The assessment and treatment of interpersonal violence from an attachment theory perspective

Daniel Sonkin, Ph.D.
http://www.danielsonkin.com/

How to use this CEU program

 

     Read the web page as you would any online article.

     You may have questions as you read, if so, just click on the highlighted “Contact Dr. Sonkin by email” link placed periodically throughout the text.

     There are also web resources mentioned throughout the presentation (eg. http://www.danielsonkin.com).

     I hope you find the presentation useful in your clinical practice.

 

What will you learn in this training?

 

     Learn about confidentiality and abuse.

     Learn about motivation and suitability for treatment.

     Learn how to structure a domestic violence assessment with perpetrators and victims.

     Learn how to identify the different typologies of perpetrators and victims of violence.

     Learn about the effects of violence on parenting.

     Learn about the neurobiology of abuse.

     Learn about risk assessment.

     Learn about abuse in same-sex relationships.

     Learn about the use of psychometric tools in assessment.

     Develop a basic understanding of attachment theory.

     Learn about assessing adult and child attachment.

     Learn how to conceptualize the therapeutic alliance from an attachment perspective.

     Learn to how to conceptualize domestic violence treatment from an attachment theory perspective.

     Learn how to address unresolved trauma and loss with perpetrators of violence.

     Learn about “earned security.”

 

Let’s begin with the goals of the assessment process.

 

When working with domestic violence perpetrators and victims, it is critical that therapists have a clear plan for assessing clients. Here is a list of the general goals of the assessment process.

 

Goals of assessment process

 

     Procure appropriate authorizations to release information.

     Procure a comprehensive history of domestic violence, child abuse, and psycho-social history.

     Assess for typology and diagnosis of perpetrators, victims and children.

     Assess for neurological correlates to violence

     Assess the risk for further violence

     Assess for continued risk to children

     Assess for individual parenting capacities

     Develop assessment-based treatment plan

 

Confidentiality and Violence

 

     Confidentiality is a significant issue with clients who are experiencing domestic violence.  Although there is no mandate to report adult domestic violence (unless you work in a medical facility; Penal Code 11160-11163.5), there are a number a legal and ethical issues that therapists should be aware of when identifying cases involving domestic violence.

     Research suggests that there is a considerable overlap between domestic violence and child physical abuse.  Hence a mandatory report may be required in some cases (Penal Code 11166-11174).

     The vast majority of children are aware of or witness violence between their parents.  This fact suggests that a significant number of children are experiencing psychological maltreatment and therefore a mandatory or permitted report may be necessary depending on the specifics of the case - in particular the therapist must assess whether or not the witnessing of violence has caused mental suffering with the child.

 

Do therapists have a duty to report child abuse in domestic violence cases?

 

     California law makes a distinction between mental suffering (PC: 11165.3), which is a mandatory report, and emotional abuse (PC: 11166.05), which is a permitted report. 

     Although it is good public policy to maintain this distinction, the legislature has done little to assist mandated reporters to differentiate these two types of abuse.

     From a clinical perspective, I believe mental suffering has resulted in some identifiable emotional, cognitive or behavioral effect on the child (e.g., depression, low self-esteem, aggression), whereas emotional abuse is likely to cause some effect over time but is not obvious at the moment.  It seems like an arbitrary distinction, but it’s the approach I have found useful over the years.

     At the same time, the CA. Family Code 3020-3032 states, “…The Legislature further finds and declares that the perpetration of child abuse or domestic violence in a household where a child resides is detrimental.” 

     This statement in law suggests that a mandatory report may be required in case where children witness violence.  However this issue is yet to be resolved on a public policy level.

 

Do therapists have a duty to investigate child abuse?

 

     In a recent case, the CA Supreme Court (Alejo vs. City of Alhambra) stated in an opinion that, “…the whole system depends on professionals (mandated reporters of child abuse) who initially receive reports of child abuse to “investigate”, and where warranted, report these account to the appropriate agencies.”

     This was  a case where a father made report to the police about alleged abuse of his son by mother’s live-in boyfriend.  The police didn’t follow up on a report made by a father.  The family sued the police department and the Supreme Court agreed with their position.

     Unfortunately, in its opinion, the Supreme Court confused the duties of the police with the reporting duties of other mandated reporters.  Of course, the police are supposed to investigate.  But other mandated reporters neither have those skills or resources - nor is it mandated in the child abuse reporting law. 

     The reporting threshold is and still remains,  reasonable suspicion.”   This “investigative duty” that has been suggested by the court, will hopefully be cleaned up by subsequent legislation.

 

Confidentiality and Violence

 

     Similar mandatory reports of abuse would be required if the victim was disabled and between the ages of 18 and 64, or an adult over the age of 65 (Welfare & Institutions Code 15610-15650).

     In cases where the therapist determines that the client is a danger to self or others, state law permits (1024 Evidence code) therapists to violate confidentiality to prevent the threatened danger.

     In addition, therapists are required to report specific threats made by patients regarding an identifiable victim.  In California, you are immune from liability if your report such threats to law enforcement authorities and the identifiable victim(s). (Civil Code: 43.92).

 

Patient Disclosures

 

     Therefore, confidentiality policies need to be explained thoroughly to the client and may be broken down in the following ways:

     Mandatory disclosures: child abuse, elder/adult dependent abuse and Tarasoff reporting

     Permitted disclosures: certain form of child maltreatment or elder abuse, danger to self, others or property of others.

     Authorized disclosures: contact with courts, other mental health/medical professionals.

 

Contact with others

 

     It is critical that all statements about domestic violence be corroborated by interviews with victims, and child witnesses, (even friends and extended family members if available through interview or through legal declarations).  Many victims may not directly tell others about their violence experiences therefore corroboration may be difficult, but therapists are encouraged to procure records to determine the exact nature of the abuse occurring in the family.

 

Examples of other authorizations to procure

 

     Medical providers (family doctor, specialists, dentists, chiropractor, etc.)

     Mental health or substance abuse treatment providers

     School records and interviews with teachers and daycare providers

     Criminal justice records (including probation reports, stay-away orders)

     Civil proceedings documents (including divorce and TRO pleadings)

     Child Protective and other social services reports

 

If you have questions about confidentiality…….contact Dr. Sonkin via email

 

Psychiatric Diagnosis and Typology

 

One of the most fascinating areas of study in the past ten to fifteen years has been the issue of typology and diagnosis. The concept that batterers represent a heterogeneous population is not just a philosophy - it is a fact based on empirical research. Similar research is now being done on victims of abuse. Let’s look at what is known to date.

 

What are the most common diagnoses observed in perpetrators and victims?

 

     Depression, anxiety or a combination of the two

     Psychoactive substance abuse and dependency

     Post-traumatic stress disorder

     Neurological disorders

     Personality disorders

 

Therefore therapists…..

 

     Need to assess for diagnosis with each client (ideally both clinically as well as psychometrically).

     Make appropriate referrals for medication assessment and management.

     Consider diagnostic criteria when making treatment recommendations.

     Take into account diagnostic criteria when assessing treatment effectiveness.

 

Batterer Typology

 

     From early on, clinicians noticed that not all batterers fit the prototype described by the early writers in the field.  As early as the late 1970s clinicians were writing about the different types of batterers.  Although these conceptualizations were based solely on clinical observation, researchers quickly took notice of this and began to look for distinguishing qualities. What emerged was very similar patterns identified by different research groups across the US and Canada.

     Ironically, each research group identified three types of batterers that followed a consistent pattern.  One type was characterized as impulsive and emotionally reactive, another was described as cold and calculating and a third group that was over-controlled with periodic explosions.  Each group clustered into different diagnoses or personality disorders which suggested that treatment for each type might be uniquely different.  What follows are each research group and the types of batterers identified. 

 

Batterer Classification Systems

 

     Hamberger and Hastings 1986:

n  Antisocial/Narcissistic

n  Schizoid/Borderline

n  Dependent/Compulsive

 

     Holzworth-Munroe & Anglin (1991)

n  Generally violent/antisocial

n  Low level antisocial was identified in 2000

n  Dysphoric/Borderline Passive

n  Dependent (Family only)

 

     Saunders (1992)

n  Generally violent

n  Emotionally volatile

n  Emotionally suppressed

 

     Tweed and Dutton (1999)

n  Psychopathic

n  Borderline

n  Over-controlled

 

What do these typology systems have in common?

 

     They each include an antisocial or psychopathic group whose violence is more deliberate or instrumental.

     They each include a dysphoric group whose violence is more impulsive.

     They each include a lower-level violence, a slightly higher psychologically functioning group whose violence is more sporadic.

 

Let’s look at one system developed by Don Dutton at the University of

British Columbia, and described in his book, The Abusive Personality.

Dutton describes his typology of batterers across two continuums.  Over control vs. under control and Impulsive vs. Instrumental.

 

n Over controlled: deny rage while experiencing chronic frustration and resentment

n Under controlled: act out frequently

n Instrumental: use violence “coldly” to obtain specific objectives

n Impulsive act out in response to a building inner psychological tension

 

Batterer Typology: Research descriptors

 

Let’s look at what psychological patterns Don Dutton found empirically in each of the types of batterers he identified.

 

 

Psychopathic Batterers

 

     Violence inside and outside home

     History of antisocial behavior (car theft, burglary, violence)

     High acceptance of violence

     Negative attitudes of violence

     Usually victimize by extreme abuse as a child

     Low empathy

     Associations with criminal marginal subculture

     Attachment: Dismissing

     MCMI: antisocial, aggressive-sadistic

 

Jacobson called these batterers “Vagal Reactors.”  Despite acting in an emotionally aggressive fashion, these men remained inwardly calm. The term stems from that idea that excitation of the vagus nerve suppresses arousal. The result of this autonomic suppression is to acutely focus attention on the external environment: the wife/antagonist. Jacobson found these men to be the most belligerent and contemptuous men he studied and showed the greatest heart rate decrease.

 

Flat emotional response + exaggerated control are two defining criteria for psychopaths (Hare, et. al).

 

Borderline Batterers

 

     Cyclical phases (Lenore Walker’s cycle of violence)

     High levels of jealousy

     Violence predominantly/exclusively in intimate relationship

     High levels of depression, dysphoria, anxiety based rage

     Ambivalence to wife/partner

     Attachment: Fearful/angry

     MCMI: Borderline

 

Over-controlled Batterers

 

     Flat affect/constantly cheerful persona

     Attempts to ingratiate therapist

     Tries to avoid conflict

     High masked dependency

     High social desirability

     Overlap of violence and alcohol use

     Some drunk driving arrests

     Lists “irritations” in anger journal

     Chronic resentment

     Attachment: Preoccupied

     MCMI: avoidant, dependent, passive-aggressive

 

Typology and assessment

 

     One can assess typology through both the clinical interview (identifying the listed characteristics) and psychometric testing (e.g. MCMI).  One can also use one of the self-report attachment measures which will be discussed more thoroughly later.

     Although similar in some ways, each type is significantly different in the psychological etiology of their violent behaviors.  Treatment interventions need to consider these differences in order the increase the likelihood of successful outcome.

 

Typology and Risk

 

     According to Dutton, the borderline batterers have the highest re-offense rates in treatment.  This is because of their extreme difficulty with emotion regulation and impulsivity.

     The Psychopathic and Over controlled batterers tend to have the most severe violence.

n   For the Psychopathic batterers, their violence is ego-syntonic and their low empathy makes them less likely to experience violence inhibition.

n   The Over-controlled batterers are compensating for inadequacy and, when overwhelmed, are likely to use violence to turn their feelings of impotence into feelings of omnipotence.

 

     What is this data likely to mean during a divorce?

     Because of their general problems with impulsivity, borderline batterers are likely to act-out with the most frequency.  However, a clear structured plan, in conjunction with treatment, could reduce this possibility to some degree.

     The psychopathic batterer is like to present well in evaluations and court, but will act-out in subtle and not so subtle ways that only the victim (who knows this pattern well) will recognize.  These victims often come across histrionic to therapists and therapists not familiar with the psychopathic batterer.  However, it is important to take serious these women and follow up accordingly.

     The Over controlled batter, like the psychopath, can present well in treatment - not because he is trying consciously to manipulate like the psychopath, but because he values control and rationality.  These clients often test with high masked dependency and during separations and divorce are likely to experience the greatest anxiety and depression.  Dutton says that these batterers can snap and perpetrate extreme violence as a means to regulate their dysphoric affect.

     According to some researchers, there is a group of batterers that test out secure on attachment measures.  What does this mean in terms of divorce?  I would predict that this group would manage the process in the most positive manner.  Not that they wouldn’t be upset - who wouldn’t get upset during a divorce process?  However these batterers have more psychological resources available to them that make them able to tolerate the process better and more effectively cope with their emotional reactions.  As you will learn later, secure individuals are more flexible, pro-social and able to regulate attachment distress in more functional ways than insecure individuals.

 

To read more about Don Dutton’s typology system as well as other excellent online articles describing his treatment and research go to his web site at: http://www.drdondutton.com/

 

Is there a similar typology of abused people?

 

     According to research and clinical experience, many, but not all, victims present with PTSD symptomology.

     We also know that many victims of domestic violence likewise present with personality disorders and unresolved childhood trauma.

     Research on abused women from an attachment theory perspective suggests that a significant percentage of victims present with insecure attachment.

     Many victims also experience psychoactive substance abuse

     Depression and anxiety is also common with victims.

     Some research suggests that there are higher rates of traumatic brain injury with victims of violence.

     Given these facts, no one has developed as comprehensive typology system as we have seen with perpetrators.  Why is this?  Perhaps there is concern that a typology system will somehow be construed as a way of pathologizing victims.  This has been a problem for many years, yet ignoring the fact that many victims do suffer from serious psychiatric disorders, does little to help them protect themselves from further victimization.

     In spite of the pressure to not explore these issues, some researchers are putting aside politics and asking important questions about the psychological characteristics of victims of domestic violence.  Let’s look at a few of these studies.

 

Substance abuse and DV (NIJ)

 

     In a study by the National Institute of Justice, it was found that the majority of women in substance abuse treatment had experienced child abuse or partner abuse;

     It was also found that over 50% of the women in substance abuse treatment, who also experienced partner abuse, had greater alcohol or drug problems.

     The abused women in shelters or safe homes, who also had alcohol or drug problems, experienced greater levels of partner abuse.

     They also found that women who were abused as children had more severe substance abuse problems.

     Almost half of the women in the shelter or safe home sample had levels of depression or anxiety classified as moderate or severe;

     In addition, a diagnosis of alcohol dependence was associated with higher levels of psychiatric disorders;

     Lastly, experiences of childhood abuse were associated with higher levels of psychiatric disorders.

 

Child abuse and Adult Re-victimization

 

     In a study by Jeremy Coid and colleagues, they found that severe childhood physical abuse and sexual abuse significantly increases the risk for adult re-victimization.  This finding has been corroborated in other studies as well.

 

Attachment and abused women

 

     In a study by Jolly and Liller, using an attachment theory perspective, they found that all women are susceptible to abuse regardless of attachment status. 

     Yet women with a preoccupied attachment classification appeared to be more likely to experience physical abuse, severe psychological aggression, and frequent psychological abuse.

     They also found that preoccupied and disorganized woman are more likely to have difficulty getting out of relationships.  These attachment categories will be discussed later.

     In their study, they found that over 60% of abused women have insecure attachment (as compared to 40% of the general population)

     Preoccupied women were 7x more likely to have experienced severe psychological abuse

     Preoccupied women were 3x more likely to have experienced severe physical abuse

     Preoccupied women women had higher anxiety and anger, were more dependent and have more negative self-mental models.

     Overall they found a significant association between depression and

n  abuse experience,

n  current abuse,

n  psychological abuse,

n  severity of psychological abuse,

n  frequency of psychological abuse,

n  physical abuse,

n  severity of physical abuse, and

n  frequency of physical abuse

 

What does this data suggest?

 

     Although a specific typology of victims has yet to be identified, we can begin to look at certain variables to help us organize how to approach intervention with victims.

     Substance use/abuse, insecure attachment, trauma symptomology, other affective disorders, previous victimization, personality disorders and history of child maltreatment to one degree or another have been significant variables in differentiating abused women. 

     Therefore, although separation of the parties is an important first step, therapists should not be lulled into a false sense of security that effective parenting will be a given, because of the severity and complexity of these disorders.

 

If you have questions about typology….contact Dr. Sonkin by email.

 

Assessment of Motivation:  Behavioral and theoretical perspectives

 

Why is motivation important?

 

     Motivation is an important issue when conducting treatment assessments because many domestic violence perpetrators, and some victims, may appear cooperative during an initial interview, but ultimately may act out ounce treatment begins.  There are a number of ways of conceptualizing motivation.  One is by looking a typology or diagnosis; another is by identifying behavioral indicators.  Let’s look at typology and diagnosis first.

 

Typology, motivation and perpetrators

 

     The psychopathic batterer may appear motivated during the interview, but is likely to have another agenda later on, without tight monitoring by the court or probation.

     Batterers suffering from borderline personality disorder, may have good intentions, but due to impulsivity are likely to act out more frequently.

     The over-controlled batterers can either be the most motivated and cooperative or could be at greater risk, especially if recently separated or if it looks like they will not be awarded custody in a divorce proceeding.

     Therapists should be aware that typology or diagnosis alone, couldn’t predict how well a person will comply with treatment.  Therapists can be wrong and clients can surprise us.

     Therefore flexibility is key to effective treatment plan development. Ultimately, diagnosis needs to be considered in conjunction with client observation, collateral reports and clinical intuition.

     Peter Fonagy, author of Attachment Theory and Psychoanalysis, states that the key feature of secure attachment is, what he calls, the reflective function.

 

Reflective function

 

     Fonagy describes this function as an ability to mentalize, or reflect on one’s internal experience and sense of self, as well as the ability to reflect on the mind of another, and to know the two are very separate. When looked at from a neurological point of view, the reflective function involves self-reflection (emotions, thoughts and perceptions), emotion regulation, autonoetic consciousness (ability to know self over time) and social cognition (also known at mind-sight - different from mind reading, but similar to empathy) - capacities of the prefrontal cortex.  Later in this class we will discuss these neurological correlates of attachment and ways to assess for reflective functioning.

     What is important here, is that the client’s ability to reflect on self and others is likely portend both cooperation with treatment plans, as well as parenting ability, and therefore may be a useful concept to attend to in evaluations process.

     Let’s look at another paradigm for understanding motivation. This model was useful in understanding why some patients comply with medical instructions and others do not.

 

Stages of Change

 

     James Prochaska and his colleagues developed a theory and assessment tool (URICA - University of Rhode Island Change Assessment Scale) that looked at readiness for change among different clinical populations.

     They found that when the treatment interventions were matched with or considered the client’s readiness for change (precontemplation, contemplation, preparation, action, maintenance) compliance was greater.

     Their theory conceptualizes motivation as a fluid process that will change over the course of time.  It may even change from low to high or from high to low.  This model may be useful for therapists who are assessing the degree of compliance with custody plans.

     The notion that motivation is a fluid process is significant for working with perpetrators and victims of abuse.  For many of these individuals are insecurely attached, which means they often resort to maladaptive defense mechanisms when experiencing attachment distress.  Therefore at different times, these individual may utilize adaptive mechanisms (particularly when experiencing low or no stress) and maladaptive mechanisms (especially when experiencing moderate or high stress), which makes prediction difficult. 

     Later when exploring risk assessment, I will discuss a conditional model of understanding risk.  This model is context related, and therefore like motivation, a fluid process.  On a more practical level look at the concrete behavioral indicators of motivation.

 

On a practical level what are indicators of motivation?

 

     Concrete or observable behaviors:

n   Attendance

n   Completing paperwork

n   Answering questions

n   Providing information for collateral contacts

n   Completing homework

n   Expressing regret, remorse, taking responsibility for actions

n   Expressing desire to change

n   Insight into problems

 

Motivation and violence

     Continued acts of violence may be an indicator of low motivation, and conversely the lack of violence may be an indicator of higher motivation

     Lack of violence may also be a sign of manipulation, common with the psychopathic batterers.

     The borderline batterer is prone to acting out, not because the lack motivation, but because they lack the necessary capacities to regulate their intense affect.

 

Stages of Change

 

     Presupposition: extremely motivated, well intentioned and hardworking (in the psychological sense) clients can have relapses - even while in batterer treatment.  A psychological analysis of domestic violence must include the idea that the client will experience both progress and setbacks in the process of treatment.  The idea that all individuals are in complete control of their behavior stems from the sociopolitical perspective that emphasizes power and control, self-will and accountability. What is key is that therapists use relapses as an opportunity to enhance intervention strategies and not just punish. 

Motivation

     Although research suggests that a percentage of perpetrators may use violence instrumentally (a thought out act), the vast majority of batterers use violence impulsively and therefore need more than the message – use violence, go to jail.  If these clients' behavior were completely under their own control, they really wouldn’t need therapy in the first place (which is of course is argued by some activists).

Motivation

     If it were true that most clients were in complete control of their behaviors, interventions would then be primarily geared toward facilitating the clients to decide they are no longer going to be violent, and that would be that.

     Violence is a function of a complex interaction of biological, psychological and social processes that require complex interventions.  Change takes time and therefore, relapses must be viewed as opportunities to deepen the work, achieve higher level coping skills, and/or refine the treatment goals or interventions.

Motivation

     From this discussion it is evident that there is no single guaranteed method of assessing or even understanding client motivation for treatment, therefore therapists should exercise extreme caution when making written assessments about motivation because such reports can have dire consequences on their clients' lives

     Whether it is behaviors, a psychometric assessment, statements in interviews or a combination of all three, it is recommended that therapists be extremely clear about how they assessed for motivation for treatment, particularly when motivation is the basis a particular custody determination.

 

If you have questions about motivation…..……contact Dr. Sonkin via email

 

Psychobiology of domestic violence

 

     Alan Rosenbaum at the University of Illinois found clinically significant prior head injury in:

n  53% of male batterers as compared to

n  25% of maritally discordant men and

n  16% of maritally satisfied men

     Along with these patterns, batterers also exhibited deficits in:

n  Learning, particularly for verbal information

n  Memory, particularly for verbal information

n  Verbal ability

n  Vocabulary knowledge

n  Exhibited high levels of emotional distress

 

What do these results mean?

 

     Always take a history for prior head injury.

     If indicated, consider neuropsychological assessment to determine specific deficiencies.

     Consider medication and cognitive rehabilitation in extreme cases.

     Consider how you use educational techniques in your treatment considering the difficulties many clients may experience with learning and memory for verbal information. In addition, consider their limited vocabulary when utilizing writing assignments and verbal presentations in group settings.

     These data supports the notion that for some clients, improving executive control function, such as response flexibility (thinking about the options and weighing the pros and cons to various alternatives) is key to helping gain control over their violent and aggressive behaviors. These findings are in line with the typology research suggesting that a significant issue for many perpetrators is controlling impulses and managing dysphoric affect.  This is also consistent with attachment theory conceptualizations of domestic violence, as I will discuss later.

     To date, there is no strong evidence that suggests that violence is genetically based.  Rather, study after study suggests that it’s the primary caretaking relationships of childhood which will ultimately determine the organization of the brain, which in turn leads to a propensity towards violence. However, the pathways to violence are varied.

     Although we are born with billions of neurons most of the connections are immature and therefore are sensitive to experience.  Early experiences of violence organized the brain in such a way that it is primed to response in a dysregulated or aggressive fashion. Neurons that fire together survive and wire together, which suggests that violence hardwires the propensity of violence in the developing mind of the child.

     The famous Minnesota Mother-Child Interaction Project illustrated that even the types of the violence are transmitted over the generation.  They found that:

n  Physical abused abused children - were more physically aggressive by early childhood;

n  Sexual abused children were prone to sexual acting out;

n  Psychological abused children were utilized more verbal acting out;

n  And neglected children became disorganized and socially inept.

     There are a number of theories that are not mutually exclusive.  These include the lack development of frontal lobes, a breakdown of corpus callosum, the ratio of brainstem/limbic system to cortical activity, the toxic effect of cortisol on the  hippocampus, decreased levels of serotonin and increase levels of noradrenaline - all suggest that violence in childhood has a profound effect on the developing brain.

     Yet we know that a significant percentage of abused children don’t become violent later in life. The pathways to violence are complicated.  Early experiences with violence and abuse that compromise the healthy development of the brain that can in turn lead to problems that exacerbate the early conditions: problems in school, drug and alcohol problems, social problems and gravitating toward peers who support the use of violence.

     Certain experiences can mitigate the negative effects of violence in childhood.  For example, having access to a positive family-like experience, having a positive adult role model, having higher intelligence or special abilities - these can all help to reduce the possibility that violence will be an eventual outcome.  And of course, early intervention in the form of psychotherapy can mitigate the deleterious effects of trauma.

     The bottom line - violence is not a forgone conclusion or outcome of early childhood victimization experiences, when positive experiences are incorporated into the child’s life story.  Child therapists are in the unique position to help to change the destiny of the next generation, through facilitating those positive experiences, and most importantly assisting parents in taking on an important role in that process.

 

If you have questions about neurobiology….….contact Dr. Sonkin by email.

 

Violence and it’s effect on child attachment

 

As it’s already been discussed, witnessing violence is traumatic to children and the associated stress will have a deleterious effect on the developing brain. When a caretaker is being victimized, it’s going to affect her or his ability to parent, which will in turn effect the attachment relationship between the caretaker and the child. Let’s look of some of the research in this area.

 

     Sullivan-Hanson (1990): No subjects in shelters were secure, and that many fit the “fearfully preoccupied” subcategory.  All of these women were at risk for having insecurely attached children.

     Steiner, et. al.: Mothers who reported higher levels of partner violence were more likely to have disorganized infants.

     Women who witnessed martial violence as children were as likely to have disorganized infants as women who were directly abused (Lyons-Ruth, 1996).

     Mothers with unresolved trauma in relation to witnessing abuse as a child were more likely to have disorganized infants (Bearman and Ogawa, 1993)

     In general, the studies suggest that when fathers are physically violent with mothers, infants are more likely to be insecurely attached to their mothers. This is partly due to the fact that mothers cannot be sensitive to the cures of their children if they are experiencing the stress of victimization.  Roger Kobak from the University of Delaware states:

 

    “Witnessing violence between parents may also threaten a child’s confidence in the parent’s availability.  The child’s appraisal of marital violence is likely to include the fear that harm may come to one or both of the parents.  Parents who are living with constant conflict and fear are likely to have reduced capacities to attend to the child.  Thus, in addition to fear of harm coming to the parents, attachment anxiety is increased by uncertainty about the parent’s ability to respond to the child’s distress and the lack of open communication with both parents.”

 

     As suggested by the data, the state of mind of the parent, regarding attachment, will have a direct effect of the attachment status of the child with both mothers and fathers.  Later in this training, you will learn that the most robust predictor of the attachment of the child is the attachment status of the parent.  If the parent is insecurely attached or has unresolved trauma from her or his own past, this will directly affect that parent’s ability to read the signals of the child and respond in an appropriate manner.  Therefore, the child is affected by numerous routes - directly by the offending parent and indirectly through the victimized parent.

     Is insecure attachment at life sentence?  No, both children and adults, through appropriate intervention, can move from insecurity to “earned security.” This too will be discussed later.

 

If you have questions about the effects on children……email Dr. Sonkin.

 

Why do women stay in abusive relationships?

 

     The most common cited reasons, that are reality-based, are economics, fear, balancing the rewards and costs of leaving, lack of protection from the courts and lack of support from friends and family.  However, even when these factors are addressed women stay and return to their abusers.  Why is this?

     Strube and Barbour, (1983) found when victims were asked why they were involved with partner at the beginning of therapy: 18% left partner if they mentioned economics (vs. 71% who didn’t mention economics), and, 35% left partner who mentioned love (vs. 71% who didn’t mention love).

     In another study of shelter residents the researchers found that only 13% say they are planning to return to their abuser, but within two months of leaving the shelter, 60% returned to their abuser.

     Attachment bonds are strong, regardless of specific characteristics of the attachment figure. Infants and adults will turn toward abusive attachment figures for comforting and protection.

     Dutton found 53% of battered women had a pre-occupied attachment status (as opposed to 10% of the general population) and only 7% were securely attached (as opposed to 60% of the general population).

     Morgan found women who were pre-occupied were more committed to their relationships and experienced more rewards than women who were more secure/less anxious.

     Anxious people are more likely to follow their hearts rather than heads.

     Don Dutton developed a theory called Traumatic Bonding that helps to understand why victims have trouble leaving their partner.  He point to periodic reinforcement (like a gambler and the slot machine) and power imbalance that both contribute to greater dependency and fear of leaving.

     Another theory that we will go over in greater detail later is the notion of unresolved trauma.  When victims put distressing thoughts, feelings or memories of trauma out of their consciousness, their anxiety about their situation is more likely to get sublimated into caretaking, substance abuse or depressive symptoms and therefore ultimately interfere with their ability to leave.

     Women who have been abused or witnessed violence as children, who are insecurely attached due to early parenting experiences will use maladaptive coping mechanisms when responding to attachment distress (e.g., abuse).  Victims who are pre-occupied (over 50% of abused women in one sample) are likely to use dependency, pleasing and trying to get the abuser to respond to their distress as a means to coping with attachment distress.  All of these defenses serve to keep the victim “stuck” and “focused on” their abuser, rather than looking to protect herself and her children.

     Disorganized or unresolved victims of abuse utilize dissociation to escape the negative thoughts, feelings and memories of abuse and therefore do not have these available to them to help motivate change.

     Therefore why women have trouble leaving is really a complex interaction of biological, psychological, relational and social dynamics.  Reducing an answer economics or lack of police protection, though significant, are not sufficient to understand why so many victims place themselves and their children in danger.  Interventions need to be geared to address all these levels of analysis.

 

If you have questions about why victims stay …email Dr. Sonkin.

 

Assessment Instruments: Structured assessment tools

 

     Many clinicians rely too heavily on the clinical interview to complete their assessment process.  Utilizing psychometric tests and structured assessment tools can provide valuable information that may be overlooked during the clinical interview.  Here are a list of tools that have been found useful in assessing perpetrators and victims of domestic violence.

 

Personality and Diagnostic Screening

 

     The MCMI (current version IV) is the most common test used in researching typologies of perpetrators. The MMPI and Rorschach have also been used in research with this population but not as often.  As you may already know, once criticism of the MCMI is it’s bias towards psychopathology, which is something to consider when putting together as assessment protocol. 

     Diagnosis specific tests such as the Trauma Symptom Inventory commonly used with victims and perpetrators and the Hare Psychopathy Checklist are commonly used with perpetrators.

     Substance abuse screens such as the Michigan Alcohol Screening Test should be included in an assessment process. 

     The Structured Clinical Interview for the DSM-IV (SCID) is also a useful structured interview to help confirm your clinical observations.

 

Domestic violence assessments

 

     Conflict Tactics Scales (v. 2) developed by Murray Straus is the most common violence assessment tool in research projects. It is freely available on his web site at the University of New Hampshire. 

     The Propensity for Abuse Scale was developed by Don Dutton and has been validated in a number of empirical studies.  This scale is available in his book, The Abusive Personality.

     Richard Tolman developed the Psychological Maltreatment Toward Women Inventory and like the Conflict Tactics Scales, is becoming the industry standard for assessing non-physical abuse by researchers. This scale is available in his article listed in the reading list.

     The Anger Management Scale developed by Stith & Hamby focuses on how clients regulate their anger.

     The Domestic Violence Inventory and Risk Assessment software developed by Daniel Sonkin was developed for clinicians to provide consistency and organization to their assessment process.  It is a very comprehensive behavioral assessment, which differs from a more psychological assessment, such as Dutton’s Propensity Towards Abuse Scale.

     The Spouse Abuse Risk Assessment (SARA) developed by Randal Kroop and his colleagues is a risk assessment program that has empirical validity and is currently being used by both researchers, clinicians and criminal justice personal.  Below are the categories used by the SARA to assess for dangerousness.

 

§                  Criminal History

§                  Past assault of family members

§                  Past assault of strangers/acquaintances

§                  Past violation of conditional release/ supervision

§                  Psychosocial Adjustment

§                  Recent relationship problems

§                  Recent employment problems

§                  Victim of/witness to family violence

§                  Recent substance abuse/dependence

§                  Recent suicidal or homicidal ideation/intent

§                  Psychotic/manic symptoms

§                  Personality disorder with anger, irritability, or behavioral instability

§                  Spousal Assault History / Past physical assault

§                  Past sexual assault/sexual jealousy

§                  Past use of weapons/threats of death

§                  Recent escalation in frequency/severity assault

§                  Past violation of no contact orders

§                  Extreme minimization/denial assault history

§                  Attitudes support/condone spousal assault

§                  Current Offense

§                  Severe assault or sexual assault

§                  Use of weapons/threats of death

§                  Violation of no contact order

 

 

If you have questions about assessment tools…contact Dr. Sonkin via email.

 

Defining non-physical violence

 

One of the most elusive issues in the domestic violence field is how we conceptualize non-physical, psychological or emotional abuse. The simple fact that we have different names suggests that defining and identifying this form of interpersonal violence is not always easy.  Why is this important?

 

     Outcome studies suggest that while there can be a forty to sixty percent drop in physical and sexual abuse during treatment and for some time afterwards, there may be a less than ten percent reduction in non-physical violence.

     Some researchers suggest that psychological abuse is a precursor or vulnerability factor for physical abuse.

     Non-physical abuse can be as traumatic and harmful to victims and witnesses as physical violence.

     Non-physical abuse is essentially acting out, as is physical violence, and therefore therapy is not successful until this problem is addressed.

 

Three models of non-physical violence

     Amnesty International model.

     Penal code model which is the main concern of the courts.

     The model used for the Psychological Maltreatment toward Woman Inventory described earlier.

 

Amnesty International

 

    Isolation of victim

    Induced debility producing exhaustion

    Monopolization of perception (obsessiveness & possessiveness)

    Threats (self, partner, family, friends, sham executions)

    Mental degradation

    Forced alcohol and drug use

    Altered states of consciousness produced by a hypnotic state.

    Occasional indulgences that keep hope alive.

 

     The Violence Inventory developed by Daniel Sonkin uses this model to describe non-physical violence.  The following slide illustrates how several of these categories are operationalized.

 

     Isolation:

n  Locked in room or closet

n  Tied up with rope, chains, handcuffs, etc.

     Induced debility producing exhaustion:

n  Forced to take on role of servant

n  Not allowed to sleep

     Monopolization of perceptions:

n  Pathological jealousy

n  Stalked (following, harassing, vandalizing personal property, trespassing, violating restraining orders)

 

Domestic Violence Inventory

 

     You can examine this inventory online at:

http://www.danielsonkin.com/dvrisk/dvrisk.html

Penal Code

§    Simple assault may be a verbal act but is most commonly accompanied by a physical gesture, such as threatening with a fist or an object.

§    Aggravated assault is usually a threat to kill as indicated by the use of a weapon, such as a knife or a gun.

§    Threats to kill or terrorizing threats

§    Stalking any attempt on the perpetrator’s behalf to follow, watch, harass, terrorize, or otherwise contact his partner against her desires.

 

Psychological Maltreatment Toward Women Scale (Tolman, 1989)

 

The PMTW has 58 questions each scored on frequency of occurrence which consist of three scales:

 

n  Domination/isolation (which included isolation from resources, demands for subservience, and rigid observance of traditional sex roles)

n  Emotional/verbal (which included verbal attacks, behavior that demeans the woman, and withholding of emotional resources).

n  Threats

 

You can access this scale online at:

http://www-personal.umich.edu/~rtolman/

 

Each model includes:

 

     Verbal abuse, degradation or name-calling.

     Threats.

     Non-physical means of control (e.g. through jealousy, compliance with expectations, withdrawal of affection, threats of violence).

     Isolation (particularly from family and resources).

 

What do these forms of non-physical abuse have in common?

 

     They all create a stressful family environment that neither feels physically or emotionally safe or nurturing.

     Over time can have a profound psychological and health effects on victims and witnesses

     Prolong exposure to stress such as this may have negative impact on the brain.

     The manifestation of any of these forms of violence is indicative of the need for continued treatment for perpetrators.

 

If you have questions about non-physical violence…contact Dr. Sonkin by email.

 

Risk Assessment

 

     Prediction of violence remains a controversial concept in the field of psychology.  Research indicates that we are likely to be wrong as often as we are right about predicting violent behavior.  Most researchers believe that the best predictor of future behavior is past behavior.  For the most part this may be true - but not always. Researchers have tried to develop methods of predicting future behavior without a lot of success.  But nevertheless, some type of risk assessment is important when working with violent individuals.

 

     We are often asked (whether we like it or not) by the court to give opinions about future dangerousness.

     Clients, and partners in particular, often want to know about prognosis and the possibilities of future violence.

     When a lethal incident does occur and a liability suit arises, the clinician is often asked to explain how he/she took measures to reduce the risk of future violence.

     A significant number of batterers do re-offend while in treatment; therefore, identifying “high-risk” cases may be clinically prudent.

 

Domestic Violence in Sonoma County (Rosenberg, M; 2000)

 

     “Partly as a result of a terrible domestic violence homicide and partly in reaction to the growing concern over the way domestic violence cases had been handled, the County of Sonoma developed a coordinated criminal justice and community response to the problem of domestic violence, which included a specifically designated court to oversee misdemeanor cases, a domestic violence unit within the adult probation department, and community service programs that provide mandated group intervention for men and women convicted of domestic violence. All misdemeanor cases of domestic violence were heard and followed in front of the same judge. At that time Sonoma County was one of the few places in the country that had a domestic violence unit in their probation department.”

     Dr. Rosenberg was hired as a consultant to monitor the certification and re-certification process for service providers of mandated group intervention programs described in California law, and to conduct a general outcome study on probationers who have gone through the domestic violence court system. In preparation for designing the outcome study, interviews were conducted with probation officers in the domestic violence unit to determine the types of information they wanted to understand about their clients. One of the most frequently voiced concerns involved working with probationers who demanded a great deal of attention and decision making as a result of their problematic behavior.

     The study was designed to determine the factors that would predict which clients were likely to be labeled “high maintenance”. In other words which client would demand greater attention from the probation staff, due to acting out prior to and during treatment, including re-offenses. 

 

Outcome of Sonoma study

 

     High maintenance probationers had:

n  higher numbers of prior domestic violence offenses

n  more serious histories of drug abuse

n  higher total SARA scores

n  and lower number of severe violent tactics used against the victim in the incident precipitating arrest.

 

     Low maintenance probationers had:

n  less prior domestic violence incidents

n   absent or low prior drug usage

n   lower total SARA scores

n  higher numbers of severe violent tactics used in the index incident

 

     Rosenberg was also interested in whether treatment outcome could be predicted.

     Program completers:

n  were those with lower numbers of prior domestic violence offenses

n  were not homeless during probation

n  were married

n  had low or no problems prior to beginning their program and after arrest.

 

     Program  Non-completers

n  Higher numbers of prior domestic violence offenses

n  Homelessness at some point during probation

n  Unmarried status

n  Higher numbers of problems prior to beginning their programs and after arrest.

 

     Both the high maintenance and program non-completers were clients with the more unstable life-style, drugs problems and more extensive history of domestic violence.

     This study suggests that a thorough pre-treatment assessment is necessary to identity those clients who may need more attention, services and structure to enhance their experience of treatment.

 

Risk Assessment

 

     Richard Heyman of the State University of New York in Stony Brook, recently conducted an extensive review of the literature on the risk of domestic violence. In summary he found that, age, SES, history of child abuse, and psychological variables all contribute to increased risk for partner physical aggression. For many of the variables the effect sizes ranged widely from study to study, with the exception of personality pathology and other forms of psychopathology. Having a diagnosable personality disorder or other mental illness is associated with greatly increased risk for partner physical aggression.

 

Conditional model of violence prediction

 

     Mulvey and Lidz proposed a conditional model of violence prediction, where context plays an important role in the manifestation of violence.  Rather than simply looking at client characteristics and predicting based on those qualities, they see a client as possibly doing some type of act of violence if certain situations or factors persist or present themselves. For example a particular batterer may become violent under certain individual circumstances (e.g., under the influence or alcohol or not using medications or not attending treatment), interpersonal circumstances (e.g., with an aggressive partner or a partner who is under the influence of drugs) and environmental factors (associating with peers accepting of violence or other social or occupational stressors).

 

Clinical suggestions

     So rather than framing risk assessment in categorical terms (at risk or not at risk), it would be important for clinicians to describe the likely context in which violence is likely to occur given your assessment of that particular client.  Mulvey and Lidz recommend considering individual biological/psychological factors (e.g., history of violence, substance use/abuse, need for medication, psychiatric disorder and the presence of symptoms), victims factors (e.g., availability, provocation, substance use/abuse) and social or environmental factors (e.g., peer support for violence, economic or occupational stressors).

 

For example:

     Mr. Jones is likely to reoffend if he relapses back into cocaine use, stops taking his antidepressant medication and stops attending therapy and his 12-step program (individual factors).  He is currently separated from his wife who has an addiction to methamphetamine and has a history of physical aggression as well (victim factors).  Should they start seeing each other, I believe it may be difficult for him to regulate his emotions given the volatility of their relationship.  Lastly, Mr. Jones has quite a few friends who supplied him with cocaine and his continued interaction with them may compromise his recovery, which could lead to additional acts of violence (social or environmental factors).

 

SARA

     The Spousal Assault Risk Assessment (SARA) mentioned  earlier is not a psychological test, but can be used as an assessment guide to ensure that pertinent information is considered and weighed. Risk factors are rated absent, sub-threshold, or present. Based on the rating the final assessment the SARA scores tell you whether there is imminent violence toward a spouse or other, or the client is high, medium or low risk for violence.

 

Propensity Towards Abusiveness Scale (Dutton)

 

     Dutton states that the PAS` can predict with 82.2% accuracy who is likely to commit violence based on the psychological characteristics assessed by this scale.

     The scale taps into background factors such as: parental treatment, attachment style, anger response, Trauma symptoms, and stability of self-concept.

     This scale can predict both physical and emotional abuse.

 

Danger Assessment Scale (Campbell)

 

     Was developed by Jacqueline Campbell, she describes this scale as a… “form of statistical prediction, contrasted with clinical prediction, because it is based on prior research and has some preliminary evidence of reliability and validity”

     The scale is based on “women’s perception of the danger of being killed by their partners.” However, the relationship of fear of the partner to actual danger is unknown.  This scale is available on the Internet (see the references).

 

Psychopathy Checklist (Hare)

 

     Designed for male forensic populations

     Structured interview and set of ratings based on the interview and corroboration’s based on case history reviews, institutional files, interviews with family members and employers and on criminal and psychiatric records.

     PC - R (20 items) (2 scales)

n   Affective (glibness, lack of empathy and pathological lying)

n   Social Deviance (antisocial behavior)

     PC - Screening version (12 items)

     A robust predictor of violent behavior in general, with many validity studies including domestic violence perpetrators.

     Predictive of re-offending for domestic violence perpetrators.

 

Risk Checklist - Violence Inventory (Sonkin)

 

     No empirical data and is not meant to have predictive validity, but rather a comprehensive structured interview for clinicians treating domestic violence perpetrators.  Based on Browne’s (1987) risk factors in her study of abused women who killed their batterer.  Covers many areas described in the dangerousness literature.  Cover the following content areas.

 

Sonkin Risk Assessment Factors

 

     Frequency of physical violence in past two years

     Frequency of sexual violence in past two years

     Severity of violence

     Threats

     Frequency of intoxication

     Frequency of alcohol use

     Frequency of drug use

     Proximity of victim and offender

     Psychiatric Diagnosis (DSM-IV)

     Severity of psychosocial stressors

     Global Assessment of Functioning Scale

     Prior criminal history/activity

     Violence towards others (check all that apply)

     Child abuse

     Victim’s Involvement With Others:

     Attitudes towards violence

     Weapons accessible (e.g. law enforcement)

     Specialized training in violence

     Perpetrator physically abused a child

     Perpetrator sexually abused a child

     Perpetrator witnessed marital violence as a child

     Child custody proceedings in progress

     Other divorce proceedings in progress

     Other legal proceedings in progress

     Animal cruelty or torture

 

Ways of Reducing Risk

 

     Separation of the victim and offender with either the victim in a safe house or shelter or the perpetrator in jail is the safest situation.  Short of that, there are no guarantees of safety. 

     Stay-away orders, restraining orders can be useful but only if the courts intimidate the perpetrator and the police enforce the orders.

     Criminal sanctions are effective, however, many perpetrators continue to use violence in spite of this.

     Social services can be useful in protecting children from abusive parents or parents who refuse to protect their children from abusive spouses.

     Treatment for perpetrators can reduce the risk for continued violence.  Therapists should not confuse education programs that treat people in large groups with therapeutic programs that provided assessment based treatment either in group or individually.

     Treatment for victims can also reduce risk. Many victims need treatment to resolve recent trauma.  Additionally, a large majority of victims have moderate to severe psychiatric disorders stemming from prior trauma and childhood abuse.  Without treatment, these individuals will not be able to make safe choices for themselves or their children.

     Addressing psychoactive substance use/abuse with both victims and perpetrators is critical to reducing risk. This is consistent risk factor in the dangerousness literature. 

     Medication can be effective with both victims and perpetrators in helping to regulate dysphoric affect associated with affective disorders and unresolved trauma.

     In extreme cases, hospitalization can be an effective method of managing risk to self or others.

 

If you have any questions about risk assessment……email Dr. Sonkin.

 

Psychopharmacology

 

     No specific drug treats domestic violence.

     However psychotropic medication can be utilized to treat concurrent diagnoses (depression, anxiety, etc).

     In addition, one can also treat particular symptoms related to violence.

 

n  PTSD symptoms

n  Obsessive and compulsive symptoms

n  Anxiety

n  Depression

 

     Serotonin Selective Reuptake Inhibitors (SSRIs) have been used with people who have violence problems (e.g., Paxil - the most sedating; Luvox - good for obsessional symptoms).

     Norepinephrine Reuptake Inhibitors (NRIs) (e.g., Wellbutrin) may be good for people with adult ADD and similar syndromes (However, this medication can also be agitating - which is problematic with people who have trouble managing irritable emotions.)

     Tri-cyclics: (e.g., Trazodone) can be useful because of its sedating effect. However this class of drugs can have problematic side-effects.

     Benzodiazepines: there are many negative side effects and therefore, these are not utilized as often.

     There are newer non-benzodiazepine anti-anxiety medications (e.g., Buspar and Vistaril) that can be useful in treating anxiety and tension symptoms.

     SSRIs can also be useful in treating anxiety as well.

 

     Although there are no drugs that treat PTSD per se, a number of psychotropic medications can be utilized to address the various symptoms:

n  Flashbacks: SSRIs

n  Hyper-arousal: Antidepressants & anxiolytics

n  Transient psychosis: Low dose anti-psychotics

n  Depression: Antidepressants

n  Panic attacks: Antidepressants, high potency anxiolytics

 

Intervention Guidelines

 

     Use the most benign intervention when beginning treatment.

     Select the medication that most closely addresses the primary diagnosable disorder/symptom.

     Have some quantifiable means of assessing efficacy and side effects.

     Institute drug trials systematically by applying one intervention, assessing impact and monitoring therapeutic levels.

     Meet on regular basis / good communication between therapist and prescribing physician.

 

If you have questions about psychopharmacology……email Dr. Sonkin.

 

Outcome Studies

 

     An examination of the outcome literature shows a range of 40-60% desistance rate of physical violence 2 years post treatment based on victim reports.  Some studies show as high as 80% with treatment.

     Other studies have indicated that probation alone is as effective as probation with treatment - with about a 50% reduction with arrest alone.

     A number of studies indicate that our success with non-physical abuse is less promising.  One study showed approximately a 7% desistance of non-physical violence.

     What does this mean? Perhaps we need to reconsider educational interventions as a sole approach to working with individuals with moderate to severe psychological disorders.

     Even with current treatment models, the standard has been cognitive and behavioral interventions, with a heavy educational component.

     If we want to reduce the rates of physical violence even further and to address more effectively non-physical violence perhaps we need to consider expanding our paradigms of understanding domestic violence and reconsider our current treatment models.

     The next section hopefully builds a rationale for expanding our paradigms.

 

If you have questions about treatment outcome.…email Dr. Sonkin.

 

Attachment Theory and Domestic Violence Treatment

 

This section will provide you an overview of attachment theory and then will discuss its application to domestic violence and unresolved trauma.

 

Rationale for Attachment Theory

 

     Violence occurs in the context of attachment relationships.

     Anger and loss is integral to attachment theory.

     Very high insecure attachment rates among batterers and victims of abuse.

     Due to high re-offense rates (particularly non-physical violence), we may need to expand our treatment paradigm.

     Attachment theory can be helping us understand why so many victims return to their abuser and ways to help reverse this pattern.

     High rates of childhood trauma among perpetrators and victims of violence.

     Attachment theory is a good lens through which to conceptualize parenting abilities.

 

Who is an attachment figure?

 

     A caregiving figure who provides protection from danger or threat

n   Parents or parent figures

n   In adulthood, can be one’s spouse or partner

     Humans form all types of attachment relationships throughout their life, but some are more significant than others.  In the first few years of life when children are learning about relationships, their primary attachment figures are parents and caregivers; in adulthood, that is usually a spouse or significant other.

 

Bowlby’s central proposition…

     ….that beginning in early infancy, an innate component of the human mind -- called the “attachment behavioral system” -- in effect asks the question: Is there an attachment figure sufficiently near, attentive and responsive?

 

If the answer is yes…..

     …then certain emotions and behaviors are triggered, such as playfulness, less inhibited, visibly happier and more interested in exploration. In the Strange Situation, developed by Mary Ainsworth, these infants are distressed when the parent leaves the room, but eventual go back to playing with the stranger.  When the parent returns, these infants are distressed (protest) but will quickly settle down and return to playing and exploration.  These infants are securely attached.

 

If the answer is consistently no…

     …a hierarchy of attachment behaviors develop due to increasing fear and anxiety (visual checking; signaling to re-establish contact, calling, pleading; moving to reestablish contact). If the set of attachment behaviors repeatedly fails to reduce anxiety (get the caregiver to respond appropriately) then the human mind seems capable of deactivating or suppressing its attachment system, at least to some extent, and defensively attain self-reliance.  This leads to detachment.  In the strange situation, these infants seem to be not phased by the parent leaving and disinterested when the parent returns.  But when their heartbeat is measured, they are indeed quite anxious. These infants are anxious-avoidant.

 

If the answer is inconsistently no…

     …the attachment behaviors described previously become exaggerated as if intensity will get the attachment figure to respond (which may or may not work). Like the dynamic between a gambler and the slot machine, the attachment figure will pay off or respond in sufficient frequency that the infant becomes preoccupied or anxious or hypervigilant about the attachment figure’s availability.  In the strange situation these infants are very distressed when the parent leaves the room, can’t settle down after the parent leaves and can’t settle down when the parent returns. These infants are anxious-ambivalent.

 

Attachment disorganization

 

     Originally attachment researchers described three attachment categories, secure, anxious-avoidant and anxious-ambivalent.  Later Main and colleagues discovered a group of infants who evidenced very distressing behavior upon the return of their attachment figure.  They might back into a corner with their hands stretched out.  Others would walk toward the parent and then collapse onto the floor.  Unlike the other categories, they didn’t seem to have an organized approach to attachment distress - hence this category was named disorganized.

     It was later discovered that these infants were behaving this way because they were afraid of their caregiver.  In fact, many of these children experienced abuse at home.  The quandary these children experienced was they were distressed and wanting soothing, but the figure they turned to was also frightening to them. They experienced what Main referred to as “fear without solution.”

 

Assessing Infant Attachment:


The Strange Situation

 

     The ”Strange Situation" is a laboratory procedure used to assess infant attachment style. The procedure consists of eight episodes.  The parent and infant are introduced to the experimental room. Then the parent and infant are left alone. Parent does not participate while infant explores.  The stranger enters, converses with parent, then approaches infant. The parent leaves inconspicuously. During the first separation episode the stranger's behavior is geared to that of infant.

     During the first reunion episode the parent greets and comforts infant, then leaves again. During the second separation episode the infant is alone. During the second separation episode the stranger enters and gears behavior to that of infant.  At the second reunion episode the parent enters, greets infant, and picks up infant; and stranger leaves inconspicuously. The infant's behavior upon the parent's return is the basis for classifying the infant into one of three attachment categories.

 

Attachment Terminology

 

     Status versus style:  In the child development field, researchers use the term “status” indicating that infants may have a different attachment to different caregivers, as well as may change over time.  Social psychologists who study adult attachment use the term “attachment style” to designate a person’s pattern of attachment in relationships.

     Categorical versus dimensional: One of the controversies in the field is whether or not there are degrees of security and insecurity.  Social psychologists have addressed this issue by viewing attachment styles on a two dimensional grid, where a person can have degrees of a particular attachment style.  Developmental psychologists have identified a number of sub-categories of attachment status that suggests one can be secure, but have qualities of dismissing or pre-occupied.

     Secure versus insecure:  One way to break down attachment is simply to identify those who are secure and insecure.  Some researchers do not believe that it is fruitful to break down the insecure categories into different types.

     Organized versus disorganized:  Individuals with secure, dismissing and preoccupied attachment status have a consistent strategy for dealing with attachment distress.  Infants who are disorganized and adults who are “Can not classify” (CC) use both dismissing and preoccupied strategies. 

     Earned autonomy:  A termed used for adults whose history leads one to expect that they would be insecure, but in fact are assessed as secure based on the Adult Attachment Interview (AAI).

     AAI (Adult Attachment Interview): A twenty-question interview that is recorded, and transcribed. The transcript is assessed for coherence (this will discussed in detail later) of the narrative.  The final classification may be secure, dismissing, preoccupied, unresolved or cannot classify.

     Self-report measures of attachment:  Any one of a number of questionnaires that are used to assess adult attachment.  The questions are usually answered directly by the subject.  Attachment is deconstructed differently on a two dimensional continuum depending on the scale (will describe two different scales later).  The final classifications may be secure, dismissing, preoccupied or fearful.

 

Attachment Terminology

 

 

 

 

Neurobiology of attachment

 

     What mental capacities result from infant secure attachment relationships that lead to an ability to tell a coherent life story (via the AAI) as an adult?  Daniel Siegel describes these capacities in his book, The Developing Mind.

 

n   Autonoetic consciousness: Knowing oneself over time.

n   Social cognition: Empathy and the ability to look into the minds of others.

n   Self-reflection:  Ability to look into your own mind.

n   Emotion regulation: Ability to soothe oneself and be soothed by others

n   Response flexibility:  Weigh options before acting.

 

     “In childhood, particularly the first two years of life, attachment relationships help the immature brain use the mature functions of the parent’s brain to develop important capacities related to interpersonal functioning.  The infant’s relationship with his/her attachment figures facilitates experience-dependent neural pathways to develop, particularly in the frontal lobes where capacities such as social cognition (the ability to put yourself into the mind of others), response flexibility (being able to weight different options, problem-solving), emotion regulation, reflective-function (the ability to reflect on ones own experience) and autonoetic-consciousness (the ability to have an autobiographical sense of self over time - past, present and future) are wired into the developing brain.”

 

     “When caretakers are psychologically-able to provide sensitive parenting (e.g. attunement to the infants signals and are able to soothe distress, as well as amplify positive experiences), the child feels a haven of safety when in the presence of their caretaker(s).  Repeated positive experiences become encoded in the brain (implicitly in the early years and explicitly as the child gets older) as mental models or schemata of attachment, which serve to help the child feel an internal sense of what John Bowlby called “a secure base” in the world. These positive mental models of self and others are carried into other relationships as the child matures.”

 

But how does this attachment develop?

 

     John Bowlby and Mary Ainsworth believed that secure attachments developed due to maternal or paternal sensitivity and cooperation.

 

Sensitivity

 

     This involves the caregiver’s ability to perceive and to interpret accurately the signals and communications implicit in the infant's behavior, and given this understanding, to respond to them appropriately and promptly.  Sensitivity has four essential components:

 

n   (a) awareness of the signals;

n   (b) an accurate interpretation of them;

n   (c) an appropriate response to them; and

n   (d) a prompt response to them.

 

Cooperation

 

     The extent to which the parents interventions or initiations of interaction break into, interrupt or cut cross the child’s ongoing activity rather than being geared in both timing and quality of the child’s state, mood and current interests.

 

What helps a parent to be “psychologically-able?”

 

     What allows a parent to have the capacities of sensitivity and cooperation?

     With a better understanding of adult attachment and brain research, it has now been shown that the most robust predictor of attachment of a child is the state of mind of attachment of the caregiver vis a vis their own parents.

     Let’s look at the research first before exploring the reasons for this phenomenon further.

 

Parent-Infant Attachment Correspondence

 

     A meta-analysis was conducted of 13 studies using three major categories.  They found that:

     75% secure vs. insecure agreement: If a parent was secure as assessed by the AAI, there was a 75% chance that their child would be securely attached. This was true for insecure parents as well.

     70% three-way agreement:  When taking into account all three organized categories (secure, dismissing, preoccupied), there was a 70% prediction of the attachment of the child based on the parent’s attachment status.

     Prebirth AAI show 69% three-way agreement: When pregnant parents’ attachment status was assessed, researchers were able to predict the attachment status of their children by age 12 months with 69% certainty.

     A meta-analysis of 9 studies using all four major categories found: 63% four-way agreement.  Which means that the researchers could predict with 63% certainty whether the infant will be secure, avoidant, ambivalent or disorganized, based on the attachment status of the parent (secure, dismissing, preoccupied or disorganized) using the AAI. 

     Prebirth the AAI showed 65% predictability based on all four attachment categories.

 

What does these data suggest?

 

     The attachment status (or state of mind regarding attachment) of the parent, is going to have a direct effect on the attachment of the infant to that parent - as high as 75% predictability. In other words, secure adults engender security in their children, dismissing adults tend to engender avoidant relationships with their children, pre-occupied adults engender ambivalent attachment in their children and adults with unresolved trauma or disorganization may act frightening or confusing with their children, causing disorganized attachment in their children.

 

Link between caregiver attachment status and infant attachment status

 

     Adults who are securely attached know how to adaptively regulate their own attachment distress: they are flexible, can regulate their emotions in a constructive way, they are sensitive and cooperative parents, can give care to partners and can receive care from others, therefore…

n  …they will engender these same qualities in their infants.  Their infants can use them as a secure base to explore the world and grow.

 

     Dismissive parents avoid acknowledging their own attachment needs as well as those of their infant and/or may be critical of their infants attachment needs…

n  …therefore their infants respond by minimizing their attachment needs and becoming avoidant.

 

     Preoccupied parents do not respond to their children’s attachment needs predictably, (sometimes being sensitive and other times not), because they are still entangled in their own attachment experiences that emotionally intrude in their present relationships. Their…

n  …infants respond by chronic attempts to feel secure and therefore, are clingy and difficult to emotionally soothe.

 

     Disorganized parents are abusive or otherwise frightening so their…

n  …infants respond by approach - avoidance oscillation. They are needing protection from the person they fear and therefore, are experiencing “fear without solution.”

 

Adult Attachment Relationships

 

     In the 1980’s, two lines of research into adult attachment evolved - one by developmental psychologists (e.g. Mary Main and Erik Hesse), the other with social psychologists (e.g. Phil Shaver and Kim Bartholomew).  Both used different methodologies to assess adult attachment (the Adult Attachment Interview & self report scales respectively).  Both lines of research deconstructed adult attachment differently. The developmental psychologists state that the only way to truly know an adult’s attachment status is to have measured them as an infant in the strange situation.  Short of that, they assess adult attachment by measuring the coherence of one’s life story vis a vis relationships with their attachment figures.  The social psychologists deconstruct adult attachment in different ways.

     Rather than to debate the advantages and disadvantages of these two approaches to adult attachment, let’s look at the characteristics of adults who are secure, preoccupied, dismissing and disorganized, and more importantly, how these qualities relate to domestic violence.

 

     Mary Ainsworth, the American researcher who brought John Bowlby’s ideas to the United States, highlighted the function of the attachment behavior system in adult life, suggesting that a secure attachment relationship will facilitate functioning and competence outside of the relationship. 

 

n   ”There is a seeking to obtain an experience of security and comfort in the relationship with the partner.  If and when such security and comfort are available, the individual is able to move off from the secure base provided by the partner, with the confidence to engage in other activities." 

 

Adult Attachment Development (Shaver and Clark, 1994)

 

Secure Adult Patterns

 

     Secure adults have mastered the complexities of close relationships sufficiently well to allow them to explore and play without needing to keep vigilant watch over their attachment figure, and without needing to protect themselves from their attachment figures insensitive or rejecting behaviors.

 

     Highly invested in relationships

     Tend to have long, stable relationships

     Relationships characterized by trust and friendship

     Seek support when under stress

     Generally responsive to support

     Empathic and supportive to others

     Flexible in response to conflict

     High self-esteem

 

Preoccupied Adult Patterns

 

What begins with attempts to keep track of or hold onto an unreliable caretaker during infancy leads to an attempt to hold onto partners, but this is done in ways that frequently backfire and produce more hurt feelings, anger and insecurity.

 

     Obsessed with romantic partners.

     Suffer from extreme jealousy.

     High breakup and get-back-together rate.

     Worry about rejection.

     Can be intrusive and controlling.

     Assert their own need without regard for partner’s needs.

     May have a history of being victimized by bullies.

 

Dismissing Adult Patterns

 

What begins with an attempt to regulate attachment behavior in relation to a primary caregiver who does not provide, contact, comfort or soothes distress, becomes defensive self-reliance, cool and distant relations with partners, and cool or hostile relationships with peers.

 

     Relatively un-invested in romantic partners.

     Higher breakup rate than pre-occupied.

     Tend to grieve less after breakups (though they do feel lonely).

     Tend to withdraw when feeling emotional stress.

     Tend to cope by ignoring or denying problems.

     Can be very critical of partner’s needs.

     May have a history of bullying.

 

Unresolved/Disorganized/Fearful Adult Patterns

 

What begins with conflicted, disorganized, disoriented behavior in relation to a frightening caregiver, may translate into desperate, ineffective attempts to regulate attachment anxiety through approach and avoidance.

 

     Introverted

     Unassertive

     Tend to feel exploited.

     Lack self confidence and are self conscious.

     Feel more negative than positive about self.

     Anxious, depressed, hostile, violent.

     Self defeating and report physical illness.

     Fluctuates between neediness and withdrawing.

 

Insecure Attachment & Psychopathology

 

     Insecure attachment is not the same as psychopathology, though studies indicate that it’s correlated with higher rates of psychiatric disorders.

     It is thought that insecurity creates the risk of psychological and interpersonal problems.

n  Avoidant: leads to deficits in social competence, and have higher rates of schizophrenia.

n  Disorganized: higher rates of dissociation, PTSD, attention and emotion disregulation problems.

n  Pre-occupied: high rates affective disorders, substance abuse, borderline personality disorder.

 

Attachment theory

     If you would like to read more about attachment theory consider purchasing one of the finest books on this topic.  It covers the most extensive variety of topics relating to child and adult attachment:

     Cassidy J. & P. R. Shaver (Eds.)(1999), Handbook of attachment: Theory, research, and clinical applications. New York: Guilford Press.

     Also consider the extensive material on Attachment Research and Theory at Stony Brook at: http://www.johnbowlby.com

 

If you have general questions about attachment theory……email Dr. Sonkin.

 

Assessing Attachment Status

 

There are a number methods of assessing attachment that fall into two general categories – interview approaches and self-report methods.  We will discuss several examples of each.

 

     Interview approaches

n   Coherence (Main - Adult Attachment Interview )

n   Self-reflective function (Fonagy, described earlier)

n   Projective test (Adult Attachment Projective - George & West)

     Self-report

n   Anxiety and Avoidance (Shaver - Experiences in Close Relationships-Revised)

n   Internal working models of self and others (Bartholomew-Relationship Status Questionnaire)

 

Adult Attachment Interview

 

The Adult Attachment Interview is a 20-question interview that asks the subject about his/her experiences with parents and other attachment figures, significant losses and trauma and if relevant, experiences with their own children.  The interview takes approximately 60-90 minutes.  It is then transcribed and scored by a trained person (two weeks of intensive training followed by 18 months of reliability testing). The scoring process is quite complicated, but generally it involves  assessing the coherence of the subject’s narrative.

 

According to Mary Main, the developer of the AAI, “…a coherent interview is both believable and true to the listener; in a coherent interview, the events and affects intrinsic to early relationships are conveyed without distortion, contradiction or derailment of discourse. The subject collaborates with the interviewer, clarifying his or her meaning, and working to make sure he or she is understood.  Such an subject is thinking as the interview proceeds, and is aware of thinking with and communicating to another; thus coherence and collaboration are inherently inter-twinned and interrelated.”

 

Grice’s Maxims of Discourse

 

One aspect to scoring the interview is looking for examples of and violations of Grice’s Maxims of Discourse.  These maxims are:

 

     Quality: Be truthful and believable, without contradictions or illogical conclusions.

     Quantity: Enough, but not too much information is given to understand the narrative.

     Relevance: Answers the questions asked.

     Manner: Use fresh,  clear language, rather than jargon, canned speech or nonsense words.

 

In addition to coherence, there are specific scales related to secure and insecure categories.

 

AAI questions

 

The AAI begins with the interviewer introducing the general research area, e.g.:

 

The reason that we're using this interview is to ask parents about their childhood in an attempt to see how things which happened to them as children may have had effects on their later relationship with their own children, and also on their experiences as adults. I'll ask you mainly about your childhood, but there will be some questions on your later years and what's going on now.

 

There are 18 questions in total, and questions each have various related probes. The first question is an integrative one: Could you start by orienting me to your early family situation, where you lived, and so on? If you could start with where you were born, whether you moved around much, what your family did for a living at various times.

 

 

The remaining questions are as follows:

 

2. I'd like you to try to describe your relationships with your parents as a young child. If you could start from as far back as you can remember.

 

3. I'd like you to choose five adjectives that reflect your childhood relationship with your mother. This might take some time, and then I'm going to ask you why you chose them.

 

4. Question 3 repeated for father.

 

5. To which parent did you feel closest and why? Why isn't there this feeling with the other parent?

 

6. When you were upset as a child, what would you do?

 

7. What is the first time you remember being separated from your parents? How did you and they respond? Are there any other separations that stand out in your mind?

 

8. Did you ever feel rejected as a young child? Of course, looking back on it now, you may realize that is wasn't really rejection, but what I'm trying to ask about here is whether you remember ever having felt rejected in childhood.

 

9. Were your parents ever threatening with you in any way - maybe for discipline, or maybe just jokingly?

 

10. How do you think these experiences with your parents have affected your adult personality? Are there any aspects of your early experiences that you feel were a set-back in your development?

 

11. Why do you think your parents behaved as they did during your childhood?

 

12. Were there any other adults with whom you were close as a child, or any other adults who were especially important to you?

 

13. Did you experience the loss of a parent or other close loved one while you were a young child?

 

14. Have there been many changes in your relationship with your parents since childhood? I mean from childhood through until the present?

 

15. What is your relationship with your parents like for you now as an adult?

 

16. How do you respond now, in terms of feelings, when you separate from your child?

 

17. If you had three wishes for your child twenty years from now, what would they be? I'm thinking partly of the kind of future you would like to see for your child.

 

18. Is there any particular thing which you feel you learned above all from your own childhood experiences? What would you hope your child might learn from his/her experiences of being parented?

 

Category Patterns on the AAI

 

     Secure:/autonomous (F):  Coherent and collaborative discussions of attachment-related experiences relationships. Valuing of attachment but seems objective regarding any particular event or relationship.  Description and evaluation of attachment-related experiences is consistent, whether experiences are favorable or unfavorable.  Discourse does not notable violate any of Grice’s maxims.

 

     Dismissing (Ds):  Not coherent. Minimizing of attachment-related experiences and relationships.  Normalizing (“excellent, very normal mother”), with generalized representations of history unsupported or actively contradicted by episodes recounted, thus violating Grice’s maxim of quality.  Transcripts also tend to be excessively brief, violating the maxim of quantity.

 

     Pre-Occupied (E): Not coherent. Preoccupied with or by past attachment relationships or experiences, speaker appears angry, passive or fearful.  Sentences often long, grammatically entangled or filled with vague usages where something is left unsaid (e.g., “dadadada”; “or whatever”) thus violating Grice’s maxims of manner and relevance.  Transcripts are often excessively long, violating the maxim of quantity.

 

     Unresolved/Disorganized (U): Not coherent. During discussions of loss or abuse, individual shows striking lapses in monitoring of reasoning or discourse.  For example, individual may briefly indicate a belief that a dead person is still alive in the physical sense, or that this person was killed by a childhood thought.  Individual may lapse into prolonged silence or eulogistic speech.  This speaker will ordinarily otherwise fit Ds, E, or F categories.

 

Transcript Examples: Secure

 

     Which parent would you say you were closest to?

     Oh I felt, closest to my mother

     And why was that?

     Uhm..[2 secs] simply because she was, she was there, uhm, you know, like I said when I, when I came home from school, she was there (Uh huh), uhm, you know, when I, when I, had a question or a problem, I knew I could talk with her, uhm…[3 secs], and , it’s just, you know, I knew she really cared, and (Uh huh), and uhm, was interested.  Even when my father was there he wasn’t really there, you know, uhm, so-- (I understand what you mean) okay.

 

Transcript Examples: Dismissing

 

     Which parent would you say you were closest to?

     Uhm, I, early on, probably, my mom.

     And why was that?

     Eh, eh, I guess, during the very early years because, eh, she got stuck taking care of us, uhm later on it flipped around and I got probably closer to my Dad because eh, I guess--too much eh, time with my Mom.

     What do you mean by too much time with your mom?

     Eh uhm, I got, I guess, of, of, uhm-- kids get sick of their parents or what they do and, even though it may be quite proper, it’s just that it’s annoying and -- and you just get tired of them.

 

Transcript Examples: Preoccupied

 

     Which parent would you say you were closest to?

     Neither, and that’s the case today.  In fact, last week my son was sent to the principal’s office and they called me at work to pick him up.  I wasn’t able to so I had to call my mother.  I heard the judgment in her voice.  I thought, another narcissist heard from. My son’s father is self-absorbed just like them. Did I tell you that he abused me?  Anyhow I had no choice but to call her, if his father got involved there would be another blowup, letters to his attorney and then I’d have to pay my lawyer.  It’s non stop.  I am not sure if this answered your question. 

 

From these examples, you can see how the discourse of the three basic categories of adult attachment differ.  Compare these brief answers to the original definition of coherence and the category patterns described above.

 

Reflective Function

 

As mentioned earlier, Peter Fonagy has developed a method of assessing adult attachment using the AAI protocol, but scoring the transcript based on the ability of the speaker to mentalize - reflect on their own inner experience and reflect on the mind of others. In his books, Fonagy speaks about the hallmark of secure attachment being the ability to reflect on one's internal emotional experience, and make sense of it, and at the same time reflect on the mind of another.  One can immediately see how these capacities are imbued in the infant through sensitive attunement of the caregiver.   When a caregiver reads the verbal and non-verbal cues of the child and reflects them back, the child sees him or herself through the eyes of the attachment figure.  It is through this attunement and contingent communication process that the seeds of the developing self are planted and realized. Insecurely attached individuals lack this reflective function either because their emotional responses are so repressed as in the case of the dismissing attachment status or exacerbated as in the case of the preoccupied attachment status that they are unable to either identify their own internal experience or reflect on that of the other. When either one of these extremes are the method of regulating the attachment behavioral system, the capacity for reflection (on oneself and others) is compromised.

 

     Reflective function is a cognitive process: How an individual understands the self and others emotions, intentions, needs, motivations.

     Reflective function is an emotional process:  the capacity to hold, regulate, and fully experience emotion. A non-defensive willingness to engage emotionally, to make meaning of feelings and internal experiences without becoming overwhelmed or shutting down.

     High Reflective Function: includes neural capacities such as social cognition, autonoetic consciousness, awareness of and regulation of complex emotional states inherent in social relationships.

 

Adult Attachment Projective

 

This test consists of eight drawings (one neutral scene and seven scenes of attachment situations).  According to the authors,

 

“These drawings were carefully selected from a large pool of pictures drawn from such diverse sources as children’s literature, psychology text books, and photography anthologies. The AAP drawings depict events that, according to theory, activate attachment, for example, illness, solitude, separation, and abuse.  The drawings contain only sufficient detail to identify an event; strong facial expressions and other potentially biasing details are absent. The characters depicted in the drawings are culturally and gender representative.”

 

     Like the AAI, the subject’s responses are recorded and transcribed and then scored based on the coherence of the responses.  Authors use similar and different scales from the AAI coding process.  According to the authors the AAP takes less time to administer and much less time to score, which makes it more useful for clinicians.  Unlike the AAI, the AAP is geared toward clinicians as opposed to only researchers in attachment.  For more information on the AAP see the references accompanying this presentation.

 

Self report measures

 

Social psychologist, Phil Shaver and his colleagues have studied the relationship between adult attachment and interpersonal relationships.  They deconstructs attachment into two continuums - anxiety and avoidance.  Securely attached individuals feel low anxiety in relationships and don’t have to avoid closeness when difficulties arise.  They also conceptualize attachment style in terms of dimensional qualities rather than distinct categories that you either belong to or not.  For example, one can be slightly preoccupied or dismissing, or extremely preoccupied or dismissing.  Using their model one can generally be secure, but leaning toward preoccupied or dismissing.  The following slide shows the relationship between each of these variables and attachment style.

 

Experiences in Close Relationships

 

     Shaver, Fraley and colleagues developed a number of self-report measures that assess adult attachment.  His most recent scale, The Experiences in Close Relationships-Revised (ECR-R) is a 36 question scale that asks about close relationship experiences, thoughts and feelings. Answers are based on a 7-point likert-type scale from “not at all like me” to “very much like me.”  The following are sample questions.  This scale can be taken on the web and results are given to the subject at: http://www.yourpersonality.net/

 

Sample Questions: Experiences in Close Relationships – R

 

     I'm afraid that I will lose my partner's love.

     I often worry that my partner will not want to stay with me.

     I prefer not to show a partner how I feel deep down.

     I feel comfortable sharing my private thoughts and feelings with my partner.

 

Kim Bartholomew has also conceptualized adult attachment, but more in line with Bowlby’s ideas.  Like Shaver, she has created a two dimensional grid representing adult attachment based on internal working models of self and others - positive or negative.  Her model may be understood as being cognitive in nature, whereas Shaver’s model is more affective/behavioral.  Here too, attachment style is viewed as dimensional rather than categorical.

 

Bartholomew has also developed a measure of adult attachment that have evolved and changed over the years.  Her most recent rendition appears to be a combination of both self-report and more interview type questions.  You can access her scales at her web site at:

 http://www.sfu.ca/psyc/faculty/bartholomew/research/index.htm

 

Sample Questions: Relationship Status Questionnaire

     I find it easy to get emotionally close to others.

     I want to be completely emotionally intimate with others.

     I am comfortable without close emotional relationships.

     I worry that I will be hurt if I allow myself to become too close to others.

 

To read a number of online articles on self-report measures and their similarities and differences to the AAI visit Chris Fraley’s web site at:

     http://www.psych.uiuc.edu/~rcfraley/index.htm

 

Or Phil Shaver’s web site at:

 

http://psychology.ucdavis.edu/labs/shaver/

 

Clinical Interview and Assessing Adult Attachment Status

 

     A recent study examined how accurate clinicians are at assessing adult attachment.  The results were not very promising.  Assessing adult attachment via clinical interview alone is not very reliable.  However, this doesn’t mean that it’s not possible.  It just means that a method has yet to be developed.

 

If you have questions about assessing attachment ……email Dr. Sonkin.

 

Domestic Violence and Attachment Theory

 

Don Dutton has developed a typology system consisting of three types of batterers.   Each type is associated with a different attachment style as assessed by self-report measures.  The Psychopathic batterers are associated with a dismissing attachment.  The Over-Controlled batterers are associated with a preoccupied attachment.  The Borderline batterers are associated with a fearful (similar to disorganized) attachment.  Let’s look at each of these types more closely.

 

     The Psychopathic / dismissing batterers are also described as using violence that is instrumental - cold and calculating (like Jacobson’s “vagal reactors”).  These batterers characteristically lack empathy - a quality one learns through sensitive caretaking as a child. These batterers tend to be more interested in getting what they want (and violence is a justified means to that end) than maintaining positive relationships (other than it serves their needs).  Therefore, you find these batterers both violent inside and outside of the home, and are often involved in the criminal subculture. This group may be diagnosed  antisocial or aggressive-sadistic.

     Unlike the dismissing batterer, the Over controlled or Preoccupied batterer is very focused on attachment, but in an angry way - as if staying angry will maintain an emotional connection. Irritations and resentments experienced toward parents is played out with his current partner with little or no awareness that this misplacement is occurring. Some preoccupied batterers appear very passive as a strategy to avoiding conflict (and possibly losing connection); however, the tension eventually builds to the point that a blowup occurs (particularly when under the influence of alcohol).

     Lastly, the Fearful or Disorganized batterer has both dismissing and preoccupied qualities.  He can abruptly shift from distancing to dependency, a pattern characteristic of persons suffering from borderline personality disorder - Dutton diagnosed this group as borderline based on the MCMI.  These batterers are the most difficult to treat because of the sudden shifts in states of mind with regard to attachment and their extreme disregulation of emotion.  These batterers find relationships very distressful in that getting close is terrifying and yet being disconnected is just as terrifying. These individual are similar to the disorganized infants who wanted soothing from their parent but were afraid of them at the same time.

 

Attachment and victims of abuse

 

     As mentioned earlier, a significant percentage of victims of abuse have been assessed as having a preoccupied attachment status.  This can manifest as extreme clinging behavior, and when distressed they look outside themselves for soothing and reassurance.  Some victims of abuse have been found to be “fearfully preoccupied” rather than angrily preoccupied, like many male perpetrators.  Many of these women have been victimized as children.  Their predominant reaction is fear rather than anger.

     In addition, many victims of abuse have been assessed as having a disorganized or unresolved attachment status.  Like the disorganized infants, these woman have an approach-avoidance pattern in relationships.  Unresolved trauma could also result in dissociative process during times of emotional distress, such as during a violent episode, recalling a violence episode or during separation or reunion with their abuser.

     Although it hasn’t been discussed in the literature, there are also victims of abuse who have a dismissing status.  From what we know about this category, it would be expected that these individuals would probably have an easier time leaving their relationship.  They are also likely to meet up with a preoccupied partner.

     Lastly, it is also possible that some victims of abuse are securely attached.  Again, it would be expected that these individuals would have the easiest time, psychologically speaking, leaving their relationship.  They are more likely to have higher self esteem, more flexible and pro-social - all skills that would assist in a transition out of a relationship/marriage.

 

Attachment and Gay/Lesbian Couples

 

     Domestic violence in gay and lesbian relationships is a serious problem.

     In one study the researchers found lesbian relationships were significantly more violent than gay relationships (56% vs. 25%).

     A study of 1,099 lesbians found that 52% had been a victim of violence by their female partner, 52% said they had used violence against their female partner, and 30% said they had used violence against a non-violent female partner.

     In a survey of 350 lesbians, rates of verbal, physical and sexual abuse were all significantly higher in the lesbian relationships than in heterosexual relationships: 56.8% had been sexually victimized, 45% had experienced physical aggression, and 64.5% experienced physical-emotional aggression. Of this sample of women, 78.2% had been in a prior relationship with a man.

     Reports of violence by men in gay relationships are lower than reports of violence in prior relationships with women (sexual victimization, 41.9% (vs. 56.8% with women); physical victimization 32.4% (vs. 45%) and emotional victimization 55.1% (vs. 64.5%).

     What does these data mean?

     Feminist explanations for violence that focus on patriarchy and sex role stereotyping does not hold true for same sex relationships.

     That there may be greater rates of attachment insecurity among lesbian couples than gay couples.

     Lenore Walker has tried to explain higher rates of violence in lesbian relationships as being due to equality of size and weight, fewer normative restraints on fighting back and tacit permission to talk about fighting back. However, Murray Straus found that power equalization produced less violence in couples rather than more.

 

If you have questions about same-sex relationships……email Dr. Sonkin.

 

Tasks of attachment-informed psychotherapy according to Bowlby

 

     Create a safe place, or secure base, for client to explore thoughts, feelings and experiences regarding self and attachment figures;

     Explore current relationships with attachment figures;

     Explore relationship with psychotherapist as an attachment figure;

     Explore the relationship between early childhood attachment experiences and current relationships;

     Find new ways of regulating attachment anxiety (i.e., emotional regulation) when the attachment behavioral system is activated.

 

Reconceptualizing Domestic Violence

 

If rage and the resultant violence can be understood, in part, as being the result of maladaptive defense mechanisms stemming from insecure attachment and that many victims have difficulty coping with violence because of their own attachment insecurity, then the process of therapy will involve helping the client move from insecurity to greater security as manifested by the capacities described by Daniel Siegel in his book, The Developing Mind. Developing these capacities will be critical to changing how men and women experience themselves and others.

 

Tasks of Attachment Informed Domestic Violence Treatment

 

     Past, present and future orientation

     Focus on understanding what is happening in the mind of others

     Learning to reflect on the self

     Develop emotion communication skills

     Focus on flexible response to situations

     Address unresolved trauma and loss

     Work with what is in the room

n   Rupture and repair: use the natural separations and ruptures in therapy to help the client develop more adaptive ways of coping with attachment distress.

 

Secure-base Priming

 

The idea of creating a secure base in psychotherapy sounds good, but is this a real concept or just another variation of the therapeutic alliance?  Researchers in adult attachment have been able to empirically test the notion that creating a secure base experience for individuals may temporarily alter an individual’s inner working models of others and therefore change behaviors or emotional states.  The idea of “secure base priming” has been gaining attention in the adult attachment literature.  Mario Mikulincer and Phil Shaver examined the effects of secure base priming on inter-group bias. 

They hypothesized that having a secure base could change how a person appraises threatening situations into more manageable events without activating insecure attachment-like behaviors such as avoidance, fear, or preoccupation. They utilized a series of well-validated secure base priming techniques that have appeared to create in subjects a sense of security one would find in individuals who would might otherwise be assessed as having a secure attachment style.  These techniques were quite creative and had powerful effects on subjects.

 

In all five of these studies, those subjects exposed to secure base priming acted in the experimental condition similar to securely attached individuals who did not receive priming but were nevertheless exposed to similar conditions assessing inter-group bias.  The authors suggest that secure base priming enhances motivation to explore by opening cognitive structures and reducing negative reactions to out-group members or to persons who hold a different world view.  The observed effects of secure base priming may reflect cognitive openness and a reduction in dogmatism and authoritarianism.

 

Other similar studies have found that secure base priming will have a positive effect on cognitive and affective states.  Although these studies are not meant to be applied to clinical situations, they have powerful implications for the clinical setting.  Aspects of the psychotherapy process are similar to these descriptions of secure base priming and through that process clients may begin to change their internal representations of self and others or attachment status.

 

Creating a secure base in psychotherapy

 

According to attachment theory…..

     ….an attachment is a tie or bond that binds two people that serves a psychological and biological function across the life span.

     The biological function is both physical protection and the development of neurological capacities in the developing brain of the infant.

     The psychological function is the development of a sense of self and an understanding of self in relation to others.

     For the adult, the biological function can be physical protection, but can also be more a psychological protection (emotional care-taking) so that the adult feels free to go out and explore the world outside the family. 

     Unlike a child/parent relationship where one person is the caregiver and another is the care receiver, in adult attachment relationships, each person will at times be the caregiver and at other times be the care receiver.  However, the balance of these two roles will vary from relationship to relationship.

 

Characteristics of attachment relationships

 

Proximity maintenance

n   One wants to be in close proximity to attachment figure.

n   One feels loss when the attachment figure is not available and there may be anger or frustration at reunion.

Safe haven

n   One retreats to attachment figure(s) when feeling anxious or fearful.

Secure base

n   The attachment figure serves as a base of security  so as to explore the physical and social world.  Knowing that you can return when feeling anxious or fearful or needing support or protection.

 

How does this relate to psychotherapy?

 

Most therapists are hoping that their clients will:

n  Want to meet with their therapist to talk about their problems.  It is expected that some clients will feel loss during separations and may express anger or frustration upon reunion. (proximity maintenance)

n  Will want to talk to the therapist when they feel distressed (safe haven)

n  Will use the therapist as a secure base from which to explore their physical, psychological and social world.

 

In other words….….form an attachment.

 

But how does this attachment develop?

 

John Bowlby and Mary Ainsworth (the American researcher who developed a brilliant method of assessing child attachment call the “strange situation”) believed that secure attachments developed due to maternal or paternal sensitivity and cooperation.  Let’s explore these concepts a little deeper.

 

Sensitivity

 

This involves the caregiver’s ability to perceive and to interpret accurately the signals and communications implicit in the infant's behavior, and given this understanding, to respond to them appropriately and promptly.

 

Sensitivity has four essential components:

n   (a) awareness of the signals;

n   (b) an accurate interpretation of them;

n   (c) an appropriate response to them; and

n   (d) a prompt response to them.

 

Cooperation

 

The extent to which the parents interventions or initiations of interaction break into, interrupt or cut cross the child’s ongoing activity rather than being geared in both timing and quality of the child’s state, mood and current interests.

 

Facilitating Secure Attachment in Psychotherapy

 

     Sensitivity and cooperation is the basis for healthy parent/child interactions. If this process breaks down the child experiences a break in the connection with it’s caregiver or feels ignored or intruded upon.  When these mis-attunements occur with considerable frequency, the child’s “attachment behavioral system” can become escalated (anxious) or cut off altogether (avoidant).

     In therapy, sensitivity to verbal and nonverbal communication and cooperation is critical to developing the attachment or connection between the client and therapist.  Frequent mis-attunements by the therapist will cause a chronic sense of frustration with the client and may lead to their emotional withdrawal and dropping out.

     Likewise, therapist are also in the position of balancing the therapeutic goals with the material the client brings into the session.  When the therapist is too focused on their agenda and not enough attuned the client’s process, the client may experience the therapy as intrusive or controlling, which may unconsciously remind them of their experiences with the parent(s). This activates attachment distress which the client will regulate in the ways they have learned in their family.

     Understanding your client’s attachment status is critical to breaking long-held beliefs about close relationships or what Bowlby described as internal working models of self and other. If the therapist responds in a manner that confirms these schema, the cycle is maintained or even exacerbated. If, on the other hand, the therapist acts in a way that disconfirms the client’s expectations, then the cycle can be broken and the door is opened for a different type of relationship.

 

Emotions

 

Daniel Siegel in his book, The Developing Mind, talks not only about the importance of sensitivity in the healthy development of children, but in therapy as well.  He states that therapists put too much stock into the discussion of categorical emotion (Anger, fear, surprise, disgust, joy, excitement and shame) and not enough focus on what he calls, primary emotion or affect.  It is the amplification of positive primary affect and the soothing or reducing of negative primary affect that characterizes healthy attachment relationships.

 

Siegel breaks down the emotion process into three phases or categories.

 

n   First there is a sensory awareness or orientating process.  The mind picks up from the body (the body usually knows what it’s feelings before the mind knows)  the message: Pay attention, this is important

n   The next phase he calls appraisal and the arousal of primary affect: The mind makes a decision or judgment that this is good or this is bad. This is also sometimes referred to as mood

n   The process can be further elaborated into categorical affect (Anger, fear, surprise, disgust, joy, excitement and shame).

 

Siegel contends that most of the emotional communication between parent and infant and between adults is this primary affect, rather than the discussion of categorical emotions. In other words much is said without saying it.

 

People who grew up in healthy families where primary positive affect was shared and negative primary affect constructively soothed are generally more sensitive in the way described earlier.  Those experiencing less positive parenting are often quite out of touch with or unable to articulate their primary affect or categorical emotions. So much of what they are feeling is communicated behaviorally rather than with words. Nor are they sensitive to these emotions in others.

 

Like a child who has not yet learned the language of primary affect or categorical emotion, many victims and perpetrators need an attuned parent-figure who will pay close attention to their non-verbal cues (facial expression, eye gaze, tone of voice, bodily motion and timing of response) and help them connect with their internal experience.  Through careful observation and emotional attunement, the therapist can help the client identify their internal experience to situations and offer them a language in which to communicate those feelings.

 

When the therapist is sensitive to these non-verbal signals and is able to help the client identify and articulate their inner emotional experience, the client feels understood by the therapist because their state of mind is being “felt by another.” 

 

For this process to occur, the therapist allows his/her mind to have an experience as close as possible to what the client’s subjective world is like at that moment - not unlike the process that occurs between an attuned parent and their child.

 

It’s important to state that the parallels between parent/child attachment and therapist/client attachment have their limitations. However, the similarities of these two relationships do lend themselves to these comparisons.

 

If you have questions about psychotherapy …email Dr. Sonkin

 

Case Examples

 

Robert

     34 year old African-American

     Started therapy shortly after a divorce from a 14 year marriage.

     No children. 

     CPA for a bank.

     Wife reports that he smothered her, in that he was excessively jealous, dependent and verbally abusive.  Also states that he refused to have children.

 

Robert presents as very friendly, talkative and anxious.  He seems interested in your ideas and asks you on numerous occasions, “What do you think he should do to get his wife back?”  When asked about his childhood experiences, he launches into a tirade about his father’s unavailability (he worked three jobs to support the family) and his mother’s involvement with other men.  He goes on for ten minutes and then stops and says, “I don’t know if that answers your question.”  He goes on to say that he has never found someone as committed as he is in relationships, even friends are unreliable.  There is a long pause and then he says, “You know, people are never there when you need them.”

 

     He explains, “My problems with jealousy in the marriage would not have been a problem if Elaine loved me and was committed.”

     When ask about other problems in the marriage he states that sex was also problem.  She never seemed interested.  They hardly had sex.  When you inquire as to frequency he replies “..four or five times a week.”

     When you ask if he thinks that his jealousy about his wife may be related to his experiences in his family he says that he never thought about that.

When asked about how he is feeling recently since the separation, he states that he’s feelings mostly angry, but has been sending her flowers and emails apologizing for anything he can think of.  Robert has some insight that his jealous feelings are not founded in reality (that his wife was not with other men), but when she worked or went out with friends or even when she was on the phone, he felt these intense feelings and believed if he could get her attention he wouldn’t feel so bad.  This insight represented an open door that Robert might be able to focus on himself long enough to make use of therapy.

Assessment

     He is preoccupied with keeping wife’s and the therapist’s attention.  Probably this was his strategy with his mother as well.

     He gets caught up in negative, analytic, and angry discussions of his past attachment experiences, so much so he forgets the original question, yet there is little insight into the connection between those experiences and his current relationships.

     Describes his current relationship as enmeshed, overly close, poorly bounded and anger-inducing at the slightest sign of separation.

     He seems overwhelmed to the point that he is unable to organize or contain his feelings in a useful manner.

 

Treatment

     Preoccupied individuals have learned to become hypervigilant regarding their attachment figures.  They are used to hyper-activating their attachment distress in order to stay connected or get their attachment figure’s attention.  Robert will need to:

 

n   learn how his past experiences are affecting current relationships;

n   how to look less to his partner for soothing and learn how to become more aware of and soothe his anxiety;

n   realize that he has choices when feeling anxious and become aware of how his clinging and dependency affects his partner.

 

     These dynamics are likely to come up in the therapy, so it will be important to use the natural ruptures that occur in sessions as opportunities for growth and change as well.

 

If you have questions about Robert……email Dr. Sonkin.

 

Howard

     45 year old man of English/German decent

     Separated, 4 children (10, 12, 14, 16)

     Presents as cool, not engaged in discussion and over-controlled.

     He has been referred to therapy as a result of being arrested for intoxication in public and misdemeanor battery.

     States that wife is staying with her sister for the past two weeks and that he misses her but is not able to articulate what he misses about her.

 

      H: “I was eating out with my wife, I wasn’t drinking more than usual and then this guy at the next table tapped me on the shoulder and says that I am talking too loud and asked if I could talk quieter.”

      T: “How did you feel when he said that?”

      H: “I didn’t think I was talking any louder than anyone else there.

      T: “What happened next?”

      H: “I just ignored him. Mary keep ragging on me to stop embarrassing her.   She wouldn’t shut up so I just reached across the table and closed her mouth.  She wouldn’t listen to me so I shut her up myself.

      T: You must have been feeling pretty angry at her.

      H: No. She wouldn’t shut up, so I shut her up.

     T: “Where did you grow up?”

     H: “Sonoma County.”

     T: “Do you still have family there?”

     H: “Yes.  Both parents and two younger brothers and a younger sister.”

     T: “How would you describe your relationship with them?”

     H: “We’re close.

     T: How often do you have contact with them?

     H: I see them once or twice a year. Usually for the holidays.”

 

§    In the following session:

§    He reported in passing that his father routinely drinks to intoxication, but only on the weekends and holidays. 

§    He denies having a problem with alcohol and stated that he was in complete control that night.

§    He described his father as authoritarian - ruled with an iron fist. His mother was depressed and unable to care for herself let alone her children. When asked about how those experienced affected him he states that it made him stronger and more independent.

§    He also states that he doesn’t see his children that often but blames this on his demanding job.

 

Assessment

     Howard presents as disengaged, self-protective, self-sufficient, sensitive to being controlled or overly influenced by others. 

     When discussing his past attachment relationships he presents few details, plays down negative experiences and even presents contradictory information.  He states that his negative family experiences were actually good for him in that they made him more strong and independent.  This is a common statement with people who have a dismissing attachment status.

     Howard constricts and plays down his emotional experience.   When the therapist suggests that the client may have felt angry, he denied such feelings. He also denies any negative feelings about his family experiences.

     His answers tend to be short and he doesn’t offer the therapist much information about himself. This is also common with people who have a dismissing attachment status.

 

     Dismissing negative feelings and experiences is a way of avoiding the pain associated with family attachment experiences.

 

Treatment

 

     Engaging Howard into therapy will be difficult because his childhood experiences has taught him that survival is based on deactivating his attachment needs and feelings.  To need therapy will require him to admit that he can’t deal with his problems on his own - a sign of weakness and vulnerability. So the first treatment issue will be engagement and finding some way of framing therapy that is not threatening to his defenses.  With clients like Howard, going to therapy to stay out of jail, may be as good as it gets initially. Focusing initially on the practical aspects of therapy, skill building, is helpful with clients like Howard. 

     Howard grew up in family with an alcoholic father and depressed mother - self-reliance may have been the best option at the time. If he stays in therapy long enough, redirecting his attention to his internal emotional experience will be key to psychological change.  I would pay attention to when he might be experiencing primary emotions that are communicated nonverbally, and slowly and sensitively help him connect with those emotions.  I am not talking about categorical feelings such as anger, sadness or fear, but rather the basic primary emotions - I feel good or I feel bad.

     This tact is not going to be very rewarding to the therapist. When you use your best sensitivity skills to help him with identifying his internal experience he’ll just look at you and say, “So what?”  But persistence is key with this client.  Years of deactivating attachment needs is not going to change overnight.  In fact, your sensitivity is likely to cause him discomfort.  He may become so frightened that somebody sees him that he will begin to act out - come late or miss sessions.  A combination of skill building, setting limits to acting out and persisting with sensitive interpretation will hopefully pierce his protective defenses.

 

If you have questions about Howard……email Dr. Sonkin.

 

Sandy

     31-year old Jewish woman

     In recovery (3 years) from cocaine and alcohol dependency.

     A survivor of child sexual abuse.

     Presents with a blunted affect, introverted, insecure, analytical, cool and lifeless. She speaks with a monotone voice and you find yourself asking her to repeat herself because she speaks so softly.

     Referred by probation for attempting to stab her husband with a knife.

 

In the first session she arrives 15 minutes late. She immediately wants to know your emergency policy.  She is concerned that therapy brings up a lot of feelings for her and she wants to know your availability between sessions.  Her previous therapist, whom she saw for three years about five years ago, was available between sessions for emergencies. 

 

You discuss your policy of not having 24-hour coverage and go over what services are available to her in the county.  You also suggest that perhaps she may need to come in more than once a week if she begins to feel overwhelmed.  She says that she can’t afford to see you more than once a week and in fact, she was wondering if you have a sliding scale.  She says that her former therapist saw her at a reduced rate.

 

When asked about the incident that resulted in her arrest she states that she and her husband had just had sex when the telephone rang. It was his old girlfriend.  She doesn’t recall all the details but she remembers getting angry and they started fighting.  She doesn’t remember how she got the knife but she thought that she was going to kill herself, but she must have started swinging the knife at her husband.  Her daughter called the police.

 

She describes a long history of short-term intimate relationships with both men and women that start off very intense (sexually and emotionally) and then end abruptly. Sometimes she angrily rejects her partner for no apparent reason.  Other times she is rejected and falls apart. Her relationship history is confusing and hard to follow.  You find yourself asking her clarifying questions.  This pattern continues into her discussion about her family of origin as well, when she disclosed that she was sexually abused by her father.

 

When asked about her previous therapy, she states that it mostly focused on her chemical addiction issues. She states that she didn’t go back to her previous therapist because she feels that she outgrew the therapist.  When you follow up on this, it appears that she felt angry at her therapist for disclosing too much information about herself.

 

You inquire about how her sexual abuse was addressed in her previous therapy.  She states that her previous therapist didn’t really deal with it because the focus of the therapy was her recovery.  She explains that the philosophy of her sponsor is to first get sober and then deal with family abuse issues.  When you ask her if that is something she would like to address in this therapy, there is a long silence, she looks up to the ceiling and then says, “He is dead now, you know my father, but he is still inside of me.”  When you ask how so, she replies, “I don’t know.”

 

Assessment

     Sandy has a mixture of dismissing and preoccupied tendencies.  She angrily leaves relationships and is reluctant to come in more than once a week (dismissing tendencies) and other times she is overwhelmed by rejection, is wanting the therapist to take care of her by being available for emergencies and reducing the fee (pre-occupied tendencies).

     Her discourse of her attachment experiences is disjointed and dissociated in speech and mental processes.

     Sandy shows some dissociative processes when asked about sexual abuse.  Her story about the incident that got her arrested suggests some dissociation as well.

     Sandy’s attachment experiences included trauma. States that she hasn’t really worked on this issue because recovery has been a priority.

     The incident of violence appears to be more related to unresolved sexual trauma than substance abuse/dependency per se.

     Some attachment researchers and clinicians state that contrary to some preliminary findings suggesting that preoccupied status is related to borderline personality disorder (BPD), disorganization may be more related to this disorder. 

     The characteristic oscillation between closeness and distancing seen with persons suffering from BPD and the similar process seen with disorganized attachment seems to make this hypothesis reasonable.

     Sandy is disorganized because she doesn’t have a single strategy for dealing with separation anxiety and reunion distress. She may oscillate between being helpless and needing caretaking and being aggressive or distancing.

 

If you have questions about Sandy……email Dr. Sonkin.

 

Julie

 

     32 years old

     2nd generation Chinese-American

     Recently filed for separation from husband (Anglo-European decent) after his arrest for domestic violence.

     Married 5 years

     2 children: 9 months, and 3 years.

     Presents as nervous, shy, formal, and somewhat frail.

      

Oldest child of eight.  Describes mother as fluctuating between depressed and unavailable, and being angry and critical.  She was overwhelmed with parenting responsibilities and demanded that Julie assist her with the younger children from an early age.  Her father was rarely home, but when he was, he was frequently angry and had high expectations of his wife and the children.  When talking about her childhood you get the silent feeling that she has failed to please her father and her mother.  She often uses child-like words, such as referring to her parents as mommy and daddy.

Julie

 

Her narrative wanders from topic to topic having difficulty responding to the therapist’s questions.  Her descriptions of childhood experiences borders on self-blame, at times using self-critical language that might have been the way her parents spoke to her.

 

Her parents disapproved of her marriage to a non-Chinese American, but grew to accept their relationship.  When they found out about the violence (Julie’s sister told them), they supported her leaving him and offered to take her in to their home.  Instead, Julie got a TRO and is still living in the family home with her children.

Julie

 

Her attorney called prior to the referral, stating that her client kept oscillating between separation and reconciliation and that she was hoping that the therapy would help her figure things out.

 

Description of last battering incident

 

Was upset that husband had been working long hours and not spending time with her or the children.  Argument escalated to the point of husband strangling her - almost to unconsciousness.  Called the police the following morning upon the recommendation of her sister.

 

Now wants to reconcile with husband after a 6 week separation.  This decision is against her family’s wishes and her attorney’s recommendations.  The attorney is a friend of their family.

 

     T:  Julie, what is it that you hope will happen at this point?

     J:  Well….. I feel bad that he has sort of gotten into so much trouble. I know he was to bla, well I didn’t have to call the police. He j..,  I  just want to, I just want to go, you know, back to before all this happened.

     T:  It may be too late for that.

     J:  If I don’t talk to the DA, they’ll drop the charges.

     T: Why would you do that?

     J:  I don’t know.  If I don’t he’ll…. I don’t know.

     T: He’ll do what?

     J:  He misses the kids, me and the kids.

     T: What has he been telling you?

     J: Well, that if I don’t make up my mind soon, he is going to file for divorce and custody of the children (clenches her fist on the arm of the sofa and turns away).

     T: What was your reaction to that?

     J: I think he is just hurting inside. He is, he’s embarrassed about everything I did to him.  I told him I was thinking about coming back.

     T: And his reaction?

     J:  He was happy about that.

     T: What do you think you want to do.

     J: I guess I just want to sort of make the situation better… I don’t know.  I want my family to be happy, but I… well, you know.

     T: Julie, I noticed just a minute ago that when you were mentioning that fact that your husband was going to file for divorce and custody there was a change in your body.  Did you notice that?

     J:  No, I don’t think so… well maybe… I don’t know.

     T: Well until that point you were sitting with your hands clasped on your lap, looking at me.  But when you mentioned that your husband was going to file for divorce, you clenched your fist and turned your head away.

     J: Huh, I don’t know.

     T: I mention it because when you did that I felt something change for you.  I had a feeling that hearing your husband say those words, possibly made you feel uncomfortable or bad.

     J:  Well, kind of.  Here I am trying to think about coming back and now he’s talking about leaving.

     T: I can see how that feels bad.

     J:  Well, Steve says he’s really sorry this time.  He really wants to work on the relationship.  He said we could go to couples counseling.  But then he says this.  It’s confusing.

     T: I can see why.

     (The next part of the session focused on helping Julie identify where that feeling was located in her body.)

     T:  We have been focusing a lot on Steve and what he thinks and wants,  but I am not getting a good idea of what you want.  Are you ready to go back?

     J: I don’t know.  People have told me that I tend to go along with others, but I think that is a good thing… being easy going, flexible.

     T: Flexibility is a good quality to have at times, but some decisions are too important to leave up to others. 

     J:  I just don’t know… I guess I am so used to doing what others expect, I don’t know.  People know me, I don’t know.

     T: I can sense the struggle in this for you.  When you are so used to taking your cues from others it’s hard to know what it is you feel, think or want.  Perhaps that’s something you can explore in here.

     J: What do I do in the meantime?  Steve wants an answer.

     T: Well, I know a lot of people in your life have some definite ideas about what you should do.

     J: Yeah………

     T:  Well, what would you tell your son or daughter if they were in a similar situation.

     J:  I’ll tell them to come to me or their father for help.

     T: So get help. That’s what your doing here.

     J: I’d tell them that unless the situation is life threatening, they should take the time to talk about the alternatives.

     T: That’s good too. Anything else?

     J:  I guess not everything can be decided based on, you know, what is right or wrong for the other person.  Kind of what you’re saying to me.

     T:   Well, maybe that’s how we can start.  Talk in here and give yourself some time to figure out your alternatives and see what you think and feel about the various choices. 

     J: But Steve, he wants an answer today.

     T: What do you think about that?

     J: This is an important decision.  I guess I owe it to my kids to do that same thing I would expect of them.

     T:  It’s not going to be easy telling Steve that you need some time.  You will be tempted to tell him what he wants to hear.

     J:  Well, maybe I don’t have to tell him.  I can have my attorney tell him that I just need more time to think things through.

     T: Sounds like a plan.

 

Julie: Assessment

 

Julie is preoccupied because her narrative during the assessment seemed to wander aimlessly from topic to topic rather than focus on the questions asked.  There was a sense that she failed her parents and there was an inchoate and vague sense of self.  Her parental experiences involved her needing to please her parents in order to receive their acceptance and therefore she didn’t develop a good sense of her own needs, thoughts and feelings, or what Peter Fonagy would say reflective function or mentalizing ability.

 

This led to Julie looking outside herself for a sense of self and a seeming inability to make her own decisions. Julie regulates attachment distress by focusing on her attachment figures.  Therefore, she was vulnerable returning to an abusive relationship or returning to her family.

 

Julie was needing for make up her own mind, perhaps discover her mind.  When I administered the TSI, she responded to the question, “Do you ever feel like you are not yourself?” by asking, “What if you don’t know what your self is to begin with?”

 

Julie treatment

 

Julie, although passive, is nevertheless preoccupied with her attachment relationships and as such is still re-enacting her family dynamics in her current relationships.  Being vague, confused and helpless is a way of maintaining her relationships and thereby regulating affect associated with potential attachment loss.

 

Treatment will involve helping Julie find alternative ways of regulating attachment distress - rather than focusing on pleasing others, discovering her own thoughts, needs and feelings and the strength to act on them.

 

Like the previous vignettes, treatment will focus on developing the capacities of the prefrontal cortex that contribute to secure attachment.

 

An important focus in treatment will be on the therapist/patient relationship.

 

Alison

     44 years old (Irish decent)

     Employed as a psychotherapist

     2 Children, son 23, daughter 20 (neither live at home)

     Currently living with husband who is employed as fireman.

     Presents as insightful, somewhat sarcastic and upset with husband’s “controlling and abusive behaviors.”

 

     A:  I attended one of your workshops on domestic violence and was very impressed with your knowledge of batterers and I thought you could help me with my situation.

     T:  I’ll try.

     A:  Well, my husband and I have been married for 28 years and from day one he has been controlling and abusive towards me.  He is always telling me what to do, criticizing my cleaning, the way I decorate the house, my friends and family, it’s non-stop.  We fight all the time and if it wasn’t for the fact that I am used to dealing with people like him, I’d be more of a wreak than I already am.

     T: So you say/

     A: /We have separated numerous times over the course of our marriage, but we seem to always get back together.  I know I love him, but I am not sure I can live with him.

     T:  Let me ask you a/

     A:  /I feel so embarrassed.  My friends and colleagues see how unhappy I am, but I just can’t seem to leave him.  He was a good father, and the sex, well that has never been a problem.  I think if I could get him into therapy somehow, then maybe this relationship has a chance.  What do you think?

     T: Do I think you should get him into therapy?

     A: Yeah, I mean I don’t think he will ever go to therapy. He’s a fireman and all of his friends joke with me about my work.  They are so self-absorbed with their masculinity - even if he did come it’s doubtful that he’d get anything out of it.  He’s just like my father, who was the fire chief in the small town where I grew up.  He dominated and controlled my poor little mother until it put her into an early grave.  She died of a heart attack last year…. [starts to cry].  It’s still hard./

     T: /I know./

     A: /His drinking and anger, it’s unbearable.  I got into this fight with my sister at the funeral.  She was always on his side and thought that mom and I were a team.  Of course, my sister will defend him till she dies - she says my mother drove him crazy with her drinking, but I know for a fact that the bastard drove her to the bottle.  She and my father were always a team.  There was no room for me in his life as long as she was around.  To this day Nancy and mom, I, we can’t really talk civilly to each other (This sentence is an example of narrative that suggestions unresolved trauma – notice how she refers to her mother in the present).

     T: It sounds like you are feeling a lot, about your relationship, your family and the loss of your mother.

     A:  I just can’t stand the verbal abuse any longer. Maybe I should just bring him with me to our next session.  You seem like you connect well with men.  What do you think?

     T:  Before we rush into anything, let’s take it slowly.  I’d like to get to know more about you, your history.  There is a lot going on in your life - a difficult relationship,/

     A: /Yes, your right./

     T: /family problems and

     A: It’s overwhelming./

     T: /a significant loss./

     A: /You sure know how to get to the bottom line.  I admire that in a therapist./

     T:  /You must be feeling so much right now.  So before making any decisions about couples therapy or not, maybe we should spend some time sorting out all the thoughts and feelings you might be having about your situation.

     A: I’d like to see you again this week.  Is that possible?

     T: Of course. 

 

Assessment

 

Just from reading this text, one can sense the anxiety in the room, which is an indicator of preoccupation.  Other signs include her anger, her non productive analysis of her relationships, her use of jargon and psychobabble, and her not giving the therapist his conversational turn.

 

Her history suggests a weak mother, who might have needed caretaking and a rejecting father.  Again her narrative is angry and critical, and the subject seems to be closed as to secure transcripts where there is the ability to review the material with a fresh perspective.

 

Treatment

 

Treatment for Alison will again follow Bowlby’s outline for psychotherapy from an attachment perspective, with a focus on the neurobiological capacities previously described.

 

Once again, the attachment behavioral system is clearly activated in the room, and therefore it is crucial to address this aspect early into the treatment process.

 

Caution!!

 

As mentioned earlier in the training, effective treatment of domestic violence cases will involve the continual assessment of risk and the formulation of interventions geared to reduce of the risk of future violence.

 

Therefore, therapists working from an attachment perspective (or any theoretical orientation for that matter) will need to balance psychotherapeutic conceptualizations and interventions with the continual assessment and treatment of violence and it’s effects.

 

 

Addressing Unresolved Trauma

 

     From an attachment perspective, trauma becomes unresolved when there is a chronic attempt to push out of consciousness distressing thoughts, feelings, perceptions, or bodily sensations (i.e., different types of memories) related to a trauma. When a traumatic experience is focused on and dreamt of (this will be explained later), instead of kept out of consciousness, there is the opportunity to make sense of what appears to be a senseless event and one is able to integrate the experience into the larger autobiographical narrative of life.

     However, in spite of one’s best efforts to keep these reminders at bay, internal or external cues will ultimately trigger painful memories. When this occurs, sudden and unwanted states of mind will be activated, which will likely impair functioning to one degree or another. This is  especially problematic in situations that require flexibility, emotional regulation and interpersonal sensitivity. In order to address trauma resolution, it is necessary to first understand the effect of trauma on the brain, in particular the neurobiology of memory.

     Memory is the way the brain learns and anticipates the future.  It makes for efficient processing of information. For example, when we are involved in playing the piano our mind is primed to remember important data  (e.g. where to put our hands and how the read the music) and not extraneous data. Without memory every act would be a novel experience.

     On a biological level, memory consists of ingrained patterns of neural activation called neural net profiles.

 

     Memories can have any one or a number of components:

 

n  Cognitive

n  Emotional

n  Behavioral

n  Perceptual

n  Mental models

n  Bodily

     There are two types of memory: implicit and explicit.

 

     During the first two years of life, while the brain is still developing, the only type of memory is implicit memory.  This type of memory is mediated via brain circuits independent of hippocampus (which is not yet online until about age 2).  Two important characteristics of this type of memory:

 

n  focused attention not necessary for implicit memory to occur and,

n  there is not a sense of remembering, but experiencing, when implicit memory is recalled.

 

     Many attachment related memories are these implicit memories.  Implicit memory occurs throughout our life.  We learn about our world even when were are not focused on learning.  When we are experiencing explicit memory, we are not aware that we are experiencing a form of memory.  There is just a sense of knowing.

 

     Explicit attachment memories are mediated primarily through the hippocampus, which is developed by the second year of life. There are two types of explicit memories.

 

     Semantic memory consists of events, data or facts and is typically mediated by the left brain, the left hippocampus in particular. 

 

     Episodic memory includes autobiographical memory.  When episodic memory is recalled, there is usually a sense of self included.

 

First there is sensory memory which lasts approximately 1/4 of a second. A portion of this information is placed into…

 

     working memory which can last approximately 30 seconds.  Working memory is short-term depending on how much rehearsing occurs.  It consists of temporary chemical changes in the brain. Significant changes in synaptic structure begins to occurs in…

 

     long-term memory which can last hours, days, or even months.  In long-term memory a stronger neural activation pattern has been established within the neural network that allows for easier recall.  For working memory to become…

     permanent memory a process called cortical consolidation needs to occur which is not completely understood, other than REM sleep is needed for this to occur.

 

Frequently clients present with semantic memories of their abuse (this or that happened), but are lacking a sense of self in their recall (their feelings, perceptions, sensations, what does this mean to my life, etc.). Resolution of these explicit attachment memories requires that…

n  These semantic memories be felt and placed into a larger autobiographical context.

 

During the course of her therapy, Sandy talked dispassionately about the sexual abuse by her father.  Though her stories were extremely detailed (semantic memory), her descriptions seemed more like a report or observation of someone else being abused.  The challenge for her was to revisit those experiences but in the retelling to include a sense of self (episodic memory) - which might involve feelings or thoughts about what those experiences mean to her life.

 

At other times clients present with autobiographical or episodic memories of their abuse (a general sense of unhappiness about their childhood) but are unable to recall the specific details of what happened. Resolution of these unresolved explicit attachment memories requires that…

n  …semantic memories are needing to be recalled so that their subjective experience makes sense.

 

Since semantic memory is a left brain process and episodic memory is mediated primarily in the right brain, integration of explicit memory is a bilateral process.

 

Bill had little or no memory about his childhood before age 14.  All he recalled was a general sense of unhappiness (episodic memory) that led to several suicide attempts as a teenager.  In talking about those feelings over the course of six months of therapy, some vague memories began to surface.  First he remembered his mother drinking and passing out during dinner.  Then he remembered being locked in his room by one of his mother’s boyfriends.  Connecting the semantic memory with the episodic memories was a relief for him.  Several months into this process he contacted his older sister, for the first time in many years, and not only received confirmation for his experiences, but she shared other experiences that he had long ago put out of his mind.

 

Recalled implicit memory, by definition, is an experience not an intellectual process.  It is up to the therapist to explain how external or internal contextual cues will trigger implicit memories. The process of integrating these memories into awareness and placing them in a larger autobiographical context  involves:

 

n   An awareness that implicit memory is activated

n   Learning to tolerate the experience long enough to make sense of it (by teaching emotional regulation skills)

n   Connecting the current context with the implicit memory and the concurrent autobiographical data

n   Using the opportunity to talk about unresolved experiences.

 

Susan who was in a woman’s batterers group was arrested after threatening to kill her partner when she discovered that she had been out socially with a female co-worker. This was after a long history of sexual jealousy on Susan’s behalf.  According to her mother, Susan’s father was having affairs from time she was pregnant with Susan until age four when they got divorced.  There were many violent arguments during those years, especially proceeding the divorce. Her mother remembered Susan getting very upset during many of those arguments.

 

Susan needed come to terms with the fact that the intense feelings of jealousy that she experienced with her partner may be implicit memories of feelings she experienced during the violent fights between her own parents.  When situations arose in her current relationship (external triggers) that evoked feelings of vulnerability or fear of loss (internal triggers) she immediately thought that her partner was going to leave her for some else.

 

Susan came to realize that the intense emotions she was experiencing may be related to implicit memories from childhood. She also grew to recognize how certain external and internal triggers led to her perceive situations as threatening. There were many situations with her partner where these memories got evoked which allowed her to learn how to feel these emotions and regulate them in a more constructive manner. Lastly, this process allowed her to talk about her relationship with her father and come to terms with it, since she hadn’t had contact with him for many years.


Trauma related links

 

     David Baldwin’s Trauma Information Pages at:

     http://www.trauma-pages.com/

     Also consider Bruce Perry’s web site at:

     http://www.childtrauma.org

     Both sites have extensive online articles relating to trauma theory and treatment.

 

If you have questions about resolution of trauma……email Dr. Sonkin.

 

Earned Security

     There is a subset of persons rated secure on the AAI in spite of experiences in childhood that would ordinarily lead us to predict an insecure status.

     Research suggests that these individuals had positive relationship with a relative, close friend, partner or therapist which allowed them to develop out of an insecure status into secure.

     These individuals are almost indistinguishable from “continuous secure” except they have higher depression rates.

     What was it about these relationships that helped these individuals achieve security?  These individuals found a secure base with someone, who was securely attached themselves, and that person(s) were sufficiently near, attentive and sensitively  responsive. Insecurity grows out of relationships and therefore, so can earned-security.

 

Luis

     Luis is 24 year old, first generation Mexican American.

     He has been married for 3 years and has a 6 month old child.  His wife is 21 years old.

     He works as manager of a popular restaurant and is going to night school to become a chef.

     He contacted you the morning after a fight with his wife where he hit her with his elbow and caused a black eye. You were able to see him that afternoon.

 

     T: Can you tell me what happened last night?

     L: We’ve been arguing a lot about feeding the baby at night.  I’m tired after working all day and going to school at  night and I just can’t focus as work when I have to get up and feed the baby.  I know she is feeling tired too and she is might be thinking that I am here complaining about her, but I know I play a role in this situation too.

     T: So what happened last night?

     L: The baby was crying and I heard him.  I think I read somewhere that you can let the baby cry for five minutes and sometimes they will put themselves back to sleep - like it’s just a false alarm.

     T: I understand. We can talk about that later, right now I am interested in what happened last night.

     L: Well, she thought I was sleeping, so she started pushing me to wake up.  I just was waiting to see if the baby was going to stop crying and so she kept pushing me harder and harder.  I know she wasn’t trying to hurt me, she just wanted me to wake up because it was my turn to feed the baby.  Anyhow, after about the fifth time, I just got angry and I took my arm, with my elbow, I was sleeping with by back to her, and I just swung it to tell her to stop pushing me.

     T:  What happened then?

     L: She started crying because I accidentally hit her in the eye.  She got up and fed the baby and slept the rest of the night in the baby’s room.

     T: You must have felt pretty bad.

     L: I swore that I would never be like my father in that way…(starts to get teary-eyed) I guess I was feeling more upset and stressed out than I realized. But that is no excuse.

     T: What do you mean you swore that you wouldn’t be like your father?

     L: He used to beat my mother and all us kids.  What ever belt he had on that day was the weapon of choice.

     T: Why do you think he acted that way?

     L: I think it was his upbringing.  He was raised in poverty and his parents beat him.  I mean, that’s no excuse and I think what he did was bad, but I understand why he did it.  Also, having 9 kids and being the sole supporter didn’t help either.

     L: I used to think that beating your wife and kids was normal.  No one ever talked about it so I just assumed it happened in everyone’s family.  I learned from my wife that it doesn’t have to be that way.  She had 10 brothers and sisters and each one felt loved and cared about.

     T: What about your mom, what was that relationship like?

     L: She tried to be a good mother, but I think she was pretty beaten down by him.  She didn’t have a lot of patience for us.  My older sister Rena was more like a mother to me.  She was so loving.  We are still very close today.

     T: Were their any other people who stand out in your mind as having an effect on your life?

     L: Definitely.  I went to boarding school between ages 8 and 14.  There was this English teacher who I was very close to.  At first he and I would talk about school stuff, but then I began to tell him problems.  When I was younger it was stuff about friends, but as I got older he’d help me with feelings I was having about girls.  I could never talk to my father about anything and my mother would just say things like, “Just do your school work and don’t think about silly things.”  But he was, I could talk to him about anything.  It seemed like anything I said was important.  It felt good.  I was sorry that I left the school.

     T: What do you hope to get out of therapy?

     L: Well, I’ve never been to a therapist before.  As I think about it I am not sure how you can help me.  Wait a minute, let me see…. Well, I guess I need help with my anger and stress.  I think I have tried real hard not to be like my father, but as I think about it now, I think it’s going to take more than just trying not to be like him.

     T: So are you saying that you don’t want to be like your father?

     L: No, not exactly.  I am saying that I don’t want to be like him in that way.  He had good qualities too, like he was a hard worker.  But sometimes it’s easier to just remember the bad times.

     T: Luis, you mentioned earlier that you are stressed out lately.  Can you tell me more about that?

     L:  Well, with work and school, and now the baby, I’m just tired a lot, moody and there isn’t time for anything fun.

     T: Has this been just since you have been in school and the baby?

     L: Well, my wife says that I tend to be a little depressed at times.

     T: Do you think this is true?

     L: Maybe, I don’t really know.

 

Assessment

 

Luis most probably will have an earned-secure AAI.  He was physically abused and witnessed violence as a child.  He mentioned two important relationships, his older sister and teacher, that seemed to provide a secure base for him to develop many of the capacities of secure attachment:  his ability to reflect on himself and on the mind of others (his wife).  You get the sense that he is thinking as the interview progressed and not just using canned speech or jargon.  He was even autonomous enough to disagree with or clarify his thoughts with the interviewer.

 

Treatment

 

Luis will certainly be easier to work with than our other examples. He is motivated, self-reflective and is able to put himself into the mind of others.  He has a balanced perspective on his childhood, but nevertheless realizes he has some work to do if he doesn’t want to repeat the violence of his father.  There is some suggestion of depression but this needs further follow-up.  The work with Luis will follow the same protocol that Bowlby laid out, and continuing to focus on developing the same capacities secure attachment that Daniel Siegel describes in his book as well. 

 

If you have questions about earned security……email Dr. Sonkin.

 

Individual vs. Group Treatment

 

     One question that frequently comes up in workshops is, can this approach be incorporated into group therapy?  The answer to that question is definitely yes.

     Of course there advantages and disadvantages to both approaches with this population. 

     With individual therapy you get to work more intensively with your clients, however the power of the group can bring about rapid changes, particularly with clients who lack motivation or refuse to see the danger of their situation. Group therapy, can also be a powerful method of getting clients ready for individual therapy.

     Therapists can use attachment theory to engage clients whether in group or individual therapy. However in group therapy you can also attend to how attachment issues play out between group members as well.

     In one group the leaders taught members how to become sensitive to the primary affect of their peers (social cognition).

     Group therapy also gives clients the opportunity to take on both the roles of caregiver and care-receiver.  The ability to flexibly take on these roles is critical to successful intimate relationships.

     Of course, working on changing attachment defensives processes (dismissing or preoccupation) can be worked out in group or individual therapy.  In fact, clients could complete one of the various self-report measures before entering group in preparation for a discussion about attachment styles in group.

     The data suggests that perpetrators with unresolved trauma are not likely to benefit from treatment unless resolution of the trauma is undertaken early on in the treatment process. This may be similar with victims of abuse as well.  Whether that is addressed in the group or adjunctive individual therapy will depend on your particular approach and your client’s needs.

 

Final thoughts: Beyond time-outs

 

This presentation was meant to expand your conceptualization of the etiology and treatment of domestic violence. I still believe that development of skills is an integral part of treatment, as well as understanding the larger social context within which domestic violence occurs. Social policy also plays a critical role in addressing domestic violence - therapy will not be sufficient.

 

However, I also hope that this presentation has convinced you that the wounding that causes violence was within the context of relationships and therefore the healing will also be in the context of relationships.

Final thoughts: Beyond time-outs

 

I am not suggesting that we throw out our current paradigms, but that we consider expanding them to include a deeper understanding into how attachment relationships may lead to violence and how attachment relationships may lead to healing.

 

It is my hope that you can take aspects of this material and use it to build upon a more effective methods of evaluating and treating perpetrators and victims of violence.

Additional reading…

 

Click on the link below to view the reading list for this presentation on the web.

n  http://www.danielsonkin.com/attachment/additionalreading.htm

     Or download the reading list (MSWord) document by clicking on the link below.

n  http://www.danielsonkin.com/attachment/additionalreading.doc

 

To receive your certification of completion…

     …please complete the following quiz and evaluation of this continuing education program by clicking on the link below. Your answers will be automatically forwarded to me when you press the submit button.  When I receive them, I will email a link to your certificate of completion.  Thank you for participating in my continuing education program.

     http://www.danielsonkin.com/attachment/evaluation.html