Concerned About Unconventional Mental Health Interventions?

Concerned About Unconventional Mental Health Interventions?
Alternative Psychotherapies: Evaluating Unconventional Mental Health Treatments

Monday, April 14, 2014

Disorderly Thinking About Developmental Trauma Disorders


Sunday Koffron Taylor [sorry, I gave the wrong name before] kindly posted for a Facebook group the following piece: http://attachmentdisorderhealing.com/developmental-trauma, the work of one Kathy Brous, who is said to be a technical writer and advertises her own book with the statement that she accidentally regressed herself back to infancy. (How’d she get back again? That’s what I want to know.)

I was floored by Brous’s statements about the posited Developmental Trauma Disorder, proposed by Bessel van der Kolk to the editors of  DSM-5 and rejected by them on the grounds that there have been no published accounts of cases that are appropriate for this diagnosis and not for other existing diagnoses. Brous appears to quote van der Kolk and Allan Schore correctly, however, so I don’t think the whole problem can be blamed on her.

Let me offer a few quotations from Brous’s article, with rejoinders to each.

First, I note that Brous refers to Allan Schore as the “father of attachment theory in the U.S.” This is an absurd statement and indicates that Brous is in fact ignorant of the actual history of attachment theory as understood by psychologists, rather than by journalists. If one had to choose “fathers” for attachment theory in the U.S., Alan Sroufe and Everett Waters come to mind as the major candidates. Schore’s contribution, if such it can be called, is something he calls “regulation theory” or “modern attachment theory”. As I was preparing an article about attachment theory for the journal Theory and Psychology several years ago, a reviewer asked me to include Schore’s ideas, which I did, looking especially at his attempts to bring material about brain injuries and about behaviors of other species into the discussion. Here is part of what I said: “.. A.N. Schore’s speculation about right-brain functioning is on shaky ground. Passing over the well-known fact of the holistic functioning of an intact brain, we can note that a careful parsing of Schore’s sources (J.R. Schore & A,N, Schore, 2008) suggests a lack of due attention to some important points. In addition to a number of references to Schore’s own publications as evidence for specialized right-hemisphere attachment functioning, Schore and Schore cited about 10 sources as indicating empirical evidence for the postulated connection. Of these, two… involved work on rodents, which was presented as supporting evidence without any textual reference to the use of data from non-humans. One paper… described hemispheric differences in processing upper and lower parts of a facial display, and concluded that lower facial displays are preferentially processed by the left hemisphere and upper facial displays by the right hemisphere; Schore and Schore mentioned only the right-hemisphere data. A fourth paper… discussed facial processing deficits in persons  for whom a cataract in early infancy had prevented stimulation of the right visual cortex; Schore and Schore cited this paper as evidence for the right-brain hypothesis without noting that the teratogenic or genetic event that caused the cataract might also have caused atypical brain development…” (Mercer,J. [2011]. Attachment theory and its vicissitudes: Toward an updated theory. Theory & Psychology, 21, 25-45). Et cetera, et cetera, all to the point that Schore’s “modern” theory is based on a stroll through the cherry orchard. Read the background material, and you see at once that Schore’s part of this belief system is largely notional.

All right, let’s soldier on to more of Brous’s remarks. How about this one? “Developmental trauma starts in utero when there’s not much more than a brain stem and goes on during the pre-conscious years… until 36 months, when the thinking brain… comes on line. It’s 45 months [apparently beginning at conception, to make the numbers right. JM] ranging from general anxiety to non-stop terror.”

Where to begin? How about psychological trauma in utero? What events are emotionally disturbing to a fetus? Are we talking about emotion-related hormonal changes in the mother, which could certainly shape aspects of brain development but would have to be related to intense and continued distress in order to do so?  Is this a theory that actually could apply only to children of mothers held in concentration camps or caught in civil wars, or is there some attempt to think about more typical developmental events? My guess is that Brous, at least, is not talking about any of these things, but instead is committed to the idea of trauma at the time of conception, a la Scientology. My crystal ball suggests that behind Brous’s references lies a belief in “cellular consciousness”-- posited learning that does not require a nervous system--  and that this is also concealed in van der Kolk’s claims about the body keeping score.

All right, and when are these “preconscious years”? Is Brous claiming that children of almost three years are not thinking in the usual meaning of the term? Are these the same children who are known as toddlers to be able to figure out whether to believe a person who has acted “nice” rather than one who has not? Are they the same ones who tell and listen to stories and express intense likes and dislikes, or who reason about their own behavior (I’ll quote one two-year –old of my acquaintance: “I like chickens, but I never kiss them, because they have beaks and no lips.”) If Brous wants to say that cognitive development is very much in progress during the first three years, or even that most people have few or no memories from that period, that’s fine--  but to say young children are “preconscious” is inaccurate and without purpose except to allow for an extravagant emphasis on their experiences of fear, even constant terror.

Let’s jump ahead a bit. Now we see that van der Kolk calls “insecure attachment and attachment disorders” the causes of the posited Developmental Trauma Disorder. But, hold the phone a moment. It’s well known that infant-parent attachment does not develop until at least 6 months after birth. Methods for measuring insecure attachment are directed at children of 12 months or older, so there’s no way anyone could reliably identify this in a child between 6 and 12 months, much less in earlier life. As for “attachment disorders”, these are not the same thing as insecure attachment (see previous post for more about this). How can it be that attachment “problems” cause DTD, but DTD is caused by events as early as conception--  as much as 15 months before attachment even begins? Like a problematic form of attachment behavior, this reasoning is disorganized/disoriented.

Just one more bit here, as I’m sure we’re all getting tired (goodness knows I am; reading this stuff is wearing). Van der Kolk has a treatment for the disorder he proposes. It’s somatosensory healing, which turns out to mean doing theater, yoga, and martial arts in order to “get them inter-personally attuned.” Folks, it’s as easy as that! These children have lived in terror from conception and had their brains skewed as a result, but children’s theater will fix it! Their bodies will change that scoreboard to say “game on”. The National Endowment for the Humanities will take over from NIMH, and the Santa Barbara Graduate Institute will be accredited by acclaim, and Alice Miller will be canonized, and I will become a hermit.






8 comments:

  1. Egads! For more of the usual mis-information floating around on RAD, read the Comments section below the HuffPost article.

    http://www.huffingtonpost.com/2014/04/23/reactive-attachment-disorder_n_5199552.html?ncid=fcbklnkushpmg00000037

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  2. Yes, Huffington Post is a problem-- not only presenting some trash,but letting people self-advertise through comments.

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  3. Is this article (by Schmid et al.) a more reasoned approach to the possibility of recognizing Developmental Trauma Disorder?

    http://www.biomedcentral.com/1471-244X/13/3

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  4. Hi Marianne-- you always have something interesting to add, and this paper certainly gives a systematic approach to the DTD issue. I notice that the authors refer delicately to the problem that different things are traumatic at different points in development (just as different things are rewarding). We are painted into a corner where we essentially have to say that something was traumatic if it caused long-term disruption, and the same thing was not traumatic if it did not, and it could have been traumatic at one point during development and not so at another point. This seems to me to get very circular and lead us to figure, as v.d. Kolk does, that if we see certain behaviors or moods in later life that is our evidence that something traumatic had to have happened. Really, we need complicated longitudinal work to support DTD, if it's going to be supported.

    Another thing on my mind about DTD is that it does not seem right to me to assume that experiences of neglect have the same effects as experiences of intense fear or pain. Ideally, children do have certain positive experiences, like being fed regularly, and some aspects of those experiences support good development. Many children who miss the positive experiences also have genuinely negative experiences, not just the omission of the good but the presence of the bad. Probably very few have all the positive stuff AND a lot of negative stuff, which would make them well-supported developmentally but "traumatized" at the same time. Neglect and abuse or other forms of trauma are usually so intertwined that we can't tell which events cause later problems.

    Schmid et al make two comments that interest me a lot. One is about misinterpretation of biological symptoms when DTD interpretations are privileged. This reminded me of something I came across recently on a FB discussion-- someone who had been treated by an alternative psychotherapy for dissociation-- but when she was diagnosed with a seizure disorder and treated medically for it, she stopped "dissociating".

    The other piece I wanted to mention was the caution about creating false memories when there's an assumption of trauma and an attempt to "winkle it out".

    The thing I think is good about the developmental trauma approach is its reminder to caregivers that a child's difficult behavior can be involuntary and trauma-related, and should not necessarily be considered characterological or even situational-- all the options should be considered. And similarly,of course, explanations other than trauma should be examined.

    I guess the bottom line is, we can't have one-stop shopping when we try to understand and treat what's going on with any child. There is so much faddishness in child welfare, just as there is in education, and it almost always turns out that things are a lot more complex than the latest fad suggests. It wasn't
    all about attachment, and it's not going to be all about trauma either.

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  5. Thanks, Jean. Your analysis makes such good sense. I appreciate your thoughtful response, especially since for my family, this whole discussion is not purely theoretical, with a recent (not particularly helpful) additional diagnosis of Complex Trauma Disorder, when I was suspecting something on the autism spectrum, and when the previous diagnoses (ADHD, PTSD, and depression seem to cover most, if not all, of the symptoms being ascribed to Complex Trauma Disorder.

    The points you make that are especially salient for me now are: (a) the danger of inferring that something traumatic had to have happened if we see certain behaviors or moods in later life; (b) the possibility of missing other diagnoses (genetic, medical, etc.) if DTD interpretations are privileged; and (c) the one-dimensional and faddish movements in child welfare (and in the associated Medicaid-supported community mental health practices whose life blood is the children in the foster care system), which close down other more precise/complex diagnoses and treatments.

    I agree with you that the effects of neglect are quite different from those of abuse that caused pain and fear. And I think that, often, neglect can be used to explain the behaviors that are too readily chalked up to "attachment disorder. As a culture, we have lots of at least anecdotal evidence about the effect of neglect on children: lots of "feral," dysregulated, and opportunistic ("manipulative"?) behaviors that can be clearly traced to not being socialized or cared for well in the home, *AND* alternatively being raised within the mores of some kind of peer gang-like structure. Lord of the Flies, gangs of street children, children raising even younger children in isolation when parents are absent: the behaviors that can result from these situations are often deeply anti-social and resistant to change. I don't think we need to use attachment theory to explain the long-lasting, self-fulfilling, hermetically reinforcing behaviors.

    In some Bruno Bettelheim universe, I guess we could see the absence of neglect along with the absence of bonding (affluent "refrigerator moms" within families where other members are perfectly loving and normal), but in most cases attachment/bonding ruptures are going to be inextricably linked with severe forms of emotional, educational, medical, and physical neglect.

    But we've become so punitive and moralistic over the decades: used to be that "feral" children were pitied and studied; now, "attachment disordered" children are demonized and blamed. Whatever we call it, years of neglect can be awfully difficult, if not impossible, to treat. But I'd rather not demonize the kids who had no hand in choosing their lot.

    Sigh ...

    Thanks, as always, for your analysis and research in these areas.

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    1. So sorry to hear that it's not altogether theoretical for you-- I was afraid that might be the case.

      As for the punitiveness you mention, I think there's one phenomenon that's largely responsible for this: the loud but unsupported claims by attachment therapists (echoed by naive journalists) that attachment disorders involve cruel behavior in childhood and culminate in serial killing-- that, according to these people, your adopted or foster child is just a Ted Bundy in the making. No one ever said this about the "wild boy of Aveyron", who was seen as a pitiable creature in need of all the help that could be found. Now that we "know" that neglected children plan to kill us, we are naturally afraid of them... unfortunately, there seems to be no way to stop quasi-professional therapists, journalists, and made-for-TV movies to stop spreading this misconception.

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  6. Dear Jean,
    I am afraid I have entered the belly of the beast.
    Brought my child recently to get more carefully assessed for learning issues (I *THOUGHT*).
    Turns out I am now being told that, though certain symptoms on the externalizing end of a behavioral scale are not high enough to reach a clinical level, they in fact are hiding the truly relevant symptoms, which are even further away from a clinical level, but which are the "underlying" issue -- the internalized "symptoms" of anxiety, depression, and suicidality, which all, of course, indicate a great deal of trauma.
    So, of course, my child requires trauma therapy -- e.g., EMDR, art therapy, Trauma Therapy. And have we thought of traveling to Boston to see Bessel Van Der Kolk, a Harvard researcher, who heads up the Trauma Center?
    In the end, Jean, this is what it sounded like to me: "Here is your child. Trauma, trauma, trauma. I know all about your child, because, for 20 years, I've worked in trauma, trauma, trauma. Nothing else about your child matters, because trauma, trauma, trauma. You're here because of learning concerns, but trauma, trauma, trauma. Let me tell you what I think you should do, but of course, you will make your own decisions. Trauma, trauma, trauma."
    I especially enjoyed the moment when, despite all the symptoms neatly graphed out, I was told to ignore the results and focus on the underlying issues (i.e., the invisible data, or data visible only to the trauma-trauma-trauma expert despite what the data showed to the rest of us).
    Trauma, trauma, trauma.
    I think I want my money back.

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    1. Oh good heavens. Yes, you do want your money back.

      This is the way it always seems to go with any of these versions of quackery: you can't see the Real Problem. Only I can see the Real Problem. And unless we treat the Real Problem, everything will get worse and worse. If you Just Treat the Symptoms, the Real Problem will be exacerbated.

      In my opinion, this view is taken because the person doesn't know how to treat the symptoms.

      It all reminds me of Nicole Hollander's cartoon "Sylvia". Sylvia has a "fast therapy" practice, and a young woman consults her about her lack of communication with her boyfriend. Sylvia: "Break up with him." YW: "But isn't that just avoiding the real problem?" Sylvia: "Words to live by!"

      I hope you can find a good old-fashioned educational psychologist who knows how to use and interpret tests of cognition. But... I think most of them have already been corrupted by trauma trauma trauma.

      Of course I don't mean to suggest that there are no traumas or long-term effects of traumas. But damn it all, not everything is about trauma any more than it was about attachment. And even if it were, EMDR and B.v.d.K are not what would be needed.

      Hang in there, do! So sorry to hear that you got caught temporarily by the bad guys.

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