A Psychological Approach to wellness: SUMMARy II
Photo by Alex Green
By Sterling M. Hawkins, MSW, LCSW-C, LICSW
Summary II PART THREE: The Minds of Children
In this section, van der Kolk devotes four entire chapters to the neurobiological development of children and what happens when that development gets disrupted by trauma. As in the previous section, I found his analysis closely reflected what I have seen in practice with families, even though I do not work directly with children. He asks good questions throughout the text, as any good researcher, that lead him and other trauma-informed researchers to conclusions that help guide treatment objectives. He makes the following observations:
“As we grow up, we gradually learn to take care of ourselves both physically and emotionally, but we get our first lessons in self-care from the way we are cared for.... Children whose parents are reliable sources of comfort and strength have a lifetime advantage— a kind of buffer against the worst that fate can hand them.” (van der Kolk, 2014, p. 112)
Van der Kolk examines the work of J. Bowlby and D. Winnicott, pioneering British psychiatrists in child development theory, particularly the impact of early relationships and the role of attachment as a buffer against traumatic experiences. He notes several distinct types of attachment that can influence patterns of child development. (pp. 117-122).
The following attachment styles in children are generally accepted by mental health practitioners:
Secure Attachment: Children feel secure, seen, and safe. They explore freely when the caregiver is present, are distressed upon separation, and happy upon reunion. They rely on their caregiver for comfort.
Avoidant Attachment (Insecure): Children appear indifferent to the caregiver’s presence or absence, and may avoid or ignore the caregiver upon return. They often learn to manage distress independently due to caregivers who consistently ignore their emotional needs.
Ambivalent/Resistant Attachment (Insecure): Children are often highly distressed when the caregiver leaves, but behave inconsistently (clinging and rejecting) upon return. This stems from inconsistent care, where the caregiver's response is unpredictable.
Disorganized Attachment (Insecure): Children show no consistent coping mechanism and exhibit fearful or erratic behaviors, often associated with caregivers who are a source of fear.
Van der Kolk notes that the need for attachment never lessens. Most humans are unable to tolerate being disengaged from others very long. People who fail to connect through work, friendships, or family often find other ways to connect, such as through illness, lawsuits, or family feuds. The latter being preferable to feeling irrelevant and alienated. (van der Kolk, 2014, p. 117)
Children are said to create internal maps of their world based on their experiences with their caretakers. Van der Kolk gives plenty of examples that inform his conclusions on how traumatized children remain traumatized into adulthood. So, as clinicians who seek to understand and interpret these maps, the question we must ask is: Is it possible to help the minds and brains of brutalized children to redraw their inner maps and incorporate a sense of trust and confidence in the future? (van der Kolk, 2014, p. 111)
According to Bowlby, attachment provides a secure base from which a child can explore and move into the world. Research over five decades supports the conclusion that when attachment is secure, children become more independent and display empathy toward others, forming thoughts that are both similar to and different from their own within their environment. Essential skills such as self-awareness, impulse control, and self-motivation enable them to become contributing members of broader society. In children who lack secure attachments, these qualities are painfully absent. (van der Kolk, 2014, p. 113)
The author begins to answer this question at the end of chapter seven, cautioning therapists treating trauma not to equate knowing with cure. He notes that our relationship maps are implicit, etched into the emotional brain, and not reversible simply by understanding how they were created. You may realize that your fear of intimacy has something to do with a past traumatic event or a prolonged period of dysfunctional parenting, but that alone is unlikely to open you to happy, trusting engagement with others. (van der Kolk, 2014, p. 124)
He does, however, voice a ray of hope: “Adults who were abused or neglected as children can still learn the beauty of intimacy and mutual trust or have a deep spiritual experience that opens them to a larger universe. (van der Kolk, 2014, p. 131). He then outlines his method for helping patients re-route their internal maps, but cautions those in the field of Psychiatric medicine to avoid becoming overly precise when assigning diagnostic labels. He writes: Given the complexity of mind, brain, and human attachment systems, we have not even come close to achieving the sort of precision often attributed to biological diseases. (van der Kolk, 2014, p. 139) “Understanding what is ‘wrong’ with people currently is more a question of the mindset of the practitioner (and of what insurance companies will pay for) than verifiable objective facts.) (van der Kolk, 2014, p. 139)
Because categories are narrow, therapists often have to assign 3 or 4 different codes to describe a single complex person. Secondly, codes focus on what the symptoms are, not why they are happening. Context is Ignored: codes often fail to account for poverty, racism, or systemic oppression. And lastly, to get insurance reimbursement, the therapist may have to "up-code" or pick a more severe diagnosis than what they actually see, which stays on the client's permanent medical record. Each of these represents a conflict between what qualifies for reimbursement and what the therapist may actually see in the client.
In chapter nine, he recounts the attempts by the American Psychological Association (APA) to create the Diagnostic and Statistical Manual of Mental Disorders (DSM-III), which was first released in 1980. This is the same manual I used in graduate school. I continue to use the recent edition (DSM-5) sparingly when I need distinct categories for what I am seeing.
Van der Kolk cites the difficulties inherent when obtaining a precise diagnosis using the DSM alone. And the overreliance on diagnosis codes has led to some patients being treated incorrectly, not to mention a diagnostic label that others (as well as the patients themselves) will use to define them. He believes the reason for this inconsistency is due to the lack of a complete trauma history. He, along with other researchers, acknowledge that the absence of a complete trauma history will likely result in an incomplete diagnosis at best, and failed treatment at worst. To address this problem, he and several colleagues designed a new study using the Traumatic Antecedents Questionnaire (TAQ), which they developed. (van der Kolk, 2014, p. 140)
I appreciated this because it’s what every therapist needs to complete, if not in its entirety, then in some abbreviated form. The forty-item questionnaire is available online for download along with instructions for scoring.
Van der Kolk concludes chapter nine by providing a brief history of the development of the Adverse Childhood Experiences (ACE) studies and noting that many adverse experiences are interrelated, even though they are usually studied separately. (van der Kolk, 2014, p. 147)
According to van der Kolk, the results from these studies confirm the implications of childhood abuse and neglect as a determinant of psychological function in adulthood, but fail to have the effect that other similar studies have had on reducing risk factors associated with negative outcomes, as in the link between smoking and the increased risk of developing lung cancer. (van der Kolk, 2014, p. 150)
The final chapter in this section (chapter ten) highlights what occurs developmentally in childhood and is expressed in adulthood when the developmental history was abusive or neglectful. In such cases, the devastation of this trauma will likely be described in negative ways that impact the lives of individuals, families, and communities.
This research compares trauma and its impact on developing primates, which share a genome similar to that of humans. And how parent-child relationships among primates mirror human parent-child relationships, and how these relationships are developed and socialized.
In the third and final summary, I will examine “The Imprint of Trauma” and “Pathways to Recovery,” followed by my conclusion.
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References:
Kolk, V. D., & Bessel, A. (2014). The body keeps the score: brain, mind, and body in the healing of trauma. In Medical Entomology and Zoology. https://ci.nii.ac.jp/ncid/BB19708339