children co-regulate emotional stress until they can do INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 2 so on their own. Social cognition is included in the many reiterations of Bowlby’s attachment internalization processes: children develop mental representations of their self, others, and their relationships with others, positive or negative (e.g. Bartholomew & Horowitz, 1991). The everyday relational patterns that become internalized go on to influence social development across the lifespan. Children with insecure or disorganized patterns of attachment can lack the abilities to regulate emotions, manage stress, interact well with others, expect positive responses from others, and maintain a positive view of themselves. Not only do these patterns manifest at a conscious level, they can also have deep-seated, embodied consequences in the neural pathways leading to the socioemotional areas of the brain. A secure attachment relationship helps to integrate the child’s internal map of self and others across time and space (Siegel, 2012). An insecure attachment leaves children’s understanding of who they are and who others are in fragmented pieces that are not consolidated and integrated at a neurological level, often making little sense in conscious awareness. An effective intervention for children with attachment disruptions, such as those who are orphaned or fostered, should integrate these neurological processes that represent the different self-states in a warm, supportive, and attuned therapeutic environment. Lifespan Integration (Pace, 2012) is an under-researched therapy proposed to address attachment mechanisms at an explicit and implicit neurological level. It involves using a timeline to construct an autobiographical narrative that bypasses unhelpful coping mechanisms while creating new, helpful and adaptive neural networks. In clinical settings, it has been observed that this therapy promotes attachment security, emotion regulation, and more positive representations of self and others, presumably through the creation of neural networks. INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 3 For children in middle childhood, this means even their “stuck” patterns of attachment can be moved towards secure representations of self and others, with better emotion regulation and relational capabilities. With a focus on attachment processes, Lifespan Integration (LI) can offer late-adopted children – those who have had little opportunity for a consistent early attachment – an integration of their self-states across time and space, allowing them to consolidate and move past their attachment-related challenges. Incorporating the adoptive parents into Lifespan Integration therapy sessions allows for the children to experience this neural integration in the presence of their new attachment figures, who become a resource for continuity of regulation and positive interaction within and beyond therapy. This allows the parent-child emotion bond to grow and become a fulfillment of what was lost in the early years. Although Lifespan Integration has strong theoretical roots in neurobiology and attachment research, little research has been done on its effectiveness with different populations. The current study sought to identify the parent-child attachment processes involved in an attachment-based neural integration intervention (Lifespan Integration), and to understand the flexibility of such attachment processes. A mixed-methods design focused on the parent-child attachment as both a mechanism and a target for change in therapy. The primary research question for the study was as follows: Does Lifespan Integration (LI) improve parent-child attachment and attachment correlates in families with adopted children? Attachment correlates include adjustment outcomes, specific parent-child relationship factors, and psychopathology symptom reduction. INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 4 CHAPTER 2: Literature Review Attachment processes can be separated into two main, interconnected domains: emotional and relational. Supported with evidence from neuroscience and behavioural studies, socioemotional functions developed through the parent-child attachment relationship are considered necessary pieces of distinguishing between secure, insecure, and disorganized patterns of attachment. Insecure and disorganized attachment processes are a key part of understanding the role of attachment in developmental psychopathology. The literature shows that adopted children are especially at risk for developmental problems due to the attachment disruptions experienced early in life. A newly researched therapy, Lifespan Integration, is proposed as effective for targeting attachment processes in adopted children. The areas of attachment, psychopathology, and Lifespan Integration will be discussed in the following sections. Attachment Processes The study of attachment conceptualizes attachment as deep emotional bonds between people and seeks to understand the processes involved in establishing and maintaining such a bond. John Bowlby, the founder of attachment theory, said attachment processes begin in infancy between the infant and primary caregiver, are necessary for survival, and create the template for all future relationships (1969). In these very early stages of development, parentchild interactions help children regulate emotion, with the parent’s responsiveness to children’s emotional distress changing the experience into a more positive and enjoyable one (Schore, 2003). The support and comfort given to the child provides a sense of security in exploring their environment. Bowlby suggests that patterns of interaction become internalized for the developing child (1988). The child begins to operate with beliefs about the availability and INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 5 reliability of an attachment figure’s emotional support. These internal working models are positive or negative expectations of the self and close others in social settings, used as a relational template for all future interactions (Bretherton & Munholland, 1999). While these organized patterns of regulation and interaction were once thought to be stable personality traits, they are now considered to be flexible and adaptable schema-like models, with the ability to change in certain situations (Baldwin & Fehr, 1995). Emotional processes. When an infant or young child cries, a secure attachment bond is associated with the caregiver who will consistently respond with appropriate affect and intensity. Both parent and child learn to match emotional states, especially positive ones (Feldman, 2003). The level of soothing children need from a caregiver depends on the intensity of the emotional arousal. The caregiver’s consistent help in experiencing positive emotions is a pleasurable experience for children, and so children may shift their interaction behaviours in order to experience such positive emotions again (Schore, 2003). Infants also gradually shift their distress expressions to account for their mother’s timing in responsiveness, allowing the interaction to be described as a rhythmic dance (Bowlby, 1988). Attunement to the child’s emotional expressions and needs is a key parenting skill for building secure attachment. In the development of the infant-parent attachment relationship, certain attachment behaviours manifest at the same time certain brain structures are undergoing major growth and myelination (Schore, 2003; Perry, 2002). This has led to the belief that brain development, particularly in areas central to emotion regulation and social processing, is heavily influenced by the caregiver’s modulation of the infant’s emotional arousal. The neurochemicals that are increased in positive attachment experiences are dopamine and endogenous opiates, and they are known to regulate neural growth. The facial expressions involved in affect synchronicity INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 6 between parent and child especially influence the wiring of the orbital frontal cortex. This area, connected to the limbic system and heavily tied to emotional processes, undergoes major maturational growth between 10 and 12 months of age, and again at 18 to 24 months. At 10 to 12 months, the securely attached infant displays separation anxiety when the caregiver leaves, suggesting that consistent emotional responses with the caregiver have become reliably coded into the orbitofrontal cortex. At the end of the second year, infants have developed the ability to reciprocate in parent-child interactions, becoming more agentic in their emotion regulation (Wilson, Passik, & Faude, 1990). Thus, the development of the orbitofrontal cortex appears to be experience-dependent, especially influenced by the parent-child relationship. As the cortical regions of the brain mature in the first two years of life, development is especially evident in the right hemisphere (Schore, 2003). This hemisphere contains many functions for adapting to and regulating the stress response to emotional and social stimuli. Secure attachment is considered a strong predictor of stress resilience, known to allow for flexibility in emotional responses based on certain situations. Insecure attachment, however, appears to inhibit the growth of the right anterior limbic prefrontal network, which acts as a control system that adapts affective responses to the demands and limits of reality (Schnider & Ptak, 1999). It is concluded that the regulatory function of the right hemisphere, particularly with regards to the orbital frontal cortex and the limbic system, is encoded into these brain areas based on the regulatory interactions of the parent-child relationship. This has an impact on the emotional responses of the child when exposed to stressful stimuli. Relational processes. The relational processes of attachment are interconnected with the emotional processes developing from infancy in the context of the parent-child attachment. The first social interaction infants have is in the act of directing their gaze to meet their parent’s. INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 7 Intense interest in the parent’s face allows the infant to follow the parent’s face in space, and mutual gaze promotes the development of an affective interpersonal connectedness based on mutual affect expressed in the other’s face and mirrored in one’s own face (Schore, 2003). Recognizing faces and emotions expressed in faces becomes more developed as the child matures. The attachment relationship facilitates such a recognition as the caregiver attunes to the child’s emotional state, responds with a similar or more positive emotion, and consistently allows the child to recognize the affective value of emotions in others’ faces. The child learns about the mental state of others through the caregiver’s response, and also about the self’s mental state in relation to others. Understanding the different perspectives of self and others is known as theory of mind (Premack & Woodruff, 1978), and one engages in this automatic perspective taking to predict and interpret behaviour (Abu-Akel & Shamay-Tsoory, 2011). That attachment predicts theory of mind performance has only recently been studied (e.g. Hunefeld, Laghi, Ortu, & Belardinelli, 2013), but that the parent-child relationship predicts social-cognitive functioning is a belief that fits well into attachment theory. Bowlby himself suggested the phenomena of “internal working models” as representations a child develops about the self and others (1969), to predict and interpret the social and emotional behaviours of attachment figures in relational settings. Based on these internalized models, the infant learns to respond in certain ways to a caregiver’s action or reaction. More than merely overt behaviours, attachment becomes encoded at a neurological level based on the social interactions between caregiver and child (Ainsworth, Blehar, Waters, & Wall, 1978). The orbital prefrontal cortex is implicated in appraising the affective value of social stimuli (Schore, 1998, 1999). As it processes social signals, the orbital cortical region initiates social engagement and interaction, promoting affiliative behaviours (Schore, 2003). INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 8 Attachment becomes a socialization process when the child, around 14 to 16 months of age, starts to experience shame from the mother’s negative responses to exploration attempts (Schore, 1991). The securely attached child still has the expectation that interactions with the mother will bring positive affect, and so experiences a shock when negative affect appears in the mother’s response (Schore, 2003). If parents help to regulate the child’s shame state, re-establishing positive affect, they help the child internalize an even further benefit of the attachment relationship: positive affect can be restored even after unexpected negative affect. This builds resiliency into the infant, tied to emotional expectations in social interactions. Insecure Attachment. When the appropriate and necessary parent-child interactions are not in place for emotion regulation and relational templates to develop, insecure attachment patterns become internalized. According to Ainsworth, Blehar, Waters, and Wall (1978), two patterns of insecure attachment develop: avoidant and resistant. When confronted with a strange situation of separations and reunions with their mother, infants with an avoidant attachment did not express their distress when the mother left and avoided or were slow to greet the mother when reunited. Those infants who were classified with a resistant attachment did not use the parent as a safe base to explore the environment, were distressed when the parent left, and were angry and resistant to being comforted by the mother when she returned. In the avoidant infants’ relationship with their parents, it was found that parents did not attune well to the infant’s affect, did not express appropriate or consistent facial emotions, and had difficulties interacting at an age-appropriate level with their children (Main, Hesse, & Kaplan, 2005). The children adapted their attachment strategies to include the expectation that an attachment figure (as represented by the parent) is not useful for emotion regulation and understanding one’s state of mind, therefore seeking the parent out during reunion is of no use. The avoidant infant’s sense of self is INTEGRATING ATTACHMENT IN AN ADOPTED CHILD disconnected and the ability to trust others is lost (Solomon & George, 2008). For resistant or ambivalent infants, a caregiver who is inconsistently available and sensitive means the children internalize a preoccupation with their own distress that is not reliably soothed by the parent (Sroufe, Egeland, Carlson, & Collins, 2005; Siegel, 2004). Due to the unpredictable and sometimes overwhelming nature of the parents’ ability to perceive and attune to the children’s emotional needs, the children also learn to maximize their attention on the unpredictable attachment relationship, attempting to predict and find comfort in an attachment figure’s responses. Insecure attachments affect the child emotionally and socially at a neurological level. Avoidant infants engage in habitual gaze aversion to modulate arousal from a caregiver’s unavailability and rejection (Main & Stadtman, 1981). This leads to a preference for the parasympathetic state, meaning that the avoidant infant is “programmed” during critical maturation periods to shut down quickly to low degrees of socioemotional stimulation (Izard et al., 1991), minimizing emotional expression and the experience of intense positive or negative affect (Cassidy, 1994). For infants with resistant attachment patterns, the caregiver overwhelms the infant and becomes a source of distress and heightened arousal (Schore, 2003). The sympathetic system is predominantly engaged in social interactions, as the infant is predisposed to display heightened emotional expression and an inability to maintain positive affect in stressful times. Both insecure patterns of attachment, avoidant and resistant, serve as coping strategies in the face of emotionally unavailable or inconsistent caregivers, leading infants with these classifications to have an organized but emotionally unhealthy course of development. Disorganized attachment. After Ainsworth and colleagues’ (1978) strange situation was replicated a number of times, a fourth attachment classification started to become evident. 9 INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 10 When reunited with their caregiver, some infants looked confused and engaged in contradictory behaviours, such as looking away from the parent, having a flat affect, and crying out unexpectedly after being calmed (Main & Hesse, 1990). This kind of attachment pattern is labelled “disorganized” because the child has no coherent strategy for making sense of their caregiver’s responses. The parent is not a source of safety and regulation for the child. The child’s disorganized attachment is mediated by abuse or sudden shifts in mental states unrelated to the child’s signals (Main et al., 2005). Both events cause the child’s sense of self to be fragmented, and such disorganizing is linked with emotional, social, and cognitive difficulties later in life (Sroufe et al., 2005). Experiences early in life are often processed only in implicit memory, and such a person may also have difficulties explicitly recalling later experiences (Main et al., 2005). A lack of an autobiographical memory for such events can prevent experiences from becoming resolved and consolidated, leading unconscious emotional, behavioural and sometimes somatic responses to occur without understanding (Siegel, 2001). The disorganized attachment style is most characterized by relational trauma and dissociative behaviours. Attachment and Psychopathology When the parent is unable to be consistently supportive of the child’s emotional needs, healthy emotion regulation is not experienced, and enduring states of negative affect can have consequences on a child’s development (Schore, 2003). At the neurological level, the experience-dependent neural systems in the developing brain are disrupted and can lead to abnormalities or deficits in later neurodevelopment (Perry, 2002). These disruptions can occur in the form of a neglect and a lack of sensory experiences during sensitive periods of development. They can also occur as extreme necessary cues that create atypical patterns of experience in the neural systems due to a traumatic experience. Increased stress hormones from INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 11 the caregiver’s lack of soothing after frightening or disorienting events can impact cell death in the right hemisphere, in particular the orbitofrontal cortex (Kathol, Jaeckle, Lopez, & Meller, 1989). This extreme stress can go on to affect further neurodevelopment, resulting in various forms of socioemotional functioning and attachment patterns. Insecure and disorganized attachment relationships can have lasting social, emotional, and behavioural consequences originating from their neurobiological makeup. Specific pathologies and populations of children are uniquely linked to the different attachment strategies and classifications, leading to a fuller understanding of developmental psychopathology, as outlined below. Insecurity and disorganization. The literature has revealed trends in the different kinds of insecure and disorganized attachment patterns. Children who are avoidantly attached can be more controlling and aggressive, predisposing them to develop conduct problems (Renken, Egeland, Marvinney, Mangelsdorf, & Sroufe, 1989). Dissociation occurs in children and adults who are avoidantly attached, when asked to recall explicit autobiographical details of their family life growing up (Sroufe, Coffino, & Carlson, 2010; Siegel, 2012). Siegel goes on to suggest that the lack of episodic recall in such autobiographical memories demonstrates an inability to remember one’s self-experience in previous relational situations. As these memory processes are activated mainly in the right hemisphere, the inability to remember is assumed to be influenced by attachment processes in early childhood, and may even require those with avoidant attachment to rely more on the left hemisphere for memory recall. Children with an ambivalent insecure attachment to their caregiver are at risk for developing internalizing disorders. These include anxiety problems, especially social anxiety (Warren, Emde, & Sroufe, 2000; Sroufe, Egeland, Carlson, & Collins, 2005). Preoccupation with early relational patterns associated with overwhelming affect and inconsistent regulation INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 12 influences current and future relationships with others and with one’s own sense of self (Siegel, 2012). For children with a disorganized pattern of attachment, dissociative symptomology in childhood also predisposes one to develop PTSD after traumatic events (MacDonald, Beeghly, Grant-Knight, Augustyn, Woods, Cabral, 2008). As well as obvious deficits in emotion regulation, difficulties with attention and controlling behavioural impulses are evident in this population (Fearon, Bakermans-Kranenburg, van Ijzendoorn, Lapsley, & Roisman, 2010). A wide range of personality disorders has also been found in this group (van Ijzendoorn, Schuengel, & Bakermans-Kranenburg, 1999). The lack of any kind of socioemotional coping strategy for those with a disorganized attachment seems to manifest in the greatest amount of psychopathology in development. Adopted children. One specific sub-population of children with attachment difficulties is those who have been orphaned and/or fostered during crucial attachment periods in the first few years of life, with some being legally adopted into loving families after such attachment periods are over. Foster children include those who have been orphaned (i.e., loss of both biological parents) or apprehended from their parents, and enter a system where caregivers are not their natural or adoptive parent. During this time, these children lack an opportunity to securely attach with a consistent, supportive and responsive caregiver, due to conditions such as parental death, abuse, neglect, multiple caretakers, and little stability in relationships. In children who have been adopted in middle childhood (approximately six to twelve years), a seemingly secure attachment with an adopted parent cannot undo the consequences of earlier attachment trauma. In a study of late-adopted children who had been institutionalized from infancy, even those with a deep emotional bond with adoptive parents at 4 to 6 years of age displayed insecure and disorganized attachment behaviours (Hodges & Tizard, 1989; Tizard & Rees, 1975). Such INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 13 behaviours included excessively trying to receive attention from others, even being friendly with unfamiliar adults and peers. Late adopted children also failed to use their adoptive parents as sources for emotion regulation in situations that caused anxiety. Even children who had been institutionalized in only the first six to eight months of their life developed mental health difficulties in middle childhood, including difficulties with peers, inattention and hyperactivity, and conduct (Rutter, Colvert, Kreppner, Beckett, Castle, & Groothues, 2007). Children are placed in the care of others (foster system, institutions, adoption, etc.) when they have experienced abuse and/or neglect by caregivers who are abusers of alcohol or drugs, suffering from chronic mental health conditions, violent, or are any combination of the above (Howe & Fearnley, 2003). Such children often display a disorganized attachment pattern (Cyr, Euser, Bakersman-Kranenburg, & Van Ijzendoorn, 2010). In a transactional approach to the adoptive parent-child relationship, this suggests that as the child brings disorganized relational patterns and behaviours to the new relationship, the adoptive parent’s inability to understand such behaviours may further perpetuate the disorganized cycle, rather than help to heal it in a secure relationship (Howe & Fearnley, 2003). The child is also unable to use the new relationship to help make sense of who they are and how to cope with stress, in light of the trauma they have experienced. The experience of adoption can be traumatic and disorienting for the adopted child. Verrier (1993) describes a “primal wound” occurring when the infant is separated from their birth mother, thus losing the sense of self that is not yet separate from the mother. For infants in the first year of life, and during gestation, the mother is one’s entire environment in which a sense of self is slowly developed based on interactions with her. However, for children who are separated from their mother in the first year of life, they are forced to quickly develop a separate INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 14 sense of self that is premature. Resulting feelings include incompleteness, as though a part of oneself is missing, and the sense that something is broken and may never be whole again. The developing child can no longer fully trust their environment and those around them. Once adopted, a child may be still grieving the loss of their birth mother. According to Verrier (1993), such children go through stages of grief, even within their loving adoptive families, and the grieving process may include behaviours that defend against vulnerability and further loss. Such behaviours include aloofness when interacting with the adoptive mother or separation anxiety that comes from a fear of further abandonment. Throughout the adopted child’s lifetime, core issues of abandonment and loss may also be accompanied by rejection, distrust, lack of intimacy, divided loyalty, guilt and shame, a fight for power and control, and conflict starting in adolescence around developing one’s identity. Middle childhood. In middle childhood, when children are approximately six to twelve years of age, the socioemotional functions related to attachment start to change as the child matures and expands his awareness of self and the world. Due to the expansion of one’s social network to include closer bonds with peers (e.g., more attention and reliance on peers than was done previously), attachment regulation patterns and relational templates start to become generalized beyond the parent-child environment. This stage of development can become problematic for those with insecure and disorganized attachment, as these styles are associated with a number of socioemotional problems. For example, secure children in middle childhood were more likely to choose more sophisticated forms of emotion regulation strategies than insecure and disorganized children when asked to complete stories of separation and distress from one’s primary attachment figure (Colle & Del Giudice, 2011). Insecure attachment in infancy is also predictive of child aggression in middle childhood (Cyr, Pasalich, McMahon, & INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 15 Spieker, 2014). In not promoting harsh parenting practices, secure attachment can protect against conduct problems at this time in a child’s life. In general, middle childhood is a time when certain behavioural, emotional, and social problems become obvious and merit assessment and diagnosis. Oppositional defiant disorder is typically evident by 8 years and the closely related child-onset Conduct Disorder by 10 years (Mash & Wolfe, 2013). Separation anxiety disorder, school refusal, and early onset obsessive compulsive disorder are also associated with middle childhood. As attachment is considered a key developmental pathway for problems that manifest in middle childhood, interventions with this age group must involve attachment processes. Intervention gap. As the neurological implications of early attachment trauma can result in many problems later, psychological interventions are needed to address the unfulfilled nature of early attachment needs and prevent future developmental pathologies. Most attachment-based, trauma-focused, or parent-child interaction focused therapies, however, do not target these early needs, instead seeking to manage problematic behaviours or a specific event. For example, a widely used treatment for children ages two to seven years is Parent-Child Interaction Therapy (PCIT; Eyberg & Matarazzo, 1980). While it aims to promote positive interactions and thus secure attachments by increasing parent responsiveness and warmth, the behavioural management techniques threaded throughout the therapy do not address the child’s emotional needs, past or present. Trauma-focused Cognitive Behavioural Therapy (Cohen & Mannarino, 1996) specifically focuses on helping children with primary trauma symptoms related to a specific event. This therapy has yet to be focused on relational, attachment trauma. There is a possibility that these therapies do address learned patterns involved in attachment relationships, but attachment is more than just social learning, as outlined above. INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 16 An intervention is needed to address the earlier, unmet needs of the self that are rooted in the unintegrated parts of one’s relational neurobiology. Perry (2009) notes that the sequential order of brain development should be accounted for in therapy, especially when early childhood trauma has occurred during key periods of brain development. The brainstem and diencephalon start developing in utero so that once the baby is born these brain areas regulate the cardiovascular and respiratory systems in the body. As the infant develops, neural networks originating in these lower brain areas are projecting to all other parts of the growing brain, assisting in organization between different brain regions. Trauma at this time in development means these early organizing neural networks will experience “extreme, dysregulated, and asynchronous” patterns of activity, influencing the higher areas of the brain to develop in a way that reflects these abnormalities (Perry, 2009, p. 242). For those with early attachment trauma, therapy must be able to engage the brain structures that were developing at this time, including the brainstem and diencephalon. Somatosensory activities as well as repetition are especially important in providing healing to trauma encoded at this level of the brain. A Possible Solution: Lifespan Integration An attachment-based intervention that works at the neurological level of understanding self and close others, in the past, present, and future, is needed. Lifespan Integration is one such intervention that views psychological problems as being the result of insufficient neural organization occurring in the presence of an attachment figure (Pace, 2012). The purpose of Lifespan Integration (LI) is to facilitate neural integration in stages of development beyond early childhood by better understanding one’s self across space and time, within an emotionally supportive interpersonal relationship. Making sense of one’s childhood experiences and early relationships allows a person to be more emotionally available in future relationships, repairing INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 17 some of the damage done by early attachment patterns. In standard LI protocol, the therapist takes on the role of parent to hold and regulate the client’s emotions. By focusing on the client’s body sensations of emotions connected to the presenting problem, the therapist helps the client find similar moments in their past when they felt the same way. This creates affect bridges to different, younger parts of self that may be in need of neural integration. These self-states are linked to implicit memories, loosely associated through the similar felt emotion, but not a coherent, integrated part of the person’s self-system and chronological timeline. The therapist leads the client’s adult or older self to engage with the younger parts of self, bringing new information, safety, and support to that younger self, in order for that part to feel more emotionally safe and regulated. Focusing attention on the body sensations of emotion in each self-state and bringing in information and resources of the older self to each point on the timeline prevents the re-traumatizing experience of focusing on each part separately and in depth. Furthermore, including the felt body experience adds a somatosensory component needed to target early-developing brain structures, as mentioned by Perry (2009). The organization of transitioning through self-states in the LI timeline allows the felt self-states to be more properly stored as explicit memories of past events. Ultimately, the client comes to understand the patterns in the decisions and choices made during the lifespan, due to the earlier dysregulated, traumatic attachment trauma. The client both physically and emotionally feels, as well as cognitively realizes, he or she is now safe and able to make other choices that promote security in self and with others. Four phases of LI therapy are used in the standard protocol (Thorpe, 2012). The first phase involves having one’s older self provide safety and support to one’s younger self in the target difficult situation and bring the younger self to a peaceful place. In the second phase, INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 18 when the younger ego state no longer feels the intense distress it once did, the older self is imagined as expressing anger on behalf of the younger self, to bring a sense of empowerment to the memory. The third phase involves the younger-self being able to directly express its own anger in the difficult situation, as it is now more integrated with the older self and now has the adult-empowerment necessary to do so. In the fourth phase, repair is imagined in a positive way, where the younger self’s needs in the difficult situation are imagined as provided, such as having comfort, safety, and support that may have not have really been there at the time. When there is no more bodily or emotional distress experienced by the younger self when the event is remembered, the standard LI protocol can end and integration of this younger self-state is assumed. Neural integration and attachment. Siegel (2012) suggests that the concept of integration is how health is achieved in mind, brain, body, and relationships, which is a core premise of Lifespan Integration. Mental health disorders are therefore operating due to nonintegrated systems. An integrated self-system is “flexible adaptive, coherent, energized, and stable” (Siegel, 2012, p. 336), and this occurs at the neural level. Neural integration is especially related to self-regulation (Woltering & Lewis, 2009). Children with insecure attachments did not experience integration of the self-system, because their regulatory system was compromised at a neural level. For those with disorganized attachment, dissociated self-states become ingrained and transitioned to when contextual cues in a given situation are similar to early traumatic experiences. Different self-states may even display different styles or patterns of attachment, suggesting the presence of multiple, non-integrated internal working models of attachment (Harter, 2003). Disorganized attachment may be experienced with some caregivers, while secure INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 19 attachments are with others, representing the experience of an orphaned or fostered child who has had multiple caregivers with indeterminate quality of caregiving. While the secure attachments may allow for a feeling of an integrated and coherent sense of self, in times of stress the dissociative self-states can emerge, which may impair other regulation and coherence processes (Siegel, 2012). There is some evidence that self-regulation, and thus neural integration, can be influenced later in life by positive and deeply supportive relationships with peers and teachers (Sroufe et al., 2005). Siegel (2012) emphasizes an autobiographical narrative process that both incorporates a third-party observer perspective for different self-states and utilizes the reflective and mentalizing abilities of the right hemisphere. Lifespan Integration combines all three of the proposed avenues for achieving neural integration. The LI timeline engages in a repetitive experience that helps to consolidate the integrative experience at a neural level, as repetition is considered to be a key part of healing from trauma (Perry, 2009). LI with children. It is reported that Lifespan Integration works well with children and adolescents (Pace, 2012; Thorpe, 2012). This is due to the plasticity of their neural systems for the integration processes, as well as having less defenses to overcome in building safety in the therapeutic setting. Pace (2012) recommends including the parent or caregiver in the LI sessions with the child, to help the child feel safe and more emotionally open. Establishing a list of memory cues for points in the LI timeline can also be better carried out with the parent’s help. The Lifespan Integration Birth to Present protocol is most often used with children if trauma or neglect occurred early in life. In this way, it is considered most useful for helping with emotion regulation and changing behaviours that started early in life. The purpose of this protocol is to imitate the connection between infant and caregiver to activate the emotion parts of the brain that were affected in infancy. Clients can then benefit from the attunement and coherence of self- INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 20 states exemplified in the therapeutic relationship. With adults, the therapist will hold a baby doll to symbolize the embodied connection. If parents are involved in the work done with children, they can be the ones to hold this doll and help with creating an attuned and supportive environment. Including the parent in therapy with the child helps to address the attachment relationship directly (Kerig & Wenar, 2005), and has been used in other therapies, such as Parent-Child Interaction Therapy (Eyberg & Matarazzo, 1980). In adopted children, presenting problems are most likely related to early experiences and Lifespan Integration works to build coherence even in the event of an unknown history (Pace, 2012). Even the smallest amount of information about the child’s birth and early experiences can help to build a Birth to Present LI timeline. The child can help his or her “baby self” come to terms with how he or she grew up, imagining each developmental milestone and pairing it with any facts known about the child’s life (e.g. changing foster homes). This approach helps to target the implicit memories stored in the body from birth, even if the child is not consciously aware of them. Involving the adoptive parent in this process, holding either the baby doll or the child, can symbolize that felt sense of security and emotional connection that brings about regulation and integration. Specific techniques from LI therapy with adopted children include using objects to help child clients understand that their earlier selves (e.g. “baby self”) experienced a lot of thoughts and feelings, such as fear and confusion around having different caregivers. Nesting cups can be used to represent how one’s baby self (the smallest cup) fits inside all other parts of self, affecting one’s whole sense of self, even in the present (Thorpe, 2012). This helps to make the integration of self-states more concrete to children. Similarly, having a baby doll present in session allows them to visually connect with their imaginal baby self, especially as it receives INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 21 love, safety, and attunement from the caregiver or therapist in session. The baby doll is used as part of the imaginal repair process, after the clearing phase is done where the client can connect to the baby self and go through the timeline without distress. Conclusion and rationale The repair of early attachment trauma in adopted children is the focus of investigation in the present study. Lifespan Integration was proposed as a therapy that focuses on early attachment needs and self-integration throughout development. Adopted children’s socioemotional functioning can start to manifest as regulatory, behavioural, and relational problems in middle childhood. While many interventions focus on managing the behaviours involved in these problems, Lifespan Integration may be effective in targeting the root of these problems: early attachment trauma. Clinical experience suggests that LI is helpful adopted children and can improve attachment relationships with their current caregivers. At this time, no research exists to investigate the effectiveness of LI with this population. The current study sought to identify the parent-child attachment processes involved in Lifespan Integration, as both a mechanism and a target for change. The primary research question for the study was as follows: Does LI improve parent-child attachment and attachment correlates in families with adopted children? Specifically, it was hypothesized that LI can be effective in significantly improving an adopted child’s insecure or disorganized attachment representations and behaviours towards security. It was also hypothesized that LI can be effective in treating the client’s socioemotional problems, including emotion regulation and social behaviour. Attachment measures were used to observe differences in attachment processes before and after LI therapy. Measures of childhood disorders and symptoms were used to understand the change in developmental problems related to attachment. Change was INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 22 also observed in general well-being measures before and after LI therapy, as well as parent and child attributions for change. Furthermore, it was hypothesized that the presence of an attuned and responsive caregiver in LI therapy can help to facilitate the change in attachment processes in therapy. INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 23 CHAPTER 3: Method Design This study used a mixed-methods Hermeneutic Single Case Efficacy Design (HSCED; Elliott, 2002, 2015). This design is used an alternative to randomized clinical trials (RCT’s) in determining the efficacy of new therapies or an existing therapy with a new population. A rich case record was established for a single case, using quantitative and qualitative measures to better understand the causality between therapy and outcomes. Quantitative data included weekly, pre-therapy, post-therapy, and follow-up outcome measures. Qualitative measures included an assessment of the child’s and parent’s attributions for change and therapist case notes that give information on therapy process. An affirmative case was built linking therapy to client change, while a skeptic case offered alternative explanations for change apart from therapy. An adjudication from three expert judges reached a conclusion about the overall likelihood of therapy being the reason for change. Paradigm. The HSCED and other systematic case study designs have helped outcome research shift from a post-positivist paradigm to more contextually-relevant paradigms (Wall, Kwee, Hu, & McDonald, 2016). With a pragmatist paradigm, HSCED fits well into Dewey’s processes of experience, reflection, and action (Dewey, Alexander, Hickman, 1998). One must create a case based on observations of what is “there,” the experience, including what others’ interpretations are of the experience. Next, one reflects on these facts, entertaining possible judgments based on these facts to promote action. Data is interpreted and explained, ideas are formed regarding solutions to the questions raised by the data, and action is taken to verify the preferred idea. Judgments are key to the later phases of the HSCED, where facts and suggested INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 24 ideas (i.e. affirmative versus skeptic cases) are weighed and the best idea for the facts is selected in an adjudication process. Randomized clinical trials (RCT’s) are not appropriate for gathering a complex understanding of attachment processes in LI therapy. The unique experience of those in a difficult, new, and potentially evolving attachment relationship was a priority in this HSCED study, as a rich case was built around such experiences represented in both qualitative and quantitative ways. In RCT’s, group-based averages are used to represent each individual’s experience, thus negating the richness and uniqueness of that experience. In the HSCED method, the clients are allowed to attribute their unique experience to various factors inside and outside of therapy. This not only allowed for a rich description to be given, but also encouraged an exploration of confounding variables, asserting the HSCED to be comparable to RCT’s in rigour. The process of determining therapy efficacy, originally thought to be done only through RCT’s, is now honoured in the rigorous and empirical nature of the HSCED design (Benelli, De Carlo, Biffi, & McLeod, 2015). The paradigmatic assumptions of experience, reflection, and action, fit well with understanding attachment processes in therapy. In understanding the adoptive parent-child dyad’s experience of attachment and wellbeing in therapy, action can be taken to address the problematic area of insecure attachment in middle childhood for all adopted children. The Hermeneutic Single Case Efficacy Design was appropriate for the current research as it helped to understand the efficacy of a relatively new therapy, Lifespan Integration, and the use of LI with a new population: adopted children in middle childhood. While clinical evidence suggested LI is a helpful intervention with adopted children, a more rigorous approach was needed to explore this possibility. By gathering a rich case record that included parent-child INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 25 attachment measures, the research question regarding the improvement of the parent-child attachment and attachment correlates in families with adopted children was addressed and adjudicated. The efficacy of LI for wellbeing improvement in this population remains a focus under this design. Participant selection and recruitment, data collection, and methodological rigour are discussed to demonstrate how HSCED was an appropriate design for the study. Participants Participation for the case study was obtained from one (N=1) adoptive parent-child dyad where the adopted child was a 12-year-old male, named Jaydee (pseudonym). This dyad was selected because Jaydee fit the criteria of an adopted child in middle childhood seeking therapy. Although the ideal age to represent middle childhood was between 8 and 10 years of age, Jaydee’s attachment trauma and clinical presentation demonstrated that he was developmentally younger than his 12 years, within the middle childhood range. Jaydee and his mother were seeking therapy based on behavioural and emotional concerns, which included both internalizing and externalizing psychopathological symptoms. The therapist and caregivers attribute most of these symptoms to the attachment trauma of being apprehended at birth and then fostered prior to adoption, as determined by the therapist and caregivers. As per inclusion criteria, Jaydee had not received Lifespan Integration therapy in the past, and the parent and child were willing to commit to the minimal four month treatment period. They were also willing and available to complete assessment and outcome measures throughout the course of the treatment period. A Lifespan Integration therapist in the lower mainland of British Columbia was chosen to recruit participants through her practice, administer the therapy, and fill out relevant case notes for the HSCED method. The therapist had prior experience working with adopted children and parents using the LI birth to present, baseline, and attunement protocols. INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 26 Recruitment. Natural sampling was used for the adoptive parent-child dyad. The selected LI therapist offered information about participating in the research study to these clients at intake as they seemed to meet criteria based on the therapist’s judgment. It is important to note that the LI therapist for this study was also the research supervisor and engaged in consultation to determine that this was not a harmful or unethical conflict of interest. Inclusionary criteria. The therapist knew the ideal client was in middle childhood (6-12 years), had experienced a disruption of attachment, and currently demonstrated moderate emotional and/or behavioural concerns. Child client motivation for therapy, i.e., willingness to address some problem, was also determined to be present, as Jaydee’s mother told the therapist that he was very interested in science and participating in scientific processes. The natural way of sampling allowed for the therapist’s expertise to help the recruitment process. Once a dyad had been selected, the parent was asked to complete a quick parenting questionnaire (Parenting Styles & Dimensions Questionnaire; PSDQ) to determine goodness of fit for the parent’s capacity to aid the child in facilitating secure attachment during therapy. The PSDQ (Robinson, Mandleco, Olsen, & Hart, 2001) helped to determine a parent’s authoritative tendencies in parenting practices. Jaydee’s mother scored high in the authoritative parenting dimension on the PSDQ, and so was included in the study based on this demonstration of a capacity to facilitate secure attachment. Once the parent-child dyad had been selected and determined to match the criteria for the study, data collection and therapy commenced. Exclusionary criteria. Children with severe emotional or behavioural concerns were excluded from the study, based on clinical judgment, due to the fact that such a severity of concerns would prevent the client from engaging in LI therapy. This was because the child participant must be cognizant enough to engage in LI therapy, and those with symptoms such as INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 27 active psychosis were thought unable to engage fully in the therapy and the study. Similarly, if a child was unable to sit in the same room as their adopted parent, this could hinder the nature of LI therapy in this study, which involved the adopted parent for attachment reasons. Parents who struggled with their own mental health difficulties that could affect their parenting skills negatively (determined by both the therapist at intake and the parenting questionnaire) were excluded from the study, as the goal of the current study was to specifically examine attachment in light of the child’s presenting problems. Research teams and judges. The HSCED method called for research teams of knowledgeable members to form both the affirmative case and the skeptic case teams. While Elliott (2002; 2015) and others debate the advantages and disadvantages of using psychotherapy experts versus graduate students to act as team members, as well as adjudicators, the current study involved a mix of both. Therapists familiar with Lifespan Integration and child development experts were represented on both the affirmative and skeptic case teams, and representatives from both teams had familiarity with the HSCED method. Graduate students knowledgeable in child development and/or Lifespan Integration were also selected for each team. Therapists from the community brought experience-based wisdom to each team, as suggested by Wall et al. (2016). Three team members were chosen for each team. The adjudication team of three independent judges was presented with both the affirmative and skeptic cases, as well as the rich case record. These judges were also chosen based on their expertise with LI, the HSCED method, and/or attachment disruptions in adopted children. One judge, Catherine Thorpe, was considered a world expert in Lifespan Integration with children; another judge, Andria Weiser, was a non-LI child therapist with doctoral INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 28 candidacy who specialized in understanding psychopathology in middle childhood; and the third judge, Chris Rensch, was a child trauma therapist familiar with LI and the HSCED method. Data Collection Procedure Informed consent for the study was received from the parent, as well as verbal assent from the child (Appendix A). After an intake interview was conducted with the mother, the Parenting Styles and Dimensions Questionnaire was administered to the parent to be sure she fit the inclusionary criteria. During an introductory pre-therapy meeting, the therapist and researcher met with the parent and child to create a list of items the clients wanted to address in counselling, which became the parent’s and child’s individual Personal Questionnaires (PQ). The parent and child then attended 10 weekly therapy sessions over the course of five months in which LI was the main intervention of each session. The Personal Questionnaires and Helpful Aspects of Therapy forms were administered weekly to the child and parent before (PQ) and after (HAT) each session. Both the parent and child chose to complete these forms directly before and after each session was chosen by both the parent and child, since they believed they did not need a few days to reflect on their experiences before completing the forms. These forms (PQ and HAT) were administered by the researcher mainly, with occasional administration by the therapist/research supervisor when the researcher was unavailable. Whenever the researcher was unavailable to administer the forms, the clients were offered an option to complete the forms at a different time when the researcher was available. The clients always chose to complete the forms with the therapist after session in each of these instances. The semi-structured Change Interviews, including the adapted child version, were given to the parent and child at the end of the five-month LI therapy period. Additional quantitative measures were given pre-therapy, post-therapy, and follow-up. These measures were the INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 29 Parenting Relationship Questionnaire (PRQ), the Behavioral Assessment System for Children (BASC-2), and the Kern’s Security Scale, all used to measure the attachment and psychopathological changes observed throughout therapy. The therapist kept weekly session notes and completed a Therapist Session Notes Questionnaire (TSNQ) for each session. The researcher also provided written notes from observing each video recorded session. Both therapist notes and researcher notes were used to include an informal observational assessment of parent-child attachment behaviours, for the rich case record. It is important to note that flexibility was needed in collecting rich data from a child client. The HSCED protocol adaptations were made after consulting a previous HSCED thesis involving a 12 year old participant (Rensch, 2015). Interview procedures needed to include expressive techniques for understanding the child’s perspective. These techniques included the sand tray, pictures, and different prompts for various questions in the interviews (see Appendix H). Expressive techniques were used if the outlined PQ, HAT, and CI interview questions yielded little to no data, to allow the child to express his feelings and reflections about therapy nonverbally, while maintaining the integrity of the forms’ questions. Measures Parenting Styles and Dimensions Questionnaire (PSDQ). An inclusionary criterion for the parent-child dyad was that the parent have the capacity to display the warmth and responsiveness necessary to facilitate secure attachment. The Parenting Styles and Dimensions Questionnaire (PSDQ; Robinson, Mandleco, Olsen, & Hart, 1995, 2001) is a 62-item questionnaire assessing one’s parenting style as authoritative, permissive, or authoritarian, following Baumrind’s parenting theory (1967). A five-point Likert scale allowed the parent to rate each item, with 1 = Never and 5 = Always. In the current study, the PSDQ was used as a INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 30 screening tool, to be sure the parent’s scores fell in the authoritative classification on this measure (see Appendix B). Simplified Personal Questionnaire (PQ). In the HSCED method, a weekly questionnaire was given to measure the client’s main problems or goals (Elliott, Mack, & Shapiro, 1999). This helped to link therapy and life events to client change and could also have given outcome measures if the client had chosen to stop therapy prematurely. This questionnaire was brief and individualized, consisting of approximately ten items of problems the client wished to work on. These problems included items pertaining to symptoms, mood, school, relationships, and/or self-concept. Every week the clients rated their distress for each problem on a sevenpoint Likert scale. Separate PQ’s were generated for the child and parent in the study and each had items that reflected goals and concerns pertaining to the child’s behaviour and well-being, as well as the parent-child relationship. The language of each problem on the child’s PQ was modified to be child-friendly and the child was asked to rate each problem using a child-friendly “smiley face” scale (see Appendix C). Developing the personal questionnaire fit well with LI therapy, as the therapist started by collaborating with the client about their presenting problems and associated memories. Helpful Aspects of Therapy (HAT). Another form of qualitative weekly data included an open-ended questionnaire that assessed patient perception of significant therapy events (Llewelyn, 1988). The seven open-ended questions about events that occurred in therapy were modified for developmental appropriateness for the child client, reducing the number of items to four (see Appendix D), while the full seven item questionnaire was kept for the parent to complete. Both versions of this questionnaire allowed for helpful and unhelpful therapeutic events to be associated with other measures of change in the HSCED process. INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 31 Therapy notes and video observations. The therapist was asked to complete her usual session notes as well as a more focused Therapist Session Notes Questionnaire (TSNQ). In addition to questions regarding what helped or hindered the therapist and client in each session (similar to the HAT), the TSNQ also contained questions regarding amount and types of LI protocols used in session. This questionnaire was customized to include attachment-related questions mentioned below (see Appendix E). Video observations also followed the TSNQ template. Change Interview. In this qualitative assessment administered at the end of therapy, the client described and rated their changes that occurred over the course of therapy, following the format of Elliott, Slatick and Urman’s (2001) Change Interview. The rating of these changes included the expectedness and importance of the changes, and a determination of whether these changes would have likely occurred without the therapy. The Change Interview was administered by the researcher instead of the therapist at the post-therapy meeting, as recommended by Elliott (2002), in order to explore unhelpful and negative aspects of therapy that the client would be uncomfortable sharing directly with the therapist. At the 1-month follow-up the parent agreed to complete the interview again with the therapist, while the researcher met with the child, to save time by allowing the interviews to occur at the same time. The parent reported feeling comfortable answering all questions with the therapist. In the interview structure, clients’ attributions for change were accounted for. An adapted, more childfriendly version was given to the child, and both parent and child interviews included more specific questions around the parent-child relationship both in and out of therapy (see Appendix F). INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 32 Parenting Relationship Questionnaire (PRQ). The Parenting Relationship Questionnaire (PRQ) is a caregiver self-report assessment about the parent-child relationship. In the current study, the 71 items in the 6-18 years version provided information on the caregiver’s parenting style, parenting confidence, stress, and satisfaction with the child’s school (Kamphaus & Reynolds, 2006). Items were rated on a 4-point scale ranging from “never” to “almost always.” This assessment was administered pre-therapy, post-therapy, and at follow-up to both of client’s parents. It was used to supplement other measures of attachment processes. Behavioral Assessment System for Children (BASC-2). To assess the child’s behaviour systematically, the Behavioral Assessment System for Children, Second Edition (BASC-2; Reynolds & Kamphaus, 2004) was administered pre-therapy, post-therapy, and at follow-up. At the time of research, the BASC-3 was just beginning to be phased in as a replacement for the BASC-2. Due to accessibility of the measure and use of the measure in previous LI research with children, the BASC-2 was deemed sufficient for the aims of the research project. The adolescent versions of the BASC-2 were used for Jaydee’s chronological age-match of 12-21 years. The multidimensional assessment approach taken by the BASC-2 required three categories of information. The parents of the child client were asked to complete the Parent Rating Scale (PRS), while the child’s main teacher and educational assistant were asked to complete the Teacher Rating Scale (TRS). Each of these scales was rated on a 4-point scale (“never” to “almost always”); the PRS contained 139 items while the TRS contained 160 items about the child’s behaviour. Parents’ perspectives were also incorporated into the intake interview for therapy, loosely following the BASC-2 Structured Developmental History (SDH). The third category of information included the Self Report of Personality scale (SRP), INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 33 administered to the child regarding his own thoughts and feelings. This scale consisted of 176 true-false and multiple choice items. Child attachment measures. Two measures were used to better understand the child’s attachment representations. The first, the Kerns Security Scale, is a child self-report measure that assessed children’s perceptions of security in parent-child relationships in middle childhood and early adolescence (Kerns, Klepac, & Cole, 1996). The Security Scale items assesses beliefs about parent responsiveness and availability, the tendency to rely on the parent in stressful times, and the ease and interest the child has in communicating with the parent. The 15 items on this scale followed a “some kids…other kids” format, such as “some kids find it easy to trust their mom but other kids are not sure if they can trust their mom” (Kerns, Aspelmeier, Gentzler, & Grabill, 2001, p. 73). For each question, the client referred to one type of child as “really true” or “sort of true” for them, choosing one of four response options. The response items were totalled and higher scores (out of 60) indicated greater security on a continuous dimension. This measure was administered pre-therapy, post-therapy, and at follow-up (see Appendix G). The quality of the parent-child relationship was gauged through observational means by someone with clinical experience regarding attachment behaviours. To prevent overwhelming the parent and child with many formal assessments and questionnaires, a more informal approach was taken to observe the parent-child relationship in a therapeutic setting. As the therapist interacted with the parent and child throughout each session, she was asked to note and later comment on attachment behaviours. This included behaviours related to proximity and contact seeking, such as the use of touch and eye contact between the parent and child (making note of who initiated such contact). The maintenance of contact between parent and child (eye-contact, physical touch, or paraverbal and verbal communicative contact) was also noted. Behaviours INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 34 pertaining to Bowlby (1969) and Ainsworth et al.’s (1978) theories regarding the child using the parent as a secure base for exploration were commented on in the therapist’s case notes, when appropriate to the events of each session. As LI allows for the potential of distressing emotions to arise for the client, the therapist was also asked to comment on the use of emotion regulation strategies in session, including the use of the parent as a co-regulator. Each session was video recorded for the researcher to also observe and note such attachment-related behaviours. Data Analysis, Case Development, and Adjudication The HSCED design followed a step by step analytical procedure: compiling and analyzing the rich case record, creating affirmative and skeptic cases based on the data collected, and presenting each case for an adjudication process. Rich Case Record. Data from the intake process, pre-therapy assessment, weekly therapy notes and measures (including the PQ and the HAT), and post-therapy and follow-up assessments were used to compile a rich case record. Quantitative data included the PQ, PRQ, the BASC-2, the Security Scale scores, and the Change Interview record scales. Qualitative data included the intake interview, the HAT, the TSNQ, and the Change Interview questions. Affirmative and skeptic cases. Two teams were given the compiled rich case record. One team was asked to develop an affirmative case of positive evidence connecting LI therapy to client outcomes. According to Elliott (2015), this case should include at least two of the following kinds of direct evidence: 1. The client and/or parent experienced changes in long-standing problems during the fivemonth course of LI therapy. 2. The client and/or parent gave clear attributions for therapy being the cause of change. INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 35 3. According the client’s HAT and Change Interview data, LI therapy’s helpful aspects were linked to post-therapy change. 4. The client’s data also showed a covariation between the weekly differences in the client’s reported problems and the LI processes that were covered in the week’s corresponding session. Elliott suggests that the information most useful to the affirmative case is the PQ, the HAT, and the Change Interview. Differences in pre-therapy, post-therapy, and follow-up attachment measures (Security Scale and PRQ), as well as the therapist’s reports on the attachment relationship were also of interest to the affirmative case, as they apply to the research question. The second team was asked to develop a skeptic case based on alternative explanations for the observed client change, if any change was observed. The skeptic case team did their best to account for the change based on nontherapeutic factors (Elliott, 2015). They were also allowed to argue using indirect evidence that change did not occur. Such indirect evidence could include: 1. Nonimprovement, such as the client’s deterioration in well-being or a lack of clinical significance in the changes observed. This also included looking at negative aspects of therapy or the importance of observed changes to the client (parent or child). 2. Statistical artifact, in that random error was observed in measurement error, regression to the mean, or experiment-wise error. 3. Relational artifact, meaning the dynamics between the therapist and client brought about the change observed, not the therapy itself. Assessing social desirability and giving room for the client to express negative comments to the researcher about the therapeutic process were options for providing evidence for this claim. INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 36 4. Expectancy artifacts, such as the clients’ (child and parent) expected change to have occurred due to preconceived expectations and cultural bias. 5. Self-generated return to baseline, meaning the changes would have occurred over the period of time regardless of therapy. 6. Extratherapy events, such as improvements in areas of life not impacted by therapy or other positive life events. 7. Unidirectional psychobiological causes, in that medical intervention may have facilitated the change. 8. Reactive effects of research, for instance, knowing one is in a research study may have affected how the client responded to the research process, similar to a social desirability bias in wanting to please the researcher and contribute to their work. The nature of the HSCED recommended PQ ratings and the HAT and Change Interview questions allowed for these events to be addressed through the client’s qualitative data. Observing and interpreting change in the quantitative measures also provided the skeptic case team with a reference point for creating alternative explanations. The purpose of the skeptic case team was to give an opportunity to address alternative explanations in the adjudication and decision-making process. Both the affirmative and skeptic case teams were able provide rebuttals to each other’s presentations, forming a dialectical approach to case development. Adjudication. The rich case record, affirmative and skeptic cases and rebuttals were presented to expert adjudicators for an adjudication process regarding the efficacy of therapy. The adjudicators were informed about the HSCED method, and were given a description of each of the measures. They were asked to complete an adjudication form rating their judgments of client change over the course of therapy, whether the change was due to the LI therapy, and how INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 37 certain they were in making these judgments. Adjudicators also were asked to identify mediating and moderating factors to the client’s change. These last questions were especially useful to the research question regarding attachment processes at work in LI therapy. Rigour and Quality The mixed-methods HSCED is based on a rigorous and challenging standard to address the scientific causal nature of psychotherapy and client outcomes, while also appreciating a client’s rich and unique perspective (Elliott, 2015). The adjudication process especially gives rigour and trustworthiness to the HSCED process as affirmative and skeptic cases are fully considered by experts meant to weigh all explanations carefully (Wall et al., 2016). These experts were chosen to be representative of all areas of the study, that is, experts in LI therapy, the constructs of attachment and/or adopted children, and mixed-methods measurement for the current study. Having multiple judges in the adjudication process also lends to the quality of the design, if all judges respond consistently to the material presented to them, particularly in concluding the therapy’s causal effect on client change. The full procedure - systematic assembly of a rich case record, the creation of both affirmative and skeptic cases, and the thorough adjudication process - lends itself to promoting the rigour and quality of the HSCED. INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 38 CHAPTER 4: Outcomes The results of the study were based on the degree to which Jaydee changed, the impact of the therapy on this change, and specific factors that mediated or moderated change. Results were demonstrated through the data compiled in the rich case record, the case development teams' arguments and rebuttals, and the adjudicators' decisions. Rich Case Record The following is a summary of the rich case record, presented fully in Appendix H. This summary highlights key features from the rich case record that were relevant to the research questions and case development process. Contextual factors. At the time of research, Jaydee (pseudonym) was 12 -years -old and in Grade 6, with an Individualized Education Plan (IEP) in place at school. He lived with his adoptive mother and father, and biological half-sister, Abigail (pseudonym), in the Fraser Valley of British Columbia. His mother was the primary caregiver. He was referred to the therapist for this project by his sister’s therapist, when Jaydee’s mother became aware of Lifespan Integration therapy as a viable treatment option for Jaydee’s trauma history and specific fears and anxiety. At intake, Jaydee and his mother agreed that nighttime dream-related fears of certain television and videogame characters were problematic for Jaydee, and interfered with both sleep and daytime thoughts. Jaydee’s mother also reported serious sibling conflict between Jaydee and Abigail (requiring police involvement on two occasions) and an insecure attachment between Jaydee and his father, such that Jaydee was often triggered towards violence when his father came home from work. His attachment with his mother was much stronger. Jaydee had a lengthy diagnostic history, receiving diagnoses at age 4.5 years of Attention Deficit Hyperactivity Disorder (ADHD); Oppositional Defiant Disorder (ODD); Affective INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 39 Disorder, NOS; and Substance-Related Neurodevelopmental Disorder (SRND). Further diagnoses include: High Functioning Autism Spectrum Disorder at age 6; Specific Learning Disorder in Math and Specific Learning Disorder in Written Expression at age 10; and Fetal Alcohol Spectrum Disorder (FASD) at age 10. Other problematic symptoms include inflexibility to change, anxiety about the future, extreme emotional reactions to any small variation outside of an expected event, and difficult regulating emotional arousal. Jaydee purposefully irritated others, including his sister and the family dog, and had significant anxiety associated with aggressive behaviour towards others. Safety plans were in place for other family members and adult caregivers. Attachment trauma. Early developmental trauma for Jaydee began pre-birth, as there was a history of cocaine, alcohol, tobacco, and marijuana use by his biological mother during pregnancy. His birth mother had been engaged in prostitution before and during her pregnancy with him. Jaydee’s birth mother was hospitalized for painful kidney stones during pregnancy, but left the hospital before receiving treatment to get a cocaine fix. Jaydee was apprehended from his biological mother at birth. It is likely, given the history of his older siblings who had both been taken away from her, that his birth mother expected Jaydee to be apprehended, or may have even planned to give him up, and this may have limited her emotional bonding with him in utero. Jaydee was born at 42 weeks’ gestation and weighed 9 pounds, spending 12 days following his birth in the Neonatal Intensive Care Unit (NICU) due to breathing and other health difficulties. He was then placed in foster care until age 9.5 months. His adoptive mother described the placement environment as “less than nurturing,” reporting that Jaydee was not held and spent most of his time in a baby seat in a playpen shared by another infant, and that the INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 40 foster parents described efforts such as averting their gaze from Jaydee “so that he would not become attached.” When he was adopted at 9.5 months, he reportedly acted as if he had never been on the floor, trembled when held, and seemed like a newborn developmentally. Another key psychosocial trauma related to adoption occurred at age 5, when close family friends of Jaydee’s adopted family had their adopted children suddenly and unexpectedly removed from their adoptive home, following a lawsuit filed to Ministry of Child and Family Development (MCFD) by their birth relatives who had previously not shown interest in raising them. Jaydee reportedly became increasingly clingy and fearful after this incident, with some of his current fears being related to this developmental period (e.g. preschool-age television show characters). Quantitative outcome data. The following is a description of the changes in scores from the BASC-2, PRQ, and the Kern’s Security Scale, measured at pre-therapy, post-therapy, and 1 month follow-up. The weekly PQ scores are also discussed in terms of trends seen over the course of therapy. BASC-2. After using the standard error of measurement to calculate 95% confidence intervals for Jaydee’s BASC-2 T-scores on the clinical and adaptive scales, it was found that across the three measurement points, all of Jaydee’s scores were likely to fall in the average range. However, a number of scale scores described clinically relevant change across time. On the Anxiety scale, his score stayed within the average range over the course of therapy, although it did decrease within this range at post-therapy and follow-up. Jaydee’s scores on the Attitude to School scale indicated a greater risk (within the average range) for disliking school at pretherapy than at post-therapy, and at follow-up this decrease had been maintained. The Relations with Parents scale saw steady increase within the average range across the three measurement INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 41 points. The Interpersonal Relationships scale scores also increased within this range with a large increase happening from post-therapy to follow-up. As Relationship to Self plays a big role in LI work, the scores on this scale were noted to be within the average range across the three measurement points, with no change in scores from pre-therapy to post-therapy, and a small increase from post-therapy to follow-up. Jaydee’s parents completed the PRS portions of the BASC-2, and reported several at-risk problems for Jaydee through their scores. Both parents rated Jaydee as being “at risk” in the scale of Aggression at pre-therapy; at post-therapy, his father’s score on this scale decreased minimally within the at-risk range, while his mother’s score was in the average range. At follow-up assessment, his father’s Aggression had further decreased to the average range. For the Anxiety scale, Jaydee’s scores by his father were “clinically significant” at pre-therapy and decreased significantly to the “at-risk” range at post-therapy and follow-up. His mother’s Anxiety scores descriptively decreased within the “at-risk” range from pre-therapy to post-, and then moved into the average range at follow-up. At pre-therapy, both of Jaydee’s parents rated Jaydee as being “at risk” in the Adaptability scale; at post-therapy, both parents’ scores decreased to fall within the average range. At follow-up for the Adaptability scale, Jaydee’s father’s questionnaires fell within the “at-risk” range again, while those by his mother increased slightly within the average range. Jaydee’s main classroom teacher and main educational assistant completed the TRS for the BASC-2 at pre-therapy and follow-up, with the educational assistant also completing the form at post-therapy. These ratings saw the least amount of change over the course of therapy. For the Anxiety scale, Jaydee’s regular teacher reported an average score, with a slight increase at follow-up within the higher end of the average range. Jaydee’s EA reported “clinically INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 42 significant” Anxiety in Jaydee across the three measurement points, with the highest score being at post-therapy followed by a slight decrease at follow-up. The Attention Problems scale also saw some change, as scores from both professionals decreased from being “at-risk” at pretherapy to “average” at follow-up. PRQ. Changes in parenting relationship problems were observed by one or both of Jaydee’s parents on every scale of the PRQ except for Satisfaction with School Services, which fell in the average range across measurement points for both parents. In particular, the Attachment scale saw change with Jaydee’s mother’s score increasing within the average range at post-therapy, while Jaydee’s father reported a decrease at post-therapy and an increase back to baseline at follow-up. At post-therapy, both parents’ scores decreased to the “lower extreme” range on the Discipline Practices scale, demonstrating more inconsistency in parenting, while this increased to “significantly below average” at follow-up. Jaydee’s mother also reported less relational frustration at post-therapy and follow-up, with her scores significantly dropping from “upper extreme” to “average” on the Relational Frustration scale. On this same scale, Jaydee’s father’s decreased from “upper extreme” to “significantly below average” at post-therapy; however, at follow-up this decrease was not maintained. Kerns Security Scale. Jaydee’s understanding of the attachment relationship with his adoptive parents was reported in a quantitative score at pre-therapy, post-therapy, and follow-up. As this scale is typically used to compare individuals within group, no norms were available to compare Jaydee to. Jaydee was consistent on over half the items across the three assessment points, indicating felt security on many of these items. Some items showed strong or moderate improvement over time, while two items showed no change or a slight change towards greater insecurity. One item that demonstrated improvement towards security was “Some kids feel their INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 43 [mom/dad] butts in a lot when they are trying to do things, BUT other kids feel like their [mom/dad] lets them do things on their own.” At pre-therapy, Jaydee responded as really true for the former type of child, while at post-therapy and follow-up he found the latter type of child to be really true for him. Jaydee’s total score on the Kerns Security Scale was x=46 (out of 60) at pre-therapy, increased to x=52 at post-therapy, and again increased to x=58 at follow-up. While these numbers suggest change, they are used to observe descriptive change rather than significant psychometric change in Jaydee’s felt security over the course of therapy. Weekly PQ ratings. Several of Jaydee’s PQ items changed significantly by two or more points. These items were: nightmares (decreased by three), difficulty going back to sleep after nightmares (decreased by four), fear of the dark (decreased by three), daytime worries about nightmares (decreased by two), stress and worry about homework (decreased by two), troubles starting homework (decreased by two). All other items decreased insignificantly by one point. Figure 1. Tracking of Jaydee’s PQ mean throughout therapy Jaydee’s mother’s PQ, reflecting her assessment of Jaydee’s problems, also had many items that changed significantly (two or more points) over the course of therapy. These items INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 44 were: extreme emotional reactions to family members (decreased by two), provoking conflict or aggression with family members (decreased by three), nightmares (decreased by two), fear of dark (decreased by two), stress and worry about homework (decreased by four), difficulties with homework (decreased by two), fear of unknown (decreased by three), fear or anxiety for no reason (decreased by three). All other items decreased insignificantly by one point. Figure 2. Tracking of Parent PQ mean throughout therapy Qualitative outcome data. Helpful Aspects of Therapy questionnaires. Jaydee and his mother both reported on what they found was helpful and/or hindering about each session. Jaydee rarely reported any unhelpful moments in his therapy over the course of the 10 sessions. He reported many helpful or important events, including talking about his fears, talking about his baby self, and telling about his dreams/nightmares. His explanations for why these events were helpful were not very descriptive, but occasionally he gave reasons for why the baby self was helpful - reassurance to show this self what had happened in his life and how he had grown up. When prompted, he did INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 45 acknowledge during two sessions that it was uncomfortable and upsetting to have his mother work with the baby doll self. His mother reported many helpful events and experiences in therapy sessions, including the therapist’s encouraging words to Jaydee, the memory cues, giving Jaydee the freedom to choose when to have her in the room, and persisting through different parts of the therapy (e.g. baby doll attunement) despite Jaydee’s resistance. She felt these helped Jaydee connect well with the therapy and showed him how they (mother and therapist) believed in him to do difficult things. Additional helpful events included using tree rings as a metaphor for ego states, the sand table, and the nesting cups used in therapy. Hindering events included the occasional increase in temperature in the room that may have affected Jaydee’s concentration, and the inability to include Jaydee’s father and sister in therapy at this point, as she believed their relationships with him would really benefit from being a part of the process. Change Interviews. Many things mentioned in the HAT questionnaires were brought up in the change interviews with Jaydee and his mother, administered at post-therapy and follow-up. The full change interview responses can be viewed in the rich case record (Appendix H). Main areas of interest in these interviews are changes noticed over the course of therapy and discussions of the therapy itself. For example, Jaydee reported at post-therapy and follow-up that he no longer had nightmares, he did not worry about his nightmares, he could control his emotions better and he rarely fought with his sister (see change list below, Table 1). He reported that nothing had changed for the worse since therapy started, however, at follow-up he did note that school anxiety was rated slightly higher on his PQ because his class was learning new topics, but it did not really bother him. As for describing therapy, he reported that he did not really like his mother with him in sessions, as it was stressful for him and he liked to be more INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 46 independent. He found their relationship to have changed at post-therapy to be described as liking and loving his mother more, and at follow-up said this had stayed the same. At follow-up, Jaydee found everything about therapy to be helpful to him, even if he did not understand how it all worked. He also said that although the baby self parts of therapy were hard for him, including his mother holding the doll, he acknowledged this was helpful. He also reported enjoying the research process, with no suggestions for what to change with research or therapy. Table 1. Jaydee’s Post-therapy Change List and Ratings Change Change was: 1- expected 3- neither 5- surprised by 1. I don’t get afraid so much. 2. I rarely fight with Abigail. 3. If I have a bad dream, I work it out instead of calling for mom. 4. When I get angry, I calm down easier. 2 3 4 3 2 1 Importance: 1-not at all 2- slightly 3- moderately 4- very 5- extremely 5 4 4 5 4 3 Without therapy: 1- unlikely 3- neither 5- likely Importance: 1-not at all 2- slightly 3- moderately 4- very 5- extremely 4 4 3 3 Table 2. Jaydee’s Follow-up Change List and Ratings Change Change was: 1- expected 3- neither 5- surprised by 1. Nightmares have stopped. 2. Less fighting with Abigail. 3. Not afraid of the dark. 4. More in control of my emotions (sadness, anger, happiness) 2 3 1 2 Without therapy: 1- unlikely 3- neither 5- likely 3 3 2 3 Jaydee’s mother also reported similar themes in her change interview as in her HAT responses. She described Jaydee as being happy most of the time, having a better relationship with his father, and instigating less conflict with his sister. She mentioned that their relationship INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 47 was doing well, as exemplified at bedtime when he requested his parents to stay with him because he loves them and wants to be close to them (rather than expressing fear of nightmares or darkness which was present at beginning of therapy). She reported seeing him become less volatile and less blaming since therapy started, and less concerned about school, although she attributed this to changes in school rules for him. At follow up, she said that all her goals for therapy were met. When commenting on what happened between Jaydee and herself in therapy sessions, she described how he used her to regulate by being very snuggly and lovey-dovey during and after session. Jaydee’s mother attributed the changes observed to several extratherapy changes as well as the therapy itself. The only stressful part of therapy for her was the commute to therapy, as it was located at least half an hour away from their home. She also mentioned the baby doll part was difficult for her, although she viewed this as helpful. Her hope for future LI sessions was to include Jaydee’s father and sister. In rating the expectedness of the changes experienced since therapy started (Table 3), Jaydee’s mother was unclear about the difference between expected and hoped for. At pretherapy, her ratings reflected more of her hopefulness that these would happen, rather than her beliefs and expectations about therapy. At follow-up this was further clarified, and she rated based more on her expectation beliefs (Table 4). Table 3. Jaydee’s Mother’s Post-therapy Change List and Ratings Change Change was Without therapy, expected to surprised was unlikely to by likely 1. Less volatile, less 1 1 provoking 2. Less blaming others 4 1 3. Nightmares stopped 1 1 4. Casual about 2 1 schoolwork (less stress about homework) Importance not at all to extremely 5 5 5 5 INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 5. No need for pullups 6. No daytime fears about nightmares 1 1 Table 4. Jaydee’s Mother’s Follow-up Change List and Ratings Change Change was expected to surprised by 1. Less volatile, less 1 provoking 2. Less blaming others 4 3. Nightmares stopped 1 4. Casual about 2 schoolwork (less stress about homework) 5. No need for pullups 1 6. No daytime fears about 1 nightmares 48 1 1 5 5 Without therapy, was unlikely to likely 1 Importance not at all to extremely 1 1 1 5 5 5 1 1 5 5 5 TSNQ. The Therapist Session Notes Questionnaire revealed several trends regarding the therapist’s perception and interpretation of what the client was experiencing in LI therapy. From the first session, the therapist found some of the most helpful or important events to be related to how the client understood and represented his baby self. The therapist reported that demonstrating awareness of the client’s baby self helped to activate the younger feeling states that were behind the presenting fear. An important part of therapy occurred with the introduction of the baby doll, as the client demonstrated discomfort, dislike, and rage towards the doll representing his younger self. The therapist interpreted this as linking the client to extremely painful embodied memories related to his early attachment trauma as an infant. The therapist also reported that having his mother hold the baby doll and act affectionately towards it even when the client expressed discomfort and resistance was especially helpful for an attachment repair focus. In particular, the therapist noticed parts in each session when the client would physically demonstrate his attachment to his mother through proximity and contact seeking INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 49 during timeline repetitions; initiation and maintenance of communication; secure base exploration when the client chose to be in session alone; and emotion regulation development throughout the course of therapy. Hindering moments included temperature in the room and the client’s resistance to participating in certain activities, particularly around the baby doll repetitions. Case Development and Adjudication Two teams of three experts each (graduate students, child therapists, and LI therapists) met to argue for and against change in the client over the course of therapy and the degree to which therapy brought about this change. Affirmative and skeptic briefs were compiled, as were rebuttals from each team (see Appendix I). These arguments were presented to three expert adjudicators who made final decisions about change and the therapy's role in the change. Below are the summaries for each perspective and step. Affirmative brief. All four types of evidence for change were addressed in the affirmative brief, including change in stable client problems, outcome-to-process mapping, event-shift sequence, and process-outcome correlation. Key areas of change in stable client problems included support from the client and parent’s PQs and Change Interviews, as well as the therapist session notes. These demonstrated an increase in positive mood, confidence, empathy and relationship with parents, and a decrease in anxiety, including specific fears. Outcome-toprocess mapping evidence included the client choosing to be without his mother in some sessions as a demonstration of ego development, as well as session summaries demonstrating insight and trauma resolution. A particularly poignant demonstration of integration occurred in the final session, when the client said “I think [my baby self] has turned 12 and a half, right now.” Behavioural markers - infant-like actions to paraverbal voice changes, a closeness with his INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 50 mother, and a new ability to fight back during nightmares - were listed as a demonstration of event-shift sequence evidence. Specific processes - the baby doll attunement activities, repetitions of the timeline, and the use of the nesting cup (all LI interventions) - were named as helpful for change and exemplified evidence of process-outcome correlation. Skeptic brief. The skeptic brief included evidence addressing a lack of change or nontherapeutic explanations for change. Nonimprovement was observed in some scales of the PRQ (father and mother) and in the teacher rating scales of the BASC-2. Measurement error was suggested with regards the client’s post-therapy change ratings. Relational artifact was discussed as a possibility because the therapist and researcher roles were observed to be blurred for the client. Change was thought to be overemphasized in the qualitative measures in light of lesser change in the quantitative measures. Expectancy artifacts were suggested alongside the client’s motivation to help science, which may have influenced his willingness to report change. The client’s mother’s familiarity with LI also may have influenced her reports on change. Extratherapy events were reported as helpful by the client and his mother as well, and so these items were related to change. The reactive effects of research were related to change in the client, since he seemed to flourish under the attention from two professionals and extra one-to-one attention with his mother. Affirmative rebuttal. The affirmative team addressed the argument of lack of change on some scales as not being relevant to LI therapy or clinical goals. They reasoned that a core process of therapy was to address Jaydee’s attachment with his mother, thus changes observed by teachers and in relationship with his father were not expected after 10 sessions of LI. It was also argued that although some of Jaydee’s SRP BASC-2 scales did not show positive change, other forms of self-report did, suggesting the quantitative measures were inadequate for fully INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 51 capturing Jaydee’s progress. A comment was also made that inconsistencies observed in Jaydee’s reporting are expected under the LI model, as a demonstration of his ability to shift between ego states to answer these questions. It was also considered developmentally appropriate for a 12-year-old to have some reporting inconsistencies. Extratherapy influences were also addressed in the rebuttal, again stating that the LI repair phase of treatment brought up much resistance from the client that correlated with observed change. It was noted that Jaydee’s ability to relate his discomfort and extreme reactions to certain forms of therapy made it unlikely that he would have the capacity to placate the researchers during measures such as the HAT and Change Interview. Skeptic rebuttal. The skeptic team found that there were affirmative claims that lacked sufficient evidence in the rich case record. One of these claims was about Jaydee displaying increased empathy over the course of therapy, as they noted that during session 7, Jaydee’s mother had reported Jaydee being rude to his father. They also suggested cognitive growth examples were due to developmental maturity over the course of 6 months. A discussion was had around whether Jaydee asking his mother to leave session a few times over the course of therapy was a display of secure or insecure attachment. The skeptic team argued that it could be seen as a sign of insecure attachment, as he was not ready to be vulnerable in front of his primary attachment figure and could not tolerate this level of intimacy with her. The argument was again made that other extratherapeutic factors may have contributed to any positive changes observed in Jaydee, as well as other non-LI therapeutic factors, such as the use of sand tray and games. Adjudication. Three expert adjudicators were contacted to be a part of the adjudication process. Upon agreement, they were given the rich case record to peruse, the affirmative and skeptic teams’ cases and rebuttals (in the order presented above) to consider, and the INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 52 adjudication form to complete. They were given 2.5 weeks to complete the adjudication form on their own, consulting the researcher and therapist as necessary. The forms included their determinations of change over the course of therapy, their assessment of the degree to which change was due to LI therapy, and their discussion of mediating or moderating factors in the change observed (see Appendices J, K, and L). In order to determine the majority of determinations amongst the three adjudicators, the median scores can be used, as recommended by Stephen, Elliott, and MacLeod (2011). A summary table of the adjudicators’ determinations present each adjudicators’ scores and the median for each question. Table 5. Adjudicators’ Scores for Change 1. To what extent did the client change over the course of therapy? 1.b. How certain are you? 2. To what extent is this change due to therapy? 2.b. How certain are you? Adj. A 80% Adj. B 80% Adj. C 80% Median 80% 80% 80% 80% 60% 80% 80% 80% 80% 100% 80% 80% 80% Change over course of therapy. Adjudicator A found four key areas of change (i.e. decrease in anxiety, decrease in problematic nightmares, increase in insight about baby self, and increase in emotion regulation) that were substantiated by quantitative or qualitative measures, or both (see Appendix J). Adjudicator B found that the most compelling evidence for change came from the client and parent self-reports, the therapist’s observations and session summaries, and the demonstration of positive relationship with parents from multiple reports (see Appendix K). Adjudicators A and B noted that the skeptic case’s argument about lack of quantitative change was not relevant to the goals of this client’s therapy. Adjudicator C based the decision for change on the affirmative team’s notes on Jaydee’s mood, his comments on his baby self becoming older, his interest in his birth mom, his increased developmental appropriateness, and INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 53 his fighting back in nightmares (see Appendix L). This adjudicator also noted that the skeptic team’s argument for the lack of improvement in relationship with his father, the influence of the research interviews being done sometimes by the therapist, and the changes in professionally observed areas (i.e. changes in school and family therapy interventions) also influenced the decision on change over the course of therapy. Change due to therapy. Adjudicator A stated that the change outcomes for this client are commonly observed in many Lifespan Integration clients. Session summaries, therapist notes, and HAT interviews contributed to this determination. Adjudicator B described the client’s demonstration of ego development and increased insight as influential in attributing change to therapy, as well as the increased and maintained connectedness with his mother. For this adjudicator, skeptic arguments about extratherapeutic factors of extracurricular activities and the increased attention received due to therapy were compelling. Adjudicator C listed affirmative case evidence including the mother’s change interview attributions and Jaydee’s perception of his baby self changing, as outlined in session summaries. This adjudicator also found the emphasis of LI timelines being connected to change important. Skeptic team arguments for expectancy effects and the involvement of other therapists were also considered by Adjudicator C. Mediating factors. Adjudicator A noted that helpful therapy processes included: the presence of an experienced, warm, and coherent therapist; support from mother in therapy; LI timeline repetitions; cognitive interventions combined with LI concepts; reenactment of nightmares; respect and cooperation with Jaydee’s desires for being with his mother or apart; self-soothing activities and objects; and encouragement and reward for tolerating distress in therapy. Adjudicator B listed the baby doll, sand tray, doll house, psychoeducation of fears, INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 54 tree/branches metaphors, and the concept of the baby self as helpful therapeutic processes. Adjudicator C found that the repetition of timelines was helpful, as evidenced by his mother’s report, and also listed factors similar to the other adjudicators. This adjudicator noted that it is common for children to not mention the LI timelines as helpful processes in therapy, and wondered if his mother’s of the baby self was associated with Jaydee’s resistance due to jealousy of the particular doll, rather than experiencing it as his baby self. Moderating factors. Adjudicator A listed several of Jaydee’s personal resources that enabled him to make the best use of therapy, including his capacity to engage with the therapeutic processes as an individual agent while also emotionally connecting with his mother. His ability to engage with the LI therapy timeline repetitions and to move between ego and emotional states was also useful, as these are considered difficult tasks for young people to complete. Adjudicator B described Jaydee’s ability to self-reflect and access or feel empathy as characteristics that enabled him in therapy, as were his relationship with the therapist and his mother. Adjudicator C noted that the client’s mother was a major personal resource for the client, including her involvement in therapy, knowledge of the therapy, awareness of mental health issues associated with adoption, and open stance to meeting with Jaydee’s birth mother and siblings. Other resources included a decrease in the demand of school work and Special Olympics activities providing social support for combating anxiety experiences. In summary, all adjudicators agreed that change occurred, and that most of this change could be attributed to LI therapy. These conclusions are “significant” under the HSCED method, as an 80% median across judges is sufficient as a reasonable standard of proof in providing clear and convincing evidence for client change and client change due to therapy (Stephen & Elliott, INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 2011). Adjudicators’ decisions were based on an analysis of qualitative and quantitative evidence, as argued and presented by the affirmative and skeptic teams. 55 INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 56 CHAPTER 5: Discussion The case of Jaydee is used to draw conclusions about Lifespan Integration and the HSCED method, as well as reflections on the flexibility of attachment processes in middle childhood. Conclusions drawn from the case are based on the adjudicators’, whose role was to make decisions based on data collected and presented by the researcher. It was the adjudicators’ role to evaluate and address any concerns with the data given in the rich case record and affirmative/skeptic briefs, and to make a decision about the client’s change outcomes due to therapy. From these conclusions, reflections about attachment processes are added to situate this case in existing attachment literature and research. Reflections on LI and HSCED In this HSCED study, Lifespan Integration is judged to be helpful and effective in addressing Jaydee’s presenting concerns considering his adoptive and attachment trauma. After consulting the rich case record, as well as the affirmative and skeptic teams’ cases and rebuttals, a majority agreement was reached that Jaydee experienced substantial change (80% median) with 80% certainty. The extent to which this change was attributed to therapy was also substantial (80% median) at 80% certainty. Using the median is appropriate for representing the majority decision in the HSCED method (Stephen, Elliott, & Macleod, 2011), and 80% is an acceptable standard of proof that represents “clear and convincing evidence” (Stephen & Elliott, 2011, p. 238). The HSCED method also allowed for an examination of the process of change experienced in LI therapy and the various parts of LI therapy that were useful. Client change. The examination and decision-making process of Jaydee’s change was based on various factors and evidence. One adjudicator relied on qualitative evidence that best fit with common experiences of those in LI therapy. Another adjudicator relied on the qualitative and INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 57 quantitative data to reflect change due to LI, without the benefit of fully understanding the LI process herself. Finally, the third adjudicator paid close attention to the HSCED-specific measures, including the PQ, HAT, and Change Interview to rely on the client’s, parent’s, and therapist’s accounts and attribution of change. It should be considered in reviewing the data collected for Jaydee that his goals were particularly focused on internal experience and family life. The affirmative team and two of the adjudicators specifically mentioned that a lack of change observed in quantitative measures from Jaydee’s teachers was not relevant to client and therapist goals. Furthermore, these experts also commented on how other standardized measures (e.g. father’s parenting measures, client’s own quantitative self-report) may not have been appropriately capturing the aspects of family life and internal experience that the therapy was targeting and that were important for the client and his family. Furthermore, Jaydee’s clinical diagnoses include learning disabilities that may have interfered with his ability to understand the standardized quantitative measures. Therapeutic processes. Lifespan Integration processes were considered to be causal influences of Jaydee’s change. The LI timelines helped integrate the different ego states that were triggered for Jaydee when his prenatal development, birth, foster and adoption experiences were discussed and imagined. Repair in the form of the baby doll being introduced as a good representation of self and having his mother demonstrate love and safety to the doll were also considered pivotal moments for the client. Common factors represented in almost all therapies were considered especially influential in the client’s experience of LI therapy and are discussed. Attachment as a key mechanism of change as well as an outcome variable is also discussed. Timeline. The two adjudicators familiar with LI therapy judged Jaydee’s change to be attributed to the LI timeline, and the other adjudicator listed how Jaydee’s experience of “hearing INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 58 his story” was impactful and helpful. In LI therapy, the timeline is what integrates earlier experiences into the present understanding of self. Those who have experienced repetitions of this timeline report that their younger or baby selves are no longer trapped in time; that is, that the younger self now realizes it is inside a person who is older, at a current age. As Jaydee reported in his final session for this study, “He turned my age right now!” (see RCR, Appendix H). By imagining or recalling the younger ego states and then being walked through one’s timeline cues by the therapist, Jaydee was able to integrate that younger ego state into his present autobiographical narrative with the understanding that the younger ego state is in the past and no longer experiencing the trauma he once did. Baby doll attunement protocol. Introducing the physical baby doll to represent Jaydee’s baby self brought about a lot of change in Jaydee’s behaviours in session. These behaviours (e.g. whining, yelling, aggressive eye contact, etc.) demonstrate resistance to the imaginal repair work that was so opposite to what he had originally experienced as a baby. The presence of the baby doll activated these unconscious body-based memories of being an emotionally neglected infant. After these moments were imagined and activated, the LI timeline was used to integrate them into the present understanding of self. Jaydee’s mother was also given an opportunity to express love, safety, emotional understanding, and care for the baby doll. One adjudicator wondered if Jaydee was jealous of this attention from his mother to the doll, which brought about his aggression. This may have demonstrated that Jaydee was unable to feel that he and that doll were one person, and so this exercise may have been merely helpful in activating unpleasant unconscious memories to be integrated through the timeline. A suggestion from the same adjudicator was to do imaginal repair work with Jaydee without the visual distraction of his mom talking to “another” baby. INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 59 Common factors. The adjudicators did note factors that were useful but not specific to LI, such as the presence of a warm, understanding, and encouraging therapist. Jaydee demonstrated having a strong relationship to this therapist, especially when inviting her to be with him when he would meet his birth mother in the future. However, many factors specific to this type of LI therapy, such as connecting to the baby self, the timeline repetitions, the physical baby doll, and having his mother engaged as an attuned presence were also listed by the adjudicators as helpful. Jaydee’s change is not attributed solely to the common factors of many therapies. Attachment factors. One of the aims of this study was to understand the attachment processes at work in LI therapy. According to LI conceptualization and one of the expert adjudicators, Jaydee’s ego development over the course of therapy was a demonstration of coherence and increased internal attachment with his sense of self. His relationship with his mother and father were reported in the Change Interview as improved, with decreased aggression towards his father, and more love and enjoyment expressed for his mother and his father. Even his sibling attachment was considered to have improved, with his mother noting a decrease in conflict, and attributing current conflict to his sister’s difficulties, rather than his own. Attachment was also considered a mechanism for change throughout LI therapy. In the beginning phases, Jaydee displayed more infant-like behaviours when imagining his baby self and going through the timeline, and he physically used his mother’s body and presence to regulate through snuggling and sensory-seeking behaviours. Later, when he chose to be in therapy without his mother and then re-connected with her at the end of session, he demonstrated security to explore without her and then return to her as a secure base for further comfort and connection. This individuation and connection process was supported by both mom and the INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 60 therapist. Another way attachment worked in this LI therapy was that his mother and the therapist worked well together to attune to Jaydee’s needs in session and throughout the process, allowing Jaydee’s mother to be the primary attachment figure for him with the support of the LI therapist. Therapeutic considerations and future directions. Jaydee’s clinical presentation at the beginning of therapy was representative of what child therapists might see in their office on a regular basis. As discussed in the literature review, adopted children are seen in therapy with a variety of presenting issues, including multiple diagnoses, and middle childhood is especially the age where early attachment traumas start manifesting as internalizing and/or externalizing symptoms. The changes observed in Jaydee over the course of therapy indicate that Lifespan Integration is a good fit for children who have experienced attachment trauma and whose caregivers are looking for a therapy that builds upon core attachment processes as well as resolving current anxieties or behavioural problems. In working with Jaydee, the therapist demonstrated that LI requires creativity when working with children, using a variety of objects and tools to gain interest from the child client and to make the abstract concepts more concrete. Jaydee’s therapist used the metaphor of a tree trunk’s rings to illustrate one’s timeline and how each piece of a person’s timeline can have impact on the present. She also used nesting cups to explain the timeline, with the baby self being the smallest cup inside. These techniques are recommended and used by a variety of LI therapists who work with children. Unique for Jaydee, at the suggestion of his mother, was the use of two timelines written on cue cards and bound with a ring, to keep Jaydee from getting bored with following the same timeline each time a repetition was done. A game was sometimes made of these rings, in that they would be hidden in the sand or behind the therapist’s back, and INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 61 Jaydee had to “find” or “choose” which one to do first. The sand tray was also an added component of Jaydee’s therapy, as it was used both for regulation purposes during and between timelines, and was also used for concrete objects when discussing timeline activities, such as when using nesting cups. The use of a weighted blanket was helpful for sensory soothing and emotion regulation when Jaydee accessed vulnerable emotional states. It was also helpful for the therapist to consult with Jaydee’s mother before each session and receive her observations from the week before beginning with Jaydee. LI protocols used were the baseline protocol, the birth-to-present protocol, and the attunement protocol. The baseline protocol was used in the beginning of therapy to orient Jaydee to the timeline process from a few days after his birth to the present. This was modified at times to have Jaydee connect with his baby self and show the baby self his timeline with varying starting points, including pre-birth development, depending on what the therapist thought Jaydee could handle. The birth to present protocol was introduced to link Jaydee’s baseline timeline to his traumatic birth and early life experiences, integrating these preverbal experiences into the present through the timeline. When the therapist judged Jaydee to be ready, the birth-to-present and attunement protocols were used by introducing the baby doll in session, with Jaydee’s mother holding the doll (representing Jaydee) and speaking words of love to the doll when prompted by the therapist throughout the timeline. These protocols using the doll brought about the most resistance in Jaydee, and so in later sessions the therapist would find a delicate balance between using these protocols and other therapeutic techniques, including baseline protocol, that Jaydee found less threatening. Future directions for LI therapy with children should continue the use of concrete objects in the room as both visual representations of LI concepts as well as for regulation throughout the INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 62 powerful therapeutic moments of LI. Close attention should be given to the way a child reacts to each protocol, using baseline when necessary to calm the child down, and introducing attunement protocol only when the therapist believes the child to be ready, after baseline and birth-to-present have been introduced. Future LI research directions. For a therapy that has much clinically rich anecdotal evidence, there is little published research about Lifespan Integration therapy. Research that has been done with LI has focused on trauma repair (Balkus, 2012), attachment in adults (Hu, 2014), and trauma in children (Rensch, 2015). This study adds to the research in focusing on LI for attachment trauma and repair in children. Further research would benefit from examining other age groups across the lifespan, including those at the chronological extremes of early childhood and older adulthood, in order to test the boundaries for LI according to age, and to reveal any adaptations necessary for working with these populations. Future research with both adults and children would benefit from a focus on neurological correlates through the LI therapy process. This is because LI, including its attachment premises, is strongly rooted in interpersonal neurobiology; thus confirming its neurobiological underpinnings would be useful in increasing its validity. Although it is appropriate and useful to use the HSCED method to understand the processes of LI in a variety of clinical populations, a further research step for the LI community would be to study multiple participants at one time (i.e. Randomized Clinical Trials) to be able to generalize conclusions to a wider population. HSCED implementation and enhancement. Following the example set by Rensch (2015), a number of HSCED measures were adapted to fit the research question of the current study, including the child-appropriateness of such measures. Elliot’s original measures are well represented in the parent’s forms, while the integrity of the measures was kept with adaptations INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 63 that were made for the child forms. The implementation of these changes also allowed for reflections on enhancement for the method with children in the future. Child Friendly. The adaptations made were for children in middle childhood. These adaptations were evident in the Personal Questionnaire, the Helpful Aspects of Therapy form, and the Change Interview. Although the child participant in this study was 12 years old, he presented as developmentally younger, representing middle childhood quite well. PQ Adaptations. Personal Questionnaire items were generated with the child, the parent, the therapist, and the researcher present. Each item was only added to the official PQ list at the agreement of the child, giving the child agency in the process. Seven different emoticons used to represent each degree of “bother” the client may have felt for each item. The original PQ descriptor items were present at the top of the paper for reference, while the smile options replaced numbers for every item. Jaydee seemed to understand these faces well, and also agreed with the verbal descriptors when commented on by the researcher (e.g., “You found that one to bother you “moderately” this week”). His mother also completed her version of the PQ, with some items being the same as the child’s and others being specific to the parent about her child. This allowed for the child’s perspective to be respected, while also including any additional or separate information the parent may add to the data collected. HAT Adaptations. For the child form, the number of questions were reduced to three main questions. The second two questions reflected the main focus of the adult HAT form in understanding how the client identified and understood helpful and hindering events or experiences in the session. Reducing the number of questions helped to make the process simple, requiring little energy from the client, on the understanding that he would be already quite fatigued from the session itself. The first question, merely identifying the most memorable INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 64 part of the session, was added to the child form to help the child begin reflecting on their session without the added pressure of evaluating the events of the session. This memory cue was then used as a basis for the following questions. Often, this was proven useful by Jaydee’s naming that same event as helpful during his reflection. However, we still did not receive much in-depth exploration of the whole session from Jaydee, which is expected for a child client. If this is important to future research, a suggestion may be to have a list generated by the therapist -or from a live viewing of the video feed by the researcher- of the events of the session. This list could be gone through with the client to check the degree of helpfulness or hindrance for each event. However, the nature of the HAT form in the HSCED method is to allow for more organic responses from the client, and so the adaptation we used allowed for this. The ratings of each event’s helpfulness or hindrance again used an emoticon scale, with five faces and dots between each pair of faces to represent the nine items found on the adult HAT form. The client was able to demonstrate his understanding of this scale by having appropriate variety amongst these rating options throughout the research process. Change Interview Adaptations. Change Interview adaptations, based on a previous version with children (Rensch, 2015), were made to be both child friendly (i.e., simpler wording in questions) and more attachment-focused. More prompts were added for the child interview to help the client generate in-depth answers, including a summary of events or experiences that happened in session for appropriate questions. A prompt was added to a few questions, “How would you describe or promote this therapy for other kids?” This prompt helped the client reflect on what he liked about his therapy or what he found was helpful. Research team and adjudicators. Experts were selected for the research team who had extensive knowledge in one or more relevant fields for this study. Criteria for selecting these INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 65 experts included expertise in LI therapy and practice, child development and therapy, and/or attachment trauma in children. Graduate students and community professionals were included in the case development teams; however, only community professionals were used for the adjudication panel. The aim of selecting experts from the community was to increase rigour and trustworthiness, as seen in other HSCED studies (e.g., Wall et al., 2016), as these experts would presumably have more clinical experience with these topics than graduate students. One of the adjudicators is considered a leading world expert in LI therapy with children, and so this bias towards LI was countered by selecting another adjudicator who worked extensively with children and youth but did not have LI training or experience. The third adjudicator was familiar with both LI and other trauma therapies for children, and was very comfortable with the HSCED method due to his own research interests. While LI therapy timelines and activities were more explicitly outlined as helpful by the first and third adjudicators, the second adjudicator (without LI experience) still named the baby self and other LI related elements as helpful and connected to client change. Limitations and Future Directions for HSCED. One item from the Change Interview needed to be clarified from the post-therapy interview to the 1-month follow-up. When rating the change list post-therapy, Jaydee’s mother inquired if “expected” change was the same as “hoped for” change. She answered this question as a combination of both concepts at posttherapy, and at the 1-month follow-up a definition, “belief that change will happen,” was provided upon consultation with the research supervisor. This question and clarification process was provided to all experts in the rich case record for their understanding and consideration of how this may have influenced her expression of change observed. No experts brought this up as INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 66 a confounding variable in the study. Further researchers may wish to clarify this concept as well as others for future Change Interviews. As the HSCED process allows for the selection of a variety of measures to be used in addition to the PQ, HAT, CI, and TSNQ, a focus for additional measurement included the key concept of attachment. While the PRQ is considered a standardized measure of parent perceptions of the parent-child relationship, a goal was set for the current study to have some measure of the child’s experience of attachment. The Kerns’ Security Scale was able to provide a sense of Jaydee’s attachment beliefs towards his parents, but this was not a standardized measure. Case developers considered it as useful to the clinical picture, but referred more to the PRQ than to this Security Scale. Future HSCED studies that want to examine parent-child attachment may wish to use a more comprehensive understanding of child attachment, such as the Child Attachment Interview (Target, Fonagy, & Shmueli-Goetz, 2003). One addition to the case development and adjudication proceedings included an invitation to view video recorded clips of the client in therapy. Two members of the affirmative team and one member of the skeptic team accepted this invitation and watched approximately 30 minutes of various clips from the client’s therapy (second session timeline, mid-session baby doll resistance, and final session insight into baby self integration). By “meeting the client” in this way, experts were able to have a better sense of what was being described in the rich case record. It is uncertain how viewing these clips influenced the experts’ arguments in case development, however, experts who did not watch the clips came up with similar points for discussion as those who did watch the clips. None of the adjudicators were able to meet to view the clips; all were still able to demonstrate understanding of the rich case record and the affirmative and skeptic arguments. INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 67 Reflections on Attachment This research came out of an examination of the history of attachment theory and research, including classification and assessment, psychopathology correlations, and attachmentbased interventions. The research question, does LI improve parent-child attachment and attachment correlates in families with adopted children?, was chosen to encourage a reflection on attachment and to allow for conclusions drawn from Jaydee’s case to expand our understanding of attachment. Assessment of attachment. Main and colleagues (1981, 1990) revolutionized our understanding of attachment when the Strange Situation was used to classify infants into three, later four, attachment types. This classification system allowed us to understand the behavioral and related mental processes associated with different forms of parenting. Most attachment assessments succeeding the Strange Situation, for both child and adult, have followed similar classification systems. Some adult assessments have moved to a dimensional understanding of attachment rather than typology-based approach (e.g. Fraley et al., 2000). These assessments, whether they are categorical or dimensional, are based on group norms, which is problematic when examining attachment in a single case. It was difficult to find an appropriate assessment for Jaydee in attempting to understand the evolution of his specific internal attachment representations, neural correlates, and integration experiences. The PRQ and Kern’s Security Scale were used in this study, but did not fully reflect attachment processes observed and inferred from Jaydee’s case. The PRQ, from the parent’s perspective, was very behaviorally-based. This measure did not draw conclusions about Jaydee’s internal experiences, the changes in the parent-child bond observed in this case, and the socioemotional changes associated with this bond. The Kern’s Security Scale, while allowing INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 68 for Jaydee to give some report about how he feels about his parents, was also based on Jaydee’s cognitive understanding of how he compares to other kids in relating to his parents. Jaydee started off therapy with a fairly positive rating on this scale, and his rating increased by a psychometrically insignificant level at the end of therapy. His high scores reflect only that he believed he compared similarly to other children who had positive and secure relationships with their parents. His scores do not reflect his early attachment experiences related to emotional dysregulation, traumatic body-based memories, and other relational and psychopathological difficulties. A better measurement for encapsulating all that we now know about attachment (e.g., emotion regulation, neural correlates, attachment trauma) is needed, particularly for children. As systematic case-study research grows to better represent practice-informed research, attachment assessment must follow to allow for an in-depth examination of attachment processes in a singlecase. Such an assessment must include a focus on healing rather than classification. Healing of attachment processes, as represented by interpersonal neurobiology literature (e.g., Schore, 2003; Siegel, 2012) and Jaydee’s specific case, is done through the integration of attachment experiences in the presence of a secure attachment figure. New assessments should include a focus on integration and the involvement of an attachment figure in integration. Consideration of attachment and psychopathology. Early attachment experiences are a clear causal pathway for one’s development. A consistent, attuned, regulated caregiver promotes resilience and regulation in children as they develop. If pathology does develop because of early attachment disruptions and traumas, a healing of these attachment experiences is possible. Integration of attachment experiences, through the presence of an attuned and coherent attachment figure, addresses many specific and complex presentations of psychopathology. INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 69 Jaydee represented several psychopathological diagnoses, such as anxiety, ODD, ADHD, ASD, and FASD. While some of these diagnoses have a researched genetic component, the reduction of symptoms related to these disorders in Jaydee suggest that attachment experiences are related to all of them. The rapid emotional and cognitive (ego) growth observed in Jaydee over the course of therapy is not typically seen in those with ASD and FASD. A large part of attachment repair is integration of past attachment experiences with one’s current sense of self, building new neural networks associated with security, coherence, and resilience. Other therapies associated with anxiety, dysregulation, and interpersonal relationships fail to account for attachment history and fragmented ego states from past relational trauma. Due to availability of resources, including the presence of a consistent attachment figure, therapies have a focus on cognitive and behavioural symptom reduction. This skillsbased approach was not used in therapy with Jaydee, and yet his anxiety and dysregulation symptoms improved dramatically by focusing instead on his attachment processes. Attachment-focused interventions. Lifespan Integration is not necessarily the only attachment-based trauma intervention available. It takes a less behavioural approach than other therapies with an attachment theory background (e.g. PCIT; Eyberg & Matarazzo, 1980), which fits well with the growing understanding that attachment is more than presenting cognitions and behaviours. Allen (2011) argued that an attachment-based therapy for school-aged children must have four conditions: 1) the presence of a primary attachment figure to facilitate change; 2) the caregiver’s capacity for attuning and responding appropriately to the child’s emotions and behaviours; 3) a focus on the present and facilitating growth in the child’s current context; and, 4) the consideration of the child’s cognitive ability and development. From these requirements, Lifespan Integration therapy could be analyzed as not being present-focused. This would not be INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 70 an accurate understanding of LI, as its premise is on meeting the parts of the client’s current, present body (i.e. neural pathways) that are stuck in the past trauma, and bringing these parts of self into the present timeline. LI with adopted children, as done in Jaydee’s case, does meet Allen’s criteria. However, these criteria, like many other cognitive-behavioural-based therapies do not give enough acknowledgment to the complexity of the client’s history with attachment disruption and trauma. Jaydee’s case demonstrates that attachment processes are complex and difficult to parse out from all the other pathologies connected to a person that may or may not be related to attachment. While teaching a parent to interact and respond well does promote conditions for secure attachment, it does not activate the parts of the brain-body that continue to house these fragmented, disconnected attachment experiences (Siegel 2012). Nor does such a parentcoaching therapy address the early disruption of normal neurodevelopment beginning in the lower areas of the brain (Perry, 2002, 2009). Integration is an ongoing process that occurs within the bounds of time and space of a person’s life. LI works well to facilitate body-based neural integration of all traumatic experiences, including attachment and relational trauma. Neural integration occurs in LI as early trauma experiences are brought to body and mind, either through memory or imagination, and then repeatedly ushered through time and space using the cues from the timeline. This repetition helps to reduce the stress response encoded in early-developing brain structures and create new neural pathways associated with the current sense of self. It is one of the only trauma therapies that explicitly uses attachment theory to address these trauma, allowing attachment with others and attachment with self to be explored and promoted. As our understanding of attachment processes grow, interventions with an attachment theory aim must look beyond the cognitive and behavioural to instead focus on the integration of complex INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 71 experiences and condition within each client. Further research is needed for any therapy that claims to do this, including Lifespan Integration. Future research and application. Jaydee’s case provides hope for families with adoptive children and therapists who work with children who have attachment trauma. It is an example of how internalized attachment patterns from early childhood trauma -abuse or neglectare flexible enough to change in middle childhood. Future research should continue to explore and unpack the attachment processes at work in therapy, including not only the parent and child’s relational behaviours, but also the emotional and integrative experiences happening at a neural level. As much of current attachment research draws on the present understanding of early neurobiological development (e.g., Schore, 2003; Siegel, 2012), future research should include neurobiological assessment as it is related to attachment trauma and repair in therapy. The mapping of neural integration over the course of therapy is a piece of key evidence missing from attachment-based therapies. In the process of Lifespan Integration therapy, Jaydee demonstrated the ability to access parts of his self that were “stuck” in his earliest traumatic moments and then integrate these parts into his present self with the help of his caregiver and therapist, using the LI timeline. The accessibility of these earlier ego states supports the argument that Jaydee’s presenting problems of age-inappropriate fears and aggression/dysregulation were most likely influenced by these earlier parts. That these presenting problems decreased or were eliminated completely over the course of therapy leads to the conclusion that his earlier insecurely attached parts were integrated back into the security of his present life situation. Integration is a key function of attachment, as sign of healthy attachment processes at work. INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 72 Therapists working with children in middle childhood with a history of attachment disruption can follow the example set of Jaydee’s case in a variety of ways. The inclusion of a secure adoptive parent helped Jaydee regulate in session and facilitated repair work with the baby doll. Using metaphors such as nesting cups and the tree rings allowed the LI ego states conceptualization and timeline process to be better explained. Recognizing the importance of the individuation and connection balance for a child approaching adolescence is necessary for working with this population, and so respecting their choice to not always involve the parent in therapy can make sense. Therapists should be aware that the introduction of the physical baby doll may be very triggering for the child client, and tools for grounding are necessary to supplement this part of LI therapy. Although LI is considered a gentle approach that does not retraumatize the client, expressions of extreme resistance from child clients can demonstrate the severity of earlier attachment disruptions. Conclusion The case of Jaydee demonstrates that early attachment trauma resulting in complex presentations in middle childhood can be addressed, cleared, and repaired in therapy. For Jaydee, such a focus on integrating his early experiences into his current timeline and understanding of self was facilitated by the presence and attunement of his primary attachment figure, his adoptive mother. The positive change in Jaydee due to this therapy, rated as substantial by adjudicators in the HSCED method, is evidence that an attachment-based trauma intervention can be effective for older children who have early attachment disruptions. Lifespan Integration is gaining research evidence to support its conceptualization and therapeutic processes. As more clinical work with children in middle childhood looks toward the study of attachment, regulation, and early experiences, LI provides a tangible intervention that INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 73 can help children integrate these early experiences into their present developmental stage, using the warm, caring, and attuned support of both therapist and parent. Security and coherence are promoted in a way that sets children up to succeed in the many socioemotional areas of life as they mature and grow. Based on premises from interpersonal neurobiology literature (e.g., Siegel, 2012), integration continues after therapy is complete, using the internal and external attachment systems system targeted and built up in this kind of LI therapy. Based on this case and continued research in attachment-based interventions, therapies such as LI therapy will continue to grow in both the clinical and research domains. Measuring the neurological underpinnings of attachment as they change and are engaged in therapy is a next step for research, as are examining other populations engaged with attachment-based therapies, such as LI. Future research with children in the HSCED method for LI or other therapies may wish to continue to adapt the HSCED instruments as discussed in this study to better grasp the child’s experience in therapy. The use of adjudicators who are experienced experts in the related fields added rigour to the case development and adjudication process in a way that other therapies examined using the HSCED method may benefit from as well. Presenting a therapy that fits well with the adoption population is beneficial to many families who are trying to give abused, neglected, and abandoned children a “second chance” at a thriving life. That these children can integrate their experiences in a way that addresses their history while promoting relational and emotional well-being in their current contexts can bring hope and relief to the families and communities who support them, and the therapists who work with them towards healing. INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 74 REFERENCES Abu-Akel, A., & Shamay-Tsoory, S. (2011). Neuroanatomical and neurochemical bases of theory of mind. Neuropsychologia, 49(11), 2971-2984. doi:10.1016/j.neuropsychologia.2011.07.012 Ainsworth, M. S., Blehar, M. 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Mind, Brain, And Education, 3(3), 160169. doi:10.1111/j.1751-228X.2009.01066.x INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 84 APPENDIX A: Agreement to Participate Research Study Title: Lifespan Integration Efficacy Principal Investigator: Carlee Lewis, MA student Counselling Psychology Department, Trinity Western University Email: carlee.lewis@mytwu.ca Phone: 604-513-2034 Thesis Supervisor: Dr. Janelle Kwee, Assistant Professor Counselling Psychology Department, Trinity Western University Email: janelle.kwee@twu.ca Phone: 604-513-2034 Description of Lifespan Integration Therapy: Lifespan Integration (LI) is a therapy that aims to enable clients to integrate difficult past experiences that compromise current functioning into their lives through therapeutic work that includes repetitions of a timeline comprised of real memories from their lifespan. By integrating the real life memory, clients heal their previous hurts and spontaneously think, feel, and act in healthier ways regarding their presenting problems. While LI has been used with adults and children with apparent success, this is the second formal study designed to investigate the efficacy of LI with children. Purpose: The purpose of this research study is to learn about whether people receiving Lifespan Integration Therapy experience helpful change or not, and to learn about what happens in the process. The purpose includes gathering details about what was helpful or not helpful as well as information on how and when any changes were noticed or experienced. No matter what the specific results are, the purpose for gathering this information will contribute to the knowledge available regarding what makes for good therapy. Procedures: There are four ‘parts’ to this study: 1. Shortly before your first therapy session, a research team member will meet with you and: - Ask you to complete a quick 32-item questionnaire about your parenting practices - Ask you to complete a questionnaire about your child’s behaviour, called the Behavioural Assessment System for Children, Second Edition (BASC-2), including the Parent Relationship Questionnaire. There is a parent and teacher form of this questionnaire and a child form for participants over age 8 - Ask your child to complete a 15-item questionnaire about their thoughts and feelings, called the Kerns Security Scale - Work with you and your child to identify goals for therapy - Conduct an audio-recorded interview to gather background information. (The interview is recorded to assist the researcher in not needing to take notes and will be kept strictly confidential and anonymous – see confidentiality section.) This meeting will take approximately 1 ½ to 2 hours. INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 85 2. The three-month therapy phase where you have 6-12* therapy sessions with your therapist and: - before each session you and your child will be asked to rate how things are going with identified therapy goals - after each session you and your child will be asked to fill out a form about what was helpful/not helpful. These will take approximately 30 minutes per therapy session (not during therapy time). * The exact number/frequency of sessions between 6 and 12 will be decided between you and your therapist depending on your needs/situation and also allows for missed appointments if needed. - as part of the data set about your experience with LI, therapists of participating clients will also be completing a “Therapist Session Note Questionnaire” which is a summary of their observations from your work together. 3. After the last therapy session for this study (i.e. after three months), the researcher will meet with you again and: - Ask you to complete the BASC-2 again - Ask your child to complete the Kerns Security Scale again - Conduct another audio-recorded interview similar to the first as well as questions about noticing or experiencing change or other interesting events during the last three months. This meeting will take approximately 1 ½ to 2 hours. 4. A final follow-up meeting very similar to the last one (#3) but after a little more time has passed – a month or so after the last meeting. Time will also be provided to debrief about the whole experience, discuss questions you may have about the study, and thank you for your participation. This meeting will take approximately 1 ½ to 2 hours. A summary of the results of the study will be available to you and mailed/emailed if request approximately one to two months after the follow-up meeting. Potential Risks and Discomforts: Participating in the procedures described above (questionnaires, forms, interviews) may stir up thoughts, memories or feelings that are uncomfortable or distressing. If this happens at a level beyond what you can manage during a meeting you can stop the process and/or discuss what is happening for you at any time. The therapy process will help with these experiences and discussing this with your therapist is suggested. Nearby counselling referrals are available upon request. You may also withdraw from the study at any time (see below). Potential Benefits: Beyond the benefits that come from the therapy directly, participating in this study provides more opportunity to learn about, reflect on, and discuss your situation and experiences. These sorts of opportunities may provide new perspectives, help solidify change, or offer unexpected experiences that may be beneficial to you. INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 86 Your participation in this study will also contribute to knowledge used in research as well as in professional therapy practice about how various treatment types work to help people. Indirectly, you will have contributed to the common good, especially to people with similar challenges as yourself. Confidentiality: Your identity and any information that you provide in connection with this study will remain strictly confidential. Exclusion to this confidentiality is if you reveal intent to harm yourself or others, then we are required by law to inform the appropriate authorities. You will be given a pseudonym (of your choosing) that will be used on all documents and forms that are in use during this study. Electronic data will be securely encrypted, and all paper documents will be kept in a locked filing cabinet. In accordance with research practices and standards, once the study is complete the data will be locked in a secure filing cabinet at the Counselling Psychology department at Trinity Western University for ten years after which it will be destroyed. Remuneration/Compensation: Participants will be given a $50 gift card. A sliding scale therapy rate may be arranged at the therapist’s discretion. Withdrawal: You may withdraw from the study at any time with notification to the principal investigator verbally or in writing. Upon withdrawal from the study any collected information pertaining to you will be deleted/shredded and will not be incorporated into the study results. If withdrawal occurs after the data analysis, anonymized non-identifying information incorporated into the results can no longer be removed. Contacts (regarding this research study): If you have any questions or desire further information with respect to this study, you may contact Carlee Lewis at carlee.lewis@mytwu.ca or Dr. Janelle Kwee at janelle.kwee@twu.ca, or either at 604-513-2034. Contact (regarding the rights of research participants): If you have any concerns about your treatment or rights as a research participant, you may contact Ms. Sue Funk in the Office of Research, Trinity Western University at 604-513-2142 or sue.funk@twu.ca. Consent: Your participation in this study is entirely voluntary and you may refuse to participate or withdraw from the study at any time without jeopardy to your relationship with your Lifespan Integration therapist. Signatures: Your signature below indicates that you have had your questions about the study answered to your satisfaction and have received a copy of this consent form for your own records. Your signature indicates that you consent to participate in this study and that your responses may be put in anonymous form and kept for further use after the completion of the study. ____________________________________ Parent signature ____________________ Date INTEGRATING ATTACHMENT IN AN ADOPTED CHILD ____________________________________ Printed name ____________________________________ Printed name of child research participant 87 INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 88 APPENDIX B: Parenting Styles and Dimensions Questionnaire Short Version REMEMBER: For each item, rate how often you exhibit this behavior with your child. I EXHIBIT THIS BEHAVIOR: 1 = Never 4 = Very Often 2 = Once In Awhile 5 = Always 3 = About Half of the Time _____ _____ _____ _____ 1. 2. 3. 4. _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ _____ 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. _____ 30. _____ 31. _____ 32. I am responsive to my child’s feelings and needs. I use physical punishment as a way of disciplining my child. I take my child’s desires into account before asking him/her to do something. When my child asks why he/she has to conform, I state: because I said so, or I am your parent and I want you to. I explain to my child how I feel about the child’s good and bad behavior. I spank when my child is disobedient. I encourage my child to talk about his/her troubles. I find it difficult to discipline my child. I encourage my child to freely express (himself)(herself) even when disagreeing with me. I punish by taking privileges away from my child with little if any explanations. I emphasize the reasons for rules. I give comfort and understanding when my child is upset. I yell or shout when my child misbehaves. I give praise when my child is good. I give into my child when the child causes a commotion about something. I explode in anger towards my child. I threaten my child with punishment more often than actually giving it. I take into account my child’s preferences in making plans for the family. I grab my child when being disobedient. I state punishments to my child and do not actually do them. I show respect for my child’s opinions by encouraging my child to express them. I allow my child to give input into family rules. I scold and criticize to make my child improve. I spoil my child. I give my child reasons why rules should be obeyed. I use threats as punishment with little or no justification. I have warm and intimate times together with my child. I punish by putting my child off somewhere alone with little if any explanations. I help my child to understand the impact of behavior by encouraging my child to talk about the consequences of his/her own actions. I scold or criticize when my child’s behavior doesn’t meet my expectations. I explain the consequences of the child’s behavior. I slap my child when the child misbehaves INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 89 APPENDIX C: Personal Questionnaires Simplified Personal Questionnaire Forms Adapted for 8-10 year old child participant By Carlee Lewis, Trinity Western University, August 2016 PERSONAL QUESTIONNAIRE Client ID___________________ Today’s date: Instructions: Please complete before each session. Rate each of the following problems according to how much it has bothered you during the past seven days, including today. Not At All 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Additional Problems: 11. 12. Very Little Little Moder ately Cons idera bly Very Conside rably Max Possib le INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 90 Parent Form PERSONAL QUESTIONNAIRE Client ID: _________________________ Today’s date: Instructions: Please complete before each session. Rate each of the following problems according to how much it has been a bother or how problematic it has been. Not At All Very Little Little Mod erate ly Consi derabl y Maximu m Possible 5 Ver y Con side rabl y 6 1. 1 2 3 4 2. 1 2 3 4 5 6 7 3. 1 2 3 4 5 6 7 4. 1 2 3 4 5 6 7 5. 1 2 3 4 5 6 7 6. 1 2 3 4 5 6 7 7. 1 2 3 4 5 6 7 8. 1 2 3 4 5 6 7 9. 1 2 3 4 5 6 7 10. 1 2 3 4 5 6 7 Additional Problems: 11. 1 2 3 4 5 6 7 12. 1 2 3 4 5 6 7 7 INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 91 APPENDIX D: HAT Forms Helpful Aspects of Therapy Form Adapted for 8-10 year old child participant By Carlee Lewis, Trinity Western University, August 2016 1. What do you remember most from your session? Either something that happened or something you felt? 2. What was the most helpful part of today’s session? 3. Do you have any idea why this might have been helpful? 4. How helpful was this particular event? Rate it on the following scale. (Circle the best face, or the dot in between faces.) 5. Was anything not helpful? YES NO Why was it not helpful? 6. How unhelpful was this particular event? Rate it on the following scale. (Circle the best face, or the dot in between faces.) INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 92 HELPFUL ASPECTS OF THERAPY FORM (H.A.T.) Adapted for caregiver of child participant By Carlee Lewis, Trinity Western University, August 2016 1. Of the events and experiences which occurred in this session, which one do you feel was the most helpful or important for your child? (By "event" we mean something that happened in the session. It might be something you or your child said or did, or something your therapist said or did.) 2. Please describe what made this event or experience helpful/important and what you or your child got out of it. 3. How helpful was this particular event or experience? Rate it on the following scale. (Put an "X" at the appropriate point; half-point ratings are OK; e.g., 7.5.) HINDERING <-------------- Neutral ---------------> HELPFUL 1 2 3 4 5 6 7 8 9 |---+---|---+---|---+---|---+---|---+---|---+---|---+---|---+---| E G M S S M G E X R O L L O R X T E D I I D E T R A E G G E A R E T R H H R T E M L A T T A L M E Y T L L T Y E L E Y Y E L Y L L Y Y Y 4. About where in the session did this event or experience occur? INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 5. About how long did the event or experience last? 6. Did anything else particularly helpful happen during this session? YES NO a. If yes, please rate how helpful this event was: ____ 1. Slightly helpful ____ 2. Moderately helpful ____ 3. Greatly helpful ____ 4. Extremely helpful b. Please describe the event briefly: 7. Did anything happen during the session which might have been hindering? YES NO (a. If yes, please rate how hindering the event was: ____ 1. Extremely hindering ____ 2. Greatly hindering ____ 3. Moderately hindering ____ 4. Slightly hindering (b. Please describe this event briefly: 93 INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 94 APPENDIX E: TSNQ Form Therapist Session Notes Questionnaire (TSNQ) Therapist Initials _______ Client (pseudonym) _____________ Date Session Notes Protocol(s) used (# repetitions): _______ Length of session: Most Helpful and/or Important Event/Experience (can be positive or negative): Description of why this event/experience was helpful and/or important. Rating of how helpful and/or important this was (put an “X” at the appropriate point; half-points are ok, e.g. 7.5) HINDERING <----------------- Neutral ------------------> HELPFUL 1 2 3 4 5 6 7 8 9 |---+---|---+---|---+---|---+---|---+---|---+---|---+---|---+---| E G M S S M G E X R O L L O R X T E D I I D E T R A E G G E A R E T R H H R T E M L A T T A L M E Y T L L T Y E L E Y Y E L Y L L Y Y Y At what point in the session did this event/experience occur? Number of protocol repetitions/other? Did anything else particularly helpful happen during this session? Please describe and give a rating between five and nine as per the scale above. Did anything else particularly hindering happen during this session? Please describe and give a rating between one and five as per the scale above. Notes on attachment experiences. 1. Proximity & Contact Seeking (touch, eye contact) 2. Initiation & Maintenance of Communication (nonverbal, paraverbal, verbal) INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 3. Secure base exploration 4. Emotion regulation Therapeutic impressions at exit. Other notes or observations regarding coherence/integration other progress/change. 95 INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 96 APPENDIX F: Change Interview Forms Client Change Interview Adapted for an 8-12 year old child participant By Carlee Lewis, Trinity Western University, August 2016 After each phase of treatment, clients are asked to come in for an hour-long semistructured interview. The major topics of this interview are any changes you have noticed in yourself since therapy began, what you believe may have brought about these changes, and helpful and unhelpful aspects of the therapy. The main purpose of this interview is to allow you to tell us about the therapy and the research in your own words. This information will help us to understand better how the therapy works; it will also help us to improve the therapy. This interview is tape-recorded for later transcription. Please provide as much detail as possible. How would you describe yourself? (e.g. 5 words to describe yourself. If role , describe what kind of ____? If brief/general, can you give me an example? For more: How else would you describe yourself?) How would others who know you well describe you? (How else? How would your best friend describe you?) If you could change something about yourself, what would it be? [whiteboard] Have you noticed any changes in yourself since you started therapy? (For example, Are you doing, feeling, or thinking differently from the way you did before?) [Interviewer: Jot changes down for later.] - Do you act different in different areas - Do you feel different….? Has anything changed for the worse for you since therapy started? - if he says no, query did it seem worse for awhile and then got better? Is there anything that you wanted to change that hasn’t since therapy started? - One time you said this (from HAT, previous talks), would this help you answer the question? INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 97 What was it like for your mom to be here for therapy? To need her sometimes and not other times? What has it been like afterwards with her? How is your relationship now? How was it to know she was getting a chance to show love to your baby self when she didn’t get a chance to before? Can you sum up what has been helpful about your therapy so far? Please give examples. (For example, general aspects, specific events) - have reminders of what has been covered in therapy (baby self, rings of a tree, shredding pictures of fears, holding a blanket, having your mom next to you and also sending her out, having the sand to use, blocks/cups Dr. J. uses that are different colours, having the parts of your life on the rings, sword fighting, playing games, etc), have visuals, even depict it in the sandtray, play it out What kinds of things about the therapy were not so helpful or even disappointing to you? (For example, general aspects. specific events) Were there things in the therapy which were hard or painful but still OK or perhaps helpful? What were they? (don’t let him say no to this!) – I know there have been times where you have struggled to come back because it has been so hard…do you remember what that was, what you’ve been working on? Has anything been missing from your treatment? (What would make/have made your therapy more effective or helpful?) - Or if you continued therapy with Dr. J what would be something you would next work on? - Want to be able to work on later…. Do you have any suggestions for us, about the research or the therapy? Do you have anything else that you want to tell me? - Suggestions for therapy for other kids with hard experiences as young kids or babies, or have fears that won’t go away. Review Personal Questionnaire (PQ) Instructions: Compare pre-therapy (screening) and post-therapy to current PQ ratings with child, noting number of points changed for each problem. Tell INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 98 client: We are trying to understand how clients use the PQ, and what their ratings mean. In general, do you think that your ratings (i.e. faces) mean the same thing now that they did before therapy? If not, how has their meaning changed? (Sometimes clients change how they use the PQ rating scale; did that happen for you?) - Sometimes people understand the levels of the faces differently as they get used to using it…do you use it differently now than you did at the beginning? Identify each problem that has changed 2+ points: (1) Compare each PQ problem change (2+ points) to the changes listed earlier in the interview. (2) If the PQ problem change is not covered on the change list, ask: Do you want to add this change to the list that you gave me earlier? •If yes -> go back to question 5 and obtain change ratings for this change. •If no -> go on: (3) For each PQ problem change (2+ points), ask: Tell me about this change: What do you think it means? Do you feel that this change in PQ ratings is accurate? Change List Change Change was: 1 - expected 3 - neither 5 - surprised by Without therapy: 1 - unlikely 3 - neither 5 - likely 1. 1 2 3 4 5 1 2 3 4 5 Importance: 1-not at all 2-slightly 3-moderately 4-very 5-extremely 1 2 3 4 5 2. 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 3. 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 4. 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 5. 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 6. 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 7. 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 8. 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 99 Client Change Interview Adapted to interview a parent of a 8-10 year old participant By Carlee Lewis, Trinity Western University, August 2016 After each phase of treatment, clients are asked to come in for an hour-long semistructured interview. The major topics of this interview are any changes you have noticed in your child since therapy began, what you believe may have brought about these changes, and helpful and unhelpful aspects of the therapy. The main purpose of this interview is to allow you to tell us about the therapy and the research in your own words. This information will help us to understand better how the therapy works; it will also help us to improve the therapy. This interview is tape-recorded for later transcription. Please provide as much detail as possible. 1. General Questions: 1a. What medication is your child currently on? (researcher records on form, including dose, how long, last adjustment, herbal remedies) 1c. What has therapy been like for you and your child so far? How has it felt to be in therapy? 1d. How is your child doing now in general? 1e. How is your current relationship with your child? 2. Self-Description: 2a. How would you describe your child? (If role , describe what kind of ____? If brief/general, can you give me an example? For more: How else would you describe your child?) 2b. How would others who know your child well describe her/him? (How else?) 2c. If you could change something about your child, what would it be? 3. Changes: 3a. What changes, if any, have you noticed in yourself and your child since therapy started? (For example, Are you doing, feeling, or thinking differently from the way you did before? What specific ideas, if any, have you gotten from therapy so far, including ideas about yourself or other people? Have any changes been brought to your attention by other people?) [Interviewer: Jot changes down for later.] 3b. Has anything changed for the worse for you or your child since therapy started? INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 100 3c. Is there anything that you wanted to change that hasn’t since therapy started? What do you think happened between you two during therapy? How did he use you to meet the therapeutic goals? What do you see afterwards between the two of you? With other family members? How was it for him not to include you during some sessions? 4. Change Ratings: (Go through each change and rate it on the following three three scales:) 4a. For each change, please rate how much you expected it vs. were surprised by it? (Use this rating scale:) (1) Very much expected it (2) Somewhat expected it (3) Neither expected nor surprised by the change (4) Somewhat surprised by it (5) Very much surprised by it 4b. For each change, please rate how likely you think it would have been if your child hadn’t been in therapy? (Use this rating scale:) (1) Very unlikely without therapy (clearly would not have happened) (2) Somewhat unlikely without therapy (probably would not have happened) (3) Neither likely nor unlikely (no way of telling) (4) Somewhat likely without therapy (probably would have happened) (5) Very likely without therapy (clearly would have happened anyway) 4c. How important or significant to you personally do you consider this change to be? (Use this rating scale:) (1) Not at all important (2) Slightly important (3) Moderately important (4) Very important (5) Extremely important 5. Attributions: In general, what do you think has caused these various changes? In other words, what do you think might have brought them about? (Including things both outside of therapy and in therapy) 6. Helpful Aspects: Can you sum up what has been helpful about your child’s therapy so far? Please give examples. (For example, general aspects, specific events) INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 101 7. Problematic Aspects: 7a. What kinds of things about the therapy have been hindering, unhelpful, negative or disappointing for you or your child? (For example, general aspects. specific events) 7b. Were there things in the therapy which were difficult or painful for you or your child but still OK or perhaps helpful? What were they? 7c. Has anything been missing from your child’s treatment? (What would make/have made your therapy more effective or helpful?) 8. Suggestions. Do you have any suggestions for us, regarding the research or the therapy? Do you have anything else that you want to tell me? 9. Review Personal Questionnaire (PQ) Instructions: Compare pre-therapy (screening) and post-therapy to current PQ ratings with parent, noting number of points changed for each problem. Tell parent: We are trying to understand how clients use the PQ, and what their ratings mean. 9a. In general, do you think that your ratings mean the same thing now that they did before therapy? If not, how has their meaning changed? (Sometimes clients change how they use the PQ rating scale; did that happen for you?) 9b. Identify each problem that has changed 2+ points: (1) Compare each PQ problem change (2+ points) to the changes listed earlier in the interview. (2) If the PQ problem change is not covered on the change list, ask: Do you want to add this change to the list that you gave me earlier? •If yes -> go back to question 5 and obtain change ratings for this change. •If no -> go on: (3) For each PQ problem change (2+ points), ask: Tell me about this change: What do you think it means? Do you feel that this change in PQ ratings is accurate? INTEGRATING ATTACHMENT IN AN ADOPTED CHILD Change List Change Change was: 1 - expected 3 - neither 5 - surprised by 102 Without therapy: 1 - unlikely 3 - neither 5 - likely Importance: 1-not at all 2-slightly 3-moderately 4-very 5-extremely 1. 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 2. 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 3. 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 4. 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 5. 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 6. 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 7. 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 8. 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 103 APPENDIX G: Kerns Security Scale Kerns Security Scale (1996) Formatted by Carlee Lewis, Trinity Western University, July 2016 1. Some kids find it easy to trust their [mom/dad] ✓ Really true 2. Really true 3. Really true ✓ Really true 5. Really true 6. Really true 7. BUT ✓ Sort of true Some kids wish they were close to their [mom/dad] ✓ Really true ✓ Really true ✓ Really true Other kids need their [mom/dad] for a lot of things. ✓ Sort of true BUT Really true Other kids do like telling their [mom/dad] what they are thinking and feeling. ✓ Sort of true BUT ✓ Other kids think their [mom/dad] does not spend enough time with them. ✓ Sort of true BUT Really true Other kids think it’s hard to count on their [mom/dad]. ✓ Sort of true ✓ Sort of true Some kids do not really need their [mom/dad] ✓ BUT ✓ Other kids feel like their [mom/dad] lets them do things on their own. ✓ Sort of true ✓ Sort of true Some kids do not really like telling their [mom/dad] what they are thinking or feeling ✓ BUT ✓ Sort of true Some kids think their [mom/dad] spends enough time with them Other kids are not sure if they can trust their [mom/dad]. ✓ Sort of true ✓ Sort of true Some kids find it easy to count on their [mom/dad] for help ✓ 4. ✓ Sort of true Some kids feel like their [mom/dad] butts in a lot when they are trying to do things ✓ BUT ✓ Really true Other kids are happy with how close they are to their [mom/dad]. INTEGRATING ATTACHMENT IN AN ADOPTED CHILD ✓ Really true 8. Some kids worry that their [mom/dad] does not really love them ✓ Really true 9. Really true Really true 11. Really true 12. Really true 13. Really true 14. BUT ✓ Really true ✓ Really true ✓ Really true ✓ Really true Other kids do not go to their [mom/dad] when they are upset. ✓ Sort of true BUT ✓ Other kids do think their [mom/dad] listens to them. ✓ Sort of true BUT Really true Other kids are sure their [mom/dad] will be there when they need [her/him]. ✓ Sort of true ✓ Sort of true Some kids wish their [mom/dad] would help them more with their problems ✓ BUT ✓ Other kids sometimes wonder if their [mom/dad] might leave them. ✓ Sort of true ✓ Sort of true Some kids go to their [mom/dad] when they are upset ✓ BUT Really true Other kids feel like their [mom/dad] does not really understand them. ✓ Sort of true ✓ Sort of true Some kids think their [mom/dad] does not listen to them ✓ BUT ✓ Other kids are really sure that their [mom/dad] loves them. ✓ Sort of true ✓ Sort of true Some kids worry that their [mom/dad] might not be there when they need [her/him] ✓ BUT ✓ Sort of true Some kids are really sure their [mom/dad] would not leave them ✓ ✓ Sort of true ✓ Sort of true Some kids feel like their [mom/dad] really understands them ✓ 10. ✓ Sort of true 104 ✓ Really true Other kids think their [mom/dad] helps them enough. ✓ ✓ INTEGRATING ATTACHMENT IN AN ADOPTED CHILD Really true 15. Sort of true Some kids feel better when their [mom/dad] is around ✓ Really true ✓ Sort of true Sort of true BUT 105 Really true Other kids do not feel better when their [mom/dad] is around. ✓ Sort of true ✓ Really true INTEGRATING ATTACHMENT IN AN ADOPTED CHILD APPENDIX H: Rich Case Record Rich Case Record - Jaydee Principal Investigator: Carlee Lewis Thesis Supervisor: Dr. Janelle Kwee Trinity Western University 106 INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 107 Overview The client, Jaydee (pseudonym), was recruited for the Lifespan Integration Efficacy research study through his therapist, who offered the opportunity to be a part of research when she engaged in the intake process with Jaydee’s adoptive mother. Jaydee’s mother knew about LI through her daughter’s therapy, and now wanted Jaydee to experience it as treatment for his trauma history and specific fears and anxiety. He engaged in LI therapy and the research process over a course of 5 months, and the following record details his developmental history, treatment, and other details pertinent to the case study. An outline of the data collected is provided in Table 1. Data collection was done mainly by the principal investigator at pre-therapy, post-therapy and 1-month follow-up points, as well as weekly as per the HSCED method. Therapy was done by an experienced LI therapist who was also the research supervisor for this study. Outline of Data Collected During the Study Pre-therapy meeting – October 24, 2016 • Personal Questionnaire (PQ) created • BASC-2 - client completed; parent and teacher forms given to complete for the following week • Parenting Relationship Questionnaire - parent forms given to complete for the following week • Parenting Styles and Dimensions Questionnaire (PSDQ) - given for following week • Kern’s Security Scale - client completed Therapy – 10 sessions: October 31, 2016 – March 6, 2017 • Personal Questionnaire (PQ) – completed by client and his mother before each session • Helpful Aspects of Therapy (HAT) – completed by client and his mother after each session • Therapist Session Notes Questionnaire (TSNQ) – completed by therapist after each session; principal investigator also used this form when watching video recorded sessions Post-therapy – March 13, 2017 • Personal Questionnaire (PQ) – completed by client and mother • Change Interview – from both client and mother • BASC-2 – client completed; completed parent and teacher forms received from previous week • Parenting Relationship Questionnaire – received from previous week • Kern’s Security Scale – client completed Follow-up – April 10, 2017 • Personal Questionnaire (PQ) – completed by client and mother • Change Interview – from both client and mother • BASC-2 – client completed; parent and teacher forms given to be returned following week • Parenting Relationship Questionnaire – given to be returned following week • Kern’s Security Scale – client completed INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 108 Intake Information At the time of research, Jaydee was 12 years old and in Grade 6 with an Individualized Education Plan (IEP) in place at school. He lives with his adoptive mother and father, and biological half-sister, Abigail (pseudonym), in the Fraser Valley of BC. His mother is the primary caregiver. He was referred to the therapist for this project by his sister’s therapist, when Jaydee’s mother became aware of Lifespan Integration therapy as a viable treatment option for Jaydee’s trauma history and specific fears and anxiety. Jaydee and his mother agree that nighttime dream-related fears of certain television and videogame characters are problematic for Jaydee, and interfere with both sleep and daytime thoughts. Jaydee’s mother also reports serious sibling conflict between Jaydee and Abigail (requiring police involvement on two occasions) and an insecure attachment between Jaydee and his father, such that Jaydee is often triggered towards violence when his father comes home from work. His attachment with his mother is much stronger. Developmental Trauma Early developmental trauma for Jaydee began pre-birth, as there was a history of cocaine, alcohol, tobacco, and marijuana use by his biological mother during pregnancy. His birth mother had been engaged in prostitution before and during her pregnancy with him. Jaydee’s birth mother had painful kidney stones during pregnancy, but did not stay in the hospital long enough to receive treatment due to needing a cocaine fix. Jaydee was apprehended from his biological mother at birth. In his biological family there is a history of alcoholism, drug addiction (cocaine) and ADHD. It is likely, given the history of his older siblings, that his birth mother expected Jaydee to be apprehended or may have even planned to give him up and this may have limited her emotional bonding with him in utero. Two of her biological children were already in care at the time of Jaydee’s birth. There had been attempts to raise these siblings with the help of her mother, Jaydee’s biological grandmother, but this did not end up working. Jaydee was born at 42 weeks’ gestation and weighed 9 pounds, spending 12 days following his birth in the Neonatal Intensive Care Unit (NICU) due to breathing and other health difficulties. He was then placed in foster care until age 9.5 months, and his adoptive mother describes the placement environment as “less than nurturing,” reporting that Jaydee was not held and spent most of his time in a baby seat in a playpen shared by another infant. When he was adopted at 9.5 months, he reportedly acted as if he had never been on the floor, trembled when held, and seemed like a newborn developmentally. His adopted mother was told by the foster mother that Jaydee tried to regularly make eye contact with the foster parents but they did not engage in this because they did not want him to get too attached to them, as they were only temporary caregivers. Jaydee has a lengthy diagnostic history, receiving diagnoses at age 4.5 years of Attention Deficit Hyperactivity Disorder (ADHD); Oppositional Defiant Disorder (ODD); Affective Disorder, NOS; and Substance-Related Neurodevelopmental Disorder (SRND). Further diagnoses include: High Functioning Autism Spectrum Disorder at age 6; Specific Learning Disorder in Math and Specific Learning Disorder in Written Expression at age 10; and Fetal Alcohol Spectrum Disorder (FASD) at age 10. Other psychosocial trauma and related fears occurred after adoption. Close family friends of Jaydee’s adoptive family also adopted a sibling pair when J was 4 years old, and the families (particularly mothers and children) spent a significant amount of time together. These friends’ children were suddenly and unexpectedly removed from their adoptive home a year later, following a lawsuit filed to MCFD by their birth grandparents who had previously not INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 109 shown interest in raising them. This incident was reportedly emotionally traumatic for Jaydee’s whole family, with his mother feeling a loss of support after having shared significant companionship with the other mom, as well as a general sense of instability in family situation. Jaydee, now at age 5, reportedly became increasingly clingy at this time, not being able to do things alone, experiencing increased night terrors, and “flipping out” even if his mom left the room. Current functioning Perhaps related to the timing of this incident, Jaydee developed and has maintained specific fears from this time in his life, including fear of Swiper the Fox from the Dora television program, the PBS kids log, and Zaboomafoo. Currently Jaydee demonstrates a simultaneous attraction and aversion to horror things. For example, he knows the details about Five Nights at Freddie’s and can freak himself out with the storyline, but doesn’t play the game himself. He is also reportedly “obsessed” with pullups and repeatedly asks his mother to wear them even though he does not experience urinary or bowel incontinence during the day or night. Other problematic symptoms include inflexibility to change, anxiety about the future, extreme emotional reactions to any small variation outside of an expected event, and difficulty regulating emotional arousal. Jaydee can also purposefully irritate others, including his sister and the family dog, and has significant anxiety associated with aggressive behaviour towards others. Safety plans are in place for other family members and adult caregivers. Current family dynamics As mentioned previously, Jaydee’s mother is the primary caregiver, and Jaydee is very close with her. Jaydee has a more insecure attachment with his adopted father, becoming more hostile and aggressive in his presence. However, his father is the one who gets up with Jaydee in the night when he experiences nightmares and has a fear of using the washroom alone at night. Mom and Dad report their marriage has remained strong even though they experience challenges with their children, which is a protective factor for Jaydee and shows resiliency in the family. Jaydee and his sister, Abigail, while biologically half-siblings, only knew and interacted with each other after adoption. Jaydee and Abigail are easily engaged in conflict that can escalate physically and aggressively at a quick pace. The adoptive extended family is well connected and supportive to Jaydee and his family. Adoption support groups are also available and utilized by the family. Furthermore, Jaydee’s biological half siblings (approximately seven), who have all been adopted, meet regularly as adoptive families to have reunions for the siblings to maintain their familial ties. Other social supports Jaydee attends a local private school and the school has been proactively accommodating his needs. He has a primary and secondary teacher, as well as a primary and secondary aide, both sets involved in a job share situation. This arrangement supports his learning needs and helps classroom management. In one psychoeducational assessment it is mentioned that Jaydee is supervised in order to prevent him engaging in verbal altercations with peers. Jaydee has attended this school since grade 2, as he was homeschooled for kindergarten and grade 1. His sister is currently homeschooled. Jaydee has no close peer relationships at school, but does have positive engagement with peers in bowling through the Special Olympics program. In bowling, INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 110 he is known as an encourager. It is interesting to note that Jaydee has had a number of peer experiences that have ended in his close friends moving away or being taken away from him. Research The Parenting Styles and Dimensions Questionnaire was administered to both of Jaydee’s parents as a screening tool to supplement therapist judgment about the parental capacity to foster a secure attachment with Jaydee throughout the LI therapy. Both parents scored higher on the parenting style of authoritative than the other two styles, authoritarian and dismissive. Jaydee’s mother scored slightly higher on this dimension than his father. This data supports the clinical judgment that both of Jaydee’s parents have the capacity to facilitate secure attachment with Jaydee, thus making them good participants for this particular LI efficacy study. The following assessments were used at various points throughout the research project: a) the Personal Questionnaire (PQ) on a weekly basis throughout therapy, to assess Jaydee’s and his parents’ individual problems that bother them; (b) the Behavioural Assessment System for Children, second edition (BASC-2) to assess behavioural issues and level of functioning through teacher reports (TRS), parent reports (PRS), and self reports (SRP); (c) the Parenting Relationship Questionnaire (PRQ) to assess relationship between Jaydee and his mother and father; (d) the Kerns Security Scale to assess Jaydee’s perception of his attachment with his parents; (e) Helpful Aspects of Therapy form (HAT), to assess client and parent experiences in therapy sessions; the (f) Therapist Session Note Questionnaire (TSNQ), to understand the therapist’s observations and reflections of each session; as well as (g) the Change Interview, a one time, post-therapy interview administered to Jaydee and his mother separately to assess change and attribution to therapy. INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 111 PQ Results The PQs (personal questionnaires) were developed during the first pre-therapy meeting with Jaydee, his mother, the therapist, and the researcher. Two PQs were generated, one with items Jaydee saw as problems he was currently experiencing, and the second with items Jaydee’s mother thought were a problem for J or were causing problems in the family system. Jaydee’s mother generated her items separately with the therapist. The items were listed in order of subjective severity. Jaydee and his mom were asked to rate each problem on their questionnaires based on how much the problems had bothered them in the past week. Each item was rated from one (not at all) to seven (maximum possible), with Jaydee’s PQ having faces in place of numbers to indicate the evaluation of the problem. This was completed before every session, as well as at post-therapy and one-month follow-up interviews. Jaydee’s PQ Items: 1. I have nightmares about Swiper the Fox, Zaboomafoo, Freddie the Bear, animatronics, or Goosebumps. 2. I have trouble sleeping or going back to sleep because of nightmares or worry. 3. I am afraid of the dark. 4. I have troubling daytime thoughts about Swiper the Fox, Zaboomafoo, Freddie the Bear, animatronics, or Goosebumps. 5. I feel stress and worry about my homework. 6. I don't get started on my homework when I feel I should. 7. I fight with Abigail. 8. I feel tricked or afraid that I am going to be tricked. 9. I feel irritated by family members. 10. I feel scared or worried for no particular reason. Parent PQ items: 1. [Jaydee is] Demonstrating extreme emotional reactions to family members 2. [Jaydee is] Provoking conflict or being aggressive with family members 3. Nightmares about Swiper the Fox, Zaboomafoo, Freddie the Bear, or Goosebumps 4. Fear of the dark 5. Stress and worry about doing homework 6. Difficulty starting or completing homework 7. Preoccupation about or using pullups 8. Fear of the unknown 9. Fear or anxiety for no particular reason 10. Daytime fears about Swiper the Fox, Zaboomafoo, Freddie the Bear, or Goosebumps INTEGRATING ATTACHMENT IN AN ADOPTED CHILD Figure 1. Tracking of Jaydee’s PQ items over the course of therapy. Figure 2. Tracking of Parent PQ items over the course of therapy. Figure 3. Tracking of Jaydee’s PQ mean throughout therapy 112 INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 113 Figure 4. Tracking of Parent PQ mean throughout therapy Observations and comments about PQ scores over course of therapy. • Jaydee’s fears were developmentally inappropriate for his age, but were developmentally appropriate at the time of his earlier traumas (i.e., adoption, friends being taken away). • Jaydee’s PQ items that changed significantly (2+ points): nightmares (decreased by 3), going back to sleep after nightmares (decreased by 4), fear of the dark (decreased by 3), daytime worries about nightmares (decreased by 2), stress and worry about homework (decreased by 2), troubles starting homework (decreased by 2). All other items decreased insignificantly by 1 point. • Jaydee’s mom’s PQ items that changed significantly (2+ points): extreme emotional reactions to family members (decreased by 2), provoking conflict or aggression with family members (decreased by 3), nightmares (decreased by 2), fear of dark (decreased by 2), stress and worry about homework (decreased by 4), difficulties with homework (decreased by 2), fear of unknown (decreased by 3), fear or anxiety for no reason (decreased by 3). All other items decreased insignificantly by 1 point. • Jaydee’s mom also made a comment about her ratings, how she rated an incident higher in later weeks even though frequency or intensity had decreased, because she had come to expect the incident to occur less, so it will still equally distressing for her when she reported it. INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 114 BASC-2 Results The BASC-2 was administered at the pre-therapy meeting, at the same time goals and PQ items were established. It was also administered after 10 sessions of LI therapy when a break was taken (post-therapy), and again a month later for follow-up. Jaydee filled out his SRP reports in the presence of the researcher who read each item aloud as he followed along on the paper and was available to answer Jaydee’s questions as necessary. Jaydee’s mom and dad, as well as his classroom teacher and teacher’s aide, were given the assessments to complete on their own outside of session. Each report (SRP, PRS, TRS) generated raw scores, standardized scores, and explanations of score means on a variety of scales. For the clinical scales, scores in the average range were t=40-59; scores in the at-risk range were t=60-69; and scores in the clinically significant range were over t=70. The following summary of each report shows the scale scores plotted and then highlights key scales of interest. BASC-2 SRP Report After using the standard error of measurement to calculate 95% confidence intervals for J’s BASC-2 t-scores on the clinical and adaptive scales, it was found across the three time periods that all of Jaydee’s scores were likely to fall in the average range. However, a number of scale scores described clinically relevant change across time. Anxiety. According to Jaydee’s PQ and intake data, his main goal for therapy was decreasing his nightmares and fears related to nightmares. Interestingly, on the BASC-2 he reported anxiety-based feelings no more than others his age. Over the course of therapy, his score on this scale stayed within the average range, however, it did descriptively decrease at post-therapy and again at follow-up. INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 115 Attitude to School. Jaydee’s PQ also suggested his attitude towards school may be impacted by the stress he can feel about homework and school. His scores on this scale indicated a greater risk (within the average range) for disliking school at pre-therapy than at post-therapy. At follow-up this decrease had been maintained. Relations with Parents and Interpersonal Relationships. Research goals of understanding and measuring attachment throughout therapy applied to these two scales especially. The Relations with Parents scale saw steady increase within the average range across the three time periods. The Interpersonal Relationships scale scores also increased within this range with a large increase happening from post-therapy to follow-up. Self-esteem. As relationship to self plays a big role in LI work, the scores on this scale were noted to be within the average range across the three time periods, with no change in scores from pre-therapy to post-therapy, and a small increase from post-therapy to follow-up. INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 116 BASC-2 PRS Reports Jaydee’s mother and father reported a number of at-risk problem areas for Jaydee through their scores. In their PQ items related to conflict and aggression with families were high priority, and their BASC-2 scores reflect theses difficulties especially at pre-therapy assessment. Acknowledging anxiety was also a theme in their PQ items. The follow scales reflect how these PQ items were reflected in the Parent Rating Scales of the BASC-2. Mother Father INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 117 Aggression. Both parents rated Jaydee as being “At risk” in the scale of Aggression at pre-therapy. This means they noted he sometimes displays aggressive behaviours such as argumentativeness, defiance, and/or making threats towards others, more than others his age. At post-therapy assessment, his father’s score on this scale still maintained the “At risk” classification, however it had decreased a couple of points. His mother’s score at post-therapy was in the average range on this scale. At follow-up assessment, his father’s scores had further decreased to the average range, while his mother’s scores slightly increased to the edge of the average range. Anxiety. Jaydee’s father score at pre-therapy on this scale was noted to be “Clinically significant,” meaning that he reported Jaydee displaying an unusually high number of behaviours stemming from worry, nervousness, and/or fear. His mother’s scores at pre-therapy was in the “At risk” category, not as high as “Clinically significant” but still strongly above average. At post-therapy, both sets of scores decreased, with Jaydee’s mother’s scores staying the “At risk” range and Jaydee’s father’s scores dropping significantly to the “At Risk” range. Jaydee’s father’s scores were maintained at follow-up, and Jaydee’s mother’s scores moved into the average range. INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 118 Adaptability. At pre-therapy, both of Jaydee’s parents rated Jaydee as being “At risk” in the adaptability scale. This means that they reported Jaydee as having difficulty adapting to changing situations and taking much longer to recover from difficult situations than most others his age. At post-therapy, both parents’ scores on this scale decreased to fall within the average range. However, at follow-up, Jaydee’s father’s scores fell within the At Risk range again, while Jaydee’s mother’s scores increased slightly within the average range. Hyperactivity. The history of diagnoses Jaydee has had includes ADHD-type symptoms, and so this scale is relevant to his clinical picture. Both parents rated Jaydee as being “At Risk” on this scale at pre-therapy and post-therapy, suggesting no change in this regard over the course of therapy. This suggests Jaydee continues to display a moderately high number of disruptive, impulsive, and uncontrolled behaviours, as measured by the items on this scale. At follow-up, these scores were maintained, with Jaydee’s father’s scores increasing slightly in the “At-risk” range. BASC-2 TRS Reports Jaydee had two school professionals complete the teacher form of the BASC-2. His regular teacher was unable to complete the form at post-therapy, so his results only reflect his understanding of Jaydee at pre-therapy and follow-up. The other professional was the educational assistant (EA) who spends the most time with Jaydee, offering him one-on-one support. Jaydee’s EA was the one who reported more problems across the time periods. It is important to note that at pre-therapy, both professionals had only known Jaydee for 1-2 months. Regular Teacher (PS) INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 119 Educational Assistant (AT) Anxiety. Corresponding with Jaydee and his mother’s PQ items around fear and stress, this scale was most appropriate to understand the impact of stress and anxiety on Jaydee’s school performance. Jaydee’s regular teacher scored this scale as average, with a slight increase at follow-up within the higher end of the average range. Jaydee’s EA reported “Clinically Significant” anxiety in Jaydee across the three time periods, with the highest score being at posttherapy followed by a slight decrease at follow-up. This means Jaydee falls within the range of children that usually display behaviours stemming from worry, nervousness, and/or fear. INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 120 Adaptability. Jaydee’s EA scored him in the “At Risk” category at follow-up, meaning that he may have difficulty adapting to changing situations and that he takes longer than others to recover from difficult situations. At post-therapy and follow-up, the scores from the EA on this scale had risen to be within the average range, suggesting that these difficulties were no longer present. Jaydee’s regular teacher found Jaydee to be within the average range across time periods, however, there was a small increase of his score within this range at follow-up. Attention problems. Jaydee’s regular teacher did report that J’s attention problems were “At Risk” at pre-therapy assessment, meaning that Jaydee has difficulty maintaining necessary levels of attention at school. Jaydee’s EA also reported similar scores at pre-therapy. At posttherapy, Jaydee was reported as still being in the “At Risk” range for attention problems by his aide, although the scores had decreased slightly. At follow-up he was reported as being in the average range by both his regular teacher and his EA. Hyperactivity. Perhaps related to Jaydee’s early ADHD diagnosis, this scale reflects restlessness and impulsiveness, as well as difficulties maintaining self-control, often in a way that maybe be adversely affecting other children at school. At pre-therapy assessment, Jaydee’s regular teacher reported he was in the higher end of the average range, and at follow-up these scores had increased further within the average range. Jaydee’s EA reported that Jaydee was “At Risk,” or well above average, in this scale at all three assessment times, and found little change from pre-therapy to post-therapy to follow-up. PRQ Results INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 121 The Parenting Relationship Questionnaire (PRQ) was administered at pre-therapy, posttherapy, and follow-up assessment times to both of Jaydee’s parents. The PRQ is a measure of the quality of the relationship between Jaydee and his parents, as reported by each parent. Problems were observed for one or both parents on every scale of the PRQ except for Satisfaction with School Services, which fell in the average range across time periods for both parents. The following graphs show the scores of each scale for each parent, followed by a discussion of scales of clinical importance. Mother Father Attachment. Jaydee’s mother had a higher attachment score than Jaydee’s father, and was on the cusp of “Significantly below average” and “Average” at pre-therapy. Over the course of therapy, attachment increased to fall squarely in the “Average” category at post-therapy, and decreasing slightly within the average range at follow-up. Jaydee’s father’s pre-therapy attachment score was “significantly below average” at pre-therapy, decreasing within this range at post-therapy, and increasing again at follow-up to what it was at pre-therapy. Communication. Jaydee’s mother’s scores were in the higher end of “significantly below average” throughout the course of therapy, suggesting that she indicated that her child does not consistently tell her about daily events, including school activities, interactions with INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 122 friends, and problems the child may be having. Her scores on this increased very slightly at post-therapy and then dropped back to baseline at follow-up. Jaydee’s father’s scores were in the higher end of the “lower extreme” at pre-therapy and follow-up, while dropping within this range at post-therapy. This means that he indicated that Jaydee does not tell him about daily events at all. Discipline Practices. At pre-therapy, Jaydee’s mother indicated that she is somewhat inconsistent when responding to a variety of Jaydee’s misbehaviour, while Jaydee’s father reported consistency within the average range. At post-therapy, both parents scores had fallen into the “lower extreme” range, indicating that they were both inconsistent when responding to misbehaviour, possibly reflecting permissive parenting or difficulties caring for a child with significant behavioural problems. At follow-up, both parent’s scores increased to the “significantly below average” range, with Jaydee’s father increasing the most, to the higher end of this range. Involvement. At pre-therapy, both of Jaydee’s parents reported engaging in few common activities wit Jaydee, such as playing games or working on projects together, with Jaydee’s mother having the lower score. At post-therapy, Jaydee’s mother’s score had increased within the “significantly below average range,” while Jaydee’s father’s score decreased within the same range. At follow-up, Jaydee’s father’s score stayed the same, while Jaydee’s mother’s score decreased slightly, but not to baseline. Parenting Confidence. Jaydee’s mother’s confidence scores increased from pre-therapy to post-therapy, and decreased to below baseline at follow-up, within the “Significantly Below Average” range. This means that throughout therapy she had a low level of confidence in her ability to make good parenting decisions, and she reports having difficulty establishing control in her household. Jaydee’s father reported an increase from pre-therapy to post-therapy in parenting confidence, and a large decrease at follow-up, within the “Lower extreme” range. This means that Jaydee’s father reports a very low level of confidence in his ability to make good parenting decisions, and he reports having difficulty establishing control in his household. Relational Frustration. At pre-therapy, both of Jaydee’s parents reported losing their patience when dealing with Jaydee and considered him to be difficult to care for, with scores falling in the “Upper extreme” range. At post-therapy, Jaydee’s mother’s scores dropped to fall within the average range, and was maintained at follow-up, reporting that she now experienced typical levels of frustration and difficulties associated with caring for her child. For Jaydee’s father, he saw a decrease in scores to the “significantly below average range” at post-therapy, reporting that he does lose his patience when caring for his child at times. At follow-up, Jaydee’s father’s scores increased significantly again to reporting more impatience and frustration. INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 123 Kerns Security Scale While parent attachment and parenting relationship patterns were assessed in part by the PRQ, a measure of Jaydee’s perception of attachment with his parents was needed to complete the clinical picture. The Kerns Security Scale was used to gain an understanding of his beliefs and perceptions about his relationship with his parents and to understand how these beliefs and perceptions might change over the course of therapy. Following a “Some kids….other kids” format, 15 items were used to assess Jaydee’s felt attachment security. An example of this would be: 3. Some kids find it easy to trust their BUT Other kids are not sure if they can trust [mom/dad] their [mom/dad]. ✓ Really true ✓ ✓ ✓ Sort of true Sort of true Really true As this scale is typically used to compare individuals within group data, no norms were available to compare Jaydee to. The following graph shows how his total score changed over the course of therapy (higher scores out of 60 are more felt security), and a discussion of items of interest follow. Kern's Security Scale 60 40 20 0 Total Score Pre Post Follow-up 46 52 58 Jaydee was consistent on over half the items across the three assessment periods, promoting felt security on many of these items. Some items saw strong or moderate improvement over time, while two items saw no change or a slight change towards greater insecurity, as discussed below. Autonomy The second question says: “Some kids feel like their mom/dad butts in a lot when they are trying to do things, but other kids feel like their mom/dad lets them do things on their own.” At pre-therapy, Jaydee reported that the first part was “really true” for him, but at post-therapy and follow-up found that it was “really true” that his parents let him do things on his own. This item appears to measure an autonomy granting/building facet of attachment security. This item saw the biggest change from pre-therapy to post-therapy and follow-up. Time spent together, sharing of thoughts and feelings, separation worries, and coregulation Items 4, 5, 11, and 13 saw moderate changes from pre-therapy to post-therapy or followup. Jaydee reported at pre-therapy that it was “sort of true” that his parents do not spend enough time with him, and then found at post-therapy and follow-up that it was “really true” that they did spend enough time with him. He also reported at pre-therapy that it was “sort of true” that he did not like telling his parents what he is thinking or feeling, but at post-therapy and follow-up INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 124 found it “really true” that he liked telling his parents what he is thinking or feeling. At both pretherapy and post-therapy assessment times, Jaydee reported that it was “sort of true” that he worried about his parents not being there when he needed them, but at follow-up he reported that it was “really true” that is sure his parents will be there when he needed them. At pre-therapy, he was undecided or in the middle of the two options for going to his parents when he is upset or not, but at post-therapy and follow-up, he reported it was “really true” that he goes to his to his parents when he is upset. Needing parents and closeness Items 6 and 7 were found to decrease in felt security at either post-therapy, follow-up or both. Item 6 says: “Some kids do not really need their mom/dad but other kids need their mom/dad for a lot of things.” For this item, Jaydee reported that he was in the middle of these two options at pre-therapy, at post-therapy reported that “really true” that he did not need his parents, and at follow-up reported that it was “sort of true” that he did not need his parents. On item 7, Jaydee reported that it was “really true” that he was happy with how close he was with his parents at pretherapy and follow-up, but at post-therapy reported it was “really true” that he wished he was close to his parents. INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 125 Session Summaries Ten therapy sessions occurred over four and a half months, with each therapy session being approximately 50 minutes in length. Jaydee’s mother was in six of the ten sessions, and waited outside the room for the other sessions, at Jaydee’s request. Aspects of Lifespan Integration therapy were used in all sessions, as the “baby self” concept from the Birth-toPresent (BP) Protocol was discussed from the first session. Full BP timeline repetitions were introduced in the second session. Jaydee initially expressed discomfort with talking about his baby self, but gradually became more comfortable with this process over time. Integration experiences became more evident, and in the fifth session, a plan to do repair work with the client’s “baby self” was made for future sessions. In the six session, a physical baby doll was brought in to represent the client’s “baby self,” and his adoptive mother was invited to safely hold and express love to the client’s baby self while timeline repetition occurred. Jaydee experienced a lot of resistance to this process, expressing anger and frustration to his mother about the doll. The baby doll and resistance pattern occurred again in the seventh and eighth sessions. Although difficult, the importance and helpfulness of such a process was commented on by the therapist, parent, and client, including observations regarding the quality of the parentchild relationship after each session. The last two sessions consisted of BP timeline repetitions without the baby doll and consolidating gains. Below are summaries of each meeting and session, as well as an outline of when sessions were missed for various reasons. Observations from the HATs and TSNQs are noted below each session summary, related to each person who was a part of the process. Pre-therapy meeting Met with Jaydee and Mom to discuss therapy and research. Established main goal of helping Jaydee with fears, and developed items for the PQ. Completed assessments. Session 1 Introduced topic of inner or “baby” self to Jaydee. Metaphors used were the rings of a tree and layers of waves (referring to a playroom figurine). Used rice tray for facilitating relationship building between Jaydee, his mom, and the therapist. Also used rice tray as a way of relaxing oneself and feeling safe in the present. Mom was present for the entire session. Client observations (HAT). Jaydee remembered the “life talk” the most from his session, describing it as talking about when he was born. He found talking about his fears helpful, suggesting it would help him get over the fears. He reported this was 7/9 helpful, and did not find anything in the session to be unhelpful. Parent observations (HAT). Jaydee’s mom, found that reassuring words from the therapist about Jaydee’s strengths and competence were most helpful in the session, particularly while engaging in sand tray activities. She believed this was because the abstract LI thoughts might be difficult for Jaydee to understand, so encouraging him to persist with the therapy in this way was important. She found this 8/9 helpful. She also found the tree ring discussion to be greatly helpful. She reported the warm temperature of the room to be greatly hindering to Jaydee, causing him to “fade” during session. Therapist observations (TSNQ). The therapist reported the most helpful or important part of the session was seeing the baby self as legitimately confused, helpless, and fearful. This helped to make the inner connection apparent, and was rated as 6.5/10 helpful, occurring during the first half of the session, as the client became flooded and needed a break during the second INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 126 half. The therapist noted that mom’s presence was attuned and comforting to the client, and she noticed Jaydee frequently touching and making eye contact with mom. She also noted the heat in the room, suggesting it hindered the client from buying in to the relevance of connecting with the baby self. Researcher observations (TSNQ – video). There are no researcher observations for this session as the session was not recorded. Session 2 When the therapist asked, Jaydee remembered the baby self concept from last week. They talked about it being like branches of a tree, some being strong and some being fearful. Mom was present during the session and helped brainstorm good, positive-based branches of the tree. They started going through timeline, highlighting positive and negative things at different ages. Jaydee was leaning on mom during the timeline repetition. Jaydee expressed discomfort with talking about his baby self. Psychoeducation was done around baby self being surrounded by scary feelings, but current self knowing about safety and this can help the baby self. Dr. Janelle encouraged Jaydee to talk with his baby self and to show him what he went through. Used doll house to portray current family home and nightmares. Jaydee talked through a bit of his timeline out loud when prompted to connect with baby self a second time. Client observations. Jaydee remembered talking to his baby self during the session, and found showing his fears in the dollhouse to be the most helpful part of the session. He rated it as 8/9 helpful because it explained how intense/fearful those things were. He did not report any part of the session as being not helpful. Parent observations. Jaydee’s mom again found the encouraging words throughout the session to be most helpful, noting that she believed J to be reassured as he looked into the therapist’s eyes when the therapist checked in with him. J’s mom rated this as 9/9 helpful. She also found the balance between letting Jaydee lead while also setting limits for him during the session to be extremely helpful. She suggested having different sets of cue cards for J’s timeline in future sessions, to prevent Jaydee from memorizing the cues while also letting him have autonomy in choosing which parts of the lifeline to go through. Therapist observations. The therapist found the first set of LI cues to be “experientially rich,” as the client lay down, snuggling up to mom, and was able to indicate he had shown his baby self the cues. She found this to be helpful and/or important because it showed that the baby self’s distress was activated, but the client was still able to be present and stay safe. While she rated this as 7/9 helpful, she did note that she was unsure if the baby self “gets it,” as the somatic releases were unclear. She also found the representation of nightmares in the dollhouse to be helpful, as it validated the client’s concern while also activating fear with the client’s sense of mastery. She found the second LI rep to have a potentially hindering moment, as the client requested to do his timeline in his head without cues, which made it unclear to the therapist if he was experientially accessing his baby self. The therapist noted that the client touched and held his mom during intense moments, even expressing discomfort to his mother about his baby self. He seemed to use her presence as an anchor for emotion regulation, squeezing her arm for pressure during protocol repetition. The therapist also commented that the sand tray games seemed to be a positive, safe experience for the client. Researcher observations. It was helpful and important that Jaydee could have his mom to sit with, lie behind during the timeline repetition. It was also important that Jaydee could express that he’s not sure if he likes talking about his baby self and that the researcher could INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 127 validate and obtain buy-in for the process by linking it to the scary experiences the baby had, while also validating safety in the present. Session 3 Reviewed pictures of fear objects to activate feelings around them. Psycho-ed about how fears are connected to inner feelings from real experiences that can be “turned on” by different things. Also explained that the real problem is not always the thing one fears. Reinforced that the specific fears have never actually hurt Jaydee but he has had some real experiences that have been really scary. Client reflected how his baby self may have felt at significant points (going backwards from new home with adoption, foster care, NICU, birth mom’s pregnancy). Client very snuggly with mom at this point. Client connected with baby self and “showed” his baby self cues throughout his life until the present, telling his baby self that he is safe and taken care of. Client actively nodded and demonstrated remembering of cues. Ended with playing in the rice tray and reinforcing client’s courage to help baby self to know he was ok. Client observations. The HAT was not able to be completed for this session. Parent observations. Jaydee’s mom found using unique memory cues that were not the same as last time to be helpful or important for this session, because she saw J connecting to them by showing surprise and delight. She rated this as 9/9 helpful. She also found taking a break in the sand table to be helpful. She did not report any part of the session to be hindering. Therapist observations. The therapist found that the most helpful or important part of the session was when the client seemed to feel empathic awareness of his baby self’s needs, before showing his baby self how he grew up. This seemed to help the activation of younger feeling states to be connected to the present fear, earning a 7/9 helpfulness rating. The therapist also reported the client’s surprise and sometimes happy recognition of his timeline cues, suggesting that these timeline cues were helpful to the client with a 7/9 helpfulness rating. This reinforced the therapist’s confidence that integration was occurring for the client. She also noted that a hindering part of the session was the client’s perseverating on a potential confrontation with the creators of his fear objects. In terms of attachment experiences, the therapist shared that Jaydee requested therapist or mom to be in the room at all times with him, even when hiding toys in the sand tray, as he was activated by the scary pictures he had seen. He held his mom’s hand to soothe. Researcher observations. There are no researcher observations for this session as the session was not recorded. Cancellation Saturday meeting cancelled due to client’s sickness; mom and Dr. Janelle wondering if this is anxiety/resistance to having dad join or coming on a weekend day. Session 4 Went through timeline again, choosing one of two timeline options. Jaydee asked his mom to leave when timeline started. Jaydee wrapped himself in blanket during timeline, and kept his eyes open, fidgeting with a toy. Mom left and then was invited back after timeline was gone through. After timeline, fears were discussed and pictures of fears were put through the shredder. Fears were again discussed and the rice tray was used with Jaydee, mom and therapist. Repair was introduced as helping the baby feel loved and cared for in future sessions. INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 128 Client observations. Jaydee observed that talking about his baby self was good, and found the most helpful part to be talking about how one of his fears is not real, as it helped him to get it off his chest and feel better about it. He rated this as 6/9 in terms of helpfulness. Parent observations. Jaydee’s mom found that the most helpful or important part of the session was giving Jaydee the freedom to ask her to leave the room, because it showed he could self-identify his need and he seemed happy when she came back into the room (9/9 helpful). She also found the encouraging words at the beginning of the session to be helpful for J. Therapist observations. The therapist observed the most helpful or important part of the session to be the client’s knowledge of what to expect in connecting with the baby self and his ability to remember vulnerable early experiences while staying with the timeline cues. From the therapist’s perspective, it seems as though the client is internalizing that his younger self is a part of him and needs to know he is o.k. This was reported as 7.5/9 helpful. Asking mom to leave in order to make himself more comfortable was also helpful for the client. This may be demonstrating his ability to use mom as a secure base to demonstrate autonomy but be close for him if necessary. The therapist felt it was important to note that near the end of the session, the client put a tiny baby doll next to the chest of a bigger doll and said “my baby doll is still here in my heart,” demonstrating integration processes at work. Researcher observations. The demonstration of positive and negative not-real versus real things in the sand tray was seen as useful because it was a tactile and participatory exercise for Jaydee to engage with the process of fears. The researcher also agreed that Jaydee’s decision for his mom to leave shows his willingness to use her as a secure base to explore the world, growing in his autonomy in an appropriate way. This seemed to be less about Jaydee’s attachment with his mother and more about his own internalized attachment processes, becoming more secure with himself. Cancellation 6 weeks off due to 3 extreme weather conditions, and a planned winter holiday break. Session 5 Rapport was re-established in the beginning as the Christmas holidays were discussed. Rice tray was used more for sensory soothing than hide and seek games this session. The majority of the session was spent on timeline cue repetitions, and Jaydee requested his mom to stay outside the room. Jaydee spontaneously wrapped himself in his weighted blanket when going through the memory cues, and kept his eyes open. He mentioned how he “deserved” something for his hard work in session, and the therapist reminded him of the gift card he would receive when the therapy/research was over. When his mom was brought back in during the end of the session, a plan was made to advance to the next stage of LI. Client observations. Jaydee found that talking about his baby self and understanding that he’s been through so much was what he remembered most about his session and what he found to be most helpful. He believed this to be because it made him aware of how safe he was (6/9 helpful). Nothing was reported as not helpful. Parent observations. Jaydee’s mom did not attend the session, but noticed his cheeks were red when she came in at the end, observing he looked sleepy. She wondered how much of this was due to the hard work done in session and how much was related to how warm the room felt when she entered. She also reported that Jaydee was happy to come to session on a Monday, but resisted hugely to coming to sessions on Saturdays. INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 129 Therapist observations. The therapist noted that going through the timeline cues was helpful or important for Jaydee, and believed that he was tracking well with them even though he did not close his eyes (7/9 helpful). She also believed the rice tray was a helpful sensory soothing experience for Jaydee, and noted that his willingness to buy into the therapy even without mom present was helpful in facilitating depth work quickly. Temperature control seemed to be difficult for this session, but overall did not seem to interfere with the LI process. Researcher observations. The researcher found the experience of Jaydee showing his baby self his safe place – his room in his home – to be most important for the session, as it demonstrated how he could choose to provide safety to his baby self in the present day. It was also helpful that his timeline cues included positive and negative experiences, as both types were used to promote resilience. Attachment experiences to note were at the end when mom was brought back in, as Jaydee snuggled right up to her, leaning his head and upper body upon her, especially as the therapist explained all the work that had been done that session. His mom stroked his head and leaned her head on top of his comfortably, with no resistance from Jaydee. Session 6 Attachment repair was introduced with positive engagement in the baby self exercise. The therapist invited Jaydee’s mother to hold a doll that represented J’s baby self, expressing and showing it love and attention, while Jaydee was instructed to connect with his internal baby self as they went through the timeline cues. Jaydee expressed some negative feelings towards the baby doll during the timeline repetition. Client observations. The client remembered the baby self and the pretend doll most from his session, citing the baby self part as the most helpful part of the session. He could not give a reason for why this was helpful, and rated it a 6 out of 9. Parent observations. Jaydee’s found the most helpful part of the session to be the encouraging words given to him throughout, coupled with ignoring his grumbling protests, as this allowed him to stick with it. She wrote “He did it!” to express how proud she was of him, and rated the experience as 8/9 helpful. She also found the temperature to be comfortable, suggesting this was also helpful for Jaydee. Therapist observations. The therapist found mom’s affectionate stance and attention toward the baby self to be helpful and/or important, in spite of the client’s own negative feelings toward the baby self. This was believed to instill positive affection in the parent-child dyad (7.5/9 helpful). It was also helpful that they went through familiar repetitions of timeline cues. The therapist conceptualized the client’s resistance towards the baby doll as helpful, but very painful and raw. She gave the metaphor of warming really cold hands under warm water so that it burns. It was also noted that there were more approach/avoidance dynamics from the client towards his mother than ever before, as at times he pushed mom away but also reached out physically. There was tender eye contact at points of imagining mom being there when he was born. While he became very emotionally distressed, he tolerated staying with the process for the entire session. The therapist believed there to be movement occurring in session, but also expected to see regressive behaviours for the client after the session and throughout the week. Researcher observations. The researcher found the experience of mom holding the baby self while the client expressed dislike (resistance) to be the most important part of the session (8/10 important). It was important because it revealed the presence of a lot of painful early attachment trauma, with resistance occurring due to the unfamiliarity and internalized disbelief of the opposite expressed through mom holding the doll in session. It was also helpful INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 130 for Jaydee to receive encouragement to keep going throughout the process as it kept him in the room and present with the cues. It is unclear to the researcher if not giving in to Jaydee’s requests to leave was hindering for him, as he was quite distressed and this may have been viewed as dismissive of his feelings. However, it also challenged him to struggle towards growth in a safe environment, so it may be helpful in the long term. Approach/avoidance behaviours with mom were also present from the researcher’s perspective, and it was clear he was expressing his need to leave only to mom, not the therapist, as his mom appeared to be his main source for comfort. Session 7 The therapist checked in with the client about his feelings for coming. As she reviewed all the hard work done by the client last week, he gave assent for working today in session. Selfstates were reviewed with nesting cups as a concrete representation in the sand. The tree ring diagram was also revisited to address progress in symptoms. The first repetition of timeline cues was done with the nesting cups, followed by a birth to present protocol with mom holding the baby doll again. At the end of the session, the rice tray was used to ground while the session was wrapped up. Client observations. Jaydee believed the baby self talk was “honestly” the most helpful part of the session. He thought this was because it was reassuring to tell the baby self everything is o.k., and rated it 6/9 in terms of helpfulness. When prompted, he did admit it was uncomfortable to talk about the baby self, and to have mom talk to the baby self. He found it both reassuring and uncomfortable. Parent observations. Jaydee’s mom found it helpful and/or important to persist in the LI process regardless of Jaydee’s resistance or reluctance, because it showed Jaydee he could do it and that they believed he could do it (9/9 helpful). She also found it greatly helpful to use the nesting cups, especially as the colours coordinated with colours from the memories in the years they represented. She thought it was extremely hindering that Jaydee’s dad and sister were not present in the therapy, and wondered if she should be mentioning them while she is talking to the baby, as Jaydee currently shows no warmth towards his dad. Email. In an email after the session, C reported Jaydee as being quite “lovey-dovey” following the session, and then quite cheerful and compliant for the rest of the day, which was a big shift from his morning’s resistance. Jaydee even expressed that he believed his mom had done a good job in session and that it must have been hard work for her. Therapist observations. The therapist noted that the most helpful and/or important part of the session was having mom hold and talk to the baby self, as this provoked discomfort in the client but also made connections in a reassuring way, promoting attachment repair. This was rated as 7.5 out of 9 in terms of helpfulness. The therapist also felt that it was helpful and honest for the client to admit resistance to coming today while also being able to agree to participate in the session, which seemed to be empowering for him. The therapist found having the doll there to be a lot easier for the client than the previous week, even though resistance was still present. She noted that although mom sat separately with the baby today, the client sought closeness to mom at the end of the session with snuggling hugs and a kiss. Eye contact was made with mom when seeking reassurance. The therapist believed it would be ideal to include dad in the LI repair process, but wonders if the client is ready for this, as dad is a distressing trigger for him. Researcher observations. It was important to note that when going through the timeline, Jaydee reacted to his mom expressing love and safety to the baby doll, including INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 131 yelling “That’s not real!” to his mom. This showed strong resistance to overcome his early baby experiences (7/9 important). It was particularly helpful that the therapist commented aloud both how hard it was for him and also how necessary it was for him, validating his distress while promoting hope. The researcher wondered if it was hindering for Jaydee to be constantly fidgeting with a number of toys during the timeline repetition, but recognized that this may have been a way of regulating, allowing him to focus on what is said around him. There did not seem to be a lot of touch and eye contact during this session, except for major eye contact when he was expressing anger towards his mom. It was also important that he maintained communication with his mom even when he was upset, instead of shutting down or ignoring her. 2 week break Snow day and family day holiday. Session 8 The session started with just the client and therapist. Discussed plans for the session and future sessions while playing with sand. Invited mom to join, and started the Birth to Present protocol with mom holding baby (client continuously resisted). Completed one repetition of the protocol, including imaginary attachment repair with mom holding and talking to baby self. Engaged client’s complaints and demands to mom with validation of him enjoying good memories and nice activities, then debriefed and calmed down with just the therapist and client present. Client observations. Jaydee found the memories of his childhood to be the most helpful part of today’s session, because it he felt it gave him an idea of what could happen and rated it as a neutral 5/9 (midway between helpful and not helpful). He reported that watching his mom do the work with the baby self was unhelpful because it made him feel upset, sad, and weird, which he rated a 2/9 for helpfulness. Parent observations. Jaydee’s mom found that moving forward with the cues, despite Jaydee’s protest, was the most helpful or important part of the session, because she believed it gave him the message that she and the therapist value him and the process. She rated this as maximum helpfulness (9/9). She also found the new sand in the tray extremely helpful, as it was an attractive fun thing for Jaydee to engage with. She did not find anything to be hindering in this session. Therapist observations. The therapist reported that the most helpful part of the session was to affirm that Jaydee could push through by continuing with cues while also engaging him in other ways. This affirmed the client’s capacity while acknowledging his discomfort, and affirmed that the client’s core needs were important (7/9 helpful). The therapist also found using sand while discussing positive experiences to be helpful, as it allowed the client to experience a sense of calm. Acknowledging mom’s “need” to attune to the baby self because of what she missed was also helpful to the client. A hindering part of the session was in the beginning when the therapist brought up continuing sessions after a break, which seemed to trigger extreme resistance from the client. The therapist also described “toddler tantrum” behaviours from the client when he made stern eye contact with his mom and expressed independence while also seeming needy towards mom. Notably, the client de-escalated completely after session, debriefing and acknowledging that he had worked hard. He was extremely snuggly and tender towards his mom when he met her in the hallway afterwards. INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 132 Researcher observations. The researcher found that having mom hold the baby and stay calm, even when Jaydee was trying to distract and engage with her in a negative way, was most helpful in this session. This was helpful as it kept the long-term focus on the baby self, and demonstrated that the love she has for all parts of him was constant and would not be given up/taken away (8/9 helpful). It was also helpful that the therapist alternated between pulling the client out of his negative focus and validating them by reframing in a more positive way. The client’s resistance was hindering his ability to feel the integrative love for all parts of him, including his baby self. Jaydee struggled to pull his mom’s attention away from the baby, leaning closer towards her and making his voice louder as the protocol went on. Once the doll was taken away, he calmed down quickly. Session 9 The session started connecting in low-pressure rapport-building to maintain a sense of safety and reduce the intensity experienced from last session. The therapist and Jaydee played a matching game and played in the sand tray. Last session was debriefed including intensity with mom while re-asserting/affirming therapeutic goals and encouraging the client in his hard work. Nesting cups were used to review timeline. Jaydee engaged with questions and comments about the different phases. O-ring cues were used for the client to connect with core self and review life with extra emphasis on current sense of security in adopted home. During the session, the client brought up meeting his birth mom, as he was curious and open to the idea. Client observations. Jaydee reported the baby self, particularly going though his life with cards, as the most helpful part of the session. When prompted to give a reason for why he might recommend the cards to other kids, he said it was because it helps to go through one’s life if one has something that is preventing them from “right now” (8/9 helpful). Parent observations. Jaydee’s mom did not attend most of the session, but felt that playing a game to connect was helpful, as were the words of affirmation and encouragement. Therapist observations. The therapist found that reviewing the timeline cues was the most part of the session because it helped to build the client’s connection to self and life story, while allowing the past to become integrated into present reality (7.5/9 helpful). She also found that the game and planning a different game for the following week was helpful as it reestablished positive aspects of the treatment process. She noted that the snow was hindering as it distracted the client to thinking about his upcoming bowling tournament’s possible cancellation due to snow. The therapist noticed that Jaydee snuggled with his mom and gazed at her at the end. The therapist reflected on the client’s progress from several sessions ago and believed he would continue to make progress. Researcher observations. The researcher found that the most helpful part of the session was beginning with a game to make Jaydee comfortable in the session with the therapist (in contrast to his discomfort from last session). This helped to repair the therapeutic relationship and increase J’s comfort and willingness to participate in the session (7/9 helpful). The researcher also noticed the distraction of the snow as hindering for the client. Session 10 The session started with a check-in through sensory play and a debrief about the presenting problems. The client demonstrated insight in depicting a 180 degree shift in experience of dreams/nightmares in that he was able to be angry/empowered, not fearful of the nightmare’s power. The therapist and client played out his dream battle with sword “noodles.” INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 133 They reviewed progress with an emphasis on gains, conquering fears and celebration of how client had grown up. A termination activity of “toxic waste candies” was done as a competition at the end – the client won. Client observations. Jaydee reported that telling about his dreams was the most helpful part of the session. This was because it made him feel better about himself and that he knew his baby self had grown up (9/9 helpful). Parent observations. Jaydee’s mom believed that acting out the battle in the dream and the toxic waste candy activity were the most helpful part of the session, because it allowed this cycle of sessions to end on a “BIG” positive, with an emphasis that the fears were conquered and that J had the power to conquer fears. Therapist observations. The therapist reported the most important part of the session being when the client said, “I feel like my baby self finally turned 12 ½.” This demonstrated that he had internalized the integration process. He saw the vulnerability and fear of the helpless younger self, and also felt the safety and nurture of his current life. The therapist rated this as 9/9 importance, because it is evidence of the client’s internalization, implicitly in the dream and explicitly in his increased insight. She noted that there was no resistance today, the room temperature was o.k., and there was nothing particularly hindering for the client. When mom joined at the end, there was some hugging and excited eye contact between the client and mom. The client chose to be in session without mom, but did not seem to push mom away. The therapist hopes to continue to work with this client in attachment repair with his adoptive father, but believes there is a positive termination right now with a sense of mutual accomplishment. Researcher observations. It was important and helpful that the client was able to discuss and celebrate that he was no longer afraid in his dreams of certain characters, and was able to face and fight off these fear objects in his dream. It was also important that during the timeline repetition, he was cheerful and engaged with the timeline, talking about different events in his life with the therapist. It was also helpful that he was able to look forward to the eating competition with the therapist at the end of the session, to celebrate their time together. Post-therapy meeting. The last PQ and Change Interview protocols were done with Jaydee first, and then his mother, both individually interviewed by the researcher. Jaydee also completed the Kerns Security Scale and the BASC-2, while his mother brought completed parent and teacher forms to the session. Both interviews were recorded and their transcripts can be found below. 1-month follow-up meeting. Jaydee and his mom met with the therapist and the researcher to again track PQ items and other symptomatology, while also setting goals for future therapy sessions. Jaydee was interviewed individually by the researcher, while Jaydee’s mom was interviewed by the therapist. At the end, everyone came together to reflect on new PQ items for future sessions and research. INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 134 Change Interviews Change Interviews were done at the post-therapy and 1-month follow-up meetings with both Jaydee and his mother. Each interview discussed changes observed over the course of therapy from the interviewee’s perspective, and asked for them to discuss what they attributed these changes to. Factors within and outside of therapy were discussed. The interview with Jaydee was done separately from his mother, and he was able to play in the rice tray while discussing these aspects. More prompts and different ways of phrasing the questions were used for Jaydee, to make the interview more understandable for him. The interview with his mother was done separately from Jaydee, and while semi-structured, was more formal. Jaydee’s Change Interview 1. How would you describe yourself? (e.g. 5 words to describe yourself. If role , describe what kind of ____? If brief/general, can you give me an example? For more: How else would you describe yourself?) Post-therapy: I speak my mind; Short-tempered - if someone is bothering me; a really good comedian – make people laugh. Follow-Up: Funny; Like to joke around; Speak my mind; Playful 2. How would others who know you well describe you? (How else? How would your best friend describe you?) Post-therapy: Fun; Sometimes mad; Can make you laugh Follow-up: joking around; Speak my mind; Hyperactive 3. If you could change something about yourself, what would it be? Post-therapy: I don’t know, I like the way I am. Follow-up: I like the way I am, I don’t want to change anything 4. Have you noticed any changes in yourself since you started therapy? (For example, Are you doing, feeling, or thinking differently from the way you did before? Ask each separately) [Interviewer: Jot changes down for later, on whiteboard if possibly.] Post-therapy: see chart at end Follow-up: No night mares, I don’t get that anymore, same with worrying about nightmares; [feeling] Kind of…can control emotions better…sadness, anger, happiness; Little bit less fighting with A than last time, that’s just siblings. 5. Has anything changed for the worse for you since therapy started? (if he says no, query did it seem worse for awhile and then got better?) Post-therapy: No. Follow-up: Not that I can tell; (when prompted from PQ) Homework – rated it higher because getting into new topics, mostly its fine 6. Is there anything that you wanted to change that hasn’t since therapy started? (One time you said this (from HAT, previous talks), would this help you answer the question?) INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 135 Post-therapy: No. [bee fear prompt] It’s just me. I don’t want to change how I feel towards bees; Fighting with A – no, it’s just sibling stuff, nothing to work on. Follow-up: No, not exactly. Nothing in general or specific. 7. What was it like for your mom to be here for therapy? (To need her sometimes and not other times? What has it been like afterwards with her? How is your relationship now? How was it to know she was getting a chance to show love to your baby self when she didn’t get a chance to before?) Post-therapy: Stressful to have her here; Congratulate each other after sessions; Yes [to relationship change] – I like and love her more; I didn’t like it for her to show love to the baby self, the doll instead of me, right in front of me (didn’t like it even when reminded it was him); For her, probably made her sad and happy. I couldn’t understand why she was sad and happy. Follow-up: I didn’t really like it, I’m more independent; [Relationship change prompt] it’s just the same – I love her, she loves me. We haven’t done anything different. 8. Can you sum up what has been helpful about your therapy so far? Please give examples. (For example, general aspects, specific events. Have reminders of what has been covered in therapy (baby self, rings of a tree, shredding pictures of fears, holding a blanket, having your mom next to you and also sending her out, having the sand to use, blocks/cups Janelle uses that are different colours, having the parts of your life on the rings, sword fighting, playing games, etc), have visuals, even depict it in the sandtray, play it out) Post-therapy: Having mom next to me and also sending her out was helpful; Sword fighting was helpful; Talking about things I’ve been through, about my life [was helpful]; Sand; Shredding pictures; Cups were mostly helpful Follow-up: Everything was helpful. It all worked. I don’t know how it all worked, it just did. 9. What kinds of things about the therapy were not so helpful or even disappointing to you? (For example, general aspects. specific events. Say something like: Dr. Janelle has told me there have been times that you have had to work very hard at, that you may not like but have been able to get through…) Post-therapy: Yup [to above prompt]; Having mom with the doll was not helpful Follow-up: Baby self was hard, but it helped. Don’t know how it helped. 10. Were there things in the therapy which were hard or painful but still OK or perhaps helpful? What were they? (I know there have been times where you have struggled to come back because it has been so hard…do you remember what that was, what you’ve been working on?) Post-therapy: Baby self doll Follow-up: When my mom held baby doll mainly; [prompt: what would you tell other kids about this?] it’s gonna be hard at sometimes, but you’re gonna get through it, will help them 11. Has anything been missing from your treatment? (What would make/have made your therapy more effective or helpful?) Or if you continued therapy with Dr. Janelle what would be something you would next work on? Want to be able to work on later….OR: For another kid in your position, what could be added to help them?) INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 136 Post-therapy: No, nothing [for next set of sessions]; For other kids…a longer session maybe…But I don’t exactly feel I need a longer session. Follow-up: No. I don’t know what I want to focus on next with Dr. J. Mom might have some ideas, I might not agree with them. 12. Do you have any suggestions for us, about the research or the therapy? Do you have anything else that you want to tell me? (Suggestions for therapy for other kids with hard experiences as young kids or babies, or have fears that won’t go away.) Post-therapy: For if they have had hard experiences as young kids or babies…suggest to them to take it slow, keep calm; For fears… talk about it, work on it; Questionnaires: filling out my own answers is helpful, makes me feel more independent; Have more fun with it (all of it)! Follow-up: No suggestions. Yeah, I kind of liked research, don’t know why, just did. No suggestions for therapy. (Other kids in this kind of therapy prompt) - suck it up until the end. I don’t know how I stayed strong to suck it up, I just did. 13. Reviewing Personal Questionnaire (PQ). In general, do you think that your ratings (i.e. faces) mean the same thing now that they did before therapy? If not, how has their meaning changed? (Sometimes clients change how they use the PQ rating scale; did that happen for you? Sometimes people understand the levels of the faces differently as they get used to using it…do you use it differently now than you did at the beginning?) Post-therapy: It’s different and the same. Sometimes it can be different and sometimes it can be the same. [didn’t want to say more about it] Follow-up: [didn’t ask this question] 14. Identify each problem that has changed 2+ points: (1) Compare each PQ problem change (2+ points) to the changes listed earlier in the interview. (2) If the PQ problem change is not covered on the change list, ask: Do you want to add this change to the list that you gave me earlier? (3) For each PQ problem change (2+ points), ask: Tell me about this change: What do you think it means? Do you feel that this change in PQ ratings is accurate? Post-therapy: [He was “fading” so went straight to rating the changes, did not ask about what it means, but agreed with changes noticed] Follow-up: see change list Post-therapy Change List and Ratings Change Change was: 1- expected 3- neither 5- surprised by 1. I don’t get afraid so much. 2. I rarely fight with Abigail. 3. If I have a bad dream, I work it out instead of calling for mom. 2 3 4 Without therapy: 1- unlikely 3- neither 5- likely 3 2 1 Importance: 1-not at all 2- slightly 3- moderately 4- very 5- extremely 5 4 4 INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 4. When I get angry, I calm down easier. 5 Jaydee’s Follow-up Change List and Ratings Change Change was: 1- expected 3- neither 5- surprised by 1. Nightmares have stopped. 2. Less fighting with Abigail. 3. Not afraid of the dark. 4. More in control of my emotions (sadness, anger, happiness) 2 3 1 2 137 4 3 Without therapy: 1- unlikely 3- neither 5- likely Importance: 1-not at all 2- slightly 3- moderately 4- very 5- extremely 4 4 3 3 3 3 2 3 Post-therapy Comments and Observations: “I usually get in arguments with Abigail but we just don’t now” Follow-up Comments and Observations: New therapy PQ items set for future sessions: 1. I could not go to sleep on my own without mom or dad. 2. I felt irritated with Dad. 3. I felt irritated with Abigail. 4. I felt grumpy comparing myself to others. 5. I felt stress or worry about school work. 6. I felt left out or excluded by other kids. 7. I felt worried about bees or wasps. Mom’s Change Interview 1. What medication is your child currently on? (researcher records on form, including dose, how long, last adjustment, herbal remedies) Post-therapy: Bach flower remedies (personalized mix from consultant) Follow-up: Bachflower remedy (adjusted 1x/month) 2. What has therapy been like for you and your child so far? How has it felt to be in therapy? Post-therapy: Good, there was resistance in the middle, got worse before it got better; Some days it was a real struggle to come; Jaydee’s voice says no, body says yes; Commitment brings him; Complaints decreased as time went on, Resistance was starting closer to campus, less right away (e.g. just saying not wanting to be here just as entering parking lot, before used to be at the house or on the freeway); definitely stressful to get him here. Follow-up: Definitely worth it. Excited and relieved for Jaydee, but wants it for daughter. Seeing real change in family dynamics. Intense moments in sessions with resistance. Hard work. Hard to know that she couldn’t protect kids from pre-adoption harm/trauma (grieving). Telling others “this is real, observable change in our family” 3. How is your child doing now in general? INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 138 Post-therapy: Happy most of the time; Better with biggest trigger (dad) – whole days go by and not getting made at him (different than before); Conflict with sister, might be more with her stuff/instigating, but it is less volatile than the past; it’s so new, mom wondering “Is this going to last? Is it just temporary?” We live our life bracing ourselves for it, it’s going to happen, that’s what it feels like, we’ve lived 12 years with it getting bigger and bigger. Right now it’s great! Follow-up: Doing great. Gives a lot more hope for future. Sees hiccups in perspective of fearing he will be out of control. He is fertile ground for more social and emotional skills to be introduced now (was taught this earlier but never really stuck, but think it will now). 4. How is your current relationship with your child? Post-therapy: Good. Something to work on maybe… Right at bedtime he now wants someone to stay and read to him (frightened before falling asleep) – he’s turning 13, this should change. He says it is because he loves them and wants closeness (this is new, instead of anger/obvious fear as previous). He wouldn’t have said this before. Follow-up: Mostly fun to be together. Less tiring. Less rages. Less perseverating. Cuddly and seeking connection. Offering affection to dad is new. Soon after finishing 4 weeks ago, was offering dad hugs and asking dad to stay home. More of a bond. Perceptive to how others are doing 5. How would you describe your child? (If role , describe what kind of ____? If brief/general, can you give me an example? For more: How else would you describe your child?) Post-therapy: Enthusiastic, go-getter (especially with bowling), happy, friendly. He wants to be a professional bowler, not perseverating on bowling like he used to, but excitement, looking forward to it when thinking about it. Struggles with school, but it doesn’t bring him down. Follow-up: Fun-loving, adventurous, enthusiastic. – example of talking about travel plans on way here. 6. How would others who know your child well describe her/him? (How else?) Post-therapy: Same way – enthusiastic and encouraging (especially of other kids in special Olympics), others (coaches) never see the angry, but it does come out at school more. Bold, not shy, go-getter. Follow-up: Also fun-loving; Naïve to being laughed at, but not bullied by peers. Endearing to adults. E.g. bakes cookies at home of former aide. Special Olympics community especially thinks of him as fun-loving. 7. If you could change something about your child, what would it be? Post-therapy: Naïve, black and white thinking. Has trouble understanding the intention/motivation in speech. Abstract stuff in academics as well as visual-spatial awareness (from psychoeducational assessment)  his lack of abilities will affect his life e.g. couldn’t do trades, be a mechanic, etc. He wants to work with people in wheelchairs (not just disabilities), is very passionate about this Follow-up: Pull-up thing – to be able to understand boundary and not cross it. Relationship with dad and sister. INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 139 8. What changes, if any, have you noticed in yourself and your child since therapy started? (For example, Are you doing, feeling, or thinking differently from the way you did before? What specific ideas, if any, have you gotten from therapy so far, including ideas about yourself or other people? Have any changes been brought to your attention by other people?) [Interviewer: Jot changes down for later.] Post-therapy: Less volatile. Less, when something goes wrong, less blaming myself or his dad. Something goes wrong in a video game, it’s our fault, or wifi, when it’s out there. So less of that. Nightmares…I find it curious that he still has the fearful time before bed, so that’s interesting. Initiating aggression, still thing with his sister. Less provoking. Wants to be her friend (even before started this therapy). Has a dollar, spends half on her. Just wants to be her friend, wants relationship with her, she’s unable to. Stress/worry about homework. School has rule not to spend more than 10-20 minutes on it. He’s ok with stopping after this. We have also decided to call his French “modified”, which means he’s auditing French. He doesn’t have to do the written part, so things have change this way to be less stressful. He just goes “oh well.” A bit more casual now. Follow-up: See emails and change list 9. Has anything changed for the worse for you or your child since therapy started? Post-therapy: In the middle of our time – was rough. Resistance to coming, ornery afterwards, this lingered for 2-3 days after session (crankiness). He needed more space, more sleep, but this would fade before the next session. But not anymore. Follow-up: No except for longing for daughter to have same change (more contrast). Worry has switched from Jaydee’s future to daughter’s (Jaydee used to seem way worse than her). 10. Is there anything that you wanted to change that hasn’t since therapy started? Post-therapy: Fearfulness at bedtime. The siblings conflict – work from her side as well – her therapy may bring him in later. Follow-up: No. goals were met. 11. What do you think happened between you two during therapy? How did he use you to meet the therapeutic goals? What do you see afterwards between the two of you? With other family members? How was it for him not to include you during some sessions? Post-therapy: snuggle at beginning (used her as safe resource). Doll – negative but persisting (no with mouth, body says yes), didn’t think it was pushing him too far. Lately, really snuggly after session, so thankful after session for food bought because he is really hungry (over the top thankfulness). Less volatile to dad and sister (not initiation but participates if she initiates). So much so with dad. It sometimes was not safe for the 2 to drive in the same vehicle, now can drive safely. Not just not physically hitting us, but even verbal swearing, etc., has stopped. Ok to have mom not included sometimes. Used to always regulate, especially physically with mom, now separation gives him a chance to regulate himself Follow-up: Self-regulated off of mom, More “lovey dovey” after session (e.g. hugging mom’s arm as they drive afterwards). Already mentioned change in relationship with other family members. Less intensity of fear. O.k. to not include mom. 12. For each change, please rate how much you expected it vs. were surprised by it? (Use this rating scale:) INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 140 (1) Very much expected it (2) Somewhat expected it (3) Neither expected nor surprised by the change (4) Somewhat surprised by it (5) Very much surprised by it 13. For each change, please rate how likely you think it would have been if your child hadn’t been in therapy? (Use this rating scale:) (1) Very unlikely without therapy (clearly would not have happened) (2) Somewhat unlikely without therapy (probably would not have happened) (3) Neither likely nor unlikely (no way of telling) (4) Somewhat likely without therapy (probably would have happened) (5) Very likely without therapy (clearly would have happened anyway) 14. How important or significant to you personally do you consider this change to be? (Use this rating scale:) (1) Not at all important (2) Slightly important (3) Moderately important (4) Very important (5) Extremely important Post-therapy: see change list chart. - Note: there was a question from mom about the difference between expected and hoped for? o Was hoping for less volatile, less provoking, but don’t know if I was expecting this. o Had read a couple of books about LI, had seen less volatility with Abigail’s LI therapy, had anticipated that his change in volatility would be faster because his trauma was less, because he’s more black and white like “oh this is the way we are going to go now” So I did expect and hope for this to happen. Follow-up: See change list chart 15. Attributions: In general, what do you think has caused these various changes? In other words, what do you think might have brought them about? (Including things both outside of therapy and in therapy) Post-therapy: Schoolwork load has helped (more reasonable for him) – him realizing the school’s expectations are more reasonable than what he was putting on himself. Accepting baby self, integrating to live like a 12 year old. “There has been a giant step forward in it, but I’m excited to think about even more!” Follow-up: New role in middle school, IEP, Special Olympics – positive outlet, positive focus. LI work – saw fears and anxiety as tied to baby experiences, and early experiences – was able to “mesh” in his brain (e.g. early hard experiences were when he was watching Swiper, etc. they became connected in him brain). 16. Helpful Aspects: Can you sum up what has been helpful about your child’s therapy so far? Please give examples. (For example, general aspects, specific events) Post-therapy: Definitely Rice/sand table (sensory) – hiding game. He asked “can we get a sand table” I’ve kind of thought, no this is special to here, keeping him here. Weighted blanket was good. Janelle speaking encouraging words – he really took that to heart, and she really INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 141 spent time emphasizing this, a descriptive affirmation (not over the top though). Candy motivator (toxic waste) – playful Science motivation “This is helping scientists” Don’t know how this will work when continuing. [prompt about asking if anything about LI process was helpful?] Baby doll, what was your experience like [as a baby], what does the baby need – still important for him even though he resisted (mom thinks very important for sister’s work). Lifelike baby was important. Follow-up: Letting go of fears and nightmares and general movement toward emotional maturity. Sand/rice tray was grounding. 17. What kinds of things about the therapy have been hindering, unhelpful, negative or disappointing for you or your child? (For example, general aspects. specific events) Post-therapy: Very stressful driving to Langley for mom, not sure about for Jaydee. One time completely at a standstill (traffic), even rainy weather is stressful. Would be nice to be in Abbotsford, or even not driving at this particularly time of the day (more traffic). Temperature in the room – but has been monitored and dealt with by opening window. [prompt, anything particular about therapy on a certain week?] No, nothing about the therapy specifically. Follow-up: Intensity of drive, Room temperature. 18. Were there things in the therapy which were difficult or painful for you or your child but still OK or perhaps helpful? What were they? Post-therapy: The baby – for Jaydee. I was surprised how painful it was for him. It was difficult for me to think I wasn’t able to protect them at that time, sad about this [tears at this time in interview]. Thinking I might have more work to do around this in my own therapy. I think J. realized its hard work for me, maybe through Dr. Janelle’s words. Follow-up: Holding the baby is the hardest part 19. Has anything been missing from your child’s treatment? (What would make/have made your therapy more effective or helpful?) Post-therapy: Include dad and sister. No, I don’t know if any therapeutic things are missing. Being in Abbotsford would have made therapy more effective or helpful. Other counsellors come to home to work with parents, also BI does and naturopath did one time, being in the home to have real-life generalization. Also right now she is worrying a little bit about other teenager being at home by herself. Other people can see how difficult it is for the 4 of them to be together, e.g. only time all together is driving to church and back and its very volatile. Follow-up: Dad and sister (going forward). 20. Do you have any suggestions for us, regarding the research or the therapy? Do you have anything else that you want to tell me? Post-therapy: coming to the home. Was glad to have read books and know bigger picture of LI  give resources to family beforehand (like a 1pager about why it works) ---would be interested to even reading those books again. A mid-week check-In might be more accurate too, hard to remember from the whole week. Follow-up: Helpful to spin it as science. Gift certificate and fun activities positive. 21. Review Personal Questionnaire (PQ). In general, do you think that your ratings mean the same thing now that they did before therapy? If not, how has their meaning INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 142 changed? (Sometimes clients change how they use the PQ rating scale; did that happen for you?) Post-therapy: I would be more accurate, more helpful, if I had a daily rating thing, sometimes hard to remember from the full week. Also some of them [the items] I don’t quite know because they have to do more with his experience, so I don’t know (e..g daytime fears at school) what it was like for him if he doesn’t tell me. Follow-up. Items 1-4 on PQ – only happened 1x in 4 week period. 22. Identify each problem that has changed 2+ points: Do you want to add this change to the list that you gave me earlier? - see change list 23. For each PQ problem change (2+ points), ask: Tell me about this change: What do you think it means? Do you feel that this change in PQ ratings is accurate? Post-therapy: I was hopeful, it’s really fresh and new, I’d like to see the holding value of it all. In months, in a year, will he have nightmares? Will he have new nightmares? This bedtime anxiety, will that…now that the ball is rolling will that change too? Like a residual effect? Even if he doesn’t choose to continue therapy? BI recommended less underwear available in his drawer to counteract need for pullups. In the past he would dig around looking at pads or anything he could find to use instead of pullups. But this stopped quickly, after November, hasn’t popped up again since Christmas. Follow-up: More family time over the month period because of spring break leads to more whining conflict in family. Fear of dark is more don’t leave me alone as I’m going to sleep/getting ready for bed. Didn’t think affection would happen with dad unless he was actually in the therapy. Mother’s Post-therapy Change List and Ratings Change Change was expected to surprised by 7. Less volatile, less 1 provoking 8. Less blaming others 4 9. Nightmares stopped 1 10. Casual about 2 schoolwork (less stress about homework) 11. No need for pullups 1 12. No daytime fears about 1 nightmares Follow-up Change List and Ratings Change Change was expected to surprised by Without therapy, was unlikely to likely 1 Importance not at all to extremely 5 1 1 1 5 5 5 1 1 5 5 Without therapy, was unlikely to likely Importance not at all to extremely INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 1. More affection to dad (didn’t think it would happen with dad) 2. More reasonable 3. Less volatile/less family conflict 4. Seeing self more independently (talking about moving out) 5. Minimal nightmares 6. Minimal daytime fears 7. Fear of the dark 8. General anxiety and fear of unknown gone 9. Difficulty with homework 10. Stress/worry about homework 143 5 1 5 2 2 1 1 5 5 5 2 5 1 1 1 1 1 1 1 1 5 5 5 5 2 3 4 4 3 4 Additional Comments from Parent throughout Therapy (from HAT): Session 2 - use different cues, maybe even have cue cards – different sets so that Jaydee doesn’t “memorize” the list. Then he can have a little say – which set of cue cards to use, maybe hold them? – they could be on an “o” ring, to flip through. Session 5 - I saw Jaydee’s cheeks were red when I came in. He looked sleepy. Probably from the hard work but also it was really warm in the room. Jaydee expressed happiness to me about coming on Monday. He resisted hugely to coming on Saturdays. INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 144 HAT Summary Client Reported Most Memorable, Helpful or Important, and Hindering Events for Each Session on the HAT Form 1 2 3 4 5 6 7 Most Remembered Event life talk – when I was born talking to my baby self No data collected the baby self – just talked about it – it was good talking about my baby self – that I’ve been through so much the baby self thing and pretend doll Probably the baby self talk Most Helpful or Important Event talking about my fears Showing how my fears (nightmares) happened in the dollhouse Explanation Rating (/6-9) 7 Anything Unhelpful in Session & why No 8 No talking about how Freddie is not real talking about my baby self Get it off my chest – feel better Because it made me think of how safe I was 6 No 6 No the baby self no, it just was 6 No probably the baby self talk, honestly well, because like to tell that everything is ok is reassuring and it was helpful 6 No, [when prompted] But it was uncomfortable to talk about baby self and have mom talk to baby self. Kinda reassuring and kinda uncomfortable. to help me get over them Explains how intensive/fearful those things are 8 memories of childhood memories it gives me an idea of what could happen 5 9 baby self – going through my life with the cards that (baby self) 8 10 telling about my dreams probably telling about my dreams I don’t know. (Prompt) It helps to go through your life if you have something that is stopping you from right now. It just was. My baby self had grown up. It made me feel better about myself. Yes, watching mom do the work with baby self…because it made me feel upset and sad and weird (2 rating) No 9 No INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 145 Parent Reported Most Helpful or Important Event for Each Session on the HAT Form Session Most Helpful or Important Event 1 While Jaydee hid things in the sand table your reassuring words about his strengths/competence. Those were important 2 Again, the encouraging words interspersed throughout the session 3 Using unique memory cues (not same as last time) Giving Jaydee the freedom to say he wanted me to leave the room I didn’t attend the session. Jaydee went in alone. Encouraging words, ignoring his grumbling protests Persisting, continuing regardless of his resistance/reluctance carrying on, persisting, moving forward with the cues despite his protest I didn’t attend most of the session; playing a game to connect was helpful; words of affirmation and encouragement are great. A battle! Acting out the battle in the dream. Dr. J. being brave to try a toxic waste candy! 4 5 6 7 8 9 10 Description of Why the Event was Helpful/Important I don’t think it totally “clicked” for Jaydee about the rings of the tree. Abstract thoughts are hard. So your reassurance was important – he’ll be able to persist. I noticed Jaydee look up and into your eyes when you said them – checking in – “Are you for real? Are you telling the truth?” I think he feels reassured that you are. I saw him “connecting” – he was surprised, delighted He self-identified the need. He seemed happy after I came back in. Rating (/6-9) 8 He stuck to it, he did it! 8 Showed him he could do it, we believed he could, we wanted him to do it. message to him: we value this, we value him, we’re going to do this. 9 9 9 9 9 9 End on a BIG positive – emphasis or fears conquered. Power to conquer fears in dreams. Parent Reported Additional Helpful Important Events and Hindering Events for Each Session Session Anything Else Helpful During Session 1 Tree ring discussion 2 letting J take the lead sometimes but setting solid limits other times time for a break – sand table Encouraging words at the beginning of the session N/A window open, not so stuffy The nesting cups. Colour orange was first, that’s “his” colour at home (cup, bowl, etc). Colour green matched backpack at that age. Extremely nice sand – attractive new fun thing N/A N/A Extremely 3 4 5 6 7 8 9 10 How Helpful Greatly Anything Hindering During Session the temperature – Jaydee was “fading” due to being too warm (I think) How Hindering Greatly Extremely Extremely Extremely Greatly I think Dad & Abigail are missing. I think I should mention them when talking to the baby Jaydee. Mom, Dad, & Abigail welcoming him. Jaydee lately is really, really, over the top, absurdly rude to Dad. Zero warmth at all to Dad. No respect, no affection, lots of rude words, aggressive words, threats. Extremely INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 146 TSNQ Summary Therapist Reported Most Helpful or Important Event for Each Session on the TSNQ Form Session Most Helpful or Important Event 1 seeing baby self as legitimately confused and helpless and fearful first rep of LI cues was experientially rich. Client “regressed” by laying down and snuggling up to mom and used signals to the therapist to indicate that he had “shown” his baby self the cues. Feeling empathic awareness of needs of baby self before showing his baby self how he grew up client seemed to know what to expect with connecting with baby self and was able to go to vulnerable early experiences and stay engaged in timeline cues. going through timeline cue repetitions. mom’s affectionate stance and attention toward baby self in spite of client’s own negative feelings toward the baby self mom holding and talking to baby self – provoked discomfort in client but also seemed to be making connections in a reassuring way. Client was able to find peaceful place. Because of resistance today, I think what was most helpful was to affirm that client could push through by continuing with cues while also engaging him in different ways. reviewing timeline cues. 2 3 4 5 6 7 8 9 10 Client said “I feel like my baby self finally turned 12 ½” – demonstrates internalization of integration/growing up Description of Why the Event was Helpful/Important inner connection was apparent Rating (/6-9) 6.5 Distress of baby self was activated but client was still able to stay in process and feel present safety 7 younger feeling states were activated and connected to present fear It seems client is increasingly internalizing that his younger self is part of him and needs to know he’s ok. 7 7.5 instills positive affection in the parent-child dyad 7 7.5 attachment repair focus 7.5 affirmed client’s capacity while acknowledging his discomfort. Affirmed that client’s core need were important. 7 build client’s connection to self and life story while past becomes integrated into present reality. Client retrospectively saw vulnerability and fear of helpless younger self and that he has safety and nurture in his current life. 7.5 9 INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 147 Therapist Reported Additional Helpful/Important Events and Hindering Events for Each Session Session 1 Anything Else Helpful During Session mom’s presence was attuned and comforted him 2 client elaborated a play-by-play of a typical nightmare in the dollhouse. I believe this was important for 2 reasons: 1) validated and “heard” what client’s most important concerns were. 2) Activated fear in the content of mastery – client had control and could show the truth that he always wakes up and is ok. remembering the life story with timeline cues. As many cues were new today, it was apparent from the client’s surprise and sometimes happy recognition, that he hadn’t thought about these events for a long time and could “see” himself growing up. Seeing the client actively track with the cues reinforced my confidence that integration processes were happening. client asked mom to leave to do timeline cues – he had reportedly told her it was sometimes embarrassing and it seemed to be what he needed to feel comfortable. Conceptualization of real versus fantasy was operationalized in sand tray. Discussed “research” about client’s fear object in scientific way and used sandtray to show positive (like Santa or Lightning McQueen) and negative fantasies. Sensory soothing of rice tray; client’s autonomy to know when he needed mom present and when he wanted to be without her; client’s “buy in” to the therapy process facilitated depth work quickly. going through the familiar repetitions of timeline cues. 3 4 5 6 7 8 9 10 acknowledging clients hard work last week and engaging resistance to coming today and eliciting agreement to participate – I think this was honest to admit resistance and empowering to agree using sand and discussion of positive experiences to experientially enjoy a sense of calm. Also framing attunement to baby self as mom’s “need” as well because of what she missed was helpful. re-established positive/enjoyable aspects of treatment process (game and planning different game next week) No resistance today at all. Client was physically comfortable (room temp ok, etc) Anything Hindering During Session heat in the room. Low buy-in about relevance of connecting to baby self. 2nd rep client requested to do it all himself in his own head. He told me that he showed everything to his baby self. However, it was not clear that he was experientially accessing baby self-state. Client tends to perseverate on confronting makers of his fears temperature control was somewhat difficult in the room today, but overall seemed to be ok. the same event engendered a lot of resistance on the part of the client. I conceptualized this as pain of something helpful but raw. It’s like warming really cold hands under warm water so that it burns. resistance present – client is triggered by doll being there, but it was much easier this week than it was last week discussing continuation of sessions at the beginning of session seemed to trigger extreme resistance. snow was distracting – client focused on fear of upcoming bowling tournament (in 2 weeks) no INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 148 Therapist Reported on Attachment Experiences between Client and Mother in Session Session Proximity and Contact Seeking 1 frequently held mom’s arm and leaned in to her and made eye contact touch and holding on to mom during intense moments. Eye contact with the therapist. 2 3 client actively sought physical and feelings through eye contact and words 4 used weighted blanket 5 6 N/A more approach/avoidance dynamics than in previous sessions. Pushed mom away at times and also reached out physically. Tender eye contact at point of “remembering” or imagining mom being there when he was born mom sat separate today – mom held baby. At the end of session, client sought physical closeness (hug, snuggle, kiss) pushing away from mom, “toddler” tantrum dynamic (eye contact stern and expressing/asserting independence while also needy toward mom) 7 8 9 10 mom came in at the end, client snuggled with mom and gazed at her. mom was only present for last ~10 min. stroking hugging (some) but more excitement – eye contact and including mom as judge in candy contest. Initiation & Maintenance of Communication Secure Base Exploration expressed discomfort to mom about talking about baby self client spoke up about his needs and feelings through eye contact and words Client requested for therapist and/or mom to be in the room at all times, even when he was hiding toys in the sandtray, as he felt activated by seeing the scary pictures was able to express autonomy by asking mom to leave but to stay close Emotion Regulation her presence seems very anchoring to him. (note: may be helpful to have weighted blanket or shawl available to client. He spontaneously squeezed onto mom for pressure during protocol repetition) held mom’s hand to soothe decrease – a lot to handle but client was able to tolerate whole session asked to go but was directly triggered by baby eye contact – spoke up about discomfort. Mom was able to reassure. client perseverated on feelings of unmet needs – maybe a “trigger” response to baby self feelings but not overtly responses to mom’s care and affection on protocol client was able to de-escalate completely after session calm today client easily engaged with therapist and mom, open posture, eager participation client chose to be in session alone but was not pushing mom away able to effectively express anger/power and know the difference between real and imaginal (dream) INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 149 APPENDIX I: Case Development Case Development – Jaydee In this document you will find arguments for and against change in Jaydee through Lifespan Integration therapy. All information about the evidence used to create this argument is in the rich case record. An affirmative team and a skeptic team of local experts (graduate students, child therapists, LI therapists) were created and tasked with key types of evidence to look for in the rich case record. Each team was able to present their case to each other, followed by a rebuttal from each side (affirmative presenting and rebutting first). The following is a summary of these arguments. Tasks In the HSCED method, the task of the affirmative team is to find positive evidence for multiple links between therapy process and client change (Elliott, 2014). To make a causal role of therapy in client change, this methodology requires that at least two different kinds of evidence support the therapy-change link. • Change in stable client problems: client experiences change in long-standing or chronic difficulties • Retrospective attribution: client attributes specific changes to therapy in general • Outcome-to-process mapping: Content of the post therapy qualitative or quantitative changes plausibly matches specific events, aspects, or processes within therapy • Event-shift sequences: significant therapy events are followed forward in time for evidence of their later effects such as stable shifts in client problem ratings • Session-by-session process-outcome correlation: Associations are found between important in-therapy process variables (HAT) and week-to-week shifts in client problem ratings (on the PQ). The task of the skeptic team is to find negative evidence refuting the causal role of therapy. Eight potential explanations were considered as competing explanations for client change or as evidence that change did not occur: • Nonimprovement: negative or irrelevant change • Statistical artifact: random error such as measurement error, regression to the mean, and experiment-wise error. • Relational artifact: interpersonal dynamics between client and therapist, including social desirability. • Expectancy artifacts: client or parent tries to convince self and others that change has occurred when it has not • Self-generated return to baseline: distress may have been temporary, client reverts back to normal functioning on his own. • Extratherapy events: improvements in relationships or school, changes in health status unrelated to therapy. • Unidirectional psychobiological changes: psychopharmacological medication/herbal remedies. • Reactive effects of research: relationship with research staff or sense of altruism. INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 150 Affirmative Brief 1. Change in stable client problems The affirmative team cited multiple items from the rich case record as evidence for change. In Jaydee’s self-report, he became happier and less anxious over the course of therapy. The change interviews also reflected change. The PQ ratings showed that realistic stressors increased in concern whereas the childlike phobias decreased over time. Session notes also reflected progress and change for Jaydee. Jaydee also displayed an increase in confidence, as he began to challenge his parent throughout therapy. In his self-report, there was evidence of a growth in empathy for both Mom and Dad. Particularly, he did not demonstrate empathy for Dad before therapy started, and this had changed positively throughout therapy, even though Dad was never a part of therapy sessions. 2. Outcome-to-process mapping Ego development and growth was displayed when he chose to be without mom in later therapy sessions. In earlier sessions, he leaned on Mom for emotional support, as his sense of self was developing, and he remained a person regardless of Mom’s presence or absence in later sessions, as demonstrated by his choice to have her near when needed and dismiss her when vulnerable work needed to be done. Even as parenting became more inconsistent on BASC-2 measures, Jaydee’s behaviours improved, demonstrating ego strength and individuation from parents, which is an internalizing process. Jaydee also became more insightful throughout the process. He started to demonstrate the understanding that therapy was hard work for him, it was also hard work for mom, and mentioned that they deserved treats for this (informally at end of session and during HAT interviews). He was able to persevere through the difficult work and reflected on the process by commenting on how his baby self had grown up in the tenth session. This also displayed cognitive growth, when he was able to recognize the irrationality of nightmare fears and also understand his baby self was now “12 and a half, right now (RCR p. 39).” This means that the resolution of his trauma allowed him to activate more cognitive parts of his brain. Some more specific indicators of trauma being resolved for this client included his interest in meeting his birth mom. His security with his adoptive mother may have also been a part of resolving this trauma so that he was not afraid of meeting his birth mother. Jaydee also demonstrated continued positive movement after therapy (1-month follow-up), suggesting that LI therapy was doing more for him than just having the benefits of a therapeutic relationship. LI conceptualizes that a client continues to internalize the integration process beyond therapy sessions. 3. Event-shift sequence The progression of more infant-like behaviours in the beginning of the LI process (e.g., holding onto mom during timeline), to his acknowledgement of his baby self growing to his real age (Paraverbal voice changes in session 10), to demonstrating connectedness with his Mom when she was not even in the therapy room (throughout), shows the resolution of trauma and growth experienced by the client throughout therapy. In the last session, the client reported an ability to fight back during his nightmares. The resolution of his recurring nightmares coincided with his LI therapy progression, suggesting that INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 151 resolving his early trauma allowed for more child-like fears to be resolved. Jaydee’s current fears reflect more age-appropriateness. The therapist continually reported seeing the client engage with the timeline cues. The therapist’s ability to keep the client within the window of tolerance (i.e. attuning to his needs) were also useful in bringing about change, such as by incorporating the weighted blanket, giving verbal affirmations, and using the sand tray in the room. These are not viewed as merely common factors, as they were used in conjunction with LI protocols. 4. Session-by-session process-outcome correlation Specific processes that brought about change were the use of the doll and mom’s presence in this. The LI timeline (“hearing his story”) and the use of the nesting cups were LI interventions the client named as helpful. While mom holding the doll while timelines were read activated the client in a push-pull and resistant way, the client reported that this was both hard and important/helpful. His PQ ratings continued to decline after this. Skeptic Brief 1. Nonimprovement • PRQ Father: The pre-therapy and follow-up scores are very similar in all dimensions, suggesting little lasting change from therapy in this parenting relationship. • PRQ Mother: The attachment scale and communication scale at pre-therapy and follow-up were similar, suggesting very little improvement in this dimension. • BASC results: There was no change in the client’s SRP self-esteem scale. One’s view of self is often related to internal attachment processes, suggesting therapy did not change Jaydee on this dimension. • Teacher and educational assistant BASC scores did not show considerable differences in anxiety, adaptability, attention, and hyperactivity, suggesting little change in these areas. 2. Statistical Artifact There is an indicator of measurement error in the client’s post-therapy change ratings (change interview). The client’s ratings are inconsistent, suggesting he may not have really understood the scale or question. For example, he reported that without therapy, change would have been likely (4/5), but that he was surprised by the change (5/5). 3. Relational Artifact • The therapist was also the research supervisor and engaged in some research interviews when the principal investigator could not be there. This may have influenced Jaydee’s ability to be honest about his reactions to the particular sessions. • The parent and client may have overemphasized changes in the self-report. For example, the teacher and educational assistant did not show considerable change differences in anxiety, adaptability, attention, and hyperactivity on the BASC reports, and they did not have the same personal relationship with the researchers that the client and parent did. This is also demonstrated in the father’s reports which did not show significant change in some areas, as he was not present in therapy. The mother and client may have been apprehensive to report nonsignificant or negative changes due to their personal relationship with the researchers. INTEGRATING ATTACHMENT IN AN ADOPTED CHILD • • 152 Jaydee “hated” the baby doll in session, but afterwards reported that the doll was helpful (client HAT). Perhaps he felt guilty about his resistance and so reported what he thought the researcher’s wanted to hear about the session. Similarly, Jaydee could not articulate what was helpful in the HAT and change interviews. He said, “Everything was helpful.” This may have been because he was only trying to give a correct answer, not an answer that was true for him. 4. Expectancy Artifacts • The client had a big motivation to “help science” by engaging in the research process. This may have skewed his perceptions of change. He may have reported change in himself because of his trust in science, and wanting to help the process, and not because change was actually experienced. • The client’s mother is familiar with LI through her daughter’s therapy, and so had positive expectations about it working with Jaydee. This is supported by the post-therapy change ratings where she repeatedly reported expecting change (1/5). • Jaydee was told in the therapy that the baby doll would help him, but experienced extreme resistance to this process. Being told that it was helpful may have influenced his choice to report the doll as helpful in his interviews. 5. Extra-therapy Events • Special Olympics bowling may have given Jaydee a positive motivation to change his behaviours and provide relational support for his anxiety. • The client was monitored over a 5-6 month period of time when developmental growth was also naturally occurring. In a session 10 video clip, the client says he feels older and wonders if this may be why he no longer experiences distress from nightmares. It may be this developmental growth contributing to his change. • In the mother’s change interview, she reports school has changed for Jaydee, in that the school work load has decreased and naturally become less of a stressor for him. • Jaydee also had other supports in his life besides LI therapy, such as a family therapist who worked with his parents and a behavioural interventionist (BI) who came to the home to work with him. These supports may have contributed to the change experienced over this time. • Sand tray, while occurring in therapy, is not an explicit part of LI and may have contributed to the change. 6. Psychobiological causes Bachflower remedies were continually adjusted throughout therapy and may have been responsible for observed changes. 7. Reactive effects of research • Merely the attention of two professionals (therapist and researcher) may have contributed to change in Jaydee. A big change was seen in his BASC-2 SRP interpersonal relationships scale, suggesting that his relationship with two more professionals may have influenced this INTEGRATING ATTACHMENT IN AN ADOPTED CHILD • 153 change, not the LI therapy. To further support this, there was nonmeaningful change in parental relations over time in the SRP, suggesting that the interpersonal relationship improvements did not reflect all relationships. The research and therapy processes also gave the client more one on one time with his mother, and so he may have flourished merely under this increased attention. Affirmative Rebuttal 1. Some scales didn’t see change The scales that did not see change may not have been measuring what was LI and clinically relevant. For example, in the teachers’ reports we would not expect to see change this early in therapy. The client received ten sessions of LI focussing on his attachment issues with his mother. After 12 years of attachment difficulties, to expect this work to be reflected in his school performance may be unrealistic. Similarly, Dad’s reports of lack of change or negative change on certain PRQ scales are not as relevant to the case as dad is not the primary attachment figure to Jaydee. As well, Dad was not a party to the counselling sessions, so no direct work with him took place. The PRQ attachment scale with mom did not support change in this area, but clinical interviews indicated that multiple factors had changed throughout the course of therapy, suggesting that while some factors may have decreased, many others increased to reflect a similar score on this particular measure. While the SRP self-esteem scale did not show change for Jaydee, his self-report in the change interview does indicate feeling very positive about himself. The evidence provided from these scales may be more reflective of how the measure was not fully capturing the client and parent experiences. 2. Inconsistencies It makes sense that some of Jaydee’s self reports would be inconsistent from an LI perspective. There are parts of himself that are not realizing he is now 12 years, and so he may be shifting among ego states when responding to certain questions. It is considered a sign of growth that he is aware of and responding from different parts of self. It is also typical of a 12 year old to be responding to such measures in an inconsistent way, due to the complex thought processes required for some of the questions. 3. Extratherapy factors There were specific instances that were difficult and worth working through for this client in the therapy session, that would have not occurred without the therapy. The degree of difficulty for the client in the LI repair phase with the baby doll demonstrates that core processes and deep trauma wounds were being drawn upon in the LI therapy that other extra-therapeutic events would not be consistently bringing up. The client and parent reported specific moments in therapy that were “Aha” moments and important to bringing about client change. 4. Pleasing/Placating Researchers and Research Process It is unlikely Jaydee was only aiming to please the researchers when interviewed after therapy about the work in his sessions. There were episodes in the sessions that indicated overt resistance to the LI therapy process. Jaydee was quick to whine and complain about things he didn’t like within therapy, and he would not have had the capacity to only filter his responses when answering the research questions in order to please the researcher. It is assumed that the LI work was done internally or subconsciously, such that he would not have had an awareness of INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 154 what was even happening in him. This means he would not have been able to even comprehend the “correct” answer the researchers’ would want to hear, and could only give a true answer for him. Furthermore, it was evident that the sessions were exhausting for him as he was observed as quite fatigued afterwards, further diminishing his capacity to people please in the HAT forms. Other Affirmative thoughts: • Mom’s PQ scores did not show the measure of improvement she expressed in interviews, as she explained she had shifted her expectations to a new baseline for Jaydee’s behaviours. Even though problem behaviours decreased in frequency and intensity, her expectation that they had decreased made them more distressing to her when they occurred. • In the post-therapy change list and ratings from Mom, she had to clarify that she had rated them more based on hoped for rather than expected. This was clarified in the follow-up ratings where she rated more on expectancy beliefs rather than wishes/desires. • Jaydee’s desire to still have parents present at his bedtime is not a regression, although atypical for this age group. His reason for having parents present at bedtime shifted from being fearful to “because I love them.” It means that he is working through the attachment bonding experiences of needing the closeness he did not have in his infanthood and had missed developmentally. His initial presentation is thought of as more dismissing attachment style, and now the dismissiveness is decreasing considerably. • He demonstrated increasing empathy for others when he shared his candy with Mom after session as recognition of her hard work in therapy with him. • Jaydee’s resistance to the baby doll is though to be reflective of vand der Kolk’s “rage of helplessness,” and internalized anger for a need that needs to be processed. This is not a negative aspect of therapy, but a necessary conflict to be worked through. Skeptic Rebuttal 1. Change • The statement that the client demonstrated greater empathy to parents lacks consistent evidence as in Session 7 it was reported by the mom that Jaydee was “absurdly rude to Dad” and did not show any warmth. • Sending mom out of the room was a sign of insecure attachment, as he was unable to be vulnerable in front of his primary attachment figure and could not tolerate this level of intimacy. • Cognitive growth may have been merely due to growing older. • Felt security decreased for items 6 and 7 on the Kerns Security scale. 2. Change caused by Therapy Dismissing bowling as a cause for change fails to appreciate the fact that bowling promotes team bonding, relationship building, self-efficacy and self-mastery, as well as giving purpose and meaning to life. 3. Processes responsible for change Other therapeutic factors, such as sand-tray work, therapeutic common factors, and the encouragement of the therapist to seek change may have promoted change rather than LI. INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 155 APPENDIX J: Adjudicator A Response Form Please highlight your answers on the scales provided (for example, use your mouse to highlight the appropriate answer and change to bold type or to a different colour). Choose only from the descriptors/percentage intervals provided. In answering the rest of the questions, please use whatever space is needed to give a full response. 1. To what extent did the client change over the course of therapy? No change 0% Slightly 20% Moderately 40% Considerably 60% Substantially 80% Completely 100% 60% 40% 20% 0% 1a. How certain are you? 100% 80% 1b. What evidence presented in the affirmative and skeptic cases mattered most to you in reaching this conclusion? How did you make use of this evidence? (Use as much space as needed) As a clinician familiar with Lifespan Integration therapy for children, I see four key outcomes in Jaydee’s therapy that consistently occur when LI is administered by a grounded, coherent therapist, which I consider occurred in this case. In order of significance they are: 1) Anxiety decreased over the course of therapy. Consistent LI timelines ‘prove’ to the body that earlier events and distresses are over, which enables the body to release outdated defenses and emotions. Jaydee’s LI sessions reflect emotions appearing and changing throughout timeline repetitions. Jaydee’s father and mother indicated a decrease in J’s anxiety as indicated on the PRS Anxiety measure, with the mother’s final measure moving into the average range from a previous clinically significant score strongly above average. Also, Jaydee’s post therapy change list includes the statement I don’t get afraid so much. 2) Jaydee got relief from his nightmares. This is a very common outcome from Lifespan Integration, which is probably derived from the resolution of unconscious material. As Jaydee progressed through sessions of LI, his nightmares decreased and his sense of self increased, which showed in his ability to “fight back against the nightmares.” Jaydee also considered “showing how my fears (nightmares) happened in the doll house” as second in terms of HAT outcomes (…memorable, helpful or important events). Jaydee reported in his Change Interview, no nightmares, I don’t get that anymore, same with worrying about nightmares. 3) Jaydee acknowledged that his baby self had grown to his real age. (Affirmative Brief paragraph 4 and 7, et al.) This is also a consistent outcome from Lifespan Integration. LI timelines appear to connect earlier ego states to present time, which enables clients to INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 156 report that their baby selves are no longer trapped in time without the knowledge that they are contained within a person who is the current age. Jaydee’s remarks that his baby self understands he is Jaydee’s real age indicates integration, which leads to decreased dissociation and decreased baby-like behaviors. This concept is listed by Jaydee under HAT outcomes in item 4,5, 6, 7, 8, and 10, including item 7: “telling that everything is okay is reassuring and it was helpful,” (regarding the baby self) and, item 10: “My baby self had grown up. It made me feel better about myself.” Jaydee acted this out in the sand tray in session 4 when he put a tiny baby doll next to the chest of a bigger doll and said, “my baby doll is still here in my heart.” Therapist TSNQ quotes client saying, “I feel like my baby self finally turned 12 1/2 ,” which therapist attributes to… “internalization of integration/growing up.” 4) Emotional regulation increased. Jaydee’s and his mother’s change interviews suggest that Jaydee evidences emotional regulation as a result of his therapy, which is also a predictable outcome for LI. Their change interviews include these statements regarding emotional regulation: Jaydee’s Post Therapy Change Interview: “No nightmares, I don’t get that anymore, same with worrying about nightmares; (I) can control emotions better…sadness, anger, happiness; little bit less fighting with sister than last time. Jaydee’s change list: 1. “I don’t get afraid so much.” And 4. “When I get angry, I calm down easier.” Jaydee’s Follow up Change list: 4. “More in control of my emotions (sadness, anger, happiness) Mother’s Change Interview remarks: 3. (Jaydee is…)“Happy most of the time; better with dad – whole days go by and (mom) not getting mad at him; less volatile than the past. 4. “Mostly fun to be together, less rages, less perseverating, cuddly and seeking connection, more of a bond, perceptive to how others are doing (CT observation: perception of others enhanced by self-regulation). 11. “Self-regulated off of mom, less intensity of fear, OK to not include mom. 16. “letting go of fears and nightmares and general movement toward emotional maturity.” Mother’s Post-Therapy Change list: 1. Less volatile, less provoking; 2. Less blaming others Mother’s Follow up change list 1. More affection to dad, 2. More reasonable, 3. Less volatile/less family conflict…8. General anxiety and fear of unknown gone, 10. change in stress/worry about homework. 5)Other positive shifts indicated on the Affirmative Brief, which I would attribute to common LI outcomes include: …childlike phobias decrease over time (par.1.) …self-reported evidence of growth in empathy for Mom and Dad (par.2.) …ego development to choose to be without mom during therapy (par.3.) …more insightful through the process, empathy for impact on mom (par.4.) …indicators of trauma resolving, including interest in meeting birth mom (par.5.) INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 157 …the presence of the baby doll activated Jaydee’s unconscious, body-based memories of his infant-self. Activating and integrating these feelings through timeline repetitions is consistent with LI therapy. (par.10.) …His PQ ratings continued to decline after this. (par.10.) 5) The skeptic brief, under non-improvement, cites “Teacher and EA BASC scores did not show considerable differences in anxiety, adaptability, attention and hyperactivity, suggesting little change in these areas.” I would add the qualifier that these did not appear to change in the setting in which they were observed by the teacher and EA. Genetic symptoms of ADHD do not consistently abate due to Lifespan Integration, although the reduction of anxiety is generally seen as an outcome of LI therapy in most settings, and was reported as change by the mother and client. 2. To what extent is this change due to therapy? Not at all 0% Slightly 20% Moderately 40% Considerably 60% Substantially 80% Completely 100% 40% 20% 0% 2a. How certain are you? 100% 80% 60% 2b. What evidence presented in the affirmative and skeptic cases mattered most to you in reaching this conclusion? How did you make use of this evidence? (Use as much space as needed). The points mentioned above – anxiety decreased as reported by the client and parents, relief and empowerment regarding nightmares, the baby self’s understanding that he has grown up and lives within the client’s current self, and increased emotional regulation - is so consistent with Lifespan Integration that I consider these outcomes directly related to LI therapy, administered by a skilled clinician, as mentioned in the examples above. The examples cited in this questionnaire under items 1. and 1b. give evidence of the effectiveness of the many interventions in Jaydee’s therapy that created positive change for him. The mother’s change interview states in question 2. that she is…seeing real change in family dynamics and…telling others, “this is real, observable change in our family.” 3. Which therapy processes (mediator factors) do you feel were helpful to the client? (Use as much space as needed). -the presence of an experienced, warm, coherent therapist -support from mom in and out of therapy, dad outside from therapy -Lifespan Integration as a therapeutic tool to connect earlier emotional, ego states to present time. -cognitive interventions such as the nesting cups, and discussions about how Jaydee’s baby self lived within him, etc. INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 158 -doll house enactment, which activated neurons that held the source of some of Jaydee’s fears. -sword fight -timeline repetitions accomplished in various forms such as different cards, cards on rings, etc. -respect and cooperation with Jaydee’s empowerment regarding mom’s presence, or not. -self-soothing tools like rice table and weighted blanket -encouragement and reward for Jaydee tolerating the uncomfortable feelings associated with his baby self and his ability to persevere through the hard parts of therapy. 4. Which characteristics and/or personal resources of the client (moderator factors) do you feel enabled the client to make the best use of therapy? (Use as much space as needed). -Jaydee’s ability to stick with a process that was hard at times -Jaydee’s ability to complete the tasks requested of him -Jaydee’s ability to name what he needed -Jaydee’s ability to be tender and intimate with his mother -Jaydee’s ability to access his infant self and other ego states -Jaydee’s ability to shift between emotional states -Jaydee’s ability to go through repetitions of his timeline, which is very fatiguing for young people. INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 159 APPENDIX K: Adjudicator B Response Form Please highlight your answers on the scales provided (for example, use your mouse to highlight the appropriate answer and change to bold type or to a different colour). Choose only from the descriptors/percentage intervals provided. In answering the rest of the questions, please use whatever space is needed to give a full response. 1. To what extent did the client change over the course of therapy? No change 0% Slightly 20% Moderately 40% Considerably 60% Substantially 80% Completely 100% 60% 40% 20% 0% 1a. How certain are you? 100% 80% 1b. What evidence presented in the affirmative and skeptic cases mattered most to you in reaching this conclusion? How did you make use of this evidence? (Use as much space as needed) Affirmative: The client and his mother’s perception and self reports, the therapist’s report of change over time, the increase in his ability to be empathetic towards dad, demonstrating increased connectedness with his mom, his report of being able to fight back during his nightmares Skeptic: Honestly, I didn’t really find any of the skeptic arguments particularly compelling in relation to this question except maybe mom’s familiarity with LI and expectancy of change; however, in my opinion there is no doubt that the client changed over the course of therapy. I know the skeptics were particularly concerned with the standardized measurements and the lack of change shown on these measures. This was a slight consideration for me; however, I feel more strongly that these measures may not have been measuring the changes that were occurring or meaningful to the client and family. I compared my own ideas after reading the rich case record of what I thought was evidence of change to the ideas presented in both the skeptic and affirmative cases and noted where my thoughts were the same and different to the ideas presented in the brief. I considered both sides, as well as the ideas that I hadn’t thought of in my own notes and made a decision on each of the points. 2. To what extent is this change due to therapy? Not at all 0% Slightly 20% 2a. How certain are you? Moderately 40% Considerably 60% Substantially 80% Completely 100% INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 100% 80% 60% 40% 160 20% 0% 2b. What evidence presented in the affirmative and skeptic cases mattered most to you in reaching this conclusion? How did you make use of this evidence? (Use as much space as needed). Affirmative: Ego development and growth and the idea that he chose to have mom in the room initially and then later asked her to leave, his perseverance and understanding of the difficult process that therapy was for him, his comment on his baby self had grown, commenting on the irrationality of his nightmares, new interest in meeting his birth mom, the shift in more infant like behaviors at the beginning of therapy, connectedness with mom in or out of the room, ability to fight back his nightmare, the use of the doll, “hearing his story” Skeptic: Extra therapy factors, particularly the Special Olympics involvement and the reduced work load at school. I was not as convinced about the involvement of Behaviour intervention as an attributable factor to change as that therapy is generally targeted at behavioral goals, I think that if it was helping, there may have been a great decrease in the standardized measures (hope that makes sense ☺), attention of two professionals, the idea that therapy gave him more one on one time with his mother. My process in this question was similar to what I described above. I considered each point against what I had considered while reading the rich case record. In some ways, I had already framed an idea from my own experience, knowledge, and history of how and I why I thought the client changed and considered it against what was being presented in the brief. I, however, paid particular attention to the “arguments” that made me have a strong emotional reaction (i.e. “That’s not correct”) and reflected on why this was and considered the argument on both sides. 3. Which therapy processes (mediator factors) do you feel were helpful to the client? (Use as much space as needed). The baby doll The concept of the baby self and baby self talk Sand tray Doll house Psycho education around the fears – real experiences that have hurt vs. reality of danger in the specific fears The tree/branches methaphor 4. Which characteristics and/or personal resources of the client (moderator factors) do you feel enabled the client to make the best use of therapy? (Use as much space as needed). Ability to self-reflect and access/feel empathy Relationship with the therapist Relationship with his mother INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 161 APPENDIX L: Adjudicator C Response Form Please highlight your answers on the scales provided (for example, use your mouse to highlight the appropriate answer and change to bold type or to a different colour). Choose only from the descriptors/percentage intervals provided. In answering the rest of the questions, please use whatever space is needed to give a full response. 1. To what extent did the client change over the course of therapy? No change 0% Slightly 20% Moderately 40% Considerably 60% Substantially 80% Completely 100% 60% 40% 20% 0% 1a. How certain are you? 100% 80% 1b. What evidence presented in the affirmative and skeptic cases mattered most to you in reaching this conclusion? How did you make use of this evidence? (Use as much space as needed) Information used from the RCR: • Looking at just the BASC and PRQ results, there were only a few items that, keeping SE in mind, changed significantly. • PQ items of Jaydee were impactful in making this decision, keeping in mind that he can best report on internalized observations. • PQ items of parents were surprisingly up and down. However, it seems that mom’s subjective rating scale changed over time. So, it seems hard to say how much change actually occurred. • Session summaries seem to indicate a radical shift in his relationship to his younger self. This allowed him to have a more positive relationship with himself. I’m surprised to not see this shift in the quantitative data. (I wonder if it takes a while for this shift to become apparent in his behavior) • Change interview: Jaydee said that his relationship to his mom changed and that he could accept his baby-self better now. Information from the Case Development • Affirmative team pointing out that (1) Jaydee said about himself that he became happier, (2) Jaydee saying that his baby-self is now 12 ½ years old, (3) him voicing interest in meeting his birth mom, (4) his demeanor changed from infant-like to developmentally appropriate, (5) he was able to fight back his nightmares • Skeptic team pointing out that (1) quantitative data suggests lack of improvement of relationship to dad, (2) some research interviews were done by the therapist, (3) stress around homework might have changed because of school’s adaptation to his needs, (4) there were other professionals involved INTEGRATING ATTACHMENT IN AN ADOPTED CHILD 162 2. To what extent is this change due to therapy? Not at all 0% Slightly 20% Moderately 40% Considerably 60% Substantially 80% Completely 100% 40% 20% 0% 2a. How certain are you? 100% 80% 60% 2b. What evidence presented in the affirmative and skeptic cases mattered most to you in reaching this conclusion? How did you make use of this evidence? (Use as much space as needed). • • • • • Mom said in change interview that all of the changes would not have been possible without therapy Therapy session summaries: There was a progression in Jaydee’s perception of his baby self, which was actively engaged and encouraged in therapy. He himself, as well as his mom, reported that this was a helpful aspect of therapy Affirmative team emphasizing timeline as being useful in the “Session-by-Session process-outcome correlation. Skeptic team pointing out that some of the change could be because of expectancy. (Expectancy is part of common factors in therapy) Skeptic team pointing out that there were other therapists and professionals involeved 3. Which therapy processes (mediator factors) do you feel were helpful to the client? (Use as much space as needed). • • • • • • • Going through his timelines over and over again. His mom pointed it out as helpful, and, as expected, Jaydee did not comment on it. It seems quite common that children his age are unaware of the helpfulness of actual processes in therapy. Him connecting to his baby-self and pointing out that it grew up Sand/Rice-tray for grounding Increased awareness of his relationships and himself Strong relationship to therapist Empathic and encouraging therapist The shredding of his fears. On a side note: I wonder if his resistance to mom holding his baby self could have been lessened by either imagining his mom holding his baby self or even actually holding him instead. I wonder if his resistance was a jealousy to the relationship his mom had to that particular doll, rather than his baby self. 4. Which characteristics and/or personal resources of the client (moderator factors) do you feel enabled the client to make the best use of therapy? (Use as much space as needed). • His mom’s continuous involvement, despite the far drive. INTEGRATING ATTACHMENT IN AN ADOPTED CHILD • • • • • • His mom knowing about LI from experience with her daughter and reading up on it. His mom’s awareness of relationship between mental health and adoption His mom’s open stance for him to meet his birth mom and other siblings. School giving less homework His perseverance Him being more involved in the Special Olympics might have helped him get social support and maybe some relief from GAD symptoms 163