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Abstract
Successful treatment of the psychological effects of early life trauma requires attention not only to what happened to the survivor but also to what did not happen. Early life trauma involves prolonged, recurring abuse, which is generally coupled with neglect. The survivor must try to contend with the impact of the abuse, while lacking the developmental learning that comes from having had a secure attachment figure. The chapters in this part describe five approaches to treating the complex traumatic disorders that result from childhood abuse and neglect. At first glance, all approaches are specialized, using unique language to describe their theoretical frameworks and therapeutic techniques. Nevertheless, despite the specificity of each treatment model, the chapters share a number of common themes that are interpersonal and affect focused in nature. How does the therapist help to create a sense of safety, when it is paradoxically both a prerequisite and an anticipated outcome of successful treatment? What is the affective core of trauma-related pathology and how should this be addressed in treatment? How can therapist and patient together create a relational framework within which traumatic memories can be addressed? Safety. Childhood trauma disrupts the developmental trajectory of attachment. Not surprisingly, many chronically abused individuals develop disorganized and insecure attachment styles [1], which have been associated with the development of dissociative disorders as well as other psychiatric disorders in adulthood [2]. Disruption of safe attachment leaves the survivor feeling profoundly unsafe in the world.
... It is worth remembering that both the therapy general principles and some therapeutic techniques developed to treat complex trauma and dissociation can be successfully applied to group family and couple therapies, and that particular forms of trauma and dissociation therapies have been specifically devised for application in group contexts Astrachan et al., 2010). ...
Epidemiological, clinical, and neurobiological studies of the last 30 years suggest that traumatic attachments during the early years of life are associated to specific psychopathological vulnerabilities based on dissociative pathogenic processes. It has been observed that the dissociative pathogenic processes caused by these traumatic attachments either may contribute to the genesis of well-defined mental disorders (e.g., dissociative disorders) or may variably occur in many other diagnostic categories, complicating their clinical pictures and worsening their prognosis. For this reason, we proposed to define the dimension of psychopathological outcomes linked to traumatic attachments and dissociative pathogenic processes as the “traumatic-dissociative” dimension (TDD). The clinical complexity of the TDD requires specific training to enable mental health professionals to recognize the signs of traumatic developments and to implement specific treatment strategies. The present article aims to review some crucial points about the clinical meaning and treatment strategies of the TDD, the dissociative pathogenic processes characterizing the TDD, as well as of the role of attachment trauma in the TDD. We also focused on the clinical and theoretical evidence suggesting that dissociation and dis-integration may be considered two different processes but highly correlated. The usefulness of clinical reasoning in terms of psychopathological dimensions, instead of distinct diagnostic categories, as well as several therapeutic implications of these issues was finally discussed.
The validity of the insecure/disorganized attachment pattern has been clearly established in over 80 studies with more than 100 samples. However, given that child maltreatment is considered one of the most important causes of insecure/disorganized attachment, it is notable that few studies have been published specifically examining the maltreatment/insecure attachment hypothesis. The purpose of this paper was to review the research findings and conduct a meta‐analysis to examine the effect size of maltreatment and insecure attachment across studies. A second goal was to conduct a subpopulation analysis to investigate effect size by type of maltreatment. Following a literature search which yielded 25 articles, we identified eight studies (n = 791) that: (a) consisted of children who experienced different types of maltreatment including cases of malnutrition and failure‐to‐thrive, (b) consisted of children under 48 months of age, (c) used the Strange Situation or a modification of it to measure attachment, (d) had comparison groups, and (e) contained sufficient detail to conduct a meta‐analysis. Results showed that the maltreated infants were significantly more likely to have an insecure attachment than the controls. A subpopulation analysis by type of abuse was conducted. Overall the findings support the maltreatment/insecure attachment hypothesis. The subpopulation analysis, although extremely small, indicates that different types of maltreatment affect the magnitude of the effect. These findings suggest further investigation into the differential impact by type or multiple types of maltreatment as well as the frequency of events on outcomes.
This paper reviews the evidence for the existence of a complex form of post-traumatic disorder in survivors of prolonged, repeated trauma. This syndrome is currently under consideration for inclusion in DSM-IV under the name of DESNOS (Disorders of Extreme Stress Not Otherwise Specified). The current diagnostic formulation of PTSD derives primarily from observations of survivors of relatively circumscribed traumatic events. This formulation fails to capture the protean sequelae of prolonged, repeated trauma. In contrast to a single traumatic event, prolonged, repeated trauma can occur only where the victim is in a state of captivity, under the control of the perpetrator. The psychological impact of subordination to coercive control has many common features, whether it occurs within the public sphere of politics or within the private sphere of sexual and domestic relations.
Group therapy counteracts the isolating effects of interpersonal trauma and enables survivors to connect with sources of resilience within themselves and others. By providing an alternative relational experience in which the survivor and her safety are valued, groups empower members to establish self-affirming and supportive relationships in their outside lives. The current paper reviews the psychological impact of chronic interpersonal violence and the relevant literature regarding group therapy for trauma survivors. We describe an approach to group treatment for complexly traumatized patients developed at the Victims of Violence Program, and through a clinical vignette, illustrate some of the ways in which group therapy can expand the relational world of survivors.
This study sought to determine the relative contribution of problems in emotion regulation and interpersonal functioning compared to PTSD symptoms in predicting functional impairment among women with childhood abuse histories. One hundred sixty-four treatment-seeking women completed measures of emotion regulation, interpersonal problems, PTSD symptoms, and social adjustment. Severity of PTSD symptoms was a significant predictor of functional impairment. In addition, after controlling for the effects of PTSD symptomatology, emotion regulation and interpersonal problems were both significant predictors and together made contributions to functional impairment equal to that of PTSD symptoms. These data indicate that emotion regulation and interpersonal problems play an important role in functional impairment among women with a history of childhood abuse. These factors should be taken into account in treatment planning to ensure successful rehabilitation from the long-term effects of chronic childhood trauma.
This study explored the relationships between childhood maltreatment (sexual, physical, and emotional abuse, as well as neglect), adult depression, and perceived social support from family and friends.
As part of an NIH-funded study of risk and resilience at a public urban hospital in Atlanta, 378 men and women recruited from the primary care and obstetrics gynecology clinic waiting areas answered questions about developmental history, traumatic experiences, current relationship support, and depressive symptoms.
Childhood emotional abuse and neglect proved more predictive of adult depression than childhood sexual or physical abuse. In females only, perceived friend social support protected against adult depression even after accounting for the contributions of both emotional abuse and neglect.
These findings may elucidate the particular importance of understanding the effects that emotional abuse and neglect have on adult depression, and how perceived friendship support may provide a buffer for women with a history of early life stress who are at risk to develop adult depression.
Data from longitudinal attachment studies of families at social risk indicate that disorganized attachment behaviors in infancy are important precursors to later dissociative symptomatology. This early vulnerability is related to patterns of parent-infant affective communication observable by the end of the child's second year. These longitudinal relations do not occur because of the occurrence of later trauma or abuse, which suggests that the quality of primary attachment relationships may partially account for why some people exposed to later trauma develop dissociative symptoms and others do not. It remains unclear whether the early relationship is predictive due to the onset of an internal process of mental segregation in infancy or to enduring patterns of parent-child dialog that continually reinforce the child's segregated and contradictory mental contents.
This study evaluated the effect of mentalization-based treatment by partial hospitalization compared to treatment as usual for borderline personality disorder 8 years after entry into a randomized, controlled trial and 5 years after all mentalization-based treatment was complete.
Interviewing was by research psychologists blind to original group allocation and structured review of medical notes of 41 patients from the original trial. Multivariate analysis of variance, chi-square, univariate analysis of variance, and nonparametric Mann-Whitney statistics were used to contrast the two groups depending on the distribution of the data.
Five years after discharge from mentalization-based treatment, the mentalization-based treatment by partial hospitalization group continued to show clinical and statistical superiority to treatment as usual on suicidality (23% versus 74%), diagnostic status (13% versus 87%), service use (2 years versus 3.5 years of psychiatric outpatient treatment), use of medication (0.02 versus 1.90 years taking three or more medications), global function above 60 (45% versus 10%), and vocational status (employed or in education 3.2 years versus 1.2 years).
Patients with 18 months of mentalization-based treatment by partial hospitalization followed by 18 months of maintenance mentalizing group therapy remain better than those receiving treatment as usual, but their general social function remains impaired.