assessment and treatment of interpersonal violence from an attachment theory
Daniel Sonkin, Ph.D.
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?
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
Learn about abuse in
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
Learn how to address
unresolved trauma and loss with perpetrators of violence.
Learn about “earned
Let’s begin with the goals of the
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
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
Assess for continued
risk to children
Assess for individual
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
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
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
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
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
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).
confidentiality policies need to be explained thoroughly to the client and may
be broken down in the following ways:
child abuse, elder/adult dependent abuse and Tarasoff reporting
certain form of child maltreatment or elder abuse, danger to self, others or
property of others.
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
(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)
documents (including divorce and TRO pleadings)
Child Protective and
other social services reports
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
abuse and dependency
Need to assess for
diagnosis with each client (ideally both clinically as well as
referrals for medication assessment and management.
criteria when making treatment recommendations.
Take into account
diagnostic criteria when assessing treatment effectiveness.
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.
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
Batterer Classification Systems
Hamberger and Hastings
Low level antisocial was
identified in 2000
Dependent (Family only)
Tweed and Dutton (1999)
What do these typology systems have in
They each include an
antisocial or psychopathic group whose violence is more deliberate or
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.
Over controlled: deny rage while experiencing chronic frustration and
Under controlled: act out frequently
Instrumental: use violence “coldly” to obtain specific objectives
Impulsive act out in response to a building inner psychological
Batterer Typology: Research descriptors
Let’s look at what psychological patterns Don Dutton
found empirically in each of the types of batterers he identified.
Violence inside and
History of antisocial
behavior (car theft, burglary, violence)
High acceptance of
Negative attitudes of
Usually victimize by
extreme abuse as a child
criminal marginal subculture
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
Flat emotional response + exaggerated control are two
defining criteria for psychopaths (Hare, et. al).
Cyclical phases (Lenore
Walker’s cycle of violence)
High levels of jealousy
predominantly/exclusively in intimate relationship
High levels of
depression, dysphoria, anxiety based rage
Attempts to ingratiate
Tries to avoid conflict
High masked dependency
High social desirability
Overlap of violence and
Some drunk driving
Lists “irritations” in
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.
For the Psychopathic batterers, their violence is ego-syntonic and their low empathy makes
them less likely to experience violence inhibition.
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
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.
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
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
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
According to research
and clinical experience, many, but not all, victims present with PTSD
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
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
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
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
Overall they found a
significant association between depression and
severity of psychological abuse,
frequency of psychological abuse,
severity of physical abuse, and
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.
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
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.
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
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
Peter Fonagy, author of
Attachment Theory and Psychoanalysis, states that the key feature of secure
attachment is, what he calls, the 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
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
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.
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
Concrete or observable
Providing information for collateral contacts
Expressing regret, remorse, taking responsibility for
Expressing desire to change
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.
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
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.
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.
Psychobiology of domestic violence
Alan Rosenbaum at the
University of Illinois found clinically significant prior head injury in:
53% of male batterers as compared to
25% of maritally discordant men and
16% of maritally satisfied men
Along with these patterns,
batterers also exhibited deficits in:
Learning, particularly for verbal information
Memory, particularly for verbal information
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:
Physical abused abused children - were more physically
aggressive by early childhood;
Sexual abused children were prone to sexual acting out;
Psychological abused children were utilized more verbal
And neglected children became disorganized and socially
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.
Violence and it’s effect on child
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.
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
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
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
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
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.
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
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
Substance abuse screens
such as the Michigan Alcohol Screening Test should be included in an assessment process.
Clinical Interview for the DSM-IV
(SCID) is also a useful structured interview to help confirm your clinical
Domestic violence assessments
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
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.
of family members
violation of conditional release/ supervision
of/witness to family violence
suicidal or homicidal ideation/intent
disorder with anger, irritability, or behavioral instability
Assault History / Past physical assault
Past use of
weapons/threats of death
escalation in frequency/severity assault
violation of no contact orders
minimization/denial assault history
support/condone spousal assault
assault or sexual assault
weapons/threats of death
no contact order
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
Penal code model which
is the main concern of the courts.
The model used for the
Psychological Maltreatment toward Woman Inventory described earlier.
Isolation of victim
Induced debility producing exhaustion
Monopolization of perception (obsessiveness &
Threats (self, partner, family, friends, sham
Forced alcohol and drug use
Altered states of consciousness produced by a hypnotic
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.
Locked in room or closet
Tied up with rope, chains, handcuffs, etc.
Forced to take on role of servant
Not allowed to sleep
Stalked (following, harassing, vandalizing personal
property, trespassing, violating restraining orders)
Domestic Violence Inventory
You can examine this
inventory online at:
Simple assault may be a verbal act but is most
commonly accompanied by a physical gesture, such as threatening with a fist or
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
Psychological Maltreatment Toward Women
Scale (Tolman, 1989)
The PMTW has 58 questions each scored on frequency of
occurrence which consist of three scales:
Domination/isolation (which included isolation from
resources, demands for subservience, and rigid observance of traditional sex
Emotional/verbal (which included verbal attacks,
behavior that demeans the woman, and withholding of emotional resources).
You can access this scale online at:
Each model includes:
degradation or name-calling.
Non-physical means of
control (e.g. through jealousy, compliance with expectations, withdrawal of
affection, threats of violence).
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
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
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
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
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
higher numbers of prior domestic violence offenses
more serious histories of drug abuse
higher total SARA scores
and lower number of severe violent tactics used against
the victim in the incident precipitating arrest.
less prior domestic violence incidents
low prior drug usage
total SARA scores
higher numbers of severe violent tactics used in the
Rosenberg was also
interested in whether treatment outcome could be predicted.
were those with lower numbers of prior domestic
were not homeless during probation
had low or no problems prior to beginning their program
and after arrest.
Higher numbers of prior domestic violence offenses
Homelessness at some point during probation
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
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
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).
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).
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
Propensity Towards Abusiveness Scale
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
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
Affective (glibness, lack of empathy and pathological
Social Deviance (antisocial behavior)
PC - Screening version
A robust predictor of
violent behavior in general, with many validity studies including domestic
re-offending for domestic violence perpetrators.
Risk Checklist - Violence Inventory
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
Frequency of alcohol use
Frequency of drug use
Proximity of victim and
Severity of psychosocial
Global Assessment of
Violence towards others
(check all that apply)
Weapons accessible (e.g.
Specialized training in
abused a child
abused a child
marital violence as a child
proceedings in progress
proceedings in progress
Other legal proceedings
Animal cruelty or
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.
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
Social services can be
useful in protecting children from abusive parents or parents who refuse to
protect their children from abusive spouses.
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.
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.
No specific drug treats
medication can be utilized to treat concurrent diagnoses (depression, anxiety,
In addition, one can
also treat particular symptoms related to violence.
Obsessive and compulsive symptoms
Reuptake Inhibitors (SSRIs) have been used with people who have violence
problems (e.g., Paxil - the most sedating; Luvox - good for obsessional
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.)
Trazodone) can be useful because of its sedating effect. However this class of
drugs can have problematic side-effects.
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:
Hyper-arousal: Antidepressants & anxiolytics
Transient psychosis: Low dose anti-psychotics
Panic attacks: Antidepressants, high potency
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
Meet on regular basis /
good communication between therapist and prescribing physician.
If you have questions about
psychopharmacology……email Dr. Sonkin.
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
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
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
Parents or parent figures
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
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
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
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…
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.
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
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.
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.
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.
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.
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
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.
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.
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
Autonoetic consciousness: Knowing oneself over time.
Social cognition: Empathy and the ability to look into
the minds of others.
Ability to look into your own mind.
Emotion regulation: Ability to soothe oneself and be
soothed by others
Response flexibility: Weigh options before acting.
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.
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:
(a) awareness of the signals;
(b) an accurate interpretation of them;
(c) an appropriate response to them; and
(d) a prompt response to them.
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
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.
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
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…
…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
…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…
…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
…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
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.
”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
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
Tend to have long,
characterized by trust and friendship
Seek support when under
Generally responsive to
Empathic and supportive
Flexible in response to
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
Suffer from extreme
High breakup and
Worry about rejection.
Can be intrusive and
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.
in romantic partners.
Higher breakup rate than
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
May have a history of
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
Tend to feel exploited.
Lack self confidence and
are self conscious.
Feel more negative than
positive about self.
Self defeating and
report physical illness.
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.
Avoidant: leads to deficits in social competence, and
have higher rates of schizophrenia.
Disorganized: higher rates of dissociation, PTSD,
attention and emotion disregulation problems.
Pre-occupied: high rates affective disorders, substance
abuse, borderline personality disorder.
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
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.
Coherence (Main - Adult Attachment Interview )
Self-reflective function (Fonagy, described earlier)
Projective test (Adult Attachment Projective - George
Anxiety and Avoidance (Shaver - Experiences in Close
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
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 begins with the interviewer introducing the general research area, e.g.:
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.
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.
remaining questions are as follows:
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.
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.
Question 3 repeated for father.
To which parent did you feel closest and why? Why isn't there this feeling with
the other parent?
When you were upset as a child, what would you do?
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
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.
Were your parents ever threatening with you in any way - maybe for discipline,
or maybe just jokingly?
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?
Why do you think your parents behaved as they did during your childhood?
Were there any other adults with whom you were close as a child, or any other
adults who were especially important to you?
Did you experience the loss of a parent or other close loved one while you were
a young child?
Have there been many changes in your relationship with your parents since
childhood? I mean from childhood through until the present?
What is your relationship with your parents like for you now as an adult?
How do you respond now, in terms of feelings, when you separate from your
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
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
(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.
(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
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
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
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
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
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.
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,
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
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
Sample Questions: Relationship Status
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.
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:
Phil Shaver’s web site at:
Clinical Interview and Assessing Adult
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
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.
What does these data
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;
relationships with attachment figures;
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
Tasks of Attachment Informed Domestic
Past, present and future
Focus on understanding
what is happening in the mind of others
Learning to reflect on
Focus on flexible response
trauma and loss
Work with what is in the
Rupture and repair: use the natural separations and
ruptures in therapy to help the client develop more adaptive ways of coping
with attachment distress.
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
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
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.
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
One wants to be in close proximity to attachment
One feels loss when the attachment figure is not
available and there may be anger or frustration at reunion.
One retreats to attachment figure(s) when feeling
anxious or fearful.
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:
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)
Will want to talk to the therapist when they feel
distressed (safe haven)
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
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
Sensitivity has four essential components:
(a) awareness of the signals;
(b) an accurate interpretation of them;
(c) an appropriate response to them; and
(d) a prompt response to them.
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
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.
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
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.
breaks down the emotion process into three phases or categories.
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
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
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
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
If you have questions about psychotherapy …email Dr. Sonkin
34 year old
Started therapy shortly
after a divorce from a 14 year marriage.
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.
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.
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.
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
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:
learn how his past experiences are affecting current
how to look less to his partner for soothing and learn
how to become more aware of and soothe his anxiety;
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
45 year old man of
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
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
H: “Sonoma County.”
T: “Do you still have
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
He reported in passing
that his father routinely drinks to intoxication, but only on the weekends and
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.
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.
feelings and experiences is a way of avoiding the pain associated with family
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
31-year old Jewish woman
In recovery (3 years)
from cocaine and alcohol dependency.
A survivor of child
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
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
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
Sandy shows some
dissociative processes when asked about sexual abuse. Her story about the incident that got her arrested suggests
some dissociation as well.
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.
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
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
32 years old
Recently filed for
separation from husband (Anglo-European decent) after his arrest for domestic
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
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.
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
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
T: Why would you do
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
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
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
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
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
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,
T: Flexibility is a good
quality to have at times, but some decisions are too important to leave up to
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.
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.
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
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 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
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, 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
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
An important focus in treatment will be on the
44 years old (Irish
Employed as a
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
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
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.
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 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.
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
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
Memories can have any
one or a number of components:
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:
focused attention not necessary for implicit memory to
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
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…
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…
…semantic memories are needing to be recalled so that
their subjective experience makes sense.
semantic memory is a left brain process and episodic memory is mediated
primarily in the right brain, integration of explicit memory is a bilateral
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:
An awareness that implicit memory is activated
Learning to tolerate the experience long enough to make
sense of it (by teaching emotional regulation skills)
Connecting the current context with the implicit memory
and the concurrent autobiographical data
Using the opportunity to talk about unresolved
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:
Also consider Bruce
Perry’s web site at:
Both sites have
extensive online articles relating to trauma theory and treatment.
If you have questions about resolution of
trauma……email Dr. Sonkin.
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
These individuals are
almost indistinguishable from “continuous secure” except they have higher
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 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
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
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
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
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
L: Maybe, I don’t really
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.
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
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
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.
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this presentation on the web.
Or download the reading
list (MSWord) document by clicking on the link below.
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