InvisALERT Solutions – ObservSMART

PTSD, Anxiety, and Disordered Attachment

Post-Traumatic Stress Disorder is listed in the DSM IV as an Anxiety Disorder, and rightfully so. But trauma as a source of anxiety is also a frequent component of disordered attachment, except that trauma here is from the cumulative effects of early neglect and abuse, rather than the shock of specific events considered more typical of PTSD. When we examine symptoms of disordered attachment – the lack of trust, hyper-vigilance, an excessive need to control people, heightened reactivity, agitation – all resonate with high anxiety. The neurobiology of cumulative trauma also shows effects similar to those of shock trauma. Memory of early traumatic mother-child interactions remains pre-verbal or non-verbal, encoded in the brain-body. These trauma-based reactive templates also trigger seemingly unrelated, distorted and disproportionate responses to circumstances and events. Because these physiological, neurological and emotional processes are sensory based and reactive to stress, they tend to operate outside of cognitive, verbal processing. Because they have no words and words cannot reach them, treatment must incorporate other modes of processing than cognitive-verbal approaches or behavior modification alone. This has major implications for the treatment of traumatized children, adolescents and adults.

First of all, treatment must be relational to have any hope of success. In his seminal work on the neurobiology of affect development, Allan Schore (1994) shows how the brain is shaped by early relational experience for better and for worse. (1) The question is whether or not it can be re-shaped by relational experience into later life. Siegel (2002), Cozolino (2002) and Farber (2000) all claim that this can happen, because of the continued plasticity of the orbito-frontal cortex, but they insist that it will only happen through qualitatively different relationships that provide closeness, caring and support.(2,3,4) Martin Teicher (2003), on the other hand, would disagree claiming that the brain has become hard-wired by the age of three, so that whatever has been done to the child in terms of brain development cannot be undone.(5) Although the debate at this point remains unresolved, both positions can be true; for if change must come from the quality and consistency of relational care, that care may not be available, regrettably, to most of these children.

Bessel van der Kolk (2002), a recognized authority on trauma, makes an additional point with respect to effective treatment. “Because young children and threatened adults cannot inhibit emotional states that have their origin in physical sensations,” conventional modes of treatment need to be modified to incorporate “bottom-up” rather than “top-down” modes of processing.(6) In contrast to top-down cognitive modes, bottom-up modes are body-based, sensory focused and designed to address the critical role of stress in generating anxiety and trauma-based emotional reactivity. Not only must treatment work through the medium of relationship, it must also effectively manage stress, so that the corrective emotional-relational experiences from therapy and parenting can have their healing effect.

Wellspring, a multi-service mental health agency in rural Connecticut, has combined relational treatment with bottom-up modes of processing in its children’s, adolescent and young adult residential programs. A cornerstone of this approach, particularly with children, is safe, healing and comforting touch. Touch is a powerful medium both for healing and for harm, because it directly contacts the body, the senses and the emotions. As a medium for receptivity and mutual exchange between the physical and psychic fields shared by people, touch is profoundly relational. In the ability of touch to provide comfort, it is also an ideal mode of bottom-up processing, because “touch activates the brain systems involved in the regulation of stress responses.” (Panksepp, 1998) (7)

Because the misuse of touch (e.g., physical and sexual abuse) has harmful effects, risk prevention has tended to dominate the clinical stage at the cost of clinical effectiveness. “No touch” policies have been instituted by many agencies to guard against potential abuse, but more pointedly to guard against the threat of litigation, often without questioning whether more harm may be done to children by perpetuating the destructive effects of early touch deprivation. What Wellspring has done is take a pro-active approach to the use of touch in treatment that combines in-depth understanding of its integral role in child-development and well-being with ethical and practical guidelines for safe and sound practice. (8)(9)

The use of touch at Wellspring is permission-based, treatment related and trauma-informed. Based on comprehensive assessments, thorough staff training and ongoing supervision, different levels of touch are used that range from supportive hugs to clinically authorized and supervised holdings designed to help fill in developmental gaps. Rightfully used, touch communicates care and affection, while providing comfort, reducing stress and fostering a depth of interpersonal communication that builds trust.

According to Siegel (2002) and Cozolino (2002), emotion is inherently integrative, so that emotionally involving therapies play an important role in the resolution of trauma.(10)(11) Wellspring not only provides an emotionally validating environment in each of its programs, Emotional Expressive Therapy (EET) is also used in group and family therapies as a component of relational treatment and bottom-up processing. EET employs a wide variety of methods, including breath-work, cube work, role-playing, playback theater, and play therapy to facilitate the structured exploration and expression of emotion, along with the processing of its related content.(12) Expressive work always occurs in the context of empathic relational support, and catharsis is only a secondary by-product. Blocked feeling typically becomes freed to flow into relationships, which helps in the effort to restore heart-to-heart familial and relational connections.

At Wellspring, EET has been used extensively and with great effectiveness with adolescents and adults, while play therapy adaptations have been most effective with younger children.

In terms of trauma resolution, emotional expression actually informs cognition, finding words for emotionally driven content, rather than the reverse. In trauma work with both children and adults, it is important to follow the lead and the limits instinctively set by the client in determining the pace and depth of the work. By calibrating emotional expression in manageable doses, the traumatic experiences at the root of it become progressively de-sensitized rather than re-traumatizing.(Lazarus and Lazarus, 2002) (13) More significant by far than its cathartic effects, EET provides a context for corrective emotional-relational experiences, which stand in sharp contrast to the traumatic past and help to change distorted perceptions of present relational reality.

Instead of encouraging aggression, which some research with children suggests, EET actually serves to diminish it, as evidenced at Wellspring by the steady decrease of restraints with children and the virtual elimination of any restraints with adolescents and adults.(14) While younger children tend to reactively explode, adolescents and adults tend to implode, using self-injury and substance abuse as self-destructive ways to deal with overwhelming feelings. As a coping skill, cutting often serves to numb overwhelming feelings that would otherwise find no outward expression. Combined with individual and family therapy, EET is an effective way to address self-injury, substance abuse, and eating disorders, where feelings can be released and explored, rather than suppressed and displaced into symptomatic substitutes. Once emotions have found expression, the content may eventually be brought into the relationships that gave rise to it.

The development of practical coping skills for emotional self-regulation is a necessary complement to emotional expression. Some of these skills are simple; others are more complex. Breath-work, focused relaxation, time-ins rather than time-outs, yoga for adolescents and adults are some of the sensory related skillsets taught and used at Wellspring. Assessments of hyper-sensitivity and hyposensitivity to touch are part of the Touch Training Manual’s assessment package that help to differentiate sensory integration and sensory modulation problems from difficulties with attachment. Training in EMDR, as another mode of therapy with bottom-up processing, has been initiated with some staff to enhance the overall therapeutic repertoire.

However, it is the natural environment of Wellspring that is the primary sensory related asset that is fundamental to reducing stress and trauma-based reactivity. Wellspring is located in a rural setting surrounded by fields, gardens and forests that are quite appealing. The country quiet combined with animal care, horticulture and adventure programming offer sensory based body-experiential modes of therapy in each of the residential programs, as well as in the elementary and secondary day schools. Relationship to the natural world, which research has shown to be stress reducing, is fostered through these programs. They also help to offset the growing cultural problem of “nature deficit disorder” that Richard Louv has talked about in his startling book, The Last Child in the Woods.(15) Relationship to the natural world of to soil, plants and animals – to manual work, as well as walking in the woods – reduces stress and is ultimately healing apart from any formal clinical interventions. When these relational and bottom-up modes of processing are also woven into the fabric of a multi-modal residential treatment program, and are anchored by individual, family and milieu therapy, they add the necessary means and power to address traumatic residues from the past.


  1. Schore, A. Affect Regulation and the Origin of the Self, Lawrence Erlbaum, Hillsdale, New Jersey, 1994.
  2. Siegel, D. J. “The Developing Mind and the Resolution of Trauma: Some Ideas About Information Processing and an Interpersonal Neuro-biology of Psychotherapy,” In EMDR as an Integrative Psychotherapy Approach. Francine Shapiro, ed., APA, Washington, D.C., 2002.
  3. Cozolino, L.J., The Neuroscience of Psychotherapy: Building and Re-building the Brain, W.W. Norton, N.Y, N.Y., 2002.
  4. Farber, S.K. When the Body is the Target. Jason Aronson, Northvale, N.J., 2000.
  5. Teicher, M. “The Neurobiological Consequences of Early Stress and Child-hood Maltreatment,” Neuroscience, 2003.
  6. Van der Kolk, B. A. “Beyond the Talking Cure: Somatic Experience and Subcortical Imprints in the Treatment of Trauma,” In EMDR as an Integrative Psychotherapy Approach, Francine Shapiro, ed., APA, Washington, D.C., 2002.
  7. Panksepp, J. Affective Neurobiology, Oxford University Press, N.Y., 1998.
  8. Safe, Healing Touch: A Wellspring Training Manual and Curriculum. The Wellspring Foundation, Inc., Bethlehem, CT, 2009.
  9. Field, T.M., Touch in Early Development, Lawrence Erlbaum, Hillsdale, N.J., 1999.
  10. Siegel, D.J. op. cit., 2002. ; 11. Cozolino, op. cit., 2002.
  11. Beauvais, R.E., “Emotional Expressive Therapy,” unpublished paper, The Wellspring Foundation, Inc., Bethlehem, CT.
  12. Lazarus, C.N. and Lazarus, A.A. “EMDR: An Elegantly Concentrated Multi-modal Procedure,” In EMDR as an Integrative Psychotherapy Approach, ed. Francine Shapiro, APA, Washington, D.C., 2002.
  13. Beauvais, R.E., “Emotional Expressive Therapy and Anger Management,” unpublished paper, The Wellspring Foundation, Inc., Bethlehem, CT., 1998.

15.          Louv, R. The Last Child in the Woods, Algonquin Books, Chapel Hill, NC., 2006.

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