The Body Keeps the Score

by Bessel van der Kolk MD

  This upward spiral can, however, be reversed by abuse or neglect. Abused kids are often very sensitive to changes in voices and faces, but they tend to respond to them as threats rather than as cues for staying in sync. Dr. Seth Pollak of the University of Wisconsin showed a series of faces to a group of normal eight-year-olds and compared their responses with those of a group of abused children the same age. Looking at this spectrum of angry to sad expressions, the abused kids were hyperalert to the slightest features of anger.11

  COPYRIGHT © 2000, AMERICAN PSYCHOLOGICAL ASSOCIATION

  This is one reason abused children so easily become defensive or scared. Imagine what it’s like to make your way through a sea of faces in the school corridor, trying to figure out who might assault you. Children who overreact to their peers’ aggression, who don’t pick up on other kids’ needs, who easily shut down or lose control of their impulses, are likely to be shunned and left out of sleepovers or play dates. Eventually they may learn to cover up their fear by putting up a tough front. Or they may spend more and more time alone, watching TV or playing computer games, falling even further behind on interpersonal skills and emotional self-regulation.

  The need for attachment never lessens. Most human beings simply cannot tolerate being disengaged from others for any length of time. People who cannot connect through work, friendships, or family usually find other ways of bonding, as through illnesses, lawsuits, or family feuds. Anything is preferable to that godforsaken sense of irrelevance and alienation.

  A few years ago, on Christmas Eve, I was called to examine a fourteen-year-old boy at the Suffolk County Jail. Jack had been arrested for breaking into the house of neighbors who were away on vacation. The burglar alarm was howling when the police found him in the living room.

  The first question I asked Jack was who he expected would visit him in jail on Christmas. “Nobody,” he told me. “Nobody ever pays attention to me.” It turned out that he had been caught during break-ins numerous times before. He knew the police, and they knew him. With delight in his voice, he told me that when the cops saw him standing in the middle of the living room, they yelled, “Oh my God, it’s Jack again, that little motherfucker.” Somebody recognized him; somebody knew his name. A little while later Jack confessed, “You know, that is what makes it worthwhile.” Kids will go to almost any length to feel seen and connected.

  LIVING WITH THE PARENTS YOU HAVE

  Children have a biological instinct to attach—they have no choice. Whether their parents or caregivers are loving and caring or distant, insensitive, rejecting, or abusive, children will develop a coping style based on their attempt to get at least some of their needs met.

  We now have reliable ways to assess and identify these coping styles, thanks largely to the work of two American scientists, Mary Ainsworth and Mary Main, and their colleagues, who conducted thousands of hours of observation of mother-infant pairs over many years. Based on these studies, Ainsworth created a research tool called the Strange Situation, which looks at how an infant reacts to temporary separation from the mother. Just as Bowlby had observed, securely attached infants are distressed when their mother leaves them, but they show delight when she returns, and after a brief check-in for reassurance, they settle down and resume their play.

  But with infants who are insecurely attached, the picture is more complex. Children whose primary caregiver is unresponsive or rejecting learn to deal with their anxiety in two distinct ways. The researchers noticed that some seemed chronically upset and demanding with their mothers, while others were more passive and withdrawn. In both groups contact with the mothers failed to settle them down—they did not return to play contentedly, as happens in secure attachment.

  In one pattern, called “avoidant attachment,” the infants look like nothing really bothers them—they don’t cry when their mother goes away and they ignore her when she comes back. However, this does not mean that they are unaffected. In fact, their chronically increased heart rates show that they are in a constant state of hyperarousal. My colleagues and I call this pattern “dealing but not feeling.”12 Most mothers of avoidant infants seem to dislike touching their children. They have trouble snuggling and holding them, and they don’t use their facial expressions and voices to create pleasurable back-and-forth rhythms with their babies.

  In another pattern, called “anxious” or “ambivalent” attachment, the infants constantly draw attention to themselves by crying, yelling, clinging, or screaming: They are “feeling but not dealing.”13 They seem to have concluded that unless they make a spectacle, nobody is going to pay attention to them. They become enormously upset when they do not know where their mother is but derive little comfort from her return. And even though they don’t seem to enjoy her company, they stay passively or angrily focused on her, even in situations when other children would rather play.14

  Attachment researchers think that the three “organized” attachment strategies (secure, avoidant, and anxious) work because they elicit the best care a particular caregiver is capable of providing. Infants who encounter a consistent pattern of care—even if it’s marked by emotional distance or insensitivity—can adapt to maintain the relationship. That does not mean that there are no problems: Attachment patterns often persist into adulthood. Anxious toddlers tend to grow into anxious adults, while avoidant toddlers are likely to become adults who are out of touch with their own feelings and those of others. (As in, “There’s nothing wrong with a good spanking. I got hit and it made me the success I am today.”) In school avoidant children are likely to bully other kids, while the anxious children are often their victims.15 However, development is not linear, and many life experiences can intervene to change these outcomes.

  But there is another group that is less stably adapted, a group that makes up the bulk of the children we treat and a substantial proportion of the adults who are seen in psychiatric clinics. Some twenty years ago, Mary Main and her colleagues at Berkeley began to identify a group of children (about 15 percent of those they studied) who seemed to be unable to figure out how to engage with their caregivers. The critical issue turned out to be that the caregivers themselves were a source of distress or terror to the children.16

  Children in this situation have no one to turn to, and they are faced with an unsolvable dilemma; their mothers are simultaneously necessary for survival and a source of fear.17 They “can neither approach (the secure and ambivalent ‘strategies’), shift [their] attention (the avoidant ‘strategy’), nor flee.”18 If you observe such children in a nursery school or attachment laboratory, you see them look toward their parents when they enter the room and then quickly turn away. Unable to choose between seeking closeness and avoiding the parent, they may rock on their hands and knees, appear to go into a trance, freeze with their arms raised, or get up to greet their parent and then fall to the ground. Not knowing who is safe or whom they belong to, they may be intensely affectionate with strangers or may trust nobody. Main called this pattern “disorganized attachment.” Disorganized attachment is “fright without solution.”19

  BECOMING DISORGANIZED WITHIN

  Conscientious parents often become alarmed when they discover attachment research, worrying that their occasional impatience or their ordinary lapses in attunement may permanently damage their kids. In real life there are bound to be misunderstandings, inept responses, and failures of communication. Because mothers and fathers miss cues or are simply preoccupied with other matters, infants are frequently left to their own devices to discover how they can calm themselves down. Within limits this is not a problem. Kids need to learn to handle frustrations and disappointments. With “good enough” caregivers, children learn that broken connections can be repaired. The critical issue is whether they can incorporate a feeling of being viscerally safe with their parents or other caregivers.20

  In a study of attachment patterns in over two thousand infants in “normal” middle-class env
ironments, 62 percent were found to be secure, 15 percent avoidant, 9 percent anxious (also known as ambivalent), and 15 percent disorganized.21 Interestingly, this large study showed that the child’s gender and basic temperament have little effect on attachment style; for example, children with “difficult” temperaments are not more likely to develop a disorganized style. Kids from lower socioeconomic groups are more likely to be disorganized,22 with parents often severely stressed by economic and family instability.

  Children who don’t feel safe in infancy have trouble regulating their moods and emotional responses as they grow older. By kindergarten, many disorganized infants are either aggressive or spaced out and disengaged, and they go on to develop a range of psychiatric problems.23 They also show more physiological stress, as expressed in heart rate, heart rate variability,24 stress hormone responses, and lowered immune factors.25 Does this kind of biological dysregulation automatically reset to normal as a child matures or is moved to a safe environment? So far as we know, it does not.

  Parental abuse is not the only cause of disorganized attachment: Parents who are preoccupied with their own trauma, such as domestic abuse or rape or the recent death of a parent or sibling, may also be too emotionally unstable and inconsistent to offer much comfort and protection.26,27 While all parents need all the help they can get to help raise secure children, traumatized parents, in particular, need help to be attuned to their children’s needs.

  Caregivers often don’t realize that they are out of tune. I vividly remember a videotape Beatrice Beebe showed me.28 It featured a young mother playing with her three-month-old infant. Everything was going well until the baby pulled back and turned his head away, signaling that he needed a break. But the mother did not pick up on his cue, and she intensified her efforts to engage him by bringing her face closer to his and increasing the volume of her voice. When he recoiled even more, she kept bouncing and poking him. Finally he started to scream, at which point the mother put him down and walked away, looking crestfallen. She obviously felt terrible, but she had simply missed the relevant cues. It’s easy to imagine how this kind of misattunement, repeated over and over again, can gradually lead to a chronic disconnection. (Anyone who’s raised a colicky or hyperactive baby knows how quickly stress rises when nothing seems to make a difference.) Chronically failing to calm her baby down and establish an enjoyable face-to-face interaction, the mother is likely to come to perceive him as a difficult child who makes her feel like a failure, and give up on trying to comfort her child.

  In practice it often is difficult to distinguish the problems that result from disorganized attachment from those that result from trauma: They are often intertwined. My colleague Rachel Yehuda studied rates of PTSD in adult New Yorkers who had been assaulted or raped.29 Those whose mothers were Holocaust survivors with PTSD had a significantly higher rate of developing serious psychological problems after these traumatic experiences. The most reasonable explanation is that their upbringing had left them with a vulnerable physiology, making it difficult for them to regain their equilibrium after being violated. Yehuda found a similar vulnerability in the children of pregnant women who were in the World Trade Center that fatal day in 2001.30

  Similarly, the reactions of children to painful events are largely determined by how calm or stressed their parents are. My former student Glenn Saxe, now chairman of the Department of Child and Adolescent Psychiatry at NYU, showed that when children were hospitalized for treatment of severe burns, the development of PTSD could be predicted by how safe they felt with their mothers.31 The security of their attachment to their mothers predicted the amount of morphine that was required to control their pain—the more secure the attachment, the less painkiller was needed.

  Another colleague, Claude Chemtob, who directs the Family Trauma Research Program at NYU Langone Medical Center, studied 112 New York City children who had directly witnessed the terrorist attacks on 9/11.32 Children whose mothers were diagnosed with PTSD or depression during follow-up were six times more likely to have significant emotional problems and eleven times more likely to be hyperaggressive in response to their experience. Children whose fathers had PTSD showed behavioral problems as well, but Chemtob discovered that this effect was indirect and was transmitted via the mother. (Living with an irascible, withdrawn, or terrified spouse is likely to impose a major psychological burden on the partner, including depression.)

  If you have no internal sense of security, it is difficult to distinguish between safety and danger. If you feel chronically numbed out, potentially dangerous situations may make you feel alive. If you conclude that you must be a terrible person (because why else would your parents have you treated that way?), you start expecting other people to treat you horribly. You probably deserve it, and anyway, there is nothing you can do about it. When disorganized people carry self-perceptions like these, they are set up to be traumatized by subsequent experiences.33

  THE LONG-TERM EFFECTS OF DISORGANIZED ATTACHMENT

  In the early 1980s my colleague Karlen Lyons-Ruth, a Harvard attachment researcher, began to videotape face-to-face interactions between mothers and their infants at six months, twelve months and eighteen months. She taped them again when the children were five years old and once more when they were seven or eight.34 All were from high-risk families: 100 percent met federal poverty guidelines, and almost half the mothers were single parents.

  Disorganized attachment showed up in two different ways: One group of mothers seemed to be too preoccupied with their own issues to attend to their infants. They were often intrusive and hostile; they alternated between rejecting their infants and acting as if they expected them to respond to their needs. Another group of mothers seemed helpless and fearful. They often came across as sweet or fragile, but they didn’t know how to be the adult in the relationship and seemed to want their children to comfort them. They failed to greet their children after having been away and did not pick them up when the children were distressed. The mothers didn’t seem to be doing these things deliberately—they simply didn’t know how to be attuned to their kids and respond to their cues and thus failed to comfort and reassure them. The hostile/intrusive mothers were more likely to have childhood histories of physical abuse and/or of witnessing domestic violence, while the withdrawn/dependent mothers were more likely to have histories of sexual abuse or parental loss (but not physical abuse).35

  I have always wondered how parents come to abuse their kids. After all, raising healthy offspring is at the very core of our human sense of purpose and meaning. What could drive parents to deliberately hurt or neglect their children? Karlen’s research provided me with one answer: Watching her videos, I could see the children becoming more and more inconsolable, sullen, or resistant to their misattuned mothers. At the same time, the mothers became increasingly frustrated, defeated, and helpless in their interactions. Once the mother comes to see the child not as her partner in an attuned relationship but as a frustrating, enraging, disconnected stranger, the stage is set for subsequent abuse.

  About eighteen years later, when these kids were around twenty years old, Lyons-Ruth did a follow-up study to see how they were coping. Infants with seriously disrupted emotional communication patterns with their mothers at eighteen months grew up to become young adults with an unstable sense of self, self-damaging impulsivity (including excessive spending, promiscuous sex, substance abuse, reckless driving, and binge eating), inappropriate and intense anger, and recurrent suicidal behavior.

  Karlen and her colleagues had expected that hostile/intrusive behavior on the part of the mothers would be the most powerful predictor of mental instability in their adult children, but they discovered otherwise. Emotional withdrawal had the most profound and long-lasting impact. Emotional distance and role reversal (in which mothers expected the kids to look after them) were specifically linked to aggressive behavior against self and others in the young adults.

  DISSOCIATION: KNOWING
AND NOT KNOWING

  Lyons-Ruth was particularly interested in the phenomenon of dissociation, which is manifested in feeling lost, overwhelmed, abandoned, and disconnected from the world and in seeing oneself as unloved, empty, helpless, trapped, and weighed down. She found a “striking and unexpected” relationship between maternal disengagement and misattunement during the first two years of life and dissociative symptoms in early adulthood. Lyons-Ruth concludes that infants who are not truly seen and known by their mothers are at high risk to grow into adolescents who are unable to know and to see.”36

  Infants who live in secure relationships learn to communicate not only their frustrations and distress but also their emerging selves—their interests, preferences, and goals. Receiving a sympathetic response cushions infants (and adults) against extreme levels of frightened arousal. But if your caregivers ignore your needs, or resent your very existence, you learn to anticipate rejection and withdrawal. You cope as well as you can by blocking out your mother’s hostility or neglect and act as if it doesn’t matter, but your body is likely to remain in a state of high alert, prepared to ward off blows, deprivation, or abandonment. Dissociation means simultaneously knowing and not knowing.37

  Bowlby wrote: “What cannot be communicated to the [m]other cannot be communicated to the self.”38 If you cannot tolerate what you know or feel what you feel, the only option is denial and dissociation.39 Maybe the most devastating long-term effect of this shutdown is not feeling real inside, a condition we saw in the kids in the Children’s Clinic and that we see in the children and adults who come to the Trauma Center. When you don’t feel real nothing matters, which makes it impossible to protect yourself from danger. Or you may resort to extremes in an effort to feel something—even cutting yourself with a razor blade or getting into fistfights with strangers.