Chld Development.. attunemnet not attachment updating Bowlby

For 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.

An 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.

While 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.

In 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).

Key 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. 

 This 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.)

 This 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.

 On Attunement  

Attunement 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).

Parents 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.

 Attunement 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.

 Difficulties 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.

The 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

A 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.  

How then to help a child, teen or adult client who has experienced developmental trauma to form a secure attachment and develop self-regulation?

 What Does Occupational Therapy Have to Do with Trauma?

Several 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.

 These 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 unexpected places.

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.

This 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 expressive therapies.

 I 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).

Not 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 attunement.