Download A Proposal for Research - Adult Survivors CAN Sustain Recovery

Not Sick, Not Well, But Really Struggling
Understanding, Managing, and Maybe,
Recovering From Adult Effects of
Disturbed Childhood Attachments
A Proposal for Research
EXECUTIVE SUMMARY
by Russell J. Wilson, July 2011
People who need people
Are the luckiest people in the world,
We're children, needing other children
And yet letting our grown-up pride
Hide all the need inside,
Acting more like children
Than children
"The marginal man...is one whom fate has condemned to live in two societies and
in two, not merely different but antagonistic cultures....his mind is the crucible in
which two different and refractory cultures may be said to melt and, either wholly
or in part, fuse." (Robert E. Park, Cultural Conflict and the Marginal Man in
Everett V Stonequist, The Marginal Man, Introduction, New York: Charles
Scribner's Sons, 1937)
“No one knows how many people with severe mental illness live what appear to
be normal, successful lives, because such people are not in the habit of
announcing themselves. They are too busy juggling responsibilities, paying the
bills, studying, raising families – all while weathering gusts of dark emotions or
delusions that would quickly overwhelm almost anyone else.” Marsha Linehan
Expert on Mental Illness Reveals Her Own Fight New York Times: 6/24/2011
EXECUTIVE SUMMARY - Introduction
The title of the proposed thesis comes from the view that whilst, in some quarters, the
“disorder” some who suffer from the effects of disturbed attachment may be said to be
suffering from “Complex PTSD” (not well); others revile the term “disorder” (not sick) and
see the distress such people suffer from as a normal reaction to abnormal events in social
relationships – in any event the effects induced often cause people to suffer, often for the rest
of their lives. The bulk of information collected will be quantitative.
The proposed research takes the form of an integration of concepts from both Psychology and
Sociology, much as Scambler's (2009) work integrates concepts from different disciplines,
and for using particular examples of the arguments he makes. For the purposes of this
proposal, the word “Attachment” is taken to technically mean that special relationship that,
hopefully, develops between infant and caregiver, that gives rise to “internal working models”
of the infant's self, their concepts of others, and their concepts of how relationships work.
Unfortunately, a variety of events can occur that disturb the establishment and maintenance of
that bond (see Appendix 1 for main paper). Approximately 35% of children experience at
least one of these events early in their lives (Chaffin et al., 2006). One of the commonest
types of factors that disturbs the attachment relationship is interpersonal, often intra familial,
abuse. Note that this abuse can occur without the attachment being disturbed in some
situations. Disturbance of the attachment relationship can result in a clinical disorder
requiring treatment (Boris et al., 2004), or in an attachment “style” which will form the model
for later relationships, not only with intimates, but in help-seeking relationships (e. g., with
medical caregivers) or with employers and work colleagues (Corrigan, Rafacz, & Rüsch,
2011; van der Kolk, 2005).
Whilst a number of research studies have shown that attachment styles are relatively resistant
to change, unless the individual spends a significant time in a treatment program or other
“healing environment”, left unchecked insecure attachment can lead on to a number of
chronic physical and psychological disorders (van der Kolk, 2005; Wegman & Stetler, 2009)
Whilst much is known about the long term effects of sexual abuse, especially about its effects
on women, much less is known about the effects of other forms of abuse, and again,
relatively little is known about the effects of abuse on men. Indeed, this is a point of
disagreement in the literature. This lack of knowledge desperately needs to be overcome as
the incidence of abuse on male children is now known to be much higher than once thought,
with offences being committed by both men and women. However, attachment style is
thought to mediate the link between childhood abuse and later outcomes, although the
literature is unclear on this, as there are indications that there could be different pathways
from childhood abuse to later outcomes for men and women. Similarly, and controversially,
the contribution of genetic and biological factors (not the subject of the proposed research) is
far from clear, with contradictory results being found when tighter procedures and
experimental designs are used. Recently the British Psychological Society has responded to
the American Psychiatric Associations draft for DSM 5, due to be published, noting the
significant contribution of social and relational factors to the distress experienced by those
previously labelled as suffering from disorders “not otherwise specified”, and particularly
personality disorders.
To date, Sociology has contributed relatively little to understanding this problem. However,
there are signs that Sociology will address some of the most pressing issues in the field.
Bessel van der Kolk, Child Psychiatrist, on behalf of the US National Child Traumatic Stress
Network, is pushing for a new diagnosis to be introduced into DSM 5 “Developmental
Trauma Disorder” (van der Kolk, 2005). One of the arguments used in support of the new
diagnosis is that clinicians are hasty in diagnosing the effects of childhood trauma as
“Personality Disorder”, and that this not only stigmatises patients, but often results in
inadequate or inappropriate treatment. This problem also exists in adult psychiatry, as
evidenced by the studies of Michalak et al (2011) and Nehls (1998). Jutel (2009) fairly calls
this a return to the Sociology of Diagnosis, heretofore relatively neglected in Sociology,
whilst Brown et al (2011) emphasise how broadly the effect on a person of receiving a
psychiatric diagnosis spreads socially. This is an aspect of “stigma”, carrying the connotation
of prejudice, discrimination, marginalisation, and shame. The shame and self-stigma, and
sense of personal invalidation has a substantial effect on her intimate relationships
(MacIntosh & Johnson, 2008)
Many of the effects of abuse, or symptoms of “Developmental Trauma Disorder” can be
thought of as the unresolved effects of shame, including emotional dysregulation, depression,
anxiety, impaired quality of life, somatic symptoms, and a guilty/judgemental self-concept
(Rüsch, Lieb, Bohus, & Corrigan, 2006; Rüsch et al., 2007, 2010; J. P. Wilson, Drozdek, &
Turkovic, 2006) Not surprisingly, victims of abuse often have an insecure attachment style,
impaired self-efficacy, personal dis-empowerment, or a heightened sensitivity to feelings of
dis-empowerment and (A. G. C. Wright, Pincus, Conroy, & Elliot, 2009; S. L. Wright &
Perrone, 2010)
Clearly, a number of other disorders will have the same or similar symptoms to those listed
here for Complex PTSD, and just as other disorders need to be clearly distinguished from
each other (taking the example of Borderline Personality Disorder and PTSD – see (Lewis &
Grenyer, 2009), so too does effort need to be made to ensure that research samples of those
with Complex PTSD (perhaps the adult form of Developmental Trauma Disorder) are indeed
sufferers of that “disorder” and not others, though this has rarely been done in the past, with
the exception of Dorahy's studies. Fortunately a suitable assessment battery for differential
diagnosis is available (for purchase) from the Trauma Research Centre of which Bessel van
der Kolk is Director. This battery, in different interview and self-report forms, is variously
called the Structured Interview for Disorders of Extreme Stress – SIDES, or SIDES-SR,
respectively – was used for field trials of the disorder for possible inclusion in DSM-IV.
Dorahy (2009, 2010) has examined a number of features of Complex PTSD, in particular the
relational consequences for adults, and has found that social disconnectedness is
characteristic of such people. Further aggravating this is the tendency for a minority of them
to “suffer” from dissociation, and that when this occurs there is a high likelihood that their
relationships with intimate partners will not survive. This is despite the fact that dissociation
might be seen as a coping strategy – perhaps an ultimate form of experiential avoidance seen
in trauma disorder cases (Walser, 2007) Perhaps this is another instance where partners need
to be brought in as part of “the clinical team” where one of the couple has difficulty dealing
with the effects of insecure attachment and shame as a result of childhood abuse, as
MacIntosh has suggested ((MacIntosh & Johnson, 2008) It will be seen later that the
variables mentioned so far have been studied in populations of people from relatively secure
upbringings, although for some reason these studies have not been done on samples of
participants with clearly identified histories of disturbed attachment and insecure attachment
styles, those individuals perhaps most vulnerable to the effects of factors like low selfefficacy and high levels of self-stigma (although what I have suggested the implications of
MacIntosh' study is actually an example of this). Such an exemplar, with clear implications
for the provision of help to those from insecure attachment histories, to try to forestall these
individuals, and their offspring, from becoming more socially marginalised, is that of Davila
and Kashy (Davila & Kashy, 2009)
Examining the cross-fertilisation of implications for practice of the MacIntosh and Walser
and MacIntosh and Davila Kashy examples naturally leads on to the broader implications for
research and clinical practice of forms of Psychology/Sociology cross-fertilisation of ideas.
Clinical innovations to help victims of abuse deal with self stigma must be matched with
innovations at a systems level to help prevent abuse victims becoming victims of
stigmatisation by not only Society generally but by agents of the “power structure” – clinical
practitioners, and psychiatrists in particular. Perhaps what sociologists might call “selfstigmatisation”, clinical psychologists might now call “implicit depressogenic and anxiogenic
self-referent cognitions” (van Harmelen, van Tol, et al., 2010)
We do not know, yet, what cognitions, precisely, are involved with either of the concepts
“self-stigmatisation” or “implicit self-referent pathogenic cognitions”, but we can be sure that
whatever therapy is necessary for people to deal with these, that therapy will be assisted if
treating clinicians are not stigmatising their patients at the same time as they are trying to
assist them. This will require innovative programs led by both psychologists and sociologists
at both client and Society and social systems levels. The proposed research takes the form,
conceptually, of this innovation, by understanding both of these sets of processes, and by
making informed recommendations based on this research. It will be argued that at the client
level therapy programs targeted at experiential avoidance and defusion are needed, and at the
Society and systems level we will need to acknowledge abuse victims are responding
normally to abnormal events (acceptance rather than experiential avoidance) and changing
the way we view and go about things (defusion).
AIMS OF THE PROPOSED EARLY RESEARCH
Initial Two Studies – Social Survey & Evaluation of Provider Stigma
Aims:
1. to evaluate the extent to which community residing individuals have experienced
negative effects as a result of disturbed attachment in the first three years of their life
2. to evaluate the incidence of different types of attachment disorders experienced by
those in the community
3. to evaluate the incidence of different forms of insecure attachment experienced by
those in the community
4. to evaluate the different types of effects people have suffered from different types of
childhood abuse, as reported by those abused victims
5. to evaluate the extent to which people have felt stigmatised by those in the healthcare
system when they have been involved in that system in the past, and by whom they
have been stigmatised, as a result of their bin g identified as a sufferer of disturbed
childhood attachment / abuse / insecure attachment style
6. to gain an overall demographic “picture”of people who have been the subject of
childhood abuse, and those with insecure attachment styles, to form the basis for
future psychological, sociological and policy formulation
7. to determine how often those with histories of disturbed childhood attachment /
insecure attachment style are able to establish intimate relationships; and the nature of
problems they have with their partners
8. to determine how often those included in (7) above hav, or insecure attachment e
difficulties with raising children, if they have had difficulty bearing children, what
help they have sought for this, how successful that help that was, and if those dealing
with problems has required dealing with issues left over from early childhood
attachment problems, or insecure attachment style
Participants:
For the purposes of this methodology only, the term “clinical participants” will be those
who identify themselves as having had an experience of disturbed attachment with their
primary caregiver before the age of three, or those with a history of possible disturbed
attachment, based on their responses to the checklists developed by Critttenden (see
Appendix 1) OR those with a measured insecure form of attachment (see Measures
section).
Wherever possible “real” – those individuals in Dunedin or Christchurch wishing to
personally present for interview / assessment will be recruited for participation.
However, experience to date suggests these will be few. Real participants will complete
a similar procedure to other participants, as below – all “assessment” / questionnaires
will be completed using computer administration, using either laptop computer and/or
over the internet.
The bulk of participants will be recruited over the internet, as follows:
The research project will be listed with GetParticipants.com, with general information
provided, and re-directing them to a separate website if they wish to participate as
either a “control” or “clinical” participant. If they decide to participant, after they
receive more information, including a formal information sheet, they will “sign” a
statement of informed consent, assuring they are free to withdraw at any tie, and
advising them if the availability of emergency counselling if they need it – to be
available from community agencies.
Following signing the Statement of Informed Consent, participants will sign on to the
project website where the questionnaires will be available – embedded using the
resources of SurveyMonkey.com. Participants will be free to either withdraw at any
time if they wish, to continue participation then and there, or to cease participation and
resume later, using a password of their own choosing. If they choose to participate they
will be given the option of passing on personal details to be later re-contacted by the
experimenter, or to participate completely anonymously – technical details are yet to be
worked out to see if their history of data gathered can be carried over from session to
session without some form of ID being collected by the experiment. Participants will at
no stage be required to divulge personal details along with their identities if they choose
not to. Participants will be assured that at no stage, even if their details are passed on to
the experiment will these details be passed on to other parties, and that these details will
not continue to be associated with any information they provide after that information is
coded for statistical analysis.
Initially there will be two studies:
 Study 1: Social Survey;
 Study 2: Evaluation of Provider Stigma
Study 1 is the Social Survey and will consist of an initial questionnaire of demographic
characteristics of the participants – both “clinical” and “control” samples will be
compared, and then quantitative comparisons will be conducted of the two samples
using explicit (questionnaire) measures as follows:
Measures:
All questionnaires are yet to be finally determined, but those identified below are likely
to be selected based on their demonstrated reliability and validity, or their having been
included in published studies, or, in the case of implicit measures, included for
experimental purposes, those developed for this research: ALL explicit (questionnaire)
measures used will be in the public domain, except where mentioned elsewhere: for the
initial studies ALL questionnaires will be in the public domain – free to use, except for
the measures to be obtained from The Trauma Center at the Justice Resource Institute,
(TRC/JRI), Brookline, MA, founded by Dr Bessel van der Kolk, Psychiatrist.
DESNOS / PTSD assessment materials – TRC/JRI – USD 190.00
ATTACHMENT-RELATED QUESTIONNAIRE MEASURES
Experiences in Close Relationships (Attachment Style) – SHORT FORM (Fraley)
Community and Interpersonal Connectedness Scale (Dorahy, 2009)
Social Comparison Scale (“self-concept”, social rank)
CD-RISC-10 (Conner-Davidson Resilience Scale – 10-item) (?moderator)
Social Desirability Scale – Short Form (moderator - “reliability check”)
Self-Compassion Scale (Neff, 2003)
General Self-Efficacy Scale (GSE)
OUTCOME CRITERION VARIABLES
QoLI (Frisch, 1994)
SF36v2 (Participant's subjective feeling of mental and physical health
SYMPTOM MEASURES
DASS-21 (+2 suicide probe questions)
DERS (Difficulties in Emotion Regulation Scale – Gratz)
Shame – Still to be decided, possibly
 Rizvi's exptl measure of shame – 50 items
 TOSCA-3 – Shame-proneness, Guilt-proneness
 ShARQ – Shame-Aversion Reactions Questionnaire
MEASURES OF ACT CORE PROCESSES
Acceptance / Flexibility – AAQ-2; AAQ – Relationships
Cognitive Fusion Questionnaire (Gillanders)
Mindfulness Questionnaire – Still to be decided
** Measures of Stigma / Self-stigma – Still to be decided – Study 2 – Stigma Study
Study 2 – Participants in the study; and samples of care providers: GPs, Psychiatrists,
Psychologists, Social Workers, and Nurses will be asked to complete questionnaire measures
of stigma and self-stigma (for providers, note the findings of (Phillips, 2010)
Participants will then be asked to complete a computerised assessment of implicit stigma
similar to that conducted by Ruggeri and Rusch (Ruggeri, Bisoffi, Fontecedro, & Warner,
2001; Rüsch, Corrigan, Todd, & Bodenhausen, 2010; Rüsch, Hölzer, et al., 2006; Rüsch,
Lieb, et al., 2006) The measures obtained using explicit and implicit measures will then be
compared and analysed. Technical details and equipment requirements for this study still
have to be determined but I am aware some people at Otago Psychology are doing internetbased studies of implicit social cognitions.
IMPLICATIONS FOR FURTHER STUDIES
A key uncertainty I have at the present time is how many people living in the
community are engaged in formal or informal relationships with intimate
partners (hopefully this will be answered by the first study outlined above).
However, further studies that might be conducted include:
For individuals:
 History of previous involvement in intimate relationships and difficulties
experienced
 Influence of stigma and attachment style on adherence to and satisfaction
with medical care
 Difficulties in social relationships: A problem with shame and guilt,
proneness to experiencing negative affect, or aversion to experiencing
negative affect?
 Comparability of Comnplex PTSD and Borderline Personality Disorder:
A comparison of patient and provider perspectives
For Couples (using couple-level analyses):
 Propensity for Intimate Partner Violence as assessed using Dutton's PAS
Scale and partners feelings about interpersonal power in couples with
histories of insecure attachment
 Difficulties with emotion regulation and individual vs. couple-level
coping in couples with histories of insecure attachment
 Impact on abuse-related shame on communication between partners with
histories of childhood abuse and insecure attachment
 Survey of interpersonal problems experienced in the relationship of
couples with histories of childhood abuse and insecure attachment
Throughout there would be an opportunity to examine the contribution of
various factors, for individuals and couples, to Quality of Life, and satisfaction
with mental and physical health status.
Not Sick, Not Well, But Really Struggling
Understanding, Managing, and Maybe,
Recovering From Adult Effects of
Disturbed Childhood Attachments
A Psycho-Sociological Examination
A Proposal for Research
by Russell J. Wilson, July 2011
People who need people
Are the luckiest people in the world,
We're children, needing other children
And yet letting our grown-up pride
Hide all the need inside,
Acting more like children
Than children
"The marginal man...is one whom fate has condemned to live in two societies and
in two, not merely different but antagonistic cultures....his mind is the crucible in
which two different and refractory cultures may be said to melt and, either wholly
or in part, fuse." (Robert E. Park, Cultural Conflict and the Marginal Man in
Everett V Stonequist, The Marginal Man, Introduction, New York: Charles
Scribner's Sons, 1937)
“No one knows how many people with severe mental illness live what appear to
be normal, successful lives, because such people are not in the habit of
announcing themselves. They are too busy juggling responsibilities, paying the
bills, studying, raising families – all while weathering gusts of dark emotions or
delusions that would quickly overwhelm almost anyone else.”
Expert on Mental Illness Reveals Her Own Fight New York Times: June 23rd 2011
Preamble
Pat Crittenden, prominent researcher in the area of childhood attachment, and developer of
the Developmental-Maturational Model of Attachment Development (Creamer, McFarlane,
& Burgess, 2005; Crittenden, 1995, 2005) has developed lists (see Appendix 1) of some of
the broad range of adverse events which, if they occur at a critical period in the development
of a child, can impede or prevent the child's developing a secure attachment style. In the
absence of such a secure attachment style, the child will develop various physical and
psychological disorders. This paper provides a brief initial theoretical rationale for why
research should be conducted looking at the effects of disturbed attachment, and attempts to
suggest appropriate elements for a recovery program for adults still suffering the effects of
disturbed early attachment. The paper briefly discusses the contribution which Acceptance
and Commitment Therapy (ACT, (Hayes, Luoma, Bond, Masuda, & Lillis, 2006; Hayes et
al., 2004; Schmalz & Murrell, 2010) ) can make to this proposed therapy, both theoretically
and practically, especially through its emphasis on the processes of Experiential Avoidance
and Defusion (a brief outline of the nature of Cognitive Fusion is in Appendix 2).
Throughout, Psychological and Sociological topics are integrated with a healthcare planning
perspective similar to that of Jacobsen et al The “sociology of the family” is largely
restricted to a consideration of how the performance of the functional roles within a family
may be negatively affected by early disturbed attachment, and an ongoing pattern of insecure
attachments.
The paper begins by considering the phenomenology of having been raised “ in two worlds”
as a result of early insecure attachment; goes on to briefly outline basic Attachment Theory;
then reviews the frequency and effects of childhood abuse – most often intra-familial and
interpersonal trauma, and the commonest contributor to disturbed attachment; before
considering lifelong physical and mental health problems that can result from early disturbed,
and ongoing insecure, attachment. The paper then discusses the diagnosis of Complex
PTSD, potentially the most appropriate diagnosis for those adults with unresolved effects of
disturbed attachment, and the similarities and differences between Complex PTSD and other
disorders. The inappropriateness of the diagnosis of Personality Disorder is highlighted, and
the consequences of this diagnosis being given for ongoing support, treatment and recovery is
discussed. The remaining section of the theoretical and academic discussion then turns to the
implications of insecure attachment for adult relationships, and other “functional” areas of the
person's life. This section closes by briefly “positioning” the research in the field of Medical
Sociology, combining perspectives from both Sociology and Psychology, much as Scambler
has done in his 2007 paper, and using Adult Complex PTSD as an example, addressing how
Sociology can contribute to the planning of health care needs for a significant segment of the
population., those approximately 35% of the population affected by disturbed attachments
early childhood. The proposal closes by outlining the methodology for the first proposed
study, the social survey, before listing some further studies that could be done, depending on
the results of the initial survey.
Stigma – Its Nature, Forms and Importance
Stigma has long been an important topic in the field of Sociology (Link & Phelan, 2001).
Social science research on stigma has grown particularly dramatically over the past two
decades, particularly in social psychology, where researchers have elucidated the ways in
which people construct cognitive categories and link those categories to stereotyped beliefs.
In the midst of this growth, the stigma concept has been criticised as being too vaguely
defined and individually focused. In response to these criticisms, Link and Phelan define
stigma as the co-occurrence of its components–labelling, stereotyping, separation, status loss,
and discrimination–and further indicate that for stigmatisation to occur, power must be
exercised. Their concept of stigma has implications for understanding several core issues in
stigma research, ranging from the definition of the concept to the reasons stigma sometimes
represents a very persistent predicament in the lives of persons affected by it. Because there
are so many stigmatised circumstances and because stigmatising processes can affect
multiple domains of people's lives, stigmatisation probably has a dramatic bearing on the
distribution of life chances in such areas as earnings, housing, criminal involvement, health,
and life itself. It follows that social scientists who are interested in understanding the
distribution of such life chances should also be interested in stigma. Despite there so far
being no research on stigma as it affects those with a history of early disturbed attachment
relations, there are sound reasons to assume it does so as difficulties arising from disturbed
attachment relations have much in common with other problems often the target of
stigmatising attitudes of many people. These difficulties include: disorders of health
(Scambler, 2009), mental illness (Abdullah & T. L. Brown, 2011) disorders of childhood
(Mukolo, Heflinger, & Wallston, 2010), substance abuse (Luoma et al., 2007), suicide and
reports of suicidal ideation (Sudak, Maxim, & Carpenter, 2008), and their burden on families
(Riebschleger et al., 2008). These problems associated with stigma are also known to be
experienced cross-culturally (Pitman & Osborn, 2011).
There are various “forms” of stigma, with different types of effects, and different ways of
“coping with”, or attempting to overcome, each (Brohan, Slade, Clement, & Thornicroft,
2010). The classic starting point for defining the stigma of mental illness is Goffman’s ‘an
attribute that is deeply discrediting’. The recognition of this attribute leads the stigmatised
person to be ’reduced... from a whole and usual person to a tainted or discounted one’ (1963,
p. 3). This presents stigma as the relationship between attribute and stereotype. In Goffman’s
terms, attributes can be categorised in three main groups: 1) abominations of the body e.g.
physical disability or visible deformity, 2) blemishes of individual character e.g. mental
illness, criminal conviction or 3) tribal stigmas e.g. race, gender, age. Elliott and colleagues
(G. C. Elliott, Ziegler,, Altman, & Scott, 1982) emphasised the social interaction in stigma . In
their definition, stigma is a form of deviance that leads others to judge an individual as
illegitimate for participation in a social interaction. This occurs because of a perception that
they lack the skills or abilities to carry out such an interaction, and is also influenced by
judgments about the dangerousness and unpredictability of the person. Once the person is
considered illegitimate then they are beyond the rules of normal social behaviour (for they
have already been “judged” and found “guilty”, as have those who have “colluded” with
them – “courtesy stigma” – including families, and treating, or researching, professionals
(Phillips, 2010), and may be ignored or excluded by the group.
Like Elliott, Ziegler, Altman and Scott (1982), Scrambler emphasises the social interaction
inherent in stigma and further explores the sociology as it is applied to physical health
concerns. In their paper, they attempt to provide a more convincing contemporary sociology
of health-related stigma. It starts with an appreciation and critique of Goffman's benchmark
sensitisation and traces his influence on the personal tragedy or deviance paradigm dominant
in the medical sociology from the 1970s. To allow for the development of their argument,
they use the examples of epilepsy and HIV rather than the research literature as a whole.
Brief and critical consideration is given to attempts to operationalise or otherwise ‘measure’
health-related stigma. The advocacy of a rival oppression paradigm by disability theorists
from the 1980s, notably through re-workings of the social model of disability, is addressed. It
is suggested that we are now in a position to learn and move on from this paradigm ‘clash’. A
re-framing of notions of relations of stigma, signalling shame, and relations of deviance,
signalling blame, is proposed. This framework, and the positing of a variable and changing
dynamic between cultural norms of shame and blame – always embedded in social structures
of class, command, gender, ethnicity and so on – is utilised to explore recent approaches to
health stigma reduction programmes.
Stigma is typically a social process, experienced or anticipated, characterised by exclusion,
rejection, blame or devaluation that results from experience, perception or reasonable
anticipation of an adverse social judgement about a person or group. This judgement is based
on an enduring feature of identity conferred by a health problem or health-related condition,
and the judgement is in some essential way medically unwarranted. In addition to its
application to persons or a group, the discriminatory social judgement may also be applied to
the disease or designated health problem itself with repercussions in social and health policy.
Other forms of stigma, which result from adverse social judgements about enduring features
of identity apart from health-related conditions (e.g. race, ethnicity, sexual preferences), may
also affect health; these are also matters of interest that concern questions of health-related
stigma (Weiss, Ramakrishna, & Somma, 2006, p. 280). Whilst (Brohan et al., 2010) review a
number of different measures of mental illness-related stigma, inspection of NIHMS
(PubMed) databases failed to yield a similar review of abuse-related measures. There are
substance use-related measures of stigma (Luoma et al., 2007; Luoma, Kohlenberg, Hayes,
Bunting, & Rye, 2008)substance-use disorders, though common in this group, are not
universal; however, insufficient research has been done to estimate their incidence in this
group.
Previously referred to in this paper as “types” of stigma are: perceived, experienced, and selfstigma, most often, the first reflecting expectations of status loss or discrimination; the
second reflecting actual experiences of stigmatisation; and the last reflecting emotional
reactions to such experiences. However, many inter-connections exist between the concepts,
reflecting the cognitive, affective and behavioural aspects of stigma necessary for fully
understanding the individual's position in relation to stigma. It is important to recognise that
stigma often operates at an “unconscious, gut level” (Rüsch et al., 2010). In the form of
prejudice and discrimination, stigma also has significant influence on what treatments
patients receive through the mediating effects of professional education and socialisation.
Stigma, Clinical Diagnosis, and Human Suffering
Implications for a Sociology of Diagnosis
A doctor's provision of a diagnosis is a powerful act. It has the potential for ruling a patient
in or out for certain forms of both assessment, and support and treatment. Often it will,
unconsciously, direct the way treating clinical staff perceive a patient, irrespective of the
patient's actual behavioural presentation – clinical staff may stop looking for signs and
symptoms for differential diagnoses of other disorders, looking only for signs and symptoms
that are consistent with the diagnosis. This is the error of “confirmatory basis”. An early
study which examined this effect, though not originally designed to do so, is that of Rosenhan
(Rosenhan, 1973). As Rosenhan himself noted at the time:
“It is clear that we cannot distinguish the sane from the insane in psychiatric
hospitals. The hospital itself imposes a special environment in which the
meanings of behaviour can easily be misunderstood. The consequences to
patients hospitalised in such an environment-the powerlessness,
depersonalisation, segregation, mortification, and self-labeling-seem undoubtedly
counter-therapeutic. I do not, even now, understand this problem well enough to
perceive solutions. But two matters seem to have some promise. The first
concerns the proliferation of community mental health facilities, of crisis
intervention centers, of the human potential movement, and of behaviour
therapies that, for all of their own problems, tend to avoid psychiatric labels, to
focus on specific problems and behaviours, and to retain the individual in a
relatively non-pejorative environment. Clearly, to the extent that we refrain from
sending the distressed to insane places, our impressions of them are less likely to
be distorted. (The risk of distorted perceptions, it seems to me, is always present,
since we are much more sensitive to an individual's behaviours and verbalizations
than we are to the subtle contextual stimuli that often promote them. At issue here
is a matter of magnitude. And, as I have shown, the magnitude of distortion is
exceedingly high in the extreme context that is a psychiatric hospital.) The second
matter that might prove promising speaks to the need to increase the sensitivity of
mental health workers and researchers to the Catch 22 position of psychiatric
patients. Simply reading materials in this area will be of help to some such
workers and researchers. For others, directly experiencing the impact of
psychiatric hospitalisation will be of enormous use. Clearly, further research into
the social psychology of such total institutions will both facilitate treatment and
deepen understanding. I and the other pseudopatients in the psychiatric setting
had distinctly negative reactions. We do not pretend to describe the subjective
experiences of true patients. Theirs may be different from ours, particularly with
the passage of time and the necessary process of adaptation to one's environment.
But we can and do speak to the relatively more objective indices of treatment
within the hospital. It could be a mistake, and a very unfortunate one, to consider
that what happened to us derived from malice or stupidity on the part of the staff.
Quite the contrary, our overwhelming impression of them was of people who
really cared, who were committed and who were uncommonly intelligent. Where
they failed, as they sometimes did painfully, it would be more accurate to
attribute those failures to the environment in which they, too, found themselves
than to personal callousness. Their perceptions and behavior were controlled by
the situation, rather than being motivated by a malicious disposition. In a more
benign environment, one that was less attached to global diagnosis, their
behaviors and judgments might have been more benign and effective.” (p. 250)
From personal experience I can attest to how it is, in some bizarre way, oddly “empowering”
to be in a psychiatric hospital, approaching the nurses' station to check my blood sugar level
(I'm a diabetic) to hear the nurse say to a patient already there “You just wait there until I'm
finished, this man here has a real (sic) illness and needs my help” – clearly physical disorders
rank higher in the prestige pecking order than do psychiatric disorders, even in a psychiatric
hospital.
Within psychiatric contexts the diagnosis “Personality Disorder” (especially Borderline
Personality Disorder) would seemingly rank the lowest in terms of perceived legitimacy of
the patient's concerns. This has significant effects on how such patients will be assessed and
how they will be treated. Bessel van der Kolk (2005), psychiatrist and psychiatric
traumatologist, and also spokesman for the U. S. National Child Traumatic Stress Disorder
Network, has used this as one argument for the introduction of the diagnosis “Developmental
Trauma Disorder” into the new system of diagnosis being introduced by the American
Psychiatric Association, the Diagnostic and Statistical Manual – Version 5 (DSM 5), due to
be published in 2013. Clearly, if an appropriate diagnosis is not available, this increases the
chances of confirmatory bias occurring, and the chances that a patient will be under-treated or
inappropriately treated – this has long been the case with Borderline Personality Disorder,
and what some have called “Complex Post-traumatic Stress Disorder” and others have called
“Disorder of Extreme Stress – Not Otherwise Specified”. A draft of the proposed diagnostic
guidelines to be included in DSM 5 was submitted to the British Psychological Society (BPS)
and elicited the following response (downloaded from the BPS internet website June 25th,
2011, regarding diagnoses in general, disorders resulting from trauma, and Personality
Disorders in particular (pp. 2 – excerpts selected based on relevance to this paper:
and p. 24 of the response document, respectively):
“The Society is concerned that clients and the general public are negatively
affected by the continued and continuous medicalisation of their natural and
normal responses to their experiences; responses which undoubtedly have
distressing consequences which demand helping responses, but which do not
reflect illnesses so much as normal individual variation.”
p. 16,
“We therefore do welcome the proposal to include a profile of rating the severity
of different symptoms over the preceding month. This is attractive, not only
because it focuses on specific problems (see below), but because it introduces the
concept of variability more fully into the system. That said, we have more
concerns than plaudits.”
“The putative diagnoses presented in DSM-V are clearly based largely on social
norms, with 'symptoms' that all rely on subjective judgements, with little
confirmatory physical 'signs' or evidence of biological causation. The criteria are
not value-free, but rather reflect current normative social expectations. Many
researchers have pointed out that psychiatric diagnoses are plagued by problems
of reliability, validity, prognostic value, and co-morbidity.”
“Diagnostic categories do not predict response to medication or other
interventions whereas more specific formulations or symptom clusters might
(Moncrieff, 2007). “
“Finally, disorders categorised as ‘not otherwise specified’ are huge (running at
30% of all personality disorder diagnoses for example). Personality disorder and
psychoses are particularly troublesome as they are not adequately normed on the
general population, where community surveys regularly report much higher
prevalence and incidence than would be expected. This problem – as well as
threatening the validity of the approach – has significant implications. If
community samples show high levels of ‘prevalence’, social factors are
minimised, and the continuum with normality is ignored. Then many of the
people who describe normal forms of distress like feeling bereaved after three
months, or traumatised by military conflict for more than a month, will meet
diagnostic criteria.”
“Diagnostic systems such as these therefore fall short of the criteria for legitimate
medical diagnoses. They certainly identify troubling or troubled people, but do
not meet the criteria for categorisation demanded for a field of science or
medicine (with a very few exceptions such as dementia.) We are also concerned
that systems such as this are based on identifying problems as located within
individuals. This misses the relational context of problems and the undeniable
social causation of many such problems. For psychologists, our wellbeing and
mental health stem from our frameworks of understanding of the world,
frameworks which are themselves the product of the experiences and learning
through our lives.”
Regarding the effects of traumatic and stressful experiences on people, they comment:
Here, the emphasis is on (normal) individual variation in response in particular contexts, on
the relational context of problems, rather than the effects of traumatic events as “disorders” or
“illnesses”, and argues for an alternative conceptualisation of these effects, a dimensionalcategorical model, and on how the Public might miss out on the potential benefits of help
offered through considering the effects as medical disorders. Consistent with a hybriddimensional, there is a clear preference for behaviourally specific symptoms and signs (as
well as an overall behavioural model):
“Diagnostic categories do not predict response to medication or other
interventions whereas more specific formulations or symptom clusters might
(Moncrieff, 2007). “
This approach is adopted in the proposed research. The BPS adopts a similar approach to
Personality Disorders as it does to Trauma Disorders (p. 24 of the response document);
What strikes me is that the American Psychiatric Association seems to be adopting a position
without learning from history. Firstly, some diagnoses seem to be proposed for adoption as a
result of voting, rather than on scientific grounds (or would think they'd remember the result
the last time this was done – successfully, from a social standpoint: the voting out – but it is
not a scientifically valid approach. Secondly, with regards to the treatment of those suffering
from “Personality Disorders” – a term which the BPS seems to be removed from the
Diagnostic Manual in favour of behaviourally specific lists of patient and social concerns.
Moreover, there are several research studies showing the invidious results of the profession's
use of the label “Personality Disorder”. Lincoln (2006) notes that the influence of social
factors on involuntary hospitalisation has been an important and controversial area of
sociological focus for many years. Traditionally, social control theory has been used to
understand disproportionate rates of involuntary hospitalisation among marginalised and
powerless groups. However, dramatic changes in the social context of mental healthcare have
necessitated a re-examination of the role of social factors control hypothesis was found.
People from marginalised groups were not disproportionately involuntarily hospitalised, but
instead were disproportionately treated and released from the hospital as people's social
resources were used to access care rather than to prevent hospitalisation. That is, many
patients were discharged from hospital after only cursory assessment and without
involvement in any psychotherapy. This study highlights the importance of the historical
relevance of our theoretical understanding of the relationship between social factors and
involuntary commitment. (Nehls, 1998)) examined the effects of psychiatric labelling
(“diagnosis”) on another heavily stigmatised group – women. Whilst Nehls study was done in
North America, it is consistent with my clinical experience in Australia and New Zealand.
Nehls notes: “In North America, there may be no other psychiatric diagnosis more laden with
stereotypes and stigma than borderline personality disorder. People who live with this label-the majority being female--are often marginalised or denied access to mental health services.”
(p. 97). In this article, the author reviews the theoretical underpinnings of the diagnosis, as
well as the stigmatising practices and limited services for seriously ill persons with borderline
personality disorder diagnoses. After conducting a similar review of services to patients
suffering from Bipolar Disorder, Michalak and colleagues (Michalak et al., 2011) remind us
of something always to be kept in mind in clinical practice: “It's (my problem) something that
I manage but it is not who I am” (their article title). So, who are these people? – this is
discussed in the next section, to the extent that available research permits, arguing the need
for more research.
Effective Healthcare Planning – Blending Sociology and Psychology
Positioning the Proposed Research
(Scambler, 2007)(2007) examines the premise that the concept of social structure so familiar
during the heyday of classical sociology has been neglected in the contemporary sociological
study of health inequalities. After a brief preliminary discourse on the structuring of agency,
he argues for a more sociologically progressive research programme, building on his critical
realist and critical theoretical approach to the changing dynamic of class relations of the
economy and command relations of the state and to the changeable distribution of asset
flows. The concepts of ‘alienation’, ‘surveillance’ and ‘aspirational consumerism’ are used.
Clearly a “whole of government” approach is needed.
The costs of failing to take social factors into account when considering health planning
initiatives: economically, socially, and personally. Smith considers the case of childhood
psychological conditions including depression and substance abuse. He uses unique data
from the US Panel Study of Income Dynamics (PSID) following groups of siblings and their
parents for up to 40 years prospectively collecting information on education, income, work,
and marriage. Following siblings offers an opportunity to control for unobserved family and
neighbourhood effects. Large effects were found on the ability of affected children to work
and earn as adults. Educational accomplishments were diminished, and adult family incomes
are reduced by 20%. Lost income was partly a consequence of seven fewer weeks worked per
year. There is also an 11 percentage point lower probability of being married. Controlling for
physical childhood diseases shows that these effects are not due to the co-existence of
psychological and physical diseases, and estimates controlling for within-sibling differences
demonstrate that these effects are not due to unobserved common family differences.
The long-term economic damages of childhood psychological problems are large—a lifetime
cost in lost family income of approximately $300,000, and total lifetime economic cost for all
those affected of 2.1 trillion dollars.
Jutel
considers the effects of diagnosis on both a broader social and on a personal level. She
notes that diagnoses are the classification tools of medicine, and are pivotal in the ways
medicine exerts its role in society. Their sociological study is commonly subsumed under the
rubrics of medicalisation, history of medicine and theory of disease. Diagnosis is, however, a
powerful social tool, with unique features and impacts which deserve their own specific
analysis. The process of diagnosis provides the framework within which medicine operates,
punctuates the values which medicine espouses, and underlines the authoritative role of both
medicine and the doctor. Diagnosis takes place at a salient juncture between illness and
disease, patient and doctor, complaint and explanation. Despite calls for its establishment,
almost two decades ago (Brown 1990), there is not yet a clear sociology of diagnosis. Jutel
argues that there should be, and, as a first step, draws together a number of threads of medical
sociology that potentially contribute to this proposed sociology of diagnosis, including the
place of diagnosis in the institution of medicine, the social framing of disease definitions, the
means by which diagnosis confers authority to medicine, and how that authority is
challenged.
Brown et al 's paper (P. Brown, Lyson, & Jenkins, 2011) extends thee study of the sociology
of diagnosis and provides a reformulation proposing the concept of 'social diagnosis' which
recognises the interplay between larger social structures and individual or community illness
manifestations. This approach is useful not just for sociological research, but has direct
implications for the fields of medicine and public health. Approaching diagnosis from this
integrated perspective potentially provides a broader context for practitioners and researchers
to understand extra-medical factors, which in turn has consequences for patient care and
health outcomes.
With the above discussions in mind, my proposed research is fairly placed within medical
sociology, drawing concepts and data from Psychology, using Complex PTSD in adults as an
example of what some primary factors need to be taken into account when planning
healthcare for a significant segment of the population – 35% of the population have a history
of events in their early childhood which disturbed critical attachment. The nature and
implications of attachment and attachment theory comprises the next section of this paper.
The Nature of Attachment and the
Implications of Attachment Theory for Adult Functioning
The majority of clients I have interviewed over the last thirty years of my clinical practice can
relate to me times when they “just haven't fitted in”. They haven't been able to say “why”
other than “just a feeling”. Indeed, most of them will add that they often had this experience
as children, sometimes from a very young age. In fact children seem acutely aware of their
social surroundings, and who they can trust and whom they need to pay attention to if they
are to succeed in this world, or at least reduce their chances of being harmed. So crucial are
these abilities that children without these social monitoring and self-protective abilities are
very often found to be suffering from a disorder called “Williams' Syndrome” (information
obtained from the Williams Syndrome Association www.williams-syndrome.org ,
downloaded July 3rd, 2011). While Williams Syndrome is “well known” to the medical world
(occurring in 1 in 8,000 births), Science has only recently discovered (Poulin-Dubois,
Brooker, & Polonia, 2011) that children of just 14 months already have a nonsense-detector
that alerts them to unreliable people, from whom they'll no longer bother taking lessons.
"Infants seem to perceive reliable adults as capable of rational action, whose novel,
unfamiliar behaviour is worth imitating," the researchers said. "In contrast, the same
behaviour performed by a previously unreliable adult is interpreted as irrational or inefficient,
thus not worthy of imitating." The new finding adds to a growing body of research showing
children's selectivity in whom they choose to learn from. For example, children prefer to
learn from adults as opposed to their peers, and they prefer to learn from people they are
familiar with and who appear more certain, confident and knowledgeable. Perhaps people
who have felt as if they “didn't fit in” have had the confusing experience of, whilst
recognising their surrounding kin by scent (Porter, 1998)One thing that could explain this
feeling of “not fitting in” could be behaviour around the infant, or directed toward the infant,
that is inconsistent with the infant's, and the caregivers', “natural roles”, most often due to
ambivalence over the child's long-term presence, or due to the caregiver's difficulty accepting
or acting in accordance with this role. It is the overall goal of the proposed research to
examine the factors that contribute to caregivers' difficulty successfully performing family
roles. It will be argued that the factors contributing to this difficulty in role performance are
both psychological and sociological in nature and that both need to be appreciated if one is
interested in effectively resolving the difficulties faced by many of those raised without the
benefits of a physically and emotionally secure family environment, whatever form that may
take. Firstly, the nature and incidence of childhood abuse, the commonest form of disturbance
of early childhood attachments, will be examined. Then factors (in particular stigma of some
form (Brohan et al., 2010), and fusion with a negative model of self (personal
communication, Helen Bolderston, March 7th, 2011, discussion of fusion with adults with
histories of disturbed childhood attachment; see (Greco, Lambert, & Baer, 2008), for a
general discussion of cognitive fusion in children, and (Schmalz & Murrell, 2010) for a
discussion of cognitive fusion in adults) impeding the successful establishment, and
maintenance, of secure dyadic relationships, and the coping resources and skills of that dyad
will be examined to see if these resources and skills might be amenable to improvement.
In a clinical sense, the term “attachment disorder” implies a need for treatment to overcome
an inability to establish relationships. Such a failure would result from unusual early
experiences of neglect, abuse, abrupt separation from caregivers after about six months but
before about three years, frequent change of caregivers or excessive numbers of caregivers,
or lack of caregiver responsiveness to child communicative efforts. A problematic history of
social relationships occurring after about age three may be distressing to a child, but does not
result in attachment disorders (Chaffin et al., 2006). ICD-10 (United Nations International
Classification of Diseases – Version 10) and DSM-IV-TR (American Psychiatric Association
Diagnostic and Statistical Manual – Version IV - Text Revision) differ over whether or not
trauma is a direct contributor to the development of an attachment disorder, although it is
believed that such trauma can occur without the development of attachment disorders, with
attachment disorders regarded as being solely due to early adverse caregiving experiences.
Agreement has not yet been reached with respect to diagnostic criteria for distinct
attachment disorders (but see (Boris et al., 2004) & (Scheeringa, Zeanah, & Cohen, 2011) for
comments on a possible typology of attachment disorders: including "no discriminated
attachment figure", "secure base distortions", and "disrupted attachment disorder" – the latter
equating to unresolved bereavement in adults.). The term attachment disorder is most often
used to describe emotional and behavioural problems of young children, but is sometimes
applied to school-age children or even to adults. However, what can be said is that
“attachment” is not a quality of the individual characteristics of one individual or the another,
rather it is the product of a reciprocal relationship between two individuals. Nor is it a matter
of one individual trusting, or loving, the other – a child's attachment-related behaviours are
likely to be very different with one familiar adult than with another. Although an attachment
is a "tie" it is not synonymous with love and affection although they often go together and a
healthy attachment is considered to be an important foundation of all subsequent
relationships.
Finally, and especially regarding these patterns of caregiver responsiveness, the term
attachment disorder is also sometimes used to cover difficulties arising in relation to various
attachment styles which may not be disorders in the clinical sense. Such attachment styles
are adaptations to the patterns of caregivers' responsiveness. Some authors have suggested
that attachment, as an aspect of emotional development, is better assessed along a spectrum
than considered to fall into non-overlapping categories. This spectrum would have at one end
the characteristics called secure attachment; midway along the range of disturbance would be
insecure or other undesirable attachment styles; at the other extreme would be nonattachment. The words attachment style or pattern refer to the various types of attachment
arising from early care experiences, called secure, anxious-ambivalent, anxious-avoidant,
(all organised), and disorganised. Roughly to out of three people have a secure style of
attachment, with one in three having some form of insecure attachment style. It is important
to remember that the concepts discussed so far have been those developed within a Western
nuclear family-centric model as existed during the days of Bowlby's writings (1969) . Other
researchers have found that whilst the specific forms which attachment takes may vary, the
three basic types of relations (secure, avoid ant, and ambivalent) are consistently evident
cross-culturally. Behaviourists see attachment more as a systems phenomena then a
biological predisposition. Patterson's group has shown that in uncertain environments the
lack of contingent relationships can account for problems in attachment and the sensitivity to
contingencies (Patterson, 2002) In the last decade, behaviour analysts have constructed
models of attachment based on the importance of contingent relationships (Kassow & Dunst,
2008). These behaviour analytic models have received some support from research, and
meta-analytic reviews (Dunst & Kassow, 2008). Mansfield and Cordova (2007) further
extend the behaviour analytic model of attachment to the understanding of relationship
partners in distress. They then apply a behavioural perspective to understand how patterns of
vulnerability and intimacy in couples emerge and how some such patterns become problematic for
couples. They close their article by providing an account of how Integrative Behavioural Couples
Therapy (IBCT, (Christensen, Atkins, Baucom, & Yi, 2010)(Christensen & Jacobson, 2009) can be
used to help couples move beyond the difficulties they experience.
The Problem of Childhood Abuse, Trauma and Neglect
Child abuse and neglect have long been a common problem in our communities (Klausner,
1968), and trauma researcher Bessel van der Kolk (van der Kolk, 2005), a spokesman for
the U. S. National Child Traumatic Stress Network, has identified intra-familial child abuse
as the Number One Public Health Problem in the United States. Van der Kolk has proposed
(2005) a diagnosis of Developmental Trauma Disorder be introduced as a response. A
problem of similar magnitude likely exists in New Zealand given the significant social and
economic imbalances in our society, although exact figures are hard to get. What is clear is
that such abuse (including neglect as a form of abuse) is causative not only of a number of
problems for the victims as children, but also, as victims grow to adult years, of a range of
much longer-term, serious mental and physical problems (Hillberg, Hamilton-Giachritsis, &
Dixon, 2011). In a population health study conducted by insurer Kaiser Permanente in the
United States (Felitti et al., 1998) it was found that 11 % of the adults surveyed reported
being emotionally abused as a child, 20 % reported sexual abuse, 30 % reported physical
abuse, 23 % reported exposure to alcohol abuse, 20 % reported exposure to mental illness, 13
% reported seeing their mothers being battered, and 5 % reported family drug abuse. The
various forms of child abuse certainly do not occur in isolation, and many children suffer
multiple forms of abuse. (Pears, H. Kim, & P. Fisher, 2008) found that 90 per cent of abused
children suffer multiple forms of abuse; with experiencing one form of abuse sometimes
seeming to sensitise the individual to responding even more adversely to future abuse (Briere
& D. M. Elliott, 1994). Indeed, studies since that of Kaiser Permanente indicate that it is
primarily the number of episodes of abuse, rather than the type of abuse episode, which
increases the complexity (Briere, Kaltman, & Green, 2008)
, and therefore perhaps the “treat-ability”, of the effects of the abuse (though controlled
studies of multi-targeted treatments have not yet been done) . It will be seen later, in the body
of the full thesis, that, though there is a generalised form of trauma effect, different types of
abuse have different qualitative effects, again reflecting the complexity of the victim's
response to trauma.
On a behavioural level, the health consequences of childhood abuse and neglect include
depression, anxiety, suicidality, alcoholism, drug abuse, sexual promiscuity, domestic
violence, cigarette smoking, obesity, physical inactivity, and sexually transmitted diseases
(cf., Felitti, Anda, & Black, 1998 – though it is only planned to look at a subset of these in
the planned research: self-reported depression, anxiety, suicidality, substance use, domestic
violence). After a child is traumatised multiple times, the impact of the trauma becomes
locked into many aspects of the child's make-up (Herman, 1992). In addition, Felitti et al
also found that the more adverse experiences a child had to endure, the more likely that child
would suffer from heart disease, cancer, stroke, diabetes, skeletal fractures, and liver disease,
as well as other forms of physical and psychosomatic illness, when grown to adulthood.
These health disorders can occur, and recur, many years into the individual's life (Allen et al.,
2001; Wegman & Stetler, 2009). Males, especially those whose mothers have suffered when
subjected to domestic violence, and who as a result are thus unable to express positive
feelings for their children will be more likely to commit crimes, displaying “externalising
behaviour” - acting out their negative feelings – and, finally perhaps, ending up committing
especially violent crimes, with some going on to abuse their own partners (Samuelson &
Cashman, 2008). In fact, nearly all prisoners in the US criminal justice population have
histories of trauma, abuse and neglect (Teplin, Abram, McClelland, Dulcan, & Mericle,
2002). Such outcomes are likely to involve not only childhood trauma and attachment style,
but negative self-esteem, negative self-efficacy, and a host of other variables (Pulakos, 1996;
S. L. Wright & Perrone, 2010)We are short of similar research in this country, but these
American findings are certainly consistent with my own twenty plus years experience
working in prison and custodial settings.
DIAGNOSTIC CONFUSION
The form of disorder due to childhood interpersonal trauma was originally called Complex
PTSD (CPTSD, Herman, 1992), and then, after prompting by the field teams working on
developing DSM IV (who discovered that only 8% of those found to satisfy the criteria for
CPTSD did not also have PTSD), came to be called Disorders of Extreme Stress Not
Otherwise Specified (DESNOS, (van der Kolk, Roth, Pelcovitz, Sunday, & Spinazzola,
2005) – in this proposal the term CPTSD will be used for historical reasons for consistency,
not to imply that CPTSD is a form of PTSD (discussed later in this paper). Both CPTSD and
DESNOS have never been “formal” diagnoses in the Diagnostic and Statistical Manual of
the American Psychiatric Association, but they have been included for clinicians to consider.
Historically, there have been some proposals to include Borderline Personality Disorder in
the family of “trauma disorders” (Herman, 1992). Lewis and Grenyer (2009) take issue with
these proposals. Unfortunately, their conclusions are limited by their extrapolating from
existing studies of “PTSD”, without arguing from a basis of studies of those with Complex
PTSD alone. After an apparently quite comprehensive review of the literature, they suggest
that BPD and CPTSD differ in terms of the “evidence-supported” treatments for the two
disorders. They argue that the recommended treatments for BPD are longer-term
psychotherapies, whether they be dialectical behavior therapy, psychodynamic, including
mentalization-based psychodynamic therapy, or schema therapy, whilst “for PTSD (sic –
but in fact also referring to CPTSD) the evidence-supported” treatment is short-term
cognitive therapy”. Implicit within this statement are some unspoken assumptions:
1.
In their review of studies, Lewis and Grenyer did not identify those studies dealing
specifically with CPTSD but rather included studies with samples containing both PTSD and
CPTSD, undifferentiated (a common weakness in studies), generalising their conclusions to
both types of patients equally – few studies clearly differentiate the groups, and specify how
they differ in terms of variables of interest – exceptions include the recent studies of Dorahy
et al. (2009) and Dyer et al (2009). Indeed, it is possible that a significant number of their
sample with Borderline Personality Disorder might instead have been suffering from
Complex PTSD (Schwecke, 2009) further confounding the conclusions they draw.
2.
Despite noting that there is considerable heterogeneity in both BPD and PTSD
populations, Lewis and Grenyer assume that, for that population suffering with CPTSD,
successful treatment will be the same as for PTSD, rather than requiring a range of different
treatments, depending on the symptoms being experienced.
The disorder's diagnostic future status remains uncertain: some recommend altering the
diagnostic criteria for PTSD , so C-PTSD appears as a variant of that disorder (Friedman,
Resick, Bryant, & Brewin, 2010), whilst others question whether it might be better placed in
another category of “reactive disorders”, along with PTSD and such disorders as
“dissociative identity disorder” (Shalev, 2009); or in a new category of “trauma disorders”,
along with acute stress disorder, and adjustment disorder, as well as PTSD.
Given that diagnostic committees of the American Psychiatric Association are traditionally
conservative, it might be best to review the proposals of Friedman et al in more detail, as
they seek to retain the criteria of DSM-IV whilst making revisions to them, some of which
will have major implications for PTSD incidence figures (particularly if Criterion A2 is
eliminated, see (Carlozzi & Long, 2008); (Karam et al., 2010)) and on interpretations of
mediating effects of variables related to PTSD (e.g., the implications of the results of
Carlozzi and Long's study for the gender differences found in Waldinger et al's (2006)
study). These researchers argue for:

Retaining Criterion A1 but broadening the scope of qualifying events, e. g., relatives
of those individuals directly experiencing a traumatic event who also suffer traumatic effects
“second hand” through the possible loss of their loved ones

Eliminating Criterion A2 altogether (see Carlozzi and Young, 2008, as it applies to
children)

introducing a four-cluster rather than the existing three-cluster model of PTSD
incorporating:

intrusive symptoms

persistent avoidance symptoms

symptoms of alterations in cognition and mood

hyper-arousal and reactivity symptoms
The existing 17 symptoms would be retained but three additional symptoms would be added
or revised:

erroneous self – or other – blame for the trauma

negative mood states

reckless and / or maladaptive behaviour (such as reckless sexual behaviour)

DSM-IV irritable behaviour would become DSM-V aggressive behaviour.
Overall in their proposal, the distinction between acute and chronic forms of the disorder has
been eliminated. They also argue that currently there has been insufficient research to
introduce a diagnosis of DESNOS. However, they do note that research has shown that
whilst some may suffer “simple PTSD”, others may suffer “complex PTSD” with
internalising symptoms, externalising symptoms, or both (see (Forbes, Elhai, Miller, &
Creamer, 2010); & (Rielage, Hoyt, & Renshaw, 2010). This proposal might serve van der
Kolk's aims in that the “environmental pathogen” (to use a concept from the diathesis-stress
model) to which susceptible individuals are vulnerable is clearly identified as “trauma”
(Resick & Miller, 2009). Speaking epidemiologically, this would see 3,000,000 children in
the United States diagnosed with Developmental Trauma Disorder annually (Scheeringa et
al., 2011), for an alternative diagnostic proposal). If van der Kolk's proposal is accepted, this
would result in some 3,000,000 children in the United States being diagnosed with DTD
annually.
One argument van der Kolk and his colleagues use for the new diagnosis is the large
number of case examples they have of where clinicians have diagnosed victims of child
abuse and trauma as suffering from“Personality Disorder”, and then failing to take into
account, in case formulation and treatment planning, the patient's history of prior traumatic
abuse (van der Kolk, 2005). How these disorders can best be classified looks certain to
remain in contention, with possible ongoing difficulties for assessment, formulation, and
treatment planning. In New Zealand, where ACC funds a lot of the treatment for sexual
abuse victims, the problem is even more contentious, since victims need to be seen suffering
from an “injury” that is the product of a criminal act.
Not surprisingly, in such a clinical context, treatments for both disorders, adult and child,
remain difficult to evaluate and improve (Kleim, 2007; Kornor, 2008). However, it does
seem essential that future research clearly take possible diagnostic differences into account.
Similarities Between Complex PTSD and Borderline Personality Disorder
Historically, some researchers, like Herman & van der Kolk (1987), have argued that the
lack of a clear etiology for Borderline Personality Disorder could be accounted for by there
being a causal relationship between Complex PTSD due to childhood sexual abuse and
Borderline Personality Disorder. In favour of this argument they cite there being common
disturbances in 5 key domains:

emotion regulation – evident in such disturbances as depression, intense anger,
irritability, and feelings of chronic emptiness

impulse control, as evidenced by substance abuse, chronic self-harm

impaired reality testing, as evidenced by paranoid ideation and dissociation

disturbed and recurrently volatile interpersonal relationships, and

impaired elf-integration (disturbances in personal identity)
However, whilst 81% - 91% of patients with a diagnosis of BPD have a history of childhood
sexual abuse, 9 – 19 % do not. Moreover, whilst both BPD and Complex PTSD similarly
have high incidences of co morbid PTSD (58% of patients with BPD), in a meta-analytic
review of 21 studies, Fossati and colleagues reported only a low to moderate effect size for
the association between childhood sexual abuse and Borderline Personality Disorder
(Fossati, Madeddu, & Maffei, 1999). Similarly while approximately 58% of those with BPD
have PTSD, PTSD is also co-morbid with a number of other disorders (Golier et al., 2003).
Ultimately, as Lewis and Grenyer (Lewis & Grenyer, 2009) note, whilst there may be
similarities between BPD and CPTSD, insufficient evidence exists to conclude that BPD is
either a form of PTSD or of CPTSD. However, and again, clearly steps must be taken to
distinguish between the disorders in research studies. Many studies have failed to do this –
notable exceptions being those of Dorahy (Dorahy, 2010; Dorahy et al., 2009; Dyer et al.,
2009). The question of whether they are members of the same family, however, remains for
future research to determine.
We currently know much more about BPD than we do about CPTSD. Amongst what is
known is that those with BPD display subtle impairments in basic emotion recognition, a
negativity or anger bias – a tendency to perceive neutral facial stimuli as expressing negative
emotions, and a heightened sensitivity to the detection of negative emotions. Furthermore,
there is increasing evidence for structural and functional changes in the neural networks
underlying affective dysregulation and emotional hyper-reactivity in BPD. (Domes, Schulze,
& Herpertz, 2009) propose that the neurobiological changes underlying emotional hyperreactivity are also responsible for subtle impairments in facial emotion recognition and other
related impairments in social cognitive processing. Taking this analysis further, Dyck et al
(2009) found that patients with BPD, in comparison to healthy subjects, showed a deficit in
emotion recognition only in the fast discrimination of negative and neutral facial expressions
(FAN Test), perhaps as would be the case when they were under stress, or experiencing
anxiety and likely to react impulsively. Consistent with earlier findings, patients
demonstrated a negative bias in the evaluation of neutral facial expressions. When processing
time was unlimited, BPD patients performed as well as healthy subjects in the recognition of
specific emotions. In addition, an association between performance in the fast discrimination
task (FAN Test) and post-traumatic stress disorder (PTSD) co-morbidity was indicated. Dyck
et also argue that their results indicate that a selective deficit in rapid and direct
discrimination of negative and neutral emotional expressions may underlie difficulties in
social interactions exhibited by patients with Borderline Personality. If a similar deficit is
exhibited by those with C-PTSD, then their reactions could be further aggravated by their
slowness to recover when under challenge due to the effects of shame (Gratz, Rosenthal, Tull,
Lejuez, & Gunderson, 2010). Studies investigating responses to facial expressions of
emotions have recently been accompanied in the literature by studies incorporating studies of
psychophysiological reactivity to imagined scenes varying in emotional content. In a recent
student, Limberg and colleagues (Limberg, Barnow, Freyberger, & Hamm, 2011) had patients
suffering from BPD respond to read and imagined scripts depicting scenes varying in
assumed emotional content (“assumed” is used because although Limberg et al assumed the
scenes would evoke these feelings in their research participants in their study there was no
check for this and on my reading of the scripts (obtained from Anke Limberg, personal
communication 5th April, 2011), after more than 30 years clinical experience with patients
with BPD, there is considerable question whether the depictions would have been reliable
triggers for the mood states examined, especially that of “abandonment”). These researchers
found that BPD patients are not more physiologically reactive to emotional cues in general
but show increased emotional vulnerability if borderline-specific schemas are activated.
Moreover, emotional reactivity is attenuated in BPD patients with PTSD. Unfortunately,
whilst they have phrased their conclusion in these terms their results, they acknowledge in
their discussion are somewhat more equivocal, presumably because their stimuli lacked the
potency they had hoped for and they go on to argue for a more powerful study involving a
larger number of participants. I think it would be worthwhile repeating their study with
alternative stimuli given the great importance knowledge about the vulnerabilities patients
with BPD have. Indeed, those with negative childhood experiences involving feelings of
abandonment, survival threat, and rejection.
Preissler and her colleagues (Preißler, Dziobek, Ritter, Heekeren, & Roepke, 2010) have
taken studies of BPD patients' reduced social cognitive abilities even further, moving beyond
processing of facial stimuli alone, using an analogue, though complex and realistic, task
requiring research participants to estimate the “theory of mind” perceptions of participants in
a filmed role-played interaction involving complex emotions and reactions; thereby
demonstrating that whilst BPD patients' lower levels of social cognitive processing may be
intact, the highest level in vivo processing is impaired. Since it has been proposed (Borelli et
al., 2010) that one of the natural roles of attachment behaviour is to facilitate, through the
caregiver's modelling of “mentalization”, the development of such skills, a learning process
that would be disrupted by the child experiencing abuse and trauma (Choi-Kain &
Gunderson, 2008) such higher level disruption in social cognitive processing might also be
expected in those with C-PTSD, individuals who had similarly suffered disrupted
relationships with their primary caregivers. The finding of Limberg et al that overall
psychophysiological reactivity is reduced relative to those who have not suffered previous
repeated abuse is consistent with other research, which also found greater mood and anxiety
disorder co-morbidity, and more pervasive dimensional dysphoria (e.g., depression, trait
anxiety; (McTeague et al., 2010)
SHAME AND OTHER NEGATIVE EMOTIONS
Another way in which patients with Borderline Personality Disorder may be like people who
have suffered interpersonal trauma early in life is in their assumed propensity to recurrently
experience the affects shame and stigma (Rüsch et al., 2007) They tend to cope with
recurrent experiences of shame by avoidance of situations wherein shame is likely to be
triggered; including such situations as those requiring self-disclosure (most explicit tests),
often being accompanied by feelings of being exposed and devalued. Shame has been defined
as a social but inner experience of self as an unattractive social agent, under pressure to limit
possible damage via escape or appeasement. Shame is usually experienced as aversive and is
accompanied by a feeling of being exposed and devalued. The subjective experience of
shame is often associated with observable shame behaviors, such as blushing, lowering the
head, avoiding eye contact, and the impulse to hide and escape. In research settings these
reactions are usually easy for the participant to discern, possibly leading to cognitive /
attitudinal responses contrary to those implicitly held by the participant. Thoughts, attitudes,
or behaviours reminiscent of earlier abuse are likely to be particularly strongly defended
against, even if they are held implicitly by the participant. Measures of propensity for socially
prescribed behaviours, therefore, if explicit, will be strongly defended against, by denial,
withdrawal, negative affective response or other means of concealment (Dyer et al., 2009).
Nevertheless, a more “direct” though implicit, measure would be preferable rather than
sharing features in common with a particular “demographic” as it would facilitate access to
cognitions / attitudes directly associated with the behaviour of interest. For these and other
reasons, Rusch and his colleagues have performed a number of studies where they have
compared the results of studies comparing patients with Borderline Personality Disorder with
other psychiatric patients and with patients without diagnosed psychiatric disorders using
both explicit and implicit measures to gauge what might be key factors to focus on in the
course of therapy. Significantly such implicit negative emotions might be linked to worse
course and symptoms of disorders, and because patients might be affected by, unaware of,
and unable to control these negative emotions, and therefore facing severe struggles
controlling negative behaviours triggered by negative emotions. Indeed, Rusch and his
colleagues found this to be the case (Rüsch et al., 2007). For patients suffering BPD with comorbid PTSD, the course of the disorder was associated with a more anxiety-related selfconcept; and implicit shame-proneness was negatively correlated with quality of life, selfesteem, and positively correlated with feelings of anger and hostility. Therefore, they argue,
both implicit and explicit feelings need to be taken into consideration when conducting
psychotherapy. The importance of this finding will be discussed in reference to a particular
behaviour problem those with histories of disrupted childhood relationships might be
vulnerable to: intimate partner violence. For now, it should be noted that, in the presence of
shame and anger, particularly where people have also suffered PTSD, there would seem a
need for them to improve their degree of self-soothing through self-compassion. (Thompson
& J. Waltz, 2008) argued that because exposure to trauma and subsequent post-traumatic
stress symptoms (PTSS) may be associated with self-criticism and avoidance of internal
experiences, finding that Avoidance symptoms significantly correlated with self-compassion,
but re-experiencing and hyper-arousal did not. Individuals high in self-compassion may
engage in less avoidance strategies following trauma exposure, allowing for a natural
exposure and recovery process.
Those with histories of abuse and interpersonal trauma may be especially sensitive to, and
slow to recover from, shame-inducing experiences (Gratz, Rosenthal, Tull, Lejuez, &
Gunderson, 2010). Recently Wilson,Turkovic and Durdic (2006) have reviewed studies of the
effects of shame on personal functioning impaired due to suffering PTSD, and have
concluded that the effects of shame and guilt can be compared across eight different areas:
1
self-attribution processes
2
emotional states and capacity for emotion self-regulation
3
appraisal and interpretation of actions
4
the impact of states of shame and guilt on personal identity
5
suicidality
6
defensive patterns
7
proneness to psychopathology and PTSD
8
the dimensions of the self-structure affected by shame and guilt
Whilst there has long been some controversy in the research literature over whether
functioning is impaired by the effects of shame, or guilt, or both, a recent meta-analysis
(Kim, Thibodeau, and Jorgensen (2011) showed that, so far as associations with depressive
symptoms are concerned, shame had significantly stronger associations with depressive
symptoms (r = .43) than guilt (r = .28). However, the association of shame and depressive
symptoms was statistically indistinguishable from the associations of 2 maladaptive variants
of guilt and depressive symptoms (contextual-maladaptive guilt, involving exaggerated
responsibility for uncontrollable events, r = .39; generalised guilt, involving "free-floating"
guilt divorced from specific contexts, r = .42). Other factors also moderated the effects.
External shame, which involves negative views of self as seen through the eyes of others, was
associated with larger effect sizes (r = .56) than internal shame (r = .42), which involves
negative views of self as seen through one's own eyes. Depressive symptom measures that
invoked the term guilt yielded stronger associations between guilt and depressive symptoms
(r = .33) than depressive symptom measures that did not (r = .21). Age, sex, and ethnicity
(proportion of Whites to Asians) did not moderate the effects. Although these correlational
data are ambiguous with respect to their causal interpretation, these results suggest that shame
should figure more prominently in understandings of the emotional underpinnings of
depressive symptoms. Due to these findings, and the traditional focus on shame in studies of
the effects of sexual trauma , shame is a key focus of the proposed research.
Areas of impaired individual functioning caused by shame contribute to further dysfunction
in such areas as interpersonal functioning, relationships with health care providers and
counsellors, work and career success, and so on, as noted by van der Kolk (2005) in his
diagnostic criteria for Developmental Trauma Disorder. These seem the same as those present
as a result of trauma disorders having their origins in childhood, reflecting a generalised
response to shame.
Shame could also impede the development of social connections and social supports, in
intimate and community settings, and further, within work settings. Dorahy et al (2009) note
that social disconnection is an essential feature of the lives of people with CPTSD /
DESNOS, perhaps reflecting (a) a problem with “temperament” wherein social connection is
uncomfortable for the individual; or (b) the self-perceived “unworthiness” of people affected
by CPTSD for, or anxiety over, being in relationships. These researchers, more recently, have
also found that a major factor leading to relationship breakup is psychological dissociation
(Dorahy, 2010). Naturally, the question arises whence do these feelings of shame arise, and
why do they seem so difficult to overcome, given the (usual) absence of the original source of
the shame: the abusive “caregiver”.
Certainly, stigma plays a role in the shame experienced as a result of childhood abuse
(Finkelhor & Browne, 1985). However, it has not yet been researched whether the recurrent
experience of stigma is sufficient to maintain these feelings of shame. But other factors also
are likely to play a role. It is here that the recent findings of van Harmelen et al (2010)
become so pertinent. These researchers, using both explicit and implicit measures found that
childhood abuse becomes, for adult survivors, associated with enhanced automatic (and
explicit) self-depression and self-anxiety associations. Additionally, when compared to
physical- and sexual-abuse, Childhood Emotional Maltreatment (CEM; emotional abuse and
emotional neglect) had the strongest link with enhanced automatic (and explicit) selfdepression and self-anxiety associations. In addition, automatic and explicit negative self
associations partially mediated the association between CEM and depressive or anxious
symptomatology. Clearly, the sufferer's own self is the source of feelings of shame by some
means. Perhaps these self associations had some “adaptive function” in an earlier context
wherein contingencies applied that are no longer in place. I propose that this is indeed the
case and that, in the present, such behaviour is evidence of some form of “psychological
inflexibility” that is limiting sufferers' coping skills repertoires Further, I intend to conduct
research looking at CPTSD, wherein people with CPTSD will be, I predict, deficient in
“mindfulness skills” so that they are not as aware of, and not acting upon, contingencies
operating “in the now” as are people raised in non-abusive contexts. Instead, they seem to be
acting on contingencies operative in their homes at the time of their being abused – perhaps
trying to escape further abuse by satisfying the demands of their abuser. From this
perspective, I intend to review treatments that might possibly be suitable for this disorder,
more comprehensively than has been done so far in treatment studies. Further, I propose that
the five categories of symptoms experienced by people with CPTSD (van der Kolk, 2005)
can be grouped into two “higher order” categories, namely (i) Experiential Avoidance and
(ii) Problems with Mindfulness and “Cognitive Fusion” with such self associated negative
emotions as Shame, Guilt, or Stigma , aggravated by sufferers' difficulty tracking
performance in accordance with their own values, rather than the values, judgements and
malicious intent of their childhood abuser / ”caregiver” and, further, that these two categories
of problems can be treated using procedures “developed” or applied from within a functional
contextual framework (Hayes, Luoma, Bond, Masuda, & Lillis, 2006).
THE INFLUENCE OF ATTACHMENT STYLE ON ADULT RELATIONSHIPS
Two main aspects of adult attachment have been studied. The organisation and stability of
the mental working models that underlie the attachment styles is explored by social
psychologists interested in romantic attachment (Fraley & P. R. Shaver, 1997) Developmental
psychologists interested in the individual's state of mind with respect to attachment generally
explore how attachment functions in relationship dynamics and impacts relationship
outcomes(Crittenden, 2005). The organisation of mental working models is more stable while
the individual's state of mind with respect to attachment fluctuates more. Some authors have
suggested that adults do not hold a single set of working models. Instead, on one level they
have a set of rules and assumptions about attachment relationships in general. On another
level they hold information about specific relationships or relationship events. Information at
different levels need not be consistent. Individuals can therefore hold different internal
working models for different types of relationships (Pietromonaco & Barrett, 2000).
Attachment styles in adult romantic relationships roughly correspond to attachment styles in
infants but adults can hold different internal working models for different relationships
(Fraley, Heffernan, Vicary, & Brumbaugh, 2011). Securely attached adults tend to have
positive views of themselves, their partners and their relationships. They feel comfortable
with intimacy and independence, balancing the two. Anxious-preoccupied adults seek high
levels of intimacy, approval and responsiveness from partners, becoming overly dependent.
They tend to be less trusting, have less positive views about themselves and their partners,
and may exhibit high levels of emotional expressiveness, worry and impulsiveness in their
relationships. Dismissive-avoidant adults desire a high level of independence, often appearing
to avoid attachment altogether. They view themselves as self-sufficient, invulnerable to
attachment feelings and not needing close relationships. They tend to suppress their feelings,
dealing with rejection by distancing themselves from partners of whom they often have a
poor opinion. Fearful-avoidant adults have mixed feelings about close relationships, both
desiring and feeling uncomfortable with emotional closeness. They tend to mistrust their
partners and view themselves as unworthy. Like dismissive-avoidant adults, fearful-avoidant
adults tend to seek less intimacy, suppressing their feelings (Hazan & P. Shaver, 1987, 1994).
Fraley (Fraley, Waller, & Brennan, 2000) has done much to introduce the current conception
of relationship styles in terms of two orthogonal constructs of Anxiety about Relationships
and Avoidance of Relationships.
Attachment Style as a Mediator Between Childhood Trauma and Life Outcomes
In connection with the relation between childhood trauma and attachment style, Waldinger
and colleagues (2006) found that not only did attachment mediate the link between childhood
trauma and adult symptomatology (acclimatization) but that this relationship differed for men
and women. For women, attachment directly mediated the association; whilst for men, both
childhood trauma and attachment contributed to the association. Childhood trauma was
associated with higher levels of somatization and insecure attachment. Insecure attachment
style was also associated with higher levels of somatization. Controlling for age, income, and
recent intimate partner violence, analyses showed that fearful attachment fully mediated the
link between childhood trauma and somatization for women. For men, there was no such
mediation, but both childhood trauma and insecure attachment styles made independent
contributions to predicting levels of somatization. Waldinger et al's findings (2006) are
consistent with the hypothesis that, for women, childhood trauma influences adult levels of
somatization by fostering insecure adult attachment. For men, the findings suggest that
trauma and attachment are both important independent predictors of adult somatization. Most
importantly, the study results support the idea that childhood trauma shapes patients' styles of
relating to others in times of need, and these styles, in turn, influence the somatization
process and how patients respond to providers. Thus, whilst attachment styles often have
important influences on interpersonal phenomena, they act at the same time as other variables
to influence final outcomes, and are not the sole determinant of those outcomes. There are
now a multitude of studies examining the influence of Attachment on interpersonal and social
cognitive processes, only some of which will be discussed in this proposal.
Unsurprisingly, Secure Attachment Style (evidenced by low Anxiety and Low Avoidance,
through its association with State and Trait Forgiveness, and not associated with childhood
trauma) is associated with positive health outcomes (Wang, 2008). The association between
forgiveness and positive health status is especially strong when one considers selfforgiveness, and perhaps even more broadly, “self-compassion” (Wilson, Milosevic, Carroll,
Hart, & Hibbard, 2008). Indeed attachment style can have negative effects on people's
behaviour even after they begin suffering dementia in old age (Browne & Sclosberg, 2006).
RELATIONSHIP BETWEEN ATTACHMENT DISTURBANCE AND INTIMATE
VIOLENCE
Donald Dutton was one of the first researchers to draw attention to the propensity those from
backgrounds in which their relationships with caregivers were marked by abuse might exhibit
a greater propensity for violence than those from more stable backgrounds (Dutton, 1995).
Dutton found that propensity for violence was not simply dependent on a history of childhood
abuse, or disruption of important relationships in childhood, but that a mix of factors
increased the risk for intimate partner violence: Borderline Personality Disorganisation
(especially Primitive Defences), Affective Lability (especially anger and rage magnitude and
customary inner directedness), and Fearful Attachment (linked to recollections of parental
punishment that were public, random, or global, generally experienced as shaming actions).
Dutton et als' findings have been replicated and found to apply for women as well as men
(Clift & Dutton, 2011; Swan, Gambone, Caldwell, Sullivan, & Snow, 2008).
Dutton et als' finding that Fearful Attachment is linked to propensity for intimate partner
aggression is particularly interesting and instructive suggesting as it does that, over and
above the effects of childhood abuse per se, it is the ongoing effect on people's lives of
disrupted attachments through its impact on the model of self and relationship the victim of
such abuse carries with them through the years that may be the most insidious effect of
disrupted childhood positive attachments with significant others. It is here also that we find
the relevance of his findings, and those of Rusch, to other people.
How the concepts gleaned from the professional literature have been incorporated into the
methodology for the first two studies of proposed research is discussed next.
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APPENDIX 1
Lists of Events and their Severity and
Level of Dangerousness
for Disturbance of Attachments in Early Childhood
(Crittenden, 2010)
APPENDIX 2
The Concept of Cognitive Fusion