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The assessment of attachment and primitive modes of relating in complex trauma: A case illustration. David Joubert, PhD Department of Criminology University of Ottawa, Canada. Attachment and trauma .
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The assessment of attachment and primitive modes of relating in complex trauma: A case illustration David Joubert, PhD Department of Criminology University of Ottawa, Canada
Attachment and trauma • AttachmentTheoryprovides a usefulheuristicframework to conceptualize the impact of traumaticexperiences. • Constructs of attachmentdisorganization, segregatedsystemsfailure of reflective self-function(mentalization) account for many trauma-relatedsymptoms. • Operationalization of attachmentconstructallows for reliable and validassessment.
Complex trauma • Oftendefined in terms of 1) multiplicity of traumaticevents, 2) severity of events. • On a psychologicallevel, characterized by altered self-capacities, a variety of cognitive symptoms, mood disturbance, overdeveloped avoidance response, somatoform distress, and posttraumatic stress. • Empirically linked to addiction, depression-anxiety, self-harm, chronic physical conditions, cluster B personality disorders (esp. borderline).
Attachment and complex trauma: Psychologicalassessment • Due to the range of alterations in psychologicalfunctioning, probably best to use combination of broadband and more specificmeasures. • Givenexistingconceptual links, narrative measures of attachment are important to include. • However, risk of « contamination » by other conditions (e.g., are characteristics of narrative a function of trauma or the expression of a distinct disorder?).
Basic premises • Includingattachment data caninform on specificstrengths or vulnerabilitiesacross a range of disorders. • Attachmentstatusprovidesuseful information on the nature of current or expectedinterpersonaldifficulties, quality of the therapeuticrelationship, methods of regulatingdistress, family-specific triggers for decompensation (e.g., ExpressedEmotion), and ways in which the individualislikely to respond to therapeutic interventions.
Case illustration - Steven • Caucasian male, 47 y.o., referred for psychologicalassessment and individualtherapy at hisownrequest. • Initial diagnosis of Major DepressiveDisorder and AvoidantPersonalityDisorder, withepisodicsuicidalideation. • Initial stated goals very vague, involvework on self-worth, « feeling lessmiserable ». Physician: He needs to betteridentify and state hisneeds. • Currently on Seroquel, Wellbutrin.
Assessmentmeasures • Interview • Diagnostic: SWAP-200 • Broadband personality: MCMI-III, SNAP • Projective: Rorschach, Earlymemories • Attachment: AdultAttachment Projective Picture System
Clinical observations • Assessmentis a slow, ploddingprocesstakingmuch longer thanexpected. • Steven insists on beginning sessions by taking me throughvarious, but repetitive, complaints (e.g., life sucks, I hate happy people, corruption and dishonestyeverywhere). • Incessantlyruminates on « evil » WalMartwhofiredhimwithoutreason, history of punishment at school. • Still, comes to sessions religiously, alwaysearly.
Diagnostic interview • Difficult to getvalid, crediblehistorical information because of vagueness. • Processfeels dry, sterile;littlerésonnancefantasmatique (evocativeresonnance). • Depressive affect withunderlyinganger and externalization of blame. • SWAP-200: Moderateelevations on Schizoid and Schizotypal PD (both 62).
Personalityassessment - Summary • Self-report: « Fake-bad » profile; Highest scores on scalessuggesting trauma, anxiety, somatization, Schizotypal and Avoidant PD. Portrays self as highlyconflicted, sociallyalienated, more comfortable in a passive-dependent position. • Projective - Rorschach: Surprisinglyrich and complex but verydysphoric and egodystonic (C’, T, ShBlends); Cognitive slippageassociatedwithchromatic stimuli; Primitive modes of relating (symbioticmerging, violent separation & reunion); strong expression of aggressive drives (AgC) alternatingwithdefense; Paranoidthemes; Fragmented percepts. • Overall impression islower-level borderline organization.
Projective assessment – EarlyMemories • Memory 1: Goes to cemeterywithfriends and sees « his » grave; tombstone has samename, year of birth, etc. Runsaway. • Memory 2: Witnessinghisfriends (twins) drown in a river; unable to savethem. Returnsdayafter and seesseveraldeadfish on the beach. Friendsays not to touchthem: « you’regonnagetgerms ». • Memory 3: Sledding in the snowwith a girl, hits a tree and breaks teeth in a « V » shape. Girl laughsathim. Described as a « good » memory.
AdultAttachment Projective Picture System • « Alone » stories muchlesscoherentthan « Dyadic » ones. • No internalizedsecure base, haven of safety or capacity to act. • Exception: Motherreassures boy in the Ambulance story. • Multiple traumaticdysregulation markers, all in the « Alone » pictures.
Sample story - Window (6 sec.)The little girl she’s looking through- through a window… She’s looking at the house, the tree, the city… She feels that it’s beautiful because she- she’s stuck there like [Absorbed Withdrawal]- like/… [Unfinished] She’s looking far away, like a vision from afar, because it looks like a window [Surreal]/… She finds it beautiful. Or it’s open curtains, like in an apartment for example. It’s nice outside… She likes looking through the window, she feels that it’s positive. (Whatmight have happenedbefore ?)Before ?... Before maybe she just cleaned her room, and she opened the curtains, and then that’s when she looked outside… And after she looked… she did that, after let’s say she’s gonna go eat. Commentary: Activation of the ABS is managed through evoking an “idealized” picture of contentment without connectedness or mentalizing activity (ISB). Analysis of defenses suggest a form of self-absorption preventing connectedness with an attachment figure.
Sample story - Bed (7 sec.)It looks like a little boy… lying in bed. Uh, it looks like he’s at home. The mummy’s reading a story book to the little boy… The little boy he’s/… You can tell he’s not listening…. I mean, uh… So there she’s at the end of the book and he’s lifting his arms as if to say “pick me up, I need a hug”. And before that, you can tell that the mummy put her little boy to bed, and after that… after the story and she gave him a hug when he reached for her, well she says “bye” and “good night”. That’s it. (And what are they thinking, how are they feeling in the story ?) Joyful, because he’s reaching for her with his arms, he wants a hug from her… He’s feeling good. Yeah…that’sit. (Ok. Anythingelse about that one ?) No. Commentary: Narrative ismuch more « grounded » thanprevious one, muchlessdefended. The boy’sneedisclearlyacknowledged, eventhoughthereis no truesynchrony due to delay in maternalresponse.
Sample story - Cemetery (9 sec.)That looks like a cemetery. Tombstones. The man is pensive. It reminds me of my father… My dad went once in his life to see his father [Spectral] at the cemetery. And he said: “It’s funny… the cemetery”, he said, “I love my dad and I came once in 30 years”. He said “I don’t feel good about tombstones”, and he said- I said “You’re right about tombstones”, I said. I was with him, that’s 5-6 years ago. I couldseemydadwassad. And I said/… What do you say when someone is having a hard time with a stone ? “I don’tblameyou if youdidn’t/… You’reforgiven, youweren’t able to seeyourfather… 30 years ». At least hewasthinking about him. So then, that’s what I told my dad. That’s what it reminds me of, the man is there with his hands in his pockets and he’s staring [Uncertain] at the stone… It’s sad. It’s sad, I feel that many good people leave, and that’s injustice… That’s what I think. Before… Before that, well he wasn’t thinking, he wasn’t even there [Odd] ! (smiles) And after, I don’t know[Uncertain] what he’s gonna do. I don’t knowif he’ll think, “it is what it is[Distancing language]” (Anything else about that one ?) No. Commentary: Personal experience includes the common marker for this card, which is contained. There is a breakdown in reflective self-capacity as indicated by the odd comment re: thinking and physical presence.
Sample story - Corner (9sec.) This is a little boy with his hands up and his head turned, he doesn’t wanna have anything to do with anybody [Withdrawn] (laughs)He doesn’t want anyone to come near him [Withdrawn]. Uh, he’s like in a corner where he escaped [Failed protection] so that an enemy [Evil-sinister] doesn’t/… [Unfinished] He’s turning his head, you can tell he’s not well…. For me it was different, I had my face against the wall [Isolation]. I wasn’t putting my hands up…. When I was young… Well, at school I was… I was the failure of the class, I was like that (shows picture) Sometimes I raised my arms, I didn’t want anyone to touch me.You can tell he’s sad. Before that, I don’t know [Uncertain] how he was feeling. And after that, I hope [Uncertain] he’s gonna be okay with some help. (Anything else about him ?) No. Commentary: As in cemetery, increasing activation of the ABS causes collapse in narrative coherency and the organization of defensiveprocesses. Steven isdrawn to hispersonalexperiencemarked by unresolvedexperiences of alienationfrom the object. Note also the mention of a malevolentinternalizedobject (« enemy » -- adult figure???).
Discussion • Decision to focus on ego-enhancingwork (ie., distinction betweeninternal and external) withsome basic exploratory components (dreams, fantasies, language). • Littleevidence of progress; maintainshis M.O. of using sessions to complain about outside world. Moodremainsdark, gloomy, withunderlyingangerthroughouttherapy. • Experiencesseriousregressionfollowingmydeparturefrom the clinic; hisdepressiontakes on psychoticfeatures. • The issue of « complex trauma » remainsunresolved. However, the incorporation of attachment in the assessmentallowed for a better(here, « post-hoc ») understanding of myfunction for him and of specificrelationalfactors (experience of loss, alienation, abandonment) thatmaybeassociatedwith a decompensationprocess.
