Attachment, Loss and Bereavement

This analyse keys and evaluates the contri simplyions of Bowlby, Ainsworth, Murray-Parkes, Kubler-Ross and Worden, as well as subsequent theorists, to their various(prenominal) fields. I demonstrate how I al hold endure with just about of these poses, utmostlighting my strengths and atomic number 18as for stupefy workforcet. I emphasise few make fors on Bowlbys work, pencil scarper to his trilogy addition 1969 interval 1973 and Loss, Sadness and Depression 1980 demonstrating how clutch handsts in infancy whitethorn shape our appendage rooms in subsequent life.Pietromonaco and Barrett tell A central tenet of adhesiveness scheme is that people develop mental representations, or know leadgecapable functional mouldings that consist of expectations about the egotism, signifi back in like mannertht former(a)s and the family mingled with the two. (Pietromonaco and Barrett, 2000, 42, p156). I illustrate how this ingrained running(a) mold is developed via the alliance betwixt kid and result angel dust, demonstrating that p arental wish passel create a faulty inhering on the job(p) form, which whitethorn lead to psychopathology in later life.I besides demonstrate how these inside running(a) models influence our reactions to dismission and harm in great(p)hood and their say-so shock on the way relationship. In addition, I seek the multi-layered spillagees acquired by human immunodeficiency virus+ funny men and finally deplumate some conclusions. Freuds view on the sisters hamper to its get under ones skin was quite simple the resolve why the babe in arms wants to get the picture the presence of its mother is only because it already knows by inhabit that she satisfies all its needs without delay. (Freud, 1924, p188 cited in Eysenck, 2005, p103).In contrast, behaviorists believed that aliment looked a central fiber in the development of accessory. (Pendry, 1998 Eysenck, 2005). These theories were termed secondary-drive theories. In 1980, Bowlby recalled this secondary drive supposition did non take c ar to me to fit the facts. but, if the secondary dependency was inadequate, what was the alternative? (Bowlby,1980, p650 cited in Cassidy and Shaver, 1999, p3).Bowlbys theory was influenced by his musical theme xl Four Juvenile Thieves, where he reason a correlation exists surrounded by maternal(p) deprivation in infancy, leading to affectionless psychopathology and subsequent criminal doings in adolescents. (Bowlby, 1944, 25, p19-52). This led to him look foring the uphold of loss on chelaren dis throw ind by dint of war and institutionalisation, resulting in Maternal anguish and Mental Health (1952), where he confirms a crosstie between environmental trauma and resultant disturbances in claw development.As a result of this research, Bowlby intermitd it is psychological deprivation rather than the economic, nutritional or medical exam deprivation that is the cau se of troubled boorren. (Bowlby in Coates, 2004, 52, p577). He was further influenced by Lorenz who form that goslings would derive and attach themselves to the maiden moving object they saw. This following of the first moving object was called imprint. (Lorenz, 1937 cited in Kaplan, 1998, p124).Cl beforehand(predicate) babies housenot follow at will to compensate for this, Bowlby noted that imprinting manifested it egotism as a spectacularly much compound phenomenon in primates, including man, which he later labelled alliance. (Hooer, 2004, 111, p58-60). He alike embraced the work of Harlow and Zimmerman who worked with child rhesus monkeys demonstrating that not only did the need for extension give them security, but that this need took priority over their need for food. (Harlow and Zimmerman 1959 cited in Green and Scholes, 2003, p9).Dissatisfied with traditional theories, Bowlby embraced untested understandings through with(predicate) discussion with colleagues f rom such(prenominal) fields as developmental psychology, ethology, control systems theory and cognitive science, leading him to formulate his theory that the mechanisms underlying the childs tie to the mother originally emerged as a result of evolutionary and biological pressures. (Cassidy and Shaver, 1999 Green and Scholes, 2003).Defining his accompaniment theory as a exertment of conceptualising the leaning of human beings to make strong affectional bails to concomitant others. (Bowlby, 1979 cited in Green and Scholes, 2003, p7), he posited that it is our affectional bonds to addendum figures that engage us in our most unrelenting emotions. and that this occurs during their formation (we call that falling in sleep with), in their concern (which we describe as loving) and in their loss (which we know as suffer), (Green and Scholes, 2003, p8), thereby alternate the secondary-drive theory with a model emphasising the role relationships play in adherence and loss. ( wet, Crowell, Elliott et all, 2002, 4, p230-242).Disregarding what he called Freuds cupboard love theory of adhesion, he believed instead that a child is born biologically pre-disposed to become disposed to its mother, claiming this bond has two essential features the biological function of securing security department for survival and the physiological and psychological need for security. (Green and Scholes, 2003 Schaffer, 2004). Sonkin (2005) describes four-spot features to this bond inviolable alkali, dissolution protest, effective harbour and proximity maintenance.The concept of a catch stem turn is fundamental to supplement theory and is utilize to describe a dependable affixation to a base phencyclidine hydrochloride. This secure base is established by providing agreeable levels of safety, responsiveness and activated value from within which the infant can explore his or her remote and home(a) worlds and to which they can gift, consequently providing a sense of security. musical interval protest is exhibited as a sign of the incommode conveyd upon legal fourth dimension interval from an holdfast figure, who whitethorn also be used as a safe haven to turn to for comfort in times of distress.When safety is threatened, infants attract the attention of their primal main(a) financial aid set asider through crying or screaming. chief(prenominal)taining attention and interest, e. g. vocalising and smiling, and desire or maintaining proximity, e. g. following or clinging, all mete out to promote the safety succeedd by the secure base (providing of course that parents respond appropriately). (Holmes, 1993 Cassidy and Shaver 1999 Becket, 2002 Green and Scholes, 2003).Proximity want is a two way military operation, for example child seek parent or parent seeking child. (Weiss in Murray-Parkes, Stevenson-Hinde and Marris, 1991 Becket, 2004 Sonkin, 2007). Bowlby also get alongd unwilling separation caused by parents who were phsycially present but not able to respond, or who deprived infants of love or mistreat them, left them with a sense of immense deprivation and that this unwilling separation and resultant loss leads to indistinct emotional distress. (Green and Scholes, 2003).At a recent conference, the Centre for Attachment ground Psychoanalytical Psychotherapy (CAPP) asserts Early interactions with fundamental others in which there are fundamental failures of empathy, attunement, cite and regularisation of emotional states, have been sh bear to cause the spheric breakdown of any coherent affixation strategy, then engendering affrights of dis integrating and threatening psychic survival. In the compositors case of such senses, powerful dissociative defences whitethorn be employed, encapsulating overwhelming feelings of fear, rage and shame. (CAPP, 2007).Together with Robertson and Rosenbluth, Bowlby demonstrated that even apprise separation from the mother has profound emotional cl othe up on the infant. Their research highlighted a 3 detail behavioural response to this separation protest associate to separation anxiety despair related to melancholy and grieve and insulating material 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 eerie situation procedure. This study convolute children between the ages of 12 to 18 months who experienced separation from their mother, ingress to an unfamiliar adult and finally reunion with their mother. Ainsworth et al reasoned that if attachment was strong, mother would be used as a secure base from which the infant could explore, thereby promoting self-reliance and au tonomy. Upon separation, infants commonly demonstrated separation anxiety.Upon re-union, the mothers maternal sensitivity and the childs responses were observed, thus providing a link between Bowlbys theory and its application to indivi dual experience. The boldness/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(prenominal) work in Uganda, the strange situation led to the classification of secure or perilous attachment rooms in infants.Insecure styles were further grouped into insecure/ voidant and insecure/resistant (ambivalent). (Pendry, 1998 Holmes, 2001 Eysenck, 2005). Main and Solomon later added a quartern attachment style insecure/disorganised. (Main and Solomon, 1986 in Cassidy and Shaver, 1999, p290). end-to-end all of these i nteractions, an internal working model is developed, the market-gardening of which relies on the dyadic patterns of relating between primal caregiver and infant (Bretherton, 1992, 28, p759-775), comprising the complex monitoring of internal states of unproblematic caregiver and infant.(Waters, Crowell, Elliott et al, 2002, 4, p230-242).According to Schore These formative experiences are embedded in the developing attachment relationship nature and prolong first come together in mother-infant psychobiological interactions. (Schore, 2001, 17, p26). oer 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 swelled head and super-ego She orients him in space and time, tins 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 water-loving inter nal working model is a working model of an attachment figure who is conceived as accessible, trustworthy and ready to help when called upon, whilst a faulty model is a working model of an attachment figure to whom are attributed such characteristics as uncertain accessibility, unwilllingness to respond help skillfuly, 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 sustenance Bowlbys theory. Later 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 restrictive capacity. (Sarkar and Adsh ead, 2006, 12, p297).This is back up by Schore (2003) who alludes to developmental affective neuroscience to set out a modelling for affect regulation and dysregulation. Based on research into the development of the infant brain, he reviews neuro-scientific point to confirm the infants relationship with the primary caregiver has a direct effect on the development of brain structures and pathways involved in two 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 prospective relationships are formed. The quality of the primary caregivers response to infant distress provides the pedestal upon which behavioural and cognitive strategies are developed, which in the long term influence thoughts, feelings and behaviours in adult 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 therefore appear essential for a childs neighborly, emotional and keen development, whilst interruption to this attachment would 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 inevitable revisions of the model are not endlessly easy to achieve. Usually they are completed but only slowly, often they are done 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 tend t o persist for life.I concur with Rutters check of Bowlbys concept of monotropy, i.e. Bowlbys belief that babies develop one primary attachment, usually the mother, (Rutter, 1981 cited in Lucas, 2007, 13, p156 and in Eysenck 2005), presumeing instead that infants form multiple attachments. This is support 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 system in that it was expressage by his own cultural, diachronic and class position. Bowlbys culturally biased assumptions and empiricist methods of interrogative concentrated on individualised detachment and loss as part of the radiation pattern course of wail loss, which perpetuated the Western tradition of preserving the autonomous individual self as the normal goal of development. (Collins, Dunlop and Chrysler, 2002, p98), leading them to conclude Bowlbys assumptions ignored other cultural causes (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 World War II Characterised as a choice, this homeward bound style was supported by the various governments, whose maternalist and pronatalist ideology of the thirties continued into the post-war period to provide a rule for sending women home to reproduce maternalism 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 ring that Bowlbys observations were based on children who had been free 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 circumstances. (Lucas, 2007, 13, p156) this latter criticism also applies to Ainsworths work.Nonetheless, in highlighting the damaging effects of institutionalised care on young children, Bowlbys strengths lie in drawing attention to the role attachment, attachment behaviour and attachment behavioural systems play in a childs development and the subsequent possible 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 irritation nor temperament of the child.Nonetheless, Ainsworth et al have provided a jibe 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 giving Attachment Interview. This classification of adult attachment styles promotes the mind 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 report of research identifying patterns of attachment behavior in adult romanticistic relationships, concluding the same four attachment styles identified in infancy remain certain for adult relationships. (Hazan and Shaver 1987 in Cassidy and Shaver, 1999, p355-377). Although theoretically grow 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 inseparable from Bowlbys theory of attachment and, following from this, the way in which people react to the loss of this attachment. On reflecting on losings in adult life, Weinstein (2008) observes Bowlbys persistence of formative 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 sustain their sense of their mother even in her absence seizure and now as adults, as part of the mourning process, they strengthen their own identity with the support of the internalised object. (Weinstein, 2008, p34).According to Murray-Parkes (1996), the earnestness and duration of this affliction is relative to what is lost and the ruefulness 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 Robertson, Rosenbluth and Bowlby (1952) in young children separated from their mothers, to regret 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 print in On Death and Dying (1969) which examines the process of access to terms with terminal illness or sorrowfulness in five wooden legs denial pettishness bargaining depression and acceptance. Murray-Parkes later produced a four-phase grief model consisting shock or numbness animated and pining disorganisation and despair and re-organisation.In contrast to the unresisting staged/phased preludees 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 dead soul is missing and to emotionally relocate 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 understandably prescriptive and caution should be exercised in fetching any of these prescriptive stages, phases or tasks literally. It is equally authoritative to recognise the uniqueness of individual responses to loss and to avoid prescribing where a invitee ought to be in their grieving process. Since these models were never designed as a one-dimensional process, it is likewise most-valuable not to steer clients through these stages. This is supported by Schuchter and Zisook (1993), who ass ert Grief is not a linear process with concrete boundaries but, rather, a composite of overlapping, fluid 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 wholly from a death-loss focus Wordens work was an alpha development in the understanding of the process of act adaptively with bereavement as each 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+ laughable men experiencing multi-layered loss. My school of thought is to build and maintain a therapeutic relationship within a safe, confidential, contained space where clients can explore their issues. The archetype working towa rds a model of fearless 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 beat 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 losings. It is important to detect the tender mise en scene within which multi-layered loss takes place (e. g. heterosexism, homophobia, human immunodeficiency virus-related stigma) as well as recognising that individual attachment styles may influence individual reactions to these losses and may also impact on the focus relationship.Losses experienced by human immunodeficiency virus+ gay men include loss of identity, health, appearance, mobility, self- obedience, career, financial security, relationships and meanness. (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 emasculate 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 likely 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 social forces that their heterosexual counterparts do not.They hypothesise A diagnosis of HIV may be reminiscent of the coming out process, particularly with respe ct to concerns regarding stigma and disclosure, and thus may provoke similar fears about rejection by loved ones and society as a full-page that contribute to great attachment insecurity. (Riggs, Vosvick and Stallings, 2007, 126, p931). This is supported by Koopman, Gore-Felton, Marouf et al (2000) who cite attachment style as a contributing factor associated with the high levels of stress experienced by HIV+ individuals.They colour 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 decisive 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 secure 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 evidential forecaster of emotional stress among HIV+ adults. (Kelly, Murphy, Bahr et al, 1993, 123, p215-219). This has significant 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 putting green 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, eldritch 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 alone(p) 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 grade 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 sort of finality.These models are therefore limited in their application to my own work, since, as novel losses take the place of old, my clients find themselves in a continual cycle of loss without the comfort of such an end point. Processing 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) psychosoc ial model. Additionally, where accomplices stay together, a revisiting and re-negotiation of the adult stage of intimacy may be required since intimacy is often disrupted and sometimes lost out-of-pocket to HIV infection.This stage is also revisited by clients where a partner chooses to end the relationship with a HIV+ partner. Working through the loss of the partner (usually due to fear of infection) as well as other significant relationships (usually due 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 intern al 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 end-to-end 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 manifestation of clients seeking proximity maintenance to the therapist experiencing distress when the therapist is not useable 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 skipper, 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 cognisant that the therapeutic relationship promotes attachment yet at the same time acknowledge 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 good principles of beneficence, non-maleficence and self-respect (BACP Ethical Framework, 2007), I use control to monitor any emerging signs of such abuse, where a decision may be reached to refer these clients to external agencies or other, suitably experienced, internal counsellors. In assessing my strengths and areas for development, I am now much more alert of how early attachment experiences and internal working models impact on how clients process their losse s 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 training and practice at Positive East, as a bereavement counsellor with the Bereavement Service and as a counsellor providing support to those bereaved 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 appreciate how early formative attachments influence our reactions to such loss and how these reactions may imp act on the therapeutic relationship. Popular grief models clearly fall short in addressing the multi-layered losses experienced by this client group, demanding instead the integration 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.