Healing from Attachment Issues: Expert Counseling Tips

You. I'd like to welcome everybody to Today's presentation. I'm Dr. Donnelly Snipes, and we're going to be talking about complicated grief and attachment. We're going to define complicated grief as opposed to regular old grief. Identify how loss of or lack of an attachment relationship may represent a loss that needs to be grieved. Think about how kids feel, how adults feel if they grew up and they never had that primary attachment relationship. A lot of times we hear things like, I never had the childhood that I should have, or I never had the parents that I wanted, or whatever the case may be. We'll explore the overlap between complicated grief and trauma, which I'll give you a hint. We're going to go over more on Thursday and we'll identify risk factors for complicated grief, especially as it relates to loss of that attachment relationship or lack thereof, and explore tasks for successful grief resolution. Real quick, we're going to talk about a couple definitions. Loss is change that includes being without someone or something. In this case, we're really focusing on that primary attachment relationship. We're not talking about adult attachment. We're really focusing in this course on that primary attachment relationship. And I will try to watch my language when we talk about caregivers, because that primary attachment relationship can be formed with any caregiver. It doesn't have to be the biological parent that gives birth. So, you know, I am going to try to be sensitive to that secondary loss. We're going to talk a lot about these. These are other losses or traumas as a result of a primary loss. So when the child, for example, loses their primary attachment figure, maybe there was an attachment. And then when the child was six months old, the primary attachment figure died. That's a loss. So what kind of other losses or traumas or symptoms or problems does the child experience as a result of that secondary loss? Another example is if a child is rejected by their primary caregiver. The primary caregiver may not be emotionally available. They're dealing with major depressive disorder and not able to connect. They are addicted to substances and not able to connect. Something like that. So the primary caregiver is there physically but not willing to attend or able to attend to the child in an emotionally sensitive and responsive manner. Grief is reaction or response to loss and includes physical, social, emotional, cognitive and spiritual dimensions. We're not going to talk a lot about spiritual today. We will talk about the others. And trauma is any situation, any situation that causes the individual to experience extreme distress. This does not have to be something that rises to the level of DSM 5 PTSD diagnosis. It can be any situation that causes the individual to experience extreme distress. So let's think about when this attachment relationship, when does it form? Generally, it needs to form between 0 and 18 months. So there's a lot of stuff that can cause an infant extreme distress. We do look at the impact of the attachment relationship, this primary attachment relationship, up through the age of five. Researchers have found that any disruption in this relationship between 0 and 5 can have lasting psychological and physical health consequences for the child. So again, I want you to think about the Adverse Childhood Experiences survey. What things were they looking at? They were looking at whether there was a parent in the household who was abusing substances or a parent in the household who had a mental illness, or if there was domestic violence or abuse or neglect in the household. All of these things can happen, you know, can be happening when the infant is born, all the way up through five and then on. So we recognize that a lot of these traumas may be happening early in this child's life. And, you know, what are the effects of, of that attachment is the quality of the relationship with the caregiver characterized by trust, safety and security. And I highlighted trust. Think about Erickson's stages. What is that? First stage, trust versus mistrust. The child learns to trust that when something's wrong, somebody's going to help them make it better. The child learns to trust his or her own sensations. If they're cold, you know, then somebody meets that responsibly with a blanket. They don't meet every cry with a pacifier or a bottle. So trust is learned and the child learns to start to interpret his or her own bodily cues. And safety and security kind of go along with that. They learn to trust that others will be there when they need them. Because at this stage, I mean, they can't even, you know, when they're first born, they can't even really control their arms and legs, let alone make their meals. So they are entirely dependent on the adult to be there and meet their basic needs. And think we're going to go Back to Psychology 101 today a lot. So forgive me, but think about Maslow's hierarchy. You know, that child, that infant, needs their basic biological needs met and they need safety. So remember, the lower level is biological needs. Food, shelter, medication, medical care, those sorts of things. And then safety comes in. Those things are provided by the caregiver. You know, there's not a lot of self esteem and hopefully there is some love. But Initially, that child needs somebody to be responsive to their physiological needs. The quality of the infant caregiver attachment is a powerful predictor of a child's later social and emotional outcome. It is really important that we help parents figure out how to connect with that child in a meaningful way so the child recognizes and receives that parent openly. They've done studies with infants and have found that infants who are responded to by a responsive, caring parent tend to welcome that child. They make eye contact, they may eventually smile, you know, even when it's not just gas. And tend to have better outcomes than a child whose parent is not responsive to their needs. Not saying that parent is trying to be irresponsive or unresponsive, but sometimes parents just, they don't have the skills, they don't have the ability to be responsive. And when a child is in that sort of relationship, even as young as 4 to 6 months of age, when that parent starts approaching, the child will avert their gaze. The child will find other ways to deal with the stress because the distress coming from the parent is too overwhelming to the child. Attachment is determined by the caregiver's response to the infant and toddler when the child's attachment system is activated. Now, our attachment system isn't always activated when babies are young. It's activated when they need something because, you know, they're calling out, they're going, I need something, Please, please bring it to me. I can't get it myself. When they are older, a lot of times that attachment system is activated when they experience anxiety from something and when they feel afraid and they need some sort of comfort. But understanding what kinds of comfort the child needs and understanding how to meet that need at different developmental stages can be a little bit challenging. For some parents, children's attachment with their primary caregiver leads to the development of an internal working model which guides future interactions with others. That's our first relationship. We learn from that that either people are going to be responsive to our needs and that we actually understand what we need, or that nobody can be trusted. And when we feel icky, there's just no way to make the icky go away because we don't know how to interpret our own cues. Three main features of this internal working model. A model of others as being trustworthy. So if that doesn't happen, what's the loss here? What do people need to grieve? If they grow up and they've never developed this image of other people as being trustworthy, how does that set them up to be Responsive to themselves. How does that set them up for future relationships with others, with friends, with their children? You develop a model of the self as valuable. When attachment needs are met, that parent is responsive and the parent drops what they're doing, you know, within reason to attend to the child's needs. The parent makes sure that the child is getting their needs met, which is communicated as or interpreted by the child as I'm valuable, that the parent cares about me and cares about me enough to help me out. If the child doesn't get that, then what do they lose? They lose self esteem. They don't see themselves as valuable or worthy. What kinds of symptoms are we going to see in later life? If people are growing up and they're not seeing other people as trustworthy, they're not seeing themselves as valuable. I'm seeing future clients in my future. And the internal working model helps people develop a model of the self as effective when interacting with others. It helps people learn that, you know, they can affect change, they can have an impact, they can do things, they can be successful. And if they don't have that, then their sense of self efficacy and motivation kind of goes out the window. Secure attachments help children feel loved and accepted, feel valuable, learn to manage their emotions. Not only are they effective at interacting with others socially, but on an emotional basis. And it can also help address dichotomous thinking and cognitive distortions. How many times think about, if you have kids or, you know, little brothers and sisters or somebody that you worked with, did a child come back and seem to be talking in dichotomous terms? Children, when they're in that pre operational stage and even sensorimotor to a certain extent, but they're not super verbal then tend to think very egocentrically and dichotomously. So whatever happens, I had something to do with it, it's my fault somehow, maybe. Whatever happens, you know, if I see it this way, then everybody else must see it the same way. And they think dichotomously. It's all or nothing. You either love me or you hate me. You're there for me or you're not. There's no middle ground for a lot of kids. But in secure attachment, the parent is there. They're that secure home base and the child can go out and venture forth and if they have a hiccup, they can come back and it's a safe space to be. And the parent can help them negotiate those cognitive distortions and recognize that, okay, you failed at that. You know, maybe that's not your thing, but look at these other things that you succeeded at. So that attachment helps the child feel safe to come, to take chances, but also to come back and process. Sue asked or pointed out that it's interesting how the daycare generation displays symptoms of attachment disorder at much higher numbers than the generation before. And I'm not sure what those numbers are, but just speculating, you know, thinking about a lot of families, they're having to be two working, both parents or both caregivers have to work. And so children are going into daycare as early as six weeks of age. So that primary attachment, it's really hard to form that primary attachment when the primary caregiver is not available from the hours of 6:30 in the morning until 6:00 clock at night. And you know, so there, and there are intermediary people. Now those daycare caregivers may be, you know, spot on awesome. And that's great. However, is it the same and it probably isn't. I'm speculating between a consistent one consistent caregiver versus, you know, the family caregiver and a consistent child caregiver. Maybe, maybe not. And technology has exponentially, as Valerie points out, exponentially impacted attachments as we become increasingly unavailable for quality human connection. I've seen, you know, new mothers that are just on their phone constantly. They're on their phone while they're breastfeeding, they're on their phone while the kids at the playground, they have difficulty being emotionally and cognitively present for that child, even in the, in the early stages. And because technology, and I'm speculating here, because technology has gotten us so used to things moving really quickly, we often, I often at least tend to get bored. Really easy movies that I could watch back in 1980 something and I thought were rockin movies back then. I watch them now and I get about 30 minutes into it and I'm like, okay, pick up the pace here a little bit. I've got to see some action. And we've become used to having a lot of stimulation. So, you know, sometimes new moms have difficulty, or not just moms. New caregivers may have difficulty being present because they're not used to slowing down. The ning brings up that new moms can also be more concerned with sharing this image of being the perfect mom than rather the focus on actual mommying. And that's true too. So we also see a lot of pictures on Facebook and Instagram of, you know, the perfectly dressed child or whatever. And there's so much time spent in impression management for the parents that sometimes the child kind of gets lost in the, in the process. They're sort of a prop, as opposed to being, you know, the end in and of itself. Attachment relationships help regulate psychological and biological functioning, including mastery and performance success. We are not going to be as motivated, we are not going to be as willing to actually step out and try when. If we don't have a secure base, if we have a secure base, then we tend to have more perseverance. That secure attachment figure is going to be more likely to encourage us to continue to try to do things and to venture out learning and performing the same thing. Not only because we tend to have more support and encouragement, but if that primary attachment relationship doesn't ever form, then one of the problems that children face is cognitive disruption. They're anxious, they're sleep deprived, they're irritable, so they have difficulty learning. This initial relationship shapes relationships with others and future attachment, adult type attachment relationships. It impacts cognitive functioning based on whether the person is constantly in this hypervigilant state with the HPA axis activated, which means they're probably always looking for threats and interpreting the world in the lens of a threat versus if they feel content and safe and they're interpreting the world through that lens. Coping and problem solving skills, we ain't born with them, so we learn those from our primary attachment relationships as well as others. That primary attachment relationship, when you see a young child interacting with that primary caregiver, you see that child when they fall down and scrape their knee, or when they try to do something and they fail, when they do something really good and they want to share it, or when they get stuck, a lot of times they will run or crawl or whatever to the primary caregiver. And that's when that person can help scaffold the child. Help them as much as they need to until they can take it the rest of the way themselves. Think about tying their shoes. I remember my son, it took us a long time to help him learn how to tie his shoes. And you know, I would get him to a point and then I'd say, okay, you try. And if he couldn't quite get it from there, I take him to the next step and I'm like, okay, now then what next? Scaffolding is when we build up the process, we support them to the point where they can launch on their own. Self esteem is formed through attachment, like we talked about earlier. The child starts seeing themselves as valuable and worthy of love and worthy of attention because they develop self esteem and coping and problem solving skills, they tend to have better emotion regulation. Also, if that attachment relationship is formed, then they are more likely to not have hypocortisolism. Remember, when the HPA axis stays activated too long, people can develop hypocortisolism, which leads to emotional dysregulation. Sleep quality is improved because when we feel secure and safe, guess what? We can rest easier. And pain intensity, interesting. But remember that pain intensity is connected to in part serotonin levels and when we're not getting sufficient sleep and when our HPA axis is activated, serotonin is really not in high supply at that point, so, so our pain perception may be more intense. All of these reasons are why a good initial attachment is so important. Attachment and safety stimulate the desire to learn, grow and explore. Caregivers provide support and reassurance or the so called safe haven and encouragement and pleasure, that secure base that they go back to. You know, maybe Tommy went out and tried to swing on this, tried to jump off the swing because we all tried to do that when we were little and fell down and hurt himself. And you know, mom goes over and takes care of it and you know, everything's fine and then she tickles his belly to make him laugh, to help him get into a different mental space. That's what the secure attachment does. It says, okay, we got this, let's figure out how to fix it and let's move on. Let's not stay stuck here in the painful moment. Loss of an attachment relationship disrupts attachment caregiving and exploratory symptoms. It activates the separation response and impacts restorative, emotional, social and biological processes. Yeah, what does that mean? When the attachment relationship never forms, then the child is anxious because they don't feel like they can trust the world. You know, imagine going through life from the time that you are, you know, breathing the air, not believing that it is a safe place, always having this fear thing going on. And infants of course aren't thinking, well, this is unsafe. It's just the primitive parts of their brain that are going, I am hurting, I am cold, I am hungry, I am uncomfortable. Bad mojo happening here. So they are constantly under stress. This impacts their restorative processes. When that HPA axis is activated, when they don't have someone who can help them get control, can help them feel safe, then they are going to have disrupted sleep, they're going to be more irritable. When children are irritable, it tends to cause the grownups to get irritable. And you see where this is Going, it inhibits exploration with a loss of a sense of confidence and agency. If that attachment relationship is never formed, then children are generally, you see two extremes. There are children who just don't care and they're going to go out and do whatever. But there's also the child who is just withdrawn and sullen. That exploratory system gets, gets all goofed up and caregiving. It produces a sense of failure. The child goes, why did my parent reject me? You know, why does mom not want to spend time with me? Why does dad not want to spend time with me? And can include self blame on the child's part. I must not be a good person, I must not be worthy of love. Or in the case of the caregiver, the primary attachment figure dying, the child can have survivor guilt. If that attachment happens and they get it, and six months a year long, that attachment figure is yanked out of the picture for some reason, they go to jail, they go to the hospital, they die, whatever, it disrupts attachment. And all of these same things can happen on top of an intense grieving process because for a lot of children, they recognize that there has been a significant loss. Lisa points out that postpartum depression and anxiety are major roadblocks for some moms. And yes, the research does indicate that postpartum depression and anxiety significantly impact this initial attachment relationship. Because moms in some cases feel numb, they are unable to emotionally connect or they're so afraid they're going to hurt their child. There's a lot of stuff out there with postpartum depression, a lot of reasons why it can disrupt the attachment relationship, which is why it's so important, and this is one of my little soapboxes, so important to screen for postpartum depression. It can happen in a parent who has never had children. It can happen in a caregiver who has given birth three other times and not had postpartum depression. But the fourth time it hits. And it can happen to non biological caregivers, that is not the person who gave birth to the child. We do see postpartum depression in partners of new parents as well. So we do want to screen for that. We do want to screen for that regularly from the second trimester all the way through the first year of the child's life. Alright, off that soapbox. And Renee points out that substance abuse will impact it too. And remember, substance abuse is one of those adverse childhood experiences. If there is a parent in the household who, who is, or someone in the household who is abusing substances, it can significantly traumatize the child or causes significant trauma. Trauma is any event that's distressing or disturbing. What does that mean? How do we know what's distressing or disturbing? I look at it in terms of what erodes people's sense of safety. Anything that triggers the fight or flight response. What triggers the fight or flight response for me is different than what triggers it for a two year old. You know, during a thunderstorm, if there's a loud clap of thunder, you know, I might jump a little bit because I wasn't expecting it. But then I go back to doing what I was doing. A two year old might not understand what that is and that might scare the little pants off of them. So we do need to be sensitive, as we've talked about in our other trauma classes, to the fact that what's traumatic for one person may not be for another, but we do need to look at it from the perspective of that person. And when we get into risk factors, in a little while, we'll also be talking about age and experience in terms of risk factors for how do we figure out what's traumatic for one person versus another? Trauma erodes a sense of safety and may cause emotional dysregulation in mental. It can cause changes in interpretations and changes in schemas of things. And physically, you know, think about a child who doesn't have object permanence yet. When mom goes out of the room, mom's gone, mom disappeared, caregiver disappeared, whoever that is, when they come back, it's like, yay, you know, it reappeared. But for a child who has not established object permanence yet, having a caregiver disappear, you know, walk out of their sight can be traumatic, especially if, you know, they've had experiences where that caregiver hasn't come back. Darkness for children can be really traumatic. I remember my daughter was scared of the dark for the longest time. Pain, anything that causes physical pain can trigger or can be distressing to people. You know, whether it's a shot or, you know, constant earaches or whatever it is. And prior experiences, if they have been in a situation that's been similar, that has been traumatic, like maybe they've been through a hurricane before and then now there's a storm coming, they may be more traumatized when the storm comes. They may be more vigilant when the storm comes. It is important to pay attention to people's history. Adverse childhood experiences that may disrupt primary attachment. We've talked about these. I'm going to highlight them again. An immediate Family member. Somebody living in the household with a mental health or addiction issue. Somebody in the household who is taken out and incarcerated. Divorce, abuse. Either child abuse. Physical, sexual, emotional, or domestic violence. The child does not have to be the one directly being abused. It can be observing domestic violence and neglect. You know, abuse, neglect, all of that stuff in there. Those are some of the more prominent adverse childhood experiences. The primary attachment figure remains crucial for approximately the first five years of life. Let's think about what's going on during that time. The trust versus mistrust Erickson stages zero to two. You know, up until, you know, little Johnny's a toddler, he's learning to trust himself and trust his own bodily responses. And, you know, some kids start to toilet train around the end of this phase, but they're learning to identify what they need and figure out how to get what get their needs met. They're learning how to communicate. I remember my son, he couldn't eat enough. Goodness gracious, he could not eat enough when he was little. And he would sign and he would. This is the more sign. And he would just sit there and do this when he was an infant, he would flap his hands like this to get us to put food in faster. I'm like, son, you gotta swallow first. But learning to interpret his cues and respond in a way that was meaningful was really important during this period. Cognitively going to Piaget object permanence is developing. So if a parent disappears, quote, unquote, when the parent's out of sight, then the parent has essentially disappeared to that child, and they're thrilled when the parent comes back. But that consistency of knowing that the parent is going to come back, you know, really isn't firmly established until after the age of two. During the next phase, autonomy versus shame and doubt. If you think about Erickson, this is when they're toilet training. This is when they're going through daycare, preschool, learning how to start doing things like dressing themselves and picking out their own clothes. They're starting to learn to have agency. And if they don't have support or if they're always being criticized or they're not forming that response, getting that responsiveness from a caring caregiver, then they may start to develop problems. Egocentrism is prominent during this phase. Like we talked about, in the phase of egocentrism, children assume that other people see, hear, and feel exactly the same as they do. So if they feel scared, they think everybody else feels scared. So it's up to us to go, you know what, honey? I Can see you're scared, but mommy's got it right now. It's all good. And help the child recognize that there are other feelings that may be going on. Children's moral sense in this phase of development is rigid. And they believe that a punishment is often invariable, irrespective of circumstances. So if they do something bad, you know, whatever they perceive as bad, and then dad gets in a car accident on the way home and is killed or put in the hospital or whatever, child may interpret that as punishment for they did something bad so dad got hurt. You know, they're trying to make sense of it in their own little. In their own little minds. They regard bad things that happen as a consequence for misdeeds and apostles punishment for behavior. And it's up to us, the responsive attachment figures to help them differentiate cause and effect and see some of these things. Children at this age are not able to extrapolate and go, oh, well, it was raining and it was slippery. So that's why dad got into a car accident. It's up to us, the caregivers, to help explain that. What is a child supposed to have from a caregiver? I hear, you know, these a lot. A lot of times when I work with clients, you know, they may not have had warden June Cleaver for their parents. Most people don't. And so they're extremely angry. And some are extremely angry and resentful and hurt and feeling rejected and dejected because they didn't have that parent. They're like, why didn't I have that? Why wasn't I worthy to have that parent? A child is supposed to have emotional support and encouragement and love from a caregiver. When that doesn't occur, you know, think about how that could be traumatic to a little kid who runs up and they've got something really exciting to show. And parents like, yeah, go away, kid. You bother me. Or, you know, I'll look at it as soon as I'm finished texting this person or whatever. So the child's like, oh, okay. And then toddles away. Or if the child is emotionally upset and the caregiver is not there to help them regulate that emotion because we're not born with that ability, then the child doesn't learn how to regulate his or her emotions. Then emotions start feeling very dangerous, which can be traumatic cognitively. When a child doesn't have a loving, responsive caregiver, it's hard to make sense of the world because children don't have much experience. If you go from the tabula Rasa theory, they're a blank slate when they're born. So they're not sure how to interpret events. Since they think egocentrically and dichotomously. If nobody's there to moderate that, to help them, you know, massage that out a little bit, then they may grow up thinking dichotomously and egocentrically, which again can be traumatic. If they're seeing everything as threatening, then the world seems threatening and they see, they get stuck in this negative feedback loop physically. When children are emotionally dysregulated and cognitively fearful and seeing things as the negative, their HPA axis is probably going to stay activated. So they're not going to get good sleep. It's probably going to impact their ability to focus, to concentrate, to learn all kinds of things. But what is a caregiver supposed to be like? Well, in an ideal world, they are responsive when the child cries. Child babies generally have five cries. Hungry, sleepy, in pain, cold and tired. Theoretically we can differentiate those cries. I don't know that I ever really paid attention and I said, oh, that's the sleepy cry. But you know, as a mom or a caregiver, you learn generally how to interpret the child's needs or where to start at. You know, sometimes you're off a little bit and you're like, okay, let's check and see if my son used to get too hot all the time. He was rarely cold, so a lot of times that was my first thing. Let's take off his booties and see if we can help him cool himself off. And then you work down, down from there, down the list to try to figure out what's going on. But the caregiver is being responsive, the caregiver is loving. Which children, a lot of times one of their love languages is touch. They've shown that infants that are in the neonatal intensive care unit show much lower stress scores when they have skin to skin contact, when they have that touch, when they're being held. When possible, some premature infants and some infants with various birth defects, it's more stressful to be held and it overstimulates them. But that's a whole different story. When a caregiver is not the way they're supposed to be, then the child tends to learn that they're not valuable or that the world is a scary place, that nobody's trustworthy. So how does this, how do we go from trauma to loss? When a child doesn't have this relationship, it is very devastating to them. It separates them from their parent. And if it was a, the attachment was formed and the person goes away. That's an obvious loss. But I believe somewhere in our psyche we're actually programmed to have that primary attachment. When it doesn't happen, it's a de facto loss. Separation distress involves intrusive, distressing preoccupation with the loss. Sometimes kids will really try and even adults, you can talk to them. And sometimes adults are still trying to earn the love or the approval of their primary caregiver that they never had. And they're like, if I just do this, maybe she'll love me. Traumatic stress reflects specific ways the person was traumatized by the loss. The person may avoid certain reminders. You know, maybe Mother's Day or Father's Day just makes them cringe because they never felt that attachment with their primary caregivers or they have intrusive and painful thoughts because they wish they had had. You know, June Cleaver as a mother they may be emotionally numb. They never learned how to control their emotions and it just became too overwhelming to feel anything. Irritability. Well, when your HPA axis that is activated and you don't have anybody to help you regulate it and you don't have the skills to do it, you're going to be irritable. Feelings of hopelessness and purposelessness. Obviously a two year old isn't going to articulate this, but you may see symptoms of depression in 2 year olds and apathy. They're just really not into playing with much of anything. They just kind of sit there and A shattered self identity. When complicated grief happens, kids have difficulty forming self esteem and a self identity. So risk factors of the child. The age in which the attachment relationship is disrupted is particularly meaningful. If it is before the age of five, it tends to lend to significantly more traumatic and traumatic issues and issues related to grief. Physical issues. If the child had physical disabilities or something then that can impact it because maybe they relied on that parent more because they were in a wheelchair or whatever. Emotional issues. If the child had pre existing emotional issues prior to the loss of the caregiver, then it might intensify the grief reaction. If they aren't able to cognitively understand what happened and most 0 to 5 year olds are not able to cognitively understand what happens, then it may impact remember at this stage they tend to think of bad things as happening as a punishment to them. So they may have difficulty coming to terms with, you know, why, why was this caregiver taken away from me? I don't know. And a lot of kids are like you gotta know there's gotta be a reason. And their personality and character traits. If they tend to be highly emotional, if they tend to be more clingy and high needs, then it may be more traumatic if their caregiver goes away. And again, it could even be a caregiver going away to treatment for six months or to jail for a year. It doesn't have to necessarily be death. The nature of the loss, obviously death is going to be different than if primary caregiver gets deployed for six months or a year. The number of losses. If the child experienced multiple losses, maybe, and I'm going to use mom as an example for primary caregiver. Maybe mom passes away and as a result, dad doesn't feel able to take care of Junior, so Junior then has to move and move in with granny. So not only did Junior lose mom, Junior lost dad, and Junior lost his home and his security. And, you know, life just got turned on its head. So that person is much more likely to have problems because of the multiple losses. The circumstances of the loss can be a problem as well. And what resources are available? Not every child who experiences the loss of a primary caregiver is doomed to a life of trauma and disorder. You know, it does happen that there are resources, there are responsive parents, there are, you know, things that can happen to help intervene. Yes, the child has to grieve, but it's not a death sentence, so to speak. And I'm glad to see that Renee says that Dr. Phil's wife is campaigning to keep parents in drug treatment with their children for these concerns rather than being separated. And I ran a mother baby unit for several years when I was in Florida. And it was amazing to see the interactions between the parents and the parents. The moms that we had in treatment came in pregnant, but if they had other children, those other children up to the age of five were able to come and room in with them. So, yeah, I think that's great. The nature of the relationship of the child with the caregiver, the length and duration. If the child never knew the primary caregiver or if there never was a relationship there, then the reaction may be a little bit different than if they had a primary attachment and then it was broken for some reason. The importance of that person in the child's life. Again, if they never form that strong attachment, then if supposed primary caregiver goes away, then the kid is going to be hurt. But it may not be as impactful in some ways. Culture and roles. Some cultures are very family oriented where lots of people take care of junior. So there's lots of not primary caregivers, but there's lots of secure attachments that are formed and that can be helpful if there are other people in there. Quality of the relationship. If it was a good relationship and it gets obliterated, that's going to be more impactful than again, if there was no real strong connection, if it was an insecure connection, then you know, that might not have the same impact if that relationship ends somehow. And the amount of daily change, if the child, like I said, is put in foster care or relative placement, not only are they, you know, potentially losing their primary caregiver, but they're also being disrupted. They may have to switch schools, their routines change. There's a lot of stuff that changes and that can be more than, more than a child can really handle. Emotional effects, dysregulation. We talked about this earlier. When the body is under consistent stress for a long time, eventually the person may develop hypocortisolism. So they become flat. Their body holds on to that, those excitatory neurotransmitters until there is a true threat. And then when there is a threat, they go from 0 to 250 like that. They also can be experienced dysregulation because they never learned coping skills. If that primary attachment relationship never developed. They never learned how to regulate their emotions. They may have anxiety. If they've grown up thinking the world is scary, then they may be desperate to find some sort of safe place because everybody seems threatening and scary. Or if they had a primary attachment and that attachment goes away for some reason, divorce, deployment, drug treatment, whatever, then you may see an increase in separation anxiety because the child is afraid that that person won't come back angry, irritable or oppositional. A lot of times children who are depressed or anxious express it this way. You know, they're trying to get somebody to help them get control. They're trying to get control somehow. Depressed, lonely, isolated, guilty and regretful. So we see a lot of the stuff that we typically see in adults can come from, can emanate from the beginnings, happening back when the child initially failed to form a healthy initial attachment. Physical effects, and these are true for trauma and complicated grief. You know, it doesn't really matter. Appetite and eating disturbances, energy, fatigue, lethargy, sleep disturbance, anxiety, GI disturbance and compromised immune response. Almost all of these are the result of ongoing stress. For the person in trauma, we look at it as HPA axis activation. But in grief as well, this is an extremely stressful time for the person. So any of these things may happen. And we know that, you know, sleep disturbances will continue to keep the HPA axis more activated, which can contribute to lethargy. And all of this stuff can upset the GI tract. When the GI tract is upset, then it can contribute to leaky gut, which can intensify depression and other symptoms and compromise the immune response. Intellectual effects of trauma and complicated grief. A lot of times these kids have difficulty understanding what's real and what's not. Is the person. I mean, even at that age, without trauma, children have difficulty identifying real from fiction. But children at this age may have difficulty. And when they get older, they still may have difficulty differentiating reality from interpretation, difficulty concentrating. They may read the same page several times when they're, when they're experiencing this. For children, if they're not reading yet, they may have difficulty sitting down and watching a cartoon, or difficulty playing on a video game, or difficulty playing with their Legos or something for more than two or three minutes. Short attention span, difficulty learning new material or short term memory loss. And important to recognize that when children are having difficulty learning new material, Maybe it's their ABCs or writing or something, or when they're undergoing trauma or complicated grief and you tell them, you know, sammy, I need you to go brush your teeth right now. And Sammy may go do something and then come back and you're like, okay, did you brush your teeth? And Sammy's like, no, it may not be Sammy being oppositional. Sammy may truly have forgotten because that short term memory is just not there. And kids are more easily distracted as well as the rest of us when we're under trauma. And yes, it can look a lot like ADD or adhd. Children may have difficulty making decisions, even things like what do you want to eat? Or are you going to wear your blue shoes or your brown shoes today? They may lack a sense of purpose. And this one's, you know, you see it more in adults who never resolve these traumas. But children who are experiencing complicated grief or the traumas from the disruption of this relationship may have a real lack of motivation. They just may be very blah. You know, one moment they may try to do something and then when it starts to go wonky, they give it up. They don't finish anything, and they have an inability to find meaning in the events of life itself. Again, children, that's kind of esoteric, but they have difficulty finding fun. Social effects of trauma and complicated grief. A lot of times children withdraw. They may isolate because, you know, it's was close to somebody, I had this attachment and it disappeared. Or if they never had that relationship, they may withdraw because they perceive the world as unsafe. Some children will search. They want to find something, somebody to comfort them. And so they may search for the person that was lost or they may search for somebody who will be there and be responsive to them, which is why some children are overly friendly, whereas other children are overly withdrawn. Avoidance, self absorption and again clinging independence. We can see these develop in as they develop and we can see these characteristics in adults who have failed to deal with some of these traumatic issues. Reconciliation tasks to help adults or adolescents who never formed that attachment. Help them acknowledge the reality of the loss. Help them understand how it might have impacted them to have a caregiver who was not responsive to their needs as a child. Help them move toward the pain of the loss while being nurtured physically, emotionally and spiritually. So help them, I hate to say embrace the pain, but help them experience the pain that you know, maybe that two year old them experienced and work through it because they may have some stuckness there. Help them develop a new self identity based on a life without that relationship. Sometimes, you know, maybe mom or dad or whoever primary caregiver was just wasn't able to be there, be present emotionally or physically or both. Help them, you know, wrap their heads around that whatever happened and maybe understand that maybe they never will be able to get that person's love because maybe that person's not capable of giving others love. And it's sad to think of that, but it's true. Sometimes it's true. They need to develop a new self identity based on success and love for themselves rather than based on trying to get the love of somebody that primary caregiver. And they need to experience a continued supportive presence in future years. They need to have some sort of adult attachment, if you will. They need to learn basic trust which serves as a basis for all future emotional relationships. And this starts with helping them learn to trust their own spidey senses and learn what do they need? Mindfulness is huge here. Learn to trust their instincts when they need to sleep, when they need to eat, when they need to rest, when they need to take a day off from work, whatever it is. They need to start listening to themselves and trusting their own intuition and then stepping out and starting to learn to form relationships with others and learn how to trust other people in a healthy way, maintaining boundaries, all that stuff. Learn how to develop fulfilling intimate relationships. If the child never formed that primary attachment, then life has Been pretty scary for them. So likely they are not real keen on being vulnerable, which makes it really hard to create fulfilling intimate relationships. If they don't feel valuable, if they don't feel safe, if they don't feel like they know how to problem solve, if they have difficulty regulating their emotions, it's hard to develop fulfilling intimate relationships. So we need to help them, you know, feel safe and learn how to regulate their emotions and then figure out what does a fulfilling intimate relationship look like and how do I deal with it when I start to feel vulnerable. Develop strategies to maintain emotional balance and resiliency. Develop the ability to control behavior which results in effective management of impulses and emotions. DBT is great for this. Helping people develop distress tolerance skills so they don't react to things, they can take a breath, get in their wise mind and then mindfully act. Help them enhance confidence and self esteem and learn how to share feelings and seek support. Again, if that initial relationship didn't exist, if there wasn't a safe home base to come back to and go I don't know what I'm doing here, then they never learned how to share feelings to get support. They may have shared feelings and got them stepped on or shared feelings and got them ignored. Create a foundation for the development of identity which includes a sense of capability, self worth and a balance between dependence and independence. Obviously this is good treatment planning here. Help them establish a core set of beliefs. What do they believe that leads to empathy, compassion and conscience? Again, start with themselves. They need to develop self empathy, self compassion and awareness of how what they do impacts them and, and then expand that to others and encourage them to begin exploring the environment with feelings of safety and security which leads to healthy intellectual and social development. Once they start feeling safe and empowered and confident and supported, then people are naturally going to start taking little steps out of their comfort zone. So help people recognize the loss, they need to acknowledge the loss. The lack of establishment of the attachment relationship and realize that it just wasn't there, okay? And understand the losses that are a result of the lack of attachment. My loss of a sense of safety, my loss of, you know, whatever it is, whatever they put in that, in that block. Help them react to the realization of the loss. Help them experience the pain. How did it feel for them when they were, you know, 18 months old, 2 years old and they couldn't get anybody to put a band aid on their boo boo or something. Feel, identify, accept and give some form of expression? This is a big one to all the emotional, cognitive and Physical reactions to the lack of or loss of the attachment figure. Have people go through that checklist. Start out with emotional reactions that resulted, you know, and explore how that happened. Have them identify that as where it came from, if it came from that attachment or attachment disruption. Help them accept it as it is, you know, it is what it is and how do you move on and improve the next moment. And then have them identify and mourn secondary losses such as their loss of a sense of safety, their loss of happiness because they felt so much distress throughout their childhood, the loss of the childhood that they think they should have had, the loss of self esteem because they never felt valued or valuable, and the loss of success because, you know, they were always struggling to get by. They didn't do well in school because they were just, you know, so unhappy all the time or so scared all the time that they couldn't find, focus. Help them recollect and re experience the relationship to review and remember realistically what happened. Instead of this ideal image of this perfect caregiver that, you know, I, the inept child just could never achieve, acquire the love of. Have them reflect and recognize that, okay, you know, now that I'm older, I look back and I realize that primary caregiver had, you know, a wicked alcohol problem at that point in time and, or really bad postpartum depression and it wasn't me that was rejected even though it felt like it. And have them revive and re experience the feelings that may have happened and then move on. So help them embrace the dialectics and relinquish the old attachments to the old assumptive world that this is the way it should be, this is the way childhood should be. Well, you know, your childhood wasn't that way and if you keep holding on to the should, you're going to stay stuck. And then help them readjust to move adaptively into the new world without forgetting the old. Have them revise that assumptive world by embracing the dialectics. Okay, I didn't have the childhood that I should have had or that I wanted to have. I can choose to stay stuck back there or move forward. Help them develop a new relationship with the self, adopt new ways of being in the world and form a new identity based on being interpersonally effective, emotionally effective and worthy of love. Oh, and yes, Renee, I love that book Toxic Parents by Susan Forward. And encourage them to reinvest. Reinvest that energy that they have have spent being scared and trying to protect themselves and being angry. Reinvest that into moving towards where they want to be. Failure to develop a primary attachment relationship can be viewed as a loss or something that was needed but never achieved. When examining the behaviors of adult or adolescent clients whose primary attachment was disrupted, the traumatic impact can often be seen. In order to help them reconcile the trauma, it's essential to help them identify and grieve the losses. Review and remember realistically what happened in order to combat inaccurate schema and memories. Review the assumptive world. You know, making the assumptions that if I just do this, then I can make her love me may not happen. Develop a new loving relationship with the self and learn how to trust the self and others to form meaningful and supportive relationships. Okie dokie, everybody.