Family keyworker as a non-clinical and democratic figure to support hard-to-reach families from an attachment perspective

Abstract

We express gratitude to both Silvia Lordello and Daniel J. Puhlman for their insightful comments on our paper entitled “The Family Keyworker as a Critical Element for Attachment Resilience in the Face of Adversity” (Berástegui & Pitillas, 2024). Lordello's and Puhlman's observations and concerns regarding our application of an attachment lens to the work of family keyworkers (FKWs) provide us with an opportunity to nuance and better explain our proposal, within what we consider a fruitful academic and technical discussion. Discussing these issues in the context of a commented paper is enriching, both to the academic debate and to the field of intervention with families. We sincerely thank Dr. Lordello and Dr. Puhlman for their attentive reading of our work, and hope that our responses to their comments may do justice to the very valuable points that they present.

Daniel J. Puhlman's commentary, entitled “Supporting and Enhancing Attachment Resilience is Essential for Helping High-Risk Families: But is the Family Keyworker the Best One for the Job?” is premised on the idea that we should carefully consider “who is providing which services, the qualifications and training these professionals receive, and the strategies and interventions they are asked to employ in providing support and assistance” (Puhlman, 2024). This consideration is crucial for interventions to be not only efficient but also ethical. He expresses concern that our proposal may risk opening the door to the use of clinical, complex intervention strategies by a broad range of family professionals. If this were the case, he rightly argues that we would face two major problems: (a) the absence of a proper foundation for working within attachment processes by FKWs, and (b) the risks associated with FKWs' use of attachment-oriented strategies. Puhlman elaborates on both concerns, stating that “working through deep and personal traumas” embedded in families' attachment functioning, as well as “helping families repair attachment injuries and wounds” requires deep conversations, time, patience, and advanced clinical training, all of which may be beyond the qualifications of most FKWs. This could push technical boundaries outside their range of tolerance and facilitate ethical dangers regarding both the professionals' scope of practice and the development of reciprocal attachment that may compromise the professional's objectivity and role integrity, potentially leading to harmful results.

We acknowledge that, from Puhlman's perspective, these concerns are reasonable. However, our translation of attachment resilience processes (Berástegui & Pitillas, 2021) into a model of family support by FKWs is never meant to become a therapeutic endeavor, nor is it oriented to facilitate processes of a clinical nature (e.g., repairing attachment wounds within families). We do not intend for our work to be interpreted as an invitation to using complex clinical strategies freely and without proper training and supervision.

In our view, not every attachment-based strategy is therapeutic in nature. Listening to families from an attachment lens involves paying attention to the families' experience of (in)security, understanding their mental states that underlie their behaviors and practices (i.e., mentalizing the family Fonagy et al., 1991), responding sensitively to emotions and needs expressed by family members, and repairing misunderstandings and misattunements in the here-and-now of intervention, among other actions. These actions are far from aspiring to repair deep, entrenched attachment injuries within families. They are all ingredients of an attachment perspective that we believe could be integrated into non-clinical work, and become a vantage point for professionals of various kinds who support families under adversity.

Attachment processes are not restricted to psychologists and therapists. On the contrary, one of the great contributions of attachment theory is that it provides a framework that may be transversal and shared among a diverse array of professionals and non-professional support figures. Our paper suggests that professionals can facilitate the transmission of security from the exosystem (e.g., the family services system; child protection; etc.) to the microsystem (e.g., attachment relationships in the family). We believe that nurses, teachers, social workers, neighbors, support groups, doctors, volunteers, priests, among others, have been doing this for ages. Our proposal to integrate an attachment perspective into the work of family professionals outside the clinical world is intended to better systematize and monitor these processes. It is not intended as a catalog of clinical techniques, but as a relational framework for FKWs.

Additionally, we emphasize the idea that, whether or not professionals are aware, attachment dynamics always take place between them and the families they serve. Professionals and families inevitably establish relationships in which responsiveness, mentalization and interactive repair are constantly negotiated. This implies that a more pressing technical (as well as ethical) hazard could be involved when professionals are unable to detect, understand, and, to a certain extent, manage this type of interpersonal processes. An attachment-sensitive lens may be fundamental in enhancing FKWs' ability to be aware of the inescapable attachment dimension involved in any significant family work. Furthermore, it may be very useful in helping FKWs engage with hard-to-reach families and provide a framework of security within which these families may dare to test new, safer ways of functioning in the face of adversity. In our view, we are not advocating for new intervention tools outside of usual practice, but rather for a framework that helps us understand the usefulness of these tools in the context of intervention with hard-to-reach families.

As mentioned, at no point in our paper do we suggest that the work of FKWs is to repair attachment wounds. Our work is focused on families suffering from social adversity and facing difficulties in engaging in supportive interventions. It is not implied that these families suffer from attachment trauma or attachment disorders requiring clinical approaches. In fact, the paper suggests that parents' difficulties in providing security may not necessarily stem from within the family (i.e., parents' attachment patterns or trauma), but from around the family (i.e., contextual danger, accumulated stress, and the inaccessibility to social support). Thus, we do not assume that all intervention with at-risk families is necessarily clinical. Even when families suffer from attachment conditions (e.g., trauma) that merit clinical interventions, non-clinical approaches can be complementary to a clinical service and have an impact on family well-being and parent–child relationships.

Attachment-centered work entails a comprehensive way of organizing the professional's view of families, their interpersonal stance, the ways they interpret what families say or do during—and between—interventions, and the ways they use their own experience to enhance security. Observation and experience reveal that vulnerable families may transition from disengaged or resistant functioning to a more reflective, sensitive position, and this not only happens when professionals are doing clinical work. We believe it may take place with help from FKWs who work in a sensitive, consistent, reflective manner, favoring the emergence of relational security. It may also take place under the effect of better social circumstances, when social support networks become more accessible or through new, positive relational experiences outside intervention. This is not clinical work, but, as we see it, it is attachment (or attachment-informed) work.

Finally, we agree with Puhlman when he asserts that establishing an attachment-informed relationship has important ethical implications that need to be addressed, but it does not seem to us that bringing these concerns to a clinical domain would be enough to solve them. Every professional who works with families is bound to follow the highest ethical standards in the development of their particular role and skills.

In conclusion, Puhlman's concerns are valuable, as they challenge us to better explain our idea of professionals whose work is to integrate a sometimes complex set of interventions surrounding families, establishing a type of rapport that is attachment-informed but not clinical in nature. We thank him for his insights and challenges, and hope that, within this text, we may have provided an apt response to both.

Silvia Lordello's commentary “Attachment Resilience in Practice: The Essential Role of Family Keyworkers” stresses that “resilience should not focus solely on the individual level but also on creating favorable environments and support systems that enable people to deal with adversity effectively” (Lordello, 2024). This remarkably interesting commentary deepens the ecological and multisystemic perspective of our work, while it analyses the resilience of attachment in a specific and particularly rich cultural context, such as the reality of families and the diverse childhoods in Brazil.

Of particular interest is the description of Community Health Agents as a parallel figure to our proposal of FKWs. Both figures share the objective of improving children's quality of life through support to their families. This parallelism underlines the idea that children's relational health, and the security of their attachments, directly impact their health and development, both mentally and physically. In contrast, the Community Health Agent highlights not only the role of the professional as a community connector but also as a member of the community with which the family is intended to be connected. This is not always the reality of FKWs, as described in our work, but we believe this aspect can help deepen the scope of this role in some contexts, especially those involving greater diversity. The professionals' belonging to the community in which the family is inserted increases their cultural competence, sensitivity, and mentalization capacity. Additionally, this rootedness makes the support more sustainable over time, helping to overcome the time limitation that affects many professional figures. Lordello shares with us that implementing the processes described as promoting resiliency of attachment (responsiveness, mentalization, and repair) does not require significant technical sophistication, but has more to do with attitudinal aspects in their relationship with the family. The aim of incorporating this perspective into the work of professionals is reframing family relations by reframing our relationship with families and, therefore, “transitioning from a dyadic lens to a multisystemic lens.”

Lordello's commentary also delves, in a very clarifying way, into the management of power within family support relationships. She highlights that the FKW is not a self-centered but a family-centered professional. Indeed, mentalization, responsivity, or interactive repair are essentially decentered and cooperative processes. In her measure of maternal responsiveness, Mary Ainsworth (1969) emphasized the dimension of cooperation as opposed to interference: the ability to offer security during childhood or adult life is closely linked to the ability to share power sensitively, to provide shared control on the relationship in a context of security. A security figure not only remains attentive and connected to the other's point of view and guides the other's behavior in harmony but can also repair misunderstandings with humility and recognize the power and responsibility one has in the relationship. To be able to act as a security figure, one must have power; one must be strong and wise (Bowlby, 1982) but also kind (as highlighted by Powell et al., 2013), in the sense of putting this power at the service of the other's well-being, and not exclusively of one's interests, which would be abusive.

The second point on which Lordello explores the dimension of power is something we had not previously noticed and which we found extremely interesting: the idea of democratizing knowledge. We share Lordello's idea that “the promotion of resilience should be the responsibility of citizens, not exclusive of professional specialties.” In fact, the functions that we propose that FKWs carry out are often accomplished by the informal support network (e.g. extended family, group of friends, neighborhood) or by professionals from the formal network (e.g. pediatricians, nurses, teachers). The idea of empowering FKWs to work with hard-to-reach families is that, as we have reflected in the article, it is even harder for many of these families to reach support. However, unlike Lordello, we think acting as a FKW requires specialized training, as most professionals are unaware of attachment dynamics. What we do share is that this attachment perspective training would benefit a wide range of professions (e.g., educators, social workers, health professionals) and that the perspective itself is enriched by interdisciplinarity. This has been our experience as trainers in the Primera Alianza program and in supervising family support teams in Spain. In these supervision teams, the diversity of perspectives and the common approach allow for responding to the attachment needs of the professional, overcoming isolation, and lowering the difficult emotions linked to working in challenging contexts. This is a condition of possibility for progressing in the exploration, refining the mentalization and sharing of knowledge in what Lordello recognizes as a “zone of proximal development” (Vygotsky, 1978) and, finally, maintaining motivation and connection with the family.

Furthermore, these FKWs are also a source of democratization of knowledge, inasmuch as they are responsible for raising awareness about the importance of relational safety in children's development. The community dimension of this figure, underlined by Lordello, highlights the importance of the FKW's role as a disseminator of a culture of care throughout the community, including influencing social policy. In this sense, Lordello stresses that the FKW “not only assists families in coping with adversities but also contributes to creating more supportive environments and systems that are essential for the healthy development of children.” Thus, the development of FKWs and other family support figures is related to promoting equal opportunities and protection for all children and can, therefore, be understood as a human rights issue.

The authors declare no conflicts of interest.