Sunday, October 25, 2009

Attachment and Vulnerability to PTSD

Attachment, as explained by Bowlby, is a biological and behavioral system. The infant or child seeks comfort and to be physically close to the caregiver. If the caregiver is available, willing and able to respond as needed, then the loop closes nicely. If this happens over and over again, then the child develops an internal working model about what she or he should expect in a relationship - any relationship - in the future, well into adulthood. This is a secure attachment.

If the caregiver is rejecting or unreliable, for any reason (for example, mental illness, crisis, trauma, substance abuse, fear, etc.), in providing care and protection, their children are left in an ongoing state of distress. Without an internal working model that facilitates confident expectations, these children are inclined to experience a generalized sense of anger and anxiety.

What Bowlby once referred to as an internal working model, today neuroscientists might refer to as - how our brain is wired.

On the whole, internal working models shape our expectations about the helpfulness of others, our worthiness to receive help and perceptions of support. Children showing a more secure attachment are less likely to react with anxiety and more likely to confidently seek support from others. Thus, under stressful conditions, the perception of support and its usefulness are reflections of working models grounded in the attachment relationship.

Our early system of need and response becomes how we see ourselves in relationships beyond our caregivers. It becomes how we expect, interpret and predict others to behave toward us in future relationships. As a result, attachment is seen as a stable process that endures into adulthood.

Research in the last 20 years focusing on adult attachment style has provided support for the stability of attachment, within individuals, across generations and across cultures. Research on adult attachment tells us that how we remember and tell the stories about our past attachment relationships can predict the quality of our current attachment relationships, specifically with intimate partners. A mother’s attachment style has been found to predict quality of interaction with her child, as well as the security of the child’s attachment. If the stories about our childhood are coherent, organized, full of detail and include both good and bad aspects of our attachment relationship, then we are more likely to have a secure attachment style in our relationships.

Ainsworth identified and categorized different types of attachment behavior as secure, insecure–avoidant and insecure–ambivalent/preoccupied. A fourth classification of disorganized–disoriented attachment was added to describe those children whose careseeking behavior lacked a coherent strategy and could not easily be categorized.

An insecure attachment style is often seen as a risk factor for the development of childhood psychopathology and is commonly found in children who have experienced abuse or neglect. The quality of attachment affects the degree to which an individual can adapt to disruptions in normal development without leading to psychopathology. It has been proposed that insecure attachment does not in itself lead to psychopathology, but leaves one vulnerable to disorder if combined with other risk factors, such as family dysfunction or trauma.

Given that attachment-seeking behaviors are activated by a perceived sense of danger, the presence of a secure attachment has the ability to mitigate trauma-induced psychopathology. Bessel van der Kolk says, “trauma occurs when one loses the sense of having a safe place to retreat within or outside of oneself to deal with frightening emotions or experiences.”

Furthermore, the frightening circumstances of maltreatment activate the attachment system. While maltreatment activates the attachment system, the need for proximity is likely to contradict with the circumstances of maltreatment, contributing to the root of disorganized attachment. If the person that a child turns to for comfort and protection is actually the same person inflicting harm, it obviously becomes very confusing and lonely for a child.

Thus, child abuse coupled with an insecure attachment may impede inner resources necessary for seeking support, coping, and adapting following trauma. An attachment framework suggests that secure working models may make a substantial difference in one’s ability to adapt and benefit from treatment. Research tells us that that the single best predictor of a positive psychological outcome for children who are surviving trauma is the support of a significant caregiver. We cannot say, for sure, why caretaker involvement improves treatment outcome. At a minimum, caretaker inclusion is presumed to assist in monitoring, understanding, and managing children’s symptoms. In this manner, caretakers are likely to be more perceptive and emotionally supportive of their children.

Researchers ask, "why do some adolescents and adults develop PTSD when exposed to a traumatic event (physical or sexual abuse, war or terrorist attack) while others don’t?" Some studies attempt to evaluate the efficacy of the quality of one’s attachments, well into adulthood, to examine the relationship between childhood abuse and vulnerability to the development of PTSD later.

Stubenbort’s findings suggest that those youngsters who had the benefit of a strong and secure attachment have more positive outcomes after treatment when functioning is measured at follow-up. This presents evidence for the hypothesis that secure attachment relationships may serve to buffer the impact of trauma and trauma-related symptoms.

A traumatic situation dramatically increases one’s psychological need for comfort and protection. A secure attachment bond provides a place from which a victim may perceive him/herself to be in touch with a powerful protector. Securely attached children are able to draw strength from a secure base and use learned adaptive strategies to contain the experience of danger. In contrast, those having an insecure attachment bond are likely to exercise maladaptive stress reducing strategies and will remain in a high state of distress and arousal.

Shapiro’s findings indicate that attachment style and coping strategies influence psychological and interpersonal functioning, mediating the direct effects of childhood sexual abuse and other types of child abuse and neglect.

Results of the Twaite study provide further support for the relationship posited to exist between childhood abuse and the emergence of PTSD in adulthood by much of the previous research, as well as the suggested association between childhood abuse and adult attachment quality and dissociative tendencies. For example, the positive relationships obtained between a history of childhood sexual and physical abuse and scores on the Impact of Event Scale–Revised are consistent with several previous studies suggesting that individuals who were abused as a child are more likely to develop symptoms of PTSD following the experience of a traumatic event as an adult.

These studies seem to warrant the hypothesized relationship between security of attachment as explaining the variability among those individuals that develop PTSD and those who do not. The implications for practice abound. Clearly, anything we can do to facilitate the effective call and response system between parent and child would be profound in its effects. The next question then focuses on us as professionals - what can we do to help parents notice, respond and soothe our students in times of stress?

References:
Bacon, H. & Richardson, S. (2001). Attachment Theory and Child Abuse: An overview of the literature for practitioners. Child Abuse Review, 10, 377-397
Shapiro, D.L. & Levendosky, A.A. (1999). Adolescent survivors of childhood sexual abuse: The mediating role of attachment style and coping in psychological and interpersonal functioning. Child Abuse & Neglect, 23 (11), 1175-1191.
Stubenbort, K., Greeno, C., Mannarino, A.P. & Cohen, J.A. (2002). Attachment quality and post-
treatment functioning following sexual trauma in young adolescents: A case series presentation. Clinical Social Work Journal, 30 (1), 23-39.
Twaite, J.A. & Rodriguez-Srednicki, O. (2004). Childhood sexual abuse and physical abuse and
adult vulnerability to PTSD: The mediating effects of attachment and dissociation. Journal of Child Sexual Abuse, 13 (1), 17-38.

Saturday, October 17, 2009

Pendulating on the Roller Coaster

Oh no! What have I gotten myself into?

(after turning in an assignment) I did it. I can do this.

(staring down another 20 hours plus of reading) OMG, this is a lot of work, how will I keep up and manage it all?

(after completing 3 weeks of schoolwork) I did it. I am doing this.

(laying down on the couch or bed because my body is too tired to move) Why did I choose this particular form of punishment and is it too late to cut out?

(after a great discussion in class or reading) Wow, this is really cool - I get to do this.

Tuesday, October 6, 2009

Evidence-Based Practice Articles

I just read two great articles about Evidence Based Practice (EBP) in Social Work. Let me know if you are interested in reading either one. They argue that some of the limitations of the EBP approach are:

1. SWs report not having enough time to read.

2. SWs report not having access to journal articles.

3. SWs have not had adequate training to interpret the evidence from research studies.

4. Based on past scientific movements in the profession, SWs may not see a need for or the appeal of the EBP framework in everyday practice.

5. A survey of agency-based field instructors found lack of time was the top barrier to implementation of EBP.

6. Social workers rarely use research evidence to strengthen decision making about client interventions.

7. Different stakeholders apply different standards to evidence that they are using to determine whether an intervention is effective or even needed in the first place.

8. SWs may see new knowledge as credible only if it fits with the existing professional theories that they agree with or with their political, religious, or other personal beliefs. So, training, professional knowledge, or personal beliefs can prevent a practitioner from being open to reviewing any evidence that is available on alternate therapies.

9. It is not known what type of evidence SWs value (and from where – psychology, social work, sociology, political science, etc.)?

10. Within social work, surveys that collect information on demographics, service counts, or reasons for referral may be an appropriate evidence of demand, but they are not necessarily an appropriate way to determine the effectiveness of interventions.

Do you agree with any of these? Could you tell me which of these (identified by their number on the list) that resonate for you? What about your colleagues?

Bonus tip:

Reviews of various types of SW practice have documented that the treatments with demonstrated effectiveness tend to be brief, group, skills-focused, intervention approaches.
(from Limitations of Evidence-Based Practice for Social Work Education: Unpacking the Complexity by Kathryn B. Adams et al.)

Saturday, October 3, 2009

My Advisor - Stuart Kirk

I was googling to find a Bertha Capen Reynolds quote for a PowerPoint presentation I am working on when I stumbled on this book excerpt online and I could not stop reading it because the ideas and writing were about the things that I care about - strengths perspective, the placebo effect, Paolo Freire's thoughts on hope, etc. I was thinking, "I really need to buy this book!" When I went to write down the book title and author I realized it was edited by Stuart Kirk - my advisor! Confirmations that I am in the right place keep coming. Thank you, Yesus because this is a lot of work!