Tag Archives: Adverse Childhood Experiences

Healing Student Trauma: Film Debut, Orange County

paper-tigers-kelsey-movie-creditsSave the date Oct. 14 in Orange County, CA!  It’s the OC’s first screening of James Redford’s “Paper Tigers,” a film on how Lincoln Alternative High heals traumatized students with new relationships.  Such “Trauma-Informed Care” has begun in schools, medical settings, judiciary and social services nationally, with top results. It can help any organization.

Watch the two-minute trailer now: PaperTigersMovie.com

From rough areas, Lincoln High’s students were headed for the “School to Prison Pipeline.”  Then Principal Jim Sporleder took this Walla Walla WA school run by gangs, with 789 suspensions and 50 expulsions a year, and turned it around.  Suspensions fell 85-90%, expulsions fell 30-50%, and attendance, GPAs, and state exam scores rose. Graduation rates rose five-fold. Students got into college with $30K in scholarships. It was so dramatic that Robert Redford’s son James Redford made this film.

On Sept. 19, Mr.  Sporleder and my other friends at ACEsConnection spoke on this work at the White House in Washington. The White House Fact Sheet features ACEsConnection and our 10,000-person organization in its third bullet under “Online Community Support for Educators.”

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“Paper Tigers” Film Screening, Friday, October 14, 7 pm
Center For Spiritual Living, 1201 Puerta Del Sol, San Clemente CA 92673
– A documentary by James Redford, Director –

– Hundreds of screenings already organized nationally –
Admission free. To ensure seats, click “Register” button here.
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How did Principal Sporleder do it?   “Let’s stop asking kids ‘What’s wrong with you?’   Sporleder told his staff — and start asking ‘What happened to you?’  Then, let’s be quiet and listen with compassion.”

If a student used the “F” bomb, instead of detention they saw the principal. “What bad stuff happened that you’re so upset?” Jim would ask. “My Dad left for Iraq, again!” or “Mom’s drunk so no breakfast,” they’d say. They’d pour out their hearts until Jim reached them emotionally and they felt heard. As they could feel and verbalize emotions, they acted out less.

Leveraging the ACE Study

How did Jim Sporleder learn to do all this?  It began when he found out about the Adverse Childhood Experiences (ACE) Study.  The ACE Study revealed that some 50% of Americans suffer childhood trauma, and that it can flood students’ brains with toxic stress to where they can’t learn.

He also found a wealth of resources on ACEsConnection.com, the social network site for the ACE Study just cited by the White House this week.

Then Jim, the school staff and the students all studied the ACE Study together. Everyone saw that the students weren’t freaks, but instead their behavior was their bodies’ natural reaction to horrible experiences over years.  Student self-respect grew.  As Robin Williams told Matt Damon, “It’s not your fault:” https://www.youtube.com/watch?v=UYa6gbDcx18

The ACE Study and Trauma-Informed Care show that one caring, dependable adult, a teacher or other mentor, can give a kid the relationship they need to heal. Once adults “got them,” the students turned around.

–ACE Study Video by Dr. Vincent Felitti, MD, co-study director: https://www.youtube.com/watch?v=GQwJCWPG478
–Full story on Lincoln High:  https://acestoohigh.com/2012/04/23/lincoln-high-school-in-walla-walla-wa-tries-new-approach-to-school-discipline-expulsions-drop-85
–Trauma-Informed Care  http://www.samhsa.gov/nctic/trauma-interventions

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Kathy’s blogs explore the journey of recovery from childhood trauma by learning about Adult Attachment Disorder in teens and adults, Adult Attachment Theory, and the Adverse Childhood Experiences (ACE) Study.
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Comments are encouraged, with the usual exceptions; rants, political speeches, off-color language, etc. are unlikely to post.  Starting 8-22-16, software will limit comments to 1030 characters (2 long paragraphs) for a while, until we get new software to take longer comments again.

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Can School Heal Kids?

Can School Heal Children in Pain? – Guest Blog by “Paper Tigers” Director James Redford, original date June 3 (photo courtesy of Mr. Redford).

aredfordAfter learning about the overwhelming effects of childhood trauma, I decided to make a film about a school that’s adopted a “trauma-informed” lens.

Documentaries are no walk in the park. They take a lot of time and money; they have a way of making a mockery out of your narrative plans…

Why bother? It’s a good question. For me, I have one simple bar that all my films must clear: an “oh my God!” moment. If a story does not elicit that reaction from deep within my bones, I don’t do it. I count on that sense of awe, concern, wonder, and alarm to carry me through the long haul of making the film…

After three years of hard work and uphill battles, my latest documentary film, Paper Tigers, premiered last week [May 28] at the Seattle International Film Festival. And yet it seems like yesterday that I first encountered the explosive research that linked poor health to childhood trauma.

I didn’t know that adverse childhood experiences — like assault, emotional abuse, observing domestic violence — could fundamentally alter a child’s body and brain. These kids are at risk for every single major disease, including (but not limited to) cancer, diabetes, high blood pressure, and cardiovascular disease. That risk doesn’t include the increased likelihood of “self-soothing behaviors” like smoking, drinking, eating too much food, doing too many drugs, having too much sex.

Put that all together and you have the underpinnings for some of the greatest societal challenges we face. It quickly became clear that social support systems require a deeper understanding of adverse childhood experiences….

The good news is that there are schools, clinics, courts, and communities that are starting to adopt a “trauma-informed” lens.

Click to Read More…

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Kathy’s blogs and Guest Blogs explore the journey of recovery from childhood trauma by learning about Adult Attachment Disorder in teens and adults, Adult Attachment Theory, and the Adverse Childhood Experiences (ACE) Study.

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‘Paper Tigers’ Film: ACE Trauma Can Be Healed

“Resilience practices overcome students’ ACEs in trauma-informed high school, say the data” — Guest Blog by Jane Stevens, Founder of ACEsConnection.com

Paper Tigers Cast Crew Seattle Premier 5-28-15Three years ago, the story about how Lincoln High School in Walla Walla, WA, tried a new approach to school discipline and saw suspensions drop 85% struck a nerve. It went viral – twice — with more than 700,000 page views. Paper Tigers, a documentary that filmmaker James Redford did about the school, premiered last Thursday night [May 28] to a sold-out crowd at the Seattle International Film Festival. Hundreds of communities around the country are clamoring for screenings. [Cast and crew of Paper Tigers after Seattle screening; photo by Jane Stevens]

After four years of implementing the new approach, Lincoln’s results were even more astounding: suspensions dropped 90%, there were no expulsions, and kids grades, test scores and graduation rates surged.

But many educators aren’t convinced. They ask: Can the teachers and staff at Lincoln explain what they did differently? Did it really help the kids who had the most problems – the most adverse experiences? Or is what happened at Lincoln just a fluke? Can it be replicated in other schools?

Last year, Dr. Dario Longhi, a sociology researcher with long experience in measuring the effects of resilience-building practices in communities, set about answering those questions.

The results? Yes. Yes. No. And yes.

In 2010, Jim Sporleder, then-principal of Lincoln High, learned about the CDC-Kaiser Adverse Childhood Experiences (ACE) Study and the neurobiology of toxic stress at a workshop in Spokane, WA. The ACE Study showed a link between 10 types of childhood trauma and the adult onset of chronic disease, mental illness, violence and being a victim of violence…

Here’s what Sporleder learned:

Severe and chronic trauma (such as living with an alcoholic parent, or watching in terror as your mom gets beat up) causes toxic stress in kids. Toxic stress damages kid’s brains. When trauma launches kids into flight, fight or fright mode, they cannot learn. It is physiologically impossible.

They can also act out (fight) or withdraw (flight or fright) in school; they often have trouble trusting adults or getting along with their peers. They start coping with anxiety, depression, anger and frustration by drinking or doing other drugs, having dangerous sex, over-eating, engaging in violence or thrill sports, and even over-achieving.

Sporleder said he realized that he’d been doing “everything wrong” in disciplining kids, and decided to turn Lincoln High into a trauma-informed school.

With the help of Natalie Turner, assistant director of the Washington State University Area Health Education Center in Spokane, WA, Sporleder and his staff implemented three basic changes that essentially shifted their approach to student behavior from “What’s wrong with you?” to “What happened to you?”

Click to Read More…

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Kathy’s blogs and Guest Blogs explore the journey of recovery from childhood trauma by learning about Adult Attachment Disorder in teens and adults, Adult Attachment Theory, and the Adverse Childhood Experiences (ACE) Study.

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The Adult Attachment Interview (AAI) (Pt.2 of 2): Mary Main’s Scary Parent Study

Scary Parents

Mary Main BerkeleyPart 1 of this blog Jan. 23 concluded that by 1978, Dr. Mary Ainsworth’s estimate for U.S. babies was that (A) 23% were Avoidant insecure (avoid parents); (B) only 69% were Securely Attached; and (C) 8% were Ambivalent insecure (unhappy and indecisive).  [FN1, 11]

By 1988, her Strange Situation study had been done with 2,000 infant-parent pairs in 32 studies in 8 countries. By 1999 it  had been done globally with 6,282 infant-parent pairs. Some countries varied, but worldwide results averaged out the same as Ainsworth’s 1978 original. [FN1, 9, 11]

In 1973 Mary Main [above] became Ainsworth’s grad student at Johns Hopkins in Baltimore, working on the Strange Situation experiments from the start. After her doctorate, Main moved to Berkeley, to see if Ainsworth’s Kampala and Baltimore findings would replicate.[FN8]  In 1978 she ran a Strange Situation study of 189 Bay Area infant-parent pairs and made the same findings. [FN10]

But by 1979 Dr. Main was making her own discoveries—out of concern about the parents. “In none of Ainsworth’s original observations was the possibility considered that some mothers… could also be frightening,” Main notes. “For my dissertation at Johns Hopkins, I watched 50 children in the Strange Situation… Using Ainsworth’s three-part classification (secure, avoidant and ambivalent), I found at least five infants could not be classified.”  Ainsworth was concerned, too; in fact, she’d left some babies in her Secure set only since they didn’t fit her other two sets. [FN8]

By 1982, Main decided to “extend attachment theory to include the import of infant exposure to anomalous fear-arousing parental behaviors… The mother is the haven of safety that must be approached in times of danger. However, when the infant’s biological haven of safety has simultaneously become a source of fright, the infant is placed in an irresolvable and disorganizing approach-flight paradox,” she said.  [FN8]

Soon after 1982, Main and Ainsworth agreed that 14-15% of babies actually belong in a new, fourth category: (D) Insecure Disorganized. Their mothers were so frightening that the babies couldn’t develop any consistent response at all. These infants “exhibited a diverse array of inexplicable or overtly conflicted behaviors in the parent’s presence” including “disorganization, disorientation, and confusion.” This includes crying loudly then suddenly freezing; ignoring the parent to rock on hands and knees; moving away; raising hand to mouth in fear; or even swiping at the parent’s face. They seemed vulnerable to dissociation.   [FN11, 8]

This finding that a whopping 15% of average U.S. babies are so insecure they’re almost incoherent was so shocking, it was checked for years and not used as a formal 4th category until after 1990 (the delay confused many scholars during 1982-1990). [FN12] But the number held. Worse, among children of American adolescent mothers the rate is over 31%, and is over 25% in many Third World nations. [FN13]

And: to remove the 14-15% of disorganized babies from Ainsworth’s original 69% Secure, reduced the Secure set to only 54-55%.  What was up with parents that 45-46% of their kids couldn’t manage secure attachment?  If so, Main would have  four categories: Avoidant 23%, Ambivalent 8%, Disorganized, 14-15%, Secure 54-55%.  [FN1, 11]

Mary Main '09 Bowlby-Ainsworth award(Inge Bretherton,Everett Waters)By 1982 Main had seen enough to begin developing the Adult Attachment Interview (AAI).  She’d seen plenty of disorganized babies – that meant a lot of scary parents. She needed a way to document the behavior of parents. [FN14] (Right: Dr. Main receives the Bowlby-Ainsworth Attachment Award, 2009.)

The AAI was designed to document the level of secure, loving attachment the parents had, during their own childhoods with the babies’ grandparents. Parents were asked “both to described their attachment-related childhood experiences – especially their early relations with parents – and to evaluate the influence of these experiences on their development and current functioning.”

Parents were studied not just on facts they gave, but on how coherent a narrative they could produce quickly. That’s easy for folks who had a secure childhood, but difficult for folks who did not. The AAI questions are designed to “surprise the unconscious” to yield information about the “state of mind with regard to attachment” that might not otherwise show up. Each AAI was taped and transcribed verbatim. Then transcripts were classified by specific patterns by independent trained specialists. [FN15, 10]

In 1983 Main also created the “Berkeley Longitudinal Study” to take the Bay Area infant-parent pairs in her 1978 Strange Situation, and study them for a generation. In 1978, the babies were 12-18 months old; Main and her team re-studied these pairs when the kids reached age 6 in 1983, and studied the kids again when they reached 19 in 1996.  [FN8].   In 1983 Main and her team gave three completely different tests to the Bay Area pairs:

— 1. The six year olds were again studied with their parents in the Strange Situation (as in 1978 when they were infants).

— 2. The “sixes” were also individually (without parents) given a new Separation Anxiety Test (SAT): they were shown pictures of children being separated from their parents, then asked how they felt. This was taped, transcribed and sorted by Main’s student Nancy Kaplan into Ainsworth’s three sets: secure, avoidant and ambivalent. [FN16, 8]

— 3. The parents were given the AAI (without their kids). Responses were sorted into three set of adult attachment matching Ainsworth’s three 1978 categories of infant attachment: Secure-autonomous (matching infant Secure), Dismissing (infant Avoidant)  and Preoccupied (infant Ambivalent). (Main’s new 4th category wasn’t in use until after 1990.) [FN 17, 8, 10]

Astonishing Results You’ve Never Heard

Mary Main, Erik Hesse '09 Bolwby-Ainsworth AwardDr Main’s first 1983 results were so astonishing that attachment researchers have been buzzing ever since.  (Dr. Main and Dr. Erik Hesse, right.) Her results were also so important that it’s outrageous that your doctor never learned this in medical school; your therapist (and mine) never heard of this; you’ve never heard of it; and so you have to read about it here, since the media doesn’t report it. It’s hard to even find this story on the internet; I had to sleuth it out.  Her results were:

First: the six year olds’ 1983 responses with parents in the Strange Situation correlated strongly to their 1978 responses in the Strange Situation as infants five years earlier. In 1978 the infants were Securely attached 69%;  Avoidant 23%, and Ambivalent 8%. In 1983 the same kids at six were the same as they had been as infants, in the same percents. [FN7]

Second: the six year olds’ 1983 solo responses to the SAT photos also produced the same results and percentages.

Third: The parents’ 1983 solo responses to the Adult Attachment Interview correlated strongly with just how their own kids had behaved as infants, five full years earlier.  The parents also turned out to be Secure-autonomous (matching infant “Secure”) 69%;  Dismissing (matching infant “Avoidant”) 23%;  and Preoccupied (matching infant “Ambivalent”) 8%.

Fourth:  The match of the parents’1983 AAI security with how securely their babies behaved five years back in 1978, was at an unheard-of level. It correlated more than 70% of the time, in a field where a 20% correlation is highly significant. “A marked relation between a parent’s discussion of his/her own attachment history (AAI), and the offspring’s Strange Situation behavior 5 years previously, had been uncovered.”  [FN8, 10]

Fifth: When the 1978 infants reached age 19 in 1996, they too were given the Adult Attachment Interview. Again results correlated strongly: the 19 year olds’ responses in the AAI in 1996, correlated precisely to their infant behavior in the Strange Situation in 1978, their behavior at six in 1983, and to their parents’ 1983 AAI responses.

That means the Strange Situation predicts an infant’s behavior for life, and the AAI proves it.  [FN8, 10]

Sixth: When after 1990 Mary Main’s four categories were used, the results of all the tests were just as strongly correlated across Main’s four categories, as when data were sorted into only three sets. Main’s four categories did become Avoidant 23%, Ambivalent 8%, Disorganized, 14-15%, and Secure 54-55%.  Whenever responses to the Strange Situation, SAT, and AAI were sorted into these four sets,  the same percents were found. [FN1, 11]

By 2009, over 10,500 subjects globally had been given the AAI and the results continued to average out the same.  [FN18]

“Researchers worldwide have replicated the relation originally uncovered in the Bay Area study between a parent’s status in the Adult Attachment Interview and an infant’s Strange Situation response to that same parent… The same average parent-to-child, secure/insecure match of 75% holds even when the interview is conducted before birth of the first child…

“Describing the strength of this relation across studies conducted several years ago, van I Jzendoorn (1995) calculated that it would take 1,087 further attempted replications, every one yielding insignificant results, to reduce the present relation between adult and infant attachment status to insignificance,” Main concluded. [FN7, p.1091]

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Kathy’s news blogs expand on her book “DON’T TRY THIS AT HOME: The Silent Epidemic of Attachment Disorder—How I accidentally regressed myself back to infancy and healed it all.” Watch for the continuing series each Friday, as she explores her journey of recovery by learning the hard way about Attachment Disorder in adults, adult Attachment Theory, and the Adult Attachment Interview.

Footnotes

FN1  NIH: Benoit, Diane, MD, FRCPC, “Infant-parent attachment: Definition, types, antecedents, measurement and outcome,” Paediatr Child Health, Oct 2004; 9(8) p. 541–545 at: www.ncbi.nlm.nih.gov/pmc/articles/PMC2724160/  4th subhead “Measurement” reports:
“The three ‘organized’ strategies (secure, avoidant and resistant) are assessed in the Strange Situation (SS), a 20-minute laboratory procedure where patterns of infant behaviour toward the caregiver following two brief separations are categorized… “Infants with secure attachment greet and/or approach the caregiver and may maintain contact but are able to return to play, which occurs in 55% of the general population… Infants with insecure-avoidant attachment fail to greet and/or approach, appear oblivious to their caregiver’s return… avoiding the caregiver, which occurs in 23% of the general population. Infants with insecure-resistant [ambivalent] attachment are extremely distressed by separations and cannot be soothed at reunions,  displaying much distress and angry resistance to interactions with the caregiver, which occurs in 8% of the general population.” [This NIH article earlier reports that the remaining “approximately 15% suffer insecure ‘disorganized’ attachment,” citing their own footnote which states “In normal, middle class families, about 15% of  infants develop disorganized attachment.” [23%+8%+15%  = 46% not securely attached.]

FN2  Felitti VJ, MD; Anda RF, MD, et. al, 1998, “Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study,” American Journal of Preventive Medicine 1998;14:245–258.  Detailed article on the ACE Study: http://acestoohigh.com/2012/10/03/the-adverse-childhood-experiences-study-the-largest-most-important-public-health-study-you-never-heard-of-began-in-an-obesity-clinic/

FN3  Karr-Morse, Robin, Wiley, Meredith,  “Scared Sick,”  Penguin Basic Books, 2012

FN4  Porges, Stephen, PhD, “Body, Brain, Behavior: How Polyvagal Theory Expands Our Healing Paradigm,” 2013, http://stephenporges.com/images/NICABM%202013.pdf
“Beyond the Brain: Vagal System Holds the Secret to Treating Trauma,” 2013, http://stephenporges.com/images/nicabm2.pdf
–“The Polyvagal Theory for Treating Trauma,” 2011, http://stephenporges.com/images/stephen%20porges%20interview%20nicabm.pdf
–“Polyvagal theory: phylogenetic substrates of a social nervous system,” International Journal of Psycho-physiology 42, 2001,  Dept. of Psychiatry, Univ. Illinois Chicago, www.wisebrain.org/Polyvagal_Theory.pdf

FN5   Earned secure attachment occurs when we experience harmful parenting, so we start with insecure attachment, but find ways to “rise above” childhood trauma and “are now securely attached… What’s more important than what happened to us, is how we’ve made sense of our own childhood,” Dr. Dan Siegel says. “When we make sense of our past… we become free to construct a new future for ourselves and for how we parent our children. Research is clear: If we make sense of our lives, we free ourselves from the prison of the past.”  (Source: video by Dr. Mary Main, Dr. Erik Hesse, Dr. Daniel J. Siegel, Dr. Marion Solomon: https://www.youtube.com/watch?v=YJTGbVc7EJY )
The question is: what ways?  How do we “rise above” and “make sense” of our childhood trauma?
“Mindfulness has been shown to be effective in healing insecure attachment,” say Siegel’s recent writings. “The purpose of both psychotherapy and mindfulness practice is to provide this internalized secure base. Attunement, whether it is internal in mindfulness, or interpersonal in attachment, is what leads to a sense of secure base.” (The Mindful Therapist: A Clinician’s Guide to Mindsight and Neural Integration, W.W. Norton, 2010;   Mindsight: The New Science of Personal Transformation,  Random House, 2010).
“The regular exercise of mindful awareness seems to promote the same benefits–bodily and affective self-regulation, attuned communication with others, insight, empathy, and the like–that research has found to be associated with childhood histories of secure attachment,” Siegel wrote earlier. “ Mindfulness and secure attachment alike are capable of generating… the same invaluable psychological resource: an internalized secure base.” (Siegel, 2007, Wallin, 2007, p. 5-6).
In his 1999 book “The Developing Mind: How Relationships and the Brain interact to shape who we are,” (Guilford Press),  Siegel defined “earned secure/autonomous attachment” as a pattern noticed by therapists doing the Adult Attachment Interview:  “individuals whose experiences of childhood… [were] likely to produce insecure attachment (avoidant, ambivalent, or disorganized),” but their AAI interview responses instead show “a fluidity in their narratives and a flexibility in their reflective capacity, such that their present state of mind with respect to attachment is rated as secure/autonomous. These individuals often appear… to have had a significant emotional relationship with a close friend, romantic partner, or therapist, which allowed them to develop out of  insecure…into a secure/autonomous AAI status.”

FN6  Bowlby, John, “The Nature of a Child’s Tie to His Mother,” British Psychoanalytical Society, London, 1958; “Attachment and Loss,” New York, Basic Books, 1969

FN7  Main, Mary,  2000, “The Adult Attachment Interview: Fear, attention, safety and discourse processes;” also titled “The Organized Categories of Infant, Child, and Adult Attachment: Flexible vs. Inflexible Attention Under Attachment-Related Stress,” Jour of Amer Psychoanalytic Assoc, 48:1055-1095; 2000.  *p.1091: “The same average parent-to-child, secure/insecure match of 75% holds even when the interview is conducted before birth of the first child…” Lifespanlearn.org/documents/Main.pdf

FN8  Main, Mary, 2005, with Hesse, Erik & Kaplan, Nancy, “Predictability of Attachment Behavior and Representational Processes at 1, 6, and 19 Years of Age – The Berkeley Longitudinal Study,” Chapter 10 of “Attachment from Infancy to Adulthood: The Major Longitudinal Studies,” edited by Klaus E. Grossmann, Karin Grossmann, and Everett Waters, pp. 245–304, New York: Guilford Press. Main refers to it as “Regensburg.”
https://lifespanlearn.org/documents/5.Main Regensburg 2005 .pdf
–Main’s summary of the Strange Situation in this document:
“Ainsworth structured the Strange Situation procedure to include three of Bowlby’s ‘natural clues to danger’ in eight episodes:  1. Introduction to the room.  2. Mother and infant are left alone in a toy-filled environment whose unfamiliarity supplies the first natural clue to danger.  However, the mother’s presence is expected to provide the infant with security sufficient for exploration and/or play.  3. Providing a second clue to danger, a stranger joins the mother and infant.  4. The mother leaves the infant with the stranger, providing two combined clues to increased danger. 5. The mother returns, and the stranger departs…. Many infants initially seek proximity but then, reassured of their mothers’ nearness, resume play. 6.  The mother leaves, and the infant remains entirely alone in the unfamiliar setting. Infant distress can be strong at this point, and this episode is often terminated rapidly. 7. The stranger, rather than the mother, enters the room. 8. The mother returns… By now, most infants are expected to be crying, and actively not only seeking proximity to mothers, but also… indicating a strong desire to be held… Nonetheless, they are expected to settle and renew interest in exploration and play by the end of this 3-minute period…
“Somewhat surprisingly, Ainsworth found that infant responses to separation and reunion in this procedure fell into three distinct, coherently organized patterns of attachment (“secure,” “insecure-avoidant,” and “insecure-ambivalent” (Ainsworth, Blehar, Waters, & Wall, 1978). … Given the length and complexity of this chapter, we suggest individuals divide reading to its three central parts (secure attachment, pp. 261–273; avoidant attachment, pp. 273–279; and disorganized attachment pp. 279–288).”

FN9  (1988 van Ijzendoorn: on global proof of Ainsworth’s 3 categories; written before Main’s 4 category put in use)
van IJzendoorn, Marinus H.; Kroonenberg, Pieter M.  “Cross-Cultural Patterns of Attachment: A Meta-Analysis of the Strange Situation,” Child Development,Vol 59 No 1, Feb 1988, p.147–56.   Abstract: http://www.jstor.org/discover/10.2307/1130396?uid=3739560&uid=2&uid=4&uid=3739256&sid=21103831443011

FN10   Hesse, E., (2008) “The Adult Attachment Interview: Protocol, Method of Analysis, and Empirical Studies,” Chap. 25 of Cassidy, Jude &  Shaver, Phillip R. (Eds), “Handbook of Attachment: Theory, research, and clinical applications,” 2nd edition, 2008, p. 552-598, New York, Guilford Press. It was online (I downloaded it Aug. 2014) but was taken down or has web issues; try here: http://icpla.edu/wp-content/uploads/2012/10/Hesse-E.-Adult-Attachment-Int-Protocol-Method-ch.-25.pdf   [His 1999 version in Cassidy & Shaver’s 1st edition, Chap. 19,  “The Adult Attachment Interview: Historical and current perspectives,” p. 395-433 wasn’t online.]

FN11   (1999 van Ijzendoorn on Main’s nw Disorganized group; confirms Main’s 4 categories)
van IJzendoorn MH, Schuengel C, Bakermans-Kranenburg MJ, Disorganized attachment in early childhood: Meta-analysis of precursors, concomitants and sequelae. Dev Psychopathol. 1999; 11:225–49. [PubMed] at https://openaccess.leidenuniv.nl/bitstream/handle/1887/1530/168_212.pdf?sequence=1

FN12  Main, Mary, & Solomon, Judith, (1986), “Discovery of an insecure disoriented attachment pattern: procedures, findings and implications for the classification of behavior,” in Brazelton T, Youngman M. Affective Development in Infancy, Ablex, Norwood, NJ
Main, M., & Solomon, J. (1990). “Procedures for identifying infants as disorganized/disoriented during the Ainsworth strange situation,” in Greenberg, M. T., Cicchetti, D., & Cummings, M. (Eds.),. Attachment in the preschool years: Theory, research, and intervention (pp. 121-160), University of Chicago Press

FN13  “Among children of American adolescent mothers, the rate is over 31% (Broussard 1995). Disorganized attachment is also common among the Dogon of Mali (~25%, True et al 2001), infants living on the outskirts of Cape Town, South Africa (~26%, Tomlinson et al 2005) and undernourished children in Chile (Waters and Valenzuela 1999),” reports NIH [op cit FN1; NIH cites v. Ijzendoorn 1999 and the other authors just mentioned]

FN14  George, Carol, Kaplan, Nancy, & Main, Mary, “Adult Attachment Interview,” Unpublished MS, Department of Psychology, University of California at Berkeley, third ed. 1996.  Original 74-page MS dated 1984, 1985, 1996.  Described in FN10 op cit Hesse 2008. ( I have it, but it was removed from the web during 2014.)

FN15  Main, Mary B., “Adult Attachment Interview Protocol,” 11 pgs, 20 questions, no date or publisher. Dr. Main requires intensive training for use of the AAI. The questions per se, marked “Do not reproduce this material without permission of the author,”  are here:  http://www.psychology.sunysb.edu/attachment/measures/content/aai_interview.pdf   UCLA’s Lifespan Learning Institute in Los Angeles holds AAI workshops and has an extensive CD  lectures on the AAI at www.lifespanlearn.org

FN16  Kaplan, Nancy, (1987), Separation Anxiety Test (SAT): “Individual differences in six-year-olds’ thoughts about separation: Predicted to actual experiences of separation,”  Unpublished doctoral dissertation, University of California, Berkeley.
Kaplan, N. (2003, April), “The development of attachment in the Bay Area study: One year, six years, nineteen years of age.” Paper at the biennial meeting of the Society for Research in Child Development, Tampa, FL.

FN17  Main 1985; Main & Goldwyn 1984

FN18  Bakermans-Kranenburg MJ, van IJzendoorn MH, “The first 10,000 Adult Attachment Interviews,” Attach Hum Dev. 2009 May; 11(3): 223-63. doi: 10.1080/14616730902814762 at http://www.ncbi.nlm.nih.gov/pubmed/19455453

More by Mary Main on the AAI:
Main, Mary, PhD, “Introduction to the special section on attachment and psychopathology: 2. Overview of the field of attachment,” Journal of Consulting and Clinical Psychology, 64, 237-243, 1996
Steele, Howard and Miriam, Editors, “Clinical Applications of the Adult Attachment Interview,” The Guilford Press,  New York, 2008

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The Adult Attachment Interview (AAI) (Pt.1 of 2): Mary Ainsworth’s Strange Situation

Mary Main & Dan Siegel December-2010-UCLAOnly 55% of us have “secure attachment”– a number which would worry us all if we knew of it–according to research on over 6,280  infant-parent pairs during 1970-1999. [FN1, 11]  And, the attachment we get as infants continues all our lives in our relationships, say related studies of over 10,500 adults done 1982-2009. [FN18]

The math says the other 45% of us suffer “insecure attachment.”  That means 45% can’t handle a committed, stable relationship with anyone, from childhood to the rest of our lives, as of 1999.  We also pass this emotional pain to our children, who turn out similarly.  A National Institute of Health article summarizes the secure rate:  “Infants with secure attachment greet and/or approach the caregiver and maintain contact but are able to return to play, which occurs in 55% of the general population.” [FN1, 11]

This is the blockbuster result of Dr. Mary Ainsworth’s 1970-1978 “Strange Situation” study of babies, as completed by her student Mary Main.  Main’s research led to shocking conclusions. (Dr. Main & Dr. Daniel Siegel, above)

Main discovered so many upset babies, that she got concerned about the parents. So in 1982 she created the Adult Attachment Interview (AAI) to study the adults, releasing results 1984-96.  Her journey was so “Strange” and involved it was published in language hard to decipher (or even google) for most folks. The tale took me weeks to unravel (footnotes below).

This huge “insecure” figure is a predictor of broken homes and broken hearts for half the nation. It starts to explain why we’ve got a 50% divorce rate. If  (like me) you’ve tried over-40 dating after divorce, it won’t surprise you that science shows 50% of adults out there can’t carry on a secure, committed, loving relationship. Ouch, you’ve experienced it.

And if 45% of us were “insecurely attached” in 1999, what’s the percent in 2016?  In 1999 most of us hadn’t heard of the Internet. In almost 20 years since, email, texting, and so on have further trashed our ability to relate in person. Several psychotherapists interviewed for this blog said that a round number of “about 50%” is a  conservative estimate for how many Americans lack secure attachment today. Many believe it’s much higher.

It gets worse; check out another “about 50%” shocker.  The 1998 Adverse Childhood Experiences (ACE) Study showed that two-thirds (64-67%) of  17,421 middle class subjects had one or more types of childhood trauma, and 38-42% had two or more types.  In less privileged populations, these numbers are far higher. A national average of all economic groups would likely show 50% or more suffer severe trauma from ACEs.

The ACE Study lists physical and sexual abuse and 8 other types, including traumas that happen even to newborns like physical and emotional neglect. [FN2]  Such trauma by definition puts children into technical “fight-flight,” a chronic state biologically proven to shut down the organism’s capacity for feelings of attachment and love. Think soldier in a  battle ramped up in “fight-flight”– he can’t really feel much love for the other side. [FN3]

And it doesn’t go away. Continued fight-flight puts the nervous system into freeze: our vagus nerve starts shutting down bodily functions, Dr. Stephen Porges shows. [FN4] So ACEs create the conditions underlying the top 10 medical causes of death in the U.S.

Half of us are in serious emotional health and medical trouble – and don’t even know it.  Let’s get informed –then we can heal. If we didn’t get securely attached as kids, we can develop “earned secure attachment.”  “It’s possible to change attachment patterns,” as Main said in 2010. [FN5]

 Strange Situation  Experiment

bowlby-johnAttachment Theory isn’t new, it just gets too little air time. British psychiatrist John Bowlby (left) developed it in the 1950s while dealing with the post-WWII crisis of dislocated orphans. [FN6]  Bowlby believed that all infants would seek to stay close to parents, since “proximity-seeking behavior” is best for survival. In 1952 he published a study of toddlers’ responses to separation from parents. It showed that “when toddlers were placed in unfamiliar surroundings that provided no stable caregivers, they underwent three… stages of response to separation: protest, despair, and finally detachment.” [FN7]

Mary Ainsworth ca 1990Dr. Mary Ainsworth studied with Bowlby in London 1950-54, then studied this same “proximity-seeking behavior” (attachment) in infant-mother pairs in homes in Kampala, Uganda, published as “Infancy in Uganda” (1967).  Next, she “found astonishing similarities in homes in Baltimore, Maryland.” [FN7]

So Ainsworth created the Strange Situation in the early 1970s, as a science experiment at Johns Hopkins in Baltimore to document this infant behavior. “Ainsworth deliberately structured the Strange Situation to include three of Bowlby’s ‘natural clues to danger’… to arouse babies to seek proximity” to the parent, Main says. Researchers watch and video-tape through one-way glass, as infant-mother pairs react to apparent danger.  First the babies respond to the strange lab room; then to two entrances of a stranger; then separation from mother at two different times. [FN8]

All or most babies were expected to stay close to parents as Bowlby thought.  Such babies “that Ainsworth termed ‘secure,’ play and explore happily prior to separation; show signs of missing the parent during separation, such as crying and calling; seek proximity immediately upon the parent’s return; and then return to play and exploration, ‘secure’ once again in the parent’s presence,” said Main. [FN8]

But 30% of babies did not act secure — they avoided mom.  Given a choice, they show no preference between mom and the stranger.  “While a majority of infants behaved as expected and were termed secure, to Ainsworth’s amazement six showed little or no distress at being left alone in the unfamiliar environment, and then avoided and ignored the mother upon her return.”  [FN7]

Ainsworth decided to categorize these babies separately, as “avoidant” of mother, so now she had two types: (A) Insecure Avoidant, and (B) Secure. She concluded that their mom didn’t respond to them, or respond with enough sensitivity to understand their actual need, so the infants felt “insecure.”  [FN8]

Still later Ainsworth saw that of the insecure babies, some had yet a third reaction: actually, they were “ambivalent” about mom. They were very distressed when mom left, but on her return, they alternated between avoiding and frantic clinging–plus, they never calmed down. Research showed that ambivalent attachment results from moms who are sometimes available, sometimes not, so babies learn they can’t depend on mom to be there when they need her.

Thus it was that “surprisingly, Ainsworth found that infant responses to separation and reunion fell into three distinct, coherently organized patterns of attachment,” and added a third category: (C) Insecure Ambivalent, Main reports. [FN8-9]

By 1978, Ainsworth’s estimate for U.S. babies was (B) Securely attached 69%; (A) Avoidant 23%, (C) Ambivalent 8%.

By 1988, her Strange Situation study had been done with 2,000 infant-parent pairs in 32 studies in 8 countries. By 1999 it  had been done globally with 6,282 infant-parent pairs. Some countries varied, but the worldwide results averaged out the same as Ainsworth’s 1970s studies. Amazing, but it makes sense considering the U.S. is a global melting pot. [FN1, 9, 11]

But stay tuned for my next blog Feb. 6, when Ainsworth’s grad student Mary Main gets into the act big time.  Main found that Ainsworth’s concept of Securely Attached had flaws that made necessary a whole new fourth category of attachment failure.  And a whole lot fewer than 69% turned out to be “secure.”

If you can’t wait for Part 2 on Feb. 6, the whole article is here: http://attachmentdisorderhealing.com/adult-attachment-interview-aai-mary-main/

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Kathy’s news blogs expand on her book “DON’T TRY THIS AT HOME: The Silent Epidemic of Attachment Disorder—How I accidentally regressed myself back to infancy and healed it all.” Watch for the continuing series each Friday, as she explores her journey of recovery by learning the hard way about Attachment Disorder in adults, adult Attachment Theory, and the Adult Attachment Interview.

Footnotes

FN1  NIH: Benoit, Diane , MD, FRCPC, “Infant-parent attachment: Definition, types, antecedents, measurement and outcome,” Paediatr Child Health, Oct 2004; 9(8) p. 541–545 at: www.ncbi.nlm.nih.gov/pmc/articles/PMC2724160/  4th subhead “Measurement” reports:
“The three ‘organized’ strategies (secure, avoidant and resistant) are assessed in the Strange Situation (SS), a 20-minute laboratory procedure where patterns of infant behaviour toward the caregiver following two brief separations are categorized… “Infants with secure attachment greet and/or approach the caregiver and may maintain contact but are able to return to play, which occurs in 55% of the general population… Infants with insecure-avoidant attachment fail to greet and/or approach, appear oblivious to their caregiver’s return… avoiding the caregiver, which occurs in 23% of the general population. Infants with insecure-resistant [ambivalent] attachment are extremely distressed by separations and cannot be soothed at reunions,  displaying much distress and angry resistance to interactions with the caregiver, which occurs in 8% of the general population.” [This NIH article earlier reports that the remaining “approximately 15% suffer insecure ‘disorganized’ attachment,” citing their own footnote which states “In normal, middle class families, about 15% of  infants develop disorganized attachment.” [23%+8%+15%  = 46% not securely attached.]

FN2  Felitti VJ, Anda RF, et. al, 1998, “Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study,” American Journal of Preventive Medicine 1998;14:245–258.  Detailed article on the ACE Study: http://acestoohigh.com/2012/10/03/the-adverse-childhood-experiences-study-the-largest-most-important-public-health-study-you-never-heard-of-began-in-an-obesity-clinic/

FN3  Karr-Morse, Robin, Wiley, Meredith,  “Scared Sick,”  Penguin Basic Books, 2012

FN4  Porges, Stephen, PhD, “Body, Brain, Behavior: How Polyvagal Theory Expands Our Healing Paradigm,” 2013, http://stephenporges.com/images/NICABM%202013.pdf
“Beyond the Brain: Vagal System Holds the Secret to Treating Trauma,” 2013, http://stephenporges.com/images/nicabm2.pdf
–“The Polyvagal Theory for Treating Trauma,” 2011, http://stephenporges.com/images/stephen%20porges%20interview%20nicabm.pdf
–“Polyvagal theory: phylogenetic substrates of a social nervous system,” International Journal of Psycho-physiology 42, 2001,  Dept. of Psychiatry, Univ. Illinois Chicago, www.wisebrain.org/Polyvagal_Theory.pdf

FN5   Earned secure attachment occurs when we experience harmful parenting, so we start with insecure attachment, but find ways to “rise above” childhood trauma and “are now securely attached… What’s more important than what happened to us, is how we’ve made sense of our own childhood,” Dr. Dan Siegel says. “When we make sense of our past… we become free to construct a new future for ourselves and for how we parent our children. Research is clear: If we make sense of our lives, we free ourselves from the prison of the past.”  (Source: video by Dr. Mary Main, Dr. Erik Hesse, Dr. Daniel J. Siegel, Dr. Marion Solomon: https://www.youtube.com/watch?v=YJTGbVc7EJY )
The question is: what ways?  How do we “rise above” and “make sense” of our childhood trauma?
“Mindfulness has been shown to be effective in healing insecure attachment,” say Siegel’s recent writings. “The purpose of both psychotherapy and mindfulness practice is to provide this internalized secure base. Attunement, whether it is internal in mindfulness, or interpersonal in attachment, is what leads to a sense of secure base.” (The Mindful Therapist: A Clinician’s Guide to Mindsight and Neural Integration, W.W. Norton, 2010;   Mindsight: The New Science of Personal Transformation,  Random House, 2010).
“The regular exercise of mindful awareness seems to promote the same benefits–bodily and affective self-regulation, attuned communication with others, insight, empathy, and the like–that research has found to be associated with childhood histories of secure attachment,” Siegel wrote earlier. “ Mindfulness and secure attachment alike are capable of generating… the same invaluable psychological resource: an internalized secure base.” (Siegel, 2007, Wallin, 2007, p. 5-6).
In his 1999 book “The Developing Mind: How Relationships and the Brain interact to shape who we are,” (Guilford Press),  Siegel defined “earned secure/autonomous attachment” as a pattern noticed by therapists doing the Adult Attachment Interview:  “individuals whose experiences of childhood… [were] likely to produce insecure attachment (avoidant, ambivalent, or disorganized),” but their AAI interview responses instead show “a fluidity in their narratives and a flexibility in their reflective capacity, such that their present state of mind with respect to attachment is rated as secure/autonomous. These individuals often appear… to have had a significant emotional relationship with a close friend, romantic partner, or therapist, which allowed them to develop out of  insecure…into a secure/autonomous AAI status.”

FN6  Bowlby, John, “The Nature of a Child’s Tie to His Mother,” British Psychoanalytical Society, London, 1958; “Attachment and Loss,” New York, Basic Books, 1969

FN7  Main, Mary,  2000, “The Adult Attachment Interview: Fear, attention, safety and discourse processes;” also titled “The Organized Categories of Infant, Child, and Adult Attachment: Flexible vs. Inflexible Attention Under Attachment-Related Stress,” Jour of Amer Psychoanalytic Assoc, 48:1055-1095; 2000.  *p.1091: “The same average parent-to-child, secure/insecure match of 75% holds even when the interview is conducted before birth of the first child…” Lifespanlearn.org/documents/Main.pdf

FN8  Main, Mary, 2005, with Hesse, Erik & Kaplan, Nancy, “Predictability of Attachment Behavior and Representational Processes at 1, 6, and 19 Years of Age – The Berkeley Longitudinal Study,” Chapter 10 of “Attachment from Infancy to Adulthood: The Major Longitudinal Studies,” edited by Klaus E. Grossmann, Karin Grossmann, and Everett Waters, pp. 245–304, New York: Guilford Press. Main refers to it as “Regensburg.”
https://lifespanlearn.org/documents/5.Main Regensburg 2005 .pdf
–Main’s summary of the Strange Situation in this document:
“Ainsworth structured the Strange Situation procedure to include three of Bowlby’s ‘natural clues to danger’ in eight episodes:  1. Introduction to the room.  2. Mother and infant are left alone in a toy-filled environment whose unfamiliarity supplies the first natural clue to danger.  However, the mother’s presence is expected to provide the infant with security sufficient for exploration and/or play.  3. Providing a second clue to danger, a stranger joins the mother and infant.  4. The mother leaves the infant with the stranger, providing two combined clues to increased danger. 5. The mother returns, and the stranger departs…. Many infants initially seek proximity but then, reassured of their mothers’ nearness, resume play. 6.  The mother leaves, and the infant remains entirely alone in the unfamiliar setting. Infant distress can be strong at this point, and this episode is often terminated rapidly. 7. The stranger, rather than the mother, enters the room. 8. The mother returns… By now, most infants are expected to be crying, and actively not only seeking proximity to mothers, but also… indicating a strong desire to be held… Nonetheless, they are expected to settle and renew interest in exploration and play by the end of this 3-minute period…
“Somewhat surprisingly, Ainsworth found that infant responses to separation and reunion in this procedure fell into three distinct, coherently organized patterns of attachment (“secure,” “insecure-avoidant,” and “insecure-ambivalent” (Ainsworth, Blehar, Waters, & Wall, 1978). … Given the length and complexity of this chapter, we suggest individuals divide reading to its three central parts (secure attachment, pp. 261–273; avoidant attachment, pp. 273–279; and disorganized attachment pp. 279–288).”

FN9  (1988 van Ijzendoorn: on global proof of Ainsworth’s 3 categories; written before Main’s 4 category put in use)
van IJzendoorn, Marinus H.; Kroonenberg, Pieter M.  “Cross-Cultural Patterns of Attachment: A Meta-Analysis of the Strange Situation,” Child Development,Vol 59 No 1, Feb 1988, p.147–56.   Abstract: http://www.jstor.org/discover/10.2307/1130396?uid=3739560&uid=2&uid=4&uid=3739256&sid=21103831443011

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Dreaming of a Safe America – Laura Kerr

Safe America Dream Laura KerrThis guest blog by Dr. Laura Kerr, PhD, Stanford University, really struck me.  For Americans as people, and our government, she notes, “unconscious dreams and unresolved traumas influence our defensive reactions to threat, much like the child that suffers chronic traumatization is altered by conditions of abuse and neglect.”  Dr. Kerr is a  mental health scholar who writes about trauma, grief and loss — and the social cost of our often not knowing they exist, or how to heal them.

“Dreaming of a Safe America,” by Dr. Laura Kerr

The airstrikes against the Islamic State, a decidedly violent and oppressive group, are deeply unsettling, bringing forth memories of 9/ll and the Iraq and Afghanistan Wars, along with fears that America will never extract itself from this region of the world, or be safe from revengeful terrorist groups. At such times, it’s natural to become defensive, fearful, and even hopeless.

One of the things that makes America a wonderful place to live is that we feel entitled to freedom and safety and feel others are entitled to freedom and safety too. Yet rarely do airstrikes like the ones on Syria feel like a simple exercise in the protection of human rights. America has too many unresolved traumas, too many unspoken desires, for the public to trust a motive as simple as the preservation of freedom and safety.

In this blog post, I try to understand how unconscious dreams and unresolved traumas influence our defensive reactions to threat, much like the child that suffers chronic traumatization is altered by conditions of abuse and neglect. I believe we are at a time in our nation’s history when we must examine the disparity between what we have dreamed of becoming and deal with the reality of what we are: stressed, even traumatized, increasingly fragmented, yet also passionate, resourceful, and capable of honest evaluation. But first we have to let go of our defenses. Even during times of war.

American Dreams

The United States, perhaps like all nations and all people, is caught in unconscious, conflicting drives and denied vulnerabilities. In Dreaming Up America, historical novelist Russell Banks identified three dreams at the heart of America’s unconscious conflicts, dreams that originally drew people to America:

There was El Dorado, the City of Gold that Cortez and Pizarro dreamed of finding. And then there was Ponce de Leon’s dream of the Fountain of Youth, where you could start life over again, and the New England Puritan dream of God’s Protestant utopian City on a Hill, the New Jerusalem…. We can think of there being three braided strands, or perhaps three mutually reinforcing dreams: one is of a place where a sinner can become virtuous, free from the decadence of the secular cosmopolitanism of Old Europe; another is of a place where a poor man can become wealthy; and a third is of a place where a person can be born again.” (2008, pp. 6-7)

The three conflicting impulses of these dreams — renewal, materialism, and spirituality — shape the nation, its institutions, social life, and the American psyche. They determine the myths Americans attempt to live, the fantasies that grab our imaginations, the ideals we hold, and our expectations for the future. These dreams also have a shadow side. They contain the unresolved traumas of past generations, and thus also perpetuate fear, shame, addictions, and disavowed needs. Without healing the shadow side of these dreams, the United States has no other option than to play out its conflicting state of impulses in unhealthy and destructive ways.

These disparate dreams of wealth, rebirth, and redemption have been with the American people since the country’s inception, although according to Banks, they became a source of internal tension after the Civil War. The United States emerged from this conflict as a nation state, which implied, at least in principle, the resolution of internal conflicts for the purpose of creating an integrated and interdependent nation. However, as we know all too well, this was not the case.

Following the Civil War, the United States was incapable of true integration. For one thing, the Civil War was particularly gruesome. Over 620,000 people died — far more Americans than in any other US-involved conflict. (About 1,264,000 soldiers have died in the nation’s wars.) And although the Civil War ended slavery, it did not end racism or inequality, and thus failed to uphold the ideal of universal, inalienable rights laid out in the Constitution, the doctrine intended to unite us all as equals.

Thus, after the Civil War, there was a false sense of integration. To use psychological parlance, we could say the US created a false self. The creation of a false self is common to trauma survivors. It hides the split off aspects of experience and identity that either the survivor is unaware of, or fears retribution for, if others were to know the traumatized parts and the memories they hold. And Americans have suffered many traumas — including the numerous wars, slavery, oppression, racism, sexism, as well as family violence — and all reveal the failure of democracy to create a country of safe and equal citizens.

When caught in a habitual cycle of denying or dissociating parts of ourselves, event the faintest reminders are susceptible to unconscious projection onto others. When traumatic memories are particularly offensive, and contain overwhelming feelings of shame or helplessness, the need to rid oneself of the offending and unacceptable traits and emotions can lead to a search for a scapegoat, someone or something to contain the overwhelming feelings that otherwise might shatter the fragile persona that keeps them at bay.

And indeed, the United States often functions much like the trauma survivor who projects the wounded parts of itself onto scapegoats rather than risk the uncertainty of facing a traumatized past. Scapegoating happens in relation to other countries and peoples when we demonize them, and in our own country when people are devalued or brutalized due to their ethnic origins, their gender or their sexual orientation, the region of the country they live in, or their lack of resources. And often those who have been victimized later become the ones seeking scapegoats.

For the rest of this post and its invaluable footnotes, CLICK HERE: http://www.laurakkerr.com/2014/09/24/dreaming-safe-america/

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Kathy’s news blogs expand on the ideas in her book “DON’T TRY THIS AT HOME: The Silent Epidemic of Attachment Disorder—How I accidentally regressed myself back to infancy and healed it all.”  Watch for the continuing series each Friday, as Kathy and her guest bloggers write about attachment disorder in adults, trauma, grief and loss, adult attachment theory, and the Adult Attachment Interview.

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Is Our Medical System Traumatizing Us?

StethoscopeHey, it happens to us all. I’m healthy as a horse, but a body part was bugging me, so at my annual check up I asked to see a specialist.  I love my family doc, er I mean “primary care,” and I love this specialist.  They’re the best there is.  And they’re victims of the system as much as we.  I’m grateful they’re here just when I need them, with all their years of training and miraculous skills. I don’t want to cause them trouble, so let’s call it “body part X.”

It took months to get authorization for the specialist, thanks to insurance lunacy. Meanwhile X got worse, but still I expected just a routine new prescription.

The new doc walked in, took one look, and said, “You’ve got [deleted] here, and also there. You can go on like that for a while, and  I could just write you another prescription for Y [as it’s been handled before].  But you’ll be back in a year because it will get worse.  It’s not for me to tell you what to do, but we can replace [body part X] with an implant…

“Outpatient surgery takes 20 minutes, insurance pays for it all because it’s legally classified as  ‘medically necessary’ since otherwise you’re going to lose your Z [essential function]. Then you can forget about the problem, you’ll be done.”  (And no, it wasn’t prostate cancer.)

“Outpatient surgery”?  So professional.  Me?  I’ve just been told, “you’re getting a knife in a real scary place.”

The specialist (I do like him) told me later that at that first meeting, he then proceeded to outline my options for the different available types of inplants, and following surgery, what functional abilities each implant type would give me. I was with him less than 20 minutes. Next he sent me on to his medical assistant to be checked by one more machine, who sent me to their lady “surgery coordinator.”  By which time I was hit by a barrage of panic from my belly.

I’ve never had more than a tooth pulled in my life, and OK, I’ve always been a “fraidy cat.” And all I could think of was “Surgery. Surgery? Surgery — there?

From the first mention of “surgery,” clearly I was in trauma. But why did this occur to no one, with so many professionals there?  They seemed so oblivious that anything upsetting could possibly have occured, I was afraid to show it.

“We’ve discovered in our work in trauma that going to the gynecologist, pediatrician, social worker at school, any of the helping professions, can be traumatic,” says trauma expert Dr. Mary Jo Barrett (below right). “People with prior trauma, especially, experience their attempts to get help from the medical system as traumatic – because they experience it as a threat to their bodies.”  [FN1]

Mary Jo BarrettAnd according to the ACE Study, roughly 50% of us suffer one or more types of Adverse Childhood Experience (ACE) trauma. That means half of us are going to experience such a medical issue as trauma.  Including clearly me.

But in fact any human who’s a mammal will experience something like this as trauma, science is just starting to show.  And even the most well-meaning, kindly medical personnel have never gotten the memo on what is trauma and how their system contributes to it.

Not to mention the legions of pretty much heartless medical personnel who have had their humanity forcibly ripped out of them by their training. Psychiatric expert Dr. Daniel Siegel, MD, says he almost quit med school when he realized he was being deliberately trained to destroy his emotions and view patients as machinery to be fixed, in the name of better performance.

No Time to Think – Let Alone Feel

Not to mention the insurance companies who now force doctors to stay glued to a stop-watch while seeing patients. Docs are forced to spend no more than X (pardon the pun) minutes per patient, no matter what, or they won’t be paid, can’t pay their staff or their astronomical malpractise insurance premiums, and must close their doors.

Upset?  Shove it.  Suddenly there I was with the “surgery coordinator,” and I had no time to panic, feel any emotion, or even to think. Wham, she hit me with a barrage of wildly complex surgery insurance questions involving a five-way tangle between my HMO, the specialist, the primary doc, the doctors’ “medical group,” and the hospital– made more complex by the fact that my insurance was about to change radically in three months. Worse, she was the type who quickly rattles off a list of in-house acronyms that only an insurance exec could understand, then says “OK?”

No, it was most definitely not ok.  In fact with all my experience handling insurance companies over many years, 15 years experience interviewing engineers about rocket science, a BS in Math and 3 foreign languages — I still couldn’t understand a word she said.  Surely she’s good at what she does, but her ability to explain what she does to another human being was sub zero.

As I began to drown under her spiel, that internal voice just got louder: “Surgery. Surgery? Surgery — there?

On she went with questions about my meds, vitamins, lifestyle, and complicated instructions about new meds they were going to give me before surgery, and when to take what in a detailed month-long schedule. The level of detail would have overwhelmed anyone who’d just been given good news. By the time she was done rattling, the office was about to close at 5 pm and I was ushered out.

No more than two minutes of the entire two hour ordeal had been allowed for discussion of, or even for me to think about, the real Square One decision at hand:  Surgery? Go for surgery, or not?

“Surgery. Surgery? Surgery — there?”  It seemed like a nightmare from which I’d soon wake up. As it turned out, that feeling lasted about ten days.  I kept thinking, “Oh, this is just a bad dream. I’ll wake up any minute.”  No such luck. Somehow I made it through an evening of appointments straight until 9 pm, drove home and collapsed at 11 pm.

Involuntary Reaction to Survival Threat

Stephen Porges mages“Medical procedures send many of the cues to the nervous system that physical abuse has,” warns Dr. Stephen Porges (left). “We need to be very careful about how we deal with people and whether or not even medical practices trigger some of the features of PTSD…

“Our clothing is taken away. They remove your glasses. We’re left in a public place and all predictability is gone. Many of the features that our nervous system uses to regulate and feel safe are disrupted,” says Porges. [FN2]

“And one of the most potent triggers of neuroception un-safety, is low-frequency sounds which the neurological system interprets as ‘predator.’ In ‘Peter and the Wolf,’  friendly characters are always the violins, flute, and oboe. Predator is always conveyed via lower frequency sounds. Medical environments are dominated by low frequency sounds of ventilation systems and equipment. Our nervous system responds, without our awareness, to these acoustic features and shifts physiological state.”

Medical pronouncements about what’s going to happen to our bodies, and medical environments generally “trigger ‘neuroception’,” Porges explains, “the neural circuits regulating the autonomic nervous system” tell our bodies that we are under threat. The news goes straight to our brain stem which takes action, without ever involving our thinking brain. Something entirely involuntary happens.

“Neuroception is not perception. It does not require an awareness of what’s going on,” says Porges. “Throw away the word ‘perception.’  Neuroception is detection without awareness.  It is a neural circuit that evaluates risk in the environment from a variety of cues. When our mammalian social engagement system is working and down-regulating defenses, we feel calm, we hug people, we look at them and we feel good.  But in response to danger, our sympathetic nervous system takes control and supports metabolic motor activity for fight/flight.  But next, if that doesn’t get us to safety, the ancient unmyelinated vagal circuit shuts us down,” says Porges, literally describing shock.

He gives an example: himself.  “I had to get an MRI. Many of my colleagues conduct research using the MRI, and I thought, ‘This will be a very interesting experience.’  You have to lay down flat on a platform and the platform is  moved into the magnet. I enthusiastically lay down on the platform for this new experience. I felt really good. I was not anxious…

“Slowly the platform moved into a very small opening of the MRI magnet. When it got up to my forehead, I said, “Could I get a glass of water?” They pushed me out and I took my glass of water.  I lay down again and it moved until my nose was in the magnetic.  I said, ‘I can’t do this.’  I could not deal with the confined space; it basically was putting me into a panic attack…  And an MRI produces massive amounts of low-frequency sounds…

“My perceptions, my cognitions, were not compatible with my body’s response.  I wanted to have the MRI.  It wasn’t dangerous. But, something happened to my body when I entered the MRI. There were certain cues that my nervous system was detecting and those cues triggered a defensive of wanting to mobilize to get out of there. And I couldn’t do anything about it. I couldn’t think my way out of it. I couldn’t even close my eyes and visualize my way out of it. I had to get out of there! Now when I have a MRI, I take medication.”

I could go on.  I could tell you how I dealt with the question “should I have this surgery” the very next day, by getting a second opinion in my area, and was told “Yes, and soon.”

I could tell you how after a few days, I realized that the next looming question was what type of implant to choose, how long it would take each type of implant to get approved through the insurance maze, and where each type would leave my body functions after surgery.  So I put out queries to the second specialist, and to three personal friends in Maryland, New York, and Illinois who are doctors, who all polled their colleague specialists in body part X.   All of them came back with conflicting advice.

I didn’t ask my first specialist because I’d been told by the surgery coordinator to wait for a packet by mail, believing it would tell me how to select implants.  But when it came a week later, it didn’t mention implants.

As noted, the specialist said later that at our first meeting, he did outline my options for the different types of implants. I was with him less than 20 minutes, half of which was a physical exam with a lot of machines.

Perhaps he gave a good briefing, but I was in “Surgery!?!” trauma, and my brain was out to lunch — like Dr. Porges in the MRI.  If so, didn’t he realize I might be too preoccupied by the word “Surgery” to hear all those critical complex details immediately?

Perhaps he just read me an incomprehensible list in under a minute.  I’ll never know; I simply can not remember even a single mention that first day of this issue, which is still tying up many of my waking hours at this writing.

Because now, nine days later, I have his read-out, and read-outs from the other four specialists – and none of them agree on the implants.  Some of them even imply that the type my specialist is recommending could be a health hazard long term.  And none of them have the remotest idea there might be a bit of trauma after all this at my end.

It’s 1 am and time to post this blog — so I can get up tomorrow and try to get this straightened out in time to select the correct implants, in time to get them authorized by insurance, in time for —  surgery.

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Kathy’s news blogs expand on her book “DON’T TRY THIS AT HOME: The Silent Epidemic of Attachment Disorder—How I accidentally regressed myself back to infancy and healed it all.” Watch for the continuing series each Friday, as she explores her journey of recovery by learning the hard way about Attachment Disorder in adults, adult Attachment Theory, and the Adult Attachment Interview.

Footnotes

FN1 Barrett, Mary Jo, MSW, “Addressing PTSD: How to Treat the Patient without Further Trauma,”
NICABM Webinar, June 29, 2011. Dr. Barrett’s latest book is “Treating Complex Trauma: A Relational Blueprint for Collaboration and Change,” orders are here:  http://goo.gl/SEiWVD  and http://www.centerforcontextualchange.org/publishedworks.html

FN2 Porges, Stephen, PhD, “The Polyvagal Theory for Treating Trauma,” 2011, http://stephenporges.com/images/stephen%20porges%20interview%20nicabm.pdf
—“Body, Brain, Behavior: How Polyvagal Theory Expands Our Healing Paradigm,” 2013, http://stephenporges.com/images/NICABM%202013.pdf
“Beyond the Brain: Vagal System Holds the Secret to Treating Trauma,” 2013, http://stephenporges.com/images/nicabm2.pdf
—”Polyvagal theory: phylogenetic substrates of a social nervous system,” International Journal of Psycho-physiology 42, 2001,  Dept. of Psychiatry, Univ. Illinois Chicago, www.wisebrain.org/Polyvagal_Theory.pdf

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Bruce Perry: No Empathy, No Survival

Dr. Bruce Perry, MD, “Born for Love:
“Why Empathy is Essential – and Endangered”
Address to The National Council for Behavioral Health
Washington, DC, May 4, 2014  – Click link or photo for video
https://www.youtube.com/watch?v=M6kDeBaJi0M

“Empathy is what makes us human,” says brain scientist Dr. Bruce Perry, MD  –  but this has not sunk in for Americans.  If simple kindness isn’t enough, what about the minor fact that it’s brain science?  Or that by ignoring this basic fact, we’re violating biology, so we’re dying as a species?

To let Dr. Perry make his point, today I’ve just got a few quotes from his May 4 Washington DC address, to provoke you to watch the video kindly posted by the National Council for Behavioral Health.

”From birth, we seek intimate connections, bonds made possible by empathy — the ability to love and to share the feelings of others,” Perry begins. But “our  policies routinely violate the biological reality of empathy, and that’s destructive…

“For example, we pass on to the next generation explicit choices that we’re going to teach math — but not music…We don’t care if everyone learns to read and perform music or not, but they’ve got to do arithmetic…  We have extensive rules for all the things everyone has to learn to drive a car… but we don’t do the same for raising a child!  We don’t make any systematic recommendations, or ensure that everybody who’s about to have a child has the fundamental knowledge of what’s necessary for the child…

“We’re exposing our children to levels of violence as a problem solving technique, at rates that are at least 50 times greater than alternate methods of problem-solving…

“We have invented ourselves into a corner with technology… into models of child rearing, education, and building communities that is fundamentally disrespectful of two of the greatest (biological) gifts our species has:  the fundamental malleability of the human brain in early life, and the fundamental relational (empathic) nature of human beings…. As a result we are much more vulnerable to mental health, social health, cognitive health, and physical  health  problems.

Humans Need Humans Around to Live

Perry another headshot“Human beings are biological creatures with genetic gifts… The only way we survived was by forming relationships, collaborative relationships…  Human beings are neurobiologically meant to be connected to others: to live, work, hunt, play, invent, and die in groups.

“We use the word ‘independent’ a lot — but the truth is there’s not a single human on this planet, ever, that’s been independent.  All of our physiology is designed to connect to others, we have huge parts of our brain designed purely to respond to the non-verbal cues of others… it’s in the way our face is oriented, our facial configuration is forward, looking at people… We have sensory apparatus on our skin that’s meant to be touched… so that we can feel somebody caress us…

“Our brain is a social organ; we are social animals. We don’t have any natural body armor, camouflage, stinging other things. We form groups!  Human beings are ‘meat on feet’ to the natural world!  The only way we survive is by forming collaborative groups, by sharing what we hunted and what we gathered with everybody else in our group.  And the typical living group was a developmentally heterogeneous, multi-family, multi-generational group: 40 to 50 people.

“And in that group…  the ratio of developmentally more mature individuals who cared for you, protected you, nurtured you…  was four to one.  But now, we think it’s an incredibly enriched early child care environment if there’s one caregiver to six kids!  That’s 1/24  the relational density the brain benefits from…

“Today, the whole organization of society flies in the face of this… In the last census, one third of American households were one person.

“On top of which, now… the typical American spends 11 hours a day interacting with digital devices, and not with fleshy objects!  And I want to talk about the consequences of this for how we end up expressing our ability to be compassionate (or not)…. You see it all the time, complaints in the psychological literature about the disconnectedness of multi-tasking constantly with our phones… but we do it ourselves…  You’re talking to someone, then your phone will vibrate — and it pulls you away from them.

” It breaks the rhythm of social contact, of empathic engagement– and the truth is: those things are physiologically meaningful.”

Again, click here for video:
https://www.youtube.com/watch?v=M6kDeBaJi0M

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Kathy’s news blogs expand on her book “DON’T TRY THIS AT HOME: The Silent Epidemic of Attachment Disorder—How I accidentally regressed myself back to infancy and healed it all.” Watch for the continuing series each Friday, as she explores her journey of recovery by learning the hard way about Attachment Disorder in adults, adult Attachment Theory, and the Adult Attachment Interview.

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Bruce Perry: Attachment and Developmental Trauma

BrousBlog9a Perry head shotDr. Bruce Perry, MD (left) documents the brain science of how attachment problems can cause developmental trauma to a fetus, infant, or child – just when the brain is developing.

And he’s taking his “attachment first” approach to Washington.  In “Trauma Impacts the Brain: Healing Happens in Relationships,” Perry leads a full-day Pre-conference University on Sunday May 4, to kick off  the National Council for Behavioral Health’s Annual Conference ’14 on May 5-7 (click here for details).

“Experiences profoundly influence the development of young children. Adverse Childhood Experiences (ACEs) shape the brain’s organization, which, in turn, influences the emotional, social, cognitive, and physiological activities,” the conference website notes.

“So often, trauma happens in relationships, but it is also in relationships that healing occurs. Explore the latest research and clinical treatment with trauma researcher, treatment visionary, and bestselling author of The Boy Who Was Raised as a Dog, and Born for Love:  Why Empathy is Essential and Endangered, Dr. Bruce Perry.”

Dr. Perry’s relationship and attachment theory healing model first assesses each child as an individual, using his  Neurosequential Model of Therapeutics (NMT).  He emphasizes that there is no one label for child trauma. Rather, “there are very individualized patterns of exposure to trauma (all with unique timing, nature, and patterns)… So we don’t call ‘it’ anything,” he wrote me recently. “We describe it — and try to ‘illustrate’ each individual’s trajectory separately” with the NMT’s individualized brain mapping technique. [FN1]

Dr. Perry recommends his books above as the best summaries of his work.  His latest research and key slides are online from his National Council webinar last fall, “Helping Children Recover from Trauma,” National Council LIVE, Sept. 5, 2013 (scroll down to Sept. 2013.)  I really recommend this – and it will only be online through August 2014.

Click here for an overview video:   [FN2]

Survival Brain Develops First

BrousBlog9c Perry Slide1 Brain 4 PartsDr. Perry says we’ve got to learn about the neuro-biological growth of the brain in order of time sequence from  conception to later development in infancy and childhood.

His “Four Part Brain” slide (above) shows the time sequence from the bottom up: first the brain stem develops (pink); then the diencephalon cerebellum (yellow); they make up our primitive reptilian “survival” brain.  Next develop the emotional limbic brain which only mammals have (green), and finally the thinking brain aka frontal cortex (blue).

The fetus’ “survival brain” develop first, because infants require breathing, heart beat, and other survival functions at birth, Dr. Perry told a March 2013 UCLA conference. The rest of the brain develops largely after birth and as an outgrowth of the brain stem. [FN3]

So injury during brain stem development in the first 45 months harms development of the entire brain, the neurons around the viscera, and most of the body.

Dr. Perry next details three key threats to an infant’s developing brain:  Trauma in utero (intra-uterine insult); post-birth attachment trauma; and other post-natal trauma – all before the thinking brain comes on line around age 3.

A fetus in utero is designed to develop in nurturing oxcytocin and other “reward” chemicals released by a mother supported by her family, all joyous a baby is coming. Intra-uterine insult occurs when the mother instead uses substances, or is under stress so that her stress hormones impact the fetus’ developing brain. This can be visible stress to the mother: domestic abuse, work stress, violence.

A fetus, however, can also be subject to stress chemicals with no visible external stress to the mother, as in mothers who are anxious, themselves victims of attachment disorder, don’t want a baby, etc.  Often these mothers have no steady pattern to their heart rate, and since a baby’s brain grows according to the mother’s heart rate rhythm, the baby’s brain develops dysregulated.

All these “causes a cascade of mental and physical problems in every part of the body and brain,” Perry says. “Every part of the whole brain these neurons enervate will be dysregulated.”

Birth: the Mother of All Stress

Attachment trauma occurs easily because birth is incredibly stressful to a baby: suddenly there’s lack of oxygen, blinding light, shocking cold, terrifying noise, and pain. This floods a baby with stress hormones — which is essential because now it’s not having needs met as in the womb; thus it’s got to protest so someone comes. “If animals in the wild didn’t feel the stress of hunger they’d just lie around and die of starvation,” Perry notes.

Mom Smile Baby If all goes as designed, an attuned mother meets the baby’s needs, feeds it, swaddles it, turns down the lights, so the baby feels safe and is flooded with reward optiates like oxytocin. If animals didn’t feel opiate rewards when they get up and eat just what they need (not dirt, for example), they’d not get up.

Then they wouldn’t survive, so the stress hormones and the reward opiates are linked. “At the relief of hungry-thirsty-cold stress, we feel pleasure,” Dr. Perry says. An attuned mother “has a well-organized neurobiology to create a healthy organized neural network for the infant of attachment and regulation…

“And in the arms of that caregiver, that is that magic moment literally weaving together the neurobiology of all these different systems. The biology of attachment is that a baby learns by thousands of good experiences that this stress is tolerable because it leads to reward, and this pleasurable outcome is cathexsized to a person, Mom… Ultimately just seeing or hearing Mom makes you feel safe and pleasurable. Let a wounded soldier talk to his mom, he’ll need 45% less pain meds.”

Or not.

If mom instead is under too much stress herself to meet needs, has too many children and no support, or herself was raised by a mis-attuned mom, “she doesn’t get reward from responding to her baby’s distress,” Perry continues. “So the pull to respond isn’t there.”

Even if no stress to the mother is visible, “if she merely meets physical needs, without involving her own pleasure systems, then the weaving together of meeting needs and the reward/safety system is weak or absent. So her baby learns that stress can be life-threatening, that stress is terrifying,” Dr. Perry concludes. [FN3 op. cit.]

The “Or Not” baby’s brain learns: “that’s all she wrote.”

It develops in a state of perpetual stress in which the stress chemicals simply do not stop and the reward chemicals never or seldom come. In this state, fight/flight cortisol flood eventually leads to “freeze” dissociation, Judith Herman reported back in 1992. [FN4]

More Perry slides at: http://attachmentdisorderhealing.com/how-your-brain-works-101/

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Kathy’s news blogs expand on her book “DON’T TRY THIS AT HOME: The Silent Epidemic of Attachment Disorder—How I accidentally regressed myself back to infancy and healed it all.” Watch for the continuing series each Friday, as she explores her journey of recovery by learning the hard way about Attachment Disorder in adults, adult Attachment Theory, and the Adult Attachment Interview.

Footnotes

FN1 Perry, B.D. and Hambrick, E. (2008), “The Neurosequential Model of Therapeutics (NMT),” in Reclaiming Children and Youth, 17 (3) 38-43;  and
Dobson, C. & Perry, B.D. (2010), “The role of healthy relational interactions in buffering the impact of childhood trauma in “Working with Children to Heal Interpersonal Trauma: The Power of Play,” (E. Gil, Ed.) The Guilford Press, New York, pp. 26-43
Both at: http://childtrauma.org/nmt-model/references/

FN2  Bruce Perry MD, Daniel Siegel MD, et.al, “Trauma, Brain & Relationship: Helping Children Heal,” www.youtube.com/watch?v=jYyEEMlMMb0 – introductory video on Attachment Disorder and development trauma. Copies at www.postinstitute.com/dvds.

FN3  Perry, Bruce D., MD,  “Born for Love: The Effects of Empathy on the Developing Brain,” Annual Interpersonal Neurobiology Conference “How People Change: Relationship & Neuroplasticity in Psychotherapy,” UCLA, Los Angeles, March 8, 2013 (unpublished).
Library of articles on interventions, trauma, brain development: https://childtrauma.org/cta-library/
Training in NMT Method and Somatosensory Regulation, Power of Rhythm — Individual and Site Training Certification Programs, DVD/streaming training, and online training: http://www.ctaproducts.org
Dr. Perry’s latest research and key slides: “Helping Children Recover from Trauma,” National Council LIVE, National Council on Behavioral Health, Sept. 5, 2013 at www.thenationalcouncil.org/events-and-training/webinars/webinar-archive/  (scroll down to Sept. 2013.)
Dr. Perry’s YouTube channel with educational videos in depth: https://www.youtube.com/channel/UCf4ZUgIXyxRcUNLuhimA5mA?feature=watch

FN4  Herman, Judith, “Trauma and Recovery,” Basic Books, New York, 1992

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The Adult Attachment Interview (AAI): Mary Main in a Strange Situation

Mary Main & Dan Siegel December-2010-UCLA[Updated 7-7-16]  Only 55% of us have “secure attachment”– a number which would worry us all if we knew about it–according to research on over 6,280  infant-parent pairs during 1970-1999. [FN1, 11]  And, the attachment we get as infants continues all our lives in our relationships, say related studies of over 10,500 adults done 1982-2009. [FN18]

The math says the other 45% of us suffer “insecure attachment.”  That means 45% can’t handle a committed, stable relationship with anyone, from childhood to the rest of our lives, as of 1999.  We also pass this emotional pain to our children, who turn out similarly.  A National Institute of Health article summarizes the secure rate:  “Infants with secure attachment greet and/or approach the caregiver and maintain contact but are able to return to play, which occurs in 55% of the general population.” [FN1, 11]

This is the blockbuster result of Dr. Mary Ainsworth’s 1970-1978 “Strange Situation” study of babies, as completed by her student Mary Main.  Main’s research led to shocking conclusions. (Dr. Main & Dr. Daniel Siegel, above)

Main discovered so many upset babies, that she got concerned about the parents. So in 1982 she created the Adult Attachment Interview (AAI) to study the adults, releasing results 1984-96.  Her journey was so “Strange” and involved it was published in language hard to decipher (or even google) for most folks. The tale took me weeks to unravel (footnotes below).

This huge “insecure” figure is a predictor of broken homes and broken hearts for half the nation. It starts to explain why we’ve got a 50% divorce rate. If  (like me) you’ve tried over-40 dating after divorce, it won’t surprise you that science shows 50% of adults out there can’t carry on a secure, committed, loving relationship. Ouch, you’ve experienced it.

And if 45% of us were “insecurely attached” in 1999, what’s the percent in 2016?  In 1999 most of us hadn’t heard of the Internet. In almost 20 years since, email, texting, and so on have further trashed our ability to relate in person. Several psychotherapists interviewed for this blog said that a round number of “about 50%” is a  conservative estimate for how many Americans lack secure attachment today. Many believe it’s much higher.

It gets worse; check out another “about 50%” shocker.  The 1998 Adverse Childhood Experiences (ACE) Study showed that two-thirds (64-67%) of  17,421 middle class subjects had one or more types of childhood trauma, and 38-42% had two or more types.  In less privileged populations, these numbers are far higher. A national average of all economic groups would likely show 50% or more suffer severe trauma from ACEs.

The ACE Study lists physical and sexual abuse and 8 other types, including traumas that happen even to newborns like physical and emotional neglect. [FN2]  Such trauma by definition puts children into technical “fight-flight,” a chronic state biologically proven to shut down the organism’s capacity for feelings of attachment and love. Think soldier in a  battle ramped up in “fight-flight”– he can’t really feel much love for the other side. [FN3]

And it doesn’t go away. Continued fight-flight puts the nervous system into freeze: our vagus nerve starts shutting down bodily functions, Dr. Stephen Porges shows. [FN4] So ACEs create the conditions underlying the top 10 medical causes of death in the U.S.

Half of us are in serious emotional health and medical trouble – and don’t even know it.  Let’s get informed –then we can heal. If we didn’t get securely attached as kids, we can develop “earned secure attachment.”  “It’s possible to change attachment patterns,” as Main said in 2010. [FN5]

 Strange Situation  Experiment

bowlby-johnAttachment Theory isn’t new, it just gets too little air time. British psychiatrist John Bowlby (left) developed it in the 1950s while working on the post-war orphan crisis. [FN6]  Bowlby believed that all infants would seek to stay close to parents, since such “attachment” promotes survival. In 1952 he published a study of toddlers’ responses to separation from parents. It showed that “when toddlers were placed in unfamiliar surroundings that provided no stable caregivers, they underwent three… stages of response to separation: protest, despair, and finally detachment.” [FN7]

Mary Ainsworth ca 1990Dr. Mary Ainsworth studied with Bowlby in London 1950-54, then researched his concept of “proximity-seeking behavior” in infant-mother pairs in Kampala, Uganda, published as “Infancy in Uganda” (1967).  Then she found “astonishing similarities” in Baltimore, MD pairs. [FN7]

Ainsworth created the Strange Situation in the early 1970s, as a science experiment at Johns Hopkins in Baltimore to document this infant behavior. “Ainsworth structured the Strange Situation to include three of Bowlby’s ‘natural clues to danger’… to arouse babies to seek proximity” to the parent, Main says. Researchers watch and video-tape through one-way glass, as infant-mother pairs react to apparent danger.  First a baby responds to a strange lab room; then to two entrances of a strange person; then to  two different separations from its mother. [FN8]

Babies were expected to stay close to parents as Bowlby thought.  Babies “that Ainsworth termed ‘secure,’ play and explore happily prior to separation; show signs of missing the parent during separation, such as crying and calling; seek proximity immediately upon the parent’s return; then return to play and exploration, ‘secure’ once again in the parent’s presence,” said Main. [FN8]

But 30% of babies did not act secure — they avoided mom.  They showed no preference between mom and the stranger!  “While a majority of infants behaved as expected and were termed secure, to Ainsworth’s amazement six showed little or no distress at being left alone in the unfamiliar environment, then avoided and ignored the mother on her return.”  [FN7]

Ainsworth decided to categorize these babies separately, as “avoidant” of mother. Now she had two types: (A) Insecure Avoidant, and (B) Secure. She concluded that their mom didn’t respond to them, or have the sensitivity to understand their actual need, so the infants felt “insecure.”  [FN8]

Still later Ainsworth saw that of the insecure babies, some had yet a third reaction: actually, they were “ambivalent” about mom. They were very distressed when mom left, but on her return, they alternated between avoiding and frantic clinging–plus, they never calmed down. Research showed that ambivalent attachment results from moms who are sometimes available, sometimes not, so babies learn they can’t depend on mom.

Thus it was that “surprisingly, Ainsworth found that infant responses to separation and reunion fell into three distinct, coherently organized patterns of attachment,” and added a third category: (C) Insecure Ambivalent, Main reports. [FN8-9]

By 1977 Ainsworth had categorized U.S. babies as (B) Securely attached 69%; (A) Avoidant 23%, (C) Ambivalent 8%.

By 1988 Strange Situation research had been done with 2,000 infant-parent pairs in 32 studies in 8 countries. By 1999 it  had been done globally with 6,282 infant-parent pairs. Some countries varied, but global results averaged the same as Ainsworth’s 1977 categories.  [FN1, 9, 11]

Scary Parents:  The Adult Attachment Interview

Mary Main BerkeleyIn 1973 Mary Main became Ainsworth’s grad student at Johns Hopkins in Baltimore, working on the Strange Situation experiments from their start. After her doctorate Main moved to Berkeley, to see if Ainsworth’s Kampala and Baltimore findings would replicate. [FN8]  In 1977 Main did a Strange Situation study of 189 Bay Area infant-parent pairs which did replicate Ainsworth. [FN8,10]

But by 1979 Dr. Main was making her own discoveries—out of concern about the parents. “In none of Ainsworth’s original observations was the possibility considered that some mothers… could also be frightening,” Main notes. “For my dissertation at Johns Hopkins, I watched 50 children in the Strange Situation… Using Ainsworth’s three-part classification (secure, avoidant and ambivalent), I found at least five infants could not be classified…

“I had visited most of the mothers in their homes,” Main said, “and I knew that at least three of the five mothers of the un-classifiable infants had behaved most peculiarly with their offspring. One—frighteningly, to me—had treated her toddler as an animal.” [FN8]

Ainsworth was concerned, too; in fact, she’d left some babies in her Secure set only because they didn’t fit her other two sets. [FN8]

By 1982, Main decided to “extend attachment theory to include the import of infant exposure to anomalous fear-arousing parental behaviors… The mother is the haven of safety that must be approached in times of danger. However, when the infant’s biological haven of safety has simultaneously become a source of fright, the infant is placed in an irresolvable and disorganizing approach-flight paradox,” she said.  [FN8]

Soon after, Main and Ainsworth agreed that 14-15% of babies actually belong in a new, fourth category: (D) Insecure Disorganized. Their mothers were so frightening that the babies couldn’t develop any consistent response at all. These infants “exhibited a diverse array of inexplicable or overtly conflicted behaviors in the parent’s presence” including “disorganization, disorientation, and confusion,” Main wrote. This included crying loudly then suddenly freezing; ignoring the parent to rock on hands and knees; moving away; raising hand to mouth in fear; or even swiping at the parent’s face. They seemed vulnerable to dissociation.   [FN11, 8]

This finding that a whopping 15% of average U.S. babies are so insecure they’re almost incoherent was so shocking, it was checked for years and not used as a formal 4th category until after 1990 (this delay confuses many scholars who look at 1982-1990). [FN12]  But the number held. Worse, among children of American adolescent mothers the rate is over 31%, and is over 25% in many Third World nations. [FN13]

Further: to remove the 14-15% of disorganized babies from Ainsworth’s original 69% Secure, reduced the Secure set to only 54-55%.  What was up with parents that 45-46% of their kids couldn’t manage secure attachment?  Main was developing  four categories: Avoidant 23%, Ambivalent 8%, Disorganized, 14-15%, Secure 54-55%.  [FN1, 11]

Mary Main '09 Bowlby-Ainsworth award(Inge Bretherton,Everett Waters)By 1982 Main had seen enough to create the Adult Attachment Interview (AAI).  She’d seen plenty of disorganized babies, and that meant a lot of scary parents. She needed a way to document the behavior of the parents. [FN14] (Right: Dr. Main (center) receives the 2009 Bowlby-Ainsworth Attachment Award.)

The AAI was designed to document the level of secure, loving attachment the parents had, during their own childhoods with their babies’ grandparents. Parents were asked “both to described their attachment-related childhood experiences – especially their early relations with parents – and to evaluate the influence of these experiences on their development and current functioning.”

Parents were studied not just on facts they gave, but on how coherent a narrative they could produce quickly. That’s easy for folks who had a secure childhood, but difficult for folks who did not. The AAI questions are designed to “surprise the unconscious” to yield information about the “state of mind with regard to attachment” that might not otherwise show up. Each AAI was taped and transcribed verbatim. Then transcripts were classified by specific patterns by independent trained specialists. [FN15, 10]

In 1982 Main also created the “Berkeley Longitudinal Study” to take 67 Bay Area infant-parent pairs from her 1977 Strange Situation and study them for a generation. In 1977 the babies were 12-18 months old.  Main and her team re-studied these pairs when the kids reached age 6 in 1982, and studied the kids again when they reached 19 in 1995.  [FN8,10]  In 1982 Main and her team gave three different tests to the Bay Area pairs:

— 1. The six year olds were again studied with their parents in the Strange Situation (as in 1977 when these kids were infants).

— 2. The “sixes” were also individually (without parents) given a new Separation Anxiety Test (SAT): they were shown pictures of children being separated from their parents, then asked how they felt. This was taped, transcribed and sorted by Main’s student Nancy Kaplan into Ainsworth’s three sets: secure, avoidant and ambivalent. [FN16, 8]

— 3. The parents were given the AAI (alone). Responses were sorted into three types of adult attachment matching Ainsworth’s three categories of infant attachment: Secure-autonomous (matching infant Secure), Dismissing (infant Avoidant)  and Preoccupied (infant Ambivalent). (Again, Main’s 4th category wasn’t used until after 1990.) [FN17, 8, 10]

Astonishing Results You’ve Never Heard

Mary Main, Erik Hesse '09 Bolwby-Ainsworth AwardDr Main’s first 1982 AAI results were so astonishing that attachment researchers have been buzzing ever since.  (Dr. Main and Dr. Erik Hesse, right.) Her results were also so important, it’s a tragedy that your doctor never learned this in medical school; your therapist (and mine) never heard of it; you’ve never heard of it; and so you have to read about it here, since the media doesn’t report it. It’s hard to even find this story on the internet; I had to sleuth it out.  Dr. Main’s initial AAI results were:

First: the six year olds’ 1982 responses to parents in the Strange Situation correlated strongly to their 1977 responses in the Strange Situation as infants — five years earlier. In 1977 the infants were Securely attached 69%;  Avoidant 23%, and Ambivalent 8%. In 1982 these kids at six responded to parents just as they had as infants, in the same percents. [FN7]

Second: the six year olds’ 1982 solo responses to the SAT photos also produced the same results and percentages.

Third: The parents’ 1982 solo responses to the Adult Attachment Interview correlated strongly with how their kids behaved as infants in the Strange Situation — five  years earlier.  The parents also turned out to be Secure (matching infant “Secure”) 69%;  Dismissing (matching infant “Avoidant”) 23%;  and Preoccupied (matching infant “Ambivalent”) 8%.

Fourth:  The match of the parents’ own 1982 AAI security, with how secure their babies were five years back in 1977, was at an unheard-of level. It correlated more than 70% of the time, in a field where a 20% correlation is highly significant. “A marked relation between a parent’s discussion of his/her own attachment history (AAI), and the offspring’s Strange Situation behavior 5 years previously, had been uncovered.”  [FN8, 10]

Fifth: When the 1977 infants reached age 19 in 1995, they too were given the Adult Attachment Interview. Again results correlated strongly: the 19 year olds’ responses in the 1995 AAI correlated precisely to their infant behavior in the 1977 Strange Situation, their 1982 behavior at six, and to their parents’ 1982 AAI responses.  This was astonishing.

It means that the Strange Situation predicts an infant’s emotional behavior for life, and the AAI proves it.  [FN8, 10]

Sixth: When after 1990 Mary Main’s four categories were used, the results of all these tests correlated just as strongly across the four new categories, as when data were sorted into only three sets. Main’s four categories did become Avoidant 23%, Ambivalent 8%, Disorganized, 14-15%, and Secure 54-55%.  Whenever responses to the Strange Situation, SAT, and AAI were sorted into these four sets, the same percents were found. [FN1, 11]

By 2009, over 10,500 subjects globally had been given the AAI and the results continue to average out the same.  [FN18]

“Researchers worldwide have replicated the relation originally uncovered in the Bay Area study between a parent’s status in the Adult Attachment Interview and an infant’s Strange Situation response to that same parent… The same average parent-to-child, secure/insecure match of 75% holds even when the interview is conducted before birth of the first child…

“Describing the strength of this relation across studies conducted several years ago, van I Jzendoorn (1995) calculated that it would take 1,087 further attempted replications, every one yielding insignificant results, to reduce the present relation between adult and infant attachment status to insignificance,” Main concluded. [FN7, p.1091]

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Kathy’s news blogs expand on her book “DON’T TRY THIS AT HOME: The Silent Epidemic of Attachment Disorder—How I accidentally regressed myself back to infancy and healed it all.” Watch for the continuing series each Friday, as she explores her journey of recovery by learning the hard way about Attachment Disorder in adults, adult Attachment Theory, and the Adult Attachment Interview.

Footnotes

FN1  NIH: Benoit, Diane, MD, FRCPC, “Infant-parent attachment: Definition, types, antecedents, measurement and outcome,” Paediatr Child Health, Oct 2004; 9(8) p. 541–545 at: www.ncbi.nlm.nih.gov/pmc/articles/PMC2724160/  4th subhead “Measurement” reports:
“The three ‘organized’ strategies (secure, avoidant and resistant) are assessed in the Strange Situation (SS), a 20-minute laboratory procedure where patterns of infant behaviour toward the caregiver following two brief separations are categorized… “Infants with secure attachment greet and/or approach the caregiver and may maintain contact but are able to return to play, which occurs in 55% of the general population… Infants with insecure-avoidant attachment fail to greet and/or approach, appear oblivious to their caregiver’s return… avoiding the caregiver, which occurs in 23% of the general population. Infants with insecure-resistant [ambivalent] attachment are extremely distressed by separations and cannot be soothed at reunions,  displaying much distress and angry resistance to interactions with the caregiver, which occurs in 8% of the general population.” [This NIH article earlier reports that the remaining “approximately 15% suffer insecure ‘disorganized’ attachment,” citing their own footnote which states “In normal, middle class families, about 15% of  infants develop disorganized attachment.” [23%+8%+15%  = 46% not securely attached.]

FN2  Felitti VJ, MD; Anda RF, MD, et. al, 1998, “Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults: The Adverse Childhood Experiences (ACE) Study,” American Journal of Preventive Medicine 1998;14:245–258.  Detailed article on the ACE Study: http://acestoohigh.com/2012/10/03/the-adverse-childhood-experiences-study-the-largest-most-important-public-health-study-you-never-heard-of-began-in-an-obesity-clinic/

FN3  Karr-Morse, Robin, Wiley, Meredith,  “Scared Sick,”  Penguin Basic Books, 2012

FN4  Porges, Stephen, PhD, “Body, Brain, Behavior: How Polyvagal Theory Expands Our Healing Paradigm,” 2013, http://stephenporges.com/images/NICABM%202013.pdf
“Beyond the Brain: Vagal System Holds the Secret to Treating Trauma,” 2013, http://stephenporges.com/images/nicabm2.pdf
–“The Polyvagal Theory for Treating Trauma,” 2011, http://stephenporges.com/images/stephen%20porges%20interview%20nicabm.pdf
–“Polyvagal theory: phylogenetic substrates of a social nervous system,” International Journal of Psycho-physiology 42, 2001,  Dept. of Psychiatry, Univ. Illinois Chicago, www.wisebrain.org/Polyvagal_Theory.pdf

FN5   Earned secure attachment occurs when we experience harmful parenting, so we start with insecure attachment, but find ways to “rise above” childhood trauma and “are now securely attached… What’s more important than what happened to us, is how we’ve made sense of our own childhood,” Dr. Dan Siegel says. “When we make sense of our past… we become free to construct a new future for ourselves and for how we parent our children. Research is clear: If we make sense of our lives, we free ourselves from the prison of the past.”  (Source: video by Dr. Mary Main, Dr. Erik Hesse, Dr. Daniel J. Siegel, Dr. Marion Solomon: https://www.youtube.com/watch?v=YJTGbVc7EJY )
The question is: what ways?  How do we “rise above” and “make sense” of our childhood trauma?
“Mindfulness has been shown to be effective in healing insecure attachment,” say Siegel’s recent writings. “The purpose of both psychotherapy and mindfulness practice is to provide this internalized secure base. Attunement, whether it is internal in mindfulness, or interpersonal in attachment, is what leads to a sense of secure base.” (The Mindful Therapist: A Clinician’s Guide to Mindsight and Neural Integration, W.W. Norton, 2010;   Mindsight: The New Science of Personal Transformation,  Random House, 2010).
“The regular exercise of mindful awareness seems to promote the same benefits–bodily and affective self-regulation, attuned communication with others, insight, empathy, and the like–that research has found to be associated with childhood histories of secure attachment,” Siegel wrote earlier. “ Mindfulness and secure attachment alike are capable of generating… the same invaluable psychological resource: an internalized secure base.” (Siegel, 2007, Wallin, 2007, p. 5-6).
In his 1999 book “The Developing Mind: How Relationships and the Brain interact to shape who we are,” (Guilford Press),  Siegel defined “earned secure/autonomous attachment” as a pattern noticed by therapists doing the Adult Attachment Interview:  “individuals whose experiences of childhood… [were] likely to produce insecure attachment (avoidant, ambivalent, or disorganized),” but their AAI interview responses instead show “a fluidity in their narratives and a flexibility in their reflective capacity, such that their present state of mind with respect to attachment is rated as secure/autonomous. These individuals often appear… to have had a significant emotional relationship with a close friend, romantic partner, or therapist, which allowed them to develop out of  insecure…into a secure/autonomous AAI status.”

FN6  Bowlby, John, “The Nature of a Child’s Tie to His Mother,” British Psychoanalytical Society, London, 1958; “Attachment and Loss,” New York, Basic Books, 1969

FN7  Main, Mary,  2000, “The Adult Attachment Interview: Fear, attention, safety and discourse processes;” also titled “The Organized Categories of Infant, Child, and Adult Attachment: Flexible vs. Inflexible Attention Under Attachment-Related Stress,” Jour of Amer Psychoanalytic Assoc, 48:1055-1095; 2000.  *p.1091: “The same average parent-to-child, secure/insecure match of 75% holds even when the interview is conducted before birth of the first child…” Lifespanlearn.org/documents/Main.pdf

FN8  Main, Mary, 2005, with Hesse, Erik & Kaplan, Nancy, “Predictability of Attachment Behavior and Representational Processes at 1, 6, and 19 Years of Age – The Berkeley Longitudinal Study,” Chapter 10 of “Attachment from Infancy to Adulthood: The Major Longitudinal Studies,” edited by Klaus E. Grossmann, Karin Grossmann, and Everett Waters, pp. 245–304, New York: Guilford Press. Main refers to it as “Regensburg.”
https://lifespanlearn.org/documents/5.Main Regensburg 2005 .pdf
–Main’s summary of the Strange Situation in this document:
“Ainsworth structured the Strange Situation procedure to include three of Bowlby’s ‘natural clues to danger’ in eight episodes:  1. Introduction to the room.  2. Mother and infant are left alone in a toy-filled environment whose unfamiliarity supplies the first natural clue to danger.  However, the mother’s presence is expected to provide the infant with security sufficient for exploration and/or play.  3. Providing a second clue to danger, a stranger joins the mother and infant.  4. The mother leaves the infant with the stranger, providing two combined clues to increased danger. 5. The mother returns, and the stranger departs…. Many infants initially seek proximity but then, reassured of their mothers’ nearness, resume play. 6.  The mother leaves, and the infant remains entirely alone in the unfamiliar setting. Infant distress can be strong at this point, and this episode is often terminated rapidly. 7. The stranger, rather than the mother, enters the room. 8. The mother returns… By now, most infants are expected to be crying, and actively not only seeking proximity to mothers, but also… indicating a strong desire to be held… Nonetheless, they are expected to settle and renew interest in exploration and play by the end of this 3-minute period…
“Somewhat surprisingly, Ainsworth found that infant responses to separation and reunion in this procedure fell into three distinct, coherently organized patterns of attachment (“secure,” “insecure-avoidant,” and “insecure-ambivalent” (Ainsworth, Blehar, Waters, & Wall, 1978). … Given the length and complexity of this chapter, we suggest individuals divide reading to its three central parts (secure attachment, pp. 261–273; avoidant attachment, pp. 273–279; and disorganized attachment pp. 279–288).”

FN9  (“van Ijzendoorn 1988,” global replication of Ainsworth’s 3 categories; written before Main’s 4th category came into use) – van IJzendoorn, Marinus H.; Kroonenberg, Pieter M.  “Cross-Cultural Patterns of Attachment: A Meta-Analysis of the Strange Situation,” Child Development,Vol 59 No 1, Feb 1988, p.147–56.   Abstract: http://www.jstor.org/discover/10.2307/1130396?uid=3739560&uid=2&uid=4&uid=3739256&sid=21103831443011

FN10  Hesse, E., (2008) “The Adult Attachment Interview: Protocol, Method of Analysis, and Empirical Studies,” Chap. 25 of Cassidy, Jude &  Shaver, Phillip R. (Eds), “Handbook of Attachment: Theory, research, and clinical applications,” 2nd edition, 2008, p. 552-598, New York, Guilford Press. It was online (I downloaded it Aug. 2014) but was taken down or has web issues; try here: http://icpla.edu/wp-content/uploads/2012/10/Hesse-E.-Adult-Attachment-Int-Protocol-Method-ch.-25.pdf   [His 1999 version in Cassidy & Shaver’s 1st edition, Chap. 19,  “The Adult Attachment Interview: Historical and current perspectives,” p. 395-433 wasn’t online.]

FN11   (“van Ijzendoorn 1999” on Main’s new Disorganized category; confirms need for 4 categories)  van IJzendoorn MH, Schuengel C, Bakermans-Kranenburg MJ, Disorganized attachment in early childhood: Meta-analysis of precursors, concomitants and sequelae. Dev Psychopathol. 1999; 11:225–49. https://openaccess.leidenuniv.nl/bitstream/handle/1887/1530/168_212.pdf?sequence=1

FN12  Main, Mary, & Solomon, Judith, (1986), “Discovery of an insecure disoriented attachment pattern: procedures, findings and implications for the classification of behavior,” in Brazelton T, Youngman M. Affective Development in Infancy, Ablex, Norwood, NJ
Main, M., & Solomon, J. (1990). “Procedures for identifying infants as disorganized/disoriented during the Ainsworth strange situation,” in Greenberg, M. T., Cicchetti, D., & Cummings, M. (Eds.),. Attachment in the preschool years: Theory, research, and intervention (pp. 121-160), University of Chicago Press

FN13  “Among children of American adolescent mothers, the rate is over 31% (Broussard 1995). Disorganized attachment is also common among the Dogon of Mali (~25%, True et al 2001), infants living on the outskirts of Cape Town, South Africa (~26%, Tomlinson et al 2005) and undernourished children in Chile (Waters and Valenzuela 1999),” reports NIH [op cit FN1; NIH cites v. Ijzendoorn 1999 and the other authors just mentioned]

FN14  George, Carol, Kaplan, Nancy, & Main, Mary, “Adult Attachment Interview,” Unpublished MS, Department of Psychology, University of California at Berkeley, third ed. 1996.  Original 74-page MS dated 1984, 1985, 1996.  Described in FN10 op cit Hesse 2008. ( I have it, but it was removed from the web during 2014.)

FN15  Main, Mary B., “Adult Attachment Interview Protocol,” 11 pgs, 20 questions, no date or publisher. Dr. Main requires intensive training for use of the AAI. The questions per se, marked “Do not reproduce this material without permission of the author,”  are here:  http://www.psychology.sunysb.edu/attachment/measures/content/aai_interview.pdf   UCLA’s Lifespan Learning Institute in Los Angeles holds AAI workshops and has an extensive CD  lectures on the AAI at www.lifespanlearn.org

FN16  Kaplan, Nancy, (1987), Separation Anxiety Test (SAT): “Individual differences in six-year-olds’ thoughts about separation: Predicted to actual experiences of separation,”  Unpublished doctoral dissertation, University of California, Berkeley.
Kaplan, N. (2003, April), “The development of attachment in the Bay Area study: One year, six years, nineteen years of age.” Paper at the biennial meeting of the Society for Research in Child Development, Tampa, FL.

FN17  Main 1985; Main & Goldwyn 1984

FN18  Bakermans-Kranenburg MJ, van IJzendoorn MH, “The first 10,000 Adult Attachment Interviews,” Attach Hum Dev. 2009 May; 11(3): 223-63. doi: 10.1080/14616730902814762 at http://www.ncbi.nlm.nih.gov/pubmed/19455453

More by Mary Main on the AAI:
Main, Mary, PhD, “Introduction to the special section on attachment and psychopathology: 2. Overview of the field of attachment,” Journal of Consulting and Clinical Psychology, 64, 237-243, 1996
Steele, Howard and Miriam, Editors, “Clinical Applications of the Adult Attachment Interview,” The Guilford Press,  New York, 2008

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