What psychological mechanisms may explain how attachment relations affect traumatic responses? It is interesting that both literature in trauma and that in attachment relations discuss the role of (1) core schemas and (2) emotional engagement as relevant psychological mechanisms.
First, if attachment relations shape core schemas, and PTSD is caused by negative schemas of the self and world formed through trauma, then it is plausible that attachment figures can play a role in influencing PTSD.
Schemas are a conceptual framework based on life experiences that help the individual organize information and interpret and adapt to the environment. Trauma can cause damage either by negatively changing one's positive schemas of one's self as competent and the world as safe or by priming existing knowledge of one's self as incompetent and the world as dangerous [24
]. Though the first pathway is intuitive, the latter pathway applies to trauma victims with previous traumatic experiences and pretrauma psychological disturbances. Foa [24
] cites studies which provide evidence for both these pathways, such as an earlier study by the author which found that individuals who had PTSD 3 months after trauma showed a less positive view about the world and themselves just after the trauma than those who recovered ([25
] as cited in [24
]). Another paper described how earlier victimization and preexisting biopsychosocial problems delay rape recovery [26
Attachment theory founder Bowlby [17
] conceived of attachment as an evolutionarily crucial form of behavior distinct from feeding and sex with the purpose of gaining proximity, care, and protection from the attachment figure, the infant caregiver or mother. Bowlby [27
] believed that repeated interactions with attachment figures shaped children's dynamic and increasingly complex internal working models of the world, self, and important relations; comforting behavior by attachment figures results in internal working models of the self as worthy and the world as safe versus the self as unworthy and the world as dangerous.
According to developmental psychologist Jean Piaget, who is commonly known for introducing and popularizing the term schema, childhood was a time of rapid schema development. Thus, behaviors by attachment figures (as well as childhood trauma) should have a stronger impact during this time in schema formation, providing the foundational schema which can be further tweaked.
Following the line of thought of the core schema theory, attachment figures that strengthen the child's schemas of the self as competent and the world as safe can play a role in mitigating the negative effects of trauma and the likelihood of PTSD.
Second, if emotional engagement with the trauma facilitates trauma resolution, then the healthy attachment relationship, which can elicit strong feelings of engagement and comfort, should help process trauma feelings and mitigate PTSD. Conversely, trauma occurring in the context of an unhealthy attachment relationship which hinders emotional engagement with the trauma should increase PTSD.
Research points to early emotional engagement with the trauma as crucial for trauma processing and recovery and emotional withholding, avoidance, or disassociation as linked to PTSD severity [28
]. Indeed, complex PTSD, occurring after long-term trauma, is more correlated with dissociative symptoms and also more difficult to treat [31
Attachment relations can play a critical role in emotional engagement with the trauma. First, it is within the context of the attachment relation that infants first learn about emotional engagement, as both the receiver and giver of it, developing styles of engagement (secure, anxious avoidant, or anxious ambivalent) based on patterns of the attachment figure's sensitivity, responsiveness, timeliness, and availability [32
]. For the infant, physical bonding is an essential aspect of emotional engagement; in lieu of verbal vocabulary, touch can communicate emotions and information to the infant based on the qualities of the interaction [33
] and facilitate state regulation and coping with stress and arousal [34
] found that the most significant commonality for those infants developing an avoidant style was mothers with an aversion for physical contact. Disengagement is then a strategy by the infant to cope with the mother's expected rejection and hostility. The attachment relation is built by interactions of emotional engagement or disengagement. In fact, an independent emotional system characterized by feelings of calm, comfort, and emotional engagement, with a discrete system of brain circuits, evolved to support attachment in human evolution for parenting, just as separate emotional systems of lust and attraction evolved to foster the other two primary behaviors of mating and reproduction [35
Attachment theory holds that this attachment style, though first shaped by the attachment figure, extends beyond the primary relation and is correlated with later responses and psychopathology [36
]. On the same note, Dieperink et al. [37
] found that adult former prisoner war veterans with secure attachment styles scored significantly lower on measures of PTSD than did those with insecure styles, and that PTSD symptom intensity was predicted better by attachment style than trauma severity. This resonates with the idea that the style of emotional engagement, first shaped by the attachment figure, is used to process later events such as trauma.
Second, attachment figures can help children emotionally engage with and process the relevant trauma. Though attachment style is relevant throughout the lifespan, the facilitation of emotional engagement by attachment figures like parents is especially pertinent for children facing childhood trauma; attachment theory holds that attachment behaviors are most visible during early childhood and during times of distress and uncertainty [17
], both of which are relevant for pediatric trauma. The evolutionary purpose of attachment is protection, and it is in such moments requiring that the attachment dynamic becomes more salient [17
], offering a reassurance distinct from and beyond social support or peer approval [32
]. Attachment figures can help children emotionally engage with their presence, providing a secure base [32
] and reliable boundaries amidst unpredictable and disruptive situations, through attentiveness to and inquiries of the child's experiences and needs; nonjudgment and acceptance of strong feelings; offering empathetic validations. Attachment figures can also help with sense making of traumatic events, negotiating implications of traumatic situations to less distressing ones.
The most empirically supported pediatric trauma treatment, trauma-focused cognitive behavioral therapy (TF-CBT), incorporates all of the previously discussed aspects, aiming to support positive core schemas and correct maladaptive ones, foster emotional engagement, and strengthen the parent child bond [38
]. This treatment for children of ages 3 to 17 suffering from trauma-related negative feelings and behaviors consists of implementing a therapeutic sequence summarized by the acronym PRACTICE, including psychoeducation about trauma; relaxation skills; affect or emotional processing and management; cognitive processing and management; trauma narration and processing; conjoint child-parent discussion; finally, enhancing well-being, safety, and development [38
]. It is important to note that the parent undergoes treatment and training along with the child (in individual sessions for the first four phases, preparing the parent to be as supportive as possible following the trauma narration and later joint parent-child sessions).
The complexity of trauma situations and degree and nature of parent involvement in the trauma, from less involved, witness, victim similar to the child, enabler, or perpetrator, will affect the parent-child dynamic, parent and child symptomatology, and healing of the trauma. As discussed in the literature review, relational traumas are more influential, and thus, traumas in which parents are involved in a more negative light will likely be more challenging. However, as discussed above, TF-CBT provides a general method for addressing childhood trauma, and with the assumption that the involved caregiver is not a current threat to the child, it utilizes the strength of the parent-child attachment dynamic in facilitating cognitive and emotional trauma processing for healing.
While TF-CBT is empirically supported [38
], it is less certain which phase or combination of phases lends to its efficacy. For instance, Deblinger et al. [39
] tested TF-CBT variations (8 weeks versus 16 weeks and trauma narration vs. no trauma narration) and found that though all variations effectively improved symptoms, parenting skills, and children's personal safety skills, the 8-week trauma narrative version most decreased parent and child abuse-related anxiety, while the 16-week no narrative condition most increased effective parenting practices and decreased child externalizing problems. Perhaps a trade-off occurs in how time is utilized in therapy, with focusing on parenting skills decreasing the child's acting-out behaviors, while talking about the trauma may relieve some of the anxiety associated with it. Overall, the paper seems to suggest that healing occurs more through the processing of emotions and beliefs in context of the strengthened parent-child bond rather than formal trauma narration or an extended length of therapy.