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?

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.

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