Attachment Narrative Therapy (ANT): An Introductory Guide

This short guide to ANT is not intended to be prescriptive about how to organise therapeutic sessions.  It is offered as a tentative structure which can be adapted with different families and to clinical contexts. The guide is organised around the Formats for Exploration with suggestions for where they might appear in the therapeutic process. It is assumed that therapy is likely to vary between 6 to 16 sessions but in some cases can be shorter or longer as is necessary.

ANT is broadly constructed as consisting of four phases:

1. Co-Creating a Secure Base 
2. Exploring strengths and difficulties
3. Contemplating and Attempting Change
4. Maintaining changes, contemplating the future and ending therapy

These phases are not distinct but may overlap and as with systemic family therapy in general there is no clear distinction between the processes of exploration and change. Exploration can prompt changes in understandings which in themselves constitute change. Likewise, attempting new ways of attempting to deal with difficulties and relating with each other can also constitute an exploration of how family members understand their relationships and what they perceive to be possible.  ANT emphasises that change happens at multiple representational levels (i.e. procedural, sensory, semantic, episodic and integrative) and therefore emphasises the use of activities, visual material, drawing, use of objects and active play-based approaches.  

Developing curiosity and formulations is an essential part of the process of ANT. In each family session at any of the four phases therapists collaboratively develop formulations about the family and their relationship with them.  Our formulations are shared with families in plain everyday language to communicate attachment, narrative systemic concepts. A reflecting format is employed to share formulations, to encourage curiosity and invite suggestions for change with family members to encourage a continual  recursive collaborative process.

It is also recognised that many of the families we see have NOT experienced secure attachments and in contrast many, if not the majority, are being influenced by histories of trauma. Hence though the initial formulations broadly use a formulation of deactivating (A - dismissing) and hyper-activating (C -  pre-occupied)  strategies it is recognised that simple versions of these have not been adaptive for family members and they are likely to be  employing more complex  self-protective strategies shaped by trauma, more commonly called mixed strategies (combinations of A- and C strategies) 

1. PHASES OF ANT

Phase 1: Co-Creating a Secure Base 

For many families, attending Family Therapy can be an anxiety provoking situation, perhaps involving fears of being judged and blamed, for parents and other members of the family. The focus on creating a sense of safety runs through the ANT programme. Examples of the initial stage of engagement are: 

• Greeting each member of the family and explanation of the therapy, timing and structure of the session, reflating team process
• Problem free talk – social talk, asking family members about interests, mutual introductions…
• Reasons for attending- exploration of views of the problems, 

Format for Exploration:  The Family Attachment Genogram,   Discussion of sources of support, resiliencies, any significant event that the family volunteers to share at this initial stage in this first phase of ANT.

Format for Exploration:  Tracking a pleasurable activity, or a process which has gone well or a problematic escalation has been avoided or reduced.

Making a start with an initial ANT formulation:  This is based on a tentative reflection of the family members’ preferred attachment orientations using a consideration of the narrative discourse markers (see Section III of this guide). It can also include the use of the Adult Attachment Interview, Parent Development Interview, the Meaning of the Child or parts of the interviews.(See section v for an integrated short  interview  we have developed  which can be used as a discrete interview or selectively woven into sessions) .

Some key aspects of this formulation are:

• What are the preferred self-protective attachment strategies for different members of the family?
• Who appears to be the most significant/important person at this time for the therapist(s) to establish a strong therapeutic relationship with? (e.g.  a mother who is responsible for the majority of the care-giving in a family.)

Reflective processes:

• Feedback to the family:  strengths and competencies, our perceptions of their  preferred attachment orientations
• Feedback from the family…  

Summary – what has been helpful/ less helpful?

Between session activities – families are asked if they would welcome suggestions for activities, such as observing their patterns of interacting, keeping a diary or thinking further about their family genograms. 

Phase 2: Exploring strengths and difficulties

Feedback:  All sessions start with general feedback from the family and specifically regarding any observations and activities they have conducted between sessions. The formats are used in a recursive way to help enrich family members’ narratives. The initial focus is on behaviours, moving on to feelings and cognitions. They are used visually and are repeated in successive sessions and can also be used by families in between sessions.

Formats for Exploration: 

Several Formats are suggested during this Phase of ANT:

• Tracking a problematic Sequence – focus on how current and historical attachment processes are involved in maintaining repetitive patterns. Start to consider aspects of the circularity/process that may be amenable to change
• Sculpting family relationships and changes - with buttons or objects -  focus on the nature of the attachment connections; those in the present, in the past and in the future. Identify attachment dilemmas, such as triangulation and conflicting loyalties
• Corrective and Replicative Intentions – identify the key ways in which family members wish to repeat or change aspects of their parenting or how they relate to each other as a couple 
• Transitions, Partings and Separations  - this complements the Format for sculpting but invites further discussion about the narratives, especially regarding experience of and preparations for separations and partings

Further work on the emerging ANT Formulation: 

Some helpful questions could be: 

• What are the preferred self-protective attachment strategies for different members of the family?
• What appear to be important triadic processes in the family?
• What are some of the core attachment dilemmas for the family? 
• How do intentions, attachment dilemmas and patterns of relating interact with each other?
• What appear to be some of  the patterns of giving and receiving comfort? 

Reflective processes:

• Feedback to the family:  strengths and competencies, our perceptions of their preferred attachment orientations, key attachment processes 
• Feedback from the family…  

Summary – what has been helpful/ less helpful?

Between session activities, keeping a diary toobserve patterns of interacting, such as requesting and giving comforting, managing conflicts and so on. In some cases if they wish, they could be invited to start contemplating areas of change.

Phase 3: Contemplating and Attempting Change

Feedback: General feedback from the family and from any activities they have conducted between sessions, any insights gained, have they noticed any changes?  

 These sessions can overlap with explorations which take place during Phase 2, but the Formats for Explorations can be used further to contemplate and attempt changes:

• Tracking a problematic Sequence – the focus moves to contemplating how the problematic parts of the cycles could be changed, this can incorporate role play activities to practice responding, feeling and thinking differently. It can also involve discussing ‘homework’ and attempts at change between sessions
• Sculpting family relationships and changes - with buttons or objects  - this continues the focus on dilemmas  but adds an emphasis on how dynamics can be altered, for example triangulations
• Corrective and Replicative Intentions – the focus is now on the consequences of the intentions and also on how we may be pulled into repeating patterns despite our intentions
• Transitions, Partings and Separations  - this can focus on how separations, such as divorce and triangulation process might be changed in how they are understood and preparations for future transitions

Continuing to develop ANT formulation: 

• What is enabling, holding back changes?
• What are some of the core attachment conflicts and traumas that may be fuelling problems and attempts to make changes? 

Reflective processes:

• Feedback to the family:   validation of intentions and aspects of change, discussing what they have learnt from the experiments to change, 
• Feedback from the family…  

Summary – what has been helpful/ less helpful?

Between session activities observing their patterns of interacting, comforting, keeping a diary and so on. In some cases if they wish, they could continue contemplating areas of change.

Phase 4: Maintaining changes, contemplating the future and ending therapy

Feedback:  General feedback from the family and from any activities they have conducted between sessions, insights gained, any changes they have noticed.

It is mentioned in the sessions that the time is approaching for the sessions to decrease in frequency or to end. It can include a discussion of how the family approaches endings of relationship and separations. This often contains a reflective conversation about how past endings and transitions have been handled/ managed.  It also features a discussion of future opportunities and challenges.

The following Formats can be utilised during this final phase of ANT:

Format: Sculpting family relationships and changes - with buttons or objects - this continues the focus on looking at changes over time in relationships. The earlier use of sculpts may have included looking at the future and this can be employed further including a mapping of future relationships with therapy. 

Format: Family Transitions and Separations -   this can complement the use of the format in the Exploration phase (Phase 2) to reflect on how the ending of the therapy may reflect or be different to how this has typically been done in the past.

Both formats can be employed to discuss what the family will take away from the session and what both the therapist(s) and the family will hold in mind about each other in the future. How some of the conversations in the session have become internalised and can be an informative to the therapist during this Phase of ANT.

Continuing to fine-tune the ANT formulation: 

• What changes has the family been able to attempt?
• What are some of the challenges that may present in the future? 

Reflective  process:

• Feedback to the family:    reflections on our experience of working with them
• Feedback from the family…  what will they hold in mind about the experience of the therapy 

Summary – what has been helpful/ less helpful?

Continuing in to the Future:  how might they use some of activities to help them manage future challenges?

 What future contact do we envisage to have with the family? (E.g. a follow – up session, to keep a session ‘in the ‘bank’, as it were.)

2. OVERVIEW OF THE ANT FORMATS FOR EXPLORATION

1. The Family Attachment Genogram,   

Genograms enable a visual presentation of information about the family. It is useful to draw the family tree on a large piece of paper and children in the family can enjoy assisting in drawing the tree. Some areas of exploration once the tree is drawn can be:

• If the family was together at, e.g. a wedding, who would be closest to who, how, why?
• Who would you be most likely to turn to for support? Why? How? 
• What are some of the dangers that people in the family have faced? Across the generations?
• How do people protect, comfort, and reassure each other?
• What are some of the traditions in how people manage their feelings, their distress? For example by talking, the use of alcohol, exercising, seeking therapy, changing  relationships…   ?
• Which of the families is yours most like emotionally, how, why?
• How are people in the family similar and different in how they express their attachment needs? 
• How does the way people manage emotions change over the generations? (Think of corrective and replicative scripts here.) 
• Who are you, your child, your partner most/least like emotionally in this family? 

2. Tracking a problematic and positive Sequence,

• Identify with the person, couple, family etc… a  positive and/or a difficult event, episode, pattern (in some cases start with a positive or  exception episode)
• Locate a recent example of this pattern….. Keep the focus specifically on this episode
• Ask one member of the family to volunteer to describe the pattern
• Start with ACTIONS … keep the focus on this to complete the description of the episode
• Invite other family members to comment on the pattern…. Discuss differences/agreements
• Formulate :  whether it is more helpful to focus on elaboration of :
  • Feelings – dismissing pattern Cognitions -  pre-occupied patterns

Consider the feedback .. are feelings escalating in this exploration or  absent…. 

• Discuss / Identify the THOUGHTS  and FEELINGS involved
• Direct focus to the critical and difficult part of the pattern, for example the outburst of anger, conflict, criticism etc.
• Consider alternative patterns of actions, thoughts and feelings that might be possible?
• Explore trans-generational connections… similar or different patterns in their  family histories

3. Sculpting family relationships and changes - with buttons or objects -  focus on the nature of the attachment connections; currently, in the past and in the future. Identify attachment dilemmas, for example triangulation and conflicting loyalties

Sculpting with family members, sculpting with objects (coins, buttons, stones, figures etc ) …

 PROMPTS (can use direct or circular questions…) 

• Map the current attachment patterns, relationships – who looks after who etc.
• How does it feel to be at the centre/ on the edge/ between your parents?
• Now that you and your brother are closer, how does that make you feel? 
• If you were to get closer to your mother, what would that be like?
• How do you think your sister feels being that distant from your father? 

4. Corrective and Replicative Intentions – identify the key ways in which family members wish to repeat or changes aspects of their parenting or relationships as a couple

Sculpting:

Sculpting with family members, sculpting with objects (coins, buttons, stones, figures etc ) …

 PROMPTS (can use direct or circular questions…) 

• Map the current attachment patterns, relationships – who looks after who etc.
• How does it feel to be at the centre, on the edge, between your parents?
• Now that you and your brother are closer how does that make you feel? 
• If you were to get closer to your mother what would that be like?
• How do you think your sister feels being that distant from your father?

5. Transitions, Partings and Separations

This format connects with the concept of the family life cycle and adds the idea that transitions involve significant changes in attachment relationships. One of the focal points of attachment theory has been on separation which connects for example, with child starting school, leaving home, ending of relationships, divorce and loss. 

The following questions are an illustration and can be used with an individual, couple or in family conversations:

• What have been some of the most significant changes/transitions in your family? How did people prepare for these? Wait until they happened? Discuss them in advance? Worry about them excessively? 
• What have been some of the most significant separations in your life, couple relationship, family? For example: Leaving home, the end of relationships, love affairs, losses… 
• What was the first time you were separated from your parents, partner, and children? 

How were you prepared for the separation?  Was it discussed and with who? 

How did you feel during the separation? How did your partner, parents.. etc feel?

• What communication was there between you when you separated? How frequently did you communicate? What did you talk about? 
• When people have died in your family, how was this prepared for? Not discussed, discussed openly….
• What have you learnt from your experience of separation?  What do you want to do similarly differently to what has happened in the past? 

3. INDICATORS OF ATTACHMENT ORIENTATIONS IN NARRATIVES

DISMISSING		PRE-OCCUPIED
distancing, flat tone   Absence of imagery   Rational, minimising    flat language Lack of episodes, cut off, self -blame  Lack of reflection, other’s perspective	Procedural Sensory Semantic, style of language Episodic Integrative	Involving, aroused affect  vivid, aroused imagery  simplifying, contradictory,   emotive, profane language              fragmented, rambling, blame others  self-serving reflection, own perspective

4. VARITIES AND INDICATORS OF TRAUMA IN NARRATIVES 

TYPES OF TRAUMA

Pre-occupying -

 continual  hyper – arousal, ruminations

       Vicarious – events occurred to others 

        Imagined  - fantasised, 

        Anticipated -  real concern but  extent exaggerated 

Dismissing 

Minimisation of severity, detached 

Blocked – no event remembered or claimed 

Displaced – effects on other source of concern 

Disorganised – multiple and complex 

Depressed – events beyond control 

INDICATORS IN NARRATIVE 

• Pre-occupying
  • Intrusions of negative affect
  • Intense animated imagery
  • Confusions: of self and others
  • Confusions:   of time and place

• Dismissing
• Minimization of the importance of the event/s
• Absence of expected emotions
• Extreme brevity
• Erroneous beliefs of having caused the events

5. SHORT VERSION OF THE PARENT DEVELOPMENT INTERVIEW

(The first section incorporates some questions for the AAI)

Can you tell me a little bit about your family – who lives in your family? How many children do you have?  What are their ages?  Has your family move around very much? What contact do you have with the rest of your family, grandparents etc. 

Sketch this as a genogram and a timeline of key events. 

PARENT’S ATTACHMENT HISTORY  

1. Can you describe your childhood?  Who was important to you and what are the main memories that stand out for you? What about your extended family? What were the most significant events in your family’s history (divorces, losses, mental health problems etc.   -   add to the Genogram and Time line)

2. When you were upset, ill, hurt or needed comfort as a child what happened?  Can you think of a specific example, who responded to you and how?

3. Can you remember the first time you were separated from your parents? How did you feel… How do you think they felt?

4. Did you ever feel unsafe in your childhood -   felt rejected, frightened or hurt physically or emotionally by your parents as a young child?  Can you describe a specific example?

5. Did anyone significant for you die during your childhood?  Can you describe the most significant loss? What happened? How did you and your parents react?

6. How do you think your childhood experiences have made you the person you are now?
7. How do you think your experiences of being parented affect your experience of being a parent now?    How do you want to be like and unlike your mother/father as a parent and as a partner in your relationship/marriage?
   

PARENT – CHILD RELATIONSHIP        

1. Can you tell me a little bit about your child? What does he/she like to do? Does he or she have a special interest?

2. How would you describe your relationship overall?  Can you give me an example of some things you like doing together? What does he/she especially like doing with you?

3. Describe a time in the last week when you and (your child) really “clicked”.  (Can you tell me more about this time?  How did you feel?  How do you think (your child) felt?). Can you also describe a time in the last week when you and (your child) were really “not clicking”. (How did you feel?  How do you think (your child) felt?)

4. Tell me about a time in the last week or two when you felt really angry as a parent.  What effect do these feelings have on you and your child?

5. Tell me about a time in the last week or two when your child was upset or angry, what did he/she do?  How did that make you feel?  What did you do?

6. How do you think that autism has influenced your relationship? When does your child need support from you?  How do you feel when this happens?

7. I’d like you to think of a time when you and your child weren’t together, when you were separated.  Can you describe it to me?  What kind of effect did it have on your child?  What kind of effect did it have on you?

8. What sort of a relationship do you think you will with your child will when he/she is an adult?

V11: ANT FORMULATION GUIDE

PROBLEM/S:   Understandings of the problem/s, ideas about cause focus of the problems, who is identified as having the problems, diagnosis – family , school, extended family, professional services…
PREDISPOSING:  Background and history,  Dangers (traumas and losses) , attachment strategies of parents/carers/children (Facts and defensive processes in how facts are narrated)  Financial, racial, gender related dangers
PRECIPITATING: Key events that are seen as triggering the difficulties, dangers, losses,  separations, transitions, illnesses etc
PRPOTECTIVE:  Corrective script/positive intentions, sources of support, skills ,/abilities, resources
PERPETUATING:  relational dynamics maintaining the problems,  core circularities( specific episodes and overall dynamics
INTEGRATIVE FORMULATION:  How the 5 Ps can be integrated to an overall dynamic of how  the problems are being maintained by current attachment/systemic dynamics

EXAMPLE: Jane and family 

PROBLEM/S:   Understandings of the problem/s in different contexts ( home, school etc) ,  ideas about causes,  focus of the problems -  who is identified as having the problems, diagnosis – family , school, extended family, professional services…	Jane thinks her children Freda and Carl  are suffering with anxiety and bereavement problemsSchool thinks Jane’s anxiety about death of their neighbour is ‘rubbing off’ on the children
PREDISPOSING:  Background and history,  Dangers (traumas and losses) , attachment strategies of parents/carers/children (Facts and defensive processes in how facts are narrated) Financial, racial, gender related dangers	Janes’  own attachment history  is of a ‘harsh critical mother’ , she had to be independent – a  De-activating self- protective strategyHistory of her neighbour being depressed and suicidalHusband ( Matt)  working long hours, Jane managing the children, suffered with fibro - myalgia
PRECIPITATING: Key events that are seen as triggering the difficulties, dangers, losses,  separations, transitions, illnesses etc	2 years previously  neighbour  (Stan) who was an older family friend committed suicide 6 months after his wife left him. Jane discovered his body and had to shortly go to the scene again to identify him when police arrived.
PRPOTECTIVE:  Corrective script/positive intentions, sources of support, skills ,/abilities, resources	Corrective scripts – Jane wants to be  a more emotionally available, warm and supportive mother than her own mother. Describes her marriage as close and supportive. School described as supportive
PERPETUATING:  relational dynamics maintaining the problems,  core circularities( specific episodes and overall dynamics	Jane and  Matt decided to tell the children neighbour died of cancer. But children  pick up mum’s anxiety (trauma)  when they ask about him and  consequently become more anxious.   In interactions with the children Jane become anxious/angry with them. Matt tells her to ‘chill out’  which make her feel unsupported and failing
INTEGRATIVE FORMULATION:  How the 5 Ps can be integrated to an overall dynamic of how  the problems are being maintained by current attachment/systemic dynamics	Jane’s  pre-dominant self - protective  attachment strategy is to avoid confrontation and difficult emotions if possible. So, she  minimises her own needs and attempts to dismiss her trauma and displaces it into concern for her children . But in turn the children’s display of anxiety  leads to her feeling a failure and blamed as a mum and therefore  seeking help for the children rather than herself. She also feels blamed by services which aggravates her sense of failure and further fosters the focus on the children. Attempts to minimise the problem  and ‘move on’ by Matt makes Jane feel she is at fault  and further pushes the problems as ‘in the children’