“It terrifies me, the fragility of these moments in our lives.”
Thursday, 4 January 2018
Chld Development.. attunemnet not attachment updating Bowlby
therapists working with patients with complex or developmental trauma,
advances of the last decade in understanding of attachment theory and
early childhood development have important implications. A therapist
can develop a strategy of treatment that more accurately addresses the
symptoms and underlying needs of a patient. Without them, a lot of
time, effort, and resources can be wasted.
important advance is found in the work of Allen Schore, applying
findings of neuroscience to attachment theory. Starting in the 1990s,
Schore published essays expanding previous understandings of attachment.
respectful towards the pioneering work of John Bowlby, whose theories
of attachment shaped practitioners since the 1960s, Schore demonstrated
the need for updates in attachment theory and application.
the words of Schore and Schore (2008): “Bowlby stated that attachment
behavior was based on the need for safety and a secure base. We have
demonstrated that attachment is more than this; it is the essential
matrix for creating a right brain self that can regulate its own
internal states and external relationships. Attachment inter
subjectivity allows psychic structure to be built and shaped into a
unique human being. Our task as therapists is to understand and
facilitate this developmental process with our clients.” (p17).
to Schore’s contribution is the awareness that a therapist interacts
with an existing right brain formation of a patient, formed long ago in
early childhood in response to the child’s attachment experience of
caregivers, environment and the unique responses of the child’s body to
the world around.
formation is intuitive, non-verbal, and pre-rational. Schore and Schore
(2008) describe it as the result of an unconscious process rooted in
physical interactions between a mother (or other caregiver) and infant,
in an exchange from the right brain of the mother to the right brain of
the infant. These early attachment experiences shape the nascent
organization of the right brain, which is the core of human
consciousness (p. 1.)
early life brain formation provides the foundation for infants to
interact with and form attachment to parents and eventually to build
relationships with others. This includes the relationship with the
therapist, whose goal is to become a “co-regulator” with the client of
emotional responses. Attunement is vital for a therapist to become a
co-regulator of a client.
is a non-verbal process of being with another person in a way that
attends fully and responsively to that person. A key aspect of
attunement is that it is a joint activity, experienced in interaction
with a caregiver. In the first years of its life, a baby is fully
dependent on others. The early brain formation described above emerges
in response to largely non-verbal interaction with another human being
including eye contact, vocalization, speech and body-language (Wylie
& Turner, 2011. p. 8).
are never able to anticipate all a child’s needs, so an infant
inevitably gets upset from time to time. Schore and Shore (2008) call
this “misattunement.” Well-functioning parents respond appropriately to
soothe the baby, which Schore calls “reattunement” (2008). In the
beginning, a baby is fully dependent on parents for calming and
soothing, but through repeated cycles of attunement, misattunement and
reattunement, babies internalize the ability to cope with inputs their
senses form within and from the external world, both rewarding and
frustrating. Emerging is a sense of self and ability to control
emotions, or emotional regulation.
is managed by the structures of the right brain, which leads the way
for development of other elements of the brain. Since brain development
is hierarchical, if infants are unable to engage in cycles of
attunement, misattunements, and reattunement, later development of other
brain functions are affected. Anda and Felitti et al., (2006) have
documented the long-lasting effects of adverse childhood experiences
(ACE) and linked them to changes in brain structures and stress response
mechanisms of the brain.
come when attunement is obstructed. If an infant does not receive
enough stimulus, sustained attention, love, caring and warmth on an
on-going basis or if the latter are available only in unpredictable
ways, developmental trauma can result.
brain needs patterned, repetitive stimuli to develop properly. Spastic,
unpredictable relief from fear, loneliness, discomfort and hunger keeps
a baby’s stress system on high alert” (Perry, 2007 p. 113). The result
is reduced ability to manage emotions, cope with stress, sustain close
relationships and more.
Emotional Regulation and Sensory Integration
common symptom for trauma survivors, of course, is difficulty in
controlling emotions, even in response to things with no apparent
connection to the traumatic events. Therefore, emotional regulation is a
key in trauma therapy.
then to help a child, teen or adult client who has experienced
developmental trauma to form a secure attachment and develop
What Does Occupational Therapy Have to Do with Trauma?
personal experiences had a big impact on my understanding of trauma
treatment. One is that I have Sensory Integration (SI) issues (read blog here), something
I was able to name as such only in my 30s. I experienced pre-verbal
trauma in infancy, which may or may not be related to the SI issues.
Although I knew that I was loved by my parents and family, circumstances
around me did not feel safe. As far back as I can remember, life did
not seem safe to me.
life-altering personal realities have kept me constantly on the lookout
for concepts and strategies that might help. I learned not to accept
the standard orthodoxies as the final word and found helpful things in
A while after, in a time when I was trying to learn about my own newly
uncovered SI issues, I observed an occupational therapist working with a
toddler in a sensory integration session. I was amazed by how relaxed
this child – who began the session very hyper-alert – became by the end,
because of a process of repetitive SI physical movements.
was an “aha” moment for me. As a therapist trying to help traumatized
clients cope with chronic hypo- and hyper-alertness and self-regulation
issues, I was surprised to witness an occupational therapist readily
achieve through strategic use of repetitive movements the same state of
relaxation I sought with my clients using other modalities mostly
read extensively about sensory integration and learned about protocols
used by occupational therapists for treating children with sensory
processing issues. For several decades, a growing number of occupational
therapists have been focusing on sensory integration. They have
developed a wide variety of SI activities, for small children, older
children,and adults. Since developmental trauma affects brain
development specific to the age at which the trauma took place, the
experience of OT practitioners is a gift for trauma therapists who want
to guide a client/parents in sensory integration work appropriate to the
age of traumatization.
Encouraged by the results I was seeing with patients, I soon made
sensory integration a pillar of my work. Gradually, I was able to
assemble a theoretical framework to explain why this unusual approach to
trauma treatment was effective. Perry, whose Neurosequential Model of Therapeutics (NMT) is
particularly insightful, captures key elements in his 2007 book. He
writes:(developmental trauma survivor) ”…these children need patterned
repetitive experiences appropriate to their development needs, needs
that reflect the age at which they missed important stimuli or had been
traumatized, not their current chronological age” (Perry, 2007. p. 138).
just any sensory integration activity will do. Each must be chosen in
response to a patient’s needs and history. A key goal is to engage the
patient’s “survival brain,” the part of the brain that is dominant
before age three and facilitates sensory integration. This process
supports improved emotional regulation and in work with a therapist who
understands attachment, it opens the possibility of developing secure