Turns out, it does kind of have a lot to do with your mother.

Well, any caregiver, really.

Kait Curtis, Jada DeLoof, and Joel Davison, of Family Services of Warren County (FSWC), recently attended a training on attachment, trauma, and dissociation in adults and children thanks to Systems of Care. The advanced workshop was presented by Annie Monaco and Elizabeth Davis, experts in the subjects of trauma, attachment, and dissociation.

What they learned is that part of becoming trauma-informed providers is making an effort to assess client attachment during the intake process.

Attachment theory, generally attributed to British psychiatrist John Bowlby, is the idea that the interactions children have with caregivers — mothers, fathers, grandparents, and even nannies or others who provide for the needs of the child — from birth to the age of three, has significant effects on that child’s future relationships and psychosocial functioning. There are four styles of attachment that children form with their caregivers, each the result of unique parental responsiveness to infants’ natural effort to gain proximity and access to them. That effort on the part of infants is based on both physical survival and emotional security, which are the instinctual drives of all people, according to attachment theory.

Children whose caregivers respond to these attachment-driven behaviors appropriately, consistently, and promptly develop secure attachments. They will grow into children and adolescents who use the parent as a secure base from which to make increasingly significant forays out into the world. They dislike being separated from their parents but are able to cope, and may accept comfort from a stranger, but have clear preferences for their caregiver, and will resume exploration of their environment upon that caregiver’s return. Securely attached children grow into adults who have appropriate senses of identity and logical expectations of relationships like marriage and parenting. They are as comfortable in meaningful and intimate relationships with others asthey are being independent, and the are able to strike a good balance between the two.

Children whose caregivers’ responses are insufficient to meet the child’s need for security and safety, and who discourage things like crying while encouraging developmentally inappropriate levels of independence, develop one form of insecure attachment called avoidant attachment. Children with avoidant attachment have superficial emotional relationships with caregivers, show little to no response to caregivers leaving them as well as returning to them, and either don’t care much when contact is initiated or may even resist it. Children with this attachment style tend to treat strangers and caregivers in much the same ways, because they see them as similar. Avoidant attachment style in childhood tends to be correlated with anxious and preoccupied adult attachments. These are adults who tend to seek a lot of intimacy, approval, and responsiveness from peers and often become overly dependent on friends and romantic partners. They tend to be less trusting and have more negative views about themselves and others. They also tend to be highly emotionally expressive, anxious, and impulsive when it comes to relationships.

A third form of insecure attachment is ambivalent/resistant attachment. These are children whose parents have responded to their attachment-seeking behaviors inconsistently, going back and forth on a broad spectrum of appropriate to neglectful responses. These children simply do not have a caregiver that’s useful as a secure base from which to explore the world. As a result, they tend to cling to caregivers and avoid being separated from them. When they are unable to avoid separation from caregivers, ambivalent/resistant children experience distress as a result of the separation – however minimal – and respond with anger, ambivalence, and hesitation to warm up to both strangers and caregivers upon their return. Their overwhelming preoccupation is the availability of the caregiver they seek attachment with, developing a tendency to seek contact with the caregiver but resisting and resenting it when its achieved. Strangers are generally unable to comfort children with this attachment style, and they tend to develop into adults whose relationships with others are dismissive and avoidant. These are adults who tend to create conditions of independence for themselves by avoiding attachments with peers and romantic partners. They believe themselves untroubled by the need for meaningful connections with others. Their own emotions are uncomfortable, so adults with this attachment style avoid them as they do connections with others. If they are in a relationship, they tend to have a low opinion of their partner, and deal with what they see as rejection by creating distance between themselves and and those they perceive as having rejected them.

A fourth childhood attachment style, disorganized attachment, tends to be that of children whose parents are either fearful of others or frightening in their behaviors toward their children. Parents who struggle to maintain appropriate boundaries with their children, who are intrusive as well as withdrawn, generally negative, who struggle to connect emotionally with their children, and those who actively abuse their children tend to raise kids who lack the ability to seek attachment, and to cope with its absence. With no blueprint for how to gain that access they instinctively crave, children with disorganized attachment try any number of things, often without a clear strategy or well-defined goal, to achieve the security and safety they long for, but can’t necessarily articulate. Children with disorganized attachment tend to have a fearful/avoidant attachment style as adults. They both desire close peer and romantic relationships, but recoil from them when they are achieved. These are adults who struggle to trust partners, and to consider themselves worthy of others’ affection. They tend to seek intimacy, but actively avoid giving in to the emotional honesty and vulnerability that are the foundations for close friendships and intimate relationships.

Trauma and attachment are related. People whose initial relationships with caregivers are negative, confusing, or painful go through life without the advantage of those whose caregivers gave them a model for healthy, positive relationships. Internalized ideas about what constitutes a normal, acceptable, and satisfying relationship with peers and partners come directly from early interactions with caregivers. And it’s less about quantity of time spent with those caregivers than it is about the quality of the attachment they develop. So those with poor childhood attachments are essentially attempting to form adult relationships – with themselves as well as with others – lacking an appropriate set of skills and tools with which to form them. Children with any of the three forms of insecure attachment can be more vulnerable to trauma later in life.

It’s not all about attachment, though, explained Kait Curtis, FSWC Clinical Supervisor. Things like temperament traits – where a person is on a spectrum of different inborn qualities like adaptability, mood, and hesitance or quickness to warm to strangers – represent the nature end of the nature vs. nurture debate. Environmental factors, such as parental responsiveness, strength and availability of support systems, and individual life circumstances meet up with the more inflexible, inborn parts of personality to determine each individual’s ability to cope with potentially traumatic situations. Those who experience chronic adversity of experience, such as longitudinal negative interactions with caregivers over the course of a lifetime, are more primed to see the world and others as generally cold and hostile. That constant disappointment, frustration, and lack of security can lead those people to dissociate.

Dissociation can sound concerning. Most people associate it with diagnosable disorders with clear diagnostic codes and criteria, like Dissociative Identity Disorder (think Tyler Durden and the unnamed narrator in Fight Club, for example). But portrayals of DID (known as Multiple Personality Disorder in the 1980’s) are generally exaggerated if not altogether inaccurate. Not only do literature and film tend to portray disorders like DID as more common than they actually are (current estimates of prevalence are between .01 and 1 percent in the general population and .5 and 1 percent in psychiatric settings, according to Maldonado et al., 2002), they can stigmatize the entire popular understanding of dissociation, which is actually a common way for those who face trauma to cope.

“Checking out,” said Jada DeLoof of FSWC, is a common method of coping with both episodic (one-time) or chronic exposure to trauma. But the dissociation common to chronic trauma-affected consumers changes both how they are best served in therapy and the amount of time they need to spend in treatment to achieve resolution of presenting problems. Dissociation, she explained, can take even a relatively quick treatment method like EMDR, which can drastically reduce the time consumers need in treatment compared with traditional Cognitive Behavioral Therapy and extend it significantly. Combining an awareness of a person’s attachment experiences in childhood with an understanding of the ways and extent to which they cope by dissociating, said Curtis, is an important part of providing trauma-informed care. And although the cliche of discussing one’s mother session after session is well-entrenched in the popular understanding of the therapeutic process, actually asking about and integrating a consumer’s attachment in plans of care is not often a part of that process.

But it needs to be, said Curtis, and it’s becoming a part of the way FSWC conducts intakes. Adding an adult attachment inventory – a set of questions that collect a consumer’s attachment history and its contribution to presenting problems — will allow services to start off well-poised to address that often overlooked but significant component to positive therapeutic outcomes.

The training, both DeLoof and Curtis agreed, offered them an opportunity as providers of trauma-informed care to reflect on how neglecting attachment in treatment planning and even just failing to acknowledge its impact on how they understand a consumer can be a major contributor to the phenomenon of the “difficult” consumer who struggles to achieve much through even extended time spent in treatment. What’s more, said Curtis, she estimated that over half of the workshop’s participants were service providers from Warren County.

It’s significant, said Curtis, for a rural area that struggles with issues like provider availability and consumers facing socioeconomic hardships that can present a significant barrier to successful treatment to be so overwhelmingly focused on the progressive standards of trauma-informed care.

The changes that a trauma-sensitive approach to treatment make in service provision, said Curtis, adjust for the unique impact of attachment issues and dissociation in consumers who may have previously been labeled treatment resistant. And that, both DeLoof and Curtis agreed, paints an increasingly hopeful picture for consumers who may have struggled long and hard to achieve relatively few positive outcomes from previous, less holistically person-centered approaches to treatment.

“It allows us to be more preventive in treatment,” said Curtis, who added that one of the hardest things for her as a provider is to see consumers in their 30’s and 40’s who recognize that they are unhappy, and that there are people who don’t live with the task of managing anxious and depressive symptoms, but who have accepted anxiety or depression as their only possible reality.

Being able to integrate considerations of attachment and dissociation from session one, particularly with pediatric clients, said Curtis, means less consumers who’ve spent decades not feeling well, but not knowing that another way is possible for them.

“System of Care dollars were able to provide Kait, Jada, and Joel those training experiences,” said Systems of Care Coordinator Emily Wilton. “We are currently looking to be able to provide many training opportunities to agencies and the community. As SOC Coordinator, I look forward to continuing to move to reinvesting dollars back into our community. There is a large number of people who are all committed to this venture. None of this would have been possible had it not been for the support of the county commissioners, Department of Human Services, and local providers/agencies.”