The texture of traumatic attachment: presence and ghostly absence in transgenerational transmission

Work on the transgenerational transmission of trauma refers to unspoken stories across generations, but the actual mode of transmission has remained somewhat mysterious. Utilizing examples from her own life, the author illustrates how attachment patterns are a primary mode of transmission of trauma. When trauma revisits a person transgenerationally through dysregulated and disrupted attachment patterns, it is within the child's empathic attunement and search for a parental bond that the mode of transmission can be found. This will become the texture of traumatic attachment: how it feels to this child to feel connected to the parent.

Innovations in Practice: Dissemination and implementation of child-parent psychotherapy in rural public health agencies

BACKGROUND

Early trauma exposure can have long-term negative health effects. Few young children receive evidence-based trauma treatment. This article explores the feasibility of implementing Child-Parent Psychotherapy (CPP), an evidence-based intervention, in rural public health agencies.

METHOD

Twenty-three clinicians across four agencies were trained. Training outcomes and implementation barriers and facilitators were assessed.

RESULTS

One hundred twelve client-caregiver dyads began the year-long treatment; 50% are currently enrolled or have completed treatment. Barriers and facilitators to implementation were identified.

CONCLUSIONS

CPP is feasible to implement in rural community mental health agencies. Important lessons were learned related to planning, implementation, and sustainability.

Davanloo's Intensive Short-Term Dynamic Psychotherapy in a tertiary psychotherapy service: overall effectiveness and association between unlocking the unconscious and outcome

Background. Intensive Short-Term Dynamic Psychotherapy (ISTDP), as developed by Habib Davanloo, is an intensive emotion-focused psychodynamic therapy with an explicit focus on handling resistance in treatment. A core assumption in ISTDP is that psychotherapeutic effects are dependent on in-session emotional processing in the form of rise in complex transference feelings that occurs when treatment resistance is challenged. Recent research indicates that an unlocking of the unconscious, a powerful emotional breakthrough achieved at a high rise in complex transference feelings, can potentially enhance ISTDP's effectiveness. While ISTDP has a growing evidence base, most of the research conducted has used small samples and has tested therapy delivered by expert therapists. The aims of this study were to evaluate the overall effectiveness of ISTDP when delivered in a tertiary psychotherapy service, and to investigate if having an unlocking of the unconscious during therapy predicted enhanced treatment effectiveness. Methods. A total of 412 patients were included in the analyses. The average length of treatment was 10.2 sessions (SD 13.3). Multilevel growth curve modeling was used to evaluate treatment effectiveness and the association between unlocking the unconscious and outcome. A number of control predictors including type of treatment resistance were selected and included in the analyses. Outcome measures were the Brief Symptom Inventory (BSI) and the Inventory of Interpersonal Problems (IIP). About half of the patients in the study were treated by therapists in training and the other half by more experienced therapists. Results. Growth curve analyses using the full intention-to-treat sample revealed significant within-group effects of ISTDP on both the BSI and the IIP. Effect sizes were large (>0.80). Unlocking the unconscious during therapy was associated with significantly larger treatment outcome. The relationship was further moderated by type of treatment resistance. Conclusion. This study adds to the empirical base of Davanloo's ISTDP with confirmed treatment effectiveness in a large-scale patient sample when ISTDP was delivered by therapists with a range of experience. Furthermore, emotional mobilization in the form of unlocking the unconscious was confirmed as a process factor enhancing the effectiveness of ISTDP.

Mothers' alexithymia, depression and anxiety levels and their association with the quality of mother-infant relationship: a preliminary study

OBJECTIVE

To evaluate the relationship between mothers and their developmentally normal infants in terms of maternal alexithymia, depression and anxiety, and marital satisfaction.

METHODS

Fifty children between 18 and 48 months of age, and their mothers, were referred consecutively to the Infant Mental Health Unit of Ankara University School of Medicine, Department of Child and Adolescent Psychiatry. The sociodemographic features of the families and the depressive symptoms, anxiety, marital satisfaction and alexithymia levels of the mothers were assessed. The relationships between children in normal developmental stages and their mothers were evaluated and rated using a structured clinical procedure.

RESULTS

There was a negative correlation between the mothers' alexithymia scores and the quality of the mother-infant relationship (p < 0.05). Mothers with high alexithymia showed higher depression and lower relationship qualities than mothers with low alexithymia, according to the correlation analysis. When depression and anxiety were controlled, high alexithymia levels were predictive of a low, impaired mother-infant relationship.

CONCLUSION

Since alexithymia is a trait-like variable which has a negative correlation with impairment in a mother-infant relationship, it must be investigated in the assessment of mothers' interactions with their babies.

Narrative responses as an aid to understanding the presentation of maltreated children who meet criteria for autistic spectrum disorder and reactive attachment disorder: a case series study

This paper offers research case studies of four severely maltreated children who had received a diagnosis of autistic spectrum disorder. A range of measures were employed to explore the children's psychological and emotional functioning, including Theory of Mind assessment (Sally-Anne Test), attachment measures (Story Stems Assessment Profile and Relationship Problems Questionnaire), along with measures to assess general psychological and emotional well-being. Contrary to the diagnosis, the children did not reveal a theory of mind deficit. However, they did indicate a profile of difficulties in mentalisation on the Story Stems. The findings are discussed in terms of the extent to which mentalisation and theory of mind are influenced by situational factors, especially the anxiety evoked by the Story Stem attachment scenarios. Clinical implications regarding mentalisation as a state vs. trait phenomenon are discussed.

Intimate partner violence and infant socioemotional development: the moderating effects of maternal trauma symptoms

The aim of the present study was to investigate the impact of intimate partner violence (IPV) on infant regulatory difficulties at 3 months of age and infant socioemotional problems at 12 months of age. Maternal trauma symptoms were explored as potential moderators of these associations. Participants included 120 primarily low-income, ethnically diverse women and their infants. Results revealed that infants whose mothers experienced IPV during pregnancy did not have significantly more regulatory difficulties at 3 months than did infants whose mothers did not experience prenatal IPV. However, infants whose mothers experienced IPV during the first year after birth displayed significantly more socioemotional problems at 12 months, as evidenced by both maternal report and observational data. Furthermore, maternal posttraumatic stress avoidance symptoms served as a moderator of the association between prenatal IPV and infant regulatory difficulties at 3 months whereas maternal posttraumatic stress hyperarousal and reexperiencing symptoms served as moderators of the association between IPV during the first year after birth and infant socioemotional problems at 12 months. The findings highlight the detrimental impact that IPV can have on very young children and the importance of maternal trauma symptoms as a context for understanding the effect of IPV on young children's functioning.

Making meaningful connections: assessing for clinical work in a child residential setting

Purpose

– The purpose of this paper is to discuss the clinical assessment of children and the development of a multi-disciplinary team in an established residential school for children aged five to 12.

Design/methodology/approach

– Using clinical examples the paper describes how assessment can identify different levels of therapeutic need, and then how the decision is made whether or not to offer milieu therapy, music therapy, dramatherapy or psychotherapy.

Findings

– The paper suggests that children who have early histories of abuse and trauma have differing clinical needs.

Practical implications

– The implication is that children will engage better with the therapy if the level of intervention is sensitive to their state of mind, which in turn will help them make better use of the environmental provision of the school.

Originality/value

– The paper offers an original perspective on the possibilities and limitations of psychotherapeutic work with extremely vulnerable damaged children in a residential therapeutic setting, the Mulberry Bush.

Intimate partner violence exposure in early childhood: an ecobiodevelopmental perspective

Approximately 15.5 million children in the United States reside in households in which interpersonal violence is recurrent. Young children are more likely than older children to be present in the home when violence between adults occurs. In a recent technical report, the American Academy of Pediatrics renewed its call to invest in research and intervention resources for children younger than five years of age. The report also outlined the ecobiodevelopmental (EBD) framework, an emerging cross-disciplinary understanding of stress and coping response in very young children. The EBD framework explains how unresolved stress experienced by infants, toddlers, and preschoolers has toxic effects on their development. The framework could also expand opportunities for social workers who have an interest in research and clinical work involving very young children exposed to violence.

Effect of nurse home visits vs. usual care on reducing intimate partner violence in young high-risk pregnant women: a randomized controlled trial

BACKGROUND

Expectant mothers and mothers of young children are especially vulnerable to intimate partner violence (IPV). The nurse-family partnership (NFP) is a home visitation program in the United States effective for the prevention of adverse child health outcomes. Evidence regarding the effect of nurse home visiting on IPV is inconsistent. This study aims to study the effect of VoorZorg, the Dutch NFP, on IPV.

METHODS

A random sample of 460 eligible disadvantaged women <26 years, with no previous live births, was randomized. Women in the control group (C; n=223) received usual care; women in the intervention group (I; n=237) received usual care plus nurse home visits periodically during pregnancy and until the child's second birthday.

RESULTS

At 32 weeks of pregnancy, women in the intervention group self-reported significantly less IPV victimization than women in the control group in: level 2 psychological aggression (C: 56% vs. I: 39%), physical assault level 1 (C: 58% vs. I: 40%) and level 2 (C: 31% vs. I: 20%), and level 1 sexual coercion (C: 16% vs. I: 8%). Furthermore, women in the intervention group reported significantly less IPV perpetration in: level 2 psychological aggression (C: 60% vs. I: 46%), level 1 physical assault (C: 65% vs. I: 52%), and level 1 injury (C: 27% vs. I: 17%). At 24 months after birth, IPV victimization was significantly lower in the intervention group for level 1 physical assault (C: 44% vs. I: 26%), and IPV perpetration was significantly lower for level 1 sexual assault (C: 18% vs. I: 3%). Multilevel analyses showed a significant improvement in IPV victimization and perpetration among women in the intervention group at 24 months after birth.

CONCLUSION

VoorZorg, compared with the usual care, is effective in reducing IPV during pregnancy and in the two years after birth among young high-risk women.

TRIAL REGISTRATION

Dutch Trial Register NTR854 http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=854.

Trauma experience in children and adolescents: an assessment of the effects of trauma type and role of interpersonal proximity

The psychiatric sequelae associated with childhood experience(s) of trauma is complex and distinguishable from that of adult trauma exposure. Categories of impairment associated with experiences of early trauma include internalizing and externalizing emotional and behavioral problems, posttraumatic stress symptomatology, and dissociation. The present study assessed the relationship between the type of trauma experience (i.e., non-interpersonal or interpersonal) and the manifestation of a wide range of psychiatric symptomatology using prospective longitudinal data from a community sample of ethnically diverse children and adolescents (N=1676; ages 4-18). The study also examined the relationship between different types of trauma experiences (e.g., direct, vicarious, interpersonal) and levels of various symptom domains (e.g., anxiety, posttraumatic stress, conduct problems). A number of factors relevant to the relationship between early trauma experience and subsequent impairment including temperament, socioeconomic status, sex, and age were included in the analyses. Results indicated that interpersonal traumas involving significant interpersonal proximity were associated with externalizing problems (i.e., oppositional defiant and conduct problems). Direct trauma experiences and emotionality were positively associated with almost all symptom domains. Implications for the relationship between trauma and developmental psychopathology are discussed.

Attachment in adults with intellectual disabilities: preliminary investigation of the psychometric properties of the manchester attachment scale-third party observational measure

BACKGROUND

The Manchester Attachment Scale-Third party observational measure (MAST) was developed to assess secure attachment style for adults with intellectual disabilities. The psychometric properties of the MAST were examined.

MATERIALS AND METHODS

Professional carers (N = 40) completed the MAST and measures related to the construct of attachment theory [Edward Zigler-Yale Personality Questionnaire (EZPQ), Emotional Rating Scale (ERS) and the Learning Disability Casemix Scale (LDCS)] regarding individuals with an intellectual disability (N = 57). Individuals with an intellectual disability (N = 14) completed the Self-report Assessment of Attachment Security (SRAAS).

RESULTS

The MAST was found to have good internal consistency, test-retest reliability and convergent validity. MAST scores were negatively correlated with level of intellectual disability and challenging behaviour (CB) as measured by LDCS.

CONCLUSIONS

Support was provided for the reliability and validity of the MAST and a relationship between attachment security, level of intellectual disability and CB. The results of the study and implications of attachment theory for service provision are discussed.

How emotional abilities modulate the influence of early life stress on hippocampal functioning

Early life stress (ELS) is known to have considerable influence on brain development, mental health and affective functioning. Previous investigations have shown that alexithymia, a prevalent personality trait associated with difficulties experiencing and verbalizing emotions, is particularly related to ELS. The aim of the present study was to investigate how neural correlates of emotional experiences in alexithymia are altered in the presence and absence of ELS. Therefore, 50 healthy individuals with different levels of alexithymia were matched regarding ELS and investigated with respect to neural correlates of audio-visually induced emotional experiences via functional magnetic resonance imaging. The main finding was that ELS modulated hippocampal responses to pleasant (>neutral) stimuli in high-alexithymic individuals, whereas there was no such modulation in low-alexithymic individuals matched for ELS. Behavioral and psychophysiological results followed a similar pattern. When considered independent of ELS, alexithymia was associated with decreased responses in insula (pleasant > neutral) and temporal pole (unpleasant > neutral). Our results show that the influence of ELS on emotional brain responses seems to be modulated by an individual's degree of alexithymia. Potentially, protective and adverse effects of emotional abilities on brain responses to emotional experiences are discussed.

Factors associated with the use of intrusive measures at a tertiary care facility for children and youth with mental health and developmental disabilities

This study seeks to identify some of the explanatory factors associated with the use of intrusive measures among children with mental health and developmental disabilities in psychiatric facilities. Intrusive intervention data were collected using an organizational database that was developed internally at a tertiary care facility. The sample was composed of 338 children/youth aged between 6 and 18 years (mean = 12.33, standard deviation = 2.70) admitted within a 2-year period. Logistic regression was used to examine the relationship between chemical restraint, physical restraint and secure isolation, and programme type after controlling for demographic and other relevant client characteristics. The study found that the number of chemical restraints and secure isolations was higher for clients with developmental disabilities than for clients with mental health, whereas the number of physical restraints was lower for clients with developmental disabilities than clients with mental health issues. Demographic variables also predicted specific types of intrusive measures. The results of this study outline the differential factors associated with specific types of intrusive measures to control aggressive and self-harm behaviours. The paper also outlines cultural change initiatives, organizational interventions, and policy implications for best practice services for children/youth in psychiatric facilities to further reduce intrusive measures.

A review on the relationship between testosterone and life-course persistent antisocial behavior

Life-course persistent antisocial behavior is 10 to 14 times more prevalent in males and it has been suggested that testosterone levels could account for this gender bias. Preliminary studies with measures of fetal testosterone find inconsistent associations with antisocial behavior, especially studies that use the 2D:4D ratio as a proxy for fetal testosterone. However, circulating testosterone consistently shows positive associations with antisocial behaviors throughout childhood, adolescence, and adulthood, particularly in males. It is suggested that high fetal/circulating testosterone interactively influence the maturation and functionality of mesolimbic dopaminergic circuitry, right orbitofrontal cortex, and cortico-subcortical connectivity, resulting in a strong reward motivation, low social sensitivity, and dampened regulation of strong motivational/emotional processes. The link between these testosterone induced endophenotypes and actual display of antisocial behavior is strongly modulated by different social (e.g., social rejection, low SES) and genetic (e.g., MAOA, 5HTT) risk factors that can disturb socio-, psycho-, and biological development and interact with testosterone in shaping behavior. When these additional risk factors are present, the testosterone induced endophenotypes may increase the risk for a chronic antisocial lifestyle. However, behavioral endophenotypes induced by testosterone can also predispose towards socially adaptive traits such as a strong achievement motivation, leadership, fair bargaining behaviors, and social assertiveness. These adaptive traits are more likely to emerge when the high testosterone individual has positive social experiences that promote prosocial behaviors such as strong and secure attachments with his caregivers, affiliation with prosocial peers, and sufficient socioeconomic resources. A theoretical model is presented, various hypotheses are examined, and future venues for research are discussed.

Beyond belief

Psychology, including health psychology, frequently invokes the concept of belief but almost never defines it. Drawing upon scholarship associated with the ‘affective turn’, this article argues that belief might usefully be understood as a structure of socialized feeling, contingently allied to discursive practices and positions. This conceptualization is explained, and its implications for health psychology discussed with respect to research on religiosity and spirituality and debates about the value of social cognition models such as the theory of planned behaviour.

The Biology of Caring

Caring, a core tenet of nursing practice, grew out of a holistic approach. Nurse theorists often note the establishment of a therapeutic relationship as the beginning point of caring, with subsequent nursing interventions reliant upon this relationship for effectiveness. Relational exchange serves as a source of either stress or healing between participants, and rarely is its impact neutral. Relational stress, in fact, has become a primary contributor to many disease processes in terms of promotion and progression and perhaps even initiation. Patient–provider relationships have a long history in medical and nursing literature as critical to providing effective interventions, but our understanding of relational dynamics between patients and providers remains fairly superficial. This theoretical article adapts a previously described biobehavioral model to illustrate the nature and centrality of caring relationships in nursing practice. The dynamic process of face-to-face engagement is deconstructed from a psychobiological standpoint in order to understand the physiological, emotional, cognitive, and behavioral impacts of relational interaction. This understanding is then applied to the patient–provider relationship. Finally, the utility of biomarkers of stress, positive emotion and resonance, and of disease is discussed relative to the patient-provider relationship. Methodological and interpretive challenges inherent in this line of research, along with suggestions to address such challenges, are also presented.

A review on the relationship between testosterone and the interpersonal/affective facet of psychopathy

Testosterone (T) has received increasing interest in the recent years as a probable biological determinant in the etiology of male-biased clinical conditions such as psychopathy (i.e. psychopathy is more prevalent in men and leads to an earlier onset and more severe expression of antisocial and aggressive behavior in men compared to women). In this review, the authors evaluated the potential relationship between T and different constructs closely related to the core characteristics of psychopathy (affective empathy, fear-reactivity, and instrumental aggression). After a thorough examination of the literature, it is concluded that high T exposure in utero and high circulating T levels throughout important life phases (most notably adolescence) or in response to social challenges (e.g. social stress, competition) could be an important etiological risk factor in the emergence of psychopathic behavior. Nevertheless, studies consistently indicate that high T is not related to a significantly reduced fear-reactivity and is only indirectly associated with the increased levels of instrumental aggression observed in psychopathic individuals. Therefore, psychopathy is likely to arise from an interaction between high T levels and other biological and socio-psychological risk factors, such as a constitutionally based dampened fear-reactivity, insecure/disordered attachment processes in childhood, and social discrimination/rejection in adolescence and/or adulthood.

Predicting maternal sensitivity: The roles of postnatal depressive symptoms and parasympathetic dysregulation

Previous research has established that maternal depression is a risk factor for a variety of negative developmental outcomes among infants and children. Although low levels of maternal sensitivity have been hypothesized to explain this risk, the biological mechanisms underlying the association between maternal depressive symptoms and low levels of maternal sensitivity have been largely underexplored. This study examined the roles of postnatal depressive symptoms and parasympathetic nervous system functioning as predictors of low levels of maternal sensitivity, during a stressful mother-infant interaction-the reunion phase of the Still-Face Paradigm. Depressive symptoms and traitlike predispositions toward parasympathetic dysregulation, as indexed by low resting levels of respiratory sinus arrhythmia, were associated independently with less sensitive parenting. Discussion considers that during stressful mother-infant interactions, both mothers with depressive symptoms and mothers predisposed to parasympathetic dysregulation may have fewer emotional, physiological, and psychological resources with which to respond sensitively to their infants' cues.

Attachment models affect brain responses in areas related to emotions and empathy in nulliparous women

BACKGROUND

The attachment model, as assessed by means of the Adult Attachment Interview (AAI), is crucial for understanding emotion regulation and feelings of security in human interactions as well as for the construction of the caregiving system. The caregiving system is a set of representations about affiliative behaviors, guided by sensitivity and empathy, and is fully mature in young-adulthood. Here, we examine how different attachment models influence brain responses in areas related to empathy and emotions in young-adult subjects with secure and dismissing attachment models.

METHODS

By means of AAI, we selected 11 nulliparous young-adult females with a secure model and 12 with a dismissing model. Subjects underwent functional magnetic resonance, whereas imitating or observing and empathizing with infant facial expressions. Subjects were tested for alexithymia and reflective functioning.

RESULTS

Dismissing subjects activated motor, mirror, and limbic brain areas to a significantly greater extent, but deactivated the medial orbitofrontal cortex (mOFC) and the perigenual anterior cingulated cortex (pACC). During emotional faces, increased activity in dismissing women was seen in the right temporal pole. Furthermore, greater alexithymia was correlated with greater activity in the entorhinal cortex and greater deactivation in the pACC/mOFC.

CONCLUSIONS

These findings provide evidence of how the attachment model influences brain responses during a task eliciting attachment. In particular, hyperactivation of limbic and mirror areas may reflect emotional dysregulation of infantile experiences of rejection and lack of protection, whereas increased deactivation of fronto-medial areas may be the expression of the inhibition of attachment behaviors, which is a typical aspect of dismissing attachment.

Working here and now with the individual and family system: A case of a traumatized girl

From the moment of conception, each and every child lives and develops in connection with other people. Most children grow up in families formed by parent(s) and siblings, and relationships with them form an important part of the environment in which they develop. Interaction with parents and siblings affects brain development and the intrapsychic structures of the child. In the last few decades, knowledge of both normal and abnormal development of the human brain and mind has increased, revealing the complicated interplay of neurophysiology, emotions, and behavior within an individual as well as in interaction with others. In an attempt to address the challenge of working with various existing frameworks, in the Child Psychiatric Department of Tampere University Hospital, Professor Tuula Tamminen started a clinical philosophy called integrative child psychiatry. It includes looking at a child's situation from different perspectives and integrating data gathered into clinical understanding to choose the optimal treatment. In this article, I describe how I used individual child therapy, family therapeutic methods, psychoeducation, and some simple behavioral techniques in the treatment of a sexually abused girl.

The emotional foundations of high moral intelligence

Moral intelligence is grounded in emotion and reason. Neuroscientific and clinical research illustrate how early life co-regulation with caregivers influences emotion, cognition, and moral character. Triune ethics theory (Narvaez, 2008) integrates neuroscientific, evolutionary, and developmental findings to explain differences in moral functioning, identifying security, engagement, and imagination ethics that can be dispositionally fostered by experience during sensitive periods, but also situationally triggered. Mature moral functioning relies on the integration of emotion, intuition, and reasoning, which come together in adaptive ethical expertise. Moral expertise can be cultivated in organizations using the integrative ethical education model.

Overnights and Overkill: Post-Divorce Contact for Infants and Toddlers

In post-divorce and post-separation contexts, overnight visitation is being recommended with increasing frequency for non-resident parents. However, there is confusion as to whether sleepover access serves the best interests of young children. My purpose in this paper is to raise awareness and to encourage debate on children's needs regarding overnight contact during early developmental phases. I review available research and reflect critically on emerging trends with reference to attachment theory, practical experience, parental and gender rights, cultural considerations, and adversarial legal contexts. I suggest that insistence on overnight contact in highly contested matters may be a form of overkill that serves parental and legal demands more than the best interests of children, and conclude that individual cases should be assessed with reference to, amongst other things, processes of separation, reunion, and attachment.