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The Neurobiology of Mood and Antisocial Behaviour in Adolescents
Ian M Goodyer MA MD FRCPsych FMedSci
Department of Psychiatry
University of Cambridge
•Anger and irritability are common features of mood disorders
• Expressed as violent acts: Suicidality ; Non suicidal self harm
•Aggression toward others
•Destruction of property (can lead away from diagnosis if a presenting feature)
The Psychopathology of Violence
Non-Suicidal Self-Injuryand Suicidality Events Over 28 Weeks’ Follow-Up
No NSSI month pre-baseline (N=105)
NSSI in month pre-baseline (N=58)
Class of Follow-Up Self-Harm Event
a b
Wilkinson PJ et al (2011) Am J Psychiatry. 2011 Feb 1. [Epub]
Depressed Adolescents with pre-baseline NSSI had a 10-fold greater risk of suicide attempt during treatment than those with no self-injury
For NSSI, χ2=39, df=1, p<0.0005; for suicide attempt, χ2=22, df=1, p<0.0005
02
04
06
08
01
00
Per
cen
tage
Wit
h S
elf-
Har
m E
ven
t
Non-Suicidal Self-Harm Suicide Attempt
Spatz Widom, C. et al. Arch Gen Psychiatry 2007;64:49-56.
Age at onset of depression
Maltreatment
Neural Systems And Affective Disorders
The Neural Maturation Gap: Understanding The Importance Of Brain Development
ObservationEarly consolidation of limbic-sub-cortical reward processing networks.Later consolidation of neocortical control networks.Spike in drug use, psychotic and mood disorders in the neural maturation gap.
HypothesisIncreased incidence of psychopathology in adolescence associated with different developmental rates for limbic and prefrontal systems.
Proposed MechanismVariation in rate of myelination of long distance cortico-cortical tracts predicts developmental reconfiguration of large scale brain networks.
Experience dependent synaptic plasticity and pruning of inactive connections are other plausible mechanisms.
Inci
denc
e N
eura
l dev
elop
men
t
Limbic System
PFC
Drug use, Psychosis,
Depressions
Proof of Principle: Differences in Volume of rAnterior Cingulate
Treadway M et al (2009) Plos One 4: e4887
N=19 N=19
19 19
Morning cortisol, child maltreatment decreased grey matter volume in the rACC
Treadway M et al (2009) Plos One 4: e4887
Vol decrease in rACC: patients
Corr abuse scales: patients
Vol decrease in rACC: controls
Corr abuse scales: controls
Greater right amygdala activity in patients (n=17) relative to control subjects before treatment. No significant difference between groups at the week 16 scan after treatment .
Longitudinal change in amygdala activity in depressed adults
Chen CH, et al (2007) Biol Psychiatry 62(5):407-14
Faster symptom improvement strongly associated with greater grey matter volume in anterior cingulate cortex, insula, and right temporo-parietal cortex. Faster improvement was also predicted by greater functional activation of anterior cingulate cortex.
Predicting clinical response at week 16
Neural Systems and Antisocial Behaviour
Proof of Principle : Volumetric Loss In Emotion Processing Areas
Fairchild et al (2011) Am J Psychiatry; epub April AiA:1–10
Smaller amygdala volume in CD cases vs controls
Amygdala: involved in fear recognitionand learning, experience of emotion
A Neural Basis For Interoceptive And Social Exchange Deficits In CD
Anterior insula: involved in empathy, processing negative emotions, and awareness of body states
Fairchild et al (2011) Am J Psychiatry Fairchild et al.; epub April AiA:1–10
Functional Brain Networks
Proof of principle: Functional brain networks change during normal adolescence and are abnormal in schizophrenia
Brain functional networks in schizophrenia are less economically wired, less modular and less clustered – we will test the developmental hypothesis that psychotic disorders emerge as a consequence of abnormal brain network maturation in the youth age range
Healthy
Schizophrenia
Alexander-Bloch et al (2010) Frontiers in Systems Neuroscience; Lynall et al (2010) J Neurosci; Fair et al (2009) PLoS Comp Biol
Mental Health And Neuroscience Network
•Partnership between University of Cambridge and UCL
•Characterise the structure and function of the normal brain in 14 to 24 year old well individuals
•Map deviant structure and functions in those with common mental illnesses arising in the adolescent years (depressions, conduct disorders, psychoses, personality disorders)
Co-Investigators
Thanks to Funding Agencies
Wellcome TrustMRCNIHRDoE
Clinical Global Impression Over The ADAPT Study Period
weeks
30% of severely depressed teenagers not helped by existing treatments: violence is one key to this
Goodyer IM et al (2008) Health Technol Assess. 12(14):iii-iv, ix-60
Improving Mood With Psychoanalytic Psychotherapy And Cognitive Behaviour Therapy: THE IMPACT
STUDY
THE NEUROBIOLOGY AND GENETICS OF CHILDHOOD
MALTREATMENT
THE NEUROBIOLOGY AND GENETICS OF CHILDHOOD
MALTREATMENT
Dr Eamon McCroryConsultant Clinical Psychologist & Senior Lecturer
Developmental Risk & Resilience Unit [email protected]
Tom grew up with his Mother, Step-Father and younger brother. Both his parents used drugs and drank heavily. Tom often witnessed violence at home and was shouted at and hit by his Step-Father. At the age of 8 Tom and his brother were removed from home, and after 3 placements were settled in a permanent foster family. Tom had serious behavioural problems at school. He also missed his mum even though he knew she couldn’t look after him. In adolescence Tom was arrested for hitting another boy. As an adult he found relationships difficult and was often depressed. By contrast, Tom’s brother did well at school, and secured a regular job, and later settled in a stable relationship.
TOMTOM
GENES
NEUROCOGNITIVE FACTORS
CHILD BEHAVIOUR
EN
VIR
ON
ME
NTBeliefs –Thoughts - Feelings
GENES
NEUROCOGNITIVE FACTORS
CHILD BEHAVIOUR
Beliefs –Thoughts - Feelings
?
?
GENES
CHILD BEHAVIOUR
1. Gene X Environment1. Gene X Environment
2. Brain Function2. Brain Function
3. Brain Structure3. Brain Structure
4. Resilience and Recovery 4. Resilience and Recovery
NEUROCOGNITIVE FACTORS
Beliefs –Thoughts - Feelings
Conclusions
1. Maltreatment leads to a series of neuro-cognitive changes that are adaptive in
the short term – but which are ultimately maladaptive…increasing the risk of later
mental health problems
2. Biological differences mean that different children will respond differently
to the same experiences
GENES
1. Gene X Environment Interaction
Could the genes Tom andhis brother carry mean thatthey responded to theirexperiences differently?
1. Gene X Environment Interaction
Could the genes Tom andhis brother carry mean thatthey responded to theirexperiences differently?
Genetic InfluencesGenetic Influences
• There are no ‘genes’ for psychiatric disorders associated with maltreatment - rather there are many genetic variants adding a small increment of risk or vulnerability.
• These genetic variants bias how all of us process emotion and respond to stress.
• Altered serotonin functioning is associated with depression
• The serotonin transporter helps removes serotonin from the synapse, terminating its action
• There are two different forms of the gene: Short allele: S - Long allele: L.
• We each have two alleles – most of us have at least one copy of the L allele.
Serotonin Transporter Gene Serotonin Transporter Gene
GENES
SS
LL
SL
Gene X Environment InteractionGene X Environment Interaction
‘S’ carries are more reactive to fear
S/S
5HTT
No differences in symptoms of depression
L/L
5HTT
L/S
5HTT
NORMAL PARENTING
MALTREATMENT
Significantly more likely to show symptoms of
depression
S/S
5HTT
‘Risk’ genotype
Children who have experienced maltreatment are more likely to
show depression if they carry two copies of the S allele (SS)
GENES
Gene X Environment InteractionGene X Environment Interaction
Dep
ress
ion
Sco
re
Genotype
SS + maltreatme
nt
MALTREATMENT
* Regular * contact with a trusted adult
GENES
S/S
5HTT
+
Risk of depression
-
GENES G x E Interaction: SummaryG x E Interaction: Summary
The additive effects of a range of genetic variants contribute to a child’s relative vulnerability or resilience to psychopathology following maltreatment.
In other words common genetic variants – that we all carry – make some of us more or less sensitive to emotional cues in the environment. Tom may have carried variants (or ‘polymorphisms’) that placed him at greater risk of poor outcome following his exposure to poor caregiving.
However, POSITIVE environmental experiences (as well as negative ones) can alter the child’s outcome. It is possible that Tom’s brother benefited from such a reliable attachment figure and reduced his risk of depression.
2. Brain Function
How might Tom’s exposureto physical abuse alter howhe processes emotion?
2. Brain Function
How might Tom’s exposureto physical abuse alter howhe processes emotion?
NEUROCOGNITIVE FACTORS
Brain FunctionBrain Function
Pollak et al., 2009
Pollak et al., 2009: Cognition% Image
Brain FunctionBrain Function
Brain FunctionBrain Function
• Physically maltreated and control children viewing facial expressions of anger, fear, and happiness were assessed using ERP which measures surface brain electrical activity.
• Differences were found only for anger - which predicts threat.
• This further suggests that physical maltreatment increases a child’s sensitivity to social cues associated with threat in the environment.
Maltreated
Control
ERP response to angry facial expressionin Maltreated and Control children (6-12yrs)
Pollak et al. (2001)
Brain FunctionBrain Function
• 10-14yr old children from a community sample referred to social services in the UK.
• Asked to complete a gender decision task in an fMRI scanner – is the face male of female?
• Preliminary data indicate a hyperactivation of the amygdala in this group.
• This is likely to represent the neurobiological locus of the observed hypervigilance to anger.
McCrory et al. (in preparation)
Greater activation in left amygdala with angry vs.
neutral faces.
Why might such hypervigilance be problematic?
Why might such hypervigilance be problematic?
Brain FunctionBrain Function
Children were instructed to attend to emotional faces while ignoringangry voices. The larger N2 response seen here is associated with inhibitory control and conflict resolution – indicating a greater attentional load.
Pollak (2008)
Abused childrenAbused children
2. Brain Function: Summary2. Brain Function: SummaryNEUROCOGNITIVE FACTORS
Physical abuse is associated with increases in brain electrical activity when procesing angry faces – this may relate to hyperactivity of the amygdala – a key brain region involved in processing threat.
Tom may have developed a greater level of hypervigilance – scanning the environment for emotional cues
This was probably an adaptive response in his chaotic home environment and kept him out of danger….but may have made it much more difficult for him to concentrate and engage at school.
The degree of hypervigilance has been correlated with greater levels of abuse and higher levels of anxiety.
3. Brain Structure
How might the experience ofmaltreatment affect thestructural development ofTom’s brain?
3. Brain Structure
How might the experience ofmaltreatment affect thestructural development ofTom’s brain?
NEUROCOGNITIVE FACTORS
Key brain structuresKey brain structures
+ Corpus callosum
Timing matters!Timing matters!
Ages of maximal effect:
Frontal cortex: 14-16 years
Corpus callosum: 9-10 years
Hippocampus: 3-5 years
4. Resilience and Recovery
Are the effects of Tom’s earlyexperience fixed andpermanent?
4. Resilience and Recovery
Are the effects of Tom’s earlyexperience fixed andpermanent?NEUROCOGNITIVE
FACTORS
GENES
Adolescence is a period of marked neurodevelopment
Adolescence is a period of marked neurodevelopment
The frontal lobes undergo marked neuro-biological change during adolescence. This regions is associated with higher order social cognitive skills, including:
• Perspective taking• Empathy• Emotional regulation
For Tom this is a period of significant plasticity when new learning can occur. In other words, at age 8 Tom’s brain is still immature and will continue to develop until his early 20’s.
The frontal lobes undergo marked neuro-biological change during adolescence. This regions is associated with higher order social cognitive skills, including:
• Perspective taking• Empathy• Emotional regulation
For Tom this is a period of significant plasticity when new learning can occur. In other words, at age 8 Tom’s brain is still immature and will continue to develop until his early 20’s.
AdolescenceAdolescence
McCrory et al., McCrory et al.,
How do factors such as…
• Number of placement changes• Professional support / intervention• School affiliation• Stable attachments• Individual coping skills
…influence the development of key frontal regions important in emotion regulation and effective social functioning?
How do factors such as…
• Number of placement changes• Professional support / intervention• School affiliation• Stable attachments• Individual coping skills
…influence the development of key frontal regions important in emotion regulation and effective social functioning?
It is likely that Tom’s brother had one or more of these kind of protective factors that have helped promote more effective social and emotional skills, despite poor early care.
Overall SummaryOverall Summary
• Maltreatment is associated with different outcomes for different children due to individual genetic factors.
• The brain is affected by maltreatment both functionally – adapting in different ways to experience – and structurally, i.e. in how different brain regions develop.
• There remains a lack of research on resilience and recovery, but we do know there is a significant period of neuro-development in adolescence. Future work will be able to identify neural markers of resilience and how these associated with different environmental influences.
Further Reading…Further Reading…
Journal of Child Psychology and Psychiatry 51:10 (2010), pp 1079–1095
AcknowledgmentsAcknowledgments
Dr Essi Viding
Developmental Risk & Resilience Unit, UCL
Supporting Children’s Development
An Attachment ApproachPasco Fearon
Research Department of Clinical, Educational and Health Psychology
What is Attachment?
Intimate bond between baby and primary caregivers
Behaviour serving to maintain proximity to a selective caregiver(s) in times of stress
Works like a thermostat – triggered by cues of danger, brings about proximimty and feeling of safety
Theorised evolutionary basis
Develops early in infancy, most clearly evident at 7-9 months by proximity seeking and stranger anxiety
Example 1
Example 2
Attachment PatternsSecure Attachment: seek proximity, communicate
need for comfort, contact is effective
Avoidant Attachment: avoids contact, minimizes expressions of need for contact
Resistant Attachment: intense expression of distress, angry upon contact, contact not effective
Disorganized Attachment: contradictory, fragmented, disoriented or fearful behaviour upon contact
Disinhibited Attachment: extreme social disinhibition, lack of stranger caution, approach and receive comfort from strangers
Patterns of CareSecurity associated with sensitivity, defined by
Awareness of infant attachment cues Accurate interpretation of infant cues Responsive to cues Appropriate response
Insecurity associated with insensitive care Negative/rejecting Interfering/intrusive Inconsistent availability
Disorganization associated with Frightening, frightened parenting Maltreatment
Disinhibited Attachment associated with Institutional care, extreme neglect
Making Sense of Disorganization
Fear as key determinant (Main & Hesse, 1990)
Parental frightened/frightening behaviour
Avoidance
Proximity seeking
Avoidance
Proximity seeking
Behavioural paradox
Consequences
Disorganized children show physiological hyperarousal
Consequences: Externalizing Problems
OriginsAttachment patterns show little sign of being
influenced by genes
Fonagy, Steele & Steele (1991) showed that interviews conducted with parents before the child’s birth predicted the child’s attachment security at 1 year
The capacity of adults to reflect on their own attachment experiences seems key
Insecure States of mind: Dismissing, Enmeshed or Unresolved with respect to loss or trauma
SummaryAttachment is critical for children’s development
Parental sensitive and responsive care promotes the development of secure attachments
Insensitive or frightening parenting or maltreatment undermines the child’s attachment
The child is left vulnerable to becoming highly stressed and to developing behavioural problems
A range of inter-dependent factors influence parental care (esp. own attachment experiences, psychiatric problems, deprivation, drug addiction, low social support)
Intervention
Focusing on Attachment
Working with Parents’
Attachment Histories
Promoting Sensitivity
Working with the
Relationship
Home Visiting Sensitive Discipline
Supportive Networks
Supporting Maltreated InfantsCicchetti, Rogosch & Toth (2006)
Predominantly neglected infants
Two interventions: Infant-Parent Psychotherapy, Parenting Education/Home visiting program
IPP•Supportively exploring connections between parent’s past and current relationship •Focus on triadic interactions (parent-therapist-baby)•Empathic, non-judgmental
PPI•Home-based education program•Physical, psychological development•Parenting•Promoting education and employment, social support•Managing stress
Before Intervention
After Intervention
Sensitivity-Based InterventionMoss et al. (2011).
Similar approach with older children (preschoolers)
8 home visits• Enhancing sensitivity by in-session interactions,
discussion and video-feedback• Intervenors trained in attachment theory and
research• 20-min discussion focused on recent family events• 10-15 min video recorded observation of interaction• 20 min video feedback session reviewing positive
interactions, exploring feelings and thoughts of parent
• 10-25 min
Impact on Attachment
SummaryMaltreatment has a major impact on children’s
attachments and their long-term development
We can make a difference
Early intervention can dramatically improve the quality of children’s attachments
Doing so may reap long-term rewards
Thinking about the Unthinkable
Mentalizing Trauma
Alessandra Lemma
Traumatic events do not discriminate:
Paul’s story
A trauma is an attack on our attachments
It is experienced as a breach in the quality and felt security of our attachments
We feel distressed and we want to be hugged
(or not…..)
Traumatic experiences undermine the psychically integrating function of narrative
Breakdown in the capacity to reflect on lived experience (i.e. to symbolise)
What causes PTSD?
Exposure to objectively defined traumatic events is not sufficient to produce PTSD
Vast majority of exposed persons do not develop PTSD, although some types of trauma carry a far higher risk than others (sexual assaults vs. automobile accidents)
Early patterns of maladaptation and/or adversity can be seen as creating vulnerabilities
These may interact with later factors to result in various kinds of mental health problems
One set of risk factors is associated with the likelihood of trauma exposure:
difficult temperament antisocial behavior Hyperactivity maternal distress loss of a parent in childhood
A second set of risk factors is associated with the likelihood of developing PTSD after exposure:
low IQ difficult temperament antisocial behavior being unpopular, changing parental figures multiple changes of residency maternal distress
Another prominent post-trauma risk factor is ongoing stress in the aftermath of the ostensible traumatic event (Vogt et al., 2007)
Unempathic responses in attachment relationships, which might resonate with earlier adverse attachment experience, play a significant role in vulnerability
What happens after a trauma has biggest impact on whether a person develops PTSD (Brewin (2003)
The most powerful post-trauma factor is lack of social support
Reducing “the trauma” to any single event is therefore arbitrary
The impact of trauma on mentalising
What is mentalizing?
Mentalizing is a form of imaginative mental activity about others or oneself, namely, perceiving and interpreting human behaviour in terms of intentional mental states (e.g. needs, desires, feelings, beliefs, goals, purposes, and reasons).
Impact of attachment trauma on the capacity for emotion regulation and mentalizing
Vulnerability stemming from traumatic childhood attachments:
These relationships evoke extreme distress
AND
Impair the development of capacities to regulate emotional distress—in part through compromising the development of mentalizing
The overall aim of trauma treatment is to help patients to establish a more robust, mentalizing self
So they are better equipped to mentalize trauma and relationship conflicts and thus able to develop more secure attachments
There is far more to treatment required than processing traumatic memories.
Attentiveness to strengthening emotion-regulation capacities is central
Research has shown that the capacity for mentalizing is undermined in most people who have experienced trauma
Mentalizing goes offline when defensive (fight-flight-freeze) responses come online
The collapse of mentalizing in the face of trauma entails a loss of awareness of the relationship between internal and external reality (Fonagy & Target, 2000)
Reliving the trauma takes the place of remembering the trauma
Mental states are expressed in concrete goal-directed actions instead of mental representations such as words (e.g.the young person who communicates emotional pain through scars on her arms …)
Following trauma, verbal reassurance means little.
Interacting with others at a mental level has been replaced by attempts at altering thoughts and feelings through action
Therapeutic work with traumatized young people
Less emphasis on techniques and more on a way of thinking about the therapeutic process and the therapist’s stance
Mentalizing stance
Focus is primarily on the patient’s mind, not on the event.
A mentalizing stance emphasises process over content
The overall aim of treating traumatized patients is to help them to establish a more robust, mentalizing self, and thus to develop more secure attachments
Mentalizing provides a buffer between feeling and action— a “pause button” (Allen, 2001)
Promoting mentalizing does not require direct processing of traumatic memories
It requires mentalizing painful emotions and conflicts in the context of an attachment relationship.
This treatment strategy runs counter to the young person’s inclination towards defensive avoidance of thinking about what has happened to them
The clinical priority is to reduce arousal so that the young person can think of other perspectives (mentalize)
Establish a sense of “interpersonal security” (Sullivan, 1953) between worker and young person that will contain their anxiety
Psychoeducation
Many traumatised young people fear they are going mad and are relieved when the therapist explicitly recognizes their symptoms as part of a known clinical picture.
A trauma breaches the felt security of attachments, and the individual may also feel in some way ‘marked’ as different by virtue of what they have endured
Developing a narrative about the trauma
The conscious and unconscious meanings and affects that are attached to the traumatic incident are a central part of the problem and recovery.
Reconstruction is an important component of working with traumatized patients.
The functioning of memory post trauma presents a particular paradox: patients complain of the intrusion of too much memory; but they may also present fragmented memories of the traumatic incident
Working with the past in the present
The aim is to help the young person to develop perspective on the past by reworking current experience (Bateman & Fonagy, 2004)
The therapeutic relationship and enactments
The young person may unconsciously seek to evoke particular responses from the therapist.
The re-exposure to situations reminiscent of the trauma may be compelling and may exert tremendous pressure on the therapist.
Objects of hope
The therapist/worker potentially provides a point of re-entry into a non-traumatized world
We can become objects of hope the young person can internalize and “use” if we can bear the pain of being unable to rescue them
We can sustain hope if we can bear to be the ‘hated other’, who at times becomes indistinguishable in the young person’s mind from the torturer or abuser
The therapist’s capacity to contain painful emotions and remain collaboratively engaged in a mentalizing stance models a way of approaching the contents of one’s mind
Legacy of Childhood Legacy of Childhood Maltreatment in AdulthoodMaltreatment in Adulthood
and reparative ways of working and reparative ways of working through traumathrough trauma
Frank Lowe, Consultant Social Worker & Adult Psychotherapist
118
Legacy of Childhood Maltreatment in AdulthoodLegacy of Childhood Maltreatment in Adulthood
Monty RobertsMonty Roberts Nigel Leat
119
Key points - there is a legacy fromKey points - there is a legacy frommaltreatment in childhoodmaltreatment in childhood But it does not have a single face - it comes in different packages,
sizes, shapes, colours etc
Children do not simply grow out of maltreatment
The degree of impact in adulthood will be influenced by various factors e.g. when, who, what and how severe and long it was
Having an experience of good enough care (a secure attachment
- capacity to reflect) is a protective factor
How did significant others respond and did anyone stand by you?
It is not a 'them and us' situation - childhood maltreatment is much more common than is assumed
120
Childhood maltreatmentChildhood maltreatment - - sexual, emotional, sexual, emotional, physical abuse or neglect is essentially traumatising physical abuse or neglect is essentially traumatising and the effects often persist into adulthoodand the effects often persist into adulthood
Childhood trauma is reliably associated with
a range of mental health problems such as depression, alcohol and drug abuse, anxiety disorder, low self-esteem; sexual dysfunction (Rorty et al, 2005)
physical health problems e.g. headaches, chronic back pain, shortness of breath, higher levels of gastrointestinal disorders and chronic pelvic pain ( see Felitti et al,1998; Spertus et al, 2003)
poorer social functioning, resilience and quality of life
sexual abuse, seems particularly linked to eating disorders (Rorty & Yager, 1996; Kent et al,1999)
emotional neglect is associated with greater Social Anxiety Disorder (Simon et al, 2009)
121
The legacy of childhood maltreatment is The legacy of childhood maltreatment is not straightforward or always visiblenot straightforward or always visible
Psychic vulnerability, distress, or wounds are not as visible as physical wounds
Deep distress and damage is not always evident in the way someone looks or how they function
Protective factors such as temperament, skills, and talents, the availability of resourceful others, social class, cultural heritage and access to treatment can affect the outcome of childhood maltreatment
122
Working below the surface – with the ‘invisible’ internal world
Trauma….”extends far beyond the visible, into the depths of the individual’s identity, which is constituted by the nature of his internal objects – the figures that inhabit his internal world, and his unconscious beliefs about them and their ways of relating to each other” Caroline Garland (1998, p10)
123
Coping with developmental tasks Coping with developmental tasks and life stressesand life stresses
Children can develop defence mechanisms in response to maltreatment which can mask the damage done, which may emerge only later in life e.g. they may appear to be
friendly, helpful and capable but in adulthood are confused, feel immense self loathing, self-harm, have problematic
relationships and self-sabotage
Face challenges with developmental tasks across the life span
Previous trauma makes dealing with subsequent stressful incidents more complex and stressful
Trauma can occur at any point in life and for many it can occur repeatedly throughout their lives
124
Childhood abuse and parentingChildhood abuse and parenting
Abused parents frequently repeat their own experiences with their own children and abusive patterns can be seen across generations
These adults seem unable to protect their children e.g. they subtly encourage or turn a blind eye to abusive behaviour.
There is much evidence of how 2nd and 3rd generation Jews were affected by parents who survived the Holocaust, e.g. how they inherited some of their parents anxieties and traumas
It seems that the more hidden or denied the parents’ traumatic history, the more likely that these will be carried unconsciously by their children
125
Deep, lonely and inconsolable Deep, lonely and inconsolable suffering suffering
Childhood maltreatment can cause long-term damage
to the personality structure
The adverse effects are more acute and profound when the abuse occurs early in the life of the child when they
are less able to differentiate between self and the other - their sense of responsibility is greater
There is a depth of damage that lingers in adult survivors
of abuse
Like a separate or hidden part of the core self it regularly intrudes into the adult’s emotional and cognitive functioning
126
Maltreatment by primary carers Maltreatment by primary carers in the early years can lead to -in the early years can lead to -
an attachment to a traumatising object
stultification of the child’s development of self, and cognitive, emotional and relationship capacities
an extreme impairment to a sense of autonomy
work with such patients as adults being more difficult because of difficulties not only with trust but with difficulties with the real or inner self
127
The effects The effects
The traumatic experience can be unspeakable- because it is pre-verbal or it is a way of protecting attachment figures
The abuse can be completely forgotten for years and the memory is only retrieved during therapy
Identification with an abuser. Part of the self remains in thrall to the abusing object and is unable to extricate itself
Addictive nature of the abusive experience which may have filled an emotional gap and provided some emotional compensation for an isolated and deprived child
Can affect choice of partner - an unconscious choice of someone who has also suffered maltreatment can facilitate a repetition of the original trauma
Actions can be the words that cannot be spoken
128
Working through trauma Working through trauma This is slow difficult work Defences against pain, fear, anxiety which block growth includes anger,
phantasies of omnipotence, avoiding vulnerability, trust, dependency and identification with the aggressor
Working with the addictive nature of the abusive experience The compulsion to repeat past experiences will manifest in the transference Making conscious the trauma and its impact – remembering what has
happened has to be explored What does the traumatic event means for the individual? Our earliest relationships not only shape later mental structure but have a
continuing influence in the internal world The client needs time to become more familiar with their resistance to
change and to work through and overcome it Working through is very arduous Often our task is to listen and bear witness
129
Working through Working through traumatrauma
Always consider the possibility of childhood trauma not only in those adults who present with symptoms of complex trauma or PTSD, but should consider it even in high functioning adults
Good/careful history talking is always essential in any treatment
Promote reflection - enable client to make links between their current difficulties and their childhood experiences
Be aware of secrets and lies as a way of protecting the abuser and protecting the self
There is a compulsion to repeat past experiences in the transference and the attending to and handling of the transference is key instrument of treatment
130
Practice challengesPractice challenges Many who have suffered insidious trauma, do not appreciate
that it can have a cumulative negative emotional impact
Engagement with help - dropout and relapse rates are dramatically higher in patients with eating disorders who reported previous traumatic events in comparison with those patients without a history of trauma
Drop-out rates could represent an expression of hopelessness that interferes with cooperation and compliance
Freud learnt that it was difficult to know whether an experience reported in therapy was real or a fantasy
The past can never be fully known, memories change, and these events can be retranslated and reinterpreted and there is always something left untranslated, yet-to-be translated (Shinebourne, 2006, p336)
131
ConclusionConclusion
The traumatic event is by its nature an unassimilated experience
For many adults, their trauma is known and not known about - it remains disassociated
Others remain silent, guilty, ashamed and protective of the abuser, not trusting or getting close to anyone
Some live largely in a parallel world driven by their traumatic experiences in attempt to achieve some kind of mastery
Childhood trauma touches and disrupts the core of one’s self and affects one’s identity or personality in adulthood
To work with trauma the worker has to contain the unbearable states of the client and work in collaboration with him/her until they can face their reality, give meaning to experiences and positively learn from them
Workers however need support to do this work and to avoid repeating the traumatic cycle of abuse and neglect
132
No Bullsh*t
“A traumatized patient….. needs to have a therapist survive what could be traumatic. The heart of the matter is that our moment of horror as therapists mirrors what the child could not cope with…… Bringing the trauma into the room, into the relationship with the therapists, is what may enable us to make a difference. To do the necessary work safely we have to ensure that we have time and adequate personal and professional support for ourselves.” ,Margaret Rustin (2001)
