Attachment Theory

Notes about attachment theory from A Secure Base by John Bowlby:

• The inclination to make intimate emotional bonds to particular individuals – care-giving and care-seeking - is a basic component of human nature.
• During infancy and childhood bonds are with parents (or parent substitutes) who are looked to for protection, comfort, and support.
• The urgent desire for comfort and support in adversity is not childish, as dependency theory implies. The capacity to make intimate emotional bonds with other individuals, sometimes in the care-seeking role and sometimes in the care-giving one, is regarded as a principal feature of effective personality functioning and mental health.
• When an individual of any age is feeling secure he is likely to explore away from his attachment figure. When alarmed, anxious, tired, or unwell he feels an urge towards proximity (to be near or close).
• Provided the parent is known to be accessible and will be responsive when called upon, a healthy child feels secure enough to explore.
• A secure home base remains indispensible for optimal functioning and mental health (at any age).
• The presence of an attachment control system and its linkage to the working models of self and attachment figures that are built in the mind during childhood are held to be central features of personality functioning throughout life.

I think that examples of "working models of self and attachment figures" based on secure attachment include the following core beliefs:

• I am loved. I am worthwhile.
• I can trust others. Others will respond to my needs and care for me.

These beliefs, based on our earliest experiences, were ingrained before we had words - encoded as feelings, bodily sensations, images - domains of the right brain.  Putting the stories of these and other emotional experiences into words and language - a domain of the left brain - completes the process and leads to integration.  Integration of the left and right brain, integration of thoughts and feelings, balancing positive and negative emotions, integration of the body and mind - is the definition of well-being, physical and mental health.

Attachment Patterns

In A Secure Base, Bowlby describes the three most common attachment patterns:

1. Secure attachment – the individual is confident that his parent (or parent figure) will be available, responsive and helpful should he encounter adverse or frightening situations. With this assurance, he feels bold in his explorations of the world. This pattern is promoted by a parent being readily available, sensitive to her child’s signals, and lovingly responsive when he seeks protection and comfort.
2. Anxious resistant attachment – the individual is uncertain whether his parent will be available or responsive or helpful when called upon. Because of this uncertainty he is always prone to separation anxiety, tends to be clinging, and is anxious about exploring the world. This pattern, in which conflict is evident, is promoted by a parent being available and helpful on some occasions but not on others, and by separations and by threats of abandonment used as a means of control.
3. Anxious avoidant attachment – the individual has no confidence that, when he seeks care, he will be responded to helpfully but, on the contrary, expects to be rebuffed. When in marked degree such an individual attempts to live his life without the love and support of others, he tries to become self-sufficient and may later be diagnosed as narcissistic or as having a false self (as described by Winnicott). This pattern, in which conflict is more hidden, is the result of the individual’s mother constantly rebuffing him when he approaches her for comfort or protection. The most extreme cases result from repeated rejections.

"One major influence that has led a parent to adopt the style of parenting she does is the amount of emotional support, or lack of it, she herself is receiving at the time. Another is the form of mothering that she herself received when a child."

"...the way a parent treats a child, whether for better or for worse, tends to continue unchanged...each pattern tends to be self-perpetuating. Thus a secure child is a happier and more rewarding child to care for and also is less demanding than an anxious one. An anxious ambivalent child is apt to be whiny and clinging; whilst an anxious avoidant child keeps his distance and is prone to bully other children."

"If the parent treats the child differently, the pattern will change accordingly."

"It is a characteristic of a mother whose infant will develop securely that she is continuously monitoring her infant’s state and, as when he signals wanting attention, she registers his signals and acts accordingly."

"Already by the age of 12 months, there are children who no longer express to their mothers one of their deepest emotions or the equally deep-seated desire for comfort and reassurance that accompanies it. It is not difficult to see what a very serious breakdown of communication between child and mother this represents. Not only that but, because a child’s self-model is profoundly influenced by how his mother sees and treats him, whatever she fails to recognize in him he is likely to fail to recognize in himself."

"As a child grows older, the pattern becomes increasingly a property of the child himself, which means that he tends to impose it, or some derivative of it, upon new relationships such as with a teacher, a foster-mother or a therapist." (we tend to repeat the pattern of relationship with new "others" that we learned before we had any words.)

"Attachment patterns predict how a child will behave in a nursery (or in the workplace!):

• Secure attachment: these children are likely to be described by nursery staff as cooperative, popular with other children, resilient and resourceful.
• Anxious avoidant attachment: these children are likely to be described as emotionally insulated, hostile or anti-social and, paradoxically, as unduly seeking of attention.
• Anxious resistant attachment: these children are likely to be described as unduly seeking of attention and as either tense, impulsive, and easily frustrated or else as passive and helpless."

"The most effective interventions are those that take into account both the patterns ingrained within the child’s personality and the way the parents still treat him or her. For example, by means either of family therapy or else by giving help in parallel to parents and child."

"For a relationship between any two individuals to proceed harmoniously each must be aware of the other’s point-of-view, his goals, feelings, and intentions, and each must so adjust his own behavior that some alignment of goals is negotiated. This requires that each should have reasonably accurate models of self and other, which are regularly updated by free communication between them. It is here that the mothers of the securely attached children excel and those of the insecure are markedly deficient."

The Way a Mother Tells Her Story

In Bowlby's book, A Secure Base, he writes about the relationship between the way a mother tells the story of her childhood and her attachment to her own child.

The characteristics of...

• the essays about  emotional experiences that improved the physical health of the writers (please see previous posts) and
• the stories of mothers talking about their childhood with secure attachments to their children

are strikingly similar. 

Check out the following excerpts from one of the book chapters:

The role of free communication, emotional as well as cognitive, in determining mental health is strongly supported by an important finding from Main’s longitudinal study.

Main found a strong correlation between how a mother describes her relationships with her parents during her childhood and the pattern of attachment her child now has with her.

The mother of a secure infant is able to talk freely and with feeling about her childhood, the mother of an insecure infant is not.

In this study, an interviewer asks the mother for a description of her early relationships and attachment-related events and for her sense of the way these relationships and events affected her personality.

A mother of an insecure infant is likely to respond to the enquiry in one of two different ways: 

• One, shown by mothers of anxious resistant children, is to describe a difficult unhappy relationship with her own mother about which she is still clearly disturbed and in which she is still entangled mentally, and, should her mother still be alive, it is evident that she is entangled with her in reality as well.
• The other, shown by mothers of anxious avoidant children, is to claim in a generalized matter-of-fact way that she had a happy childhood, but not only is she unable to give any supporting detail but may refer to episodes pointing in the opposite direction. Frequently, such a mother will insist that she can remember nothing about her childhood nor how she was treated.

A mother of a secure infant is likely to report having had a reasonably happy childhood and to show herself able to talk about it readily and in detail, giving due place to such unhappy events as may have occurred as well as to the happy ones.

Then there are mothers who describe having had a very unhappy childhood but who nonetheless have children showing secure attachment to them. A characteristic of each of these mothers, which distinguishes them from mothers of insecure infants, is that, despite describing much rejection and unhappiness during childhood, and perhaps tearful whilst doing so, each is able to tell her story in a fluent and coherent way, in which such positive aspects of her experiences as there were are given a due place and appear to have been integrated with all the negative ones. In their capacity for balance they resemble the other mothers of secure infants. It seemed to the interviewers and those assessing the transcripts that these exceptional mothers had thought much about their unhappy earlier experiences and how it had affected them in the long term, and also about why their parents might have treated them as they had. In fact, they seemed to have come to terms with their experience.

By contrast, the mothers of children whose pattern of attachment to them was insecure and who also described an unhappy childhood did so with neither fluency nor coherence; contradictions abounded and went unnoticed. Moreover, it was a mother who claimed an inability to recall her childhood and who did so both repeatedly and strongly who was a mother whose child was insecure in his relation to her. As an added note, Main reports that it has been found that all these correlations also hold true for fathers.

In light of these findings, Main and her colleagues conclude that free access to, and the coherent organization of information relevant to attachment play a determining role in the development of a secure personality in adult life.

For someone who had a happy childhood no obstacles are likely to prevent free access to both the emotional and the cognitive aspects of such information.

For someone who suffered much unhappiness or whose parents forbade him or her to notice or to remember adverse events, access is painful and difficult, and without help may indeed be impossible.

Nevertheless, however she may accomplish it, when a woman manages either to retain or regain access to such unhappy memories and reprocess them in such a way that she can come to terms with them, she is found to be no less able to respond to her child’s attachment behavior so that he develops a secure attachment to her than a woman whose childhood was a happy one. This is a finding to give great encouragement to the many therapists who for long have sought to help mothers in just this kind of way.

What I see here is that we learn skills from our parents that lead to secure attachments or we develop those skills when we tell our stories by integrating both facts and feelings, both positive and negative emotions, in a coherent and organized narrative. I see hope through integration.

Why Does Writing Heal?

Again, we go to Pennebaker for an explanation of the underlying mechanisms of change - put another way, what makes writing heal?

"The original theory that motivated the first studies on writing was based on the assumption that not talking about important psychological phenomenon is a form of inhibition...and could be viewed as a long-term low-level stressor.  Such stress...(increases) the risk of illness and other stress-related disturbances.  Just as constraining thoughts, feelings, or behaviors linked to an emotional upheaval is stressful, letting go and talking about these experiences should, in theory, reduce the stress of inhibition."

It takes energy to avoid and avoidance has its price.

"Findings to support the inhibition model of psychosomatics are accumulating individuals who conceal their gay status, conceal traumatic experiences in their past, or are considered inhibited or shy by other people exhibit more health problems than those who are less inhibited."

"In a recent study, students were randomly assigned either...

1. to express a traumatic experience using bodily movement, 
2. to express a traumatic experience first through movement and then in written form, 
3. or to exercise in a prescribed manner for 3 days, 10 minutes per day.

Whereas participants in the two movement-expression groups (#1 & #2) reported that they felt happier and mentally healthier in the months after the study, only the movement-plus-writing group (#2) showed significant improvements in physical health and grade point average.  The mere expression of a trauma is not sufficient.  Health gains appear to require translating experiences into language."

This finding reminds me of a podcast* on the nctsn.org website where Bessel van der Kolk, a trauma researcher, explains the importance of movement, theater, and sports in trauma treatment but ends his talk by saying that sooner or later the child will need to tell the story in order to heal. 

When examining the writing of study subjects, Pennebaker found some patterns:

"Three linguistic factors reliably predicted improved physical health:

1. The more that individuals used positive emotion words, the better their subsequent health.
2. A moderate number of negative emotion words predicted health.  Both very high and very low levels of negative emotion words correlated with poorer health.
3. Most important, an increase in both causal and insight words over the course of writing was strongly associated with improved health.  People who benefited from writing began with poorly organized descriptions and progressed to coherent stories by the last day of writing."

"Does a coherent story about a trauma produce improvements in health by reducing ruminations or flashbacks?  Does a story ultimately result in the assimilation of an unexplained experience, thereby allowing the person to get on with life?  These are the theoretical questions that psychologists must address."

A question all of this raises for me is:  
Writing about a traumatic event is healing.  That is, what is healing about writing is focusing on both the facts and the feelings and over time, crafting  a coherent, organized, detailed and integrated narrative.  So maybe the exposure therapy technique for trauma treatment involving verbal repetition of the trauma narrative can be replaced with writing.  Any clinician can attest to the energetic exchange that happens when we listen to the traumatic stories of our clients over and over while implementing this evidence-based technique.  If writing "independent of social feedback" is healing, then I wonder if helping clients to release the energy of these painful stories without taking it on may be better facilitated through a writing process?

As I shared these articles with my husband, he commented that writing as healing makes sense.  That is, if your stomach hurts what feels good is to vomit or digest and get rid of the toxin (by pooping).  If you have an infected lesion, you have to squeeze out the puss.  If you have painful emotions, then you have to write it out - release those toxins so they don't fester.  It also seems like yet another example of the connection between mind and body - writing about emotional experiences improves physical health.  So what is the energy contained in painful emotions?  When the energy is trapped in the body, it makes us sick.  So what is the best way to release the energy safely and effectively?

What also struck me is that it is no coincidence that elementary school teachers and secondary English teachers make such an impact on their students.  They provide the tools, expectations, opportunities and relationship context for writing as healing, everyday.

Finally, my next post will be about the stories that mothers tell about their childhood and the storytelling qualities that predict secure attachment in their children.  The similarities in narrative quality between the writing that heals and the narratives that predict secure attachment is eerie.  And if secure attachment protects against PTSD symptom development, then I can't help but wonder about the connection and implications...

*Master Speaker Series:  Developmental Impact of Childhood Trauma by Bessel van der Kolk

Reference:
Pennebaker, J.W. (1997).  Writing About Emotional Experiences as a Therapeutic Process.  Psychological Science, 8(3), 162-166.

Writing is Healing

Pennebaker (1997) wrote about writing as therapy.  Here are some gems from the article:

"For the past decade, an increasing number of studies have demonstrated that when individuals write about emotional experiences, significant physical and mental health improvements follow."

"The mere act of disclosure is a powerful therapeutic agent that may account for a substantial percentage of the variance in the healing process."

In ancient indigenous cultures in Mexico, there was a community leader called "Comedor de Pecados" or "Eater of Sins."  It seems we have always needed a place to put it - a ritual for disclosure.


In this article, Pennebaker shares the standard script or writing directive used in his studies:

"For the next 3 days, I would like for you to write about your very deepest thoughts and feelings about an extremely important emotional issue that has affected you and your life.  In your writing, I'd like you to really let go and explore your very deepest emotions and thoughts.

You might tie your topic to...
...your relationships with others including parents, lovers, friends, or relatives
...to your past, your present or your future
...or to who you have been, who you would like to be or who you are now.

You may write about the same general issues or experiences on all days of writing or on different topics each day.  All of your writing will be completely confidential.  Don't worry about spelling, sentence structure, or grammar.  The only rule is that once you begin writing, continue to do so until your time is up."

"Even though a large number of participants report crying or being deeply upset by the experience, the overwhelming majority report that the writing experience was valuable and meaningful in their lives."

Writing has been found to be associated with...

• significant drops in doctor visits from before to after writing
• beneficial influences on immune function
• long-term improvements in mood and indicators of well-being compared with writing about control topics
• significant reductions in distress
• improvements in grades among students who write about emotional topics
• getting new jobs more quickly and reduced self-reported alcohol intake among Senior professionals who have been laid off from their jobs 
• lower rates of absences among university staff members who write about emotional topics compared to control participants

"When individuals write or talk about personally upsetting experiences in the laboratory, consistent and significant health improvements are found.  The effects are found in both subjective and objective markers of health and well-being.  The disclosure phenomenon appears to generalize across settings, most individual differences, and many Western cultures, and is independent of social feedback."

Reference:
Pennebaker, J.W. (1997).  Writing About Emotional Experiences as a Therapeutic Process.  Psychological Science, 8(3), 162-166.

Writing It Out - Integrating Thoughts and Feelings

Pennebaker (1986) conducted a study about journaling.  He randomly assigned subjects (college students) to one of the following groups and asked them to write about...

(1) ... a superficial or trivial topic - for example, a description of their living room or the shoes they were wearing.  (Control Group)

(2) ... their feelings associated with one or more traumas in their life (Trauma-Emotion Group)

(3) ... the facts surrounding traumatic events (Trauma-Fact Group)

(4) ... both their feelings and the facts surrounding the traumas (Trauma-Combination Group)

(all groups wrote for 15 minutes per night on four consecutive nights)

Before and after writing each essay, he measured their...

• blood pressure
• heart rate
• self-reported moods
• self-reported physical symptoms

Four months after the end of the study, subjects completed questionnaires about their health and general views of the experiment.

Before and six months after the study, the health and counseling center records of study participants were collected.

This is what he found:

• At first, the Trauma-Combination Group writers had a large increase in blood pressure from before to after the essay.  After the first writing session, they showed moderate decreases in blood pressure from before to after the session.
• Those that wrote about trauma reported more negative moods after writing the essays, whereas Control Group writers felt more positive.
• There was an overall increase in health center visits for illness in all conditions except the Trauma-Combination group.
• A trend suggesting that those in the Control Group reported the most days their activities had been restricted due to illness and the Trauma-Combination Group the least.
• Overall, participants in the Trauma-Combination and Trauma-Emotion Groups reported reductions in health problems relative to those in the Control and Trauma-Fact Groups.
• Those in the Trauma-Emotion and Trauma-Combination Groups were more likely to have thought about their essays than those in the Trauma-Facts or Control Groups.

"Although I have not talked with anyone about what I wrote, I was finally able to deal with it, work through the pain instead of trying to block it out.  Now it doesn't hurt to think about it." -- Trauma-Combination writer

In his discussion, Pennebaker notes:
"Theorists argue that the resolution of a trauma is associated with the cognitive work of organizing, assimilating, or finding meaning to the events surrounding the trauma."

"...tying both the cognitions (thoughts) and affect (feelings) surrounding traumatic events was optimally effective in maintaining long-term health."

"Jourard (1971) argues that self-disclosure allows for one's feelings and thoughts to become more concrete, which ultimately results in greater self-knowledge.  Disease results, according to Jourard, when the motive toward self-understanding is blocked."

"We have argued that the act of inhibiting behavior is physiologically stressful.  Previous surveys indicate that not confiding in others about a traumatic event - which we view as a form of behavioral inhibition - is associated with disease."  (We avoid to take a break from the pain of talking about or thinking about the memory, but avoidance takes its toll)

"Although writing about traumas appears to have positive long-term health effects, we must pinpoint the aspect of this exercise that is beneficial.  Possibilities include making an event concrete, linking the affective and cognitive aspects, the reduction of forces associated with behavioral inhibition over time, and so forth."

Reference:
Pennebaker, J.W. & Beall, S.K. (1986).  Confronting a Traumatic Event:  Toward an Understanding of Inhibition and Disease.  Journal of Abnormal Psychology, 95, 274-281.

Universal Screening (Rocks!)

Say there is a mass traumatic event - many people affected. Or say you work at a school - with thousands of students.

What is the most efficient way to identify those that need intervention?

• Individual clinical interviews? (Probably not)
• A brief questionnaire excellent at predicting a PTSD diagnosis that "performs equivalent to agreement achieved between two full clinical interviews"!

Edna Foa et al. has developed a questionnaire for efficient identification of PTSD among children and adolescents. This can be done for other common, and sometimes hidden, disorders. Teachersfrequently refer students (boys) with disruptive behavior disorders. But how can clinicians identify the underlying disorders (ADHD, PTSD, attachment disruption)? And for students not presenting with disruptive behavior disorders, how can clinicians identify the internalizing disorders (depression, anxiety, PTSD)? And what about the girls?

Universal screening is not only promising for efficient identification of disorders, but a fair and equitable referral system for distributing services. Otherwise, only the most disruptive students get the attention and mental health services. Universal screening provides practical hope for preventing children from "falling through the cracks."

Source:

Brief screening instrument for post-traumatic stress disorder
CHRIS R. BREWIN, SUZANNA ROSE, BERNICE ANDREWS, JOHN GREEN, PHILIP TATA, CHRIS McEVEDY, STUART TURNER and EDNA B. FOA
BRITISH JOURNAL OF PSYCHIATRY (2002) , 181, 158 - 162

Imagery Rescripting and Reprocessing Therapy

"Imagery rescripting and reprocessing therapy (IRRT) was originally developed in the mid-1990s for treating adult survivors of childhood sexual abuse (Smucker & Dancu, 1999). The treatment has now been expanded to other traumatic events such as industrial and motor vehicle accidents and violent assaults (Smucker & Boos, 2005).

IRRT includes four main components of treatment:

(1) imaginal exposure, which is utilized to activate the trauma memory along with distressing emotions and related maladaptive cognitions;

(2) imagery rescripting, during which the trauma memory is modified to replace victimization/traumatic imagery with mastery and coping imagery;

(3) self-calming/nurturing imagery, during which clients visualize themselves as an ADULT (today), calming, comforting, and reassuring the traumatized CHILD (back then); and

(4) linguistic processing, which involves transforming the traumatic imagery and emotions into a verbal narrative while simultaneously challenging related maladaptive beliefs (Grunert et al., 2003; Smucker, 1997; Smucker & Boos, 2005; Smucker & Dancu, 1999).

The goal of IRRT is to decrease PTSD and related symptoms through emotional processing of the trauma memory and to modify maladaptive schemas while increasing the survivor’s ability to self-soothe (Grunert et al., 2003).  

Maladaptive secondary beliefs, such as powerlessness, mistrust, guilt/shame, and incompetence, are challenged during the mastery and self-nurturing imagery rescripting phases (Smucker, Dancu, Foa, & Niederee, 1995).

Socratic questioning during the imagery rescripting reportedly helps the survivor identify, challenge, and modify maladaptive beliefs while empowering them to take mastery of the imagery (Grunert et al.; Smucker & Boos, 2005; Smucker & Dancu, 1999).

As noted by Grunert et al. (2003), imagery rescripting employs imaginal exposure “not for habituation, but for activating the images, emotions, and beliefs associated with the traumatic memories” (p. 344). This distinction may be particularly appropriate for adult survivors of child abuse with PTSD who are unable or unwilling to process their childhood traumas through intensive prolonged imaginal exposure and for whom nonfear emotions (e.g., guilt, shame, anger) are predominant (Smucker, Grunert, & Weis, 2003). Through active cognitive restructuring, imaginal rescripting allows for transformation of the traumatic memory to an adaptive one and an emphasis on positive, corrective cognitive changes to negative secondary beliefs and pathogenic schemas (Grunert et al.; Smucker & Niederee, 1995).

A number of case studies and anecdotal reports—along with an unpublished randomized pilot study with adult survivors of childhood sexual abuse suffering from PTSD (Dancu, Foa, &Smucker, 1993)—suggest that IRRT is effective in reducing PTSD symptoms and modifying trauma-related beliefs. Randomized, controlled trials, however, are needed to further empirically validate IRRT’s clinical usefulness with traumatized populations."


SOURCE:

Imagery Rescripting in the Treatment of Posttraumatic Stress Disorder
Mary E. Long, MS, PhD
Randal Quevillon, PhD
Journal of Cognitive Psychotherapy: An International Quarterly, Volume 23, Number 1
© 2009

Imagery Rescripting for Nightmares & PTSD

ABSTRACT:  The use of imagery in psychotherapy has received surprisingly little attention from researchers despite its long history in psychology and the significance of imagery in a number of psychological disorders. One procedure warranting increased attention is imagery rescripting, an imagery technique in which an image is modified in some way to decrease distress. Imagery rescripting is relatively new with a small but growing empirical base. This article briefly reviews hypothesized mechanisms for therapeutic change via imagery techniques, emphasizing imagery rescripting, and how they might be relevant in the treatment of posttraumatic stress disorder (PTSD). We review studies employing imagery rescripting as a component of treatment, followed by recommendations for future direction.

ARTICLE EXCERPTS:
"Imagery rescripting is a cognitive-behavioral technique most often used as a component of nightmare treatments, such as imagery rehearsal therapy (IRT) or, more recently, Exposure, Relaxation, and Rescripting therapy (ERRT) (Davis & Wright, 2005; Krakow, 2004; Krakow et al., 2004; Marks, 1978). IRT is currently the most commonly used technique to treat trauma-related nightmares (Davis & Wright, 2005). The effectiveness of IRT has been typically examined in a group setting over one to three sessions (Krakow, 2004). The session(s) generally include psychoeducation and cognitive skills training regarding insomnia and nightmares, an imagery rescripting component, and follow-up to discuss progress and review concerns/experiences (Krakow et al., 2000). One set of instructions for the imagery rescripting component is as follows: Choose a nightmare and modify it any way you wish; rehearse the modified nightmare for at least several minutes daily; and modify additional nightmares as necessary every 3 to 7 days, rehearsing no more than one or two new dreams per week (Krakow, Kellner, Pathak, & Lambert, 1995)."

"Some theorists indicate that imagery may be a conduit for effective therapeutic treatment of PTSD. The vivid activation of traumatic imagery in a safe setting can help survivors improve imagery control, habituate to trauma images and related physiological arousal, and identify and modify maladaptive schemas (Foa & Kozak, 1986; Lang, 1977; Laor et al., 1998; Grey, Young, & Holmes, 2002)."

It's not clear yet why imagery rescripting works.  Some believe that what helps is being exposed to the traumatic memory or nightmare until we get used to it.  But imagery rescripting worked in studies whether or not people were exposed to this painful material.  When I say "worked," I mean people slept better and felt better ("improving global sleep quality and reducing symptoms of distress.")

"Several underlying mechanisms other than exposure have been proposed to explain the
benefits of imagery rescripting, including the following:  

• The process of modifying the image results in information that is incompatible to the original experience, which further challenges and modifies maladaptive beliefs and schemas (Beck et al., 1985);
• manipulating and modifying the nightmare image results in an increase in mastery (Germain et al., 2004); 
• and it re-establishes the mind’s natural capacity to manipulate images (Krakow, 2004). 

Though these mechanisms have been proposed to explain the benefits of imagery rescripting, they have not been empirically validated, and further research in necessary."

"...studies of imagery vividness and imagery control in PTSD imply that incorporating imagery control and vivid imagery work may improve treatment outcomes (Laor et al., 1998). The results are particularly relevant to a PTSD treatment utilizing imagery rescripting because this technique specifically focuses on the client manipulating and modifying images to reduce distress. It has been suggested that the imagery rescripting component of IRT may reduce PTSD-related nightmares and sleep disturbance by re-establishing the mind’s natural capacity to manipulate images (Krakow, 2004)."

Here are some information processing theories to explain how and why using imagery works to treat PTSD:

Lang (1977) proposed a bioinformational theory for the use of imagery in treating anxiety disorders such as PTSD. This theory suggests that traumatic or fear-producing images are encoded in neural memory structures containing sensory, behavioral, physiological, and meaning elements (Lang, 1977). Eliciting these emotional images activates cognitive schemas in this fear network and can result in negative emotions, cognitions, behaviors, and physiological states. The emotional image can be used therapeutically to access the fear network, subsequent to which the information in it can be processed and the network modified. To effectively access, process, and modify this fear network, Lang stated that an individual must engage affectively and physiologically in the traumatic image through a vivid,
detailed description of the image experience (Lang, 1977; Lang & Cuthbert, 1984, 1998).

When the client gets activated by telling the story, there is an opportunity to change the associated thoughts, feelings and negative core beliefs (examples of negative core beliefs: "I should have done more," "I deserved what happened to me," "It was my fault").

Okay, this next processing theory was developed by Foa et al.:

"They extended Lang’s information-processing theory in their study of PTSD, placing more emphasis on the internal structures containing meaning of the traumatic event (Foa & Kozak, 1986). They suggest that PTSD develops in reaction to an internal neural network containing stimulus, response, and meaning representations related to the traumatic experience. This emotional processing theory suggests that to effectively emotionally process and modify the fear network and reduce fear, the network must first be activated, and then corrective, incompatible information must be integrated (Foa & Kozak, 1986). The fear network is activated through prolonged imaginal exposure during which the individual can habituate to the trauma memory and integrate corrective material about their current safety and ability to cope with the memory (Rothbaum & Mellman, 2001)."

"Finally, Chemtob, Roitblat, Hamada, Carlson, and Twentyman (1988) proposed a parallel distributed processing (PDP) model that draws from the information-processing theories of both Lang and Foa. They posit that memory structures and related emotions and actions are organized hierarchically and that information is processed in parallel distributed information processing networks. According to Chemtob et al. (1988), persons with PTSD have continued potentiation of the threat-arousal node, the highest level of the hierarchical network, and a bias to attend to threat, resulting in ongoing expectancies of threat, potentiation of the threat node, and misinterpretation of ambiguous cues. This can result in a positive feedback loop where the initial trigger activates threat-related structures and degraded stimuli triggers further activation of PTSD-related images, negative schemas, feelings, and behaviors (Chemtob et al.). Chemtob et al. argued that the hierarchical structure and its potential activation by seemingly unrelated triggers explain the intrusive symptoms of PTSD sufferers. Similar to Foa’s model, the network must first be activated, and corrective, incompatible information must be integrated through processes such as habituation (Witvliet, 1997)."


Interesting challenge or enhancement to the work of prolonged exposure:

"Prolonged imaginal exposure, largely associated with the above-mentioned cognitive theories of PTSD, is a therapeutic technique involving imagery that has been used successfully with many PTSD sufferers. Prolonged imaginal exposure has a substantial amount of empirical support regarding its effectiveness in treating PTSD resulting from a variety of traumas (Rothbaum, Meadows, Resick, & Foy, 2000). Empirical research has indicated, however, that linguistic processing of traumatic memory may not result in the physiological arousal believed to be required for habituation to occur (Cuthbert et al., 2003). Modification of traumatic images in imagery rescripting may offer an avenue for better modification of negative appraisals of the traumatic event as well as for decreasing intrusive imagery and related anxiety. Further, substituting negative imagery with positive images may result in increased ability of the PTSD sufferer to picture positive images and thoughts related to future experiences, plans, and goals (Hackmann & Holmes, 2004)."

RCTs (randomized control trials) are the gold standard for testing the effectiveness of an intervention. Here is one RCT and what they did:

"Krakow and colleagues (2000, 2001) examined the efficacy of IRT in treating chronic nightmares, reducing PTSD severity, and improving global sleep quality in women who had been sexually assaulted. Their manualized protocol consisted of three sessions in group format over a 4-week period. The first two sessions were 3 hours in length during which the following was accomplished:

• providing education about nightmares and sleep hygiene;
• challenging maladaptive beliefs related to the causes and treatment of trauma-related nightmares;
• practicing imagery with pleasant images; providing cognitive-behavioral tools that aid in managing unpleasant images;
• having participants identify one nightmare and “change it any way you wish”;
• rehearsing the modified nightmare;
• and instructing participants on how to rehearse the modified nightmares between sessions (Krakow, Hollifield, et al., 2001).

The final 1-hour session was spent examining progress in reducing sleep disturbances and discussing questions or problems. Participants in both studies reported significant decreases in nightmares and PTSD severity, as well as an improvement in sleep quality (Krakow, Hollifield, et al.; Krakow et al., 2000)."

Another RCT did something similar to the above study, but added exposure:

"Davis and Wright (2005) examined the addition of an exposure component to the IRT protocol described above. They hypothesized, based on the literature and empirical support indicating the effectiveness of exposure in reducing PTSD symptoms, that the addition of exposure would facilitate a reduction in nightmare frequency and distress symptoms. Their modified IRT protocol, ERRT, is similar to IRT except that participants spend more time exposed to the content of the original nightmare (writing and discussing it then examining trauma-related themes) and actively modifying sleep hygiene (i.e., gradual modification of negative sleep-related habits) (Davis, et al., 2003; Davis & Wright, 2005, 2006). ERRT resulted in significant decreases in reported nightmare frequency and severity, decreased symptoms of depression and PTSD, and improved sleep quality and quantity (Davis & Wright, 2007). Comparing results of the IRT and ERRT randomized controlled trials is difficult due to the differences in measures used, but ERRT appeared to result in improved sleep quality based on larger effect sizes (Davis & Wright, 2007)."

SOURCE:
Imagery Rescripting in the Treatment of Posttraumatic Stress Disorder
Mary E. Long, MS, PhD
Randal Quevillon, PhD
Journal of Cognitive Psychotherapy: An International Quarterly, Volume 23, Number 1
© 2009

The Connection between Attachment and PTSD

Insecure attachment leaves people vulnerable to traumatic events in that they feel overwhelmed and there is no safe place inside or available to them to cope.


I wish I could find the source of that statement, although it rings true enough when vetted by our own experiences.  Based on the subject and terms, I would guess I heard it from Bessel van der Kolk, trauma researcher-extraordinaire and a very plucky fellow.

Abstract about Child Abuse, Attachment and Managing Emotions

ABSTRACT:  Childhood abuse and neglect and loss of self-regulation.

AUTHOR:  van der Kolk BA, Fisler RE.
Trauma Clinic, Massachusetts General Hospital, Boston.
Abstract

Secure attachments with caregivers play a critical role in helping children develop a capacity to modulate physiological arousal. It has been shown that most abused and neglected children develop disorganized attachment patterns.

Loss of ability to regulate the intensity of feelings and impulses is possibly the most far-reaching effect of trauma and neglect.  The inability to modulate emotions gives rise to a range of behaviors that are best understood as attempts at self-regulation. These include aggression against others, self-destructive behavior, eating disorders, and substance abuse.

The capacity to regulate internal states affects both self-definition and one's attitude toward one's surroundings. Abused children often fail to develop the capacity to express specific and differentiated emotions: Their difficulty putting feelings into words interferes with flexible response strategies and promotes acting out. Usually, these behaviors coexist, which further complicates diagnosis and treatment.

Affective dysregulation can be mitigated by safe attachments, secure meaning schemes, and pharmacological interventions that enhance the predictability of somatic responses to stress. The ability to create symbolic representations of terrifying experiences promotes taming of terror and desomatization of traumatic memories.

Bull Menninger Clin. 1994 Spring;58(2):145-68.

Abstract about the Origins of Cutting/Self-Mutilation

ABSTRACT:  Childhood origins of self-destructive behavior

AUTHORS:  BA van der Kolk, JC Perry and JL Herman
Department of Psychiatry, Harvard Medical School, Boston, Mass.

OBJECTIVE: Clinical reports suggest that many adults who engage in self-destructive behavior have childhood histories of trauma and disrupted parental care. This study explored the relations between childhood trauma, disrupted attachment, and self-destruction, using both historical and prospective data.

METHOD: Seventy-four subjects with personality disorders or bipolar II disorder were followed for an average of 4 years and monitored for self-destructive behavior such as suicide attempts, self-injury, and eating disorders. These behaviors were then correlated with independently obtained self-reports of childhood trauma, disruptions of parental care, and dissociative phenomena.

RESULTS: Histories of childhood sexual and physical abuse were highly significant predictors of self-cutting and suicide attempts. During follow-up, the subjects with the most severe histories of separation and neglect and those with past sexual abuse continued being self-destructive. The nature of the trauma and the subjects' age at the time of the trauma affected the character and the severity of the self-destructive behavior. Cutting was also specifically related to dissociation.

CONCLUSIONS: Childhood trauma contributes to the initiation of self-destructive behavior, but lack of secure attachments helps maintain it. Patients who repetitively attempt suicide or engage in chronic self-cutting are prone to react to current stresses as a return of childhood trauma, neglect, and abandonment. Experiences related to interpersonal safety, anger, and emotional needs may precipitate dissociative episodes and self-destructive behavior. 

It all seems to begin and end with relationships. How do we spread the message of attachment security?  What is it?  How do we ensure it?  Do we understand what is at stake?  It is preventative and healing.  Attachment security mediates and moderates the development of PTSD - for victims of childhood abuse, for veterans, for holocaust survivors.  Regardless of the trauma, it is relationship that soothes our distress.

Evidence-Based Practice and Practice-Based Evidence

If what you are doing is working, then don't change it.

If what you are doing is not working, then try something different.

Simple and easy?  Then try these questions:

• How do you know if what you are doing is working?  What does that look like? feel like? How do you measure it?
• Are clients improving?  Are clients accomplishing their treatment goals?  How do you keep track of this?
• Do you feel competent and hopeful as a clinician?  A study showed that there is a difference in the rate of professional burn-out between clinicians who spend years of seeing clients improve (lower) vs. not improve (higher).
• A study showed that clients can be happy with their therapist and still not show any improvement in the problems that brought them into therapy in the first place.  Good relationship, but no progress - is this success?

• If you conclude somehow that it is not working, then what do you try instead?  Do you take stabs in the dark?  Reinvent the wheel? Or do you consult others who have done it or are doing it and find out what worked for them?
• Clinical supervision and consultation, way past the required 3,200 hours, is always helpful. 
• What about research?  Does going to the research literature to see what has been tried sound appealing?  If not, why not?  When I read the literature, I am amazed at how much is known (has been known for years!) about what works.  And yet, it is not being done - it is not yet the standard practice.  Approaches and interventions that could help our clients improve tremendously - sooner rather than later - lie dormant and unused.  Clients who are low-income and ethnic/racial minorities are least likely to receive evidence-based treatment.  That just sucks.  It's not always about working harder, longer hours or doing more.  Sometimes it's just about doing things differently.  Risking a ride on the learning curve - trying a new approach.  It's more work (especially emotionally) at first when learning something new.  But then, if you have chosen the right intervention for the problem at hand, it is less work with greater rewards.  Because the pay-off has already been proven effective (in clinical trials or quasi-experimental designs).

• If, in your practice, you discover something that works then do you have a responsibility to share it with others and add to the knowledge base in our field?

My daughter logged in the hours drawing this picture and my sister-in-law logged in the hours coloring it.  Enjoy!

From my quirky clan to yours - Happy Holidays and Happy New Year!

Beliefs and Placebo Response

The trick is not to be scared of our own power - defined as the ability to get things done.   I'm not saying to deny that you feel scared. I am saying don't be paralyzed or outdone by it.

We are stronger than the fears that arise. The fears may be triggered by our mistaken negative thoughts, internalized oppression, and negative core beliefs about ourselves, others and the world.

Somebody may have told us that we couldn't, or that we didn't matter or that it was impossible for us. But what if we refused to believe that? What would we accomplish then? What would that vivid and beautiful reality be like? What would be the picture in our minds eye if we believed that were true?

My mentor, Roberto Gutierrez, tells me all the time that 50% of the work is visualizing it. The rest is doing the work, overcoming obstacles and persisting through setbacks. The miracle is that it can be done. Can you see it? Are you willing to take what you imagine and make it real? What would that feel like? What would that be like when you take what you imagine and make it real? What would the people that you care about do in the service of your dream? What would they do to help you make your vision real?

So this might all just be cheese to the average cynical skeptic. But when I read about the powerful "nuisance" that the placebo response is causing to pharmaceutical companies, I smile and think that what they consider as "noise" or interference in their clinical drug trials may in fact be the power of our own beliefs to heal ourselves at work. Placebos are beating out new drugs, and established drugs for that matter, in clinical trials.

In light of what we are learning about the placebo response, I have all sorts of questions: What are the biological changes that occur as a result of feeling hopeful? What are the biological effects of fear, negativity and hopelessness? Do we fully know and understand the capacity and limits of our innate ability to heal ourselves?

     "In a study last year, Harvard Medical School researcher Ted Kaptchuk devised a clever strategy for testing his volunteers' response to varying levels of therapeutic ritual. The study focused on irritable bowel syndrome, a painful disorder that costs more than $40 billion a year worldwide to treat. First the volunteers were placed randomly in one of three groups. One group was simply put on a waiting list; researchers know that some patients get better just because they sign up for a trial. Another group received placebo treatment from a clinician who engaged in small talk. Volunteers in the third group got the same sham treatment from a clinician who asked them questions about symptoms, outlined the causes of IBS, and displayed optimism about their condition.
     Not surprisingly, the health of those in the third group improved most. In fact, just by participating in the trial, volunteers in this high-interaction group got as much relief as did people taking the two leading prescription drugs for IBS. And the benefits of their bogus treatment persisted for weeks afterward, contrary to the belief - widespread in the pharmaceutical industry - that the placebo response is short-lived."

I understand how some patients might "get better just because they sign up for a trial."  It reminds me of when my friends tell me they feel better about a stressful family or work-related problem just by making an appointment with an expert to address it.

I wouldn't call the third condition a "sham treatment" especially when some of the elements described sound like health education or psychoeducation.  Also, there may be a lot going on therapeutically when a clinician displays "optimism" about a patients condition - beliefs, mirror neurons, health effects of optimism, etc.?

I also imagine the thoughts, beliefs and expectations of patients coming to Harvard (!) for a clinical trial as compared to how they feel at their regular health care facility.  "I am going to get world-class treatment!"

So how do we harness the power of our own beliefs to heal ourselves?  Especially in light of their well researched power to best medications.  How do we infiltrate our modern culture with these age old practices of confidence, beliefs, credibility and hope?  How do we consciously and consistently pair these elements with evidence-based interventions and treatments?

When I fell and hurt myself as a kid, there was always someone near who would say to me, "sana, sana colita de rana, si no te alivias hoy, te aliviaras man~ana."  This nursery rhyme of healing words and their intention always helped a little.  How far can we push the limits and capacity of words and hope now?

Reference:  The Placebo Problem by Steve Silberman from Wired and published in The Best American Science Writing, 2010.

Five Essential Elements for Mass Trauma Intervention

"We identified five empirically supported intervention principles that should be used to guide and inform intervention and prevention efforts at the early to mid-term stages. These are promoting:
1) a sense of safety
2) calming
3) a sense of self- and community efficacy
4) connectedness and
5) hope."

Hobfoll, et al. (2007). Five Essential Elements of Immediate and Mid-Term Mass Trauma Intervention: Empirical Evidence. FOCUS, 7 (2), 221-242.

I am on a committee of the National Child Traumatic Stress Network (NCTSN) to develop a fact sheet for different audiences about coping with economic downturns. To complement the solid content developed by academicians and community providers, I wanted to add quotes from teachers to bring the information to life. So I reached out to the dedicated educators I know. What they are sending reads like inspiring poetry. I would read it to you, but I get choked up when I do. Thanks and God bless all the responders represented below:

• I feel a sense of safety when... my son is with me.
• I feel calm when... I listen to music.
• I feel I can handle challenges when...I have a plan.
• I feel connected when... I'm with my family or friends.
• I feel hopeful when... my son says " Mama when I grow up..."

• I feel a sense of safety when there are clear boundaries and rules, and those around me are also following them.
• I feel calm when my physical environment is orderly.
• I feel I can handle challenges when I know I have time to make mistakes.
• I feel connected when I receive public kudos.
• I feel hopeful when I am rested, ready, and looking at a short to-do list :).

• I feel connected when people listen.
• I feel calm when I'm on vacation with no to do lists. :-)

• I feel a sense of safety when the work day is over and I'm home.
• I feel calm after I read the Scriptures.
• I feel I can handle challenges after I slow down and pray for strength.
• I feel connected when I make time to spend it with my loved ones.
• I feel hopeful when years later my students come back and tell me what their educational goals are.

• I feel calm when I'm doing the dishes (!) and making art.
• I feel a sense of safety when someone acknowledges that I've done a good job.
• I feel I can handle challenges when I've had time to think about the problem first - even if it's only a short while.
• I feel connected when other people work with me on a solution to a problem or to create something new.
• I feel hopeful when I see progress in something I was working toward - or when a break is coming and I know I'll have time to distance myself for a little bit and come back recharged.

• I feel a sense of safety when I'm at home.
• I feel calm when there's nothing pending.
• I feel I can handle challenges when I have my husband's support.
• I feel connected when I'm with my family.
• I feel hopeful when I go to church.

• I feel a sense of safety when I have positive relationships with others.
• I feel calm when I am prepared and my environment is orderly.
• I feel I can handle challenges when I am supported.
• I feel connected when I have a mutual participation in community.
• I feel hopeful when work is completed and I work with others.

Wanna try this sentence completion activity and add to the list?

Do We Believe We Can?

According to Bandura, the concept of self-efficacy asserts that expectations of personal mastery are the primary determinants of changes in behavior.

(Do we let our beliefs make us give up before trying? Or do we try in the firm belief that we can do it.)

Expectations of self-efficacy determine the initial decision to perform a behavior and the amount of effort to expend in the behavior, as well as the amount of persistence in the face of adversity.

(Do we let our beliefs make us quit trying too soon? Or do our beliefs make us refuse to give up no matter what, until we get to where we choose to go?)

Self-efficacy has a direct influence on the choice of activities; people avoid situations that they believe they cannot cope with and become involved in activities they feel capable of handling.

(It is one thing to avoid something that we don't want - that is self-determination - that is us choosing our own behaviors, path and destiny. It is quite a different thing to defer our dreams because someone done told us that we were not capable of handling it. To which I say on our behalf - Fuck 'em. Continuing to believe that baloney after that person is / those persons are long gone is what I would call internalized oppression. Yes, that means now we are doing it to ourselves - holding ourselves down. To which I say on our behalf - Fuck 'em.)

The stronger the perceived efficacy, the more effort is expended in an activity. Those who persist in threatening situations and master the experience gain efficacy reinforcement, whereas those who choose to avoid threatening situations or cease their activities early reinforce negative efficacy expectations (Tollett et al, 1995).

If we believe that we can, then we will choose to try.
We will dig deep and double our efforts. We will persist - "do it or die trying."
Most of the time the only difference between success or failure is whether or not we give up (sure failure) or persist.
Because we refuse to give up, we will achieve whatever it is we set out to do.
Undaunted by obstacles and barriers, we overcome or cope with these stumbling blocks by problem-solving, trouble-shooting, and just plain figuring-it-out. However. long. it. takes.
This accomplishment gives us a sense of competence, mastery, confidence and control.
The next time we are faced with a choice to try something new, a sense of accomplishment from past experiences makes it more likely that we will give something new a shot again.
We are developing a track record of success. We are amassing evidence to support our belief that we can do it, through the expenditure of enough energy (work) and the logging of enough hours.

Let's Talk About It for Good Health

Facilitating open communication between parent and child is a worthwhile treatment goal when addressing childhood trauma.

Openness in discussing one's emotions is often described as an essential component in coping with anxiety that may be associated with distressful events.

Many theoretical perspectives, such as psychodynamic and cognitive-behavioral theories, hypothesize a direct relationship between healthy coping and openness in disclosing information about one's emotions and feelings.

Research supports the theoretically defined relationship between disclosure of emotions and healthy coping. Talking about feelings associated with traumatic or distressing events is linked to psychological well-being, improved functioning, better self-reported health, and better immune responses (Lutz, 2007).

Family members may be out of sync about willingness to communicate: one may continue to be quite upset as others feel ready to move on.

A breadwinner, caregiver, or single parent may suppress strong emotional reactions in order to keep functioning for the family; children may try to help by stifling their own feelings and needs or trying to cheer up parents.

Communication processes foster resilience by bringing clarity to crisis situations, encouraging open emotional expression, and fostering collaborative problem-solving.

It must be kept in mind that cultural norms vary considerably in the sharing of sensitive information and expression of feelings (Walsh, 2003).

It has been my clinical experience (working with parent and child dyads) that these difficult and often painful conversations need a clinician to mediate or facilitate the exchange in a therapeutic session if the conversation is to occur at all and be successful - with rewards that are worth all the effort.

IHI: Defining Quality: Aiming for a Better Health Care System