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.
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.