Mindful Awareness of Attachment

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  • It’s great to be here… I want to thank The Refuge and The Meadows for making this happen. Thank you all for attending. I’ve had the pleasure to spend time with therapists and counselors today. I am really a therapist at heart. I have always enjoyed making connections between fields and bridging gaps between disciplines. I started out as a nurse in high school. I paid my way through college by managing a group home for mentally ill adults. I was a psychology major, but minored in chemistry and did my pre-requisites for medical school. I became very interested in holistic medical practices, so I applied only to Osteopathic medical schools. After finishing med school, I went on to psychiatry – my real love. However, I went out of my way to work with very skilled dynamically/analytically oriented therapists. I was on scholarship for med school and was therefore obligated to do a loan-repayment plan in a rural setting – which ended up being just outside of Davis California. I knew I wanted to work in addiction and trauma, so I entered graduate school while I did my loan repayment. I am still working on my PhD in Human Development and my research has brought together researchers in psychology and neuroscience (as you will see from the presentation). So, you can see that I have really tried to bring various disciplines together in my own work. I am so blessed that my path has led to The Meadows – I am able to use all of my past experience, training, and skills. It has been a great fit. I was a Meadows junky, well before I took the job and probably even before I knew about The Meadows.
  • Mother Treated Violently Your mother or stepmother was sometimes, often, or very often pushed, grabbed, slapped, or had something thrown at her and/or sometimes often, or very often kicked, bitten, hit with a fist, or hit with something hard, or ever repeatedly hit over at least a few minutes or ever threatened or hurt by a knife or gun. Household Substance Abuse Lived with anyone who was a problem drinker or alcoholic or lived with anyone who used street drugs. Household Mental Illness A household member was depressed or mentally ill or a household member attempted suicide. Parental Separation or Divorce Parents were ever separated or divorced. Incarcerated Household Member A household member went to prison.
  • Mother Treated Violently Your mother or stepmother was sometimes, often, or very often pushed, grabbed, slapped, or had something thrown at her and/or sometimes often, or very often kicked, bitten, hit with a fist, or hit with something hard, or ever repeatedly hit over at least a few minutes or ever threatened or hurt by a knife or gun. Household Substance Abuse Lived with anyone who was a problem drinker or alcoholic or lived with anyone who used street drugs. Household Mental Illness A household member was depressed or mentally ill or a household member attempted suicide. Parental Separation or Divorce Parents were ever separated or divorced. Incarcerated Household Member A household member went to prison.
  • Nature of the Child: Valuable, Vulnerable, Imperfect, Dependent, Spontaneous/Open Core Issues: Self-Esteem Issues (Less Than vs Better Than), Boundary Issues (Too Vulnerable vs Invulnerable), Reality Issues (Bad or Rebellion vs Good or Perfect), Dependency Issues (Too Dependent vs Antidependent or Needless/Wantless), Moderation/Containment Issues (Out of Control vs Controlling of Others) Secondary Symptoms: Negative Control Issues, Resentment/Raging, Spirituality Issues, Addiction Issues/Depression/Physical Illness, Intimacy Issues Relational Problems: Relational Esteem Issues, Enmeshment & Avoidance Issues, Dishonesty, Problems with Interdependence, Intensity Issues
  • John Bowlby, with the pioneering work of Mary Ainsworth, posited that a behavioral system involving social attachment evolved in order to enhance survival and reproductive fitness. Bowlby emphasized that attachment behaviors were activated in the child during times of illness, stress, fear, separation, and loss – and that gaining proximity to a responsive caregiver allowed physical safety, but also engendered a feeling of security so that the child could return to exploring the environment (learning).
  • Circle of security on Spokane Washington works with at-risk mothers to help them understand the basics of attachment. They use this simple graphic to talk about the child’s need to have a safe haven in times of need and a secure base from which to explore the world. Later, I will argue that there is much we can take from attachment theory to better understand and negotiate the therapeutic alliance.
  • The key to understanding attachment is that these daily interactions are integral to brain development. The daily dyadic dance between parent and child; a) starts in the womb and progresses through basic life-sustaining practices around b) feeding and c) protection, d) affect regulation, e) play, f) of course fathers are involved in heterosexual and same-sex unions, g) and various other kinds of developmental transitions. These patterns of interaction get written into the brain-body system. If a child is repeatedly rejected or enmeshed when they present their needs, they will learn to be very careful about making their attachment needs known. On the other hand, if a child experiences inconsistent care or outright abandonment, they may long for closeness and actively seek after attachment relationships. These two dimensions of 1) Attachment Anxiety and 2) Attachment Avoidance typify attachment insecurity – which doesn’t mean they aren’t able to attach, but instead means that they have to come up with various emotional, cognitive, and interpersonal strategies to maintain the attachment relationship. Bowlby hypothesized that the attachment system was active throughout the lifespan (“cradle to grave”) and influences mate selection, sexuality, and parenting.
  • When I learned about The Meadows model, I was astounded to see that there was a clinical program addressing these adult attachment issues. Pia Mellody’s work elegantly describes some of the cycles that Love Addicts and Love Avoidants experience and how they frequently find each other in relationships. We see a number of sexually compulsive individuals that are Love Avoidant and have partners that are Love Addicts. For example, I just admitted a man last week that lost his father at 13 years old and his mother slipped into Major Depression and Alcoholism. He was forced to care for his younger sister and the day-to-day affairs of the home. In this case of neglect, he had to shut-down his attachment needs and he started engaging in intensity-seeking behavior (drugs, alcohol, sexual acting out). All these years later he comes in after years of compulsive behaviors and increasing distance from his family. We will be able to help him.
  • A couple of years ago, I went to see Dr. Bessel van der Kolk in San Francisco. I was coming home on the BART and stopped at Richmond station for a transfer. I was there for nearly an hour and it was clear that many people there were facing a number of these contextual variables. I tend to watch parent-child interactions – just my thing. There was a women who didn’t look older than 30, but was probably 35. She was really laying into a cute little 3 year old boy. She was very critical, yelling at him, and she even swatted him several times. There were several other teenage children nearby who seemed afraid and distressed. It was a very hard scene for me to watch… personally very triggering for me. I recognized that I was from a very different culture, but the behavior was hard for me to justify – even understanding cultural differences. We boarded the train and one of the teenagers took the young boy on her lap. I couldn’t tell if it was her child or if she was an older sister who was used to stepping in and caring for him. The women sat by herself and then, as the anger subsided, her facial expressions turned to sadness and then very quickly to dissociation. This 30’something women began to suck her thumb and rocked gently in the train seat… my own harsh judgment melted… she was carrying her own pain and it was affecting the next generation and probably more than that. This is what attachment clinicians call “the ghosts in the nursery”… maltreatment and attachment insecurity can reverberate into the generations… unless we can intervene.
  • Tell story of aunt Lisa. As a teen, I was being rebellious and went to the city on my motorcycle. My headlight went out and so I called my aunt to see if I could stay until the next morning. She said “yes”, but looking back on the call, there was a hint of distress in her voice. When I arrived at the home, she seemed a little nervous, but I was a teen worried about my own hide… I didn’t recognize the distress in her marriage. Years later, after she divorced her husband, she told me that they had an awful fight that night and she thought he was going to kill her. I called in the middle of the fight. She spent years in an abusive relationship. Almost ten years later, she was vice president of a marketing company and she worked on the 12 th floor of a downtown office building. One day she was riding the elevator up to her office after hours. Unexpectedly, two men boarded the elevator just as the doors were about to close. They were rough looking, scruffy, and she thought she could see a weapon on one of them. Her anxiety started to become uncontrollable and around the fourth floor, one of the men turned to her and she fearfully blurted out, “Just take my purse, please don’t hurt me!” The men quickly softened their appearance and reminded my aunt that they worked as police officers on the 6 th floor. They were undercover at the time.
  • When speaking to a diverse group it is challenging to speak on topics that are relevant to case managers, therapists, and the medical group. However, there are three aspects of therapeutic interactions that may be common to all of us. I arbitrarily called them; Perception, Preparation, and Process. An analogy that might help to illustrate these points is that of a play director. In this analogy, Perception is how the director interprets the story, Preparation can be considered setting the stage, and Process is the work of guiding the action. In therapeutic work Perception is our view of ourselves, others and the world, Preparation is the therapeutic frame or structure, and Process is the actual therapeutic intervention.
  • Our patients, especially those with trauma histories are extremely adroit at reading cues. If we think that we can mask over our internal experience with technique – I think we are fooling ourselves. You saw the video with the infant and still-faced mother – we have been studying people’s body, face, intentionality, mind for our whole life… So, what do we do? I would argue that our best bet is to learn to be present with what is happening inside of us while we are with our clients. Its this very interesting dual process where we are with the other person, but also with our own reactions. Technique is important – I’m suggesting that we just wing it. Its like an elite athlete, like Michael Jordan. I imagine he did thousands, tens of thousands of simple lay-ups, over and over and over. Yet, he rarely used that exact technique in a game, right? It is messy in a game; there are defenders, fans are yelling, the clock is winding down, his left knee was maybe hurting… and from the years of practice comes this amazing, novel, creative maneuver that dazzles and mesmerizes. He needed the technique, but in the game he was present, he was just being. Athletes call this “flow”, right? Therapy is messy, unpredictable. I had very good training in therapy as a psychiatry resident. I worked with some fabulous therapists, one of whom was Dr. Arthur Traub – a European-born Jewish analyst who loved to put trainees on the spot. Well, I was interested in doing some couples therapy and so I was studying John Gottman’s work… learning the techniques. A couple was referred to me – the woman was struggling with an eating disorder and self-harm behavior and the man was coming because his wife was unhappy with the marriage. During our first session, it was clear that the wife had a lot of anger and resentment, but she was having difficulty sharing some of her concerns. She was shutting down and it seemed there was something they weren’t talking about. Finally the man said that he had taken-up wearing diapers for pleasure and that his wife was angry because he had been pressuring her to change his diapers and treat him like an infant. Well, I wasn’t prepared for that! After that first session I called Glen Gabbard, the well-known analyst at the Meninger Clinic because he published an article titled, “Adult Baby Syndrome” about a man who wore diapers and wanted to be treated like an infant. I told Dr. Gabbard about my clients and asked what I should do with them? He said, “How the hell should I know, I’ve only seen one client with this condition and he left therapy after 3 sessions!” He did tell me that I might consider treating it like a couple with a cross-dressing partner. So, I used acceptance-commitment therapy and we had decent outcome. I wrote and published an case report article on the therapy and now I get emails from the UK, Australia, etc. with therapists asking me how they should treat their clients… I get to say, “How the hell should I know.”
  • Relying on the wisdom of her body (and with help from the therapist), Karen was able to drop below the habitual thoughts and feelings associated with love addiction and actually experience the pain associated with early attachment insecurity (i.e., “I’m unlovable”).  More importantly, she was able to contrast, and even dissolve, this deep pain through an embodied experience of secure attachment (i.e., “unconditional acceptance and love”).  Later she had great difficulty describing this therapeutic process in words, but it proved to be an “emotionally corrective experience” that she carried with her throughout her treatment.  Gradually, by bringing awareness to feelings in her body, and the associated thought processes, Karen learned more about her love addiction patterns and she developed tools to tap into a hidden wellspring of compassion and positive regard for herself.
  • Mindful Awareness of Attachment

    1. 1. Mindful Awareness of AttachmentFostering Emotion Regulation and Resiliency in Trauma Recovery Dr. Jon Caldwell Board Certified Psychiatrist The Meadows of Wickenburg www.drjoncaldwell.com
    2. 2. Far Reaching Effects of Trauma  Adverse Childhood Experience (ACE) Study  17,000 Kaiser members in CA participated  ACE: abuse, neglect, household dysfunction  Outcomes: quality of life, illness, death  Findings:  ACE are common; 2/3 (1 ACE), 1/5 (3+ ACE)  Early initiation of tobacco & sexual activityRelational  Teen pregnancy, ↑ sexual partners & STD’sMental HealthAddiction  Intimate partner violence  Alcoholism & illicit drug use  Depression & suicide attempts
    3. 3. Far Reaching Effects of Trauma  Adverse Childhood Experience (ACE) Study  17,000 Kaiser members in CA participated  ACE: abuse, neglect, household dysfunction  Outcomes: quality of life, illness, death  Findings:  Lung disease (COPD)  Liver diseasePhysical Health  Heart diseaseand Wellness  Autoimmune disease  Poor health-related quality of life
    4. 4. Far Reaching Effects of Trauma What would account for the relation between relational trauma in childhood and diverse health outcomes in adulthood??
    5. 5. Presentation Overview Relational trauma disrupts brain-body processes underlying self regulation (particularly emotion regulation) Relational trauma affects self/emotion regulation in part because of deleterious influences on attachment relationships Attachment relationships are paramount to the development of self/emotion regulation Trauma treatment can help restore brain- body capacity for self/emotion regulation Mindfulness on the part of therapist and patient may facilitate trauma treatment
    6. 6. Nature of Child Childhood Onset of Parent Mediated Trauma Effects Child Maltreatment ---Infancy---Middle Childhood---Adolescence---Adulthood---- Parent-Child Core Issues Attachment InsecurityDevelopmental Immaturity Dysregulated Negative Mental Stress-Response and Representations of Emotion Processing Self and Others Intergenerational EffectsSecondary Symp Social/Interpersonal Difficulties Unmanage- ability Mental Health ProblemsRelational Probs Adult Attachment Insecurity Intimacy Challenges Maladaptive Parenting
    7. 7. Case Study – “A Felt Sense of Security”Karen, as I will call her, was a 37 year-olddivorced female who entered treatment afterbecoming depressed and suicidal following abreakup with a boyfriend. She reported thatsymptoms of depression and anxiety hadbeen a problem for most of her life, but theyalways got much worse during periods ofrelationship turmoil. Similar to previousepisodes, when the most recent relationshipended, she turned to alcohol and binge eatingto numb the pain.
    8. 8. Attachment TheoryAttachment Behavioral System Enhance survival/reproductive fitness Proximity, safe haven, & secure base Organize social attachment behaviors Internal Working Models (IWMs) Self/emotion regulation capacity Cargiving Behavioral System  Reproductive fitness via protection  Activated by child attachment cues  Variety of behaviors to fit context  Responsive, sensitive, boundaried, flexible, and unintrusive caregiving
    9. 9. Attachment Theory
    10. 10. Case Study – “A Felt Sense of Security”As a child, Karen’s mother struggled withalcoholism and her father with workaholism;she remembered feeling like she wasconstantly hungry for their attention and love.In fact, as a young girl she was certain thather father had a trap-door in his office wherehe would disappear and carry out his “secretlife”. Even when her parents were available,she often worried that she was “annoying” andshe feared that her desire for attention actuallydrove them away.
    11. 11. Attachment Theory
    12. 12. InternalWorkingModels(IWM’s)
    13. 13. Internal Working Models (IWM’s) Temperament and genetics have relatively small effect on attachment classification IWM’s (mental representations of self, others, and the world) are written into the biology via repeated interaction patterns Attachment insecurity is linked to:  Behavioral instability in preschool years  “Negative attribution biases”, externalizing, and internalizing behaviors in middle school years  Accelerated pubertal timing and sexual debut  Unstable peer relationships and pair-bonds in adolescence
    14. 14. Adult Attachment Style Hyperactivating Strategies Deactivating Strategies My faults cause others to leave me I can’t trust and depend on others Intense need for closeness Downplay need for closenessAnxious about rejection & separation Hide or dismiss vulnerabilities Cling, control, claustrophobic Avoid intimacy & interdependence Dysregulation of negative affect Suppress emotionAttachment-Related Attachment-Related Anxiety Avoidance
    15. 15. Case Study – “A Felt Sense of Security”Karen reported that whenever a romanticrelationship ended, she felt a profound senseof emptiness and loss. After her partner left,she couldn’t stop thinking about what shemight have done wrong and she feared thatshe would never have a healthy relationship.She fantasized incessantly about getting backtogether and about how she would “fix” herselfto make the relationship work. These kinds ofthoughts plagued her day and night until thehelplessness and despair were overwhelming.
    16. 16. Intergenerational Cycles Parent Factors MaltreatmentTime Attachment Depression Cognitive/Emotion Parenting G1 Beliefs and Behavior Context Factors Poverty Addiction Teen mother Co-parent Risk Housing Risk G2 Child Factors Education Risk Genes Disability Temperament
    17. 17. Onset of Parent Mediated Effects Child Maltreatment ---Infancy---Middle Childhood---Adolescence---Adulthood---- Parent-Child Attachment Insecurity Dysregulated Negative Mental Stress-Response and Representations of Emotion Processing Self and Others Intergenerational Effects Social/Interpersonal Difficulties Mental Health Problems Adult Attachment Insecurity Maladaptive Parenting
    18. 18. Child Abuse and Adult Attachment  Community sample (N=76) at-risk mothers  18-44, ≤ 18 child, no D&A x 6 mo., no psych meds  At least 1 risk factor: poverty, ↓ education, housing stress, no co-parent, addiction hx, age < 21  Child Maltreatment (sexual/physical/emotional abuse & physical/emotional neglect), Depression, Adult Attachment, Parental Self EfficacyChildhood Parental Abuse / Self-Efficacy .39** -.44** Neglect Parental Depression R2 = .32 .37** -.18ns .41** Attachment Caldwell, J. G., et al (2011). Journal of Aggression, Anxiety Maltreatment & Trauma, 20(6), 595–616.
    19. 19. Child Abuse and Adult Attachment  Emotional abuse was strongest predictor of Attachment Anxiety and Maternal Depression  Emotional abuse frequently involves a caregiver and is often associated with other forms of abuse  Emotional abuse affects attachment relationships and is a repeated “little t” in relational traumaChildhood Parental Abuse / Self-Efficacy .39** -.44** Neglect Parental Depression R2 = .32 .37** -.18ns .41** Attachment Caldwell, J. G., et al (2011). Journal of Aggression, Anxiety Maltreatment & Trauma, 20(6), 595–616.
    20. 20. Case Study – “A Felt Sense of Security”Karen’s parents divorced when she was nine-years-old and their separation only intensifiedher father’s distance and her mother’salcoholism. The pain and lonelinessassociated with her parents’ divorce waspartially ameliorated by a warm and lovingrelationship with her maternal aunt, who hadbeen a stable figure throughout her life.However, at thirteen-years-old, her aunt died,and not long after that, Karen began usingfood and alcohol in excess to alter her mood.
    21. 21. Onset of Parent Mediated Effects Child Maltreatment ---Infancy---Middle Childhood---Adolescence---Adulthood---- Parent-Child Attachment Insecurity Dysregulated Negative Mental Stress-Response and Representations of Emotion Processing Self and Others Intergenerational Effects Social/Interpersonal Difficulties Mental Health Problems Adult Attachment Insecurity Maladaptive Parenting
    22. 22. Child Abuse and Emotion Regulation Self/Emotion regulation is related to integration of limbic & prefrontal cortices Child abuse is known to alter frontal-limbic circuits (hyperarousal dyscontrol)
    23. 23. Child Abuse and Emotion Regulation * Trauma-related brain changes may result in Hyperarousal- Dyscontrol SyndromeAmygdala: Hyper- OFC: Hypo-activeresponsive to negative inhibitory control of theemotional stimuli limbic system (amygdala)
    24. 24. Child Abuse and Emotion Regulation Self/Emotion regulation is related to integration of limbic & prefrontal cortices Child abuse is known to alter frontal-limbic circuits (hyperarousal dyscontrol) Frontal-limbic circuits aide emotion regulation via “Cognitive Control” or “Executive Function” The ability to rapidly and flexibly coordinate emotions, thoughts, and actions to adaptively meet changing environmental demands and act in accordance with rules, intentions, or goals.
    25. 25. Non-Emotional Conflict AdaptationNon-Emotional:Male/Female FEMALE FEMALE FEMALE xC cI iI SlowerReactionTime Faster MoreCognitiveControl Less Anterior Dorsolateral Cingulate Prefrontal Cortex Cortex
    26. 26. Emotional Conflict AdaptationEmotional:Neutral/Fearful NEUTRAL NEUTRAL FEARFUL xC cI iI SlowerReactionTime Faster MoreCognitiveControl Less Anterior Dorsolateral Cingulate Prefrontal Cortex Cortex Limbic System
    27. 27. Findings – Congruency/Task Congruency & Task Type Congruency & Task Type Reaction Time Accuracy Nonemotional Emotional Nonemotional Emotional 720 96Reaction Time (ms) 680 94 Accuracy (%) 640 92 600 90 560 520 88 Congruent Incongruent Congruent Incongruent Trial Type Trial Type All comparisons between congruent vs incongruent and nonemotional vs emotional were sig. at p < .01
    28. 28. Findings – Conflict Adaptation Impairment in Conflict Adaptation Due to Fearful-Face Women w/ abuse were less able to regulate emotion to meet task’s cognitive goalsCaldwell, J. G., et al (2012). Cognition and Emotion, (Under review).
    29. 29. Onset of Parent Mediated Effects Child Maltreatment ---Infancy---Middle Childhood---Adolescence---Adulthood---- Parent-Child Attachment Insecurity Dysregulated Negative Mental Stress-Response and Representations of Emotion Processing Self and Others Intergenerational Effects Social/Interpersonal Difficulties Mental Health Problems Adult Attachment Insecurity Maladaptive Parenting
    30. 30. Adult Attachment, Emotion, Resiliency Hyperactivating Strategies Deactivating Strategies My faults cause others to leave me I can’t trust and depend on others Intense need for closeness Downplay need for closenessAnxious about rejection & separation Hide or dismiss vulnerabilities Cling, control, claustrophobic Avoid intimacy & interdependence Dysregulation of negative affect Suppress emotionAttachment-Related Attachment-Related Anxiety Avoidance
    31. 31. Adult Attachment, Emotion, ResiliencyN=38870% ♀ Cognitive Hyperactivating22 yrs Rumination Attachment Strategy Negative Affect Attachment- Related Anxiety Emotion Low Dysregulation Resiliency Attachment- Related Avoidance Emotional Ambiguity Emotion Deactivating Suppression Attachment Strategy Caldwell, J. G., et al (2012). Individual Differences Research, (Accepted for Publication).
    32. 32. What Does This Mean for Treatment? Early trauma has a profound effect on relationships and emotion regulation A safe therapeutic environment is critical to help reduce limbic hyperarousal and facilitate prefrontal cortex engagement Emotion regulation and resilience can be cultivated by reducing the tendency towards hyperactivation and deactivation Within the safety of the therapeutic relationship, trauma- & attachment-related mental representations and affective patterns can be reorganized (brain & body)
    33. 33. Mindful Approach to Trauma TreatmentMindfulness: A processof regulating attention tothe present moment witha quality of curiosity,openness, & acceptance Mindfulness & secure attachment share qualities Mindfulness may be alternate pathway for deactivating and hyperactivating strategies
    34. 34. Mindful Approach to Trauma Treatment4.74.64.54.44.3 Secure4.2 Anxious4.1 Avoidant 43.9 N=21 N=28 N=443.8 Mindfulness
    35. 35. Mindful Approach to Trauma TreatmentMindfulness: A processof regulating attention tothe present moment witha quality of curiosity,openness, & acceptance Mindfulness & secure attachment share qualities Mindfulness may be alternate pathway for deactivating and hyperactivating strategies Mindfulness is related to self/emotion regulation Mindfulness is effective in treating many illnesses Mindfulness is linked to frontal-limbic brain circuits
    36. 36. Doing and Being in Therapy Perception Preparation ProcessAnalogy Interpretation Setting the Guiding theof Play of story line stage action View of self, Therapeutic TherapeuticTherapeuticInteraction others, and Frame or Intervention the world Field
    37. 37. Being and Doing in Therapy Repeatedly, research shows that “therapist variables” are the most important aspects of treatment (more than technique) At its core, the therapeutic relationship is a relationship – an intersubjective dance Technique is important, but our beingness will usually trump our doingness in therapy Therapy is unpredictable and messy - requiring openness, spontaneity, flexibility This therapeutic stance is enhanced by an embodied, mindful presence in therapy
    38. 38. That’s ok – I I Why? Is mean, it’s Ring,someone more really like not don’t Ring. you’re my like being important Unfortunately Can we meet IIt’s time it’s Mm see to can hmm.favorite doc… here anyway. waiting? our time visit. end our is up. hard for you. tomorrow?
    39. 39. Mindfulness - PRAISEPauseRecognize ReactivityAllow and AcceptInvestigateSense (body)/Storyline (mind)Enlighten
    40. 40. Mindful Approach to Trauma Treatment Mindfulness is part of therapeutic approach:  MBSR, MBCT, MBRP, MB-EAT, DBT, ACT Therapist’s mindful awareness of self (body, emotions, thoughts) likely to enhance therapeutic relationship and outcomes Mindful awareness can clarify transference- countertransference interaction patterns Mindful awareness may short-circuit (brain) attachment-related reactivity and instead, facilitate wise responding Mindfulness practices may cultivate the capacity for emotion regulation and a resilient approach to life’s many challenges
    41. 41. Case Study – “A Felt Sense of Security”Half-way into treatment, Karen was stillstruggling with intense thoughts & emotionsregarding her ex-boyfriend. The therapist askedKaren to close her eyes and imagine letting goof the relationship. Karen said, “It would feellike saying goodbye to a part of me… therewould be a hole in there.” She pointed to herchest. The therapist asked, “As you imaginethat hole in your chest, what does it feel like inyour body?” Karen’s face winced and her eyesshut tight as she responded, “It’s like a sharp,stabbing sensation.”
    42. 42. Case Study – “A Felt Sense of Security”The therapist inquired further, “As you arefeeling the stabbing sensation in your chest,do you notice any other thoughts oremotions?” Karen paused, her hand over herchest now, “I worry that the hole will never befilled – that I will never find anyone else.” Thetherapist tenderly implored, “How does it feelin your body as you say that?” Her breathingincreased and her shoulders tensed upwards,“Now I feel tightness in my chest and throat.”
    43. 43. Case Study – “A Felt Sense of Security”Knowing that the tightness was defendingagainst something even more vulnerable, thetherapist deepened the approach, “What wouldhappen if you never found anyone else? Whatwould that say about you?” Karen’s shouldersreleased, she bent over slightly and began tocry, “Maybe it’s me… maybe I’m just unlovable.” The therapist gently asked, “How does that feelin your body?” Through streaming tears, Karenreplied, “There’s a deep ache in the pit of mystomach – that’s where the hole leads – that’swhere it ends. It really hurts.”
    44. 44. Case Study – “A Felt Sense of Security”Karen was invited to stay in-touch with the deepache in her stomach while the therapist guidedher in some breathing exercises. Once Karen’semotions were more regulated, the therapistasked her to think about a relationship inchildhood where she felt unconditionalacceptance and love. Karen immediatelyidentified her deceased aunt and tears welled-up in her eyes once again. The therapistqueried, “If your aunt were here right now, howwould she respond to the ache you are feeling?”
    45. 45. Case Study – “A Felt Sense of Security”Karen was still crying, but a faint smile cameacross her face, “She would give me a big hugand then she would just stay here with me.”The therapist asked, “When you think aboutyour aunt’s response, how does that feel inyour body?” Her frame straightened and hersmile broadened, “It feels warm all over…more open and free inside my body.” After afew moments of quiet introspection, shespontaneously added, “The ache is gone.”
    46. 46. Summary Child maltreatment has far-reaching consequences – in part because it negatively influences critical attachment bonds – which are a primary means for humans to develop and maintain the ability to adaptively and flexibly regulate emotions and self to meet environmental demands. Trauma treatment can help restore the capacity for self/emotion regulation and relational intimacy, leading to resilience in the face of life’s past and present adversities. Mindfulness may be a key component in this process.

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