Integrating Play Therapy in the Home-Based Setting Module

Module Sections:

Forming a Unified Framework

Attachment Theory

Attachment theory can be considered the foundation of mental health work with children. As clinicians understand the importance of attachment in a child's development, they are better able to understand the difficulties children present with for therapy. When infants experience a relationship with a caregiver that is secure and consistent, the child is able to develop enduring connections in future relationships. A healthy attachment is not something the caregiver or child develops alone. It is something a child and caregiver create together in an ongoing relationship. James (1994) defines a secure attachment as "a love relationship that is caring, is reciprocal, and develops over time. Attachment provides the nurturance and guidance that foster gradual and appropriate self-reliance, leading to mastery and autonomy" (p .24). When John Bowlby first began discussing the importance of attachment he described it as the "lasting psychological connectedness between human beings" (p . 69)

Infants instinctively need to attach to that secure base with their caregiver. The development of this secure base is critical to the infant's development of a trusting relationship with a caregiver and ultimately for future relationships. The Trust Cycle is how the infant learns to interpret emotional responses in others and in turn, how to respond to those emotional responses. This cycle is how a child learns how to trust through everyday experiences. The four components of the trust cycle are:

  1. Need on the part of the infant (e.g., hunger, needing a diaper changed)
  2. Emotional response (e.g., crying, fussing)
  3. Gratification (e.g., the caregiver provides food or comfort)
  4. Trust (e.g., the child learns that someone will help him in a time of need)

Cain, p. 19

This trust cycle is closely aligned with Erickson's first stage of development, trust vs. mistrust. As Cain states: "the caregivers ability to read the infant's social cues, and the infant's ability to give the necessary social cues, are critical to the attachment process. "(p. 19) Over time it is expected that the caregiver will be able to distinguish between cries of hunger, irritability, fear, illness, etc. and respond accordingly. The infant learns he is not alone in the world and can count on someone else to help meet his needs thus creating that reciprocal relationship and secure base. As the child develops with this secure base, he will also be able to differentiate and separate from the caregiver toward greater independence. The caregiver naturally establishes boundaries for the child and the child tests these boundaries as he explores and learns and develops. Some refer to this time as the Terrible Twos!

According to the Evergreen Psychotherapy Center: Attachment Treatment and Training Institute children who develop a secure attachment base will do better in the following areas over time:

  • Self-esteem
  • Independence and autonomy
  • Resilience in the face of adversity
  • Ability to manage impulses and feelings
  • Long-term friendships
  • Relationships with parents, caregivers, and other authority figures
  • Prosocial coping skills
  • Trust, intimacy and affection
  • Positive and hopeful belief systems about self, family and society
  • Empathy, compassion and conscience
  • Behavioral performance and academic success in school
  • Promote secure attachment in their own child

The Attachment Figure

The attachment figure is the person who is primarily responsible for the infants overall care specifically attending to the needs of feeding, diapering and comforting. This may be a parent, grandparent, caregiver or some other person in an infant's life who is attending to the needs of the child the majority of the time. This person is crucial to the child being able to create that secure base and ultimately develop the skills and abilities necessary for successful relationships later on. When the trust cycle or Erickson's initial stage of trust vs. mistrust is interrupted, because of an event (e.g., hospitalization, separation) or a caregiver simply is unable to provide the security the child will learn to depend on self for security. In working with children with attachment issues, it is vitally important to also understand the caregiver's attachment history. In order to engage the caregiver in a successful treatment process, the caregiver must have the ability to participate fully. Understanding the caregiver's attachment history will assist the therapist in designing a treatment process with or without the caregiver that will meet the child's attachment needs.

Guilt and shame are often feelings a child with attachment issues are most familiar with and comfortable expressing. These are often expressed through various acting out behaviors, demonstrating to the caregiver that they are not needed and that the child cannot be controlled. The severe temper tantrums when not getting what she wants, the sometimes intentional attacks on what the child perceives as important to the caregiver, and the general defiance can all be representations of this guilt and shame the child feels. During infancy the child did not experience that secure and consistent attachment base and therefore that trust cycle was never established. The child responds with cautiousness and defensiveness. Parents of children with attachment issues often express frustration because they may have a great day with a child only to have the child end it with some acting out behavior. More than likely, this is a result of that insecurity the child experiences as a result of feeling vulnerable. Power struggles occur often with children with attachment or trauma histories. These children need to have a sense of control and will battle continuously for that control.

Audio Companion: Integrating Play Therapy