Mentalizing in the Development and Treatment of Attachment Trauma

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This book brings together the latest knowledge from attachment research and neuroscience to provide a new approach to treating trauma for therapists from different professional disciplines and diverse theoretical backgrounds.The field of trauma suffers from fragmentation as brands of therapy proliferate in relation to a multiplicity of psychiatric disorders. This fragmentation calls for a fresh clinical approach to treating trauma. Pinpointing at once the problem and potential solution, the author places the experience of being psychologically alone in unbearable emotional states at the heart of trauma in attachment relationships. This trauma results from a failure of mentalizing, that is, empathic attunement to emotional distress. Psychotherapy offers an opportunity for healing by restoring mentalizing, that is, fostering psychological attunement in the context of secure attachment relationships-in the psychotherapy relationship and in other attachment relationships. The book gives a unique overview of common attachment patterns in childhood and adulthood, setting the stage for understanding attachment trauma, which is most conspicuous in maltreatment but also more subtly evident in early and repeated failures of attunement in attachment relationships. For the first time, the burgeoning literature on mindfulness is integrated with the overlapping literature on mentalizing. Current research in neuroscience is linked to the main clinical concerns: attachment, mentalizing, mindfulness, and trauma. Creatively integrating these diverse perspectives, the author offers an up-to-date scientific explanation of trauma and treatment while writing in plain language without jargon for a broad audience. Thus the book is not only an essential resource for psychotherapists and counselors but also an ideal guide to give to clients to help them understand their condition and the process of healing.

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CHAPTER ONE Attachment in childhood

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CHAPTER ONE

Attachment in childhood

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hen I educate adult patients about psychiatric disorders,

I use a stress-pileup model to advocate a developmental perspective. While acknowledging the role of genetic risk and temperament, the model predicates childhood adversity as promoting vulnerability to disorder in the face of adulthood stress. Yet, taking the devil’s advocate position, I preface this presentation by posing the question: Why should you care how you got into difficulty? Why not just concentrate on how to get out of it? Patients readily assert that knowing how they got into difficulty can help them get out and stay out of it. My focus on attachment and mentalizing in development and treatment provides the substance for their assertion. I add that adopting a developmental perspective fosters compassionate understanding, particularly for patients who fail to acknowledge their history of adversity and its impact on their development. Then they berate themselves

 

CHAPTER TWO Attachment in adulthood

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CHAPTER TWO

Attachment in adulthood

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ollowing Bowlby and Ainsworth, I have been taking it for granted that attachment is as applicable to adulthood as it is to infancy. Yet not all researchers agree; attachment theorists have had to make a case for this extension from childhood to adulthood, and I start there.

The strongest case can be made for full-fledged attachment in intimate or romantic relationships, although other relationships such as close friendships can meet attachment needs to some degree.

This background sets the stage for adulthood versions of the main attachment patterns as evident in romantic relationships: secure, ambivalent, and avoidant. I also will consider various matches and mismatches between two adult partners’ attachment patterns as well as the balance between stability and change in adult attachment. The entire review prepares the ground for one of the most significant discoveries in attachment research: the transmission of attachment security and insecurity from parents to infants. Research on intergenerational transmission enriches our understanding of the three prototypical attachment patterns as they are manifested in adults’ discourse about their childhood attachment experiences. On the heels of the stark infant attachment prototypes, these two perspectives on adult attachment patterns—current romantic relationships and recollected childhood

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CHAPTER THREE Holding mind in mind

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CHAPTER THREE

Holding mind in mind

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ow that you have a good grasp of attachment theory, I hope that the concept of sensitive responsiveness has taken hold in your mind. The caregiver’s sensitive responsiveness is essential for the development of secure attachment. And your sensitive responsiveness to your own emotional distress is essential for you to maintain an internal secure base in your relationship with yourself. In identifying maternal sensitive responsiveness as the linchpin for secure attachment, Mary Ainsworth dramatically propelled developmental research forward. But sensitive responsiveness remains a broad and somewhat vague concept, and its modest link to secure attachment in studies of the intergenerational transmission of attachment security leaves room for further clarification; we are left with a “transmission gap” (van IJzendoorn, 1995) that needs filling: how do we get from parental security to infant security? There is no single or simple answer to this question, but this chapter addresses an important piece of the puzzle. The next chapter on attachment trauma addresses what is missing in the transmission of attachment security.

 

CHAPTER FOUR Attachment trauma

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CHAPTER FOUR

Attachment trauma

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have taken pains in the previous three chapters to establish a foundation in attachment and mentalizing that I consider necessary for understanding the core of trauma, namely, feeling alone in the midst of unbearably painful emotion. In this chapter, I will drive home this basic point by immersing you further in the findings of attachment research.

I use the term, attachment trauma, in two senses: first, to refer to trauma that takes place in attachment relationships; second, to refer to the adverse long-term impact of such trauma on your capacity to develop and maintain secure attachment relationships. Put simply, profound distrust is a central manifestation of attachment trauma. Plainly, such distrust undermines your relationship in which the trauma occurs. But you also can be traumatized more broadly in being unable to find comfort and security in other attachment relationships later on—including psychotherapy relationships.

 

CHAPTER FIVE Neurobiological connections

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CHAPTER FIVE

Neurobiological connections

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t is a truism that all the processes I have discussed in this book have a biological basis; this chapter provides some substance for that truism. I am not keen on what I have dubbed biomania, that is, excessive enthusiasm for exclusive focus on neurobiological findings as the be-all and end-all of understanding psychological processes and psychiatric disorders. Yet neuroscience is yielding findings that are not only intrinsically fascinating but also promise to enhance our self-understanding.

Put simply, we are now in a position to begin using our expanding knowledge about the brain to understand the organization of the mind

(Shallice & Cooper, 2011).

This chapter links current neurobiological research to the main topics of previous chapters: attachment and attachment trauma, mindfulness, and mentalizing. I also use the neurobiological framework to highlight the role of consciousness in the development of the self and in emotion regulation, giving prominence to the role of the prefrontal cortex in these processes. I make no pretense of providing a comprehensive review but rather aim to illustrate the potential contributions of neuroscience to our understanding of attachment and mentalizing and to illuminate some of their key facets along the way.

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CHAPTER SIX Treatment

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CHAPTER SIX

Treatment

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n the Introduction to this book, I proposed that understanding is the treatment, and the preceding five chapters have laid out a way of understanding attachment trauma, based on extensive research.

In effect, I have established—in the abstract—ways of mentalizing attachment truama for the purpose of orienting treatment and guiding the process of mentalizing individal patients’ experience. I respect the value of specialized, evidence-based treatments for particular psychiatric disorders.Yet these specialized approaches are of limited value in treating attachment trauma, owing to the fact that our patients present us with a panoply of disorders and problems. As in general medicine, we need specialists. But we also need generalists, and I count myself as one. Accordingly, as this book attests, I am far more invested in working collaboratively with patients to achieve understanding—a meeting of minds—than in applying any particular therapeutic techniques.

 

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