The Assessment and Treatment of Interpersonal Violence for Child Custody Evaluators

Daniel Sonkin, Ph.D.
http://www.daniel-sonkin.com/

How to use this program

• You just read the material as you would any web page.

• You may have questions as read. If so, just click on the highlighted “Contact Dr. Sonkin by email” link placed periodically to contact me.

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

They say hindsight is 20/20….

• Dennis: “I wish my parents would have just divorced - it would have been better for all of us.”

• Ellen: “I am glad my parents stayed together and worked things out.”

• Joe: “After the separation the court let my mother move as far away from my father as possible. My relationship with him just died. To this day I think that was not a good thing.”

• Leah: “Things got so much better after the divorce. All the fighting and bickering just stopped. It was the right thing to do even though it was hard at first.”

• Mica: “My parents were given joint custody which just allowed my father to continue driving my mother crazy. I couldn’t wait to leave them both.”

• Sara: “They gave my mother custody because of my father’s drinking and anger problems. He got treatment and she got involved with someone even more violent, but the court would never let my father have custody - once an batterer, always a batterer I guess.”

Which of these individuals witnessed family violence?

• All of them.

• And yet they each had different reactions to parents staying together, getting divorced and custody arrangements.

• The point here is that deciding custody issues is very political and psychologically complex and is made more political and complex when domestic violence is a factor.

• There are differing opinions about custody, joint custody, and the parenting abilities of perpetrators and victims of domestic violence.

Child custody and domestic violence

• In perusing the literature on divorce and domestic violence you will find experts recommending that batterers not get custody of their children, that joint legal custody rarely works and that abused women just need to get away from their batterer and they make good parents. You will also find father advocates who make equally strong statements about what is in the best interests of children. And yet people who working with cases on a day-to-day basis know that it’s not this simple.

• As I am sure you already know, making child custody recommendations can affect the lives of many people, and once an order is signed by a judge, it can be very difficult to change. And although it is crucial for you to understand the dynamics of domestic violence, it is important that you not take any one philosophy or study and use it to justify a cookie-cutter approach to child custody cases. Each case needs to be evaluated on it’s own factors - therefore evaluator, knowledge, flexibility, creativity and tolerance for ambiguity are critical qualities to deciding child custody cases that include domestic violence.

What will you learn in this training?

• Resources available to victims and perpetrators;

• Effects of exposure to domestic violence and psychological trauma on children;

• Domestic violence and culture (including gender, class, ethnicity, and sexual orientation;

• Current legal, psychosocial, public policy, and mental health research related to the dynamics of family violence;

• How to assess for violence;

• The impact of violence on parenting abilities;

• How to use psychological and domestic violence assessment tools;

• The relationships between alcohol and drug use and violence;

• The relationship between high-conflict relationships and violent relationships;

• Understand the importance of, and procedures for, obtaining collateral information;

• Learn how to structure safe and enforceable child custody and parenting plans;

• Learn how to recognize evaluator negative and positive reactions to victims and perpetrators.

2003 California Rules of Court

• Rule 5.230. requires domestic violence training for all court-appointed persons who evaluate or investigate child custody matters and to ensure that this training reflects current research and consensus about best practices for conducting child custody evaluations by prescribing standards that training in domestic violence must meet.

n 16 hours of advanced training must be completed within a 12-month period. These 16 hours must include:

n 12 hours of domestic violence training

n 4 hours of community resource networking

• Plus 4 hours of update training is required each year

• The full rule can be accessed at: http://www.daniel-sonkin.com/custody/rule523.htm

Current California Family Law Codes that relate to Domestic Violence (click on the link below):

2008 Family Law Codes that relate to Domestic Violence

Administrative Office of the Courts, “Domestic Violence in Court-Based Child Custody Mediation in California”

• This report highlights the prevalence of interpersonal violence among parents in court-based child custody mediation in California. These statistics present some of the key findings from the report. Data on interpersonal violence in these cases come from surveys administered to parents and to mediators by the California Administrative Office of the Courts (AOC) as part of the Statewide Uniform Statistical Reporting System. These data were collected in 1999. At that time, 2,500 mothers and fathers and 2,812 mediators from a representative sample of cases were surveyed in 51 of California’s 58 county court systems.

Key Findings

• Violence between parents was reported in more than three-quarters of the cases. In 76% of cases, at least one parent reported that interparental violence had occurred in the relationship.

• Asking parents if “physical violence” has occurred in their relationship may result in under-reporting of domestic violence. More cases reported that “pushing, grabbing, shoving, throwing things, slapping, kicking, biting, or hitting” had occurred in the relationship (66%) than reported that “physical violence” had occurred (55%).

• If threats of violence have occurred in a case, physical violence usually has as well. In 97% of cases that reported threats of violence had occurred, at least one parent also reported that one or more violent behaviors had occurred.

• In 41% of all cases, at least one parent reported that their child(ren) had witnessed violence between the parents.

• Mothers reported that interparental violence had occurred between the parents more often than did fathers (71% vs 58%).

• In 47% of all cases, at least one parent reported on their survey that interparental violence had occurred, but neither parent raised domestic violence as an issue before or during the mediation session.

• About half of cases (57%) that raised domestic violence as an issue received separate mediation sessions

• The full report can be found at:

• http://www.courtinfo.ca.gov/programs/cfcc/pdffiles/resupDV99.pdf

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

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

• Procure appropriate authorizations to release information.

• Procure a comprehensive history of domestic violence, child abuse, and psychosocial history.

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

• Assess for neurological correlates to violence

• Assess the risk for further violence

• Assess for continued risk to children

• Assess for individual parenting capacities

• Assess for co-parenting capacities

• Develop assessment-based child custody plan

Confidentiality and Violence

• Confidentiality is a significant issue with clients who are experiencing domestic violence. Although there is no mandate to report adult domestic violence (unless you work in a medical facility; Penal Code 11160-11163.5), there are a number of legal and ethical issues that evaluators 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 evaluator must assess whether or not the witnessing of violence has caused mental suffering with the child.

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

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

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

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

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

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

Do therapists have a duty to investigate child abuse?

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

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

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

• The reporting threshold is and still remains, “reasonable suspicion.” This “investigative duty” that has been suggested by this court, will hopefully be corrected by subsequent rulings.

Confidentiality and Violence

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

• In cases where the evaluator 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).

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

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

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

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

Confidentiality - 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 evaluators are encouraged to procure records to determine the exact nature of the abuse occurring in the family.

Examples of other authorizations to procure

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

• Mental health or substance abuse treatment providers

• School records and interviews with teachers and daycare providers

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

• Civil proceedings documents (including divorce and TRO pleadings)

• Child Protective and other social services reports

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

Psychiatric Diagnosis and Typology

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

What are the most common diagnoses observed in perpetrators and victims

• Depression, anxiety or a combination of the two

• Psychoactive substance abuse and dependency

• Post-traumatic stress disorder

• Neurological disorders

• Personality disorders

Therefore evaluators…..

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

• Make appropriate referrals for medication assessment and management.

• Consider diagnostic criteria when making custody recommendations.

• Take into account diagnostic criteria when developing parenting plans.

Batterer Typology

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

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

Batterer Classification Systems

• Hamberger and Hastings 1986:

n Antisocial/Narcissistic

n Schizoid/Borderline

n Dependent/Compulsive

• Holzworth-Munroe & Anglin (1991)

n Generally violent/antisocial

n Low level antisocial was identified in 2000

n Dysphoric/BorderlinePassive

n Dependent (Family only)

• Saunders (1992)

n Generally violent

n Emotionally volatile

n Emotionally suppressed

• Tweed and Dutton (1999)

n Psychopathic

n Borderline

n Over-controlled

What do these typology systems have in common?

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

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

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

Dutton Typology

n Let’s look at one system developed by Don Dutton at the University of British Columbia, and described in his book, The Abusive Personality.

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

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

n Under-controlled: act out frequently

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

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

Batterer Typology: Research descriptors

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

Psychopathic Batterers

• Violence inside and outside home

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

• High acceptance of violence

• Negative attitudes of violence

• Usually victimize by extreme abuse as a child

• Low empathy

• Associations with criminal marginal subculture

• **Attachment: Dismissing**

• MCMI: antisocial, aggressive-sadistic

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

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

Borderline Batterers

• Cyclical phases (Lenore Walker’s cycle of violence)

• High levels of jealousy

• Violence predominantly/exclusively in intimate relationship

• High levels of depression, dysphoria, anxiety based rage

• Ambivalence to wife/partner

• **Attachment: Fearful/angry (disorganized)**

• MCMI: Borderline

Over-controlled Batterers

• Flat affect/constantly cheerful persona

• Attempts to ingratiate therapist

• Tries to avoid conflict

• High masked dependency

• High social desirability

• Overlap of violence and alcohol use

• Some drunk driving arrests

• Lists “irritations” in anger journal

• Chronic resentment

• **Attachment: Preoccupied**

• MCMI: avoidant, dependent, passive-aggressive

Typology and assessment

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

• Although similar in some ways, each type is significantly different in the psychological etiology of their violent behaviors, the treatment interventions needed to address violence and most importantly, how their parenting abilities are likely to be impaired and the ultimate the impact those qualities will have on their children.

Typology and Risk

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

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

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

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

What is this data likely to mean during a divorce?

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

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

• The over-controlled batter, like the psychopath, can present well in an evaluation - 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 divorces are likely to experience the greatest anxiety and depression. Dutton says that these batterers can snap and perpetrate extreme violence as a means to regulate their dysphoric affect.

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

Typology and parenting abilities

• Secure: Are generally sensitive and cooperative parents. Although they may have setbacks, they generally are responsive to interventions, suggestions, etc., and see the areas where they have problems.

• Fearful/Disorganized: Will fluctuate between being overly intrusive or controlling and cold and withdrawn.

• Avoidant: Deny or denigrate their own attachment needs are likely to do the same in their children.

• Preoccupied: Enmeshed in, or angry about their own family experiences so have difficulty seeing their children’s needs as separate or different from their own.

• All insecure batterers are likely to use others, such as their children, to regulate their own attachment distress, therefore intervention is necessary to change these patterns and improve parenting abilities.

• To read more about Don Dutton’s typology system as well as other excellent online articles describing his treatment and research go to his web site at:

• http://www.drdondutton.com/

Is there a similar typology of abused people?

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

• Many victims of domestic violence also 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 present with 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.

• In spite of these trends, 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 and their children from further victimization.

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

Substance abuse and DV (NIJ)

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

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

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

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

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

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

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

• This study suggests that clinicians need to assess for and treat substance abuse problems with victims of abuse, and not just assume that when they leave or separate from their abuser, these problems will automatically resolve.

Child abuse and Adult Revictimization

• 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.

• Therefore clinicians need to assess for and treatment unresolved trauma with victims of spouse abuse otherwise a victim will gravitate toward another abusive relationship, bringing danger to her/himself and their children.

Attachment and abused women

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

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

• They also found that preoccupied and disorganized woman are more likely to have difficulty getting out of relationships.

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

• Overall they found a significant positive correlation between depression and

n abuse experience,

n current abuse,

n psychological abuse,

n severity of psychological abuse,

n frequency of psychological abuse,

n physical abuse,

n severity of physical abuse, and

n frequency of physical abuse

What does this data suggest?

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

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

• Therefore, although separation of the parties is an important first step, evaluators 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.

Attachment and Parenting

• The vast majority of victims of abuse are preoccupied, disorganized or secure.

• Preoccupied: The majority of abused women present this attachment status. Like the preoccupied batterer, the preoccupied victim is so caught up in her own attachment distress that it’s difficult for her to separate her child’s needs from her own. There is a class of preoccupied victims, who are fearfully preoccupied. These women experience intrusive memories of their abuse experiences (either recent or childhood) that interfere with their ability to respond sensitively to their children.

• Disorganized: A significant percentage of abused women present this attachment status. Like the disorganized batterer, the disorganized victim will fluctuate between dismissing (denying their own and their children’s attachment distress/needs) and preoccupied (Not able to separate their distress from their children) strategies. Many disorganized individuals have a history unresolved abuse or trauma that causes dissociation when others are in distress. This psychological leaving or turning away can be quite frightening to young children. Disorganization in its more severe forms can lead to dissociation and violent reactions to emotional stress.

• The research suggests that if a parent is assessed as insecurely attached, there is a high probability (~80%) that their child will have an insecure attachment status with that parent. Although separation and divorce is an important first step in the healing process, many victims of spouse abuse may need some form of intervention to not only address the severe psychiatric conditions (e.g., substance abuse, PTSD, etc.) common with domestic violence victims and perpetrators, but some also some form of intervention that addresses the issues of attachment between the parents and their children.

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

Assessment of Motivation: Behavioral and theoretical perspectives

Why is motivation important?

• Motivation is an important issue when conducting child custody evaluations because many domestic violence perpetrators, and some victims, may appear cooperative during an interview, but ultimately may act in ways that undermined the child custody plan. 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 and motivation

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

• 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 be the most motivated and cooperative. Likewise they could be at greater risk, especially early in the separation process or if it looks like they will not be awarded custody.

• Evaluators should be aware that typology or diagnosis alone, cannot predict how well a person will comply with a child custody or parenting plan. Evaluators can be wrong and clients can surprise us. Therefore flexibility is key to effective plan development.

• Ultimately, diagnosis needs to be considered in conjunction with client observation, collateral reports and clinical intuition.

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

Reflective function

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

• What is important here, is that the client’s ability to reflect on self and others is likely portend both cooperation with custody arrangements, 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.

Motivation

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

• They have 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.

• They are currently studying treatment motivation with domestic violence perpetrators. They believe a discussion about readiness for change can be helpful in strengthening the effects of intervention. The URICA can be found on their web site at:

• http://www.vcu.edu/vattc/urica.html

• Their theory conceptualizes motivation as a fluid process that will change over the course of time. It may even change from low to high or from high to low. This model may be useful for evaluators 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 let’s look at the concrete behavioral indicators of motivation.

Concrete or observable behaviors:

n Attendance

n Completing paperwork

n Answering questions

n Providing information for collateral contacts

n Completing homework

n Expressing regret, remorse, taking responsibility for actions

n Expressing desire to change

n Insight into problems

Motivation and violence

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

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

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

• 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 socio-political perspective that emphasizes power and control, self-will and accountability. What is key is that evaluators should use relapses as an opportunity to enhance intervention strategies and not just punish.

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

• 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 evaluators 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 evaluators be extremely clear about how they assessed for motivation for treatment, particularly when motivation is the basis a particular custody determination.

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

Psychobiology of domestic violence

Alan Rosenbaum at Northern Illinois State University, DeKalb, found clinically significant prior head injury in:

n 53% of male batterers as compared to

n 25% of maritally discordant men and

n 16% of maritally satisfied men

Along with these patterns, batterers also exhibited deficits in:

n Learning, particularly for verbal information

n Memory, particularly for verbal information

n Verbal ability

n Vocabulary knowledge

n Exhibited high levels of emotional distress

What do these results mean?

• Always take a history for prior head injury.

• If indicated, consider neuropsychological assessment to determine specific deficiencies.

• Consider medication and cognitive rehabilitation in extreme cases.

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

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

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

• Although we are born with billions of neurons most of the connections are immature and therefore are sensitive to experience. Early experiences of violence organizes the brain in such a way that it is primed to respond in a dysregulated or aggressive manner. Neurons that fire together, survive and wire together, which suggests that parents who have dysregulated affect hardwires this tendency 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 generations. They found that:

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

n Sexual abused children were prone to sexual acting out;

n Psychological abused children utilized more verbal acting out;

n And neglected children became disorganized and socially inept.

• It appears that different forms of abuse effect the developing mind of the child in such a way that they become prone to particular patterns of dyregulation, that leads to the manifestation of behaviors similar to their parental models. There are no guarantees that, for example sexual abuse will lead to sexual abuse in the following generation, but the data suggests that the probability that this will occur is greater than chance. But even if the behavior is not repeated, similar themes (e.g., sexual) or other problems are likely to occur (e.g., depression).

• There are a number of theories of how abuse in childhood leads to psychological problems later in life, 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.

• And yet, we also know that 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, particularly when positive experiences are incorporated into the child’s life story. Child custody evaluators are in the unique position to help to change the destiny of the next generation, through facilitating those positive experiences, and most importantly assisting parents in taking on an important role in that process.

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

Violence and it’s effect on child attachment

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

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

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

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

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

• In general, the studies suggest that when fathers are physically violent with mothers, infants are more likely to be insecurely attached to their mothers. This is partly due to the fact that many mothers have insecure states of mind vis-à-vis their own attachment histories. In addition, just as the developing infant is unable to develop certain neural capacities when most of it’s energy is directed toward survival, neither can the mother put sufficient energy into parenting when her attention is so directed toward regulating intense relationship stress.

Roger Kobak from the University of Delaware states:

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

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

• Is insecure attachment at life sentence? Historically, this has been a criticism of attachment theory, that these early childhood experiences are fixed and unchangeable. Now, as a result of longitudinal studies following subjects from 12 months of age to 30 years, we know that although there is consistency between childhood attachment and adult attachment status, quite a number of people do move - generally from insecure to secure. The term “earned security” has been developed and researched and it has been found that certain experiences are likely to help a person move from insecurity to security. Some of these were mentioned earlier in the discussion of mitigating factors affecting the expression of violence and abuse later in life.

If you have questions about how violence affects child attachment……email Dr. Sonkin.

Why do women stay in abusive relationships?

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

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

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

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

• Dutton found 53% of battered women had a pre-occupied attachment status (as opposed to 10% of the general population) and only 7% were securely attached (as opposed to 60% of the general population). Preoccupied attachment is associated with emotional dependency, looking to others for approval, being “stuck” in either ambivalence or anger towards attachment figures.

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

• Morgan and Shaver, in a recent paper on commitment and abusive relationships, stated that abused women who are preoccupied with attachment relationships are “…anxious people who 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 points 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 I will discuss 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 motivation to leave. In other words, if you don’t think about your situation, you won’t need to change it.

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

• Disorganized or individuals with unresolved trauma, 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 important, are not sufficient to understand why so many victims place themselves and their children in danger. Interventions need to be geared to address both the practical and psychological levels.

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

Structured assessment tools

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

Personality and Diagnostic Screening

• The MCMI (now in it’s forth version) is the most commonly used test in researching typologies of perpetrators. The MMPI and Rorschach have also been used in research with this population but not as often. As you probably already know, the MCMI is biased toward psychopathology and is oriented toward Axis II diagnoses.

• The Trauma Symptom Inventory is commonly used with victims and perpetrators. The research version of this test is freely available on John Briere’s web site at: http://www.johnbriere.com/tsc.htm

• The Hare Psychopathy Checklist is valuable in predicting future violence as well as identifying psychopathic batterers.

• An alcohol abuse screen (e.g., Michigan Alcohol Screening Test) should be included in all assessments with both victims and perpetrators. There are many freely available alcohol and drug screens available over the internet.

• The Structured Clinical Interview for the DSM-IV (SCID) is also a useful structured interview for diagnostic assessment. The interview is available through the American Psychiatric Press.

Domestic violence assessments

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

• http://pubpages.unh.edu/~mas2/ctsb.htm.

• The Propensity for Abuse Scale was developed by Don Dutton and has been validated in a number of empirical studies. This scale is available in his book, The Abusive Personality. To read an article on this and other domestic violence risk assessments visit Dr. Dutton’s site at:

• http://members.shaw.ca/DonDutton/Papers/1%20Validation%20PAS%20in%20diverse%20male%20pops..html

• 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. It is easy to administer and score. This scale is available at:

• http://www-personal.umich.edu/~rtolman/pmwimas.htm

• 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 on his web site:

• http://www-personal.umich.edu/~rtolman/pmwimas.htm

• The Kingston Screening Instrument for Domestic Violence (K-SID) (Gelles & Tolman; 1998) shows some promise as to being a useful tool, but it is not currently available to clinicians.

• The Anger Management Scale (Stith & Hamby) focuses on how clients regulate their anger and can be a useful tool in both evaluation and treatment. It was published in a recent (2002) issue of the journal, Violence and Victims.

• The Domestic Violence Inventory and Risk Assessment software (Sonkin, 1999) was developed for clinicians to provide consistency and organization to their assessment process. It is a very comprehensive behavioral assessment. This scale can be viewed at:

• http://www.daniel-sonkin.com/software.html

• The Danger Assessment Scale, developed by Jacqueline Campbell, is a scale that assesses risk based solely on the victim’s emotional perceptions and behavioral information. It is also available on the web at:

• http://www.son.jhmi.edu/research/CNR/Homicide/DANGER.htm

• 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 researchers, clinicians and criminal justice personal.

• Due to the complexity of domestic violence cases it is highly recommended that evaluators use psychometric instruments to assess psychological diagnosis and typological characteristics. It is also highly recommended that when domestic violence is identified during the course of an evaluation that any one or a number of the discussed structured instruments be used to assess frequency and severity of physical, sexual and non-physical abuse and it’s psychological effects of victims and witnesses.

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

Defining non-physical violence

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

Why is this important?

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

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

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

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

Three models of non-physical violence

• Amnesty International model.

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

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

Amnesty International

• Isolation of victim

• Induced debility producing exhaustion

• Monopolization of perception (obsessiveness & possessiveness)

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

• Mental degradation

• Forced alcohol and drug use

• Altered states of consciousness produced by a hypnotic state.

• Occasional indulgences that keep hope alive.

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

• Isolation:

n Locked in room or closet

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

• Induced debility producing exhaustion:

n Forced to take on role of servant

n Not allowed to sleep

• Monopolization of perceptions:

n Pathological jealousy

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

You can examine this inventory online at:

http://www.daniel-sonkin.com/dvrisk/dv assessment.html

Penal Code

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

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

§ Threats to kill or terrorizing threats

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

Psychological Maltreatment Toward Women Scale (Tolman, 1989)

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

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

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

n Threats

• You can access this scale online at:

• http://www.personal.umich.edu/~rtolman/pmwimas.htm

Similarities

Each definition includes:

• Consideration of verbal abuse, degradation or name-calling.

• Threats to kill, hurt, take children, etc.

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

• Isolation (particularly from family and resources).

Why identify and address non-physical abuse?

• All forms of psychological abuse create a stressful family environment that neither feels physically or emotionally safe or nurturing.

• Over time can have a profound psychological and health effects on all family members.

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

• It often becomes the primary means acting-out toward the partner and/or children after a formal separation or divorce.

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

Risk Assessment

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

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

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

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

• A significant number of batterers do re-offend after a separation; therefore, identifying “high-risk” cases may be clinically prudent.

• Even when they are in treatment, a significant percentage of batterers are at risk to offend, or for some time afterwards.

• Lastly, many abusers continue their violence in subsequent relationships thereby placing their children at risk for continued exposure.

Let’s look at a number of studies on risk and domestic violence.

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

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

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

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

Outcome of Sonoma study

• High maintenance probationers had:

n higher numbers of prior domestic violence offenses

n more serious histories of drug abuse

n higher total SARA scores

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

• Low maintenance probationers had:

n less prior domestic violence incidents

n absent or low prior drug usage

n lower total SARA scores

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

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

• Program completers:

n were those with lower numbers of prior domestic violence offenses

n were not homeless during probation

n were married

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

• Program non-completers

n Higher numbers of prior domestic violence offenses

n Homelessness at some point during probation

n Unmarried status

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

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

• This study suggests that a thorough assessment is necessary to identity those clients who may need more attention, services and structure to enhance their experience of treatment or cooperation with child custody plans.

Risk Assessment

• Richard Heyman of the State University of New York in Stonybrook, 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.

Assessing Risk

• Traditionally, risk assessment has focused on identifying behavioral patterns (alcohol use, prior violence, etc.) in making decisions about an individual’s risk for future violence. The problem with this method is that many individuals who are violence who don’t exhibit the traditional histories one would expect. These problems were followed by a greater interest in looking at personality factors (e.g., authoritarian personality or psychopathy) as well. These trends led to better accuracy in prediction. More recently, researchers have been looking at contextual factors in assessing risk. The conditional model of violence assessment is once such approach.

Conditional model of violence prediction

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

Clinical suggestions

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

A risk assessment using the conditional model

• Mr. Jones is likely to reoffend if he relapses back into cocaine use, stops taking his antidepressant medication and stop attending therapy and his 12-step program. He has indicated that he loses his patience when he doesn’t “get his way.” Therefore, he may need help in learning how to negotiate with his 8-year-old son, who is a very verbal, self-determined young man (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, he 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).

Specific Risk Assessment Tools

• The Spousal Assault Risk Assessment (SARA) mentioned earlier can be used as an assessment guide to ensure that pertinent information is considered and weighed. Risk factors are rated absent, sub-threshold, or present. Based on the rating the final assessment the SARA scores tell you whether there is imminent violence toward a spouse or other, or the client is high, medium or low risk for violence.

Propensity Towards Abusiveness Scale (Dutton)

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

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

• This scale can predict both physical and emotional abuse.

Danger Assessment Scale (Campbell)

• Jacqueline Campbell 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.

Psychopathy Checklist (Hare)

• Designed for male forensic populations

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

• PC - R (20 items) (2 scales)

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

n Social Deviance ( antisocial behavior)

• PC - Screening version (12 items)

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

• Predictive of re-offending for domestic violence perpetrators. Particularly good for identifying the psychopathic batterers.

Risk Checklist - Violence Inventory (Sonkin)

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

• Frequency of physical violence in past two years

• Frequency of sexual violence in past two years

• Severity of violence

• Threats

• Frequency of intoxication

• Frequency of alcohol use

• Frequency of drug use

• Proximity of victim and offender

• Psychiatric Diagnosis (DSM-IV)

• Severity of psychosocial stressors

• Global Assessment of Functioning Scale

• Prior criminal history/activity

• Violence towards others (check all that apply)

• Child abuse

• Victim’s Involvement With Others:

• Attitudes towards violence

• Weapons accessible (eg. law enforcement)

• Specialized training in violence

• Perpetrator physically abused a child

• Perpetrator sexually abused a child

• Perpetrator witnessed marital violence as a child

• Child custody proceedings in progress

• Other divorce proceedings in progress

• Other legal proceedings in progress

• Animal cruelty or torture

Ways of Reducing Risk

• Separating the victim and offender with either the victim in a safe house/shelter, or the perpetrator in jail. Children in custody of caregivers who can provide protection from trauma.

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

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

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

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

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

• Addressing psychoactive substance use/abuse with both victims and perpetrators is critical to reducing risk. Alcohol and drug use 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.

• Explicit parenting plans that specifically lay out custody arrangements and what parent can do when the other parent does not follow-through with their obligations.

• Using third parties to witness the transfer of children.

• Use of supervised visitation.

• Mandated parenting classes.

• In-home therapy

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

Psychopharmacology

• No specific drug treats domestic violence.

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

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

n PTSD symptoms

n Obsessive and compulsive symptoms

n Anxiety

n Depression

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

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

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

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

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

• SSRIs can also be useful in treating anxiety as well.

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

n Flashbacks: SSRIs

n Hyper-arousal: Antidepressants & anxiolytics

n Transient psychosis: Low dose anti-psychotics

n Depression: Antidepressants

n Panic attacks: Antidepressants, high potency anxiolytics

• Use the most benign intervention when beginning treatment.

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

• Have some quantifiable means of assessing efficacy and side effects.

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

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

If you have questions about psychopharmacology and domestic violence……email Dr. Sonkin.

Treatment Outcome Studies

• An examination of the outcome literature shows a range of 40-60% desistence 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% desistence of non-physical violence.

• 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.

• Treatment models that emphasize educational interventions are not going to be effective in the long run with individuals suffering from moderate to severe psychological disorders.

• Models that emphasize that violence as a “choice” are no different than archaic notions that people who are depressed (or suffering from other psychological disorders) are weak.

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

Domestic Violence and the Law

For many years domestic violence was treated like a civil matter, in that police were not encouraged to arrest, but rather mediate or refer to the family law courts. Since the early 1980’s, advocates for battered women have lobbied for mandatory arrest laws that included incarceration and treatment for offenders.

What are typical criminal statutes relating to domestic violence

• Section 273.5 PC: willful infliction of corporal injury on a spouse, former spouse, cohabitant, former cohabitant etc.

• Section 242 PC: any willful or unlawful use of force or violence upon the person of another.

• Section 243 (e) PC: battery against a spouse, cohabitant, parent of the defendant's children etc.

• Section 240 PC: Assault - an unlawful attempt, coupled with a present ability to commit a violent injury etc.

• Section 136.1 PC: intimidation of victims and witnesses.

In reality, domestic violence may be a factor in any criminal incident from burglary, trespassing and vandalism to the more serious offenses of aggravated assault and battery, sexual assault, kidnapping and murder. One of the most common criminal violations in divorce situations is the violation of a temporary restraining order or stay-away order.

Emergency Protective Order (EPO)

• This is a temporary protective order lasting 5-7 days, issued by the police to a victim of domestic violence immediately after an incident has occurred. The order provides protection for the victim by requiring that the abuser stay away from the victim and his/her residence. The 5-7 day period gives the victim enough time to file a request with the court for a permanent restraining order.

Criminal Stay Away/Protective Order

• This is an order issued by the court in a criminal case against the perpetrator of violence, often as a part of the abuser’s probation. This order usually requires that the perpetrator have no contact with the victim. Sometimes a criminal protective order requires only that the individual not harass, threaten or hit the victim. The length of the protection provided by the Criminal Protective Order varies widely. Criminal Protective Orders usually last only while the criminal case is active. If the prosecutor decides not to charge the crime, then the protective order is removed. Victims may not be notified when there are developments in a criminal case, and they may not know whether the Criminal Protective Order is active or not. For these reasons, it is a good idea to also request a civil restraining order, even if the victim is already protected by a criminal order.

Ex-parte Order

• This is an order issued by the court without notice to the responding person or persons (party). These orders must be temporary in nature and typically will not last longer than 15-20 days.

Temporary Restraining Order (TRO)

• This order is issued when a petition for a permanent restraining order is filed in civil (non-criminal) court. This order protects the victim while he/she is waiting for a hearing on his/her request for a permanent restraining order. It usually prohibits the respondent (restrained person) from contacting the petitioner (victim). The hearing on the permanent restraining order must be scheduled no more than 20 days after the temporary restraining order is issued. The respondent must be served with the TRO before police can enforce the order.

Restraining Order After Hearing

• This is the “permanent” restraining order issued by the court against the respondent (restrained party) after a hearing in court. The court can only issue a Restraining Order After Hearing if both the petitioner and the respondent have been given notice about when and where the hearing was going to occur. The respondent will have an opportunity to defend him/herself at the hearing. However, if after being given proper notice, the respondent does not come to the hearing, the court may still issue the restraining order. The Restraining Order After Hearing sets forth the specific restrictions ordered by the court against the respondent and can last up to three years. A victim may renew the order when it expires, if necessary.

Civil Restraining Orders

§ There are two types of restraining orders that may be requested in civil court: Domestic Violence Restraining Orders and Civil Harassment Orders. If the victim is planning to file for a restraining order she/he needs to know which type of restraining order to file. This is important to know because certain orders, such as custody orders, can be made with Domestic Violence Orders and not with Civil Harassment Orders.

§ In order to qualify for a Domestic Violence Restraining Order the petitioner must have one of the following relationships to the person they want restrained: spouse or former spouse; person with whom you share or shared a living space; Have or had a dating/engagement relationship; parents of a child; relative to the second degree (grandparents, but not cousins).

• In order to qualify for a Domestic Violence Restraining Order the person they wish to have restrained must have committed at least one of the following acts:

• Recent physical violence (usually within the past 6 months)

• Recent threats of physical violence (past 3-6 months)

• Harassment (excessive phone calls, threatening or upsetting notes etc.)

• Recent sexual assault or molestation

• Stalking

• Verbal abuse (only where very severe)

• A signed statement setting out the particular incidents of abuse and, if possible, the dates on which it occurred may be enough evidence. However, the following items are very helpful to the court:

• Police reports of recent incidents

• Medical/hospital records

• Photographs of injuries

• Emergency Protective Orders

• Criminal Protective Order

Domestic Violence Orders can provide various types of relief from abuse:

• Restrained person cannot contact victim

• Restrained party must stay at least 100 yards away from victim

• If victim lives with the restrained party, victim can have him/her removed from the property (this is only effective if victims has some claim to the property)

• Victims can request child custody and child support, and set a visitation schedule

• Restrained party may be required to attend a batterer’s treatment program

• Victim may get legal control of property that belongs to both of victim/offender or to victim alone

• Restitution (reimbursement for costs resulting directly from injuries caused by the batterer i.e. medical bills or lost income)

• Restrained person may not possess any firearms

How to file

• Request an application for a Domestic Violence Order from the Family Law Department in local courthouse.

• Give the completed application to the Family Court.

• Within 48 hours your Temporary Restraining Order should be ready. It will provide you with your hearing date for the permanent (3 year) restraining order.

• Have the restrained party served with a copy of the temporary restraining order (this generally must be done at least 5 days prior to the hearing).

• The person who serves the restrained party must fill out a Proof of Service, documenting that the restraining order was served.

• Attend the hearing and receive a copy of the permanent (3 year) court order (Restraining Order After Hearing). Must bring the completed Proof of Service to the hearing.

• If the restrained party was not present at the hearing, victim must have him/her served with the Restraining Order After Hearing.

• Provide a copy of your restraining order and, the proof of service, to the police department in victim’s area.

• Keep a copy of restraining order on person at all times.

Civil Harassment Orders

• Courts may be more hesitant to grant Civil Harassment Orders because, unlike Domestic Violence Orders, the protected party does not have to have any intimate relationship to the restrained party. However, in many respects Civil Harassment Orders are very similar to Domestic Violence Orders.

• No specific relationship to the restrained party is required. This is the primary difference between a Civil Harassment Order and a Domestic Violence Order.

• Unlike the Domestic Violence Order, a Civil Harassment Order can only be obtained if there is an actual or reasonable threat of harm. Verbal abuse—name-calling—is generally not enough for a Civil Harassment Order.

• The court cannot issue a restraining order without “reasonable proof” that the party to be restrained committed the abuse. A signed statement setting out the particular incidents of abuse and, if possible, the dates on which it occurred may be enough evidence.

• In general the protected party will receive an order requiring that the restrained party not contact or come within a 100 yards of them. However, other orders may be requested.

• The process for obtaining a civil harassment order is identical to the process for obtaining a Domestic Violence Order, except that you need to request an application for a Civil Harassment Order. There is also often a filing fee with Civil Harassment Orders, which is waived for Domestic Violence Orders.

Synclair/Cannon Child Abduction Prevention Act of 2002

• The Synclair/Cannon Child Abduction Prevention Act of 2002, which went into effect Jan. 1, requires California courts to consider flight-risk factors when granting custody to divorcing spouses. Risk factors include strong familial, emotional or cultural ties to another state or country, including foreign citizenship.

• The law is considered a national model to help prevent the approximately 163,000 kidnappings by parents each year. Up to 15 percent of those children are taken out of the country and few return. But advocates for domestic violence victims say the law could inadvertently trap battered women--especially immigrants--in abusive relationships. In addition, they say, abusers could use the law to gain custody of their children.

• Warning signs of parental kidnappings that courts must consider under Synclair-Cannon include applying for passports, obtaining copies of school or medical records, terminating housing leases, liquidating assets and closing bank accounts. Domestic violence counselors routinely advise battered women to get legal documents and finances in order before they flee their abusers. Non-legal residents need passports to apply for public assistance such as food stamps, a common scenario for immigrant women with children who leave their abusers.

• Under Synclair-Cannon, other warning signs for kidnappings that California courts must consider in custody battles are having no strong ties to the state and no financial reason to stay in the state, such as being unemployed.

• Most troubling to legal experts is that if a parent has previously taken their child without the other parent's consent, that parent is considered a flight risk--regardless of whether the fleeing parent reports the child's whereabouts to the state, as required by law. Now, battered women who have fled with their children to a shelter and then reported their whereabouts to the state would be considered potential kidnappers.

The Violence Against Women Act of 2000 (VAWA 2000)

• The Violence Against Women Act of 2000 (P.L. 106-386), enacted on October 28, 2000, improves legal tools and programs addressing domestic violence, sexual assault, and stalking. VAWA 2000 reauthorizes critical grant programs created by the original Violence Against Women Act and subsequent legislation, establishes new programs, and strengthens federal laws. Among other things it addresses issues related to dating violence, stalking and battered women who are immigrants.

• Defines "dating violence" as violence committed by a person who is or has been in a social relationship of a romantic or intimate nature with the victim. The existence of such a relationship is determined by the following factors: 1) length of the relationship; 2) type of relationship; and 3) frequency of interaction between the persons involved.

• Amendments to Domestic Violence and Stalking Offenses

• Amends the interstate domestic violence and stalking offenses to clarify the elements of these offenses and to improve effective prosecution of these crimes.

• Expands the interstate stalking law to include interstate cyber-stalking and adds entering or leaving Indian country to the interstate stalking offense.

• New Protections for Battered Immigrants

• Makes numerous improvements that expand battered immigrants' access to immigration relief and remove abusers' ability to use immigration laws as a tool of control over immigrant victims. For example, VAWA 2000:

• Allows a battered immigrant who was divorced from the abuser within the previous two years to file for VAWA relief, provided that the divorce was connected to the abuse.

• Authorizes the Attorney General to waive certain barriers to battered immigrants' access to lawful permanent residence, including waivers for certain crimes of domestic violence and other crimes connected to the abuse.

• New Protections for Battered Immigrants

• Clarifies that battered immigrants' use of public benefits specifically made available to VAWA self-petitioners under the welfare law does not make them ineligible for their green cards on the ground that they are likely to become a public charge.

• Allows VAWA self-petitioners to adjust their status to lawful permanent resident in the United States rather than having to go abroad to do so.

• New Protections for Battered Immigrants

• Creates a new nonimmigrant U-visa for victims of certain serious crimes, including domestic violence, sexual assault, stalking, and trafficking crimes if the victim has suffered substantial physical or mental abuse as a result of the crime, the victim has information about the crime, and a law enforcement official or a judge certifies that the victim is or is likely to be helpful in investigating or prosecuting the crime. The number of visas is capped at 10,000 per year. The Attorney General may adjust U-visa holders to lawful permanent resident status if they have been present in the U.S. for three years and it is justified on humanitarian grounds, to promote family unity, or is otherwise in the public interest.

National Domestic Violence Hotline

• Victims of domestic violence should know that help is available to them through the National Domestic Violence Hotline on 1-800-799-7233 or 1-800-787-3224 [TDD] for information about shelters, mental health care, legal advice and other types of assistance, including information about self-petitioning for immigration status.

If you have questions about domestic violence and the law……email Dr. Sonkin

Attachment Theory and Domestic Violence

This section will provide you an overview of attachment theory and its application to the assessment and treatment of domestic violence and unresolved trauma.

Rationale for Attachment Theory

• Violence occurs in the context of attachment relationships.

• Anger and loss is integral to attachment theory.

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

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

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

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

• Attachment theory is child development theory that considers parenting behaviors and children responses to that environment.

Who is an attachment figure?

• A caregiving figure who provides protection from danger or threat

n Parents or parent figures

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

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

Bowlby’s central proposition…

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

If the answer is yes…..

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

If the answer is consistently no…

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

If the answer is inconsistently no…

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

The Development of Attachment

Attachment disorganization

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

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

Assessing Infant Attachment: The Strange Situation

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

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

Attachment Terminology

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

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

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

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

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

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

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

Neurobiology of attachment

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

n Autonoetic consciousness: Knowing oneself over time.

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

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

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

n Response flexibility: Weigh options before acting.

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

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

But how does this attachment develop?

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

Sensitivity

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

• Sensitivity has four essential components:

n (a) awareness of the signals;

n (b) an accurate interpretation of them;

n (c) an appropriate response to them; and

n (d) a prompt response to them.

Cooperation

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

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

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

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

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

Parent-Infant Attachment Correspondence

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

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

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

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

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

• Prebirth (similar to last slide) the AAI showed 65% predictability based on all four attachment categories.

What does these data suggest?

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

Link between caregiver attachment status and infant attachment status

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

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

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

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

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

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

• Disorganized parents are abusive or otherwise frightening so their…

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

Adult Attachment Relationships

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

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

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

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

Adult Attachment Development (Shaver and Clark, 1994)

Secure 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.

Secure Adult Patterns (Shaver and Clark, 1994)

• Highly invested in relationships

• Tend to have long, stable relationships

• Relationships characterized by trust and friendship

• Seek support when under stress

• Generally responsive to support

• Empathic and supportive to others

• Flexible in response to conflict

• High self-esteem

Preoccupied: 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.

Preoccupied Adult Patterns

• Obsessed with romantic partners.

• Suffer from extreme jealousy.

• High breakup and get-back-together rate.

• Worry about rejection.

• Can be intrusive and controlling.

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

• May have a history of being victimized by bullies.

Dismissing: 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.

Dismissing Adult Patterns (Shaver and Clark, 1994)

• Relatively un-invested in romantic partners.

• Higher breakup rate than pre-occupied.

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

• Tend to withdraw when feeling emotional stress.

• Tend to cope by ignoring or denying problems.

• Can be very critical of partner’s needs.

• May have a history of bullying.

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

Disorganized Adult Patterns (Shaver and Clark, 1994)

• Introverted

• Unassertive

• Tend to feel exploited.

• Lack self-confidence and are self-conscious.

• Feel more negative than positive about self.

• Anxious, depressed, hostile, violent.

• Self-defeating and report physical illness.

• Fluctuates between neediness and withdrawing.

Insecure Attachment & Psychopathology

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

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

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

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

n Pre-occupied: high rates affective disorders, substance abuse, Borderline Personality Disorder.

Attachment theory

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

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

• Also consider the extensive material on Attachment Research and Theory at Stony Brook at:

• http://www.johnbowlby.com

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

Assessing Attachment Status

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

• Interview approaches

n Coherence (Main - Adult Attachment Interview )

n Self-reflective function (Fonagy, described earlier)

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

• Self-report

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

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

• Clinical interview

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.

Coherence

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

Grice’s Maxims of Discourse

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

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

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

• Relevance: Answers the questions asked.

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

In addition to coherence, there are specific scales related to secure and insecure categories. In general, these maxims are utilized to assess for violations of coherence. Hence, the content of the life story (the AAI questions) is not as important as the way it is told.

AAI: Sample Questions

§ 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. 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?

AAI Scoring

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

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

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

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

Self-Reflective Function

• As mentioned earlier, Peter Fonagy has developed a method of assessing adult attachment using the AAI protocol, but scoring the transcript based on the ability of the speaker to mentalize - reflect on their own inner experience and reflect on the mind of others. This is described more in detail in his book listed in the references.

Adult Attachment Projective

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

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

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

Self report measures

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

Experiences in Close Relationships

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

Sample Questions: Experiences in Close Relationships – R

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

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

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

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

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

Relationship Status Questionnaire

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

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

Sample Questions: Relationship Status Questionnaire

• I find it easy to get emotionally close to others.

• I want to be completely emotionally intimate with others.

• I am comfortable without close emotional relationships.

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

To read a number of online articles on self-report measures and their similarities and differences to the AAI visit:

Chris Fraley’s web site at: http://www.psych.uiuc.edu/~rcfraley/index.htm

Phil Shaver’s web site at: http://psychology.ucdavis.edu/labs/shaver/

Clinical Interview and Assessing Adult Attachment Status

• A recent study examined how well 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 is not possible, it just means that a method has yet to be developed.

If you have questions about assessing adult attachment status……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 are 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 dysregulation 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. Like their male counterparts, they can be extremely clingy when distressed and 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.

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

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

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

Attachment and Gay/Lesbian Couples

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

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

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

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

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

What does this data mean?

• Feminist explanations for violence that focus on patriarchy and sex role stereotyping do 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 domestic violence and attachment……email Dr. Sonkin.

Psychotherapy, attachment theory and domestic violence

Tasks of attachment-informed psychotherapy according to Bowlby

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

• Explore current relationships with attachment figures;

• Explore relationship with psychotherapist as an attachment figure;

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

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

Reconceptualizing Domestic Violence

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

Task of Attachment Informed Domestic Violence Treatment

• Past, present and future orientation

• Focus on understanding what is happening in the mind of others

• Learning to reflect on the self

• Develop emotion communication skills

• Focus on flexible response to situations

• Address unresolved trauma and loss

• Work with what is in the room

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

Secure-base Priming

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

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

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

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

Creating a secure base in psychotherapy

According to attachment theory…..

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

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

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

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

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

Characteristics of attachment relationships

Proximity maintenance

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

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

Safe haven

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

Secure base

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

How does this relate to psychotherapy?

Most therapists are hoping that their clients will:

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

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

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

In other words….

• ….form an attachment.

But how does this attachment develop?

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

Sensitivity

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

• Sensitivity has four essential components:

n (a) awareness of the signals;

n (b) an accurate interpretation of them;

n (c) an appropriate response to them; and

n (d) a prompt response to them.

Cooperation

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

Facilitating Secure Attachment

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

Facilitating Secure Attachment in Psychotherapy

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Case Examples

Robert

• 34 year old African-American

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

• No children.

• CPA for a bank.

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

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

Robert

• 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 a problem. She never seemed interested. They hardly had sex. When you inquire as to frequency he replies “..four or five times a week.”

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

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

Assessment

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

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

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

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

Treatment

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

n learn how his past experiences are affecting current relationships;

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

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

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

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

Howard

• 45 year old man of English/German decent

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

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

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

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

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

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

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

• T: “What happened next?”

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

• T: You must have been feeling pretty angry with her.

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

• T: “Where did you grow up?”

• H: “Sonoma County.”

• T: “Do you still have family there?”

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

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

• H: “We’re close.

• T: How often do you have contact with them?

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

In the following session:

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

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

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

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

Assessment

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

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

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

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

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

Treatment

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

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

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

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

Sandy

• 31-year old Jewish woman

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

• A survivor of child sexual abuse.

•