Tag Archives: Allan Schore

New EMDR Therapy for Developmental Trauma

Paulsen Sandra PhotoGuest blog by Dr. Sandra Paulsen (left) & D. Michael Coy, MA, LCSW

[First I discovered it deep within myself and called it “trauma since the sperm hit the egg.”  Then I read that Bessel van der Kolk calls it “developmental trauma,” in his drive to have it finally recognized by the psychiatric profession. Dr. Allan Schore calls it “trauma in the first 1000 days, conception to age two.”  Earlier it was “complex PTSD” or C-PTSD.  In EMDR therapy, Dr. Sandra Paulsen, therapist Katie O’Shea, LCPC (who began this work), and D. Michael Coy, MA, LCSW, use “Early Trauma” (ET).  The science is in Chaps. 16 & 20 of Paulsen’s 2014 book. [FN1]
[Well: “ET, phone home!” Dr. Paulsen & friends have good news: they’ve created new EMDR therapy
protocols to heal developmental trauma. -kb ]

Eye Movement Desensitization and Reprocessing (EMDR) therapy “enables people to heal from the symptoms and emotional distress that result from disturbing life experiences,” says Dr. Francine Shapiro’s EMDR Institute website. Standard EMDR therapy has been shown to heal traumatic memories with a conscious, visual component, also called “explicit” memory. As EMDR clinicians, we have seen frankly astounding changes in our clients, both in how they see themselves and in how they experience and take initiative in the world.

But with in utero and infant Early Trauma (ET) occurring from conception to age three, also called developmental trauma, there is no conscious, explicit narrative memory — infants have not developed the parts of the brain which can think.  These traumas precede the existence of consciousness, so they’re called pre-conscious or “implicit” memories. Such memories are “somatic,” that is, held purely in the body — so healing is far more challenging.

How can we listen to the unspoken experience when, so early on, there were no words to tell it? How can we help the body tell its silent—or silenced—story?

Limitations of EMDR Therapy Standard Protocols

OShea Katie PhotoSandra Paulsen and colleague Katie O’Shea  (right) observe the limitations of standard EMDR as applied to early trauma, specifically:

1) There is no explicit memory in the first years of life, only implicit memory, so the standard EMDR procedure of targeting a memory of trauma could not apply;
2) If a client were able to access early experience in EMDR therapy, it could easily be overwhelming, without adequate preparation;
3) Early experience, when accessed, also accesses the client’s “felt sense” from that early time, with all the limits of self and inner structure that went along with pre-natal, infant, and early childhood developmental stages; [FN1]
4) Because of the paramount importance of relationship and caregiver attachment in infancy, the processing of early experience via EMDR therapy required modification to ensure the client had the felt sense of the therapist’s compassionate and attentive presence; and,
5) Because very early experience is ephemeral and does not consciously register as pictures or videos (as later memories may), the new EMDR therapy needed to explicitly accommodate the subtlety of infant early processing.

For these reasons a four step protocol was developed, starting with the work of therapist Katie O’Shea, who later brought it to the attention of Sandra Paulsen. They then worked to make these new ideas coherent with the latest neurobiology research by Jack Panksepp, Allan Schore, Daniel J. Siegel, et. al.

Four Steps of the Early Trauma (ET) Approach to EMDR Therapy

Early Trauma reprocessing includes the following steps to provide remedies to the limitations of standard EMDR therapy approaches above.  NB: There is substantially more to the treatment than described in this brief summary.

1) Cultivating structured containment of all experience yet to be “learned from or sorted through,” to leave a clear “emotional desktop” for work to occur;

2) Developing a felt sense of safety as a starting point for the work, which is achieved by tapping into and strengthening a naturally occurring (but sometimes hidden) “safe state” in the body. Both steps 1 and 2 may require client practice outside of therapy sessions;

3) The most mysterious step—resetting the affective circuits—involves clearing the emotional pathways that develop in each of us early on during our development in the womb, but which may be congested from maladaptive early learning and inhibitions about whether emotions are okay and safe. Once the circuits are clear, they can function as they were intended, to conduct emotional information between the brain and the body. This step may work directly on subcortical affective circuits, according to Jaak Panksepp in his groundbreaking book, Affective Neuroscience. For individuals with complex trauma histories and/or emotional dysregulation and imbalance, there may need to be additional preparation, most commonly ego state work; further education about healthy emotion, brain functioning and/or trauma; sometimes somatic work; and,

4) Clearing the early trauma, which happens by processing small time periods, beginning with a time before conception (owing to what is theorized to be generational, cellular memory), then moving on to conception, gestation in the womb, birth, and on through the first few years of life. These time periods are variable with the client, depending how “gnarled” the roots of the tree have become by growing around early obstacles. The clearing may be of somatic/implicit memory or of explicit memory, or mental constructs related to the time periods. For each time period, if it doesn’t resolve spontaneously, there is an imaginal good outcome of “what you needed, the way you needed it to be.”
As noted, there is much more to it, but for many the careful application of these steps produces a critical emotional shift with subsequent increase in emotional stability, comfort, and peaceful relation to one’s emotions and the self.

The Mechanics of the Early Trauma Approach

Sandra Paulsen BookThe experience of the infant is almost entirely a “felt sense,” as there is not much cognition at the beginning. So when therapy taps into those early felt senses, it often occurs without as the access to the more conscious and cognitively informed resources usually available to adults. Because of its central role in early life, this felt sense is an ideal entry point for attending to early, emotionally overwhelming experience so that it can be reprocessed and cleared.

As we are relying upon the most primitive information available to reprocess early experience, the standard EMDR therapy modality of eye movements or taps conducted with equipment may be too scary, too technical, and too alienating for some. Therefore, the reprocessing is facilitated by tapping on the client’s ankles, while the client is sitting back in a comfortable, reclining chair.

Because processing may occur over a period of hours, people often want to take off their shoes. This certainly makes it easier to tap on the ankles, and is mentioned here because people sometimes wish they’d worn different socks!
Early trauma reprocessing is designed to come in from the beginning, ‘under the floor-boards’, so to speak, so it is typically quite gentle and tolerable in comparison to consciously-focused EMDR therapy. Grounding is needed much less than in standard EMDR therapy procedures. People learn a lot about their own story in this lovely and very powerful procedure.

Highly-dissociative people are only appropriate for this method if they have already established considerable groundwork in therapy and there is a self-system to allow the work. The early trauma therapist ideally is experienced in working with dissociative clients and addressing concerns protective parts may have, as this piece is critical to ensuring positive outcomes in early trauma resolution work. If a potential client is dissociative and, after the initial evaluation, the early trauma therapist agrees to work with the client using the EMDR early trauma approach, it is necessary that the client have an ongoing therapeutic relationship to receive them after leaving the intensive work, assuming that the client is not working with the early trauma therapist in an ongoing treatment relationship. When the client has a primary therapist, it is typically necessary for the client to grant written permission for the early trauma therapist to collaborate with the primary therapist before and/or after the early trauma work takes place.

Intensive or Week by Week Treatments?

D. Michael CoyAlthough early trauma reprocessing can occur piecemeal, from week to week, hour by hour, this can be both terribly inefficient and not particularly cost-effective. The ideal way to experience this type of reprocessing is in extended, face-to-face sessions. Because the work is subtle, deep, and more felt than thought about in a conscious way, extended sessions allow the work to unfold viscerally and deeply. It’s akin to being on a commercial flight from Chicago to Minneapolis versus a flight from Chicago to Tokyo: yes, you get somewhere in both cases, but if you’re on the long-haul flight, you’re up in the air longer, you move more quickly, and your fuel efficiency is significantly better.

Notably, the Dr. Paulsen uses the intensive approach exclusively. In some instances where there is an ongoing therapy relationship, and insurance coverage is involved, the early trauma therapist and client may resolve that week-by-week treatment is the only way to go. This is the only option for a number of the clients who see Michael (above left), either because the client is not able to do the intensive work immediately (owing to extended preparation being needed), wishes to use their insurance in order to afford it, or they’d like to do the work in the context of longer-term therapy work.

However, the client should expect that it will take a number of months to complete the process of clearing early trauma. Michael does both intensive and week-to-week early trauma resolution work, as appropriate and necessary. Other therapists experienced in the EMDR early trauma approach likely structure the work in a way that fits the needs of their own practice and clients.

It is not easy to predict whether a client will need one, two, or more days of intensive work to clear the entirety of early disturbances and replace it with a felt sense of well-being. This goal is typically possible, but not necessarily easy to schedule or predict. Most people who have participated in intensives require two to three days, or more, to clear the first few years. The time required is variable, based upon how many traumatic experiences there were, how much neglect there was, and how maladaptive the learning outcomes were from those experiences. (Note that it’s not you as an adult who consciously assesses all of what was traumatic in those early times. Your brain did that for you before you were even consciously aware that any kind of wounding was taking place.)

Is This Treatment Right for You?

As different EMDR early trauma therapists may handle assessment, differently, we will speak here to how we approach it. Diagnostic assessment involves looking with the client at the following factors: 1) the client’s present safety and stability; 2) the client’s capacity for experiencing emotion and body sensation; 3) any internal conflicts that may complicate or block trauma resolution; 3) medical concerns; 4) substance use; 5) any evidence of structural dissociation, which would require additional assessment and preparation prior to embarking on trauma resolution work of any kind.

Biographical assessment is also an important piece of assessment. The biographical assessment covers areas of the client’s history such as work, education, military service, nutrition and self-care, basic family history, spiritual and cultural experience, and so on. Biographical assessment can provide both a helpful ‘fly over’ of the client’s experience, as well as point out the ‘smoke trails’ emanating from the client’s early, unresolved experience.

During and After Early Trauma Intensive/Reprocessing

On the first day of the intensive, the therapist and client ensure that all the necessary preparatory steps have either already been undertaken, or they will begin there in the work together.

It is not unusual for a client to feel ‘drained’ after early trauma reprocessing has taken place. Most people don’t want to do much in the evenings after an intensive session. The work is profound and will take some time set aside for introspection just plain rest.

Self-care is key in this work, so plan on drinking plenty of water, getting plenty of sleep, inviting oneself to dream, eat good food, maybe take some anti-oxidants because the client will be releasing energetic holdings. Fruits and vegetables will be put to good work in reconfiguring a ‘new you’. If the client is traveling from a different time zone, it is recommended that they are taking Melatonin or some other supplement (as approved by their primary care physician, as appropriate) to manage the effects of jet lag.

After the work, the nervous system will be “knitting and purling” for a time, and this is usually gentle and comfortable. Occasionally, if the work was paused in a gnarly hurtful baby spot, the client may feel stuck there. In those instances, the client may need help in person or by phone to move through such a spot.

It is also really important to keep in mind that any unusual experiences during the work or in the time right after the work may be related to the work. One can think of these as ‘vapors leaking up from King Tut’s tomb’. So, for example, if the client’s spouse, partner, or a good friend seems, for whatever reason, suddenly to resemble demon spawn, they are encouraged to consider the possibility that something about the early work has a theme of demon spawn in it somewhere.

Similarly, if it seems to the client that the early trauma therapist is suddenly just like the meanest parent ever, they are encouraged to mention this, because, although it may have a basis in present time (and, for Michael, his dogs might agree, depending on which chew-thing he’s rescued from them that day), we’ll consider that, often those kinds of feelings and perceptions are part of the client’s story, telling itself without words. The therapist and client use
information in the room and about what is happening between them, moment to moment, as clues to that story. Client and therapist become detectives together, hearing the client’s story together, however it seems to want to be heard. The most common unsettling experience after early trauma work is to feel oddly inert or flaccid. This seems to be part of a baby state, as if baby is just sitting, waiting, not mobilized for much action.

Closing Thoughts

We feel honored to do this important early trauma work with their clients. Michael was fortunate to have been trained in the EMDR early trauma approach both by its originator Katie O’Shea and by Sandra Paulsen, PhD, with whom Katie has collaborated to bring it to public consciousness and develop it into a replicable, systematic process for healing early wounding that can be used safely and effectively even in the most complex situations. (Notably, a cartoon book for therapists and clients on the EMDR early trauma is currently in press.)

We consider this work a sacred trust. It is such a privilege to hear the story of the baby within that may never have been told or heard before, except in symptoms or reenactments. The EMDR early trauma therapist’s intention is to help the client review, release and repair very early experience in a way that provides a felt sense of well-being. We encourage our clients to spend a little time before we meet identifying, if they don’t already know, what their highest resource is, and what their relationship is to the spiritual realm. Then we are more able to support the client’s process in a way that makes sense to them, on their own terms. This is the most helpful way we know to repair very early injuries, hurts, betrayals and disappointment.

See also the EMDR therapist finder directory of the EMDR International Association: http://www.emdria.org/search/custom.asp?id=2337

Sandra Paulsen, PhD, is the founder of the Bainbridge Institute for Integrative Psychology and a leading edge practitioner who has integrated her knowledge of Ego State Therapy, somatic therapies, and EMDR therapy to effectively treat clients struggling with complex trauma and dissociation safely and effectively. Dr. Paulsen accept clients for early trauma treatment in the intensive format but only via therapist referrals at this time. See: http://www.bainbridgepsychology.com/ET-Referring-Clinicians.html

D. Michael Coy, LCSW, LICSW, is a Master’s level therapist in independent practice in Chicago, IL, certified in EMDR therapy and also trained in clinical hypnosis, Ego State Therapy, and essential somatic methods for enhancing trauma resolution work. Michael’s primary focus is with clients who struggle with complex PTSD and/or dissociative disorders. Michael is also a clinical associate of the Bainbridge Institute for Integrative Psychology. For more information about Michael, see https://www.dmcoy.com.

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Kathy’s 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, “Neurobiology and Treatment of Traumatic Dissociation: Toward an Embodied Self,” by Lanius, Paulsen, and Corrigan, 2014, http://www.amazon.com/Neurobiology-Treatment-Traumatic-Dissociation-Embodied/dp/0826106315
See also especially Dr. Paulsen’s website: http://www.bainbridgepsychology.com/EarlyTraumaOShea.html.

FN2  For Eugene Gendlin’s foundational work on the “felt sense,” a term he developed, see Gendlin, Eugene T (1978), Befindlichkeit: Heidegger and the philosophy of psychology. Review of Existential Psychology and Psychiatry 16 (1–3): 43–71. 
Dr. Peter A. Levine uses Gendlin’s “felt sense” work strongly in his “somatic experiencing” trauma healing:  Levine, Peter A., PhD, “Healing Trauma: A Pioneering Program for Restoring the Wisdom of Your Body,” ‘Sounds True, Inc.,’ Boulder CO, 2005; ISBN 1-159179-247-9

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Allan Schore: What is the “Self”?

Allan Schore 2In March 2013 I was standing unknown in a crowd of professors and therapists at a UCLA conference, and noticed a quiet gentleman on my right.  I’d seen his photo online.  “Dr. Schore?” I asked.  “Yes,” said Allan Schore, turning calm eyes on me.

“I’m so grateful for all you’ve done to show that babies can’t control emotions, that’s the mother’s job to model, and emotions are ok,” I blurted,  suddenly in tears. “I’m writing a book on what it feels like on the inside, when we don’t get that as an infant.”

Dr. Schore didn’t flinch; his eyes grew wide with empathy. He got it.  He got a total stranger, right by the conference stage, got that I had walked through a hell of emotional pain to study this. He got that I was feeling love for him because he’s shown there’s a scientific reason for the pain.  He got that “emotions are ok” and only emotions from a caring other can heal this, so he gave me emotions: presence and compassion. On the spot. “We see it every day,” he said.

Just sayin’: He walks the walk.

UCLA professor Allan Schore is a world leader in Attachment Theory. He’s known as “the American Bowlby” after British psychiatrist John Bowlby who first wrote about attachment in the 1950s. [FN1]  Schore was among the first to put together the latest brain science on how an infant’s brain forms biologically (“developmental neuroscience”), with the early psychology of the infant mind (“developmental psychoanalysis”).

Dr. Schore’s 9-28-14 Oslo speech “The Most Important Years…the Right Brain and Its Importance” is a must-see to understand infant developmental trauma. He calls it  “trauma in the first 1000 days, conception to age two.”  Schore reviews how the theories he’s published since the 1990s are being proven to be hard science by today’s scanning technologies (content starts minute 8): https://www.youtube.com/watch?v=KW-S4cyEFCc

Schore is known for documenting the “origin of the self”– what, scientifically, is the “Self”?  What is it that makes me, Me?

He calls it “the origin of the early forming subjective implicit self.” It’s entirely subjective; each infant has a different experience.  It’s “implicit memory” because the self forms in infancy when memory is only subconcious. It all happens years before we have thought and conscious “explicit memory” at age two or three.

This isn’t mere geek-speak; the mental, emotional, and physical health of all humans depends on it. We can’t remember what happened before age 3 when our self was formed, but the experience had massive impact. It’s all still “down there,” driving our feelings and behavior big time for the rest of our lives. When the self is damaged during formation in early infant and childhood, a person can feel miserable all their life. The ACE Study shows this often leads to biological disease and premature death.

The Self and Emotions : Secure Attachment

brousblog4c Claire+MosesBabies are born with a massive level of emotions; Schore showed they are also overwhelmingly dependent on the mother to show them how to handle it all. An infant’s brain doubles in size “from the last trimester of pregnancy through the second year” Schore says. “At birth, there are hardly any cortical (conscious thinking brain) areas that are myelinated and online… so it’s impossible for the baby to regulate its own emotions…

“The mother is the regulator of that baby,” he says, and this shapes its entire brain. “Over the first year… the mother’s interactions are also shaping the very wiring of those higher regulatory centers… Attachment communications which are emotional are forging the connections in the early developing right brain… The right brain literally is imprinted by these attachment relationships while it is being created…”  FN2

It’s all subconscious. With “secure attachment,” when a baby cries, the mother “attunes” to it. An “attuned” mother doesn’t say “think” or “ought to.”  She feels a strong, emotional urge to comfort her baby; she subconsciously intuits whether her baby cries because it’s hungry, wet, or tired. “The mother is able to pick up the baby’s communications,” Schore says. “She is not doing this by language, there is no thinking or language before age two.  She is picking up bodily-based nonverbal communications:  facial gestures, auditory tone of voice, and tactile expressions.  The attachment communication is more than between the mother and the infant’s minds; it’s between their bodies…

“She is psychobiologically attuning to the internal rhythms… of the baby’s autonomic nervous system and central system arousal…  It’s an attunement of mind and body. In doing so, she is regulating the baby’s rhythms and allowing the baby to create different emotional states that are associated with these different rhythms. This is not a matching of behavior; it is more of an intuitive matching of the internal rhythms of the baby.

“The baby is expressing these internal rhythms through the emotional communications it is sending back to the mother, in the prosody of the baby’s voice, or in the cry, or in the expression on the baby’s face, or in the gesture.  They are matching each other’s subjective state. Now, when two people match their subjective states, there is a sense of empathy, there is a sense of a bond; a sense that ‘someone’s body is exactly resonating with my body.’  When that occurs there is an amplification of arousal, and this amplification of arousal leads to things like joy states. ”

Infants also have no sense of self.  Instead, Schore adds, there’s a “mother-baby continuum” for at least the first six months of life where the “dyad” (mother and child) often don’t know (and don’t care) where one person ends and the other begins.

We begin life as a sea of emotions, and then mom models for us again and again, that she can comfort our wild emotions. Unconsciously we pick up that skill. After we cry and mom comforts us for the millionth time, one day we feel our way to stop crying because we’ve “internalized” mom’s comfort. We subconsciously learn to manage emotions, to both enjoy good emotions, and also –very important — to tolerate and be able to fully feel negative emotions, without fearing or repressing them.

This is also called “Emotional Object Constancy.”  Mom was an external object, but now we’ve taken her image inside us, so we feel loved and emotionally secure 24×7, even when we’re alone.

Our “self” begins when we first start to “regulate” our own emotions (“affect”) this way. When we realize we can feel our emotions and also modulate them, without screaming for someone else to do it for us? That’s when we first realize that we are not just an appendage of mom. We’ve got some independent “self.” “Essentially, one’s self-concept is focused around a positive sense of emotionality in the self,” says Schore.

Insecure Attachment and Trauma

Still Face Experiment 2Or not.

Back to that baby born with a massive level of emotions. Babies are supposed to receive all that attuning above, then they’re fine.

Or not.

What if we’re an “Or Not” baby? What if we cry but no one comes?  Or what if someone comes but can’t  attune?  That baby learns that there is no comfort, that emotions are terrifying, and the world is a scary place.  Dr. Schore’s friend Ed Tronick shows this graphically with his “Still Face Experiment;”  click for video.  [FN3]

That baby often does not develop much of a self.  To the extent no one showed it how to manage emotions, the day couldn’t come when it could “regulate like mom.”  That is really uncomfortable; it’s what’s behind the feeling that “I have a hole in me.”

Schore says this is the root of developmental trauma.  “In trauma there is an intense negative state about the sense of self” with “extremely high states and low states of arousal, an inability to internally regulate their state or to use other people to help them regulate their state and bring them into a sense of comfort.”

With insecure attachment, he says, “there are problems that the caregiver is having emotionally…  There is anxious insecure attachment, where the mother is preoccupied or unpredictable… There is also avoidant insecure attachment, where the mother is mostly cold…

“And there is ‘mind blindness,’ so to speak. There are some mothers who cannot read the tone of the baby… We know depressive mothers have problems reading facial expressions, especially the facial expressions and the gestures of the baby. You see inter-generational transmission of these deficits …”

Schore first showed this scientifically in his three blockbuster books “Affect Regulation and the Origin of the Self,” “Affect Dysregulation and Disorders of the Self,” and “Affect Regulation and the Repair of the Self.” FN4

“Affect Regulation” means we can freely feel our emotions without being emotionally blocked, we can enjoy our emotions – yet also be “on top”of our emotions, so they don’t feel overwhelming, painful or frightening.  If not, we suffer “Affect Dysregulation ” i.e., some level of emotional chaos.

We all know people who either can’t or won’t access their emotions, or others whose emotions go out of control to where they and those around them feel miserable.  Others  swing to both extremes, but never simply enjoy their emotions without freaking out or hurting people.

The good news is: there is repair, as Dr. Schore’s third book lays out in detail. At a support group, Al Anon meeting, therapist’s office, or with friends, repair means doing exactly what Schore did for me on the floor of that conference: being present emotionally with another emotionally-attuned human being.

If we can sit for an hour and attune to another human willing to share our emotion state and help us learn to gradually shift and modulate it, we learn to “regulate.”  Brain scans now show that we can literally repair the same neural circuits which got out of tune when it didn’t go right for us as kids.

It takes time, perseverance, courage, and real human beings like Allan Schore.  I’ve met them, they’re out there.  Find them.

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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  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

FN2  Schore, Allan N., PhD, “Affect Regulation and Mind- Brain-Body Healing of Trauma,”   National Institute for the Clinical Application of Behavioral Medicine (NICABM), June 15, 2011
Schore, Allan N., “The right brain implicit self lies at the core of psychoanalysis,” Psychoanalytic Dialogues  21:75–100, 2011 www.lifespanlearn.org/documents/2011Handouts/Schore/Schore%20Psych%20Dialogues%2011.pdf
Interview with Allan Schore – ‘the American Bowlby,’  by Roz Carroll, UK ;  The Psychotherapist, Autumn 2001, www.thinkbody.co.uk/papers/interview-with-allan-s.htm

FN3  Dr. Ed Tronick of the U Mass Boston’s Infant-Parent Mental Health Program did his first “Still Face Experiment” work in 1975; his 2007 video  has over 1.3 million hits.  First a mother and child play in a responsive, attuned way, so the baby learns to interact with the world. Then she suddenly stops attuning. Video at: www.youtube.com/watch?v=apzXGEbZht0&feature=youtu.be

FN4  Norton Textbook Series on Interpersonal Neurobiology:
Schore, Allan N., “The Science of the Art of Psychotherapy,” April 2012; 480 pages
Schore, Allan N., “Affect Regulation and the Origin of the Self,” Norton textbook May 2003; first edition 1994; 432 pages

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Developmental Trauma: What You Can’t See…

Bessel van der KolkWhat you can’t see, can hurt you.

Dr. Bessel van der Kolk, MD (left) and leaders in brain science and attachment are calling for a hard look at developmental trauma.  Developmental Trauma Disorder (DTD) was identified by van der Kolk in 2005, but the psychiatric Powers That Be deny it exists. [FN1]

“Clearly our field would like to ignore social realities,” Dr. van der Kolk said recently, “and study genes…”

He’s also shown it’s at the root of borderline personality disorder and bipolar disorder. He implies (I’m sure it’s true) that it’s at the root of most cases mis-diagnosed as  ADHD/ADD.  See van der Kolk video: http://www.acesconnection.com/clip/bessel-van-der-kolk-childhood-trauma-affect-regulation-and-borderline-personality-disorder-69-min

I dubbed it “trauma since the sperm hit the egg” when I realized I had it.  Dr. Allan Schore calls it “trauma in the first 1000 days, conception to age two.”  It used to be called “complex PTSD” (C-PTSD) or “Early Trauma” (ET).

Developmental trauma starts in utero when we don’t have much more than a brain stem, and goes on during the pre-conscious years. It can continue until 24 or 36 months depending on when the thinking brain (frontal cortex) comes on line.  That’s up to 45 months living in general anxiety to non-stop terror — before age 3.  A very long time to an infant.

DTD occurs as a continual process, not discrete incidents, while a baby has not developed a thinking brain able to recall incidents.  Frequently it occurs before there are any discrete incidents.

“No one can see it” means “it never happened.”  As I’ve said, “No one beat me or raped me. What’s wrong with me?”  Try getting that treated.

Neuroscientists Dr. Daniel Siegel, MD, Dr. Bruce Perry MD and others detail how attachment failures cause developmental trauma in this video: www.youtube.com/watch?v=jYyEEMlMMb0 [FN2]

Insecure Attachment as the Cause

Allan Schore 2DTD is a “Relational Trauma, trauma in the context of a relationship” as Dr. Allan Schore (left), father of attachment theory in the U.S., identified it in the 1990s. [FN3] Only relational processes can explain DTD, not incidents.

Yet all the American Psychiatric Association (APA) can fathom is Post-Traumatic Stress Disorder (PTSD) — since it’s caused by a visible incident such as war injury or rape. Developmental trauma has no incident. It’s ingrained in brain and visceral tissue, with no obvious “big bang,” so some call it “little ‘t’ trauma,” as opposed to visible PTSD “Big ‘T’ Trauma.”

Insecure attachment and attachment disorder generally are the cause of developmental trauma, not vice versa, Dr. van der Kolk details in his May 2005 Psychiatric Annals pdf  noted above and in FN1.  He emphasized this again in a terrific May 10, 2013 speech at Yale on child trauma, borderline personality disorder and bipolar disorder (click for video).  He lists DTD’s symptoms as relational and chronic: inability to concentrate or regulate feelings, chronic anger, fear and anxiety; self-loathing; aggression, self-destructive behavior. [FN4A]

Working with the National Center for Child Traumatic Stress Complex Trauma Network (NCTSN), van der Kolk reports that he ran a survey of 40,000 children nationally being treated for multiple traumas. Most of them  “do not meet the criteria for PTSD… (as) the majority of issues are not specific traumas, but issues in their attachment relationships,” he says.

Van der Kolk describes studies by his colleague Dr. Marylene Cloitre, on attachment problems as the cause of DTD.  “Marylene looked at chronic complex trauma symptoms, then she did child attachment interviews, Dr. Mary Main’s interviews, in which I hope all of you have been trained, because they are very very helpful to see what were peoples’ experiences of their childhoods,” he said [referring to the Adult Attachment Interview (AAI)]. [FN4B]

Dr. Cloitre found “that pure PTSD symptoms are a function of specific traumatic incidents, but the other symptoms she identified – affect dysregulation, mood regulation, anger expression, chronic suicidality, self-injury, disturbance in relations with self and others… do not occur in PTSD.  They are rather a function of a disturbed attachment relationship,” van der Kolk repeated.

Yet psychiatry, he says, “is not good at treating attachment difficulties. There is very little treatment” of it.  Innovative somatosensory healing programs at van der Kolk’s Trauma Center in Boston using “theater programs, yoga, martial arts for kids, etc. — to get them inter-personally attuned — are not standard treatment even though we do statistical research and publish it,” he notes.

The Body Keeps the Score

Bessel Book bodykeepsscoreBecause DTD happens before we have a thinking brain, the body is forced to store all the memories as somatic trauma. “There is somatization. The body keeps the score,” he says, the title of his latest book, “this is a somatic experience, and you become a terrified organism. Your immune system changes, your stress hormone system changes and your perception of your body changes.”

PTSD’s existence was hard to get recognized at first, too. It took Dr. van der Kolk and friends a chunk of the 1970s and ’80s to get the government to stop insisting that war trauma didn’t exist. Doctors finally established the diagnosis PTSD by showing that Vietnam vets were re-living discrete terrifying incidents from the past.

But “in fact there was no basis for any opinion about the prevalence” of any childhood trauma, even of childhood sexual abuse, before the 1995-1998 Adverse Childhood Experiences (ACE) Study,  study co-director Dr. Vincent J. Felitti, MD, notes. “That’s because such information is almost completely protected by shame and secrecy, by families, and by individuals.  Doctors also have been inhibited by our own ignorance and major gaps in our training, from asking into certain areas of patient history.” [ FN5]

In 1995 Felitti ran an obesity program at Kaiser Permanente in San Diego. But he had a 50% drop-out rate, just when those quitting were losing up to 100 pounds.  “As we interviewed almost 300 of the dropouts, every other person spoke of having childhood sexual abuse; most of them seemed to have been waiting to tell someone after hiding it for years,” Felitti said. “They also often mentioned verbal and physical abuse and other traumatic experiences such as watching their mother being beaten.

“We were amazed. I thought, ‘This can’t be true. People would know if that were true. Someone would have told me in medical school.’  [FN6]

“We wanted to know: to what degree does this happen in the whole population?  That’s how we created the ACE Study.  We took at first 8 and later a total of 10 categories of traumatic childhood experiences which we’d heard about from our obese patients, then found 17,421 average, middle-class adults who agreed to interviews.

“We were astonished to find that the percent of the general public who suffer from traumatic experiences in childhood and adolescence is far higher than imagined… Two-thirds (64-67%) of middle class subjects had one or more types of childhood trauma, and 38-42% had two or more types. One in six had an ACE Score of 4 or more; one in nine had an ACE Score of 5 or more.”  In less privileged populations the numbers are far higher.

Similarly, Dr. van der Kolk describes a patient in the 1980s who could not recall if she were sexually abused, yet drew portraits of her family with menacing genitals. “So we went to the textbook — Freedman,  Kaplan, & Sadock’s  ‘Comprehensive Textbook of Psychiatry’ — with which I sat for my board exam in psychiatry.  It said:  ‘Incest is very rare; it happens in 1 out of 1.1 million women.’   At the time there were about 200 million Americans, so I thought, ‘Hmm… About 100 million women, 110 women are incest victims; how come 47 of them are in my office?’/” [FN4 Yale video.]

“The text says it is also very benign,” he went on quoting it: ‘There’s no agreement about the role of father-daughter incest as a source of psychopathology. The act offers an opportunity to test a fantasy whose consequences are found to be gratifying and pleasurable…In many cases it allows for a better adjustment to the external world.  The large majority of them are none the worse for the experience ’. ”  [FN7]

Developmental Trauma: Psychiatrists Still in Denial

Shrink knitting my brainBut even today, until DTD is in the APA’s official Diagnostic and Statistical Manual of Mental Disorders (DSM), most mental health professionals will not diagnose or treat it, and no insurance company will cover it.

So in 2012 Dr. van der Kolk’s NCTSN network submitted data on 200,000 children around the world to the APA to document DTD.  He spoke on DTD before the National Association of State Mental Health Directors, which treats 6.1 million patients a year with a $29 billion budget, and they wrote to the APA urging that DTD be included in the next DSM-5 in 2013.

But the APA refused and in June 2013, issued DSM-5 without mention of developmental trauma. Van der Kolk in his Yale video ridicules the APA for asking only two questions on child trauma in preparing DSM-5: “1. Can we assume life was pretty good growing up? and  2. Was anyone in your family a drug addict or an alcoholic?”

“Clearly our field would like to ignore social realities,” van der Kolk responds, “and study genes or biological functions — because for us to actually find out how the environment shapes the brain, would get us into very difficult situations.”

The APA refusal letter actually made a veiled dig against the Adverse Childhood Experience (ACE) Study and denied that “childhood adverse experiences” are a “substantive” problem – which is outrageous.  Dr. van der Kolk read that letter at Yale in May 2013 and let ’em have it:

APA:  “The consensus was there was just too little evidence to include DTD in the DSM-5. There have not been any published accounts about children with this disorder.”
Dr. vdK aside: “No, because it’s not in the textbooks!”

APA: “The notion that childhood adverse experiences lead to substantive developmental reduction is more clinical intuition than a research-based fact. “
Dr. vdK aside: “We submitted research data on 200,000 children from around the world to substantiate our diagnosis.”

APA: “The statements made cannot be backed up by prospective studies.”
Dr. vdK aside: “Actually, they can.”

Dr. van der Kolk could make a lot more money as a TV comedy star, after dealing with this idiocy for a lifetime. Despite the tragedy, his psychiatrist audience also had a good laugh — the APA is that absurd.

Developmental trauma is the “invisible” part of “the Silent Epidemic of Attachment Disorder.” [FN8]. DTD can happen as a by-product when a mother or her child are beaten or sexually abused – but it also happens on a wide-spread basis with no visible incident.

Perhaps 20-40% of our population goes through life never knowing they even have DTD. That’s why many of them go on to become leaders of industry and government. That’s why Dr. van der Kolk has said that the US Congress is “dissociated,”  or they’d feel the simple human compassion to know that sending youth to war brings back a flood of PTSD suicides.  (To me that means more than 50% of Congress has attachment problems, which is why they made a career of trying to control others. ) [FN9]

———————————

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  van der Kolk, Bessel, MD, “Developmental Trauma Disorder: Toward a rational diagnosis for children with complex trauma histories,” Psychiatric Annals 35:5, 401-408, May 2005   www.traumacenter.org/products/pdf_files/preprint_dev_trauma_disorder.pdf
This article also details how developmental trauma is attachment-based:  “Early patterns of attachment inform the quality of information processing throughout life [11]. Secure infants learn to trust both what they feel and how theyunderstand the world…. (more),” he reports.
But “When caregivers are emotionally absent, inconsistent, frustrating, violent, intrusive, or neglectful, children are liable to become intolerably distressed and unlikely to develop a sense that the external environment is able to provide relief. Thus, children with insecure attachment patterns have trouble relying on others to help them, while unable to regulate their emotional states by themselves. As a result, they experience excessive anxiety, anger and longings to be taken care of. These feelings may become so extreme as to precipitate dissociative states or self-defeating aggression…”
Dr. van der Kolk has been Medical Director of The Trauma Center in Boston for 30 years (www.traumacenter.org).

FN2  Daniel Siegel, MD, et.al, “Trauma, Brain & Relationship: Helping Children Heal,” www.youtube.com/watch?v=jYyEEMlMMb0
Introductory video on Attachment Disorder and how development of the mind-body system can cause trauma. Copies at www.postinstitute.com/dvds.

FN3  Schore, Allan N., PhD, “Effects of Early Relational Trauma on Right Brain Development, Affect Regulation, & Infant Mental Health,” 2001, www.trauma-pages.com/a/schore-2001b.php

FN4A  van der Kolk, Bessel, MD: Video, Yale University, May 10, 2013, “Childhood Trauma, Affect Regulation, and Borderline Personality Disorder,” http://acesconnection.com/video/bessel-van-der-kolk-childhood-trauma-affect-regulation-borderline

FN4B  Cloitre, Marylene, et. al, (NYU Child Study Center, Department of Psychiatry, New York University Medical College,  marylene.cloitre@nyumc.org), “Attachment organization, emotion regulation, and expectations of support in a clinical sample of women with childhood abuse histories,”   Journal of Traumatic Stress, 2008 Jun;21(3):282-9. doi: 10.1002/jts.20339.  Abstract: Despite the consistent documentation of an association between compromised attachment and clinical disorders, there are few empirical studies exploring factors that may mediate this relationship. This study evaluated the potential roles of emotion regulation and social support expectations in linking adult attachment classification and psychiatric impairment in 109 women with a history of childhood abuse and a variety of diagnosed psychiatric disorders. Path analysis confirmed that insecure attachment was associated with psychiatric impairment through the pathways of poor emotion regulation capacities and diminished expectations of support. Results suggest the relevance of attachment theory in understanding the myriad psychiatric outcomes associated with childhood maltreatment and in particular, the focal roles that emotion regulation and interpersonal expectations may play. http://www.ncbi.nlm.nih.gov/pubmed/18553408

FN5   Vincent J. Felitti, MD;  Robert F. Anda, MD, MS;  “The Lifelong Effects of Adverse Childhood Experiences,” Chapter 10 of Chadwick’s “Child Maltreatment,” Sexual Abuse and Psychological Maltreatment, Encyclopedic Vol 2 of 3, STM Learning, Inc., Saint Louis, p.203-215; March, 2014

FN6   Stevens, Jane, “The Adverse Childhood Experience Study” — the largest, most important public health study you never heard of — began in an obesity clinic,”  ACEsTooHigh.com

FN7  Freedman, Alfred M., Kaplan, Harold I., & Sadock, Benjamin J.,  “Comprehensive Textbook of Psychiatry,” 2nd Edition, Williams and Wilkins Co., Baltimore, 1975; 2609 pages.  Now in 9th edition; known since 4th edition as “Kaplan and Sadock’s.”

FN8  Lanius, Ruth A., MD; Vermetten, Eric; Pain, Claire; Editors, “The Impact of Early Life Trauma on  Health and Disease: The Hidden Epidemic,” Cambridge University Press, 2010. “Early Childhood Adversity, Toxic Stress, and the Role of the Pediatrician,” American Academy of Pediatrics,  2012 (New York Times 1-7-12), and many more.

FN9  van der Kolk, Bessel, MD, “What Neuroscience Teaches Us About the Treatment of Trauma,” June 6, 2012 webcast, National Institute for the Clinical Application of Behavioral Medicine  (NICABM) : Most of Congress is “dissociated,” van der Kolk told this 2012 globally-televised webcast, or they’d feel the simple human compassion to know that sending youth to war brings back a flood of PTSD suicides. We already knew from Korea and Vietnam that “for every solider that will die on the battlefield, there will be 30 suicides, as is happening right now,” van der Kolk said.  But “society dissociates from the reality of it and then Congress says, ‘Oh, gosh, isn’t that amazing!’  No it’s not amazing, that’s what happens!”
Short promo clip: http://www.nicabm.com/nicabmblog/how-trauma-traps-survivors-in-the-past/
Link to buy video, mp3 audio, transcripts: http://www.nicabm.com/trauma-2012-new/
On Congress, see also http://www.theatlantic.com/politics/archive/2014/06/why-it-matters-that-politicians-have-no-experience-of-poverty/371857/

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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) a while, until we get new software to take longer comments again.

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Hole in My Heart

#4 in my ongoing book series; original post August 9, 2013

brousblog4a Siegel Hawn CooperIf there’s been an Adult Attachment Interview (AAI) since 1996 which can diagnose the 50% of Americans with attachment disorder, why doesn’t our medical system use it? [FN12a]

Why aren’t family doctors asking why a patient “just feels lousy” for years, to send us at least for one AAI check by a therapist? Why haven’t more than a small minority of therapists even heard of the AAI? Using it would’ve saved me three years in failed treatment hell.

Instead it’s been left to activists like comedienne Goldie Hawn, alarmed by the jump in stress and violence among children, to put attachment specialists like UCLA’s Dr. Dan Siegel, MD on TV with plastic models of the brain, to wake us all up.  Check out the priceless video above.  “You sent us a brain in the mail !” Anderson Cooper exclaims. [FN12b]

Models of the brain and brain science show a lot: where Attachment Disorder gets created, why we don’t even know that it’s there, and how to heal it.

Most of what occurred with family or caregivers in the almost 4 years from conception to 36 months, which makes us securely or in-securely attached, happened ‘way before we had much of a thinking brain – and before we had any conscious memory banks. So we still fly blind about it today.

Our brain parts which allow us to calm ourselves, feel good alone, or even make sense of sights, sounds, touch, and other sensory data pouring in from outside, weren’t working at the time attachment misfired. Babies can’t self-calm or feel good alone. The “thinking brain” hippocampus which makes sense of that barrage of incoming data, doesn’t even work until 24 to 36 months. That’s why we can’t remember much before age 3.

But the problem is down there, in the pre-thinking, un-conscious parts of the brain which were online, and down in our body with a vengeance. We can have cancer for a long time and be unaware of it until late in the game. Attachment Disorder too is usually an 800lb gorilla which is utterly outside of consciousness. Yet wounded un-conscious parts of our brain have been in a state of panic since attachment misfired before age 3.

Hole in My Heart

brousblog4b Cyndi Lauper“There’s a hole in my heart,” or  “a hole under my feet,” people report. We’re anxious, panicky, depressed about being dropped off at school, or to do work, marriage, child rearing. We feel unequipped to do Life.

I’d felt emotional pain as a “hole in my heart” ever since I could remember; I alternated between denial and praying my parents wouldn’t notice my fear. My first memory of TV was a documentary about an early open-heart surgery on a “blue baby” born with cardiac perforation.

As the camera showed a scalpel probing a gap in bloody tissue, the announcer intoned, “Here is the hole in Julie’s heart.”  I couldn’t forget the sight and my terror at the announcer’s voice for years.  Fairy tales with witches, children’s stories like Peter and the Wolf, TV and movies were as likely to terrify me as a kid as to entertain. “Normal?” Anything resonate?

One day in 2010, I went to my local library on a job request for a sale coaching book, a branch so small that self-help and psychology were shelved together.  I stumbled on books of case studies of people whose parents died early, like “The Loss That Is Forever: The Lifelong Impact of the Early Death of a Mother or Father,” by Dr. Maxine Harris. [FN13a]  “Irrelevant, my parents died in 2008,” I said, but tossed the book in my car trunk with the rest.  There it sat for six weeks until the night before due date.

I opened it and was blown away.  The case studies report exactly the disoriented feelings I’d had all my life.  A week later my branch closed for two years renovation; what an accident.

I wrote this long before I ever saw Cyndi Lauper’s video “Hole in My Heart,” but it’s a shock how empty she feels inside. [FN13b]  “I’ve got a hole in my heart that goes all the way to China!” she wails, “You gotta fill it up with love before I fall inside… You can’t see the bottom, you can’t see the bottom, but believe me – it’s a long way down…”

Poor Cyndi, she thinks the hunky guys who bail her out at the end are gonna solve her problem.  She doesn’t know her pain is from her childhood emotions about parents.  Those hunks are just gonna hurt her again.

OK, so that’s Psychiatry 101: “80% of the pain in adult romantic relationships is projecting the pain we received in childhood.” [FN14]  Trouble is, 99% of Americans are unaware of that fact, and we 50% with Attachment Disorder fight it tooth and nail. We want someone to hold us so bad we could die – someone, anyone, who cares!  So don’t confuse us with the facts.  But it never works, ‘cos it’s a flight from reality.

Emotional Object Constancy

There’s a way out, recently dubbed neuroplasticity.  As the Anderson Live video shows, we can re-train our brains using compassionate therapy, meditation and other “brain gym work” to change the neural structures that hold painful old memories. It was thought that nerve tissue, if damaged, could never heal, but recent science shows the reverse.  “We’re hard-wired to heal,” say doctors Henry Cloud and John Townsend. [FN15a]

But to do it, humans require “face time,” face to face work with other “Safe People,” human beings who actually care enough to be present with us. [FN15b] Because it was face time, or lack of it, which damaged our developing brains in the first place.

brousblog4c Claire+MosesFace time is what develops a baby’s brain into an adult brain. An emotionally attuned mother, who feels her baby’s internal states, shows it how to sooth and feel better.  She does it wordlessly, with a lot of eye contact (tech term “limbic resonance”).  The emotional lobes of the mother’s brain and the baby’s brain actually resonate to each other, as attachment specialist Dr. Allan Schore has shown. [FN16a,16b]

This is my neighbor and her son, whom she’s carried pretty much constantly for a year in a face-to-face carrier, not because anyone told her to, but because, she says, “it feels natural.”  I see them several times a week and I have never seen this baby without a glorious smile.

Like any newborn, he would have cried non-stop at first if she weren’t always there; again, babies don’t have the neural hardware to sooth themselves. But gradually over weeks and months, this baby could be put down for a longer and longer time without getting upset.

“Why should that be?” asks Dr. Henry Cloud. What’s he got now, that he didn’t have before?  The mother’s love comes from the outside, then literally goes inside her baby, via limbic resonance.  She gives the gift of feeling loved inside to her baby, called “emotional object constancy.”

This is a deep knowing, that we have so warmly attached to mother, the love object, that even when she is absent, we do not feel alone or lonely. We instead feel constancy: we feel that we carry around mom’s love inside us 24×7. This is the source of the strength which allows a healthy child to be dropped off at school and feel so secure inside, that he’s eager to try something new and play with strangers.

The way out of attachment disorder is to create more emotional object constancy, that feeling of deep attachment and safety the baby in the photo has. The reason we feel bad, anxious, depressed or have chronic emotional pain, is usually that this did not develop well when we were kids.

Communicating object constancy to kids is a major reason humans have families. Pre-agricultural man required at least six adults to raise one child safely – four to feed and take care of mom while dad hunted, so mom could safely take care of the child 24 x 7 and get this job done. Who has time for that in this ratty economy? [FN17]

If you have Attachment Disorder, my tale will start to resonate if you let it. If you let yourself feel the hurt with me, you’ll start to unfreeze your frozen bad feelings and if you get the right help, you’ll feel the healing, too.

Secure attachment can be “earned,” as Dr. Mary Main, creator of the AAI, also said.  But we need  face time with safe people to do it, to widen what Dan Siegel calls our “window of tolerance” to feel frozen feelings.

Days before Christmas 2011 at a local nursery, a friend dared me to sit on Santa’s lap.  As I alighted gingerly, he asked, “And what do you want for Christmas, young lady?” Lost and alone for the holidays, I looked the poor guy straight in the eye and blurted without thinking, “Please Sir, I want peace of mind.”

“Don’t we all,” he said, tearing up.

I think I’ll go find the nice man this Christmas 2013 and thank him for making my wish come true.

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This is from Kathy’s forthcoming book DON’T TRY THIS AT HOME: The Silent Epidemic of Attachment DisorderHow I accidentally regressed myself back to infancy and healed it all. Watch for the continuing series of excerpts from the rest of her book 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.

Kathy Brous from FEMHC 1READ MORE from “DON’T TRY THIS AT HOME: The Silent Epidemic of Attachment Disorder”
by Kathy Brous

 

 

Footnotes
12a. Op Cit blog #3: George, C.; Kaplan, N.; Main, Mary, “An Adult Attachment Interview,”  Unpublished MS, University of California at Berkeley, 1994
12b. Siegel, Daniel J.,MD & Hawn, Goldie, TV Special on the Brain, CNN Anderson Live, Sept. 24, 2012.  See www.drdansiegel.com/press/ for more; or direct to video at http://cdnapi.kaltura.com/index.php/extwidget/openGraph/wid/0_c40uup5m
13a. Harris, Maxine, PhD, “The Loss That Is Forever: The Lifelong Impact of the Early Death of a Mother or Father,” Penguin Books, New York, 1996
13b. Cyndi Lauper video: www.youtube.com/watch?v=hP9b4zlO2cU
14.   Verrier, Nancy, PhD, “Coming Home to Self: The Adopted Child Grows Up,” self-published, Lafayette, CA, 1993
15a.  Cloud, Henry, PhD, “Changes that Heal,” Zondervan, Grand Rapids, 1990. See also:  “Getting Love on the Inside,” Lecture CD, April 2002, Cloud-TownsendResources.com
15b.  Townsend, John, PhD & Cloud, Henry,Phd, “Safe People,” Zondervan Press, Grand Rapids, 1995. Also by both: “Boundaries,” Zondervan Press, Grand Rapids, 2004
16a.  Schore, Allan N., PhD, “Affect Regulation and Mind-Brain-Body Healing of Trauma,” National Institute for the Clinical Application of Behavioral Medicine (NICABM), June 15, 2011, www.nicabm.com  See also his book  “Affect Regulation and the Origin of the  Self”, Norton textbook May 2003; first edition 1994.
16b.  Op Cit blog #2: Lewis, Thomas MD, Amini, Fari MD, Lannon, Richard MD; “A General Theory of Love”,Random House, 2000. Great link: www.paulagordon.com/shows/lannon/
17.  Perry, Bruce, MD, PhD, “Born for Love: The Effects of Empathy on the Developing Brain,” speech at conference “ How People Change: Relationship & Neuroplasticity in Psychotherapy,” UCLA Extension, Los Angeles, March 8, 2013. See also his article  “Overview of Neuro-sequential Model of Therapeutics (NMT),” www.childtrauma.org, 2010

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