Fundamento

Trauma Informed Relational Framework-Attachment and Trauma

The table below describes a 2-day training event developed within CHO 4 Ireland, in response to the growing awareness of the need for the adult mental health service to be trauma responsive. The training is further described thereafter.

Table 2.2: Trauma Informed Relational Care Framework Training Profile

Theoretical Framework

Trauma-informed attachment framework

Topics Covered  Childhood trauma – epidemiological perspectives: the ACE studies

 Impact of early trauma on brain development – physiological development and allostatic load

 Attachment – developmental importance and relationship to emotion regulation and social/emotional outcomes

 Putting it all together – experiential learning, witnessing developmental trauma: a window for reflection on

developmental trauma and the need for relationship repair  Integrating these understandings into trauma-informed

practices – moving from what is wrong with you to what happened to you

 Reflective practice as the bedrock for trauma-informed care Learning Aims &

Objectives

 Understand the impact of trauma in early childhood  Understand developmental trauma and its impact on long-

term functioning, in particular mental health

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understanding mental health presentations

 Use reflective practice to understanding the impact of childhood trauma in mental health presentations

Type of Learning Blended Learning

Trauma theory has resulted in a paradigm shift in how clients are understood and responded to within mental health services. As such it is imperative to have a relevant and theoretically coherent framework which encourages flexibility in responding to client needs. Since it is now broadly accepted that trauma which occurs in infancy and early childhood has an impact across the lifespan, attachment theory incorporating trauma theory can provide a conceptual understanding for clinicians regarding how developmental trauma impacts mental health outcomes.

It also reinforces awareness of how adverse early life experiences can impact on a client’s current behaviour and presentation. The figure below is a representation of how early attachment relates to the development of individual mental health.

Figure2.2: Theoretical Foundation of Attachment Theory in Mental Health

2.9.1 What is Attachment Theory?

Attachment theory incorporates evolutionary theory, developmental psychology, and neuroscience as a means of understanding how infants develop through relationships and an internal working model of the self in relation to others, which guides attention, interpretation, and predictions about future interpersonal interactions and relationships. As the figure above illustrates, attachment works in concert with both brain

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development and that of the emotional regulation system to influence mental health outcomes.

Bowlby (1969) suggests that infants develop a sense of themselves initially in the attachment relationship with their primary care-giver. Since infants utterly depend on their attachment figure for survival, the brain stem-based reflexes kick-start attachment- seeking behaviours such as eye-tracking and gaze at birth (Siegal, 2007). These later develop into proximity seeking, and so on. It is through such primary attachment relationship that infants develop the internal working models which inform how they interact with care-givers and others throughout their lives (Bowlby, 1988). Infants are not born with the capacity to recognise or regulate their emotions due to the underdeveloped frontal cortex. Thus, primary attachment relationship helps infants to develop emotional regulation (Wallin, 2007) and, as such, their social and emotional development takes place within the context of the primary relationship.

Mentalisation is an essential part of a secure attachment (Fonagy et al., 2002) whereby the child develops the internal ability to reflect on the intentions, behaviours, and motivations of self and others. Mentalisation is thought to occur when the child uses the care-givers ability to mirror the child’s affective states and inferred mental processes to make sense of both visceral and inner experiences. This takes place through the daily interactional processes between child and parent (Siegel, 2007).

2.9.2 Types of attachment, development and impact on mentalisation skills

Attachment theory purports that infant/children develop attachment styles (internal working model) are predicated on how parents attend to their attachment needs (Ainsworth et al., 1978; Bowlby, 1988). As parental sensitivity and responsiveness are a key determining factor, their capacity to recognise the infant’s distress, and to tolerate and respond in a timely manner whilst managing their own emotional state, ensures a secure attachment. In avoidant- dismissive attachment pattern, parents consistently respond with little or no care or attention to emotional needs. Since it follows that the child’s ability to be self-reliant is correspondingly validated, long-term emotional withdrawal becomes the internal working model. In an ambivalent-anxious attachment pattern the parent responds inconsistently to the child’s needs: either they are not at all available or they are excessively intrusive on the child. In this case, an internal working model emerges whereby emotions are expressed in an excessive manner: the child

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cannot self-regulate and therefore develops an over-reliance on the care-giver resulting in anger towards the caregiver. Such attachment styles inhere a protective function during childhood since they enable the attachment dynamic to be maintained. However, in adulthood these attachment dynamics can give rise to mental distress and psychopathology.

Disorganised attachment is more common in maltreated infants. However, it does not necessarily follow that an infant displaying behaviours such as stereotypies, misdirected movements, freezing, apprehension regarding parent, and so on (Granqvist et al., 2017), has been maltreated. The aetiology of disorganised attachment is varied and can include neurological or developmental difficulties, genetic predisposition, or excessive situational stress (Granqvist et al., 2017). However, disorganised attachment associated with maltreatment occurs because the child has no way of coping with the caregiver who is simultaneously the source of fear, and to whose “safe-haven” they are “genetically driven” (Danquah & Berry, 2014). This causes confusion and a fundamental breakdown in the child who is unsure whether to approach or flee from their care-giver.

Disorganised attachment is often the result of intergenerational trauma whereby the caregiver has also experienced unresolved early emotional trauma and may enter mildly dissociative states, looming over the child and arousing fear (Schore, 2015, p.122). Therefore, the type of attachment relationship established in early infancy and childhood can be a risk factor which impacts the developmental trajectory, internal working models and brain development. Disorganised attachment is a known risk factor for developing behavioural problems (Granqvist et al., 2017). However, it is more likely that a child with disorganised attachment has also encountered other stressful life events through its lifespan which perpetuate behavioral and psychological difficulties (Granqvist et al., 2017). Attachment then is not a static trait, and the impact of parents seeking help, a supportive relationship, or therapeutic intervention, can significantly alter the pathway (Granqvist et al., 2017).

2.9.3 Brain Development

Experience is responsible for the majority of postnatal brain development (Nelson, Zeanah & Fox, 2019). Thus, the quality of caregiving in early relationships is vital for healthy psychological development as it supports growth in neurobiological structures,

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the stress response system, and attentional systems (Nelson et al., 2019). The stress response system or hypothalamic-pituitary-adrenocortical (HPA) axis is the hormone system responsible for the speed with which the body responds to stressful events. As its development occurs within the first few years of life it is vulnerable to early-life environment (Nelson et al., 2019; Van Der Kolk, 2015). Studies in children who experience early social deprivation (Dozier, Manni & Gordon et al., 2006; Fries, Shirtcliff & Pollak, 2008, cited in Nelson et al., 2019) suggest that severe psychosocial neglect has a lifelong negative impact on the functioning of this system. One protective factor in the HPA axis development is the quality of attachment relationship, as caregivers act as co-regulators in response to infant behaviours, emotional states, and biological needs. The infant is supported by the caregiver to build bio-behavioural structures through experiences which progress to healthy stress response systems and secure attachment.

2.9.4 Emotional Regulation

Emotional regulation is defined as the capacity to influence the experience and expression of one’s emotions (Rutherford, Wallace, Laurent & Mayes, 2016), and there is some evidence to suggest that emotional regulation is influenced by a genetic component (Eisenberg & Morris, 2002). There is also agreement that familial socialising with the parent shapes this ability (Bariola et al., 2012; Zeman, Cassano, Perry-Parrish & Stedegall, 2006).

Siegel suggested it is “in the face” of the early attachment relationship through marked mirroring and partial contingency mirroring that the infant beings to recognise and internalise differing emotional states (Siegel, 2007). Parents are believed to socialize their child’s emotional regulation through: 1) learning through direct observation of the parent (modelling); 2) the parenting practices, i.e. if a parent responds to a child with conditional regard whether positive or negative is associated with internalising or externalising difficulties; and 3) parent-child attachment (Rutherford et al., 2016). At the heart of emotional regulation is the ability to recognise and reflect (reflective

function) our own and others’ emotions and to decide how we will respond. The impact

of developmental trauma as understood within the attachment relationship provides clinicians with an understanding that supports a paradigm shift in how the client’s current behaviour is understood in relation to past experiences. The relational aspect of

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attachment theory also provides mechanisms through which clinicians can begin to reflect on and change their practice.