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Mechanisms of Change: Relationships that Work for Adults and Children. Adapted by Ellaine B. Miller, Ph.D. From presentation by Margaret Keiley , Ed.D , LMFT Auburn University, AL. Getting to Know Each Other . Challenging Provider Issues Make me Feel Like???. What’s Your Style?.

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mechanisms of change relationships that work for adults and children

Mechanisms of Change: Relationships that Work for Adults and Children

Adapted by Ellaine B. Miller, Ph.D.

From presentation by

Margaret Keiley, Ed.D, LMFT

Auburn University, AL

getting to know each other

Getting to Know Each Other

Challenging Provider Issues

Make me Feel Like???

theoretical underpinnings

Theoretical Underpinnings

Attachment Theory

Affect Theory

Change Theory

attachment theory
Attachment Theory

What is Attachment?

Why does attachment exist?

  • Survival mechanism
  • To maintain the proximity with a caregiver, especially in a stressful situation
  • Goal is to reduce arousal and reinstate a sense of felt security
  • To provide a “secure base” from which to explore

What about attachment and caregivers?

attachment styles
Attachment Styles
  • SecureWarm, available, and responsive caregiver
  • Ambivalent-insecureInconsistent caregiver
  • Avoidant-insecureEmotionally unavailable or


  • DisorganizedIntrusive, abusive caregiver

Insecure attachment styles interfere with a person’s ability to regulate affect and to explore his/her world

internal working models
Internal Working Models
  • Working models of the world

Who attachment figures are and how one might expect them to respond

  • Working models of the self

How acceptable or unacceptable one is in the eyes of attachment figures

These internal working models of how attachment relationships operate predispose individuals to habitual forms of engagement with others, including the regulation of affect

internal working models cont
Internal Working Models (Cont.)
  • Secure:Self is worthy and competent; world and others seen as safe and trustworthy
  • Anxious:Self is unworthy; world and others seen as undependable and rejecting
  • Avoidant:Self is unlovable, incompetent, never good enough; the world and others are seen as untrustworthy and never satisfied
  • Disorganized:No organized internal working models

Last three attachment IWMs are driven by FEAR of:

Rejection, Incompetence, Caregiver

affect theory
Affect Theory
  • What is affect?

Information about our experience and desire

  • How is affect regulated?
    • Affect regulation involves tolerance, awareness, expression, and control of the physiological, behavioral, and experiential aspects of affect
    • Affect regulation is first co-constructed as part of the attachment process in infancy

We need access to the information that is contained in affect in order to make decisions about what we want & how we want get what we want. So it must be regulated.

link between affect attachment
Link between Affect & Attachment
  • Secure individuals are able to flexibly manage their emotions and their distance from others in conflictual interactions
  • Ambivalently (Anxiously) attached individuals tend to heighten distress and anger as well as pursue in conflictural interactions
  • Avoidantly attached individuals tend to restrict the communication of anger and distress and withdraw from conflictual interactions
  • Disorganized individuals have no organized attachment strategies or affect regulation strategies: Sometimes pursue and heighten distress, sometimes withdraw and restrict expression
examples of the links between affect attachment
Examples of the Links between Affect & Attachment
  • Secure

Overtly/Hidden: express vulnerable feelings

  • Ambivalent

Overtly: nagging, angry criticism, and pursuit

Hidden: fear of rejection or sadness about disconnection

  • Avoidant

Overtly: stonewalling, withdrawing, or flat affect

Hidden: anger, hurt, sadness, and fear of incompetence

  • Disorganized

Overtly: stonewalling, withdrawing, flat affect, pursuit, anger

Hidden:terror, terror, terror

summary map attachment positions and affects
Summary MAP: Attachment Positions and Affects
  • Secure:Flexibility in movement toward and away from the other and tolerance of own and others’ affect (not afraid of feelings)
  • Ambivalent:Pursue, show distress, hide sadness and fear
  • Avoidant:Withdraw, show little distress, hide anger, fear, and sadness
  • Disorganized:No organized position, vulnerability always hidden, terrified
physiology of affect
Physiology of Affect
  • The regulation of emotional arousal is the key factor in determining the nature and form of close relationships. (Porges’ Polyvagal Theory and Gray’s Motivational Theory)
  • Emotional arousal gets our attention. THEN
  • We are able to calm ourselves, attend to what is in front of us and respond appropriately. We can regulate the arousal in order to keep it in the tolerable zone (SECURE)
  • Or we move into a highly aroused panic mode that is not cognitively controlled. The result is we revert to a habitual mode of interaction, either fighting (rage, AMBIVALENT/ANXIOUS) or fleeing (fear, AVOIDANT)
high arousal red zone
High Arousal (Red Zone)
  • When you are highly aroused and in a panic mode, you CANNOT engage your brain to make decisions
  • You go directly into a habitual mode of response without thinking:

Flight, Fight, or Freeze


Central Nervous System

Autonomic Nervous System

Sympathetic Nervous System

Motivational Functioning

Parasympathetic Nervous System

Regulatory Functioning

Vagal Complex:

Vagus Nerve, Dorsal Motor Nucleus, Nucleus Ambiguous

Reward System: Behavioral Activation System


(Dopamine System)

Punishment System: Behavioral Inhibition System


(Serotonin System)

Vagal Tone:

Emotional Trait

Vagal Reactivity or

Vagal “Brake”:

Emotional State


Vagal Tone (VT): Heart Rate Variability

  • High VT: Heart rate variability high: Easier to regulate reactivity appropriately; emotional & communication flexibility
  • Associated with better child, adult outcomes
  • Low VT: Heart rate variability low: Harder to regulate reactivity appropriately; emotional inflexibility and communication difficulties

Associated with both externalizing and

internalizing problems

Aggression – anger, rage

Depression – sadness

Anxiety – fear, panic


Vagal Reactivity (VR): RSA Reactivity

This vagal “brake” regulates heart rate increases and decreases to deal with environmental demands

VR facilitates effective coping with challenges by allocating cognitive and motivational resources

VR reflects intra-individual shifts in levels of fear and anger

Moderate VR: Optimal engagement, prepare to respond

Excessive VR: Emotional lability

Vagal tone stabilizes by age 1, but vagal reactivity is somewhat amenable to alteration and change


Porges’ Polyvagal Theory (PNS): Regulatory Functioning

Influences on the Heart:

Vegetative Vagus – Deceleration of heart rate associated with orienting (older, reptilian brain)

Smart Vagus – After orienting Decision Point: One of two decisions (mammalian brain)

1. Attend to and engage:Sustained attention and further deceleration of heart rate

2. Fight-Flight:Rage-Panic:Excessive acceleration of heart rate and enlist SNS

change is hard
Change is Hard
  • Why?
  • What can we do about it?
stages of change
Stages of Change
  • Precontemplation
  • Contemplation
  • Preparation/Determination
  • Action/Willpower
  • Maintenance
  • Relapse
mechanisms of change

Mechanisms of Change

1st order : De-escalation

2nd order : Permanent Change

mechanism of change
Mechanism of Change
  • Low Arousal (First Order Change)

Cognitive change – Reframe allows for awareness of initial internal working models (Emotional and Cognitive changes)

Behavioral changes – De-escalation of cycles

  • High Arousal(Second Order Change)

Repeated in-session Change of Cycles

Consolidation of change of relationship cycles (out-of-session change)

low arousal 1 st order change
Low Arousal: 1st Order Change

De-Escalation of Cycles with Reframe

  • The trainer reframes providers’ overt feelings and behaviors to illuminate their vulnerable feelings, attachment desires and positions, and the consequences of their behaviors
  • The results of reframing are:

Cognitive change

Internal working models change (Emotional and Cognitive changes)

Behavioral changes – De-escalation of cycles

high arousal 2 nd order change
High Arousal: 2nd Order Change

Training Visit Interventions and Directives

  • The trainer directs the provider to respond in a different way.

To express his/her vulnerable feelings to the other, that is to ask directly for what she or he wants

Or to help him/her to hear, understand, and respond to this expression of vulnerable feelings and attachment needs

This directive RAISES the AROUSAL LEVEL of the participants

  • Over time, the participants learn to take new positions with each other and that helps to reorganize their interactional patterns
evoking high arousal
Evoking High Arousal
  • Only evoke the vulnerable feelings of the provider
    • Fear
    • Sadness
    • Incompetence/Anger of the withdrawer
  • Do not evoke the overt or defensive feelings
    • Rage, Anger
    • Shame
    • Embarrassment
  • Do we think we know what our own attachment style is?
  • Do we have an idea of what our providers’ attachment styles are?
  • Having and idea about our own and others’ styles can help us engage with others in a more positive and productive way.
types of providers
Types of Providers
  • What are the characteristics of the providers you are involved with?
  • Can we create profiles?
styles of engagement
Styles of Engagement
  • How do we relate to or engage in meaningful conversation with each type?
  • Is this a one-size fits all approach?
  • Do we need different approaches?
process of change in training mentoring

Process of Change in Training/Mentoring

1. Engagement

2. Assessment

3. 1st Order Change: Reframe

4. 2nd Order Change: Directives

5. Consolidation

engagement strategies
Engagement Strategies


Validation & Normalization

Heightening Vulnerable Feelings

The Use of Metaphors & Stories


What is assessed?

  • Attachment positions
  • Overt and vulnerable feelings related to positions
  • Interactional cycles and consequences

We assess these things by tracking and reflecting the interactional cycles and the consequences

1 st order change reframe
1st Order Change -- REFRAME
  • Address negative feelings (yours and provider’s)
  • Change the script
  • Stop the cycle
2 nd order change directives
2nd order change -- DIRECTIVES
  • Change the cycle
  • Stop
  • Think
  • Respond differently
  • Practice, practice, practice
  • Needs to hold up under stress
practicing strategies
Practicing Strategies
  • Applying the theories
  • Role play
  • Attachment style
  • Affect/vagal tone
  • Change is hard
  • Culture
  • Family of origin
  • Present situations
  • History
  • Trust