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Sex Offender Treatment:The Brain, Attachment Theory, and Trauma Processing






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Sex Offender Treatment:The Brain, Attachment Theory, and Trauma Processing. Jay Adams, Ph.D jayklaus@tcsn.net . Section I. Brain Facts. Human brain development begins in the last trimester of pregnancy.
Sex Offender Treatment:The Brain, Attachment Theory, and Trauma Processing

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Sex offender treatment the brain attachment theory and trauma processingSlide 1

Sex Offender Treatment:The Brain, Attachment Theory, and Trauma Processing

Jay Adams, Ph.D

jayklaus@tcsn.net

Section i brain factsSlide 2

Section I. Brain Facts

Human brain development begins in the last trimester of pregnancy.

An infant’s brain weighs about 400 grams at birth, and increases to 1000 grams in the first year of life.

An infant is born with the sympathetic branch of the ANS (“arousal system”) already activated, and sparse neural connections, but has twice as many neurons as an adult. The sympathetic nervous system promotes the infant’s attachment-seeking behavior because that will make survival more likely.

Sex offender treatment the brain attachment theory and trauma processingSlide 3

Right brain development has already begun in utero, while the left brain (linear processing) does not start to develop until near the end of the second year. The right brain is more responsive to the neurotransmitter dopamine and its pathways for more specific negative emotions, such as fear, distress, anxiety, depression, and disgust, which are registered in the amygdala. “…environmental experiences form part of the child’s autobiographical memory laid down as chunks of emotionally pleasant or emotionally aversive experiences stored in the right brain” (Allez, 2011, p40). We have access to these memories via the body and the senses (may be experienced in “sudden flashes”) rather than words, and they are referred to as “implicit memory” in contrast with verbal, or narrative, memory.

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When the infant brain perceives threat or stress, a cascade of stress chemicals flows along the hypothalamic-pituitary-adreno axis (HPA axis) increasing heart beat and breathing, tensing muscles, raising blood sugar and dilating the eyes. Long lasting high levels of anxiety lead to ongoing high levels of the hormone cortisol, which eventually destroys brain tissue and disturbs connections in various parts of the brain. “…the amygdale is left to fend for itself within a flood of ongoing internal and external perceived stressors, amplified by rivers of cortisol coursing through the body, sending the false message that today is as threatening as the original traumatic time” (Badenoch, p.127).

Sex offender treatment the brain attachment theory and trauma processingSlide 5

Chronic stress may lead to excess pruning in certain brain regions. Both hemispheres go through various alternating spurts of development, through-out childhood. Within minutes of birth, an infant will see, hear and move to the rhythm of the mother’s voice. Infants may be genetically programmed to seek and recognize the face of the mother. Newborns come equipped with only those preprogrammed emotional neural circuits that are necessary to protect from harm and promote survival.

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These are (Panskepp, 1998):

  • SEEKING—active arousal, curiosity, excitement, engagement

  • CARE—feelings of warmth & tenderness when w/others (safety)

  • PLAY—joy in interacting, promotes bonding

  • FEAR—roots of the fight/flight mechanism, triggers escape—Sympathetic NS over-stimulated

  • PANIC—fear of separation from important others, includes loneliness, precipitates vocalizations to ensure survival—Sympathetic NS overstimulated

  • RAGE—eventually becomes the “fight” response—Sympathetic NS overstimulated

  • LUST—sexual arousal and pleasure, later motivates reproduction

Sex offender treatment the brain attachment theory and trauma processingSlide 7

Take home message #1:

  • Every human brain is unique but the processes that governs how human brains develop are universal. *For more information on brain development, see Allez, 2011; Badenoch, 2008;Schore, 2003a & b; Siegel, 1999.

Section ii attachment the unifying conceptSlide 8

Section II: Attachment: The Unifying Concept

Sex offender treatment the brain attachment theory and trauma processingSlide 9

a.John Bowlby—Defining features of attachment

John Bowlby developed attachment theory, proposing that attachment is the affective bond that develops between an infant and its primary caregiver(s). It begins to form as soon as the infant is able to distinguish one face from another (about 5 mos.). It is innate and provided by evolution to assure species survival. The quality of attachment evolves over time as the infant interacts with its caregiver(s), and is determined by both the interactions between the two and the state of mind of the caregiver(s) relative to her or his own attachment figures.

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There are four defining features of the attachment bond:

Proximity maintenance--infant wants to be physically close to its attachment figure(s)

Separation distress--infant experiences distress when separation occurs

Safe haven--infant retreats to its caregiver when anxious or sensing danger

Secure base--infant is able to explore the world knowing that its attachment figure(s) will be there and protect it.

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“Attunement” means that the parent is sensitive to the infant’s verbal and non-verbal cues, able to enter the mind of the child (empathy) and respond appropriately and congruently with its affective state; This is “right brain to right brain communication.” Attunement is central to the development of emotional regulation. Attachment bonds develop over the first two years of life and beyond, overlapping the most prolific period of brain development. Siegel: “The brain creates a core sense of self by embedding the response of the other in the neurons.” We know that attachment status is not the same as “temperament,” because an infant can have a different attachment status with different objects, e.g., father or nanny.

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b. Mary Ainsworth—“strange situation” observations

Mary Ainsworth first brought attachment theory to the US from Britain and developed a method of assessing and categorizing called the “Strange situation” (1978), which examines how toddlers between the age of 18 and 24 months react to being in a room filled with toys with mother and a stranger, react to mother leaving the room, and react to mother’s return. Since then there have been thousands of observational studies, in numerous cultures, using this paradigm. Ainsworth initially identified 3 types of attachment patterns in toddlers, which she called “secure,” “anxious/avoidant,” and “anxious/ ambivalent.” With more studies, she became aware of a fourth pattern which did not fit any of the other three and included behavior which was bizarre, such as approaching and avoiding the attachment figure: “arching away angrily while at the same time seeking proximity.” She called it “disorganized attachment.”

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Humans are the only species whose young seek a person rather than a place when frightened. These contradictory child behaviors are believed to be what happens when the caregiver herself is the source of fear, and the child has no “safe base.” Creepy, frightening and bizarre maternal behavior may be the product of brief dissociative reactions triggered by the mother’s own unresolved trauma or losses. Disorganized attachment is fear based. Most mothers do an adequate job, given that about 60% of the toddlers showed secure attachment. However there is evidence that this percentage is declining, possibly due to mothers returning to work before the child is 2 (Allez, 2011;see Bruce Perry) due to economic necessity. Mothers do not have to be perfect, as research suggests that 32% attunement is enough to produce a securely attached child. About 13% of children show disorganized attachment, and these children are over-represented among mentally ill and criminal populations.

Sex offender treatment the brain attachment theory and trauma processingSlide 14

c. Adult attachment research -- Mary Main & the AAI

Mary Main, a student of Mary Ainsworth, developed the Adult Attachment Interview (AAI, 1993). Consisting of 20 questions, it takes 60-90 min. to administer, with 2 weeks training, followed by 18 months of reliability testing. Scoring is complicated, consisting of assessment of the coherence of the subject’s narrative.

Sex offender treatment the brain attachment theory and trauma processingSlide 15

According to Main, “A ‘coherent interview’ is both believable and true to the listener; in a coherent interview, the events and affects intrinsic to early relationships are conveyed without distortion, contradiction or derailment of discourse, the subject collaborates with the interviewer, clarifying his or her meaning, and working to make sure he or she is understood. Such a subject is thinking as the interview proceeds, and is aware of thinking with, and communicating to, another; thus coherence and collaboration are inherently inter-twined and interrelated.” It is not the trauma history of the parent that is crucial, but the degree to which it has been processed and resolved. Disorganized individuals tend to have lapses in the monitoring of reasoning and discourse in their interview when discussing loss or experiences with abuse (Hesse, 1999).

Sex offender treatment the brain attachment theory and trauma processingSlide 16

Sample questions from the AAI:

1. Please describe in general terms your relationship with both parents as a child.

2. I’d like you to choose 5 adjectives that reflect your childhood relationship with your mother. This might take some time, and then I’m going to ask you why you chose them.

3. I’d like you to choose 5 adjectives that reflect your childhood relationship with your father. This might take some time, and then I’m going to ask you why you chose them.

4.To which parent did you feel closest and why? Why isn’t there this feeling with the other parent?

5.When you were upset or injured as a child, what would your parents do?

6. What happened when one of your parents was ill?

7.What is the first time you remember being separated from your parents? How did you and they respond?

8. How did your parents respond if someone close to them died?

9.Do you feel your parents were threatening to you in any way?

10.Do you think that any of your childhood experiences hindered your development?

11.Why do you think your parents behaved as they did?

12. What is your current relationship with your parents like?

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d. Six Ideas Basic to Attachment Theory

1. During infancy through early childhood, the child’s needs for attachment, when fulfilled, build an internalized sense of safety that is increasingly hard wired into the central nervous system.

2. Through interactions w/early attachment figures, the child learns about self, others & the world..

3. Through early relationships, the child internalizes ideas about self and others, which become embedded in emotional and cognitive “schema” (or “core beliefs”) that form the basis for beliefs, interactions, relationships and behaviors, including the way in which the child comes to experience itself in society, and its capacity to understand and interact with others

4. Attachment experiences are internalized in the form of “felt” security, and in internal representations of self, (self-confidence, self-efficacy) and others (ability to depend on).

5. Through attachment experiences, children develop the ability to self-regulate. This occurs through the responsive attunement of attachment figures, i.e, the emotional repair of distress, repeated many times.

6. Attachment patterns are relatively enduring. They provide the foundation upon which future social interactions and relationships are built.

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e. Findings from Adult Attachment Research

Securely attached children become secure or autonomous adults.

Anxious/ambivalent children become preoccupied adults. They seek attachment but experience anxiety as a consequence. They show anxiety at mother’s leaving, and are difficult to soothe upon reunion.

Anxious/avoidant children become dismissing adults. These children seemed content when mother was gone, and were not interested in re-connecting, but they scored high on physiological measures of anxiety while she was gone, indicating that they had already learned to hide their distress.

Disorganized children become fearful adults; high % among criminals and the mentally ill.

The attachment status of the parent will accurately predict the attachment status of the child 80% of the time. Although changes over time can influence the attachment status of a child, there is strong continuity between infant attachment patterns, child & adolescent attachment patterns, & adult attachment patterns. Changes can occur in either direction, but, for the majority of individuals, the manner in which they learned to manage anxiety early in life will continue unless their circumstances change or other experiences (positive relationships, good therapy) intervene.

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Badenoch (2008) describes insecure attachment styles in terms that can help us understand many of our clients. “…research tells us that children who develop an avoidant attachment often have one or more parents with a dismissing state of mind with respect to attachment…The child makes a bid for closeness, triggering the parent’s fear of connection. In response the parent sends a signal telling the child to move away… …children often learn early that attempting to be close costs them pain” (pp.67-68). This is like living in an “emotional desert” devoid of “interpersonal glue,” and, at the extreme, may be related to the development of narcissistic personality disorder, because the child learns that contact with others is not going to be rewarding and that he must rely on himself.

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In contrast, ambivalently attached persons “have inner worlds that feel like a jungle rather than a desert. The word ambivalence reflects children’s uncertainty about how mother will respond to them. Will she provide safety, warmth, and empathy, or be so internally overwhelmed (and overwhelming) the she can’t accurately sense their states of mind or care for their needs?” (p.68) These mothers alternate between responsivity, and intrusiveness. “When infants…encounter a terrified/terrifying parent, they have an insoluble problem…If we were to observe 1-year-olds with disorganized attachment in the Strange Situation with the unresolved [disorganized] parent, …Even before mother leaves, they might reach for her while looking away, or freeze in a dissociated trance, or take two steps forward and then collapse on the floor” (Badenoch, 2008, p.72). Slade (1999): “In essence, attachment categories do tell a story. They tell a story about how emotion has been regulated, what experiences have been allowed into consciousness, and to what degree an individual has been able to make meaning of his or her primary relationships.”

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Attachment is not a technique, and not a theory of pathology, but a theory of child development, which means it deals with how development occurs, and is thus universal. It is a theory that helps us understand how connections are made and how they may have been damaged or distorted in individual clients. Attachment theory forms the background while treatment pursues the goals of social competence and connectedness, and teaches us how to build programs that will promote these goals. Attachment relationships contribute to other functions children must accomplish: learning basic trust and reciprocity, exploring the environment with safety and security, ability to self-regulate, creating the foundation for identity, establishing a pro-social moral framework, generating core beliefs, developing defenses against stress and trauma. Attachment seriously affects the child’s capacity to handle later trauma, loss and stress, into adolescence and beyond.

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f. Attachment and Psychotherapy

The hallmark of secure attachment is the ability to reflect on one’s internal emotional experience and make sense of it, while at the same time reflecting on the mind of another (core of empathy). These capacities are imbued in the infant through sensitive attunement of the caregiver. When a caregiver reads the verbal and non-verbal cues of the child and reflects them back, the child sees him or herself through the eyes of the attachment figure. Through this attunement and communication process, the seeds of the developing self are planted and realized. In treatment the client has the opportunity to have attachment patterns pointed out and examined in a safe environment.

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*“Autonoetic [self-knowing] consciousness of traumatic events may be disturbed in individuals who have experienced trauma that remains ‘unresolved’ (Siegel, 1999, 2001). This unresolved state of mind has important implications for how the mind functions within the interpersonal relationship of attachment. Some individuals may become flooded by excessive implicit recollections in which they lose the self-monitoring features of episodic recall and feel not as if they are intensely recalling a past event but rather that they are in the event itself (Siegel, 1995, 1996). Under such conditions, a parent may lose the capacity for flexible, attuned responses to a child. This mechanism may be one explanation for the finding that adults with an attachment classification of “unresolved trauma or grief” tend to have children who have a disorganized attachment. Main and Hesse (1990) have proposed that the parent’s frightened, frightening, or disorienting behaviors with the child lead to a paradoxical injunction in which the child is terrified by the very figure who is supposed to be the source of comfort and soothing (Main, 1999). Children with disorganized attachment have been shown to be vulnerable to the development of dissociative symptoms later.

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In its essence, unresolved trauma or grief can be conceptualized as a lack of cortical consolidation regarding that aspect of an individual’s life history and may clinically be seen as the absence of a coherent narrative version of a traumatic experience. Unresolved states remain isolated from the normal integrative functioning of the individual and can impair flexible responsivity and the development of a coherent sense of self. Unresolved trauma leaves the individual prone to an unstable state of potential implicit activations that tend to intrude on the survivor’s internal experience and interpersonal relationships. For a parent, such unresolved states of mind can have a devastating effect on the individual’s children. Parental disorganization due to unresolved trauma or grief is associated with the child’s development of disorganized attachment and risk for dissociative adaptations. Preventive measures involving assessment and intervention at the level of unresolved parental grief and trauma might provide an effective strategy for promoting child mental health.” *Excerpted from Seigel (2001).

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Attachment theory is currently the dominant theory in clinical psychology, and is being increasingly applied to forensic populations, including sex offenders. This is a good thing but there are a few possible sources of confusion in the literature. There is often a failure to differentiate among the different styles of insecure attachment, and this may create the impression that all sex offenders have disorganized attachment, or are impaired to the same degree. Given that sex offenders are known to be a very heterogeneous group, it seems likely, for example, that some have the capacity for empathy but lack sufficient impulse control. Insecure attachment may be confused with Reactive Attachment Disorder (RAD), which implies NO attachment and fosters the notion that most, or many, sex offenders are psychopaths and cannot be treated. Recently developed self-report tools to measure attachment status may be creating misinformation. Implicit memories are often present but not available, and there are other reasons for inaccurate reporting of available memory, such as denial and the need to protect parental figures. There is no short cut to learning about a client’s attachment status. The most accurate and valuable information is obtained from taking a careful and detailed history. How this information can be used in therapy with sex offenders is described below in Section IV.

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Take Home Message #2:

Asking “Was this sex offender sexually abused?” is not sufficient because the pathway from victim to perpetrator is more complex. In order to do an accurate evaluation and plan effective treatment, obtain as much data about the individual’s attachment history as possible, and keep assessing it as you have more opportunity to observe the client’s behavior.

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Section III.Complex Developmental PTSD (DESNOS)

The majority of sex offenders have suffered some form of childhood abuse, e.g., Hanson (1997) found that 75% of 409 sex offenders in treatment reported being sexually, physically and/or emotionally abused. However most of them never fit the specific diagnostic criteria for PTSD, and their trauma symptoms are often overlooked or misdiagnosed. The reason for this lies in part in the historical circumstances under which the criteria for PTSD were developed. This occurred in the 1970’s, and were derived primarily from studies of returning Viet Nam veterans. Obviously war veterans experience trauma primarily in late adolescence or early adulthood. At the same time PTSD was being defined, the women’s movement was bringing sexual violence against women and children out of the closet, so increasing numbers of therapists began treating adults who had been abused as children. Many of these therapists noticed that their clients frequently displayed a set of symptoms that were pervasive but not as acute as those seen in PTSD. This set of symptoms is known by a variety of names, the two most common being “complex developmental PTSD” and “DESNOS”--Disorders of Extreme Stress Not Otherwise Specified (Luxenberg et al., 2001).

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Adults abused as children differ from war veterans in two significant ways. In the vast majority of child abuse cases, at least some of the trauma suffered was at the hands of one or more trusted individuals who should have cared for and protected them. Secondly, childhood trauma occurs at a time when the human brain is not fully developed and is much more likely to be affected by adverse circumstances (Perry, 1997; Siegel, 1999). The resulting syndrome or symptom pattern consists of 6 sets of symptom clusters, which must be addressed in order to achieve lasting treatment effects with many sex offenders.

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A. Affect dysregulation (“poor impulse control”)

The first group of symptoms have to do with difficulty modulating and tolerating strong emotion, high reactivity to emotional and sexual stimulation, slow return to baseline, and an inability to self-soothe. Individuals with affective dysregulation tend to “overreact” to minor stress, becoming easily overwhelmed because they experience their emotions more intensely than other people. They have trouble calming themselves once emotionally aroused, and may engage in extreme and/or self-destructive behaviors in an attempt to provide distraction from emotional pain. Maladaptive attempts to regulate affect can include eating disorders, substance abuse, compulsive sexual activity, self-injury, and suicidal preoccupation. In forensic settings, where staff are often unfamiliar with the literature on early trauma, this emotional lability is frequently mistaken for bi-polar disorder. Another form of distracting behavior, excessive risk taking, may be incorrectly interpreted as an indicator of psychopathy.

What causes “affective dysregulation”?

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Infants are born with the capacity to experience certain emotions which have a survival value. When their innate startle response is frequently triggered by environmental events, such as parental yelling or fighting, breaking dishes or furniture, or other loud noises, a “kindling effect” occurs. Each time the startle response is triggered, the connections in the brain which cause it are strengthened, and this in turn makes it more likely to be triggered in the future. As the connecting fibers become more numerous, it takes less and less to trigger the response, making it more likely that it will recur. What results is a child who is hyper-aroused and may respond with fear to stimuli that other children would perceive as neutral. The parts of the brain which are involved are those which regulate emotional and sexual arousal, the amygdala and the hippocampus of the limbic system.

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Prolonged hyperarousal while the brain is developing, without repair through “maternal attunement” and soothing, causes difficulties in affect regulation. This means that the individual becomes emotionally vulnerable, highly reactive to emotional/ sexual stimuli, with an intense response to such stimuli and a slow return to baseline, and lacking the ability to inhibit inappropriate behavioral responses to strong emotion (think Hanson’s “difficulties with general self-regulation and sexual self-regulation” ). This condition is the result of repeated experiences in which the infant has been emotionally stimulated and upset, without consequent repair by the attachment figure, leading to an alteration in their brains’ ability to handle stress and to modulate emotional/sexual arousal. Punishment cannot not decrease impulsivity, and increased impulse control cannot be faked.

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Treating Affect Dysregulation with Dialectical Behavioral Therapy (DBT)

A substantial proportion of sex offenses are impulsive, and therefore very likely not driven by paraphilias. The central tenet of Relapse Prevention (and all CBT) is that thoughts determine feelings and behavior, and that beliefs and thoughts are under voluntary control. Developmentally, we experience feelings before we develop rational thinking. The feelings we experience very early in our development, and how our caretakers respond to those feelings, determine both how our nervous systems respond to stress and how we interpret the world around us. Marsha Linehan, the originator of Dialectical Behavior Therapy (DBT), states, “The fundamental message given to clients in DBT is that cognitive distortions are just as likely to be caused by emotional arousal as to be the cause of the arousal.” Her work (1993) with borderline personality disorders has specifically targeted the problem of affect dysregulation with promising results. It has been found to be effective with complex PTSD clients, so there is every reason to believe that it can be equally effective with sex offenders who have poor impulse control and other indicators of problems regulating affect.

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Linehan’s approach is based on two fundamental assumptions:(1) that distress tolerance and emotional regulation are internal skills that can be taught but require repeated practice to learn, and (2) that problems with affect regulation do not reflect a “structural defect” but rather arise from developmental disruptions. Such problems can be addressed individually or in a small group of 4 or 5, which typically takes about 6 months with severe borderlines in outpatient therapy. With sex offenders, it should be done before processing offense behavior because it will reduce the risk of emotional overwhelm and consequent flight from treatment, and will provide the offender with skills to handle the strong affects that are likely to emerge during offense-specific therapy.

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Linehan recommends that problem behaviors related to affect dysregulation be approached in a specific order. The first type of behaviors that must be dealt with are suicidal ideation and/or behavior, and self-injurious behavior. Self-injury is much more common among sex offenders, and other forensic clients, than is generally thought. In forensic settings, such behavior is considered by custody staff to be either an attempt at suicide, or a manipulation designed for secondary gain. In fact, the vast majority of self-injury is never known to staff and clearly serves other psychological purposes than suicide or manipulation, because it is done in secret. Opportunities for therapeutic work are missed when staff do not know how to respond to self-injurious behavior in any other way but punishment. Self-injurious behavior may have different meanings for different clients, or multiple meanings for the same client.

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It is important to understand self-injury because it may result in accidental death or dangerous infections from untreated wounds. Linehan stresses that these behaviors must be the first focus of treatment because of their potential lethality. Her approach is especially applicable to sex offenders because it conveys an immediate message that treatment is going to delve into some very private and difficult areas, but hopefully at the same time offers that this will be done in a supportive and empathic way. Clients are provided with large file cards (“diary” cards) at each session and are instructed to record any experiences of suicidal feelings and behavior, and of self-injury. Each experience is then processed in the group with regard to what feelings or events may have triggered it, any memories associated with it, etc., in much the same way that a Behavior Chain would be constructed in Relapse Prevention work. The goal is to identify maladaptive behaviors, behavioral deficits that are maintaining them and environmental and behavioral events that may be interfering with more appropriate responses. Clients are taught ways to tolerate the stress of unpleasant feelings, more adaptive behavioral responses to perform when they occur, and emotional regulation skills.

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Distress tolerance skills include distraction, ways to self-soothe, and learning to “bear the moment” through the use of “core mindfulness” skills such as relaxation training, meditation, prayer or whatever technique the client feels drawn to and is likely to use. Skills to increase interpersonal effectiveness include deciding on goals, practicing assertion training and limit setting, modeling, and role playing. Emotional regulation skills involve learning how to identify and label affect by becoming more aware of body cues, reducing vulnerability to hyper-emotionality through the use of stress reduction techniques, increasing the frequency of positive emotional events, and developing an ability to experience emotion without judging, rejecting, or fearing a loss of control. When everyone in the group has been able to eliminate suicidal ideation and self-injury, the therapist then moves on to other behaviors that interfere with therapy, including things like coming late or missing sessions, not paying in timely fashion, etc.

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Finally, the therapist turns the focus to behaviors that “interfere with the quality of life.” These include serious substance abuse, severe eating disorders, high risk and sexually compulsive behaviors, repeated hospitalizations, being in abusive relationships, etc. Most clinicians who treat sex offenders are well aware that many of them continue to masturbate to deviant sexual fantasies while in treatment. A primary weakness of Relapse Prevention is that it unrealistically assumes abstinence from the beginning. A DBT group, which should precede offense-specific treatment, is the ideal place to introduce the concept that continued masturbation to deviant fantasies is detrimental to recovery and to provide the client with the tools to interrupt deviancy and replace it with more appropriate behavior. This enables the client to begin the actual sex offender treatment with a much greater sense of control and understanding, so that the processing of his offenses, or listening to others’ offenses, will be less likely to induce a lapse. While Linehan’s approach consists of some fairly traditional cognitive-behavioral techniques, she considers them as merely a first step in preparing clients for more in-depth work on trauma resolution. She recognizes that early treatment of adult survivors of abuse in many instances put premature emphasis on processing traumatic incidents too soon, overwhelming clients and in some cases causing them to leave treatment in worse shape than before (Briere, 1996).

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Toxic Shame

The parasympathetic branch of the ANS (“brake system”) is developing when a child is learning to walk, experiencing new freedom and excitement in his ability to explore. At the same time, the orbitofrontal cortex in the prefrontal region of the brain has matured to a point which allows for mental self-representation and self-consciousness, i.e., the emergence of awareness of self as a separate entity. Schore (2003) has described shame as the emotion evoked when a child’s arousal state is not met with an attuned response by the parent. Some shame is inevitably experienced as children learn to self-regulate and to restrain some of their impulses, but its toxic effects can be avoided by redirecting the child’s attention to something else. Unfortunately a parental “NO” is often uttered more to meet the parent’s needs than those of the child’s, and under those conditions is less likely to be followed by “repair.” Shaming is not a good parenting strategy. “Shame-induced interactions coupled with sustained parental anger and/or lack of repair of the [emotional] disconnection lead to humiliation, which Schore has proposed is toxic to the developing child’s brain” (Siegel, 1999).

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Many of the practices common in the treatment of sex offenders elicit shame but it is often not recognized or dealt with in treatment. Some examples are the preparation of a detailed timeline and autobiography, the detailed processing of crimes through the construction of a Behavior Chain, phallometric assessment, and writing unsent letters to victims, not to mention dealing with their own abuse. Individuals who have difficulty with affect regulation are likely to become overwhelmed and to either increase externalizing the blame for their behavior, flee from treatment, and/or act out in other ways. DBT can be helpful to inoculate clients against toxic overwhelm, but shame is likely to be elicited repeatedly in sex offender treatment. It may be experienced as a feeling of being “under a magnifying glass” or the “imposter syndrome” a sense of low self-esteem, worthlessness, being defective or empty inside, and unlovable. Visual cues are a lowering of the head and avoiding eye contact, or conversely, staring with a look of contempt (a common prison behavior). It may be misinterpreted as anxiety. It offers a crucial opportunity for repair.

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A review of the literature on shame and guilt by Proeve and Howells (2002) found that proneness to shame is correlated with irritability, suspiciousness, resentment, anger arousal, and the externalization of blame. They note that shame inhibits empathy, and caution that victim empathy work which stresses victims’ experiences is likely to trigger a feeling of personal threat, which leads to the emotion of shame. In research on large samples of domestic violence perpetrators, Dutton (1998) concluded that the primary emotion behind wife battering is shame that has been converted to anger. These findings indicate that our attempts to increase empathy in sex offenders may often been counter-productive.

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B. Disturbances in attention and consciousness

A second group of symptoms are disturbances in attention and/or consciousness. It is not uncommon for individuals who were severely abused at an early age to have memory gaps, in some cases for large segments of their childhoods. Such gaps may occur as a result of dissociation or because sexual abuse often takes place at times when children are asleep. Briere (2002) has noted that “avoidance strategies are used [by survivors of abuse] a) to reduce awareness of potential environmental triggers; b)to lessen awareness of memories once they are triggered; and c) to reduce

cognitive and emotional activation once CERs [conditioned emotional responses] to these memories are evoked” (p.10). Avoidance strategies are self-reinforcing because they reduce emotional pain, but unfortunately they also contribute to the failure to develop a strong sense of identity discussed below under “c.Disturbances in self-perceptions/impaired self-reference.”

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Dissociation may be mistaken by therapists as “resistance” or lack of motivation, for example, when clients don’t remember things from session to session, forget to do homework, “tune out” during victim empathy films, etc. It got a bad reputation during the “repressed memory wars” as strange and bizarre but is actually something that most of us have experienced, at least in mild forms. It is a normal self-protective reaction, but must be addressed early in treatment and replaced by more adaptive ways of dealing with pain, because of its interference with treatment and deleterious effects on the development of the self. Clinicians need to be familiar with the signs of dissociation, and assessment for it should be an ongoing part of treatment with sex offenders. Memory gaps may be addressed in treatment by encouraging clients to talk to non-abusive relatives, look at childhood photos or draw the floor plan of where they lived during the time when they believe their abuse occurred.

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During the first year of life, memories that contain elements of behavioral impulses, sensations, perceptions and emotions are encoded by the amygdala without conscious awareness. With repeated experience, these “implicit memories” cluster into mental models as our higher cognitive processes develop. “…processes in the amygdale develop generalized, nonverbal conclusions about the way life works—the essence of mental models. These conclusions create anticipations of how life will unfold and remain largely below the level of conscious awareness, guiding our ongoing perceptions and actions in ways that tend to reinforce the foregone conclusions” (Badenoch, 2008, pp.24-25).

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C. Disturbances in self-perception (“impaired self-reference”)

A third group of symptoms concerns disturbances in self-perception, or “impaired self-reference” (Briere, 1992). Childhood abuse survivors are vulnerable to a host of painful emotions and cognitive distortions. Some of these long-term effects are the result of direct messages from perpetrators, who often blame the victim and/or invalidate the victim’s feelings (“Shut up or I’ll really give you something to cry about;” “I know you want it.”). In addition, the immature, egocentric nature of a young child’s thinking virtually guarantees that the child will blame himself for the abuse, creating a sense of being “damaged goods.”

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Physical and sexual abuse are also emotional abuse because they represent an attack on the self: “The assault is not only upon the physical body, but upon the individual’s perception of the self as competent, and among other things, the perception that the world is beneficent or neutral, rather than innately hostile” (Navarre, 1987). In addition, the use of dissociation and the necessary adaptation of scanning the external environment for signs of danger occur at the expense of the survivor’s awareness of internal cues. Thus “severe child maltreatment may interfere with the child’s access to a sense of self--whether or not he or she can refer to, and operate from, an internal awareness of personal existence that is stable across contexts, experiences, and affects. Without such an internal base, the survivor is prone to identity confusion, boundary issues and feelings of personal emptiness” (Briere, 1992, p.43).

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One of the most common characteristics of sex offenders described in the literature is that they are they are out of touch with their feelings and bodily cues. Lisak (1997) has examined the link between male gender socialization and the perpetration of sexual abuse. He notes that boys learn at a very early age that there are many emotions that they are not allowed to display. Except for anger, virtually all the emotions associated with childhood abuse are “off limits” for boys: fear, anxiety, helplessness, humiliation, shame, vulnerability. “Once evoked, these states are likely to create distress, since they are precisely the emotions that the male has had to suppress in the service of achieving and maintaining his masculine identity” (p.164).

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Male socialization, Lisak contends, obstructs a male’s ability to respond sympathetically to both his own and other people’s distress i.e, it interferes with empathy. “As he learns that vulnerable emotional states are ‘unmasculine,’ and that they must be expunged from his experience lest he be forced to label himself ‘unmasculine,’ the male is forced to respond as aggressively to his own internal displays of vulnerability as he would to those of others” (p.166). This leads to a lack of empathy, which allows sex offenders to hold the “attitudes tolerant of offending” identified by Hanson and Harris (1998) as related to sexual recidivism.

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D.Disturbances in interpersonal relationships

A fourth group of symptoms involve disturbances in interpersonal relations. The most profound and pervasive of these is an inability to trust (Hanson’s “problems with intimacy”), rooted in insecure attachment. Abused individuals experience fear and ambivalence with respect to interpersonal attachment and vulnerability. As closeness increases, they expect re-victimization, become more anxious, and may push others away or engage in behavior that sabotages the relationship. Because of the problems that result from past abuse and the use of dissociation to cope with it, they do not have a strong sense of “inner guidance” or a healthy template for interpersonal interactions. Consequently they do not read social cues well and make poor judgments about whom to trust. Some abuse survivors alternate between trusting everyone and trusting no one.

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Abuse survivors may identify with the “victim” role, or, in an effort to fend off feelings of powerlessness, identify with the aggressor, increasing the likelihood that they will become perpetrators (Lisak, 1997). Their past experiences have often created faulty assumptions regarding the acceptability of high levels of aggression in relationships (Briere, 1992). Moreover, past abuse and betrayal by adults fuel the excessive need for control that motivates many sex offenders. Survivors of sexual abuse may engage in indiscriminate sex because they believe that is their only value, or may avoid sex altogether. Survivors of abuse have distorted interpersonal scripts and blurred boundaries. They typically re-enact their interpersonal traumas with the therapist, intimate partners, and/or other group members (Briere, 1992; Courtois, 1988). “Intimacy deficits” which are a common long-term effect of childhood abuse, were found by Hanson and Harris (1998) to be related to sexual offense recidivism.

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E. Somatization

A fifth group of symptoms are persistent physical symptoms that often defy medical explanation. The most common are digestive symptoms, chronic pain, cardiopulmonary symptoms, chronic pelvic pain, conversion symptoms, irritable bowel syndrome, headaches, “acid” stomach, and sexual dysfunction. Clinicians who have worked with sex offenders in inpatient settings are aware that they often have multiple ill-defined physical complaints which resist medical treatment. These complaints are not manifestations of hypochondria or a need for attention, but rather the long-term effects of repeated early traumatic experiences, which have compromised the body’s ability to cope with stress. Traumatized individuals have overactive sympathetic and parasympathetic nervous systems, which over time cause the body to react like a car that is constantly having the gas and the brakes applied at the same time. The body wears out prematurely under these conditions, explaining the findings of the Kaiser ACE study, which clearly linked a history of childhood abuse to the 10 leading causes of death (Felitti et al., 1998).

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F. Disturbances in meaning systems

Finally, individuals with severe trauma histories often show disturbances in meaning systems, i.e., they fail to find meaning in the things which usually give life a sense of purpose. They are often alienated from any system of spiritual belief (“How could God have let this happen to me?”) and have an adversarial view that all human relationships are a power struggle and that everyone is out for himself. This may be accompanied by a profound sense of learned helplessness and a pervasive decreased sense of competency. Herman (1992) has observed that those who seem to recover best are those who find some over-arching meaning or activity related to the abuse, e.g., getting legislation introduced or changed, or speaking as a victim advocate.

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Take Home Message #3:

It makes no sense to stress the damage our clients have done to their victims, while ignoring or invalidating the damage done to them as children. An understanding of “complex developmental PTSD” is essential to effectively treat sex offenders.

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Section IV.ProcessingTrauma

A.How trauma treatment works

What happens in trauma treatment and why it works is probably best understood from the perspective of a systematic desensitization paradigm. Humans are genetically programmed to want to affiliate, because this is something that has allowed the species to survive. Thus connecting with other humans is an innate drive that is rewarding at a neurological level. The relationship with the therapist(s), and in some cases with other group members, activates this innate drive, which leads to the effective counter-conditioning of negative thoughts and emotions from early experiences. This is thought to take place in 5 phases:Exposure, Activation, Disparity, Counter-conditioning and Resolution.

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Clients experience memories of earlier interpersonal trauma from various sources in treatment—processing the their own offenses or those of others, doing homework assignments such as writing an autobiography or timeline, hearing about the abuse histories of others (exposure and activation), and viewing “victim empathy” films. They expect that abuse or abandonment will happen if they delve into these memories, but in reality the situation is safe, unlike childhood. The therapist is not abusive, rejecting or otherwise dangerous (disparity). Clients experience positive emotional states (safety, affiliation, comfort, support, validation), which gradually diminish and begin to extinguish negative feelings and responses (counter-conditioning). Eventually, as these negative feelings begin to weaken, clients are able to become aware of how they have affected their lives, process them and develop more effective positive coping responses. These feelings may never disappear completely, but when they do re-surface, they no longer have the same destructive impact (resolution). Recovery from early abuse has been likened to a spiral, in which clients re-visit the same issue a number of times, each time viewing it from a different perspective, as their trauma processing proceeds (Sgroi, 1989).

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The therapist’s personality is the most powerful tool in treatment. Linehan observed that “the relationship with the therapist is the primary re-enforcer,” although peers in the group may also be important. Because therapy triggers the attachment relationship, the client’s attachment status will begin to emerge and become more observable in the client’s reactions and behavior. Assessment should be an ongoing process and client reactions should be carefully monitored and explored in treatment. These reactions may include dependency, intrusiveness, a need to control or denigrate, fear and rage, and distortions of the therapist’s motives and behavior. While this may elicit extreme discomfort and strong counter-transference in the therapist, greater awareness of what clients are struggling with will enable therapists to provide a “safe place” where the past can emerge and be explored.

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Take Home Message #4:

Research on what make psychotherapy effective has consistently found that the relationship with the therapist is the most powerful and important variable. This has been largely ignored in sex offender treatment, as if sex offenders are different from all other clients. Therapy cannot be successful outside the context of human relationship.

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B.Philosophy of trauma treatment

There is an innate tendency for humans to process trauma-related memories, moving toward more adaptive functioning. In trauma treatment, the client’s personal experiences and perceptions form the basis for interventions, not the therapist’s theory or pre-conceptions. Briere (1992) has referred to this as the “phenomenological approach,” because the focus is on the client’s individual experience. The client is viewed as adaptive, rather than mentally ill or defective. Symptoms and defenses are seen as accommodations to early victimization (survival strategies) and/or responses to the long-term effects of abuse. Re-framing is not merely empty reassurance. It is rather a totally different perspective, an alternative way of understanding the client’s behavior, emotions and cognitions. (“One man’s ‘cognitive distortion’ is another man’s reality.”) The goal of trauma treatment is not only symptom removal. Therapy must also focus on correcting distorted assumptions/core beliefs as well as other long-term effects of abuse. Symptoms serve a deep psychological purpose and therefore cannot be easily given up. Therapists need to understand the adaptive significance of symptoms in order to formulate appropriate treatment.

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It is useful to explain the adaptive significance of some of the most serious symptoms, tension reduction behaviors (TRBs) such as dissociation, drugs, self-injury, eating, gambling and compulsive sex, also pointing out that people often rely on these because they have nothing else. Their affective overwhelm has prevented them from learning more effective coping skills. It is equally important to make clear that the feelings which trigger these behaviors must be accessed and processed because they continue to exert a destructive influence on the client’s life and to distort his perceptions of others. This validation often provides relief for clients (“Maybe I’m not mad, or bad”), giving them the support needed to go deeper. Rarely a client “gets stuck” at the level of merely excusing his behavior with “I molest kids because I was molested.” Rather than dismissing him as “resistant” and “whining,” it is more likely a sign that he is terrified and may not even know why. This may suggest a need for some individual contact, or simply backing off and letting him remain in the group until he feels safer.

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Some examples of positive reframing of “symptoms” often seen in our clients that may help reduce counter-transference:

“attention seeking”=behavior designed to ensure proximity, or “attachment seeking”

“callous, unemotional”=avoidant/dismissive attachment, may be defensive rather than antisocial; may indicate the presence of dissociation or learned fear of revealing real feelings

Anxiety=lack of a sense of personal competence, lack of skills, failure to develop a sense of self-efficacy

Impulsive behavior or “low frustration tolerance”=affective dysregulation

“Self-defeating behavior”--may stem from a sense of “not deserving,” a fear of responsibility due to a sense of personal incompetence, or maladaptive learning

“Oppositional behavior”--may reflect unwillingness to trust authority because of early experience, or a need for control

Manipulation--failure to believe that others will meet your needs, a sense of powerlessness

“Not hearing” feedback--may feel threatened, not caring, because of past experiences

“Resistance”=“What we call it when clients try to defend themselves from therapists’ mistakes” (Briere)

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Basic Principles of trauma treatment

1.Provide and ensure safety

It is not necessary for the therapist to actively introduce trauma, because it will come up regularly in the normal course of treatment, for the reasons I have described. It is necessary for the therapist to anticipate it, recognize it, and know how to deal with it so that clients do not become frightened or overwhelmed. An important part of this is to establish a “culture of treatment” in the group so that “the client will not perceive himself or herself, to be criticized, humiliated, rejected, dramatically misunderstood, needlessly interrupted, or laughed at during therapy” and that boundaries and confidentiality will not be breached. The expectation should be that trauma issues will be honored and help will be offered by both therapist and other group members. The client will be supported, not ignored, isolated, or made to feel “weird.” Group members can play an important role to reduce the sense of isolation, offer support, and confront in a way that is caring rather than punitive. For many clients, this may be their first experience of intimacy that is not sexual.

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2.Provide & ensure stability, both life stability & emotional stability, through the initial use of DBT

3.Maintain a positive & consistent therapeutic relationship. Potential benefits, derived from research:

Decrease treatment drop out and increase attendence (Rau &

Goldfried, 1994)

Less avoidance & greater client disclosure (Farver & Hall, 2002)

Increased compliance w/ all forms of treatment including meds

(Frank & Gunderson, 1990)

Greater openness to therapist feedback (Horvath & Luborsky,

1993)

Increased tolerance of painful thoughts and feelings (American

Psychiatric Assoc, 2001)

Hanson: Therapist must be “able to form a meaningful

relationship with offenders:” warm, empathic, & rewarding. From

a trauma perspective, these qualities are necessary for counter-

conditioning to occur

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4.Treatment should be tailored to the individual client, by taking a thorough history

Treatment aimed at affect dysregulation needs to address which feelings are most difficult to regulate. Identify predominant schema: self-perceptions as bad, inadequate, or helpless; others as dangerous, rejecting, or unloving; future as hopeless. Treatment may trigger abandonment, rejection, or betrayal;clients may perceive the therapist as punitive, critical or abusive. It is useful to know that “X” has abandonment issues, “Y” perceives caring as intrusive or sexual, “Z” expects domination or hostility from authority figures. A detailed history should help to identify attachment style

5. Work within the “therapeutic window,” (Briere) or “window of tolerance” (Badenoch), optimizing the client’s ability to process painful material and avoiding emotional overwhelm.

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6. Take gender issues into account

Sex role socialization affects how trauma is

experienced and expressed. There are gender

differences in symptoms & behavior. For men, anger

is the only acceptable feeling; likely to react with

compensatory hyper-masculinity, compulsive sex,

and/or “identification with the aggressor.” Women are

more likely to internalize feelings, men more likely to

externalize. Both may feel like they are “damaged

goods.”

7. Monitor counter-transference

It is important for therapists to be attuned to their own internal experience. Seek consultation with a colleague who understands trauma issues, and have a strong support system.

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Techniques to help identify triggers

Does this feeling make sense? Appropriate to the situation? Too intense? With memories?

Was there an unexpected alteration in awareness? Has this previously occurred in a similar situation?

Identify properties of trigger: interpersonal conflicts, sexual situations or stimulation, interactions with authority figures, people with physical or psychological characteristics similar to perpetrator, boundary violations, sound of crying

Explain TRBs, construct an alternate strategy designed to decrease powerlessness & increase control

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Cognitive interventions:

Talking about trauma makes it more real, validates the client’s feelings, makes the assumptions, perceptions & beliefs that were encoded at the time more clear; listeners “bear witness,” give feedback

Growing awareness of what could reasonably have been done--“I shouldn’t have let him.” Clinician should refrain from making critical comments about perpetrators or trying to talk clients out of their perceptions. (Ex: Susan Forward) Cognitive interventions are most effective when clients experience original trauma-related thoughts & self-perceptions (e.g., guilt, self-blame) with present logical perspective. Opposite of Relapse Prevention’s direct confrontation of “thinking errors.” This counters blaming or shaming statements perpetrators may have made to victims .Writing can also be helpful.

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Ask gentle, open-ended questions to challenge assumptions & interpretations:

“Do you remember any thoughts you had at the time?”

“Do you think there was anything else you could have done at the time?”

“So that made you feel it was your fault. Can we talk about it in more detail and see what made you think that?”

“If this happened to someone else, would you come to the same conclusion?”

“Would you treat your own child in that way?”

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Emotional processing:

Occurs when trauma-related internal or external stimuli (1)triggers elicit implicit &/or explicit memories, which then (2)activate emotional responses that were initially encoded w/these memories, but (3)are not reinforced in the current external environment, and (4) are counter-conditioned by opposite emotional experiences (empathy, validation, support), leading to(5)extinction.

Not always this simple or straight-forward, because it also involves cognitions & expectations.

Much processing occurs at implicit, nonverbal, often relational, levels in therapy context, “right brain to right brain”.

Avoidance may be adaptive. Therapist should not try prematurely to remove resistance, denial, or dissociative symptoms because this may trigger “tension reducing behaviors” (TRBs). This was a common and damaging mistake that was often made in the early years of trauma treatment.

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Concept of the “therapeutic window”--intense emotion should be elicited only in middle of session, when there is time for processing and the client does not leave overwhelmed.

Trauma processing is a balancing act, using again gentle questioning:

“What were you feeling/how did it feel when it happened?”

“What are you feeling now as you describe the trauma?”

“Are there any thoughts associated with that feeling?” (common one: “I‘m crazy”)

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Grounding techniques to interrupt acute intrusion, prevent client from going deeper

Do not attempt to process trauma material if client has a high anxiety level, including panic attacks; severe depression or current high suicide risk;psyhcosis;overwhelming guilt or shame associated with trauma;recent, substantial exposure to trauma;substance dependence.

1. Focus attention on the therapist and the current setting, away from internal processes. Move closer, into client’s visual field, get him to focus on your face, call his name, do not necessarily touch him.

2. Ask client to briefly describe his internal experience: “Joe, is something upsetting happening to you right now?” Have client describe what is going on in general terms, if he can. If he is too frightened or distressed, go to 3.

3. Orient ct to immediate, external environment: safe, here & now, in the therapy room; focus attn on feeling of chair or couch underneath or of feet on the floor.

4. If necessary, have client focus on breathing or relaxation exercises for several minutes, stress safety.

5. Repeat 2 & assess client’s ability to return to session. Repeat 3 & 4 as needed. Give client as much control as possible under the circumstances.

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Strengthening Identity and Relational Functioning (Self & others)

Different attachment styles are believed to be related to the development of different personality disorders, although there is not yet a great deal of definitive research on this. Many clients are stuck in a “Catch 22:” they have a weak, inadequate internal sense of self and don’t feel competent, but at the same time they don’t trust others and are afraid to give up control. Abuse survivors have often had repeated experiences that their needs are not important, and their feelings invalid or “crazy.” This may have been further exacerbated by the use of dissociation on the one hand, or hypervigilance on the other, both of which may have been necessary for survival but distract from awareness of one’s own internal response. After learning how to tolerate strong emotions and being given tools for how to respond to them in more effective ways (DBT), they may need support to learn to determine their own needs and values.

,

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A goal of treatment is that the person be able to maintain an internal reference point in times of stress and have direct access to a positive sense of self. As the self becomes stronger, it becomes easier to accurately predict one’s reactions to things, and therefore prepare for them. This quickly becomes self-reinforcing. Ways to begin this process include directing the individual to focus on some figure from his past that he admired or that was supportive of him. If there is no such person, have him start considering figures from favorite books or movies, or getting suggestions from other group members.

Memories may be specific and implicit, e.g., abandonment. Some people may function extremely well in many areas of life, except when something triggers a specific issue. Ex: astronaut in diapers, recent LAPD case

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Treatment relationships are a powerful source of interpersonal triggers, both therapist & group members. It takes trauma survivors a long time to trust. Therapist must consistently support introspection & self-exploration, with the long-term goal of empowerment & development of client‘s inner life, learn to value the self. In therapy, the client has the opportunity to have his attachment patterns pointed out & examined in a safe environment. Assessment should be ongoing, as the client’s behavioral response to the therapeutic relationship and other group members will provide more information about his attachment style. An adult’s attachment status can change as a result of a long-term (5 years) relationship with a securely attached person. A positive attachment experience appears to activate dopaminergic and beta-endorphin reward systems, leading a person to seek affiliation.

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When attachment activation occurs during therapy, one of 3 possible things occur:

1. Positive sustained feelings are likely to effectively counter-condition negative thoughts & feelings associated with previous traumatic experiences

2. May produce other kinds of child-parent thoughts, feelings, & behavior in the client, who must be monitored carefully. Clients may become more dependent & clingy, fearful, or angry

3.Clients whose early attachment experiences were especially insecure or traumatic may find that the treatment relationship becomes a powerful trigger. “Implicit memories” may become connected

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Take Home Message #5:

Empathy cannot be taught, it must be experienced and thus fostered. This experience enables the client to begin to feel empathy toward himself, and ultimately toward others. From the moment treatment begins, the therapist should model empathy, creating an atmosphere that nurtures change and gives clients permission to be empathic with one another. It is only through experiencing empathy that clients can become empathic. Obviously there are times when sex offending behavior must be confronted, but confrontation is only effective in the context of a caring, safe relationship.

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“If you want sex offenders to come to treatment, you have to give them something that feels like help.”

A. Nicholas Groth, sex offender treatment pioneer

“If we see their problems as current moral weakness rather than as the scabs of old wounds, we rob them of their history.” Joel Dwoskin, Ph.D., University of Arizona

“We don’t try to cure the patient of what happened to them. We try to cure them of what they now do to themselves and others in their attempts to cope with what happened to them.” Althea Horner

“It could be argued that unless the offender is heard as a victim in his own right, his capacity to develop empathy will be impaired” (Craissati et al, 2002).

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Useful websites

Childtrauma.org (Bruce Perry, especially his paper “Incubated in Terror”)

ACEstudy.org (Dr. Felitti)

Traumacenter.org (Bessel van der Kolk)

Trauma-pages.com/a/shore-2001a.php (Allen Schore)

Trauma-pages.com/a/shore-2001b.php (Allen Schore)

JohnBriere.com

istss.org/resources/index.htm (International Society for Trauma Stress Studies)

trauma-pages.com/pg4.htm (David Baldwin’s Trauma Pages)

http://www.psychology.sunysb.edu/attachment/measures/measures_index.html

“Understanding Juvenile Sex Offenders Through the Lens of Attachment Theory”—presented at CCOSO’s 2007 conference by Dr. Phil Rich;e-mail me at jayklaus@tcsn.net for a copy


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