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THE CHILD ATTACHMENT &PLAY ASSESSMENT(CAPA) TRAINING

Using narrative stems to assess attachment, play and mentalizing in children aged 3-11 years

By Dr Steve Farnfield

Trainers: Dr Steve Farnfield, and Fan Zhang

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PRACTICAL COURSE INFORMATION

• Three teaching blocks: 3+3+2 days.

• Each day between 10:30 and 16:30 with lunch and coffee breaks.

• Lunch between 12:45 and 13:45.

• Sessions will be video recorded with consents and available on Vimeo.

• All information on Slack. Fan can be contacted via Slack or email. Steve can be contacted via email.

• All practice videos on the CAPA’s website. For tech support, go to Fan.

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WHAT ARE WE TRYING TO ACHIEVE WITH THE CAPA?

• Distinguish between safe and at-risk children

• Identify DMM attachment strategies

• Assess mentalizing in children

• Screen for unresolved loss and trauma

• Develop interventions

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AIM OF PART 1

• Understanding of the theories and models underpinning the CAPA.

• Become familiar with the DMM attachment strategies.

• Become familiar with the procedural elements of the CAPA and able to give

codable interviews.

• Understanding of the coding process and the constructs used.

• Able to recognise and code the following strategies: Bs, A1-2 and C1-2.

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THE CAPA-NARRATIVE STEMS

• A doll play procedure.

• The interviewer gives the child the beginning of a story (the stem) and asks

the child to “show me and tell me what happens next”.

• Can be used with children aged from 37 months to about 11 years.

• Video recorded: the coder’s main source of information.

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THE HISTORY OF THE INSTRUMENT

• Established by the MacArthur Working Group (Bretherton et al., 1990)

• The prototype coding system by Robinson and colleagues (2004).

• There have been various additions and modification by other groups, for

example, the Anna Freud Centre’s version.

• Typically used a behavioural observation method and certain behaviours fall in

categories which indicates a certain attachment strategy.

• The CAPA is more qualitative and dynamic. Behaviours are only expressions of

their attachment FUNCTION!

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THE CAPA-UNDERPINNING IDEAS

• Two discrete but connected behavioural systems: attachment –

play/exploration.

• Crittenden’s DMM: developmental and dynamic

• Winnicott’s potential space: inner and external reality and the development of mentalizing in children

• Mentalising: thinking about thinking- evaluating others’ internal experiences

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IT FURTHER DRAWS ON:

• Constructs in MacArthur & Story Stem Assessment Profile (Hodges et al.,

2003;2009) Coding Systems

• Play therapy with traumatized children

• Observation of children’s behaviours in the DMM Strange Situation Procedure(PAA)

• Discourse markers and constructs in the DMM-Adult Attachment Interview

• Porges polyvagal theory

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CONSTRUCTS USED IN CODING

• The child’s relationship with the interviewer

• Child’s level of physiological arousal: with or without attachment functions

• Social engagement signals (body langauge)

• Discourse, either verbal or in the play (telling or showing)

• Mentalising: play based categories developed around the potential space

• Markers and patterns for unresolved trauma, unresolved loss and depression

• DMM modifiers: intrusion of forbidden negative affect (INA) , expressed somatic signs (ESS), reorganising (R) and

• Quasi-autistic (QA) which is unique to the CAPA

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VALIDATION

• Farnfield, S (2015) The child attachment and play assessment (CAPA): validation

of a new approach to coding narrative stems with children ages 3 to 11 years. International Journal of Play Therapy.

• Farnfield, S (202) Report to the Mulberry Bush School: attachment, trauma and play.

• In progress: the CAPA, heart rate variability & play therapy (Hadiprodjo); the

CAPA, HRV, cortisol & alpha-amylase (Zhang).

• Validity: the CAPA reliably discriminates between at risk and normative insecure children.

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THE LEARNING PROCESS

• Underpinning theories: attachment strategies, functions of behaviours and

physiology

• Information from the constructs used in the CAPA coding process

• Exemplars: what does this video remind you of?

• Calibration: what are your tendencies as a coder? What process fits me best?

How does my coding fit with in a group?

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EXAMPLE OF THE CAPA

• 6-8 stories

• Two different sets depending on the child’s age: preschool (3-8 yrs) and school

age (8-11 yr), but not hard and fast!

• Dramatisation at the point of conflict then invite the child to show or tell what happens next

• Ask thinking and feeling questions

• Practice makes perfect

• Watch Hannah

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CRITTENDEN’S DMM

• A theory of attachment in its own right

• A testable set of constructs that have greater explanatory power regarding the

identified range of maladaptive behaviours than is provided by the mainstream ABC+D model.

• Adaptive strategies that promote self protection and survival, sometimes under conditions of great danger to the self or attachment figures.

• Opportunity for sex and reproduction is critical.

• Patterns of behaviours than becomes organized based around the functions of

the self protective strategies.

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DMM ATTACHMENT

STRATEGIES

• Developmental potential limits the variety of strategies, as well as dangers one is exposed to.

• Strategies are not fixed for life. It changes with the context :dynamic maturation.

• As the context becomes more complex, one can have more than one strategy: adaptation.

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DMM ATTACHMENT STRATEGIES

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DMM ATTACHMENT STRATEGIES

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DMM ATTACHMENT STRATEGIES

• Again, not hard and fast, the

strategies depend on the complexity of the child’s life

context, as well as chronological age.

• A8 imitation is coded for children in the CAPA.

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PLAY AND EXPLORATION

• Equally important for survival

• Pretend play and mental representation development: theory of mind, 4-6

years.

• Based on observed and experienced life scripts: enactment

• Used as an opportunity to mentally process own experiences: exploration in

play

• In infancy and preschool years, play is constrained when they don’t feel safe (A and C strategies) and given full rein when they do (B strategies).

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WINNICOTT’S POTENTIAL SPACE

• A third place between the infant’s inner self and outer reality

• A kind of mental lap where the infant, with the help of mother, learns how to

play

• Exploration can take place without real world consequences, thus the freedom to be myself and find out who ME is

• Safety (secure attachment) maximises the opportunity to bring the real world and play world together

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ATTACHMENT AND PLAY IN POTENTIAL SPACE

• Type A inhibited; externally generated information

• Type B playful, integrated – the foundation of reflective functioning/theory of

mind

• Type C affect led; acts on internally generated information

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WHAT DOES THE CAPA ACTUALLY ASSESS?

Attachment or exploration?Or both?

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A DEVELOPMENTAL APPROACH

• The child’s behaviours with the interviewer is based on previous experience with attachment figures built up since birth.• This enactment of previous experience is largely

unconscious or preconscious.

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THE DEVELOPMENT OF THE NARRATIVE SELF

0-2m

Affect regulation

2-4m

Turn taking

4m-2 yrs

language

2-6yrs

Peer interaction

6 yrsonwards

Narrative self

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CONSTRUCTS USED IN CODING

• The child’s relationship with the interviewer and social engagement signals

• Child’s level of physiological arousal

• Discourse, either verbal or in the play (telling or showing)

• Play based categories developed around the potential space: mentalizing

• Markers for unresolved trauma/loss and depression, etc.

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RELATIONSHIP WITH THE INTERVIEWER AND SOCIAL ENGAGEMENT SIGNALS

• How does the child deal with the stranger (the interviewer) socially?

• How is their connection?

• What are the social engagement signals (body language and facial expressions)?

• And most importantly, what are the functions of these signals?

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DO YOU SPEAK MY LINGO?

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SOCIAL ENGAGEMENT SIGNAL S

• Can be clear and explicit; fleeting; subtle.

• Meant to be perceived by the other side of the social

relationship to communicate what we want them to see.

• Some universal and some culturally specific.

• Important for us to understand the function of a person’s

attachment strategies: how does the child want to be perceived?

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SYNCHRONY PROMOTES SELF REGULATION AND

MENTALISING

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UNMATCHED SOCIAL ENGAGEMENT IS

UNCOMFORTABLE

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USE WHAT WE HAVE LEARNED

Ayeesha CARE-Index video

Questions:

- How does Ayeesha want to be perceived by her mum?

- What did she do to achieve this? Or what social engagements signals did she use?

- Was it effective in the relationship?

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THE FUNCTION OF SOCIAL ENGAGEMENT SIGNALS

• “same” behaviours may not mean the same thing or have the same functions

• How can we tell?

Contingencies! • What happened just before and after the signal? In other word, what in the

interaction activated the need for this signal and what effect did it achieve?

• Compare smiles in Shanice and Precious

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LEVEL OF PHYSIOLOGICAL AROUSAL

• Polyvagal theory: the vagus acts as a brake for the sympathetic and

parasympathetic nervous systems’ balance.

• Physiological regulation is important for social engagement - otherwise, it’s fight/flight or freeze.

• There are bodily indicators of physiological arousal.

• Differentiate behaviours with sensory integration/regulatory purposes and social engagement signals.

• Watch Chloe

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DISCOURSE AND INFORMATION PROCESSING

• The information comes from all senses and and the mind needs to organiseand make sense of it.

• The mind unconsciously processes information about danger, safety and comfort in an attachment context.

• Sources: internal V.S. external

• Information types: cognition V.S. affect

The brain maintains a representation of what goes on in the body.

Feeling is the conscious experience of emotion.

Damasio, 2000

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DISPOSITIONAL REPRESENTATION-CRITTENDEN FOLLOWING DAMASIO

• The information we receive is constantly being re-worked according to

perceived level of threat

• This information forms mental representations (consciously and unconsciously) of every interaction we have. For example, think ‘mother’ and you will have a multitude of representations accounting for the many different interactions with your mother

• A DR of attachment is a disposition to act that connects the person to the context in a particular way, using information that they already know to predict

the outcome of this action

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BOWLBY-DEFENSIVE EXCLUSION

• The exclusion of information which, if we allowed it to reach conscious

processing, would cause us to suffer more than we do now.

• The basis of psychoanalytical defences.

• What was said and what was omitted are equally important.

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INFORMATION: COGNITION AND AFFECT

Sensory Stimulation

Temporal order

Cognition

intensity

Affect

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COGNITION

• Temporal order- what follows what

“Mum took out the cake. Then the boy saw it.”

• Conditions: if/then; when/then

“When my father was drinking, I knew I had to stay out of his way”

• Causations: who/what lead to what

“He broke the glass because it was slippery.”

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AFFECT

• Information from all 5 senses

• Physiological arousal – motivates action

• All significant memories are imaged and written in the body

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COGNITIVE AND AFFECTIVE MEMORY SYSTEMS

Cognition Affect

Implicit Procedural Memory

From birth

Imaged Memory

From birth

Explicit Semantic Memory

3 yrs onwards

Connotative Language

3-4 yrs onwards

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PROCEDURAL MEMORY

• Rapid, preverbal and preconscious – can be inaccurate

• ‘Knowing how’ to do something e.g. knowing how to ride a bike.

• In terms of attachment – what has the child learned about the likely response

of the parent if they show distress (what the Strange Situation Procedure

• assesses)

• Information about ‘when’ in the sequence a particular event will occur

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IMAGED MEMORY

• Preverbal and preconscious – can be erroneous

• Any significant memory is imaged

• Represents sensory aspects of the context and is linked to previous

experiences – leads to changes in arousal

• Images of touch, taste and smell are particularly powerful

• Information about ‘where’ an event might happen

• The sickening taste that goes everywhere with the child who feels rejected by

his parents

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SEMANTIC MEMORY

• Develops with language from second year of life

• ‘when…then…’ / ‘if…then…’ statements

• Includes family scripts about how to behave (“Mum needs to know where I am

so that she knows I am safe”) and can be used to blame someone else (“Dad didn’t say I couldn’t go there”)

• Borrowed - Children adopt observations from others about their own behaviour

• In terms of attachment – what does the child think about themselves based on

existing family scripts

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CONNOTATIVE LANGUAGE

• Verbal counterpart of imaged memory – introduced by Crittenden

• Used to increase or decrease affect on both speaker and listener;

• Taunting chants used to evoke an emotional response: evocative

• Used to control or down regulate arousal – e.g. using a‘mantra’: plain and dry

• Affects how we and others feel – feeds into disposition to act

• How does the the speaker use language to regulate their own and the listener’s emotions

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EPISODIC MEMORY-THE STORY TELLING

• Develops from the third year of life

• Integrates cognitive and affective information

• Pre-school children need guidance from parents who can also teach children

what to include, omit, distort – important because this is how children make meaning of past events

• Involves reactivation of neural networks at the time of the event and also networks that represent the state of self in the present

• Important subset is source memory –where has the information come from?

How do I know what I know

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INTEGRATIVE OR WORKING MEMORY

• LeDoux (2002) calls it a work space

• Refers to the process by which information from all the other systems

becomes consciously available

• Active process in which past and present information is integrated to form new DRs

• Time consuming – Under conditions of threat and perceived danger we don’t have this time – revert to an old DR that might not be as adaptive

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DISCOURSE ANALYSIS

• Refers to coherence of speech and coherence of play

• We are more interested in HOW the story is told than what it is about.

• Defensive exclusion in action: what should be said but is not present in the story telling?

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A STRATEGIES DISCOURSE

• Removes negative affect from conscious processing

• Blames the self

• Exonerates parents

• GTO – good temporal order

• Tend to be connotatively flat but there are exceptions

• Information is biased towards external source: parental perspective

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C STRATEGIES DISCOURSE

• Uses feelings to organise thinking

• Uses own perspective: internal source

• PTO – poor temporal order

• ROS – run on speech

• Uses evocative and imaged language to increase or maintain arousal

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B STRATEGIES DISCOURSE

• GTO Good temporal order

• Coherent - dysfluency does not transform meaning

• Easy repair of breakdown in communication

• Integrates feeling and thinking

• Thoughtful, high mentalising

• Humour

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EXAMPLE

• Two “Spilt Juice” stories told by two children

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MENTALISING

“Mentalization … is the process by which we realize that having a mind mediates our experience of the world” and as such “is intrinsically linked to the development of the self” (Fonagy et al. 2004:3).

Fonagy, P., Gergely, G., Jurist, E.L., and Target, M. (2004) Affect Regulation, Mentalization, and the Development of Self. London: Karnac Books.

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MENTALISATION

“The mental world can feel either totally real or totally unreal to a young child, and we suggest that playing with reality, making the real unreal and vice versa, is the principal avenue for the development of mentalization” (ibid page 18).

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MENTALISATION AND ATTACHMENT

• “Attachment has been selected by evolution as the principal “training ground”

for the acquisition of mentalization.”( Fonagy et al 2014).

• For Fonagy the evolutionary function of mentalising is to develop social co-operation in humans.

• There is a primacy given to high level mentalising over distortions of mentalising (cf. secure v insecure attachment).

• Thinking about other people’s minds guides how we behave around them.

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