Preventing Complex Trauma: Attachment Therapy for Expecting Mother’s and Father’s
University of Calgary
Complex Childhood Trauma
Many health professionals; psychiatry and other health science workers have been advocating for the inclusion of complex post traumatic stress disorder (C-PTSD) to be included in the Diagnostic Statistic Manual for Mental Disorders (DSM). This pursuit is in hope of having professionals better identify and work with people who have experiences of childhood trauma. The latest research from neurobiology has now invited us to better fully understand the impacts of childhood trauma on ourselves, society and our environment. Research in this field is showing us what love and secure attachment can do for the growing mind and bodies of our children.
The ACE study has shown, child abuse and neglect is the single most preventable cause of mental illness, the single most common cause of drug and alcohol abuse, and a significant contributor to leading causes of death such as diabetes, heart disease, cancer, stroke, and suicide.
In reviewing the data from the ACE score it was found that its overall costs exceeded those of cancer or heart disease and that eradicating child abuse in America would reduce the overall rate of depression by more than half, alcoholism by two-thirds, and suicide, IV drug use, and domestic violence by three-quarters (Van der Kolk, 2015, p. 150).
In particular, trauma in the form of interpersonal victimization like sexual and physical abuse, is associated with difficulties that include “depression, low self-esteem and suicidal ideation; physical problems like chronic pain; psychiatric problems such as anxiety/ panic, borderline [personality disorder], post-traumatic stress, and dissociative identity disorder; and behavioural problems including substance use, eating disorders, domestic violence and self-injury” (as cited in Knight, 2014, p. 26) Farrugia et al. 2011; Kuo et al. 2011; Shafer and Fisher 2011; Spitzer et al. 2006). Children with four or more adverse (ACE) childhood experiences had: “two and a half times the risk for COPD and hepatitis” versus a person with no adverse childhood experiences. “Four and a half times the risk for depression and twelve times the risk for suicidal ideation” (Bell, 2015). When a child’s brain is developing under too much stress, we see changes in the parts of the brain that responds to pleasure and rewards (Bell, 2015). This change has been connected to increased substance use. Impulse control and executive functioning is also commonly effected which is connected to difficulty in learning (Bell, 2015). “Casey Family Programs found that foster care youth had PTSD at twice the rate of U.S. war veterans (As cited by Bell, 2015).” Unfortunately, many of these individuals with high ACE scores struggle to find help in our systems that are short term, solution focused and reactionary in nature.
“Some researchers (as cited in St. Petersburg, 2005) by Alpers, Johnson, Hostetter, Iverson, & Miller, 1997) have estimated on the basis of newly adopted orphanage children that physical growth falls behind by approximately 1 month for every 5 months children live in such orphanages.” Children residing in the orphanages in a more recent study confirmed these results finding similar delays in physical development (St. Petersburg, 2005). We can understand from this research that the cost of childhood trauma to our criminal system, our child protection systems, and our medical systems is profound. Focusing on the prevention of childhood trauma is perhaps the best investment we can make for our society.
“We need to build a responsive system that is focused more on prevention than on responding after the trauma has occurred. We have to build communities of hope around vulnerable children and families. Building communities of hope is a multi-faceted approach that begins with the recognition that we have allowed, over time, certain communities to become more and more traumatized (Bell, 2015).”
Although all of us have been affected by trauma in our lives it is a relatively small part of our population that is suffering from complex childhood trauma (23% of Americans have an ACE score of 2 and higher). Yet this portion of people is suffering greatly, and the impacts can be felt throughout our systems. If these systems could work together to prevent the traumatization of children, the results would no doubt be amazing. We can start by focusing our efforts toward the caregivers and parents who have experienced this early trauma. This can help us stop cycles of violence, abuse and neglect that we commonly see being passed from generation to generation.
Combining and reviewing the research from the human science fields has provided an understanding of how “the brain and is shaped by our communication within interpersonal relationships” (Siegel, 2020, p. 1). “Human connections shape neural connections, and each contributes to [the] mind. The mind shapes how we interact with our environment. Our mammalian brains are profoundly social, our relationships have profound impacts on our neuronal function” (Siegel, 2020, p. 4). The attachment system is responsible for facilitating the expansion of the child and infants coping strategies (Schore, 2001). The development of “self” is largely a reflection of how we are treated by our caregivers (Brier et al. 2014, p. 202). When parents are distracted or preoccupied with their own unresolved relationships histories children cannot figure out what makes the relationship good or bad, they constantly trying to rearrange themselves to fit the parents’ changing moods and responses. “Or they attempt to manipulate or control the parent to eke out the positive merging, support and/or love” (Heller, p. 10). As humans we are wired to connect, finding love is what is most important to us.
We all grow up in a relational field with our original caregivers a matrix of sorts that embodies the relational dynamics of the family and thus become familiar to us, as in of the family. These ingrained patterns may strongly influence how we see and feel in all of our later relationships. They create a blueprint of expectations of sorts, built out of our early encounters with others. When we are raised with secure attachment, we tend to find relationships are easier. We expect to be treated well and know that is what we deserve. We treat our partners with respect as well. We trust our partners and others realistically, and we trust in humanity and the world more or less unconditionally. (Heller, p. 2)
Insecure attachment between the caregiver and child has been described as similar to eating at a bad restaurant every day; you don’t feel good, you often have an upset stomach and perhaps suffer from multiple health complaints. But if this is the only food you know, how do you understand that there might be a better option? At some point one would have to experience a better meal? One would have to have the experience of what it is like to feel comfortable in their body. Then if this individual wanted to provide this healthier meal to their own child one would have to learn about the ingredients, learn about which tools are helpful, and learn the skills and understanding of where to go to get ingredients when they don’t have them (Heller, p. 7-8). Individuals who have lived with childhood trauma experience an inability to access the internal sense of self such as; determining one’s owns needs, a consistent sense of self, having an internal reference point at times of stress, and a positive sense of self (Brier et al. 2014, p. 198). These struggles highlight the disruptions in attachment between the child and caregiver.
Supporting Secure Attachment
The critical pivot point for trauma-informed providers is the shift that is happening from: “what is wrong with you?” to “what happened to you?” (Ali, 2019). Therapy for these individuals is complex given the developmental nature of the trauma. However, the counselling relationship can provide a great opportunity for individuals to experience relational safety while they examine their core schemas and capacity to form and maintain meaningful connections (Brier et al., 2014, p. 202). When disorganized attachment was studied in relationships between mother and baby it was found that the mothers “didn’t want to intentionally harm their children but that they did not know how to attune to their needs” (Van der Kolk, P. 122). “The hostile/ intrusive mothers were more likely to have childhood histories of physical abuse and/ or witnessing domestic violence, while withdrawn/ dependent mothers were more likely to have histories of sexual abuse or parental loss” (Van der Kolk, P. 122). Providing support for healthier caregivers can start with a core belief and understanding that these individuals inherently want to be good parents. This knowing understands that we can ‘earn’ or ‘learn’ how to reorient to Secure Attachment through a healthy relationship of any kind (Heller, p. 4). “We can stop watching the same old recurring movie built out of the past that we continue to project onto our lives” (Heller, 2013, p. 6).
Attachment Therapy for Parents
When new parents embark on the journey of having children, they are both scared and excited, highly motivated to be the best caregiver they can be, this is often felt as a time for new beginnings and for hope. Additionally, self-development is also commonly driven by caring individuals making the therapeutic relationship a powerful environment for the “development of a healthy sense of self” (Brier et al., 2015, p. 199). “When we do the hard work of discovering the dilemmas, we carry within us from childhood, we become freer and more transparent to present-day reality” (Heller, p. 10).
Early inferences about self and others, referred to as “relational schemas” are encoded preverbally. These childhood memories are non-verbal, and they do not have a sense of time, they are triggered by environment stimuli, and are referred to as implicit memories (Brier et al. 2014, p. 202). This means that talk therapy styles may not be effective for working with these early childhood memories. “The solution requires finding ways to help people alter the inner sensory landscape of their bodies (Bell, 2015).” This means utilizing mindfulness practices to bring body-based awareness to moments of secure attachment, such as feeling safe, feeling heard and feeling seen. Many individuals who are experiencing symptoms of complex trauma will struggle with this as they will describe a lack of supportive and close relationships in their lives. Therapy can work to support the individual to discover where in their life they might feel some of these qualities of security and safety. Sometimes this might mean studying the relationship one has with a pet, with nature, or a spiritual power; it also about studying the therapy relationship. Attachment therapy believes on an intrinsic level that we all have an original healthy impulse for secure attachment and bonding (Heller, p. 10). “Healthy impulses arise naturally in the safe context of therapy or other safe enough relationships” (Heller, p. 7). We can bring mindful awareness to these relationships by posing questions like; “How do you feel when your pet greets you at the door? What sensations do you notice in your body?”
When shame or cognitive distortions present asking the individual to imagine how their loving pet might treat them can create a powerful internal system of support.
Creating and Maintaining Safety
Often in trauma counselling there are times when the client wants to drop out and commonly it feels like this happens just when something important is occurring. For individuals who are coping with their childhood trauma there is often a focus on external directedness. This focus has been noted in the borderline personality disorder criteria as “misplaced and intense anger”; for these individuals this can be explained as a necessity to survive victimization (Brier et al. 2015, p. 201). It is important for both the client and the therapist to be aware of this common experience so it can be normalized and prepared for. Creating transparent agreements such as having a closing session and engaging in ongoing treatment planning can help the individual endure these difficult moments or at least safely end the sessions. One of the signs that the counsellor has created a safe environment is when the client is able to let the counsellor know what is working and what is not. The art of attachment repair has been described as one of the best predictors of longer, happier, healthy relationships (Heller, 2013, p. 6).
Client Centered Environment
Clients who present with these symptoms will often have negative self-perceptions ranging from self-hatred and criticism to unreasonable expectation of self. In attachment therapy the counsellor must work to visibly accept the client’s needs and perceptions as “intrinsically valid” and communicate the client’s “basic relational entitlements” (Brier, 2014, p. 200). Learning to identify internal feelings and needs can be complex when there has been a lack attunement. Attunement is the feeling of being in sync, understanding the needs and emotions of another. Attunement can happen in therapy with an adult responding to an activated memory of their felt child self (Brier et al. 2014, p. 203). In a client centered environment, the focus is on what the client needs or perceives rather than on what the therapist expects. This environment fosters identification on internal states, perceptions, and needs (Brier et al., 2014, p. 200). Longer term therapy should be expected in attachment work as building a relationship of trust, and deep connectedness provides the most affective state for processing relational trauma, especially when it is preverbal in nature ((Brier et al., 2014, p. 210). As the building therapeutic relationship in itself become the natural platform to challenge old relationship schemas.
Our systems commonly request that the most complex individuals get better before we are able to help them, we say they are “not ready”. By doing this we are reinforcing the felt narrative that there is something wrong with these individuals. These same individuals who have experienced the most painful rejection one can; rejection in our most vulnerable state in infancy and through childhood. This experience of rejection continues to be reinforced through our systems. These individuals commonly end up in our hospitals, criminal systems and child protection systems often not by choice. We have only begun to understand that these individuals are suffering from childhood experiences of abuse, violence and neglect. Social workers and other professionals are often feeling that they are failing these individuals. Burn out and compassion fatigue as well as “patient” blaming are all common in all of these systems. Our mental health systems are providing short term, solution focused therapies, providing little help. The complex nature of childhood trauma with impacts on brain development require long term attachment-based therapies. These therapies must be body based, drawing from the field of neurobiology. When our system starts to provide the adequate long term supports for each unique individual, we will see a revelation in well-being. This well-being will affect us all, on all levels, professional roles will shift from reactionary to preventive and supportive. This would result in job satisfaction and reductions to the costs in health, law enforcement and decreases in incarceration. Providing tools and therapeutic supports to caregivers can stop cycles of abuse, violence and neglect, creating healthier children, individuals and families and hope for the future.
Ali, T. (2019, September 12). ACEs (Adverse Childhood Experiences): One Family Physician’s Experience. This Changed My Practice. http://thischangedmypractice.com/aces-adverse-childhood-experiences/
Bell, W. C. B. (2015, March 10). Hope, trauma and resilience: a conversation about vulnerable children in America [Keynote address at the 2015 Kevin J. Robinson Forum on Social Justice]. Resilience in the Face of Childhood Trauma, Philadelphia, United States of America.
Briere, J. N., & Scott, C. (2014). Principles of Trauma Therapy: A Guide to Symptoms, Evaluation, and Treatment ( DSM-5 Update) (Second ed.). SAGE Publications, Inc.
Heller, D. P. H. (2013). Navigating the Labyrinth of Love – How Attachment Styles Sneak into Adult Relationships. Https://Dianepooleheller.Com/Wp-Content/Uploads/2018/12/Navigating-the-Labyrinth-of-Love.Pdf. https://dianepooleheller.com/wp-content/uploads/2018/12/Navigating-the-Labyrinth-of-Love.pdf
Kolk, V. B. (2015). The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma (Illustrated ed.). Penguin Books.