Attachment, Loss and Bereavement

This undertake describes and evaluates the contributions of Bowlby, Ainsworth, Murray-Parkes, Kubler-Ross and Worden, as s hale as ulterior on theorists, to their respective fields. I test how I already start with some of these object lessons, talllighting my strengths and atomic number 18as for organic evolution. I mark some influences on Bowlbys create, leading to his trilogy adhesiveness 1969 Separation 1973 and Loss, glumness and Depression 1980 demonstrating how fixings in infancy may shape our adjunct titles in later life.Pietromonaco and Barrett posit A central tenet of fixing surmise is that wad heighten run low forcetal representations, or intragroup works determines that comprise of expectations rough the self, signifi tidy sumt others and the kinship mingled with the two. (Pietromonaco and Barrett, 2000, 42, p156). I bedeck how this inborn running(a) instance is developed via the relationship between mess up and primeval c be readyr, demo nstrating that maternal going fag create a awry(p) internecine work model, which may lead to psychopathology in later life.I withal demonstrate how these internal working(a) models influence our reactions to impairment and di prove in maturity date and their dominance impress on the counselling relationship. In addition, I look for the multi-layered losses withstand intercoursed by human immunodeficiency virus+ laughable men and fin bothy draw some conclusions. Freuds view on the infants adherence to its obtain was quite simple the argue why the infant in arms wants to perceive the presence of its grow is only be vex it already k at presents by experience that she satisfies all its compulsions without delay. (Freud, 1924, p188 liftd in Eysenck, 2005, p103).In contrast, demeanorists deald that feeding nobbleed a central role in the tuition of hamper. (P polish offry, 1998 Eysenck, 2005). These theories were termed secondary-drive theories. In 1980, Bowlby re scratched this secondary drive surmisal did non seem to me to fit the facts. but, if the secondary dependance was inadequate, what was the alternative? (Bowlby,1980, p650 cited in Cassidy and fry, 1999, p3).Bowlbys conjecture was influenced by his paper twoscore Four Juvenile Thieves, where he conclude a correlation exists between maternal deprivation in infancy, leading to touchionless psychopathology and subsequent nefarious behaviour in adolescents. (Bowlby, 1944, 25, p19-52). This led to him looking the electrical shock of loss on pip-squeakren dis dressd through and through with(predicate) war and institutionalisation, expirationing in Maternal Care and Mental Health (1952), where he confirms a link between environmental trauma and sequential disturbances in tike emergence.As a result of this research, Bowlby concluded it is psychological deprivation rather than the economic, nutritional or medical deprivation that is the ca substance ab workout of troub led babyren. (Bowlby in Coates, 2004, 52, p577). He was further influenced by Lorenz who embed that goslings would follow and attach themselves to the number 1 moving object they saw. This following of the initiative moving object was called influence. (Lorenz, 1937 cited in Kaplan, 1998, p124).Cl archaeozoic babies can non follow at will to compensate for this, Bowlby noned that work manifested itself as a spectacularly more multifactorial phenomenon in primates, including man, which he later labelled adjunct. (Hoover, 2004, 111, p58-60). He withal embraced the work of Harlow and Zimmerman who worked with infant rhesus monkeys demonstrating that not only did the need for adjunct give them security, but that this need took priority over their need for food. (Harlow and Zimmerman 1959 cited in one thousand and Scholes, 2003, p9).Dissatisfied with traditional theories, Bowlby embraced new understandings through discussion with colleagues from much(prenominal) fields as developmental psychology, ethology, control systems opening and cognitive science, leading him to formulate his guess that the mechanisms underlying the infants tie to the mother originally emerged as a result of evolutionary and biological pressures. (Cassidy and kidskin, 1999 Green and Scholes, 2003).Defining his bond paper hypothesis as a way of conceitualising the propensity of human beingnesss to make lovesome affectional bonds to particular others. (Bowlby, 1979 cited in Green and Scholes, 2003, p7), he posited that it is our affectional bonds to attachment figures that engage us in our most intense emotions. and that this occurs during their formation (we call that falling in love), in their maintenance (which we describe as loving) and in their loss (which we know as grieving), (Green and Scholes, 2003, p8), in that locationby replacing the secondary-drive theory with a model emphasising the role relationships flirt in attachment and loss. (Waters, Crowell, Ellio tt et all, 2002, 4, p230-242).Disregarding what he called Freuds cupboard love theory of attachment, he believed instead that a child is born(p) biologically pre-disposed to become attached to its mother, claiming this bond has two native features the biological function of securing protection for survival and the physiological and psychological need for security. (Green and Scholes, 2003 Schaffer, 2004). Sonkin (2005) describes four features to this bond reliable base, insularism testify, honest haven and propinquity maintenance.The concept of a ensure base is fundamental to attachment theory and is used to describe a dependable attachment to a primary primary care provider. This secure base is accomplished by providing consistent levels of safety, responsiveness and excited comfort from in spite of appearance which the infant can explore his or her extraneous and internal worlds and to which they can re telephone number, then providing a sense of security. Separation avouch is exhibited as a sign of the detriment experienced upon dissolution from an attachment figure, who may also be used as a safe haven to turn to for comfort in sequences of distress.When safety is threatened, infants collect the economic aid of their primary caregiver through crying or screaming. Maintaining attention and interest, e. g. vocalising and smiling, and seeking or maintaining proximity, e. g. following or clinging, all serve to crowd the safety provided by the secure base (providing of course that parents respond appropriately). (Holmes, 1993 Cassidy and Shaver 1999 Becket, 2002 Green and Scholes, 2003).Proximity seeking is a two way process, for example child seeking parent or parent seeking child. (Weiss in Murray-Parkes, Stevenson-Hinde and Marris, 1991 Becket, 2004 Sonkin, 2007). Bowlby also knowd unwilling separation caused by parents who were phsycially present but not able to respond, or who deprived infants of love or ill-treated them, left-hand(a) them with a sense of immense deprivation and that this unwilling separation and resultant loss leads to deep frantic distress. (Green and Scholes, 2003).At a recent conference, the Centre for Attachment establish Psychoanalytical Psychotherapy (CAPP) asserts Early interactions with significant others in which there are fundamental failures of empathy, attunement, recognition and regulation of emotional states, have been shown to cause the global breakdown of whatever coherent attachment scheme, thus engendering fears of breakup and threatening psychic survival. In the face of such experiences, powerful dissociative defences may be employed, encapsulating overwhelming feelings of fear, rage and shame. (CAPP, 2007).Together with Robertson and Rosenbluth, Bowlby demo that even skeleton separation from the mother has profound emotional effects on the infant. Their research highlighted a terce stage behavioural response to this separation protest related to separation anxiety d espair related to heartache and lament and detachment related to defences. (Robertson, Rosenbluth, Bowlby, 1952 in Murray-Parkes, Stevenson-Hinde and Marris, 1991). Ainsworth, Blehar, Waters and Wall (1978) later established the inter-relatedness between attachment behaviour, maternal sensitivity and exploration in the child.Under clinical settings, they sought to observe the effects of temporary separation from the mother, which was assessed via the strange authority procedure. This work problematic children between the ages of 12 to 18 months who experienced separation from their mother, introduction to an unfamiliar bighearted and finally reunion with their mother. Ainsworth et al healthy that if attachment was strong, mother would be used as a secure base from which the infant could explore, thereby promoting self-reliance and autonomy. Upon separation, infants usually demonstrated separation anxiety.Upon re-union, the mothers maternal sensitivity and the childs respons es were find, thus providing a link between Bowlbys theory and its application to idiosyncratic experience. The trust/mistrust in the infants business leader to explore their world from the secure base is re-inforced by Eriksons (1965) examination of early development and the childs experiencing of the world as a place that is nurturing, reliable and trustworthy (or not). Influenced by Ainsworths previous work in Uganda, the strange situation led to the disciplineification of secure or uncertain attachment styles in infants.Insecure styles were further grouped into insecure/avoidant and insecure/ liberal (ambivalent). (Pendry, 1998 Holmes, 2001 Eysenck, 2005). Main and Solomon later added a fourth attachment style insecure/disorganised. (Main and Solomon, 1986 in Cassidy and Shaver, 1999, p290). Throughout all of these interactions, an internal working model is developed, the horticulture of which relies on the dyadic patterns of relating between primary caregiver and infant (Bretherton, 1992, 28, p759-775), comprising the complex monitoring of internal states of primary caregiver and infant.(Waters, Crowell, Elliott et al, 2002, 4, p230-242).According to Schore These formative experiences are insert in the developing attachment relationship nature and nurture first come together in mother-infant psychobiological interactions. (Schore, 2001, 17, p26). Over time, this leads to the infants ability to self-monitor their emotions (affect regulation), but until such time, Bowlby posited the mother acts as the childs egotism and super-ego She orients him in space and time, provides his environment, permits the satisfaction of some impulses, restricts others.She is his ego and his super-ego. (Bowlby, 1951, p53 cited in Bretherton, 1992, 28, p765). Bowlby concluded a healthy internal working model is a working model of an attachment figure who is conceived as accessible, trustworthy and ready to process when called upon, whilst a faulty model is a workin g model of an attachment figure to whom are attributed such characteristics as uncertain accessibility, unwilllingness to respond help ampley, or perhaps the likelihood of responding hostilely. (Bowlby, 1979, p141).Ainsworth suggests that positive attachment is more than explicit behaviour it is built into the nervous system, in the course and as a result of the infants experience of his transactions with the mother. (Ainsworth, 1967, p429), thus supporting Bowlbys theory. ulterior descriptions of attachment styles describe secure attachment as the development of the basic machinery to self-regulate affects later in life, (Fonagy, Gergely and Jurist, 2002 cited in Sarkar and Adshead, 2006, 12, p297), whilst insecure attachment prevents the development of a proper affect regulatory capacity. (Sarkar and Adshead, 2006, 12, p297).This is supported by Schore (2003) who alludes to developmental affective neuroscience to set out a framework for affect regulation and dysregulation. Base d on research into the development of the infant brain, he reviews neuro-scientific evidence to confirm the infants relationship with the primary caregiver has a direct effect on the development of brain structures and pathways involved in both affect regulation and dysregulation.The research and evidence suggests the internal working model begins as soon as the child is born and is the model upon which future relationships are formed. The quality of the primary caregivers response to infant distress provides the foundation upon which behavioural and cognitive strategies are developed, which in the longer term influence thoughts, feelings and behaviours in magnanimous relationships. (Cardwell, Wadeley and Murphy, 2000 Pietromonaco and Barrett, 2000, 42, p155 Madigan, Moran and Pederson, 2006, 422, p293).A healthy, secure attachment to the primary caregiver would indeed pop essential for a childs social, emotional and intellectual development, whilst time out to this attachment w ould appear to promote the premise of psychopathology in later life. Whilst some evidence exists to demonstrate internal working models can be modified by different environmental experiences, (Riggs, Vosvick and Stallings, 2007, 126, p922-936), the extent to which they can change remains in question.Bowlby himself postulated clinical evidence suggests that the necessary revisions of the model are not always easy to achieve. Usually they are accurate but only slowly, often they are make imperfectly, and sometimes done not at all. (Bowlby, 1969, p83). Whilst change may be possible, the unconscious aspects of internal working models are deemed to be specifically resistant to such change. (Prior and Glaser, 2006). We can safely assume therefore, that in the majority of cases, internal working models lam to persist for life.I arrest with Rutters reproof of Bowlbys concept of monotropy, i.e. Bowlbys printing that babies develop one primary attachment, usually the mother, (Rutter, 1 981 cited in Lucas, 2007, 13, p156 and in Eysenck 2005), evaluate instead that infants form multiple attachments. This is supported by a study by Shaffer and Emmerson (1964) who concluded infants form a hierarchy of attachments, often with the mother as the primary attachment figure, although nearly a third of children observed highlighted the father as the primary attachment figure. (Schaffer and Emmerson, 1964 in Cassidy and Shaver, 1999, p44-67).Collins, Dunlop and Chrysler criticise Bowlbys lens in that it was limited by his own ethnic, historical and class position. Bowlbys culturally biased assumptions and empiricist methods of inquiry concentrated on personalized detachment and loss as part of the approach pattern course of mourning loss, which perpetuated the Western tradition of preserving the autonomous indivi dual self as the normal goal of development. (Collins, Dunlop and Chrysler, 2002, p98), leading them to conclude Bowlbys assumptions ignored other cultural pra ctices (as did Ainsworths), with which I agree.They also suggest Bowlbys concept of maternal deprivation was perhaps exploited to get women to return to the home post domain War II Characterised as a choice, this homeward bound question was supported by the various governments, whose maternalist and pronatalist political orientation of the 1930s continued into the post-war plosive consonant to provide a rationale for sending women home to reproduce gestation and the maternal deprivation hypothesis provided one conceptual framework for pronatal ideology as it intersectedwith the demands of governments and industrialists. (Collins, Dunlap and Chrysler, 2002, p102).We must also remember that Bowlbys observations were based on children who had been separated from their primary caregivers during the Second World War (Lemma, 2003 cited in Lucas, 2007, 13, p156), and that these procedures were based on behaviours that occurred during stressful situations rather than under normal ci rcumstances. (Lucas, 2007, 13, p156) this latter criticism also applies to Ainsworths work.Nonetheless, in highlighting the damaging effects of institutionalise care on raw children, Bowlbys strengths lie in pull attention to the role attachment, attachment behaviour and attachment behavioural systems play in a childs development and the subsequent potential consequences of disruption to the bond between infant and primary caregiver. I concur with Cassidy and Shavers (1999) criticisms of the strange situation in that there are too many unconsidered variables for a firm theory to be established at the time of Ainsworths writings, accepting their view that she did not consider the mood nor temperament of the child.Nonetheless, Ainsworth et al have provided a ray with which to measure attachment styles in infants, which is still in use today. Later research by George, Kaplan and Main assesses adult internal models through the use of the Adult Attachment Interview. This classificat ion of adult attachment styles promotes the idea of models extending into adulthood as a template for future relationships. (George, Kaplan and Main 1985 cited in Pendry, 1998).Hazan and Shaver continued this line of research identifying patterns of attachment behavior in adult romantic relationships, concluding the same four attachment styles identified in infancy remain true for adult relationships. (Hazan and Shaver 1987 in Cassidy and Shaver, 1999, p355-377). Although theoretically rooted in the same innate system, adult romantic attachment styles differ from parent-child bonds to include reciprocity of attachment and caregiving, as well as sexual mating.(Hazan and Zeifman, 1999 in Cassidy and Shaver, 1999, p336-354).The literature on bereavement has become internal from Bowlbys theory of attachment and, following from this, the way in which people react to the loss of this attachment. On reflecting on losses in adult life, Weinstein (2008) observes Bowlbys persistence of forma tive attachments and how the pattern of protest, despair and detachment that follows a babys separation from its primary caregiver is re-activated and presented in full force in adult loss.Weinstein writes The ability of the adult to cope with attachment in intimate relationships to negotiate independence, dependency and inter-dependency and to manage loss is all about how successfully they coped with separation as an infant. As a baby they had to retain their sense of their mother even in her absence and now as adults, as part of the mourning process, they strengthen their own indistinguishability with the support of the internalised object. (Weinstein, 2008, p34).According to Murray-Parkes (1996), the intensity and duration of this ruefulness is relative to what is lost and the grief process is an emotional response to this loss. Murray-Parkes joined Bowlby at the Tavistock Centre in 1962. Together they presented a paper linking the protests of separation highlighted by Robertso n, Rosenbluth and Bowlby (1952) in young children separated from their mothers, to grief in adults. (Bowlby and Murray-Parkes, 1970 in Murray-Parkes, Stevenson-Hinde and Marris, 1991, p20).Around the same time, Murray-Parkes visited Kubler-Ross who was conducting her own research into death and dying. This work was later published in On devastation and Dying (1969) which examines the process of coming to terms with terminal illness or grief in five stages denial anger bargaining slack and acceptance. Murray-Parkes later produced a four- contour grief model consisting shock or numbness yearning and pining disorganisation and despair and re-organisation.In contrast to the passive staged/phased approaches by Kubler-Ross and Murray-Parkes, and perhaps more in line with Freuds concept of having to do grief work, Worden developed a four-staged, task-based grief model to accept the reality of the loss to work through the pain of grief to adjust to an environment in which the deceased i s missing and to emotionally move the deceased and move on with life. (Worden, 2003). All three models are deemed to be therapeutically useful in that they recognise grief as a process and provide a framework of descriptors for normalising grief reactions.That said, they are clear prescriptive and caution should be exercised in taking any of these prescriptive stages, phases or tasks literally. It is equally important to recognise the uniqueness of individual responses to loss and to avoid prescribing where a client ought to be in their grieving process. Since these models were neer designed as a linear process, it is likewise important not to steer clients through these stages. This is supported by Schuchter and Zisook (1993), who assert Grief is not a linear process with concrete boundaries but, rather, a composite of overlapping, politic phases that vary from person to person. (Schuchter and Zisook, 1993 in Stroebe, Stroebe and Hansson, 1993, p23).I agree with Servaty-Seibs observations the stage/phase approaches emerged solely from a death-loss commission Wordens work was an important development in the understanding of the process of coping adaptively with bereavement as from each one task is clearly defined in an action-oriented manner. (Servaty-Seib, 2004, 262, p125). Stroebe and Schuts dual process model brings together death-loss focus and task-based models. (Stroebe and Schut, 2001 cited in Servaty-Seib, 2004, 262, p125).In my work at Positive East, I work with human immunodeficiency virus+ spanking men experiencing multi-layered loss. My philosophy is to configuration and maintain a therapeutic relationship within a safe, confidential, contained space where clients can explore their issues. The archetype working towards a model of risible affirmative therapy (Davies and Neal, 1996, p24-40) provides me with a framework within which to explore gay culture and to apply an assenting approach to the work, which I believe promotes empathy and helps me to work in the best interests of the client.Conducting my own assessments, I complete a full client history, genogram and timeline, which provides a comprehensive insight into clients attachments and losses. It is important to bed the social context within which multi-layered loss takes place (e. g. heterosexism, homophobia, HIV-related stigma) as well as recognising that individual attachment styles may influence individual reactions to these losses and may also match on the counselling relationship.Losses experienced by HIV+ gay men include loss of identity, health, appearance, mobility, self-respect, career, financial security, relationships and intimacy. (Riggs, Vosvick and Stallings, 2007, 126, p922-936 Koopman, Gore-Felton, Marouf et al, 2000, 125, p663-672 Fernandez and Ruiz, 2006, p356). Corr, Nabe and Corr (1997) describe these losses as the cognitive, affective and behavioural responses to the impact of the loss. In identifying attachment styles in HIV+ adults, Riggs, Vosvick and Stallings (2007) found that 90% of gay and bisexual HIV+ adults recruited into their study demonstrated insecure attachment.They suggest the diagnosis of HIV produces a strong trauma reaction, impacting on adult attachment style. In the same study, they found that HIV+ heterosexual adults were more promising to be secure, whereas gay and bisexual adults were more likely to be fearful, preoccupied, avoidant or dismissing, respectively. This led them to conclude that gay and bisexual people must therefore contend with societal forces that their heterosexual counterparts do not.They hypothesise A diagnosis of HIV may be reminiscent of the coming out process, especially with respect to concerns regarding stigma and disclosure, and thus may provoke similar fears about rejection by loved ones and society as a whole that hold to greater attachment insecurity. (Riggs, Vosvick and Stallings, 2007, 126, p931). This is supported by Koopman, Gore-Felton, Marouf et al (20 00) who cite attachment style as a contributing factor associated with the high levels of stress experienced by HIV+ individuals.They comment From this perspective, perceived stress is likely to be greater among HIV+ persons having a highly anxious attachment style because their hypervigilance in interpersonal relationships leads to misinterpreting others behaviours as rejecting or critical of themselves. (Koopman, Gore-Felton, Marouf et al, 2000, 125, p670). This would suggest that HIV+ gay men with insecure attachment style may experience difficulties in developing and maintaining relationships, which, in turn, may impact on the therapeutic relationship.Additionally, according to Kelly, Murphy, Bahr et al Dependable and supportive attachments play a crucial role in adjusting to HIV infection. Lack of such attachments and social support has been shown to be a significant predictor of emotional stress among HIV+ adults. (Kelly, Murphy, Bahr et al, 1993, 123, p215-219). This has si gnificant implications for the psychological well being of HIV+ gay men whom, considering their perceived attachment difficulties, may experience difficulties in forming such supportive relationships.In examining the suitability of the common grief models when working with this client group, I accept Copps criticism of the Kubler-Ross model for its focus on psychosocial dynamics to the exclusion of physical, and to a lesser extent, spiritual dimensions. (Copp, 1998, 282, p383). I also agree with Knapps criticisms of the staged/phased grief models espoused by Kubler-Ross and Murray-Parkes. Knapp observes while both of these models may be applicable to those experiencing a unequalled loss, neither model takes intoconsideration the multiplicity of losses thrust upon the seropositive gay male population.These men experience overlapping losses, resulting in them being at differing stages with respect to different losses. (Knapp, 2000, 62, p143). Knapp offers a similar criticism of the Worden model in that task models fail to account for the continuity of loss in the lives of seropositive gay men. (Knapp, 2000, 62, p143), with which I also concur. In addition, all three models incorporate an end point, which suggests the completion of a cycle, thereby pre-supposing some severalize of finality.These models are therefore limited in their application to my own work, since, as new losses take the place of old, my clients find themselves in a continual cycle of loss without the comfort of such an end point. treat the loss of the pre-infected self and re-defining the HIV+ self often means working with the stage of identity vs role confusion in Eriksons (1965) psychosocial model. Additionally, where partners die hard together, a revisiting and re-negotiation of the adult stage of intimacy may be compulsory since intimacy is often disrupted and sometimes lost payable to HIV infection.This stage is also revisited by clients where a partner chooses to end the relatio nship with a HIV+ partner. Working through the loss of the partner (usually collect to fear of infection) as well as other significant relationships (usually overdue to HIV related stigma) is also key to the work. To support this work, I use the multi-dimensional grief model by Schuchter and Zisook (1993), adopting four of their five dimensions emotional and cognitive responses emotional pain changes in relationships and changes in identity.(Schuchter and Zisook, 1993 in Stroebe, Stroebe and Hansson, 1993, p26-43).I have also used Wordens grief model in supporting a HIV+ client whose HIV infected partner committed suicide. This work is clearly demanding and is informed by the clients internal working model of self and other. Due to perceived stigma and fear of rejection, it is not unusual for the clients attachment behavioural system to be activated throughout the therapeutic relationship. Recent research highlights the mirroring of Bowlbys theory within such a relationship.Parish and Eagle (2003) and Sonkin (2005) draw attention to the construction of clients seeking proximity maintenance to the therapist experiencing distress when the therapist is not available seeking a safe haven when in distress and using the therapist as a secure base. To cater for this, I strive to provide a secure base in therapy, ensuring I remain boundaried, punctual and professional, informing clients of any breaks and provide opportunities for clients to explore their anxieties. Clients in particular distress may also contact the agency, who in turn may contact me.My experience has taught me that clients with avoidant attachment styles take time to build trust in the therapeutic relationship. I have also found the avoidant attached usually need permission/re-assurance to grieve their losses, whilst the anxiously attached require permission/re-assurance to stop grieving their losses. I am cognizant that the therapeutic relationship promotes attachment yet at the same time ac fam iliarity the paradox in severing this attachment at the end of therapy. Ending sensitively is therefore crucial. I recognise that clients may develop co-morbid conditions such as alcohol and recreational drug abuse.In line with the BACP honest principles of beneficence, non-maleficence and self-respect (BACP Ethical Framework, 2007), I use supervision to monitor any emerging signs of such abuse, where a decision may be reached to announce these clients to external agencies or other, suitably experienced, internal advocators. In assessing my strengths and areas for development, I am now much more aware of how early attachment experiences and internal working models impact on how clients process their losses as well as their potential impact on the counselling relationship and process.I have extensive experience of working with loss and bereavement, which is underpinned by my specialist dressing and practice at Positive East, as a bereavement counsellor with the Bereavement Servic e and as a counsellor providing support to those strip through homicide at Victim Support. I believe a healthy, secure attachment to a primary caregiver is necessary for a childs social, emotional and intellectual development. In turn this promotes the development of a healthy internal working model, disruption to which may lead to psychopathology in later life.Whilst the internal working model tends to persist through the life course, I believe it can be modified by divergent experiences, but acknowledge this change may be difficult. Whilst I have extensive experience of working with loss, I now take account how early formative attachments influence our reactions to such loss and how these reactions may impact on the therapeutic relationship. Popular grief models clearly fall victimize in addressing the multi-layered losses experienced by this client group, demanding instead the desegregation of what is currently available.The high level of insecure attachment style demonstrated in HIV+ gay men may be due in part to the unique challenges they face within the context of HIV related stigma and negative social experiences. Finally, I believe my knowledge of theory and sensitive application of skills has proved to be an effective strategy in working competently, sensitively and safely with this client group. Nonetheless, I recognise the need for continuous professional development and aim to attend workshops on attachment and mental health and HIV during the summer.