Working with the Developmental Trauma of Childhood Neglect

Using Psychotherapy and Attachment Theory Techniques in Clinical Practice

Ruth Cohn

• Publisher: Routledge
• Year: 2021
• ISBN:
  9781000429244
• Edition: 1
• Topic: Psychology
• Subtopic: Post-Traumatic Stress Disorder (PTSD)
• Index: Psychology

This book provides psychotherapists with a multidimensional view of childhood neglect and a practical roadmap for facilitating survivors' healing.

Working from a strong base in attachment theory, esteemed clinician Ruth Cohn explores ways therapists can recognize the signs of childhood neglect, provides recommendations for understanding lasting effects that can persist into adulthood, and lays out strategies for helping clients maximize therapeutic outcomes. Along with extensive clinical material, chapters introduce skills that therapists can develop and hone, such as the ability to recognize and discern non-verbal attempts at communication. They also provide an array of resources and evidence-based treatment modalities that therapists can use in session.

Working with the Developmental Trauma of Childhood Neglect is an essential book for any mental health professional working with survivors of childhood trauma.

Chapter 1

Ancestral Roots

I discovered and became compelled by the developmental trauma of neglect almost by chance. I entered the field of psychotherapy in the 1980s when psychological trauma was barely making its entrance as a sub-field. PTSD was named and newly entered the Diagnostic and Statistical Manual (DSM) in 1980, largely in response to the symptom picture of the returning war veterans from Viet Nam. I grew up with the horror of that war flashing on the TV screen daily, and that was compelling enough. When sexual abuse and domestic violence against women and children came increasingly into public awareness, and the sequelae and symptoms of these traumatic experiences garnered the PTSD diagnosis as well, the nascent field called to me as an area of early specialization. I was even more drawn to it as I was the child of two survivors of the Nazi Holocaust, and had my own share of trauma, both personal and vicarious. In those days, there was not yet a literature or much training for how to treat trauma.

I soon came to hone in on work with adult survivors of childhood sexual abuse, primarily women. I offered individual and later group therapy for the women, and for 15 years had two ongoing women's survivor groups, learning much by the seat of my pants. The area of greatest pain and distress for the women invariably centered on relationship, and that was the worst of what brought them to my door (although flashbacks, nightmares and the numerous variations of suffering and dysregulation that made a living hell of their lives, were certainly significant as well). I also found that many of them were in, often longstanding, partnerships. Many complained that their partners “did not understand” or failed to support their healing process. I thought perhaps an additional way I could intervene might be by offering trauma education to partners of sexual abuse survivors, to help expand their support network. Thus emerged my first one-day workshop for male partners of survivors of childhood sexual abuse.

In that first workshop, eight men eagerly, if somewhat nervously, crowded into my office. They were of many stripes, some blue collar and others highly successful professionals. But they all seemed oddly similar. When asked about themselves, they responded by talking at length about the partner. When asked about their own story, there was “no story.” They said “nothing happened to me.” There was something ghostlike about them; their actual existence seemed to be uncertain. Yet, in the world they were highly competent and adaptive. One built houses, from scratch; one was a surgeon; one a renowned professor and author, an electrician. All had plenty beside their names. It was in the interpersonal world that they became vapid and invisible.

Trauma and its healing are consuming. As any of us who have worked with it, can attest, the survivor's entire brain and body are reset in the direction of threat and terror. Recovery is rarely quick and it is virtually ­diagnostic that for quite some time there is little attention for much else. What kind of person would partner, and persist long years, with someone whose interest and attention were so meager, who is engrossed and overwhelmed by pain and fear? What sort of childhood would prepare and train them to endure that kind of solitude in a partnership? These questions evolved into my interest in what I came to understand as neglect.

That first workshop day was a watershed for all of us. I did gently press them to talk about themselves. The day became lively and by the end of the day they wanted to continue meeting, and asked for an ongoing group. We continued meeting, largely intact for many years. When I began to complain that I was getting too old to work so late into the evenings, they protested. “We will pay more, we’ll meet less often, but please keep it going.” They were learning so much about connection from their relationships with each other. And they were the living laboratory where my nascent study of neglect began.

Starting out, I was flying somewhat blind. The trauma treatment I was steeped in, did not seem to apply to them. Clients with incident or “shock” trauma have “hyper-aroused” nervous systems, meaning they live in a chronic state of fight or flight. The freeze or numbing response, which is the one I learned about more in depth later, I would find to be more applicable to neglect. Initially, I was not sure what neglect survivors needed in the way of their own treatment.

A number of important theoretical, biological and even sociological influences have been essential in evolving my ideas about treatment for neglect ever since. I want to be sure to acknowledge, validate, connect the elements and guard against appearing to ­“re-invent the wheel.” I do not have to reach far to recall them. We never really work alone even though solitude can create an illusion of self-sufficiency. Both the experience of neglect, and our culture of “rugged individualism” relentlessly re-enforce that myth.

ATTACHMENT THEORY

Most significantly, attachment theory has a tremendous influence on my thinking, with its emphasis on the profound impact of relationship and relationship dynamics on psychological, emotional, social and physical development.

The British psychologist John Bowlby and his assistant Mary Ainsworth created the initial framework for attachment theory, beginning in the 1930s and 40s. The elegant theory, as the reader may know, works from the premise that our first relationships with primary caregivers, provide the template for all subsequent relationships, and the tenaciously repetitive nature of relationship patterns. Left to themselves these patterns persist through the lifespan.

Bowlby identified four main attachment styles. The first and most favorable of course, is the securely attached, where the parents’ consistency and presence provide predictability, and a ready supply of what the infant needs to physically thrive, and also feel comfortable and safe. Of course, there is no perfect caregiver, but this child develops with a reasonable expectation of receiving a consistent supply of focused attention, gratification and protection, which contribute to the unfolding experience of having value and a sense of self that reflects that.

When the parents’ presence and care are intermittent or unpredictable, the child lives in a chronic state of uncertainty, not knowing if and when they can hope to be taken care of, in general not knowing what to expect. The result is a gnawing and consuming anxiety, and later confusion about what this unpredictability means, and what it means about them. This is what Bowlby called the anxious ambivalent style. In the absence of a consistent, watchful eye, the child is unprotected, and vulnerable to harm, which will make for still more anxiety. This anxiety follows them through their relationship lives, making trust and calm elusive at best, and often more like a minefield.

The last-added disorganized style is characterized by what Berkeley attachment expert Mary Main described as the “dilemma without solution.” This dilemma is that the source of comfort and the source of terror are the same person. So, the child is caught in the terrible bind between reaching toward and recoiling from that person, which results in an inability to act, or “freeze” response. My client, Lisa had such a history. Her mother at times exhibited doting attention, even appearing to favor her over her two siblings; at other times fits of fierce and painful violence; and at still other times was completely absent. During the desolate absences was when Lisa was victimized and sexually abused by others. As a young adult, she was intermittently anxious or numb; and desperately lonely, while finding relationship an impossibly unsafe gamble. After our first session, Lisa experienced a bout of what she described as paralysis. She could not get out of bed for a week. Meeting a new potential caregiver, reaching out for comfort, activated the age-old terror of danger. Then she was racked by shame. Struggling with both overt trauma and neglect, the exquisitely bright and attractive young woman perennially lamented “what is wrong with me?”

Bowlby's avoidant style is what I found most accurately describes most of our neglect clients. I object to the terminology as it can imply intentionality on the part of the child, which is hardly the case. This child's experience is primarily neglect. The parent is pretty reliably not present, and the child feels forgotten, abandoned or in one way or another not seen and known.

The mothers of these infants were particularly striking in that “they expressed an aversion to physical contact when their infants sought it, and expressed little emotion during interactions with them … [they] were insensitive to their infants’ timing cues” and again, “seemed to dislike close physical contact with their infants.”

The extreme includes physical neglect, where food, clothing, shelter and essential health care for whatever reason, are not furnished. But often in insidious cases, the parents might be in body at least, right there. Neglect resulting from parental narcissism is not uncommon. It might even include intrusiveness, but attention to what the child feels and cares about, what they need, in effect who they are, is bitterly lacking. The child is left alone far too much, and some of the essential developmental experiences of the parent-child interaction do not occur.

The default, of necessity, is self-reliance, and what can appear to be a “calm” indifference to others. However, the avoidant child is not really calm at all, as evidenced in the subsequent attachment research of Mary Ainsworth.

Ainsworth, an associate of Bowlby's, later established herself as a developmental psychologist in her own right. She is best known for her research known as the “strange situation.” In this study, Ainsworth orchestrated a brief sequence of interactions where she observed young toddlers in four discrete interactions: when the mother left the room; when a stranger entered and approached the child; when the stranger left the room; and when the mother returned. The series was filmed, the intent being to study the reactions to separation and reunion of the different attachment styles. In my generation, we all saw the films in graduate school, and the images from those grainy old black-and-whites remain vivid and not infrequently return to my mind's eye.

About the avoidantly attached, the research showed:

An infant classified as ‘Avoidant’ … will usually engage with the toys in the presence of the caregiver. The infant is unlikely to show affective sharing (e.g. smiling or showing toys to the caregiver) before the first separation …. Upon separation the infant is unlikely to be ­distressed …. The infant with an avoidant relationship tends to treat the stranger in much the same way as she does the caregiver, and in some cases the infant is actually more responsive with the stranger. Upon reunion with the caregiver, the avoidant infant shows signs of ignoring, turning away or moving past the caregiver rather than approaching. If picked up the avoidant infant will make no effort to maintain the contact.

I remember the poignancy of seeing the apparently self-contained little person playing quietly in the corner looking oblivious or unbothered as others came and went. Other later research on psychophysiology has consistently shown that beneath this seemingly placid little exterior, heart rate, skin conductance and EEG (electrical activity in the brain), all markers of hyperarousal/anxiety, shoot high when the caregiver leaves the room.

Of course, our adult clients don’t remember their infancies. However, when I find myself visited by the images from the scratchy old movies, I don’t dismiss them. I quietly notice them. When the time might be right, I might ask clients what they know about what was going on in their parents’ lives when they were infants, or how old they were when a younger sibling was born. Sometimes I say nothing. In some cases, interventions including recounting aloud the description of the image in the videos are powerful. Since their first appearance in the 1970s, the research has been repeated many times, and the films, both the originals and subsequent versions are readily and freely available, and well worth watching.

Particularly painful, is the data in Attachment Theory about the mother's rejection of the physical body of the child, and of physical contact. Shame, self-hatred or at best, dramatic disconnection from the body are all things I often sadly see in these clients. Sexual and eating dysregulations are not uncommon.

Much as the theory describes, these clients are fiercely or desperately self-reliant and self-sufficient; highly sensitive to rejection and loss, and ambivalent about relationship. They more often do remember from later in childhood, that the mother was absent, distracted, narcissistic, somehow disabled or simply not interested. And these children must do for themselves. So they learn to do it all, expect that, and think little of it. It becomes their “ambient air,” their ­“normal,” their default mode, and to lesser or greater degrees, something to defend and protect.

Like the mother or the stranger in the videos, I found that indifference about the therapist; or therapist as an interchangeable part, or not necessarily distinguishable from another therapist or another person may persist for quite a while with these clients. One individual being unique or special to another may be a foreign concept, certainly (but not only) a therapist. They may think of therapy as the work of “fixing” something that is “broken,” certainly not about a relationship. And of course, therapy is a different, and in some ways, odd relationship arrangement. They may precipitously leave therapy without closure, with no thought that the therapist would miss anything but the money. A therapist who needs acknowledgment or validation from the client will have a very difficult time, at least for a while.

These are extreme characterizations, and certainly not the only things we see, but attachment theory taught me to view such ­patterns in the light of early relationship templates. Being profoundly unseen and not known creates a dehumanizing norm, for both self and other.

A DIP INTO PSYCHOANALYTIC THEORY: “PROJECTIVE IDENTIFICATION”

Early in my work with neglect clients, I was shocked and alarmed to discover that it could be easy to “become” that mother. I learned quickly that “projective identification” is a powerful way that clients have of communicating to us what they have no words for, and/or little if any awareness of.

In terms of communication, projective identification is a means by which the infant can feel what he/she is feeling. The infant ­cannot describe his feelings in words for the mother; instead, he/she induces those feelings in her.

This is of course an oversimplified distillation of one aspect of Thomas Ogden's complex interpretation of the concept. For our purposes, I would simply substitute the word “client” for infant, therapist for mother, and add possibly “behaviors” to feelings induced in the other. Being mindful of the possibility is an extremely important aspect of our toolkit. When working with people who are often acutely unaware of, or ill equipped to tell their own story, we therapists must be att...