The Integration of the Adult Attachment Interview (AAI) with the Three Pillars of Attachment Repair and Ideal Parent Figure Imagery (IPF)

The Development of the Three Pillars Approach To fully understand the theoretical underpinnings of the Three Pillars model for healing insecure attachment in adults, one must go back to the pioneer of attachment research, John Bowlby. According to Bowlby, the therapist provides a “secure base” from which the patient can explore in psychotherapy the vast array of their intrapsychic and external experiences (Bowlby, 1988). This position has been widely accepted in the field. However, attachment research has yielded the vital information that one’s formation of the “Internal Working Model,” (IWM) as Bowlby (1988) termed it, is well established between 12 and 20 months of age. The narrative portion of the brain in humans, however, does not become fully developed until the beginning of the fourth year of life (Pillemer & White, 1989). Therefore, it is perhaps unreasonable to assume that the adult population presenting with consistent relational issues, rooted in their insecure model of attachment, will be able to explain, describe, or even recall the quality of the events when they were 12 months old. Since behavioral memory is the primary memory system in the first years of life, these attachment-related disturbances in adults are likely to be expressed by repetition compulsion of unhealthy patterns in relationships and the perceived inability to disengage with such behaviors. The IWM, it seems, it just out of reach of the narrative and rational mind. Building upon this knowledge, Brown and Elliot (2016) developed the Three Pillars model. This model was intended to offer a comprehensive way to resolve the structural core of attachment insecurity by restructuring and re-mapping the internal working model of attachment in clients using imagined ideal parent figures, guided by the five conditions that create secure attachment (Listed Below). Often by this process alone, the client begins strengthening several developmental capacities that were impeded by the insecure upbringing (Elliot, 2021). Two specific capacities that are often not nurtured in children with insecure attachment styles are the development of metacognitive capacity (2ndpillar) and enhancing collaborative abilities (3rd pillar). There are many ways in which therapists can aid in the development of metacognition and collaboration with patients. For the sake of this chapter, we will focus mainly on the 1st pillar; the actual restructuring of the insecure IWM of attachment through the co-creation of ideal parent figures who embody the five conditions that promote secure attachment (Listed Below). In fact, by focusing on the restructuring work, one is also promoting the development of metacognitive capacity by encouraging patients to examine the mind states and behaviors of the ideal parents and how those effect their own state of mind and behavior. They also learn collaborative abilities as they work together with their ideal parents and the therapist to create and maintain these conditions of security via the secure imagery. The Intersection Between the AAI and the Three Pillars The Adult Attachment Interview (AAI) provides significant and clinically valuable information to the “Three Pillars” practitioner. It has been demonstrated clinically that safety and protection, attunement to behavior and emotion, emotional soothing, expressing delight in the being of the child, and encouraging the child’s own individual exploration, are five conditions that promote secure attachment (Brown & Elliott, 2016). Several questions on the AAI are designed to elucidate which, if any, of the conditions were met for the client by one or both parents or primary caregivers. If it is clear that the subject had a father that was neglectful (for example, not having any memories of being held in a soothing way), then the development of the ideal father will include an emphasis on physical presence, proximity, physical affection, and soothing that feels safe. If the client grew up with a stifling mother, where the child’s own exploration was ignored and replaced with the needs of the parent, then the ideal mother will emphasize the encouragement of the client’s individual exploration, the development of the their strongest and most unique sense of self, with no agenda other than to support that development. During the AAI, the subject is asked to give five words or phrases that describe the early child relationship between them and mother, and then with father. If the subject states that their mother was absent and neglectful, and they have memories to support that assertion, then take those negative words that they used to describe the relationship and use their positive opposites in the development of the Ideal Parent Figures. As an example, if the client describes the father as, “absent,” and, “neglectful,” then the clinician takes note that the ideal father must be present and attentive, the positive opposites. If the client gives ‘glowing’ words or phrases like, “very loving,” “caring,” and “supportive,” and then does not have adequate memories to support that assertion, then the clinician should be aware of the possibility that idealization may be occurring and it is likely not an accurate depiction. The interview is then transcribed and scored by a reliable scorer through the AAI Institute. The coder scores the transcript and provides the referring clinician with the report. Verbal feedback only is given to the patient during the next session. The raw data and report are not to be shown to the client for ethical reasons and to preserve the integrity of the test. Probable childhood experiences, probable states of mind with regard to attachment, and probable attachment classifications are verbally discussed with the client. Using the evidence from the interview, the therapist and client will collaborate (3rd pillar) to co-create the imaginal imagery of the client’s own unique ideal parent figures. Restructuring the IWM of attachment using the co-creation of secure imagery informed by the Adult Attachment Interview Before even asking the client to imagine an ideal figure, it is helpful go over the five conditions that create secure attachment (Brown & Elliott, 2016, pp. 288-292). 1. Safety and protection 2. Attunement to behavior and emotion 3. Emotional soothing 4. Expressing delight in the very being of the child 5. Encouraging the individual exploration of the child Reviewing each of the conditions in detail, giving concrete examples of what each of those conditions might look and feel like in a parent, can bring to life these five conditions for the patient who otherwise may have never experienced them. As one begins to talk about the ideal “figures,” this is a part of the treatment that can have a great deal of variability in responses. For some clients, they are eager and excited to imagine these figures. They are probably visual learners and creatively inclined. Then, there are those who are less visually inclined, who come into the process with a preconceived notion that they will not be able to imagine a figure. These clients require more assistance in the beginning. It may behelpful to ask the client to think of a person in their life—a teacher, mentor, benefactor —whom when they think of them, they experience a sense of warmth or safety. Encourage them to use the figure of that person, but realize that it is not actually them, and to embellish upon the image of the figure to make it even more safe and secure. As long as the client has some sense of what their ideal parent figures look like, and can they can imagine them in their mind, then begin the 1st IPF imagery session. The intention is to plant the seeds of the five conditions of secure attachment, so that the client can begin to practice imagining scenes in which the ideal parents are creating those five conditions around them. There is first a period of settling in. This is done right away to get the client “out of their head” and the narrative memory and “into the body.” As stated earlier, our IWM is well established prior to the development of narrative memory. Easing clients out of the world of thinking and into the felt sense of the body is crucial for this process. Clients are asked to imagine that they grew up in a family different than their family of origin, with a set of parents completely and ideally suited to meet all of their attachment needs. They begin by simply imagining themselves as a young child, quite innocent and carefree and curious. They are asked to place their attention back in the body of that child, like they are back being that child again. The client is encouraged to invite the ideal parent figures into the imagined scene; at first keeping them at some distance away, and looking them up and down with great curiosity as themselves as a young child. “What is it about these figures that makes you feel instantly secure? Imagine all the things they could be saying. Imagine how they would move, their tone of voice, the way that they look at you, it makes you feel instantly safe. There’s nothing threatening about them. They are only a place of total safety and protection.” The client is encouraged to embody that feeling of safety. The next four conditions are then introduced. The client is asked to shift the scene to imagine that the ideal parents are completely attuned to their behavior and their inner state of mind. “They would never divide their attention, or be too busy. They can tell, just by looking at you, what you are feeling. And they can track you, moment by moment, and shift and change as your mood shifts and changes. Really take that attunement in. Notice the effect is has on your body and mind.” The client is then asked to imagine that something has happened, something small, and they have become upset. They are encouraged to imagine the fear or anxiety that comes when they get upset, and to actually experience it as the child in the imagery. But then, right away, before they start to suffer, the ideal parents come right into the scene. They see the client-as-child. “They see exactly what is wrong; why you are upset. That deep level of attunement allows them to know exactly what is upsetting you, and then they know just what to do and how to be to make whatever you’re upset about go away, even if just a little bit at first.” The client is asked to imagine all the things the ideal parents could be saying and doing, and especially their ways of being, to make some of what they are upset about dissipate. “Imagine that one or both ideal parents can give this child easy and natural, safe, and totally appropriate physical affection – such as a hand on the back, or a soft kiss on the top of the head — and feel that that physical closeness and contact as good and safe. But notice too, that just as easily as they give you physical affection, they give you space when you need it. That is completely fine with them. Imagine that. When you want physical affection, they are there and they do it. When you have had enough, before you even have to ask, they have given you space. Really take that attunement in.” The client is asked to continue to shift the scene to imagine how these parents are totally delighted in the very being of the client (expressed delight). “There is nothing you have to do, there is nobody you have to be, no job you need to have. It is just your very being, just your being as a child is more than enough for them. It gives them great joy, and they are not subtle about it. They are gently reminding you of your worth and that you are the very center of their life. You can really feel it in your body. You can really tell that there is nowhere they would rather be than just holding this space, being together with you.” And finally, the client is asked to imagine that they are getting a bit older, and discovering new things, and these ideal parents are their biggest support and their biggest cheerleaders. “They have no agenda for you. Rather, they support you to be most fully you, your most unique and distinct self, you really being you. and that is what they support. They have no agenda for you other than to support you on your path, and they are dedicated to doing so.” Finally, the clinician might ask the client to look forward. “As you get older, imagine that you had these ideal parents, every step of the way, at every single developmental milestone. They were there, to hold you when you were scared, to support you when you were tired, to soothe you when you were upset, and to consistently remind you of your essential worth and importance. You can come to depend on the fact that your needs will be met every step of the way. And because these ideal parents were there to meet your needs and keep you safe, you come to deeply believe that the world is a safe place that can meet your needs. Really imagine that.” The client is asked to let the scene go and bring their attention back to the body and breath. This is the first cue that the session is coming to an end. A slow transition back and out of the imaginal framework is helpful. A gentle count backward from 5 to 1, reminding them that when the countdown is complete, they will be fully present. It is important to leave 5 to 10 minutes to debrief after the imagery, to get an idea from the client what happened, assessing their ability to track their own experience throughout the imagery. Perhaps there will be a question or clarification. There may be a variety of responses to the first session of planting the seeds of the five conditions that create secure attachment. Either the client becomes elated and feels like they are in the making of a breakthrough because they felt and imagined these safe and secure conditions, or the client can become sad, grieving the fact that their birth parents did not provide these five conditions. When this occurs, it is totally normalized. The clinician could let the client know that the sadness, or grief, is not uncommon as one imagines these secure conditions. But, that at the end of the sadness is healing. And sadness is okay. The clinician might encourage them to simply acknowledge the sadness and see it, because it needs to be seen. The client’s experience of sadness and grief can be included in the context of ideal parents and the five conditions, such that the IPFs notice and respond with loving, soothing care. In this way the client has the experience of ‘negative’ emotions being welcomed, of being helped to feel and regulate them. Touch the sadness but live in the security. Secure attachment allows us to be able to hold both. In the next session, one would begin with a check-in. The clinician should look for signs that the client can do several things: that, when asked, they can imagine their ideal parental figures. It is made clear that it is not vital that they decide on every detail of the ideal parent figure’s face, as the imagined caregivers will likely change and become refined over time as the client becomes more aware of what their needs are and the ideal parents are able to respond to those needs. But it is encouraged that their imagery is clear and detailed. More important than having the figures decided in their mind is the experience with the ideal parents, the felt sense of the five conditions that create secure attachment. Ideally, the client will be able to imagine their ideal parental figures in a variety of sense modalities, especially feeling them and the effects of the five conditions viscerally. It is also helpful for the client to be able to imagine them the IPFs working together (collaborating, 3rd pillar) to achieve those five conditions. The client would be able to imagine this visually and feel the conditions viscerally. This, of course, might not happen in only the 2nd session. The client may have some trouble still with settling on the figures, especially clients who have an avoidant or dismissing attachment pattern. The clinician can normalize that this is a process; that they will continue to shape and refine their ideal figures and that is totally permissible. Again, normalizing, acknowledging and dignifying the difficulty, praising them for their effort in imagining these experiences that were not available to them as children. And one might take this opportunity to add that some sadness, some grief, is part of the process. As one begins to imagine attunement and expressed delight, there is often a sense of grief that this was not necessarily our experience as children. This is, of course, harder with the dismissing client who has idealized one or both parents. But, because of the AAI, the therapist will know this and approach the topic more lightly. The therapist should not approach the sadness and grief as an obstacle, but rather emphasize the necessity of allowing these emotions to flow through them, to resolve them in real time, with the help and collaboration of their ideal parent figures, so the sadness and lack of resolution can no longer have an effect on their behavior or the partners they choose. Effectively, restructuring what one imagines as possible for themselves (the Internal Working Model). The AAI transcript and coding provide the therapist with information about the client’s particular experiences that were problematic for the development of attachment security. The therapist takes note of this information, and lets it inform the application of the IPF imagery process. As always, the session begins with a period of settling into the body (see Elliott, 2021, for the developmental principles underlying this step). Then, for example, with a client who has had little sense of safety with caregivers as a child, the therapist is going to want to emphasizes how the ideal parent is completely non-threatening and supportive of feelings of safety. The client is encouraged to imagine all the ways the parents could be, all the things they could say, all the things they could do, all the ways they could be with them, that would make them feel just a little safer, even just a little at first, including in the body. And then leave some space for the client to imagine, and then simply check in. “So what are you experiencing?” If the response is aligned with the idea of safety and the client is imagining things the parent might say and do, then the therapist could emphasize that. “Yes, really feel what that’s like to know at a deep level that you are completely protected.” If they simply cannot imagine anything that would give them safety in their body, the therapist will continue to normalize the difficulty, and have them notice that the ideal parents see how difficult it is. “And they see that as the most normal and natural thing in the world. And if you need all of the time in the world to get comfortable with these ideal parents, that is totally fine with them.” Have the client really take that in. And continue to check-in with what they are imagining, and, collaboratively, the client and therapist build the visualization with the goal of achieving those five conditions of secure attachment in their mind and in their body. As the client gets more practice and can more easily cultivate and spontaneously engage with the ideal parents, one can then move into “activations.” The client brings up a time from the week when they were uncomfortably activated in some way, such as feeling afraid or alone. After recalling that experience, they are encouraged to really be aware of that experience in their mind and in their body, to get curious about it like a detective, and to report to the therapist their experience is in the moment. The therapist might ask, “What is going on in the body? What story is the mind telling? And what’s the feeling?” “I have tightness in my throat, the story is that I’m unlovable, and I’m sad.” It is crucial that the therapist embody and maintain the presence of the ideal parent during this exploration; always safe, accepting, and warm. The therapist then asks the client to go back in their memories, back as far as they can, and look for a memory or a time or a scene of a circumstance where there was some aspect of this activation; some aspect of this feeling. “I’m in my room playing with Legos and I want to be with my parents but I don’t know where they are.” The therapist then asks the client to bring the ideal parents right into the scene. They see the client-as-child, they see what’s wrong, and know instantly what to do and how to be to soothe them, even if just a little bit at first. And the therapist can ask, “What are you experiencing?” and collaboratively create a new and different experience, replacing the neglect of birth mother with the total attunement and collaboration of the ideal parents. The effect on the psyche and the nervous system is profound. The client is beginning to learn that the secure base does not exist out in the world somewhere, but it is within themselves. Often times, just not feeling alone in the memory can be quite soothing. To further illustrate how the AAI can be used in conjunction with the Three Pillar method, a case illustration will be given. For anonymity, he has been named Patient 1. Patient 1 Patient 1 is a 38-year-old Hispanic male who presented with relational difficulties, most specifically and especially with his girlfriend and mother. He had a history of psychotherapy, mostly Cognitive-Behavioral Therapy (CBT), as he described. He was still having trouble disengaging with unhealthy patterns and unhealthy people. As he described it, he had many tools and strategies, but his ability to employ those strategies was directly related to his level of regulation or dysregulation at that given moment. He had heard about the Three Pillars and especially that Ideal Parent Figure therapy could help with that base level of dysregulation, and was interested to give it a try. The AAI Among the early questions on the AAI, the subject is asked to give five words or phrases or adjectives that would describe the relationship between themselves and the mother, and then the father. These five words or phrases are then used as the subject of further inquiry. Patient 1 set a very “high bar” for himself. He began by providing ‘glowing’ words and phrases to describe the relationship with actual mother. As he lists them, the interviewer writes them down. Each word is brought to the subject’s attention, and they are asked to provide an actual memory, a concrete and authentic recollection of a time, moment, scene from childhood that would illustrate why they chose the phrase. For example, when I asked Patient 1 why he chose “very loving,” he paused in silence for about twenty seconds, and then said, “I don’t know,” with a big smile on his face. He was encouraged to think a little longer, normalizing that it is a difficult question for many. He eventually provided a very general memory, stating that she was “always caring.” I again asked for a specific memory from as far back as he could remember of how the relationship was very loving and always caring. For “always caring,” Patient 1 described how his mother would pick him up from school with some regularity and he could trust that she would be there. When queried about how the ride home usually went, Patient 1 stated that they would usually just talk about the mother. Next, he was asked to give five words or phrases that describe the relationship between himself and his father when he was a child. He seemed to be much quicker to respond this time, and the words were quite different. “Tyrant.” “Liar.” “Needed me to be like him.” One can see rather quickly that there is a drastic difference between Patient 1’s early relationship to his mother to that of his father. He was then asked to provide evidence for his words or phrases, by providing a detailed memory, scene, experience, from childhood that would illustrate why he chose those words. This time, he almost seemed eager to answer the questions. When I had asked him the same questions about his mother, he seemed to struggle a bit. He was not as eager to answer. But for his father, when asked to give evidence for why he said, “Tyrant,” he provided a detailed memory of a time when he had made a pact with his dad, that if he just pointed out when his father was enraged, then he would stop being rageful in that moment. Then, some days after, his father got angry and Patient 1 told him, “Dad, you’re doing it.” And it made no difference. He did not abide by the agreement. Using the AAI Results in Conjunction with the Three Pillars The amount of information gathered by the third AAI question and its inquiry was astounding. In that short time, Patient 1 provided very positive and general words to describe his relationship with his mother. Yet, when asked to provide evidence for the words he chose, he either did not have any evidence or the evidence he presented contradicted his initial word or phrase in some way. This notifies us that there is likely a dismissing strategy in place, namely idealizing. Idealization scores are raised when the subject gives positive words to describe the relationship and then does not have adequate evidence to support the positive picture that they paint (Brown & Elliott, 2016). The clinician must see this as a defensive posture against having to actually and authentically explore the relationship with mother. This is something that the Three Pillars/IPF practitioner sees as very important and useful. There is idealization with his mother, and “love” and “care” seems to be confused with his duty to her and the self-seeking needs of the mother, needing to talk about her on the way home from school. Firstly, understand that this is a loss for Patient 1. The house of cards cannot hold up to the AAI questions. There is evidence that his mother was overinvolved and that he confused that for secure attachment. There is also evidence that his father was an angry, rejecting, and untrustworthy man, with whom Patient 1 is consciously and significantly angry. The anger comes out in his speech in the interview, and it comes out in the five words he chooses for dad. As IPF practitioners, the above information is crucial. Because Patient 1’s mother was overinvolved and role reversing at times, his ideal mother will emphasize the 4th and 5th conditions that create secure attachment. “Notice how your ideal mother has no agenda for you. Feel the spaciousness in that. She wants you to be your strongest, most unique self. She would never put herself before you, for any reason at all. And notice how easy it is for her to give you space. You don’t even have to ask, because as soon as you start to feel crowded, she can attune to that and sense it and adjust and move away. Imagine that.” Patient 1 also sees his father as a predator. He is scared of his father. Additionally, through the AAI results, it was found that he does indeed have unresolved physical abuse from dad. This is something to be taken very seriously, mindfully, and gently. “Start by simply imagining yourself as a young boy, quite innocent and carefree and curious… And then imagine that that boy, you, the boy you are, that you grew up in a family different than your family of origin, with a set of parents completely ideally suited to meet each and every one of your attachment needs. Begin by simply inviting your ideal dad’s figure to be known, to enter the scene, always keeping him some distance away.” After pausing for a moment, “Imagine everything about this figure is completely nonthreatening. And in fact, notice that he sees that this is difficult for you. He totally understands. He really sees you. Experience what that’s like in your body, to be seen this way, and have it safe and soothing. Notice also that you don’t have to figure it out right away. Your ideal dad knows this is difficult, and if it takes you all of eternity to get comfortable with him, that is completely fine with him.” Thus, through many months of co-creation of secure imagery using Patient 1’s ideal parent figures, he has taken his tyrannical and untrustworthy father’s behavior and co-created an imaginal ideal father figure that is completely non-threatening, totally attuned, safe, spacious, and encouraging. Today, he has a relationship with both ideal mom and ideal dad, and they him. Even if he is not directly imagining them, he experiences that they are available and with him, because they have now integrated and become part of his most unique and secure self. By using present time activations in session to go back to earlier memories at the root of the activation, having the ideal parents come right into the memory and see the child and soothe the child in exactly the right way, one can literally re-map or restructure their “internal working model” of attachment and of life in general. This is the movement from a worldview which proclaims that, despite all of one’s best efforts, one’s needs will not be met; to one that proclaims this world is more than enough to meet one’s needs. And not only that, but that the client is more than enough as they are. This is the movement from sickness to health, from illness to wellness, from insecurity to security. The world is becoming more and more global, and in-person weekly office visits with a therapist have become more difficult, timely, and expensive. Therefore, the “therapist as a good enough attachment figure,” or TAGAF, model has become even more tenuous. The Three Pillar model is unique and forward thinking, in that it equips clients and patients with a secure base that lives inside their own hearts and minds. Eventually, just imagining the presence of the ideal parent figures helps clients at once feel not alone, that they have a team of support that is reliable and safe. Having that secure base within you, available at all times, is often enough to allow one to feel safe enough to pursue their most authentic and unique lives, no longer limited by their insecure working model of the world. At last, the world is seen to the client as a safe place that can meet their needs. By beginning treatment with the administration and scoring of the Adult Attachment Interview (AAI), the Three Pillar practitioner begins with a real advantage. It is possible to infer from Probable Childhood Experience domains which, if any, of the five conditions that promote secure attachment were promoted to the client from their birth mother and father. If certain conditions were lacking, then the clinician should ensure that the ideal parent emphasize those conditions. If certain conditions were overemphasized, then the clinician likewise knows to have those conditions be tapered or tame in the ideal parents. And finally, by using positive opposites of the five words and phrases that clients use to describe childhood relationships with their birth parents as asked in the AAI, the client can begin to define their ideal parent figures. Equipped with these imagined ideal parent figures and a skilled therapist to aid in the co-imagining of the felt sense of secure behaviors, the client is able to reappraise and eventually restructure their Internal Working Model of attachment.