Sanctuary for the Abused
Wednesday, January 17, 2018
Attachment to the Perpetrator
Colin A. Ross, M.D.
Over the last few years I have come to believe that a core problem in the psychotherapy of dissociative identity disorder is the problem of attachment to the perpetrator. This is also true for survivors of severe chronic childhood trauma who do not have D.I.D. The treatment that follows from this new model is different from the treatment of the ‘90s which focused more on memory recovery and abreaction. My sense of things is that the dissociative disorders field as a whole is shifting in this direction, away from “memory work” as such.
Memories are still a major element of therapy, and the trauma of the past is still talked about a lot. It’s a matter of a shift in emphasis rather than a change to a whole new way of providing therapy.
In the old model, which goes back to Pierre Janet in the nineteenth century, the idea was that the blocked memories were driving the symptoms – uncover the memory, process it and the symptoms go away. The key thing was to recover the information about what happened and all the feelings that go along with it. The old model was not wrong, it just wasn’t complete. For one thing, recovery involves learning a lot of new skills, not just abreacting trauma.
In this new model, the core problem is attachment, not dealing with memories and feelings as such. All baby birds and mammals must attach to a caregiver in order to survive. The attachment systems that control the behavior of mother and child (also father and child) are built-in genetically. The baby bird does not decide to chirp for food, and the mother bird does not decide to go out collecting food. All this just happens. The same is true for human children. A baby does not conduct rational adult analysis of human interaction patterns and then decide that crying has positive survival advantage. The baby just cries.
Similarly, the nursing mother who has a letdown reflex when her baby cries does not consciously decide to release more oxytocin from her brain in order to make her milk flow. Her body just does that for her. There are countless attachment behaviors that are built-in biologically. The parents also make conscious decisions about how to take care of the child for which they are responsible as adults. But the little child just attaches naturally in order to survive.
The basic goal is survival. Attachment serves that goal. This is true biologically, emotionally, humanly, spiritually, however one wants to look as it. To thrive and grow the child must attach to its caretakers. Separation and individuation from these caretakers is a task that is down the road developmentally, from the perspective of the newborn baby.
In a reasonable, healthy family this works out reasonably OK. The parents are imperfect and everybody has the usual neurotic conflicts about not having gotten all the love and nurturance that would have been ideal and perfect. We all have ambivalent attachment to our parents to some degree; we all are faced with the task of separation and individuation and none of us are complete successes.
In a family with active physical, sexual, or emotional abuse, however, things are different. The young child in this family – say it is a girl – must attach to her father for her survival. She cannot run away from home, get married, or go away to college because she hasn’t even gone to kindergarten yet. She depends on her parents for food, clothes, a roof, and her basic survival needs. She also needs her parents for her emotional and spiritual development. The problem is that the father she must attach to, in order to survive, is also the perpetrator who is abusing her.
Just as love, approach and attachment to parents are built-in biologically, so is the recall reflex. If you touch a hot stove by mistake, your brain pulls your hand away even before you consciously experience the pain. Your biology does this for you, without any conscious analysis or decision-making. Similarly, your body goes into recoil mode from child abuse automatically. You just automatically withdraw, pull back, and shut down.
One way to cope with the abuse would be to go catatonic. This would be developmental suicide. Except possibly in rare cases (which therapists never see in their offices) the body will not allow permanent catatonia – the attachment systems must be kept up and running for the organism to survive whether it is a child, a kitten, a bird, or a rabbit. There must be an override of the withdrawal reflex.
How can this be accomplished? By dissociation. The fundamental driver of the dissociation, in this way of looking at things, is the problem of attachment to the perpetrator. In order to survive, the child must attach to the person who is hurting her. There is no escape and no other option. In order to maintain the attachment systems up and running, they cannot be contaminated by the traumatic information coming in through the sense; that reality must be dissociated.
What difference does this model make in therapy? First, the focus of therapy is not on the content of the memories – the target is the ambivalent attachment. This ambivalent attachment is visible in current relationships and in the structure of the internal world.
This is true whether the diagnosis is DID, PTSD, DDNOS or borderline personality disorder. Borderline personality is an inevitable consequence of the problem of attachment to the perpetrator and is a biologically normal human response to severe chronic childhood trauma.
A focus on the problem of attachment to the perpetrator sidesteps most of the controversy about false memories since the content of the memories is not the main concern. If the memories are accurate, they explain how the problem of attachment to the perpetrator arose; if they are inaccurate, they symbolize that problem. Either way, the ambivalent attachment is the focus, not the content of the memories.
In the new model, there is much, much less abreaction in therapy, if any. By this I mean, the kind of full-tilt abreaction where the person is back in the past, reliving the trauma as if it is happening all over again. Within the new model, abreaction is unnecessary and retraumatizing. What does occur is what I call intense recollection. The description of the trauma is still intense, vivid, and difficult, but it is grounded. Even in relatively pure cognitive therapy, as I do it, there is lots of intense feeling.
The first goal of therapy is to hold both sides of the ambivalent attachment in consciousness at the same time – to feel both the love and the hate. The love is always there, somewhere. I believe it is biologically impossible to extinguish your love for your parents, no matter how abusive they were.
Therapists can make a mistake by identifying with and supporting one side of the ambivalent attachment only. A not uncommon error is to validate and identify with only the anger, and push the love, attachment and approach underground. A pseudo-resolution of ambivalent attachment can occur when there is an artificial complete separation from the parents – this can be just a cover for unresolved ambivalence.
This error by therapists is a fertile ground for false memories.
In some situations, the parents are in fact so manipulative and abusive in the present day that complete separation is the only healthy option. That’s not what I’m talking about. I am thinking of people whose parents are semi-OK in the present and who are missing out on a limited positive relationship in the present because they have shut down the positive side of their attachment.
Once both sides of the ambivalent attachment are held in conscious awareness at the same time, and processed a bit, the next step is grief work. One must mourn the loss of the parent one never had. The task is to dissolve the unrealistically all-good or all-bad parent, deal with the actual disappointment and loss, and complete the task of separation and individuation. This is a job we are all working on. Those who were not severely physically, sexually, or emotionally abused as children have a much easier time because they did not have to dissociate in an extreme way to survive extreme conditions.
One reason I like this model is because it makes the extreme nature of the trauma clear, but emphasizes the fact that the core of therapy is a common human problem.
Labels: abuser, childhood abuse, memories, reactive attachment disorder, repetition compulsion, stockholm syndrome, trauma
Saturday, November 24, 2012
Reactive Attachment Disorder (RAD)
RAD: What Is It?
As a fairly new diagnosis to the DSM-IV manual, Reactive Attachment Disorder (RAD), sometimes known as Attachment Disorder (AD), is frequently misunderstood, and is misdiagnosed as Bipolar Disorder or Attention Deficit Disorder (or even NPD) as often as 70% of the time.
Today, perhaps more so than at any point in history, kids are apt to be separated, ignored, or neglected by their birth parents, shuttled between multiple foster parents and day care workers, or traumatized by physical, sexual, or emotional abuse. Even while physically present, some mothers are yet incapable of providing adequate care and attention for their children.
RAD kids have learned that the world is unsafe, and that the adults around them can’t be trusted to meet their needs. They have developed a protective shell around their emotions, isolating themselves from dependency on adult caregivers. Rather than depending on their parents or other adults to protect them, the protective shell becomes the child’s only means of coping with the world.
Dependent only upon themselves for protection, they come to see anyone who is trying to remove this protective barrier as a threat, not to their emotional well being, but to their very lives. They turn on those who seek to help them the most.
People require attachments with others in order to develop psychologically and emotionally. Attachment is the bond that normally develops between a mother and her child during the first few years of a child’s life. The quality of this bond affects the relationships that a person will have for the rest of his life.
Attachment develops in the early years of life when a mother responds to her baby’s cries by meeting its needs, appropriately feeding, consoling, soothing, and comforting, as well as keeping the infant safe from abuse and harm.
Fundamental to RAD kids is that they haven’t bonded and are unable to trust. They have learned that the adults in their lives are untrustworthy. Trust hasn’t worked for them. Without trust, there cannot be love, and without love they are emotionally underdeveloped. Instead of love, rage has developed within them.
In the first few years of life, at a time even before they have learned to speak, they have learned that the world is a scary place, and that they cannot rely on anyone else to get them through it.
Normal parenting doesn’t work with RAD kids. Neither does traditional therapy, since these therapies are dependent upon the child’s ability to form relationships that require trust, something that is at the root of the problem. Sticker charts and behavioral programs don’t work because the RAD child doesn’t care what you think about his behavior. Natural consequences work better than lectures or charts. Structure is a necessity, but only when combined with nurturing.
While these kids can be healed, they have to want it, and the prognosis is not good. Without healing, these kids grow up unable to form healthy relationships with other human beings. Too often, these kids develop into sociopaths devoid of conscience or concern for anyone other themselves.
Stages of Conscience Development
Indicates stages of normal development. Some children do not move through stages within the time frames described below. Others seem to regress to Shame during adolescence. Attachment disordered children are often stuck in Pleasure/Pain.
Pleasure/Pain
The child does what brings him pleasure and avoids what brings him pain. The child has no inner moral code, and no awareness of other’s feelings or needs. This stage is typical of children under the age of three. Children with attachment disorder are often stuck here.
If I misbehave long enough, people will give up and I can do whatever I want.
You’re not my friend if you don’t take my blame.
Shame
The child feels bad when criticized or punished. The child feels shame. By apologizing, asking forgiveness, distracting behaviors, or a wide range of other coping skills, the child will focus on eradicating the feeling of shame, but not on changing the behavior that led to the feeling.
Sometimes a child will stick to one strategy for making the shame go away, whether it is effective or not. At this point in development, the child is not likely to be focused on the effects of his behavior on others. This stage is typical of children age 3 to 7.
Before the age of 5, children don’t understand the concept of possession. Normal kids may not understand stealing until the age of 9.
Children in this stage want the parent’s approval, but once they are out of your sight that’s not enough to sustain them.
I did something wrong and I want to make the shame go away.
If I think you’re watching, I’ll behave.
Mature Guilt
The child wants to live in a way that brings pleasure to himself and others. When the child hurts others, they see the effects of their behavior on on the other party, feel guilt, attempt to make amends, and change their behavior. The child tries to find another way to meet his needs without hurting others. Under good conditions, this stage is typical of children age 7 to 11.
Essentially honest and able to accept blame.
What would happen if everyone took things?
Basic Environmental Conditions for Emotional Health
A relatively stable, predictable environment in which the child knows how to get their needs met.
An environment in which the child can be stopped from hurting themselves and others.
A sense of being loved as a person, even after misbehaving.
An environment in which punishment or reward is based on the child’s behavior rather than the moods of adults.
Discipline Techniques for Each Stage of Conscience Development
Pleasure/Pain
With infants and toddlers in pleasure/pain who have little awareness of expectations, consequences, or other’s needs, our discipline approaches need to be based on:
Childproof environments to reduce tension.
Prioritize misbehaviors to be acted upon.
Rely on action and distraction rather than requests or orders.
Immediate use of timeouts after misbehavior.
Not recommended for attachment disordered children.
Continuous use of praise and rewards and other positive reinforcements.
Ignore minor misbehaviors when possible.
ShameWith young children who have some, but not enough, awareness of expectations and other’s needs, our discipline approaches need to be based on:
Communication of expectations and needs of others.
Restitution in order to make amends in addition to apologizing.
Develop a sense of empathy through constant discussion of emotional needs of others.
Use of logical and natural consequences to correct misbehaviors rather than
punishments.
Continuous praise for proper decisions made by child.
Using invectives, surprise rewards, and tangible rewards to reinforce specific expected behaviors.
Mature Guilt
Both children and adolescents benefit when the important adults in their lives encourage discussion of:
Usual feelings and typical reactions to other’s behaviors.
The effects of their behaviors on others.
Negotiating problems by looking at options and the consequences that might result.
Parental expectations that the child regulate his own behavior.
Behavioral consequences to actions, yet avoiding the tendency to over-punish.
Praise to continue to reinforce expected behavior.
Rewards are often the inner pleasure the child receives by meeting expectations.
With Older Children and Teens in Pleasure/Pain, Add the Following Recommendations:
An environment with clear, predictable structure in which there are immediate positive and negative consequences for wanted and unwanted behaviors.
A short published list of rules that the child has signed and dated.
The rewards and consequences to behaviors are determined by the adult and the youth.
Caregivers who act rather than react. It may be a waste of time and energy to tell
the child to do something or not to do something if the adult is not prepared to follow up with action.
Adults who will protect themselves by limiting the power the child has over them.
Adults who will find others to support their self-esteem, get away regularly, and not let the child provoke battles in adult relations.
In Addition to Basic Behavior Modification, Effective Approaches for Working With a Child Stuck in Shame Include:
Emphasize restitution to the person harmed by their behavior.
Adults must prepare for the child’s efforts to make them feel guilty for the punishment.
Using descriptive, specific praise frequently.
Deal with the child’s misbehaviors before the adult gets angry.
Disconnect how the adult feels from how the child feels. The child may be unhappy, but the adult doesn’t have to be.
Talk about feelings only when the level of conflict is low; otherwise focus on behavior.
Labels: anger, children, fear, reactive attachment disorder, shame, unsafe
