The Meadows Blog

It is estimated that each year three million cases of child abuse are reported to authorities in the United States (source: Childhelp.org). Childhood abuse comes in many forms and can be anything from physical abuse, sexual boundary violations, neglect of medical and physical needs, to emotional and social maltreatment and injustices.

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As Humans, we are intensely social creatures. Close relationships with other people are often the source of our greatest joy in life, but they can also be associated with tremendous pain and suffering. Early relationships with caregivers, siblings, and extended family are not merely a static backdrop to a mechanistic unfolding of human development - these relational experiences have profound effects on biological and psychological processes, for better or for worse. We now know that children come into the world with sophisticated neurobiological systems that are keenly attuned to the social environment and in turn these systems are shaped by the social milieu. This means that the narrative of the early social experience is written into the biology of the developing child, or in other words, nurture actually becomes nature.

Unfortunately, overt forms of childhood abuse and neglect are all too common and can result in serious long-term physical and psychological consequences. In fact, large research studies have shown that adverse childhood experiences can lead to serious health risks, including many forms of chronic illness and even shortened length of life. However, it is increasingly recognized that covert forms of relational trauma and emotional abuse can also lead to deleterious outcomes, particularly in the area of social-emotional development.

While the term "relational trauma" often connotes overt forms of maltreatment such as physical and sexual abuse, it can also be used to describe covert forms of maltreatment such as abandonment, enmeshment, parent-child role reversal, verbal abuse, love-withdrawal, and many other forms of emotional abuse. Relational trauma can be difficult for children, caregivers and outside observers to recognize, which means it can persist throughout much of childhood and even into adulthood. For this reason, relational trauma can have insidious effects on development through persistent, maladaptive interaction patterns. These social interaction patterns occur while the brain is developing and can therefore shape the way that individuals think and feel about themselves, others, and the world around them.

Attachment theory is a very useful framework for understanding how differences in the quality of close interpersonal relationships, particularly parent-child bonds and adult romantic bonds, influence health and well-being throughout the lifespan. In the mid-nineteen hundreds, John Bowlby proposed that an attachment behavioral system evolved in humans (and other animals) because it improved the chances of offspring survival and successful reproduction by fostering proximity to caregivers, protection and safety, and sense of security for the developing child. Bowlby argued that a secure attachment relationship between a parent and child doesn't lead to dependency, which was the contention of his psychoanalytic colleagues at the time, but instead creates a secure base for the child. In fact, he postulated that attachment security, and specifically a secure base, actually facilitates exploration and learning in childhood and ultimately leads to greater autonomy and social competence later in life.

According to attachment theory, when a child experiences conditions such as pain, sickness, loneliness, or fear, the attachment system is activated and there is a natural, even biological, drive to seek comfort and safety from an attachment partner. In a secure attachment relationship, the attachment figure is sensitive and responsive to the child's desire for closeness and safety. Moreover, a secure attachment relationship provides a safe haven where intense emotional states are co-regulated and the child is able to return to engaging openly with the environment. This cycle of attachment system activation, proximity and support seeking behavior, interpersonal interaction (with the possibility of co-regulation of affect), and a return to environmental exploration occurs repeatedly in the day-to-day exchanges between attachment partners. It is in the context of this repeated "dyadic dance" that patterns of attachment behavior take shape. In turn, these attachment-related patterns contribute to the organization of biological pathways in the brain and body that underlie emotion regulation capacities and mental representations of the self and others (i.e., internal working models).

Due to the attachment system's critical role in human development, it remains active even in adverse conditions, such as relational trauma, emotional abuse, neglect, and maltreatment. As suggested by Pia Mellody in her model of development, children are born "valuable, vulnerable, imperfect, dependent, and spontaneous". This precarious natural state of the child necessitates that he or she seek comfort and support from an attachment figure, even if that caregiver is ill-equipped to consistently provide a safe haven or a secure base. The child can't simply choose to not to attach - like the physiological drive to drink when thirsty, children are compelled to seek closeness and security when feeling threatened in some way. Thus, in the context of relational trauma, the child experiences an instinctive drive to find support and safety in an attachment figure who, often without malicious intent, may also be a source of fear, anger, shame, and pain.

This "double-bind" situation is emotionally and mentally confusing - the child is torn between the attachment-related drive to seek security and love, and the self-protective impulse to avoid pain and fear. It is no wonder that relational trauma often leads to an insecure attachment pattern where the child unwittingly adopts various mental and emotional strategies aimed at obtaining or maintaining a sense of relationship security, while also protecting against loss, pain, and fear. In this light, insecure attachment patterns represent the child's best efforts to negotiate incredibly complex relational circumstances and, at least in the short-term, can be seen as a successful adaptation to environmental adversity. However, in the long-run, the distorted mental representations and emotional processes that are often associated with insecure attachment relationships can have significant effects on core areas of development.

The elegant theoretical model used at The Meadows treatment centers, which is based on extensive clinical work by Pia Mellody and her colleagues, indicates that relational trauma leads to developmental immaturity by causing an individual to become polarized along five core dimensions of development: 1) self esteem (less than versus better than), 2) boundaries (too vulnerable versus invulnerable), 3) reality issues (bad/rebellious versus good/perfect), 4) dependency (too dependent versus needless/wantless), and 5) moderation (too little versus too much self-control). The model goes on to predict that relational trauma and the subsequent distortions of the core issues result in higher rates of addiction, mental health disturbances, and spiritual disconnection. Finally, the model describes how these cascading variables almost invariably lead to problems with intimacy and romantic relationships in adulthood.

While relational trauma can have direct effects on these core dimensions of development, it may be helpful to also consider the indirect effects that are mediated by the attachment relationship. For example, when a child experiences abandonment and neglect, it may be adaptive for the child to amplify or "hyperactivate" the attachment system to get proximity and support from an elusive caregiver. Under these conditions, the child may engage in energetic and insistent attempts to remain close to the caregiver out of a fear that separation will bring abandonment, loneliness, and insecurity.

As a way of making sense of a caregiver's repeated failures to be emotionally and physically present, the child often develops a deep sense of personal unworthiness - a belief that "something is wrong with me" - thereby assuming a "one-down" position. Additionally, the child may resort to mental rumination, perseveration, and fantasy about the attachment relationship as a way of keeping it alive and filling the internal void associated with its absence. These individuals often experience their own self-worth as being highly dependent on the actions of others. So, naturally they are hypervigilant and hypersensitive to possible relationship threats and can experience intense negative emotions when threatened with loss or separation. This "anxious" or "preoccupied" behavioral pattern represents one dimension of attachment insecurity and accurately describes some of the socioemotional challenges for individuals who have been exposed to relational trauma.

Another form of relational trauma is enmeshment or parent-child role-reversal, which paradoxically involves abandonment. Often, the enmeshed caregiver isn't able to meet the attachment needs of the child because he or she is getting their own needs met through the child. In contrast to attachment-related anxiety, under conditions of enmeshment, the child may find it most adaptive to suppress or "deactivate" their own attachment system so that he or she can effectively meet the caregiver's needs and thereby maintain closeness and support. In fact, over time, the child may tacitly learn that his or her own bids for proximity and security elicit disapproval, frustration, and anger from the caregiver, and actually threaten the attachment relationship.

Therefore, when the attachment relationship is marked by enmeshment, the child dutifully meets the caregiver's interpersonal demands by suppressing, avoiding, and down-playing their own attachment-related desires. This role-reversal can create a sense of false empowerment for the child and a "one-up" position. However, it can also foster an undercurrent of resentment and rebellion as the child yearns to be free of the expectations and roles given to him or her by the caregiver. Often these individuals feel unable to depend or rely on others to meet their attachment needs, so they avoid interdependence and instead resort to rugged self-reliance and a commitment to deal with adversity alone. This "avoidant" behavioral pattern represents the other main dimension of attachment insecurity. Like its counterpart, it is often associated with relational trauma and is thought to have long-term consequences for socioemotional functioning.

It should be noted that abandonment and neglect are not always associated with attachment-related anxiety, and enmeshment is not always associated with attachment-related avoidance. Certainly the reverse can be true for both types of relational trauma, and in some cases, individuals who have experienced relational trauma can show elements of both attachment-related anxiety and avoidance. Also, even though these two dimensions of attachment behavior are considered insecure, they are nevertheless organized patterns of mental and emotional strategies aimed at maintaining intra- and inter-personal equilibrium within the context of a suboptimal attachment relationship.

However, in recent decades it has been discovered that some children who are exposed to relational trauma exhibit disorganized attachment patterns involving contradictory approach-avoidance behaviors toward the caregiver. Disorganized attachment can involve various un-integrated elements of the anxious and avoidant dimensions, as well as more ominous signs such as "freezing" or trance-like expressions and coercive or controlling interpersonal behaviors. Of importance to clinicians, disorganized attachment in early childhood has been linked to later deficits in mentalization (i.e., understanding one's own and other's mental and emotional states), dissociation, and mental health disturbances.

The effects of relational trauma on the attachment system and on subsequent developmental trajectories are moderated by a number of contextual factors. For example, evidence suggests that genetic and temperamental factors play a role in how susceptible a person is to traumatic experiences. Children with the DRD4 variant of the dopamine receptor gene are more negatively affected by relational trauma than those children without the genetic susceptibility. Also, in light of the growing awareness of critical or sensitive periods in development, it stands to reason that the timing and type of relational trauma are important variables. In some cases, the negative consequences associated with an insecure attachment to a particular caregiver can be buffered to some degree by a warm and loving relationship with a different caregiver. The family system as a whole, with its intricate dynamics and various roles, is an important, but frequently overlooked moderating variable. Finally, it is important to remember that the child is an active agent in their own development, so how he or she perceives and formulates the experience of relational trauma will have considerable bearing on its developmental consequences.

There is mounting evidence that the effects of early relational trauma and attachment insecurity can reverberate across generations. Bowlby hypothesized that the attachment behavioral system remains active throughout the lifespan and that attachment-related patterns of thinking and feeling influence adult romantic relationships and parent-child relationships. It should be noted that attachment insecurity in childhood doesn't guarantee that an individual will experience significant problems in being able to bond with romantic partners or children in adulthood. However, consistent with the clinical model used at The Meadows treatment center, longitudinal research has shown that relational trauma and attachment insecurity in childhood are associated with disturbances in core developmental areas, which are in-turn related to higher rates of mental and emotional problems, addiction to mood altering substances and behaviors, and challenges in negotiating adult relationships. For practitioners who recognize and routinely encounter the intergenerational effects of relational trauma in their clinical practice, attachment theory provides an elegant framework that connects childhood attachment experiences to adult pair-bonding and parenting.

Adult attachment orientations, whether assessed by a semi-structured interview or a self-report questionnaire, generally fall on the previously noted dimensions of attachment-related anxiety and avoidance. In a series of research studies, my colleagues and I showed that adults with a history of childhood maltreatment, particularly emotional abuse, were more likely to have problems with emotion dysregulation (especially when facing fear), addictions, depression, and adult attachment-related anxiety and avoidance. Importantly, these two attachment dimensions are remarkably similar to the constructs of Love Addiction and Love Avoidance, which are an integral part of Pia Mellody's model and the clinical work at The Meadows. While more research is needed to understand how these two perspectives interface with each other, they are both extremely useful frameworks for understanding how early relational experiences influence cognitions, emotions, and behavior in adult relationships. Adult attachment will be discussed in greater detail in future articles.

Fortunately, individuals who have experienced relational trauma and attachment insecurity can receive treatment that leads to a path of true and lasting recovery. Certainly, early intervention with at-risk parents and children is ideal, but there is also much hope for adults who have experienced trauma in childhood or adult relationships. Indeed, recent findings indicate that the brain is more "plastic" or malleable than we once thought. In fact, research has shown that social experience, including therapeutic experiences, can have meaningful effects on gene expression, physiological processes, and brain function. This means that the neurobiological pathways that were sub-optimally organized in the context of relational trauma and attachment insecurity can be re-organized by the application of appropriate treatment techniques. Similar to a secure attachment relationship, effective treatment generally involves the creation of a secure therapeutic environment where raw, painful thoughts and emotions associated with past trauma can be safely explored and metabolized so that personal and interpersonal well-being can be restored. The Meadows has been offering this kind of treatment for decades and remains a world-leader in the treatment of trauma and addiction.

Jon G. Caldwell, D.O., is a board certified psychiatrist who specializes in the treatment of adults with relational trauma histories and addictive behaviors. He currently works full-time as a psychiatrist at The Meadows treatment center in Wickenburg Arizona. For a number of years he has been teaching students, interns, residents, and professionals in medicine and mental health about how childhood adversity influences health and wellbeing. His theoretical perspective is heavily influenced by his PhD graduate work at the University of California at Davis where he has been researching how early childhood maltreatment and insecure attachment relationships affect cognitive, emotional, and social functioning later in life. His clinical approach has become increasingly flavored by the timeless teachings of the contemplative traditions and the practice of mindfulness meditation.

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Note: This article is excerpted from the recent book by Peter A. Levine and Maggie Kline: Trauma Through a Child's Eyes: Awakening the Ordinary Miracle of Healing (North Atlantic Books, 2007). The article originally appeared in the Spring 2007 edition of Cutting Edge, the online newsletter of The Meadows.

Preventing and Healing the Sacred Wound of Sexual Molestation
By Peter A. Levine & Maggie Kline

Unless you have personally experienced the deep wound of childhood sexual trauma, it may be difficult to imagine how complex, confusing, and varied the long-term effects can be. This is especially true when the molestation was perpetrated by someone the child trusted, or even loved. When a child's innocence is stolen, it affects his or her self-worth, personality development, socialization, achievement and, later, intimacy in adolescent and adult relationships. In addition, these children are prone to somatic symptoms - such as physical rigidity, awkwardness, or excessive weight gain/loss - born of a conscious or unconscious attempt to "lock out" others and not be in one's own body. Also common are tendencies to live in a fantasy world, to have problems with attention (spacing out and daydreaming) and to dissociate in order to compartmentalize the awful experiences.

Sexual trauma varies widely, from overt sexual assault to covert desires that frighten and confuse a child by invading his or her delicate boundaries with unbounded adult sexual energies. When parents have experienced unresolved sexual violations themselves, or were lacked models for healthy adult sexuality in their families of origin, they may have difficulties protecting children without conveying a sense of fear and rigidity around issues of touch, affection, boundaries, and sensuality. Or conversely, parents might avoid offering either discussion or protection due to their own lack of experience in sensing, within themselves, the difference between potentially safe and dangerous situations and people.

Are Some Children More Vulnerable Than Others?
The majority of parents, communities, and school programs warn children to avoid "dangerous strangers." Sadly, strangers are seldom the problem. Other myths persist as well, such as the beliefs that only girls are vulnerable and that most assaults happen at or after puberty. Although statistics vary, the numbers of preschoolers and school-age children reporting sexual assault are astonishing. Approximately 10 percent of sexual violations happen to children younger than 5 years old , more children between 8 and 12 report molestation than do teenagers, and 30 to 46 percent of all children are sexually violated in some way before they reach the age of 18.

Sexual trauma is pervasive - it prevails no matter one's culture, socio-economic status, or religion. It is not uncommon even within the "perfect" family.
In other words, all children are vulnerable, and most sex offenders are "nice" people whom you already know! If you have been putting off talking with your children about sexual molestation until they are older, or because you are uncomfortable with the topic, we hope that what you learn here will bolster your confidence to begin these discussions sooner rather than later.

The Twin Dilemmas of Secrecy and Shame
The sexual molestation of children is further complicated by the added shroud of secrecy. Since 85 to 90 percent of sexual violations and inappropriate "boundary crossings" are committed by someone the victim knows and trusts, the symptoms are layered with the complexity of betrayal. Even if not admonished (or threatened) to keep the assault secret, children often do not tell due to embarrassment, shame, and guilt. In their naivete', they mistakenly assume that they themselves are "bad." They carry the shame that belongs to the molester.

In addition, children fear punishment and reprisal. They frequently anguish over "betraying" someone who is part of their family or social circle, and they fantasize about what might happen to the perpetrator. This is especially true if he or she is a family member on whom they depend. If not a family member, the violator is usually someone well-known. Neighbors, older children, babysitters, a parent's boyfriend, and other friends of the family or step-family are frequently the offenders. Or it may be someone who has prestige and social status or who serves as a mentor, such as a religious leader, teacher, or athletic coach. How can children know - unless you teach them - that they are not to blame when the perpetrator is not only someone known, but someone revered? Parents can pave the way to safety by teaching their children to trust and act on their own instincts, rather than submitting to an older child or adult who is using status for his or her own gratification.

What is Sexual Violation?
If sexual violation doesn't typically involve a "dirty old man" using candy to lure a child into his car, what is it? Simply put, it is any instance of anyone taking advantage of a position of trust, age, or status to lead a child into a situation of real or perceived powerlessness around issues of sex and humiliation. In other words, when children must passively submit to the will of another, rather than having the choice to defend themselves or tell someone - whether or not they are "forced" - it constitutes sexual violation or assault.

This can range from being shown pornography by a teenage babysitter, to an insensitive medical examination of a child's private parts, to being forced to have sexual intercourse with a parent or other adult. While actual rape by a parent or step-parent is less common, exposure to pornographic material or being asked to strip, look at, or handle exposed genitals, as well as rough handling during medical procedures, are far too common.

Steps Caregivers Can Take (and that adult survivors can learn) to Decrease Children's Susceptibility
Model Healthy Boundaries: No one gets to touch, handle, or look at me in a way that feels uncomfortable.
Help Children Develop Good Sensory Awareness: Teach children to trust the felt sense of "uh-oh" they may feel as dread in the gut or rapid heartbeat, which lets them know something is wrong and they need to leave and get help.
Teach Children What Sexual Violation Is, Who Might Approach Them, and How to Avoid Being Lured: Teach children how to use their "sense detectors" as an early warning sign.

Offer Opportunities for Children to Practice their Right to Say "No."
Teach Children What to Say and Do: Also, let them know that they should always tell you what has happened so that you can keep them safe and help them deal with their feelings.

In summary, let's look further at boundary development:

Model Healthy Boundaries
There is a delightful children's picture book by James Marshall about two hippopotami who are good friends. One's name is George, the other Martha. They visit and play together and have dinner at each other's houses. One day Martha is soaking in her bathtub and is shocked to see George peeking through the window, looking right at her! George was surprised at her outrage, and his feelings got hurt. He thought that this meant Martha didn't like him anymore. Martha reassured George that she was very fond of him. She explained, in a kind manner, "Just because we are good friends, George, doesn't mean that I don't need privacy when I'm in the bathroom!" George understood.

This little George and Martha story models setting boundaries, communicating them clearly, and honoring the boundaries of others. Parents need to show good boundaries themselves, respect children's need for privacy (especially between the ages of five to seven), and support them when they are in unappealing situations and are defenseless to help themselves. This begins in infancy. The following illustration will help you understand how to offer this protection:
Little baby Arthur fussed and arched his back each time Auntie Jane tried to hold him. His mother, not wanting to offend her sister, said, "Now, now, Arthur, it's OK, this is your Auntie Jane. She's not going to hurt you!"

Ask yourself what message this sends to Arthur. He is already learning that his feelings aren't important, and that adult needs take precedence over a dependent's needs. Babies show us their feelings by vocal protests and body language. They are exquisitely attuned to the vocalizations and facial expressions of their parents. Their brain circuits are being formed by these very interactions that deal with respect for feelings and boundaries around touch.

For whatever reasons, Arthur did not feel safe or comfortable in Aunt Jane's arms. Had his "right of refusal" been respected, he would have learned that his feelings do make a difference, that he does have choices, and that there are adults (in this case his mother) who will protect him from other adults whose touch he does not want. A few tactful words to Jane, such as, "Maybe later, Jane - Arthur's not ready for you to hold him yet," would leave an imprint impacting the baby's newly developing sense of self. And if his mother's appropriate protection continues, Arthur's brain is more likely to forge pathways that promote self-protective responses that may safeguard him from an intrusion and assault later in his life. Although not in his conscious awareness, these unconscious body boundaries formed in the tender years of infancy will serve him well.

Trauma is a breach of energetic and personal boundaries. Sexual trauma, however, is a sacred wound - an intrusion into our deepest, most delicate and private parts. Children, therefore, need to be protected by honoring their rights to personal space, privacy, and control of their own bodies. As different situations develop at various ages and stages, children need to know that they do not have to subject themselves to "sloppy kisses," lap sitting, and other forms of unwanted attention to please the adults in their lives.

Other Areas in Which Children Need Respect and the Protection of Boundaries
Children instinctively imitate their parents. Adults can capitalize on this favorable attribute when it comes to toileting behavior. A lot of power struggles and unpleasantness for toddlers and parents can be avoided altogether. By respecting your child's timetable, you will encourage her to joyfully model mom's behavior and toilet "train" herself. Take the "train" out of toileting, and your little boy will proudly do it like "Daddy does," at his own pace.

Prevent unnecessary trauma in this major developmental area by following your child's lead rather than by listening to the "experts" who believe in timetables. Forcing a child who is not ready to use the toilet disrespects his right to control his own bodily functions and sets a lifelong pattern of expecting to be dominated by someone else. By encouraging rather than pushing, you will be assisting your child to develop healthy self-regulatory habits and a natural curiosity about his or her own body. In some cases, you may even help to prevent eating disorders, digestive problems, constipation, and related difficulties. And, as a side effect, you'll produce happy, spontaneous children.

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