Often, during the first week of treatment at The Meadows, people will skeptically inquire, "Do experiences in childhood really continue to affect my life as an adult?" While social scientists and mental health clinicians have been exploring this question for decades, other fields of science and medicine have been slow to recognize the effects of childhood adversity on adult health and well-being. However, this trend may be changing, in part due to a very influential study by a group of researchers at the Centers for Disease Control and Prevention that are examining the long-term effects of adverse childhood experiences (ACE) on various health outcomes in over 17,000 members of a managed healthcare organization in California.
In general, the results of the ACE study1 show that adverse childhood experiences (e.g., abuse, neglect, abandonment) are relatively common and are associated with higher rates of early initiation of tobacco use and sexual activity, adolescent pregnancy, multiple sexual partners and STD's, intimate partner violence, alcoholism, illicit drug use, depression, and suicide attempts. Of course, this resonates completely with our clinical experience and treatment model at The Meadows. However, these investigators also found that adverse childhood experiences are related to elevated rates of liver disease, autoimmune disease, chronic obstructive pulmonary disease, ischemic heart disease, and lower levels of health-related quality of life.
These compelling data suggest that childhood maltreatment is associated with a variety of mental, emotional, social, and physical health problems in adulthood. In fact, results such as these have led some people to elevate childhood maltreatment to the level of a "public health threat". Yet, as indicated by the conceptual model used in the ACE study (see Figure 1), there are considerable gaps in our scientific understanding of the mechanisms and mediating pathways connecting adverse childhood experiences to the host of deleterious outcomes mentioned above.
Attachment theory has proven to be a useful framework for understanding how early relational experiences influence developmental pathways and adult functioning (see earlier article on attachment). Over fifty years ago, John Bowlby (the "father" of attachment theory) studied adverse childhood experiences in delinquent and homeless children and found that a warm, continuous, and secure attachment relationship between caregiver and child was of critical importance, not only because this biologically-driven bond enhances survival and reproductive fitness, but also because it establishes the foundation for successful social-emotional development and resiliency throughout the lifespan.
One way that attachment security may contribute to positive health outcomes is by fostering an open, flexible, and optimistic approach to life's diverse and often unpredictable challenges. The development of such a resilient approach to life may come about as repeated experiences in secure attachment relationships organize and optimize emotion-regulation strategies and cognitive representations of self and others (i.e., internal working models). Consistent with this view, attachment insecurity has been associated with rigid, maladaptive responses to environmental demands and difficulties in appropriately understanding, expressing, and regulating emotions.
As a central feature of attachment theory and resiliency, the regulation of emotion may be an important variable linking childhood adversity to the various mental, emotional, physical, and social problems described in the ACE study. To address this clinically relevant question, my mentor and esteemed colleague, Phil Shaver, and I conducted a research study2 that has been accepted for publication in the journal of Individual Differences Research. In this study, 388 young adults completed questionnaires regarding adult attachment style (e.g., secure, avoidant, anxious), emotion regulation tendencies (e.g., emotional suppression, cognitive rumination, negative affect, emotional clarity, mood repair), and resiliency (i.e., an open, flexible, and adaptive approach to life).
Consistent with our hypotheses, the results indicated that, compared to attachment security, the two dimensions of attachment insecurity (i.e., anxiety and avoidance) were associated with lower levels of emotion regulation and resiliency. Interestingly, attachment-related anxiety and avoidance were connected to these outcomes through distinct cognitive-emotional pathways. For example, people scoring high in attachment-related anxiety reported a greater tendency to ruminate on negative thoughts and experience negative emotions, while people scoring high in attachment-related avoidance frequently relied on suppression of emotion and reported problems in clearly understanding their emotional states.
These results are very congruent with general theories on attachment and with my clinical experience at The Meadows. Attachment-related anxiety (similar to Love Addiction in The Meadows model) is characterized by hyperactivation of the attachment system, involving energetic and insistent attempts to attain proximity, support, and love. Generally, these individuals are hypervigilant to possible relationship threats (i.e., rejection or separation) and respond to such threats with intense mental rumination and high levels of negative emotion (e.g., anxiety, fear, shame, or anger). On the other hand, attachment-related avoidance (similar to Love Avoidance) involves deactivation of the attachment system, inhibition of the quest for support, and a commitment to deal with threats alone. These individuals divert attention away from possible relationship threats and tend to suppress their emotions, which contributes to a lack of understanding about the nature of their emotional states.
In contrast, repeated experiences with sensitive and responsive attachment figures increase a person's general sense of safety and security and foster optimistic beliefs about others' trustworthiness and one's own ability to effectively manage distress. Security-based strategies integrate cognitive and affective processes so that emotions can be openly acknowledged and clearly understood, while at the same time, metabolized and expressed without one's becoming excessively distressed or disorganized. In summary, the results of our study suggest that secure attachment relationships optimally organize emotion regulation capacities in a manner that enhances flexible adaptation to life's demands. This relationally acquired resiliency may be underdeveloped in people who have experienced childhood adversity and may contribute to diminished health and wellness.
Fortunately, recent evidence suggests there is considerable plasticity in the neurobiological systems underpinning social-emotional processes, which means there can be meaningful changes in emotion regulation and intimate relationships. Therefore, people who have experienced childhood adversity and relational trauma are not destined to experience the negative outcomes described in the ACE study. In fact, many professionals think of the alliance between therapist and patient as a type of attachment relationship where the capacity for emotion regulation, intimacy, and resiliency can be cultivated in an environment of safety and security. Treatment is available and there is hope for recovery.
1. Felitti VJ, Anda RF, Nordenberg D, Williamson DF, Spitz AM, Edwards V, Koss MP, Marks, JS. The relationship of adult health status to childhood abuse and household dysfunction. American Journal of Preventive Medicine, 1998;14:245-258.
2. Caldwell JG, Shaver PR. Exploring the Cognitive-Emotional Pathways Between Adult Attachment and Ego-Resiliency. Individual Differences Research, 2012 (Manuscript accepted for publication; available upon request).
Attachment Theory in Action: Feeling Attachment Security in the Body
Several months ago, as I sat waiting to board a flight, my attention was captivated by an active toddler sitting (for the most part) on her mother's lap. Beneath naturally curly locks of hair, her eyes, bright and curious, darted about the busy terminal, feasting on the smorgasbord of novel stimuli. When a scruffy-looking man passed by in a wheelchair and offered a gnarled hand to the young child, she fearfully buried her face in her mother's loose-fitting sweater. The girl's mother instinctively pulled her close and whispered softly in her ear while giving the grizzled man an apologetic smile. As the man pushed on, his course laugh still lingering in the air, the girl gingerly emerged from her safe, sweater-cocoon to survey the scene. Still within her mother's secure embrace, the girl stood-up and ventured an inquisitive glance in the direction of the retreating man. Her fear had been down-regulated and she was able to explore the environment once again.
Interactions like this between a parent and child are repeated on a regular basis throughout early development. From the perspective of attachment theory, these dyadic experiences are the foundation for all social-emotional development. It is noteworthy that, from the earliest moments of life, attachment experiences are interactions between two minds and two bodies. As illustrated by the example above, the mother sensitively responded to the nonverbal intentions and emotions of the child by communicating safety and security through an embodied interaction with her child. In this way, attachment experiences, whether secure or insecure (as in the case of relational trauma and abuse), are incorporated into the body's self-regulatory systems, and as a result, can play an important role in how the body reacts and responds in close relationships later in life.
This article is part of a series on attachment theory and relational trauma (see the first article for an overview) and is meant to illustrate how attachment theory can guide a therapeutic approach that incorporates working with emotions and the body. To ensure patient confidentiality and anonymity, the clinical example in this article is a fictional account based on many different patient histories and various treatment experiences. Although the following clinical information isn't associated with one particular person, it is representative of many people who have experienced relational trauma.
Karen, as I will call her, was a 37 year-old divorced female who entered treatment after becoming depressed and suicidal following a breakup with a boyfriend. She reported that symptoms of depression and anxiety had been a problem for most of her life, but they always got much worse during periods of relationship turmoil. Similar to previous episodes, when the most recent relationship ended, she turned to alcohol and binge eating to numb the pain.
Karen reported that whenever a romantic relationship ended, she felt a profound sense of emptiness and loss. After her partner left, she couldn't stop thinking about what she might have done wrong and she feared that she would never have a healthy relationship. She fantasized incessantly about getting back together and about how she would "fix" herself to make the relationship work. These kinds of thoughts plagued her day and night until the helplessness and despair were overwhelming.
As a child, Karen's mother struggled with alcoholism and her father with workaholism; she remembered feeling like she was constantly hungry for their attention and love. In fact, as a young girl she was certain that her father had a trap-door in his office where he would disappear and carry out his "secret life". Even when her parents were available, she often worried that she was "annoying" and she feared that her desire for attention actually drove them away.
Karen's parents divorced when she was nine-years-old and their separation only intensified her father's distance and her mother's alcoholism. The pain and loneliness associated with her parents" divorce was partially ameliorated by a warm and loving relationship with her maternal aunt, who had been a stable figure throughout her life. However, at thirteen-years-old, her aunt died, and not long after that, Karen began using food and alcohol in excess to alter her mood.
Karen's childhood history indicated that she likely had insecure attachment relationships with both parents that could be categorized as ambivalent/preoccupied. In other words, her early development was marked by implicit feelings of insecurity because she was unsure whether or not her parents could consistently provide a safe and secure presence in her times of need. Additionally, she believed that this lack of security was her own fault, which led to a pervasive fear of abandonment and a preoccupation with maintaining closeness. These patterns of thinking and feeling seemed to carry-over into adulthood where her romantic relationships were characterized by an anxious attachment style and showed clear signs of love addiction (as described in Pia Mellody's work).
This kind of assessment of Karen's attachment relationships was very helpful in formulating her treatment plan at The Meadows. Recognizing that she would likely harbor tremendous fear and anxiety about rejection and abandonment, treatment providers were careful to establish a secure therapeutic environment with clear limits/boundaries and a consistent, warm, and responsive presence (elements that were missing from her early attachment relationships). Through various forms of treatment (including highly experiential inner-child work), she was able to acknowledge and process long-held feelings of pain, fear, anger, and shame regarding her early attachment relationships.
Although Karen strongly identified with the concept of love addiction, halfway through her treatment she was still struggling with intense thoughts and emotions regarding the unhealthy relationship that preceded treatment. During a session when she was particularly emotional about this subject, the therapist asked Karen to close her eyes and imagine what it would feel like to finally end the relationship and say goodbye to the relationship partner. Karen said, "It would feel like saying goodbye to a part of me... there would be a hole in there." She pointed to her chest. The therapist asked, "As you imagine that hole in your chest, what does it feel like in your body?" Karen's face winced and her eyes shut tight as she responded, "It's like a sharp, stabbing sensation."
The therapist inquired further, "As you are feeling the stabbing sensation in your chest, do you notice any other thoughts or emotions?" Karen paused, her hand over her chest now, "I worry that the hole will never be filled - that I will never find anyone else." The therapist tenderly implored, "How does it feel in your body as you say that?" Her breathing increased and her shoulders tensed upwards, "Now I feel tightness in my chest and throat." Knowing that the tightness was likely defending against something even more vulnerable, the therapist deepened the approach, "What would happen if you never found anyone else? What would that say about you?" Karen's shoulders released, she bent over slightly and began to cry, "Maybe it's me... maybe I'm just unlovable." The therapist gently asked, "How does that feel in your body?" Through streaming tears, Karen replied, "There's a deep ache in the pit of my stomach - that's where the hole leads - that's where it ends. It really hurts."
Karen was invited to stay in-touch with the deep ache in her stomach while the therapist guided her in some breathing exercises. Once Karen's emotions were more regulated, the therapist asked her to think about a relationship in childhood where she felt unconditional acceptance and love. Karen immediately identified her deceased aunt and tears welled-up in her eyes once again. The therapist queried, "If your aunt were here right now, how would she respond to the deep ache you are feeling?" Karen was still crying, but a faint smile came across her face, "She would give me a big hug and then she would just stay here with me." The therapist asked, "When you think about your aunt's response, how does that feel in your body?" Her frame straightened and her smile broadened, "It feels warm all over... more open and free inside my body." After a few moments of quiet introspection, she spontaneously added, "The ache is gone."
Relying on the wisdom of her body (and with help from the therapist), Karen was able to drop below the habitual thoughts and feelings associated with love addiction and actually experience the pain associated with early attachment insecurity (i.e., "I'm unlovable"). More importantly, she was able to contrast, and even dissolve, this deep pain through an embodied experience of secure attachment (i.e., "unconditional acceptance and love"). Later she had great difficulty describing this therapeutic process in words, but it proved to be an "emotionally corrective experience" that she carried with her throughout her treatment. Gradually, by bringing awareness to feelings in her body, and the associated thought processes, Karen learned more about her love addiction patterns and she developed tools to tap into a hidden wellspring of compassion and positive regard for herself.
Like most people, Karen's childhood experiences with attachment figures profoundly influenced how she felt about herself and her relationship partners. Indeed, the mental and emotional scripts associated with early attachment relationships are written into the neurobiology of the developing child and, often without conscious awareness, are acted out on the stage of romantic relationships. Fortunately, meaningful and lasting alterations to these scripts can be facilitated by a variety of therapeutic techniques, particularly those that are experiential in nature and involve working with emotions and the body.
THE DANCE: LOVE ADDICTON/LOVE AVOIDANCE
By MARGARITA KOUTSIS, MFT
CULVER CITY SENIOR CENTER
4095 OVERLAND AVENUE
CULVER CITY, CALIFORNIA 90232
For information on The Meadows or its southern California-based activities, please contact Colleen Capistrano, Southern California Community Relations Representative, at 800-313-7755 (714-886-7674 local) or email email@example.com
HE LOVES ME, HE LOVES ME NOT. SHE LOVES ME, SHE LOVES ME NOT. UNDERSTANDING LOVE ADDICTION AND ATTACHMENT STYLES
By VICTORIA MUNOZ MC, LPC
CHAPARRAL CHRISTIAN CHURCH
6451 EAST SHEA BLVD
SCOTTSDALE, ARIZONA 85254
PLEASE NO SMOKING ON CHURCH PROPERTY
Parking is available in both the North and South parking lots at the Church.
For information on The Meadows or its Arizona-based activities, please contact The Meadows at 800-632-3697 or email firstname.lastname@example.org
I have been working in the field of sexual compulsivity for almost twenty years and during that time I have seen a seen a shift in the attitudes and education of medical and clinical professions. For a long time sexual compulsivity was seen as an unsubstantiated disorder. It was not legitimized by clinical trials, research studies or even more profound, recognized in the Diagnostic and Statistical Manual of Mental Disorders. However, in recent years the attitudes and treatment is shifting both professionally and culturally. These changes are positive, but still I pause. I believe we can do better. Diagnosing and assessing sexual disorders is challenging. Not for the client whose behaviors are overt, having been caught with evidence in hand. This disorder can be a pattern of complex interactive behaviors that often leave the professional perplexed.
Or even more profound leave them believing they have a complete assessment of the subjective world of the addict. At The Meadows extended care treatment specifically for sexual disorders, Dakota we have seen clients, (mixed gender population) who were not diagnosed with sexual disorders. Fortunately skilled clinicians saw signs or red flags and were astute enough to refer them to Dakota.
Consider this case. A female patient came into primary care with the following presenting issues: depression, alcohol abuse, self-reported "flirting" while drinking. A skillful clinician was able to see the indicators of a sexual disorder. By the time the client discharged from extended care the clients list of sexual behaviors included; compulsive masturbation, masturbation to the point of injury, erotic literature, sexual fantasy, seductive role sex, Internet pornography including sado masochism and rape sites.
Consider the case of a 31-year-old female. Her presenting issues upon admit included; depression, Post Traumatic Stress Disorder and love addiction. After five weeks in extended care she had disclosed sexual behaviors including; working as a prostitute and stripper, seductive role sex, phone sex, affairs, anonymous sex (sex clubs and swinging), working as a dominatrix, use of urination and defecation for sexual arousal and sexually exploited by boss.
The same is true for men. This is especially true in cases where men have had same sex encounters but identify as heterosexual. The confusion and shame is so overwhelming they do not disclose, keeping it a secret. They may be willing to talk about a pornography stash or acting out with prostitutes but a complete sexual disclosure is something they are unwilling to risk.
As we all know in addiction, it is the secrets that kill. It is the shame associated with the secrets that compel the compulsive lying. It is vital that we as clinicians create a safe and healing environment for the client to unburden themselves with the truth.
I often say this work is not for the faint at heart. Sexual addiction can lead our clients into very dark, socially unacceptable behaviors that can be both shocking and disturbing. It is our responsibility as clinician to hold that safe place for our clients to heal.
This may seem like a rudimentary statement but consider the previous case; it is much easier and or comfortable to explore issues of love addiction then the dark and seedy reality of a client who views defecation as sexually gratifying.
I like the idea that it is my responsibility as a therapist to hold temporarily for the client the burden of this shame. I respectfully and skillfully urge the client to describe his or her shame and the behavior it has generated. The client hands it off to me for storage until that time in our therapy when I can hand it back to him or her for inspection. At that point, the client has grown able to appreciate that he or she is not endemically evil, but is the victim of abuse.
I am able to hold the shame, the anxious hope, whatever belief system, or whatever emotion the client is feeling, and say to this suffering and trusting person, "You know what? I believe you can work through this, and that you can and will become even more than you now believe is possible. And I will hold all the shame or other emotion for you while we are doing this work together."
What can make for successful interventions is becoming the solid ego state against which the wounded ego can collide, yet survive. I mirror for them the respect, understanding, and safety they have never known. The wounded part begins to heal. The therapist becomes the good parent. The client internalizes that identity. The healing takes place within the therapeutic relationship.
The goal of early treatment is to help clients trust that I respect them in their full humanity, even the darkest parts. I want them to understand that I can deal with their demons and find the healthy soul trapped within. This is the beginning of the healing.