Trauma and Attachment

Sarah Benamer, Kate White

• Publisher: Routledge
• Year: 2018
• Print ISBN: 9781855756663
• eBook ISBN: 9780429923272
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

This monograph contains a rich variety of material that is not usually included in traditional writings on trauma. In addition to the theoretical and clinical perspectives, poetry and storytelling join in to weave a vivid tapestry of multifaceted approaches to trauma. Whilst remaining true to its theoretical base (which, of course, is Bowlby's attachment theory), the monograph succeeds in locating its subject matter in wider perspectives, thus enabling the reader to appreciate the complexity of contributing factors. It is not easy to compile a single publication out of a conference; yet, this monograph achieves its objective by offering a coherent treatment of trauma that also includes some up-to-date approaches and innovations. The papers are written with authority, clarity and sensitivity and will provide the reader with a most beneficial elaboration of trauma from an attachment theory perspective.

The John Bowlby Memorial Lecture 2006. Developmental trauma disorder: a new, rational diagnosis for children with complex trauma histories¹

Bessel van der Kolk

Childhood trauma, including abuse and neglect, is probably the single most important public health challenge in the USA, a challenge that has the potential to be largely resolved by appropriate prevention and intervention. Each year, more than three million children are reported to authorities for abuse or neglect in the USA; about one million of those cases are substantiated (US Department of Health and Human Services, Administration on Children, Youth and Families, 2003). Many thousands more undergo traumatic medical and surgical procedures and are victims of accidents and of community violence (Spinazzola et al., 2005, p. 433). However, most trauma begins at home; the vast majority of people (about 80%) responsible for child maltreatment are children’s own parents.

Inquiry into developmental milestones and family medical history is routine in medical and psychiatric examinations. In contrast, social taboos prevent obtaining information about childhood trauma, abuse, neglect, and other exposures to violence. Research has shown that traumatic childhood experiences not only are extremely common, but also have a profound impact on many different areas of functioning. For example, children exposed to alcoholic parents or domestic violence rarely have secure childhoods; their symptomatology tends to be pervasive and multifaceted and is likely to include depression, various medical illnesses, and a variety of impulsive and self-destructive behaviours. Approaching each of these problems piecemeal, rather than as expressions of a vast system of internal disorganization, runs the risk of losing sight of the forest in favour of one tree.

Complex trauma

The traumatic stress field has adopted the term “complex trauma” to describe the experience of multiple, chronic, and prolonged, developmentally adverse traumatic events, most often of an interpersonal nature (e.g., sexual or physical abuse, war, community violence) and early-life onset. These exposures often occur within the child’s care-giving system and include physical, emotional, and educational neglect and child maltreatment beginning in early childhood (Cook et al., 2005, p. 390; Spinazzola et al., 2005, p. 433).

In the Adverse Childhood Experiences (ACE) study by Kaiser Permanente and the Centers for Disease Control and Prevention (Felitti et al., 1998), 17,337 adult health maintenance organization (HMO) members responded to a questionnaire about adverse childhood experiences, including childhood abuse, neglect, and family dysfunction. Eleven per cent reported having been emotionally abused as a child, 30.1% reported physical abuse, and 19.9% sexual abuse. In addition, 23.5% reported being exposed to family alcohol abuse, 18.8% were exposed to mental illness, 12.5% witnessed their mothers being battered, and 4.9% reported family drug abuse.

The ACE study showed that adverse childhood experiences are vastly more common than recognized or acknowledged and that they have a powerful relationship to adult health half a century later. The study confirmed earlier investigations that found a highly significant relationship between adverse childhood experiences and depression, suicide attempts, alcoholism, drug abuse, sexual promiscuity, domestic violence, cigarette smoking, obesity, physical inactivity, and sexually transmitted diseases. In addition, the more adverse childhood experiences reported, the more likely a person was to develop heart disease, cancer, stroke, diabetes, skeletal fractures, and liver disease.

Isolated traumatic incidents tend to produce discrete, conditioned behavioural and biological responses to reminders of the trauma, such as those captured in the post traumatic stress disorder (PTSD) diagnosis. In contrast, chronic maltreatment or inevitable repeated traumatization, such as occurs in children who are exposed to repeated medical or surgical procedures, have pervasive effects on the development of mind and brain.

Chronic trauma interferes with neurobiological development (Ford, 2005, p. 410) and the capacity to integrate sensory, emotional and cognitive information into a cohesive whole. Developmental trauma sets the stage for unfocused responses to subsequent stress (Cicchetti & Toth, 1995) leading to dramatic increases in the use of medical, correctional, social and mental health services (Drossman et al., 1990). People with childhood histories of trauma, abuse, and neglect make up almost the entire criminal justice population in the USA (Teplin, Abram, McClelland, Dulcan, & Mericle, 2002). Physical abuse and neglect are associated with very high rates of arrest for violent offences. In one prospective study of victims of abuse and neglect, almost half were arrested for non traffic-related offences by age thirty-two (Widom & Maxfield, 1996). Seventy-five per cent of perpetrators of child sexual abuse report that they themselves been sexually abused during childhood (Romano & De Luca, 1997).

These data suggest that most interpersonal trauma on children is perpetuated by victims who grow up to become perpetrators or repeat victims of violence. This tendency to repeat represents an integral aspect of the cycle of violence in our society.

Trauma, care-givers, and affect tolerance

Children learn to regulate their behaviour by anticipating their caregivers’ responses to them (Schore, 1994). This interaction allows them to construct what Bowlby called “internal working models” (Bowlby, 1980). A child’s internal working models are defined by the internalization of the affective and cognitive characteristics of their primary relationships. Because early experiences occur in the context of a developing brain, neural development and social interaction are inextricably intertwined. As Don Tucker has said,

For the human brain, the most important information for successful development is conveyed by the social rather than the physical environment. The baby brain must begin participating effectively in the process of social information transmission that offers entry into the culture. [Tucker, 1992]

Early patterns of attachment affect the quality of information processing throughout life (Crittenden, 1992). Secure infants learn to trust both what they feel and how they understand the world. This allows them to rely on both their emotions and their thoughts to react to any given situation. Their experience of feeling understood provides them with the confidence that they are capable of making good things happen and that, if they do not know how to deal with difficult situations, they can find people who can help them find a solution.

Secure children learn a complex vocabulary to describe their emotions, such as love, hate, pleasure, disgust, and anger. This allows them to communicate how they feel and to formulate efficient response strategies. They spend more time describing physiological states such as hunger and thirst, as well as emotional states, than do maltreated children (Cicchetti & White, 1990). Under most conditions, parents are able to help their distressed children restore a sense of safety and control. The security of the attachment bond mitigates against trauma-induced terror. When trauma occurs in the presence of a supportive, if helpless, care-giver, the child’s response is likely to mimic that of the parent—the more disorganized the parent, the more disorganized the child (Browne & Finkelhor, 1986).

However, if the distress is overwhelming, or when the caregivers themselves are the source of the distress, children are unable to modulate their arousal. This causes a breakdown in their capacity to process, integrate, and categorize what is happening. At the core of traumatic stress is a breakdown in the capacity to regulate internal states. If the distress does not ease, the relevant sensations, affects, and cognitions cannot be associated—they are dissociated into sensory fragments—and, as a result, these children cannot comprehend what is happening or devise and execute appropriate plans of action (van der Kolk & Fisler, 1995).

When care-givers are emotionally absent, inconsistent, frustrating, violent, intrusive, or neglectful, children are likely to become intolerably distressed and unlikely to develop a sense that the external environment is able to provide relief. Thus, children with insecure attachment patterns have trouble relying on others to help them and are unable to regulate their emotional states by themselves. As a result, they experience excessive anxiety, anger, and longings to be taken care of. These feelings may become so extreme as to precipitate dissociative states or self-defeating aggression. “Spaced out” and hyper aroused children learn to ignore either what they feel (their emotions), or what they perceive (their cognitions).

When children are unable to achieve a sense of control and stability, they become helpless. If they are unable to grasp what is going on and unable do anything about it to change it, they go immediately from (fearful) stimulus to (fight/flight/freeze) response without being able to learn from the experience. Subsequently, when exposed to reminders of a trauma (e.g., sensations, physiological states, images, sounds, situations), they tend to behave as if they were traumatized all over again—as a catastrophe (Streeck-Fischer & van der Kolk, 2000). Many problems of traumatized children can be understood as efforts to minimize objective threat and to regulate their emotional distress (Pynoos et al., 1987). Unless care-givers understand the nature of such re-enactments, they are likely to label the child as “oppositional”, “rebellious”, “unmotivated”, or “antisocial”.

The dynamics of childhood trauma

Young children, still embedded in the here-and-now and lacking the capacity to see themselves in the perspective of the larger context, have no choice but to see themselves as the centre of the universe. In their eyes, everything that happens is related directly to their own sensations. Development consists of learning to master and “own” one’s experiences and to learn to experience the present as part of one’s personal experience over time (Kegan, 1982). Piaget (1954) called this “decentration”: moving from being one’s reflexes, movements, and sensations to having them.

Predictability and continuity are critical for a child to develop a good sense of causality and learn to categorize experience. A child needs to develop categories to be able to place any particular experience in a larger context. Only then will he or she be able to evaluate what is happening and entertain a range of options with which they can affect the outcome of events. Imagining being able to play an active role leads to problem-focused coping (Streeck-Fischer & van der Kolk, 2000).

If children are exposed to unmanageable stress, and if the caregiver does not take over the function of modulating the child’s arousal, as occurs when children are exposed to family dysfunction or violence, the child will be unable to organize and categorize experiences in a coherent fashion. Unlike adults, children do not have the option to report, move away, or otherwise protect themselves; they depend on their care-givers for their very survival.

When trauma emanates from within the family, children experience a crisis of loyalty and organize their behaviour to survive within their families. Being prevented from articulating what they observe and experience, traumatized children will organize their behaviour around keeping the secret, deal with their helplessness with compliance or defiance, and acclimatize in any way they can to entrapment in abusive or neglectful situations (Piaget, 1954).

When professionals are unaware of children’s need to adjust to traumatizing environments and expect that children should behave in accordance with adult standards of self-determination and autonomous, rational choices, these maladaptive behaviours tend to inspire revulsion and rejection. Ignorance of this fact is likely to lead to labelling and stigmatizing children for behaviours that are meant to ensure survival.

Being left to their own devices leaves chronically traumatized children with deficits in emotional self-regulation. This results in problems with self-definition as reflected by a lack of a continuous sense of self, poorly modulated affect and impulse control, including aggression against self and others, and uncertainty about the reliability and predictability of others, expressed as distrust, suspiciousness, and problems with intimacy, resulting in social isolation (Summit, 1983). Chronically traumatized children tend to suffer from distinct alterations in states of consciousness, including amnesia, hypermnesia, dissociation, depersonalization and derealization, flashbacks and nightmares of specific events, school problems, difficulties in attention regulation, disorientation in time and space, and sensorimotor developmental disorders. The children often are literally are “out of touch” with their feelings, and often have no language to describe internal states (Cole & Putnam, 1992).

When a child lacks a sense of predictability, he or she may experience difficulty developing object constancy and inner representations of their own inner world or their surroundings. As a result, they lack a good sense of cause and effect and of their own contributions to what happens to them. Without internal maps to guide them, they act, instead of plan, and show their wishes in their behaviours, rather than discussing what they want (Streeck-Fischer & van der Kolk, 2000). Unable to appreciate clearly who they or others are, they have problems enlisting other people as allies on their behalf. Other people are sources of terror or pleasure but are rarely fellow human beings with their own sets of needs and desires.

These children also have difficulty appreciating novelty. Without a map to compare and contrast, anything new is potentially threatening. What is familiar tends to be experienced as safer, even if it is a predictable source of terror (Streeck-Fischer & van der Kolk, 2000). Traumatized children rarely discuss their fears and traumas spontaneously. They also have little insight into the relationship between what they do, what they feel, and what has happened to them. They tend to communicate the nature of their traumatic past by repeating it in the form of interpersonal enactments, both in their play and in their fantasy lives.

Childhood trauma and psychiatric illness

Post traumatic stress disorder (PTSD) is not the most common psychiatric diagnosis in children with histories of chronic...

Table of contents

• Cover
• Half Title
• Title
• Copyright
• Contents
• CONTRIBUTORS
• ACKNOWLEDGEMENTS
• TRAUMA AND ATTACHMENT INTRODUCTION TO THE MONOGRAPH OF THE 13th JOHN BOWLBY MEMORIAL CONFERENCE 2006
• ATTACHMENT THEORY AND THE JOHN BOWLBY MEMORIAL LECTURE 2006: A SHORT HISTORY
• TRUTH AND RECONCILIATION?
• SURVIVING THE CARE SYSTEM: A STORY OF ABANDONMENT AND RECONNECTION
• THE JOHN BOWLBY MEMORIAL LECTURE 2006. DEVELOPMENTAL TRAUMA DISORDER: A NEW, RATIONAL DIAGNOSIS FOR CHILDREN WITH COMPLEX TRAUMA HISTORIES
• DEVELOPMENTAL TRAUMA IN ADULTS: A RESPONSE TO BESSEL VAN DER KOLK
• THE HUNGRY SELF: WORKING WITH ATTACHMENT TRAUMA AND DISSOCIATION IN SURVIVORS OF CHILDHOOD ABUSE
• THE SHADOW OF MURDER: LOVE AND HATE IN TIMES OF VIOLENCE
• HOW DO WE HELP OURSELVES
• TRAUMA AND ATTACHMENT READING LIST
• INTRODUCTION TO THE CENTRE FOR ATTACHMENT-BASED PSYCHOANALYTIC PSYCHOTHERAPY