Handbook for Treatment of Attachment Problems in C

An Historical Compendium of Pitching, Pitchers, an

Beverly James

• Publisher: Free Press
• Year: 1994
• ISBN:
  9781439108314
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

Attachment Disorder occurs when a child has difficulty establishing new attachments if old ones are severely disrupted, and it is typically seen in victims of various types of trauma. This text seeks to explain how best to treat these children so that they can love and trust again and form lasting relationships.

1 Human Attachments and Trauma

Bowlby, 1980 Intimate attachments to other human beings are the hub around which a person’s life revolves, not only when he is an infant or a toddler or a schoolchild but throughout his adolescence and his years of maturity as well, and on to old age. From these intimate attachments a person draws his strength and enjoyment of life and, through what he contributes, he gives strength and enjoyment to others.

As the fetus must be in the womb to survive, so must a child have a human attachment relationship in which to develop, feel protected, be nurtured, and become that which is human.

The attachment relationship is typically established within the context of a family, be it single-parented, adoptive, foster, tribal, or nuclear. But it is a family—it is the matrix that provides the child with the necessary feelings of safety and a place in which to grow. It is every child’s birthright (Fraiberg, et. al. 1975).

Serious attachment disturbances and trauma coexist in the lives of many children and families; each may be the originating event giving rise to the other. Loss of a primary attachment relationship can be traumatizing to any age child. Traumatizing events in a family can result in serious attachment disturbances between parent and child. Clinicians and caregivers charged with helping children and families deal with severe attachment problems or traumatizing events venture into an arena that is complex, highly specialized and replete with uncharted territory. This chapter presents basic concepts in attachment and trauma on which is built an integrated treatment framework presented in subsequent chapters. The concepts are gleaned from the professional literature and from the clinical and caregiver experiences of those who work intimately and intensively with child and family attachment-trauma problems.

What Is Attachment?

An attachment relationship, hereafter referred to as attachment, has various definitions. The most useful to me as a clinician is that an attachment is a reciprocal, enduring, emotional, and physical affiliation between a child and a caregiver. The child receives what she needs to live and grow through this relationship, and the caregiver meets her need to provide sustenance and guidance.

Infants and very young children usually develop a preferred, or primary, attachment. This is the person selectively sought by the child when there is need for comforting and reassurance. Although other attachments are formed as the child matures, the primary attachment typically remains with the parents, usually the mother. The primary attachment figure may call on others to assist in meeting the child’s parenting needs but maintains his role as primary provider of the child’s comfort and security through consistency and quality of relationship.

The caregiver, or parenting person, is the one who provides ongoing care. The caregiver may be the youngster’s biological parents, an older sibling, a grandparent, a foster or adoptive parent, a childcare worker, or someone else.

The mission of the primary attachment person is threefold, and each mission bears its own message:

As protector: “Everything will be OK. I’ll take care of you, set limits, and keep you safe.”

As provider: “I’m the source of food, love, shelter, excitement, soothing, and play.”

As guide: “This is who you are and who I am. This is how the world works.”

Attachment provides the building blocks of children’s development. Youngsters learn to modulate affect, soothe themselves, and relate to others through these relationships. Attachment is the base from which children explore their physical and social environments; their early attachment experiences form their concepts of self, others, and the world.

Formation of Attachments

Primary attachments are most optimally formed when baby and caregiver are ready, willing, and able to do so. The caregiver and child each bring to the relationship varying abilities, forms of expression, needs, and temperament. The connection is formed and reinforced through sensorial contact—gazing, smelling, tasting, hearing, touching, rocking, feeding, playing, vocalizing. A secure attachment grows for caregiver and baby when both experience their relationship as emotionally and physically gratifying. The child comes to perceive the caregiver as the source of joy, surprise, loving warmth, and relief from pain. The caregiver experiences the child’s unfolding development as a source of satisfaction.

Attachment-seeking behaviors start when the infant cries for the parent and become more complex as the child develops. The cry of alarm or discomfort of an infant or young child cues a caregiving response in the adult. The parenting response can provide relief for the child in distress as well as provide a sense of competency and well-being for the parenting person. Other attachment behaviors include proximity-seeking and attention-getting on the part of the child. A child experiencing stress increases her attachment behaviors. We see this when children are frightened or injured. The primary attachment person becomes a conditioned, instant source of comfort over time and is perhaps best exemplified by the mother whose healing kiss on a minor injury makes the pain disappear and allows the child to resume play. This attachment, once formed, persists even though the primary attachment person may be absent.

Barriers to Attachment

Barriers to early attachment formation include the physical or emotional unavailability of the parent or baby and can be partial or complete. Unavailability can result from a child’s or caregiver’s physical pain, illness, drug addiction, or developmental disability, among other things. Chronic emotional disturbances, such as depression, dissociation, extreme shame, and distorted perceptions, can interfere with attachment formation.

In our clinical practices we often see barriers to later attachment formation among people who have suffered loss and disruption of earlier primary attachments. Forming a new relationship can represent an act of disloyalty, loss of hope, lack of love, or the sealing of one’s fate if the act is perceived as guaranteeing that the person with whom one has an attachment will no longer love them. The child or adult who lives apart from an attachment figure may be unable or unwilling to form an intimate relationship with another person because doing so may represent a threat to the existing but unavailable attachment. For example, some divorced parents who no longer live with their birth children resist forming attachments with stepchildren because doing so would make them feel disloyal. A child living apart from a birth parent may resist forming a new attachment because she believes that any positive relationship with another adult will ensure the estranged parent will not return.

Someone who has experienced parental maltreatment may have considerable difficulty forming later attachment relationships because the child, the parent, or both do not know how to relate to another person in an intimate, reciprocal relationship. This is sometimes seen in parents who have histories of attachment disturbances and in abused children who have been placed in out-of-home care. Trust, a needed ingredient for attachment formation, may not be possible or come easily to these parents and children. Or the experience of intimacy in an attachment relationship may be intolerable because it leads to feelings of vulnerability and danger. Clinicians often find such dynamics in newly formed adoptive, foster, and stepparent relationships.

Dance of Development

Attunement, or harmony, in attachment relationships will naturally fluctuate—it is affected by changes in mood, availability, awareness, and interest of child and caregiver, among other things. A serious, chronic lack of attunement between child and parent can negatively affect a child’s development. While there are other important developmental lines—motor, cognitive, and linguistic, for example—attachment is most central and essential for the survival of the infant.

As with most love relationships, both child and caregiver experience stimulation, interest, pleasure, delight, and satisfaction when they are emotionally and physically attuned to each other and the needs of both are being met. The attachment dance between parent and child is always in motion. The dance may be graceful, with each person responsive to his or her own and to the other’s varying rhythms over time. Constricted or jarring choreography may reflect confusion over who is leading and who should follow, with attachment partners continually stepping on each other’s toes or becoming preoccupied in doing their own solo and thus being unresponsive to the other.

The needs and abilities of both caregiver and child are in a continuous state of change, constantly influenced by the growth of child and parent and the surrounding world. The general tendency toward independence exhibited by the youngster as she develops toward adulthood needs to be matched by the caregiver’s willingness to let go. The child needs to learn to cope with emotional tension, make decisions, protect, and care for herself as her parents let go of their caregiving functions. Clinical experience with interdependent extended families and tribal and clan systems suggests that children’s attachment needs may be met through consistent, quality care provided by multiple attachment relationships.

The toddler’s biological development and the security provided by attachment facilitate exploration and learning in a larger social world. The child will often have attachments with extended family members or other adults who augment the functions of the primary attachment. These relationships can provide support for the parent-child attachment and mitigate possible relationship problems.

The youngster’s entrance into an expanded environment during the school years provides more challenges and opportunities whereby she can compare herself with others. The functions of the attachment are gradually internalized by the child as she develops autonomy and views herself both as a part of the family and as a member of the community.

The functions of the primary attachment—protection, limit-setting, nurturance, and guidance—recede in primacy during adolescence as they shift to the youngster herself, to peers, and to other adults in the community. The adolescent practices adult functioning, while the attachment relationship provides a safety net. Adolescent attachment with peers and adults outside the family is interdependent and characterized by shared attachment functions.

Adulthood brings attachment functioning full cycle with the development of mature attachment relationships with family, marriage partner, and one’s own children.

Adaptations to the Attachment Relationship

Children of all ages—infants to adolescents—alter their behavior in service of preserving attachment relationships when their parenting needs are not met. Such alterations are necessary for their survival and are often wise and creative but not necessarily healthy. Thus we see children suppressing spontaneous thoughts, feelings, and wishes and instead playing adaptive roles in order to stimulate caregiving behavior in their parents. All children do this from time to time; however, it becomes a serious problem when the child must assume a role in order to obtain basic care. It then becomes an attachment dance of disturbed patterned behavior. Children’s adaptive roles include being overly compliant with abusive parents, being entertainers with distracted parents, being minicaregivers with needy parents, being demanding bullies with nonresponsive parents, or being manipulators with neglectful, withholding parents.

The children’s adaptive behavior is reinforced by the parent’s eventual response to their needs. The youngster’s sense of worth becomes wedded to the role that elicits adult caring. A child who must ignore her authentic thoughts and feelings in exchange for parental care and attention will identify with the role she must play and not have a real sense of self, or she can develop a sense of self that she believes is unacceptable to society and perhaps to herself, since her selfhood was not acceptable to her own parents.

Categories of Attachment Problems

Problems within the parent-child attachment relationship can seriously disrupt a youngster’s development. These problems can generally be placed into three categories:

Disturbed attachment

Attachment trauma

Trauma-related attachment problems

Disturbed Attachment

Attachment security is related to the quality and consistency of the parent’s response to the child’s expressions of physiological, emotional, and social needs. In the absence of problems that interfere with the process, parents have compelling desires to respond positively to children’s basic needs. Children too are neurologically “wired” from birth to be responsive; the child is very much attuned to the manner, timing, and frequency of the caregiver’s response to her signals. Attachment disturbances develop when there is an ongoing lack of attunement, or mismatch, between parent and child. This disharmony can have several causes, including impairment of child or parent functioning that interferes with the sending of, recognition of, or response to attachment signals; difficulties adapting to temperament differences; inadequate parenting skills; or inconsistent, disruptive parenting.

Greenspan and Lieberman’s (1988) review includes studies of physiological and neurochemical reactions to disturbances in attachment that reveal the interactive nature of biological and behavioral systems. They cite examples showing that it is possible for caregivers to alter early constitutional patterns of infants in a favorable manner.

Attachment Trauma

Loss of the primary attachment figure represents a loss of everything to a child—loss of love, safety, protection, even life itself, and prolonged unavailability of the primary attachment is the same as total loss for a young child. This was graphically brought to the attention of the public by Spitz’s (1947) haunting pictures of children in orphanages and by Robertson’s (1957) film of a child’s traumatizing separation from her parent during an eight-day hospitalization. These candid portrayals of children’s suffering resulted in both professional awareness and changes in social policy regarding children’s attachment needs.

Children experience their primary attachment figure as necessary for survival—he or she is the person whose presence provides protection and whose actions reduce the child’s terror to manageable size and enable the youngster to cope with changing situations (Spitz, 1945). Other adults can provide some comfort when the child’s worries are minor, but a child’s deep fears can be alleviated only by the presence of an attachment relationship. The loss of the attachment figure evokes a fear that cannot be assuaged, depression and despair that are inconsolable, because the source of safety and love is gone.

The child abused by a primary attachment figure suffers in multiple and complex ways. There is the pain, confusion, and fear of the abuse itself; there is the mind-boggling experience of having the source of danger and the source of protection residing in one person. Most terrifying of all is the fear of loss of the attachment relationship, a loss children often believe is likely to happen if they try to protect themselves from being abused by a parent.

Children adapt to these situations by engaging in protective practices, such as dissociating, anesthetizing themselves physically, and muting sensory awareness. They commonly deal with the need to maintain a relationship with an abusive parent by blaming themselves for the abuse. This directs rage away from the abuser and frees the child to seek love and protection from that person, thus preserving the essential attachment relationship.

Trauma-Related Attachment Problems

The urgent and life-threatening aspects of traumatic events and family difficulties arising in the wake of trauma can obscure the serious attachment problems between parent and child that are generated by the traumatizing event. Single-incident traumatic events, such as injuries, severe illness, or catastrophes, can result in impaired functioning, prolonged separation, fear, anxiety, and misinterpretation of behavior. Any of these happenings can lead to patterns of child or parent behavior that seriously interferes with the attachment relationship. The parent might not be able to recognize or respond adequately to the child’s needs; the child might not be able to adequately express needs or respond to the adult. A family member who avoids contact with a child because contact stimulates painful memories for either the child or the parent exhibits trauma-related impaired functioning. Parents who emotionally smother a child because they fear the consequences of not doing so also exhibit impaired functioning. Should such behaviors continue past an initial crisis stage, significant attachment problems may develop.

Chronic and repeated traumatizing events likewise impact attachment relationships. A child traumatized by an abusive parent, for example, can develop a severe disturbance in her attachment relationship with the nonabusive parent—she may believe she was not protected because she was unworthy or unlovable. An abusive parent may deliberately drive a wedge between the child and the other parent with lies and threats to both. A child’s attachment relationship can be seriously compromised by a nonprotective or coercive parent or by a parent who has an investment in the child forgiving the abusive parent.

Life in a violent home or in a violent community can create attachment disturbances because children believe their parents cannot protect them. Youngsters might look for power and strength in peer groups rather than in parent relationships. Their parents then become restrictive and punitive, and the children perceive that behavior as unloving.

Integration of Attachment and Trauma Dynamics

Serious attachment disturbances and traumatizing experiences often coexist in children’s lives. Both can be perceived as threats to survival. Both the attachment process and traumatizing experiences affect children biologically, psychologically, and behaviorally; both influence a child’s self-concept and how future relationships and events are experienced. Treating attachment proble...

Table of contents

• Cover Page
• Title Page
• Contents
• Acknowledgments
• Introduction
• 1 Human Attachments and Trauma
• 2 The Alarm Numbing Response
• 3 Attachment vs Trauma Bonds
• 4 Assessment of Attachment inTraumatized Children
• 5 Relationship Based TreatmentCategories
• 6 Treatment Essentials
• 7 Treatment Process
• 8 A Brief Treatise on CoerciveHolding
• 9 Comprehensive CaseDescriptions
• 10 Maladaptive AttachmentRelationships
• 11 Saying Goodbye to LostRelationships
• 12 Connecting in New AttachmentRelationships
• 13 Recovering Self Shattered byAttachment Trauma
• 14 Wisdom from Those Who’veBeen There
• 15 Lost Children
• 16 Dynamic Play Therapy
• 17 Developmental Play Therapy
• 18 Playback Theatre
• 19 A Residential Care AttachmentModel
• 20 Adoption and Attachment
• 21 What If…
• Bibliography and References
• Index
• Contributors