ATTACh
PROFESSIONAL
PRACTICE MANUAL
Revised
12/18/01
CONTENTS
Introduction
ATTACh Mission,
Vision & Philosophy
ATTACh Basic
Assumptions
ATTACh
Professional Standards of
Practice
ATTACh Safety
Principles
ATTACh Ethics
Committee
ATTACh
Declaration of Complaint
Form
How to contact
ATTACh
INTRODUCTION
ATTACh, the Association for Treatment and
Training in the Attachment of Children, is an international
organization of families and professionals concerned about
children who have experienced breaks in their attachment
during the first few years of life. A primary focus of
ATTACh is to educate the public about attachment issues in
order to improve both prevention and treatment efforts.
Therefore, since its establishment in 1989, a major
undertaking of ATTACh has been to gather accurate information
related to the field of attachment for dissemination to
professionals and parents.
Children expressing severe symptoms related
to attachment disruptions have frequently not responded
to traditional interventions. These children have
developed strong defenses that are highly resistant to
change. Attachment and bonding therapy includes an array
of treatment strategies which continue to evolve and
expand. A rich diversity of therapeutic approaches is
essential in treating children with attachment problems.
Responsible practitioners in any mental health discipline
serving children with severe emotional and behavior problems,
including attachment and bonding therapists, do so with the
utmost attention to the psychological and physical well being
and safety of the children and adults involved.
Building upon our original statement of
ATTACh’s mission, vision, and philosophy, over the last 10
years, ATTACh has developed a series of guidelines for its
clinical members to provide direction in the rapidly
developing field of attachment and bonding work. These
include: Professional Standards of Practice
published in 1997, Basic Assumptions published in
1999, and Safety Principles published in 2001. It
is imperative for therapists providing attachment and bonding
services to be ethical, responsible and accountable for their
work. Members of ATTACh are expected to follow
these standards and guidelines in addition to those of the
member’s own professional association(s).
It has been our experience that these
guides have been helpful to both parents and clinicians
seeking information about attachment and bonding
services. Should you need more information, please do
not hesitate to contact us:
ATTACh
866-453-8224
info@attach.org
MISSION
ATTACh recognizes and promotes healthy
attachment and its critical importance to human
development.
VISION
ATTACh will be the international leader in
the education and promotion of attachment theory and
services.
PHILOSOPHY
ATTACh values and interdisciplinary
membership of professionals and families who care about
healthy attachment and are dedicated to helping those with
attachment difficulties.
ATTACh expects clinical and professional
members to operate within their respective codes of ethics and
non-clinical members to exercise good judgment based on the
best interest of the child and family.
ATTACh promotes a continuum of services to
enhance the quality of attachments ranging from primary
prevention and education, to specialized treatments.
ATTACh respects a diverse spectrum of
intervention models designed to build and/or strengthen
attachments.
ATTACh believes therapeutic interventions
should always be based on sound differential diagnoses.
ATTACh encourages research, education and
collaboration to continually increase knowledge of and
improvement in attachment theory.
ATTACh BASIC
ASSUMPTIONS
The primary goal of treatment with children
and adults with attachment problems is to enable them to form
healthy attachment relationships with their current and future
families, and to resolve the dysfunctional feelings and
behaviors developed in response to the early attachment
breaks. Members of ATTACh represent a variety of
treatment models about which there is a range of
consensus. The following are basic assumptions about
which there is general agreement.
WHAT WE BELIEVE ABOUT
ATTACHMENT:
1. Attachment is the
fundamental building block of development, without which all
other stages of development will be distorted. It
impacts cognitive, neurological, social and emotional
functioning. If a child does not establish basic trust
in the early months, he/she may not form the type of
reciprocal, responsive relationships necessary for effective
functioning in areas such as marriage, parenting, therapy,
education and employment. Attachment disruptions often
place a child at high risk for other serious problems.
2. Security of attachment is on a
continuum.
3. Attachment can occur between a
child and a primary caregiver in a variety of alternative
family constellations such as a foster family or an adoptive
family.
Attachment difficulties can occur in any
family constellation; such as birth, adoptive, foster, step,
etc.
4. Healthy attachment relationships
include trust, empathy, reciprocal behaviors, attunement,
communication, touch, and both physical and emotional
closeness. Attachment therapy emphasizes these aspects
of relationships among all participants: parents and
child, parent and parent, therapist and child, and therapist
and parents.
5. Unresolved issues about early
traumatic experiences which have interfered with the formation
of secure attachments may need to be explored and resolved so
the child and/or family can be receptive to experiencing trust
and the formation of sincere, secure, reciprocal
relationships/attachments.
WHAT WE BELIEVE ABOUT CHILDREN:
1. The child’s primary attachments
prenatally and during the first years of life provide the
foundation for personality development.
2. A break or trauma in a child’s in
utero bond or early attachments often interferes with his/her
ability to form subsequent attachments, and negatively
influences the child’s beliefs and behaviors about future
relationships. Each child is a unique individual and may
express attachment difficulties in a variety of ways.
3. Appropriate attachment treatment
and parenting can relieve the effects of a break or strain in
primary attachment.
4. Every child needs to grow up in a
consistent, safe and nurturing environment which promotes
healthy attachments.
WHAT WE BELIEVE
ABOUT FAMILIES:
1. The bulk
of the work of healing attachment difficulties occurs at
home,
between the parents and the child.
2. Crucial
to treatment progress is the parent’s commitment to keeping
the
child in the family.
3. Parents
deserve complete and unbiased information on a continuing
basis
and in a supportive manner.
4. Families
dealing with attachment difficulties need understanding and
support from a variety of resources for their unique
challenges.
WHAT WE BELIEVE ABOUT ATTACHMENT
THERAPY:
1. Attachment therapy is hard work
for everyone involved.
2. This difficult work must occur
within a therapeutic atmosphere that conveys safety,
protection and hope and provides empathy and comforting to all
family members as the work proceeds.
3. Both the child and the family must
have a developmentally appropriate understanding of the
therapeutic processes and goals.
4.
Discovering the child’s individual inner working model
(beliefs about self, others and environment) is important for
therapeutic success. The child can be helped to change
negative life perceptions, and as a result change their
responses to events and relationships.
5. As attachment and treatment are on
a continuum, interventions should be flexible and specific to
the needs, history and cognitive-emotional state of
each member of the family.
6. Attachment therapy requires a
family systems approach. The heart of this disorder is
the child’s relationship with their primary caregiver.
Working with the family system is essential to the success of
the child’s treatment. It is insufficient to treat the
child’s clinical issues as the mechanism for forming an
attachment with the primary caregiver. These
issues did not cause the attachment disorder, and therefore
correcting them is not sufficient to correct the disorder.
7. Parents may have problems which
have to be understood and addressed if they are to help their
child resolve attachment and other problems.
8. Parents and professionals together
need to educate the various systems involved in a child’s life
and advocate for adequate funding.
WHAT WE BELIEVE ABOUT EVALUATION OF
ATTACHMENT THERAPY:
1. There is value in conducting long
term follow-up and assessment of outcomes.
2. We support and encourage research
to improve our ability to assess and treat children and
families.
ATTACh PROFESSIONAL
STANDARDS OF PRACTICE
Attachment
therapy is a therapeutic process that is designed
to
promote,
develop, or enhance a reciprocal attachment relationship and
meets
the criteria of that therapeutic process as defined and
developed
by ATTACh.
II.
CONDUCT OF THE PRACTITIONER
Individuals involved in the treatment process conform to the
highest
level of ethical and professional standards as signified by
the
following:
A.
Practice conducted in compliance with state/providence
rules/laws. Practice will conform to the code of ethics
of the state/providence licensing and/or certifying
body.
B.
The practitioner will adhere to legal and professional
standards as related to confidentiality.
C.
Practitioners will practice within their area of
competence and in keeping with their level of training,.
D.
Practitioners will be aware of and work towards
resolving their own biases and issues that affect the manner
in which they work
E.
Clinical practitioners will utilize training,
supervision and/or peer consultation and therapy for support
and continued skill development.
F.
Clinical practitioners will present to clients
treatment options, and their possible benefits and
limitations.
G.
Parents are essential members of the treatment
team The practitioner should always approach a family
and child with respect and without blame. They should
support, not undermine, the authority and values of the
parents during therapy sessions, providing them with relevant
information about the treatment process and offering every
opportunity to ask questions.
H.
When indicated, it is the responsibility of the
clinical practitioner to encourage the child’s
parents/guardians to educate the family/community network (for
example, case workers, neighbors, religious groups, day care
workers, schools, law enforcement officers) about the nature
and function of the family’s attachment difficulties. If
the parents request, and if appropriate, the practitioner may
assist in this process.
I.
Clinical practitioners will strive to be aware of their
potential influence in the area of past memories and their
need for special care in the handling of new
disclosures.
J.
Attachment practitioners are committed to
contributing to development of a valid and reliable body of
scientific knowledge based on research.
K.
ATTACh members have an ethical obligation to report a
breach in the Standards of Practice to the Ethics Committee;
this should be preceded by informal attempts at resolution
with the practitioner in question.
ATTACh is committed to establishing effective clinical
practice, within
a framework of ethical standards.
A.
Clinical practice for ATTACh members must be based on
the following goals
1.
To maintain the best interest and safety of the child
and
family
2.
To strengthen and enhance the family unit
3.
To use the most effective techniques to provide the
desired clinical outcome
4.
To utilize input of those involved in the therapeutic
process including the parents and child
B.
Clinical practice procedures for ATTACh members may
include but are not limited to the following:
1.
Thorough assessment, including the following as indicated:
a.
History of treatment
b.
Psychological history
c.
Educational history
d.
Medical history
e.
Attachment and social history including
breaks/disruptions in attachment.
f.
Developmental history (including prenatal and birth)
g.
Family functioning
h.
Intellectual and cognitive skills and deficits
2.
Diagnosis or description of problem includes:
a.
Differential diagnosis (this may include any or several
DSM or ICD diagnoses)
b.
Attachment symptomatology
c.
Breaks in attachment history
3.
Treatment planning
a.
Is guided by assessment and diagnosis
b.
Defines therapeutic modalities
c.
Clarifies for relevant parties (i.e., parents, referral
sources, therapeutic/foster parents, follow-up therapists, and
child when appropriate) the rationale for the intervention;
the respective roles and responsibilities of each person
involved.
d.
Utilizes a treatment team of other significant persons
in the child’s life when indicated
e.
Includes informed consent from client and parents prior
to treatment as an essential element of treatment
planning. Therapeutic contracting should also occur
during treatment
f.
Builds on the strengths of the child and family
g.
Includes measurable goals
h.
Is reviewed and updated regularly
4.
Treatment process
a.
Attachment therapy emphasizes relationships among all
participants, including:
i.
Trust
ii.
Empathy
iii.
Reciprocal behaviors
iv.
Attunement
v.
Communication
vi.
Touch
vii.
Physical and emotional closeness
viii.
Humor and playfulness
b.
Parents and children are active members of the
treatment team working to develop healthier patterns of
interacting and communicating.
c.
The family’s emotional response to the therapy needs to
be monitored, as well as the child’s. Parents may have
problems which must be understood and addressed if they are to
help their child resolve attachment problems.
d.
When there are differences between the parent(s) and
practitioner, the practitioner and parent(s) will actively
work to resolve them
e.
The practitioner needs to take an active and directive
stance in working with the child and family on core issues
that the child and family may find difficult to address.
Because the child’s defenses against healthy relationships are
so strong, therapeutic interventions may be confrontational
and challenging and may involve holding, touch, or physical
proximity, while never losing sight of everyone’s need to feel
and be safe.
f.
Holding as a therapeutic technique provides a
multi-sensory experience that refines attunement, facilitates
emotional reciprocity and honesty, enhances empathy responses,
allows the child to experience emotional openness in a safe
way, and reenacts the holding nurturing experience of infancy;
all of which provide a corrective cognitive-emotional
experience.
g.
The practitioner with the parents is in charge of the
session and of the child, in a nurturing, safe, and empathic
manner. The adults take the lead in attachment therapy
and are always observing and responding to the feelings and
needs of all family members.
h.
When exploring unresolved issues, treatment will take
into account past and present family dynamics. Issues
regarding birth parents will be addressed in a respectful and
honest manner. Treatment will differentiate the new
parent relationships from the old ones.
i.
Interventions should be flexible and specific to the
needs and emotional state of each member of the family; and
both the family’s and child’s response to therapy will be
monitored
j.
A central therapeutic activity is for the child and
family members to experience and then express their emotional
responses to past and present situations that are interfering
with attachment
k.
Each child and family is unique, and a variety of
therapeutic techniques may be utilized based on the child’s
history and inner working model; and on parent’s abilities and
style
l.
The practitioner may model and elicit various
cognitive-emotional states in order to facilitate the child’s
integration of cognition to emotion
m.
There is no known medication for attachment
disorder. Children may sometimes need medication for
coexisting conditions; however inappropriate or
over-medication may thwart the therapeutic process.
n.
Parent-child interactions that are central to
establishing a healthy attachment, (i.e. eye contact, physical
contact, tone of voice, smiles, other non-verbal communication
and gestures) are central to the interactions of
therapy. These interactions may be exaggerated with the
child to produce a therapeutic effect
o.
In those cases when family members decide that they are
unable/unwilling to work toward forming a secure attachment, a
practitioner will, after careful work and evaluation, respect
a family’s choice and offer an alternative treatment plan.
a.
supporting the parents’ authority and need to maintain
control over the family environment, while assisting the child
to feel safe enough to relinquish his/her compulsive need to
be in control.
b.
increasing the child’s readiness to rely on the parent
for safety, help, comforting, nurturing
c.
encouraging a positive, supportive, family
atmosphere
d.
encouraging a high level of nurturance
e.
encouraging structure and limits
f.
increasing reciprocal, positive interactions between
parent and child.
g.
helping the child make choices that are in his own best
interest, and in the best interest of his family, and to
accept the consequences of those choices
h.
helping parents become emotionally available for their
child as healthy and safe individuals. This may include
examining their own issues, such as the marital
relationship, infertility, grief and loss, childhood trauma,
etc.
i.
helping families and children develop reasonable
expectations of success
IV.
VIOLATIONS OF STANDARDS
If
these standards are violated by a member of ATTACh, the
Ethics
Committee
reserves the right to take appropriate actions. These
may
include,
but are not limited to requiring the member to submit a
protocol
and to cooperate with any licensing body. A resignation
or
removal
from the organization does not automatically terminate a
current
ethics investigation.
ATTACh SAFETY
PRINCIPLES
ATTACh members are expected to apply the
information they receive from
ATTACh and other sources within a context of safety. As
this principle is applied, the resulting strategies and
procedures used by each member will be designed to monitor and
safeguard the psychological, emotional, and physical
well-being of everyone involved in the intervention process.
The touchstone that underlies all of
ATTACh’s safety principles is “...do no harm.”
The following principles provide examples of how
this fundamental axiom would be applied. These principles do
not represent an exhaustive list, but are presented in order
to provide the clinician or parent guidelines for the
multitude of individualized situations that might arise.
1.
All participants involved in an intervention will
ensure that the physical and emotional health and welfare of
everyone involved in an intervention are monitored at all
times.
2.
Each person will be responsible for seeing that
effective steps are taken to adjust or terminate an
intervention process when there is any indication that
someone’s psychological or physical safety may be being
compromised.
3.
The child will never be restrained or have pressure put
on them in such a manner that would interfere with their basic
life functions such as breathing, circulation, temperature,
etc.
4.
Parents and/or other appropriate individuals should
observe, participate in, and/or monitor the therapy
process being utilized.
5.
Touch will always be appropriate and used for
therapeutic purposes. Sexual touch is never
appropriate.
6.
Therapeutic interventions will be carefully selected to
protect the child from physical pain.
7.
No form of shaming, demeaning, or degrading interaction
is acceptable as a therapeutic intervention.
8.
Treatment options, such as holding, paradoxical
interventions, and “sitting,” should never be used as
punishment for perceived misbehavior.
It is never possible to anticipate all
situations where the issue of the well-being of participants
might be, or might become, an issue. Therefore everyone
involved in the intervention process with a child and family
is expected to use good clinical judgment coupled with good
common sense. The following questions can be used throughout
treatment to assist practitioners and parents in their
decision-making process:
1.
What am I trying to accomplish with this particular
child and/or family?
2.
Will this intervention contribute to what I am trying
to accomplish?
3.
Is there a less intrusive or less restrictive
intervention that will accomplish the same purpose?
4.
What, if any, safety issues should I consider when
selecting an intervention for a child and their family?
5.
What are the treatment implications when deciding
not to use a specific intervention with a particular
child and family?
6.
How do I provide effective treatment interventions
while at the same time maximizing the well-being and safety
for everyone involved in the intervention process?
7.
Is everyone involved in the intervention informed and
appropriately prepared to carry out his or her part of the
process?
8.
Is the intervention being considered consistent with
the Standards of Practice, Basic Assumptions, and Safety
Principles of ATTACh?
9.
Is the intervention being considered within the
standards of practice, and ethical standards of the
professional organization and licensing or certification body
of each individual involved?
ATTACh ETHICS
COMMITTEE
ATTACh has created an Ethics Committee
comprised of three members, at least one current board member
and two either from the board or from the membership at large,
to carry out its mission. The purposes of the Ethics
Committee are to:
1.
Educate membership and the larger community to
standards of ethical professional practice.
2.
Ensure responsible use of the standards of practice in
making decisions and taking appropriate actions.
3.
Protect its members against exploitation and
injustice.
4.
Discipline its members when unethical conduct is found
to exist.
To make an ethics complaint, the
complainant must submit the Declaration of Complaint:
Ethics form in duplicate and attach all required
documentation. These documents should be mailed to:
ATTACh
P O Box
11347
Columbia, SC 29211
Declaration of
Complaint:
Ethics
Two copies
of the Declaration of Complaint, together with a brief
statement about the complaint, should be filed with ATTACh
Ethics Committee. Additional persons joining the above
named complainant in these charges should be listed on an
attached sheet with addresses and phone numbers.
I,
______________________________________________, hereby file a
complaint for consideration by the ATTACh Ethics Committee
against:
Name of
Respondent
_____________________________________________________________
Address of
Respondent
___________________________________________________________
___________________________________________________________
Phone of
Respondent
____________________________________________________________
I charge the
above party with demonstrating unethical conduct through a
violation or violations of the ATTACh Professional Standards
of Practice. I have read the ATTACh Professional
Standards of Practice, and agree to abide by the conditions
set forth in them. I pledge to treat all associated
materials and processes confidentially. I understand
that adjudication data may be accessed by approved researchers
and reported in aggregate form. Identifying information
will be treated as confidential.
Signature
_______________________________Date
filed_____________________
Address of
Complainant
_______________________________________________
__________________________________________________________________
Phone number
of Complainant
_____________________________________________________
DATA TO BE FURNISHED BY COMPLAINANT
This
complainant must provide the following information related to
the complaint in a separate statement to be attached to this
required Declaration of Complaint form:
- Statement of complaint. This
brief and specific statement should identify the conduct
that violates the ATTACh Standards of Practice. It
need not include all the evidence the complainant is
prepared to present, but it should serve as a clear and
complete statement of the charges being made against the
respondent. The statement must cite the pertinent
sections of the standards.
-
Action taken to
press the complaint through other channels. The
statement should identify any other actions taken to seek
redress in this matter. Many states have state
licensure laws that may provide a channel for filing a
complaint of unethical or unprofessional conduct; if such a
complaint has been filed, state what has been done
and what the outcome has
been. If legal action is under way, state the status
of the matter.
3.
Sources of evidence. The complainant should list
individuals who may be in a
position
to substantiate the facts and should also list any documentary
sources
of information that
support the complaint. Presentation of these witnesses
and
documents is the responsibility of the
complainant.
ATTACh
P O Box 11347
Columbia, SC 29211
Web: www.attach.org
Voice: 866-453-8224
Fax: 803-765-0284
Email: info@attach.org
