By Esen Uygun

Topic: Prenatal and early attachment in the context of sexual assault and intergenerational trauma

In this paper, I will focus on peri, pre & post-natal attachment ruptures and how sexual assault may further impact on attachment injuries. Ways of working with clients who have experienced both will also be examined.

It is a common belief that the attachment between child and mother – I will use the words mother and the main carer interchangeably, as mothers, usually are the main carers; however, I acknowledge that the father or other family members also can be the main carers- start forming immediately after birth. However, the pre & peri-natal research points towards the bonding between the child and the main carer, starting before birth.  (Chamberlain, 2013)

From conception onwards, the foetus and the mother biologically negotiate the allocation of the mother’s physiological resources as the mother’s body becomes a key source of nourishment for the foetus. (Costello, 2013)

“In utero, mutuality is the rule, not the exception: mother and baby eat together, breathe together, and sleep together; they smoke, drink alcohol, have accidents, and even go into surgery together. Therefore, the experience of the baby is a duet rather than a solo. (Chamberlain, 2013, p. 89)

According to medical observations, when babies are in utero there is a strong interaction between something happening to the mother and subsequently her fetus. Anything mothers consume will affect the babies. If a mother consumes alcohol, nicotine, prescribed or other drugs they will also be consumed by the baby, which might affect their breathing movement. Foetuses breathing movement altered; faster or slower to get more oxygen or stop inhaling the smoke, alcohol consumption in the mother also affects the fetus across the placenta, affecting brain and spinal cord cells. Although the fetus does not actually breathe in the womb, these movements allow the fetus to practise breathing in preparation for birth and severance of the umbilical chord.

It has also been noted that mothers, who took Valium for a small procedure, five out of sixteen foetuses movement changed within three minutes of taking Valium, and they become immobile from twenty minutes to three hours. Giannokoulopoulos, Sepulveda, Kourtis, Glover & Fisk (1994) & Chamberlain (2013) reported that when mothers of neonates were exposed to painful clinical procedures their babies heart rate, and blood pressure were increased. This tells us that when mothers go into surgery their babies also undergo to that surgery. According to Thomas Lewis, babies are extremely vulnerable to pain because their body has not completed pain-dampening nerve pathways to cope with the pain. (Chamberlains, 2013). Foetusses and neonates’ nervous systems register the medical traumas, which may create behavioural and emotional problems later in life. (Levine & Kline 2007) 

Again, in other research, it has been reported that when mothers were given an alcoholic beverage; immediately after consumption of the alcoholic drink the foetuses breathing movement stopped, and “One prenate stopped within three minutes and stayed still for fifty minutes.” (Chamberlain, 2013, p.44-45) 

Chamberlain (2013) stated that when a mother was chased by a psychotic husband both mother and fetus were evidently upset, which was evidenced in the heart rate of her fetus. When there was violence against the mother, the fetus was also on the receiving end as the mother’s stress hormone increased and this was then fed to the child through the amniotic fluid. The research conducted by the University of Zurich (2017) indicates : “Too much stress for the mother affects the baby through amniotic fluid.” ( ScienceDaily, 2017). If a pregnant mother has been exposed to long-term stress/trauma, the stress hormone in amniotic fluid rises, which can result in a premature birth and/or other birthing issues. If the violence is physical, then of course there may be direct physical injury as well as the impact of high maternal cortisol levels.

Research has clearly indicated that trauma changes the biochemical substrate of the body. Traumatic stress is associated with increased cortisol, norepinephrine, and decreased oxytocin (Costello, 2013). Thus during pregnancy a traumatised mother’s chemical production will be shared with a foetus, which will have implications for a developing baby because; “The womb is not an isolation tank.”(Chamberlain, 2013, p.49). 

Before I progress to talk more about the mother and child attachment, I would like to talk about the stress hormone that our body produces as a protective mechanism. Cortisol is a steroid, produced by the human body to prepare humans to cope with stressful or life-threatening events. High levels of cortisol are normally meant to be in our system for a short period of time. When there is long-term stress, then there is a long-term secretion of cortisol in the body. Having the cortisol in our body for longer periods of time results in damage to hippocampus, which is harder to change later in life. (Hart, 2008). The Hippocampus is known to manage our affect regulation and as well as the formation of memories –especially long term. 

The internal environment of the mother’s womb provides information to the fetus in regard to what to expect after birth. Accordingly, the baby’s intelligent nervous system adjusts itself in order to increase the chance of survival after birth.  Especially in the third trimester, a fetus will be well informed about his/her environment and consequently start shaping him/herself chemically for what’s to come (Alexander, 2015).

Epigenesis suggests that human gene can be altered by environmental factors such as stress. The research in epigenetics reported that trauma and/or nervous tension experienced by the mother can lead to change in the fetus/baby’s DNA expression without changing DNA sequences. DNA methylation is an epigenetic mechanism, which often modifies the function of the gene and the gene expression. Methylated genes and changed gene expression can be transferred across generations. (Alexander, 2015). 

“In fact, methylated genes (and altered gene expression) can be transmitted across generations through the process of mitosis and, in some cases, during meiosis (Pretorius, 2010). Therefore, epigenesis is not limited to the impact on the child of stress that was experienced by the parent but even on genetic expression within the grandchild.” (Alexander, 2015; P.109-110) 

According to research results babies’ motor, and mental development was adversely effected due to the mothers’ exposure to high stress levels during the pregnancy. (Chamberlain, 2013). Prenatal stress is a predictor of behavioural problems in infant/child. It is suggested that mother’s who are exposed to long term trauma/stress hormones can lead to their children being at greater risk of developing ADHD, learning difficulties, aggression, anxiety, conduct disorders and vulnerability to developing PTSD and/or other mental health problems in their adult life (Alexander, 2015).

The above examples inform us that babies are not born with a “clean slate” but have been significantly affected by their experiences in utero. They are connected with the mother, not only on a physical level, but also on an emotional level, and they are very attuned to the mother’s senses and experiences. “Fetal behaviour is more personal than mechanical.” (Chamberlain 2013, p.42). In the third trimester, a foetus will be familiar with its mother’s voice, smell, food that the mother likes, her touch, her walking patterns, heart rate, and emotional state/s, etc.. Newborn babies, as young as 2 weeks old, are attuned to their mothers emotions; consequently they can differentiate their mother’s emotional state through the mother’s voice, and movements, which is mastered during the prenatal period. However, mothers may not be as fully present to the foetus and/or their newborn babies, which will influence their child’s attachment style (Costello 2013). 

In addition to these entire stimuli, the foetus will be exposed to the mother’s external world i.e. other people’s touch, sound, light, noise. Research shows that babies demonstrated awareness around violence or danger (Chamberlain, 2013). This might explain why when the mother is in distress the baby also becomes unsettled and dysregulated quickly. Because, they are so familiar with their mother’s emotional state and movements, they pick up very quickly when something is happening to their mothers or to them.  

As soon as babies are born, they can separate their mothers from others and definitely show more interest and engagement with their mother. They show their preferences for their mother’s smell, heartbeat, voice, and face over others. The baby’s brain development is tied to the mother. The attachment relationship will form the baby’s developing brain (Alexander, 2015). “The genes determine what properties are available – the hand that one was dealt, so to speak – but experience determines how the hand is played.” (Hart, 2008 p.28).

Attachment after birth

Hart (2008) and Costello (2013) talked about imprinting as a process for human’s offspring to form a bond with their mother. Imprinting happens early in human life, which leaves permanent markers on the nervous system that might be difficult to erase (Costello, 2013). The imprinting connects the young person to their mother physiologically and emotionally. Through connecting, interacting, and communicating with the mother, babies are imprinted on their mothers. “Imprinting takes place in primitive neural circuits and is often a rigid system that resists change. The imprinting process that forms the basis for the attachment process involves an early and largely irreversible branding of previous experiencing into a developing nervous system” (Hart, 2008 p.283).

The mother and infant attachment relationship is the main determinant for an infant’s developing brain, even before a child is born. Of course, the child will continue its rapid growth after birth; especially during the first seven years of life. However, these early life influences will shape the child’s and later adult’s affect regulation. Perry, Pollard, Blakley, Baker & Vigilante (1995) argue that life experiences in early childhood organises the brain system. The brain organizes itself according to the immediate environment, to increase the chance of survival. The parent becomes the external regulator for the child, as the child does not have the ability to regulate. So, we learn to regulate ourselves from a main carer.  If they are regulated, than we will learn to be regulated, if they are not regulated, we will be dysregulated, just like them (Hart, 2008). 

Because of our need for a secure base, human babies will change, shape, and bend-backwards to accommodate the main carer’s needs in order to stay close to their attachment figure, regardless of how negative this closeness might be for the child.   (Costello, 2013) I think Bessel Van der Kolk sums it up beautifully. “If a mother cannot meet her baby’s impulses and needs the baby learns to become the mother’s idea of what the baby is” (Van Der Kolk p.113).

Mothers who experience depression pre-birth or post-partum may be more disconnected from their infants and will be less likely to respond with touch to their infants. Our skin is the biggest and one of the most sensitive organs that we have. The skin of babies begins developing in the uterus at around five weeks after conception. According to Chamberlain (2013, p.58) “Touch is the first sense to develop in utero and is usually the last to go at death when simply holding the hand of a person in a coma raises the hearth rate.” It has been proven that babies stress related chemicals reduce when parents spend skin-to-skin touch with their babies and therefore this is encouraged in neonatal intensive care units. “In response to touch, stress hormones like cortisol and beta-endorphins drop sharply while immune system production of natural killer cells increases.” (Chamberlains, 2013, p.63). 

Touch increases the production of oxytocin. Touch exhilarates the growth and encourages weight gain. Well-fed kids with no loving attention may fade and die. Physical environment is one thing, but the emotional, skin-to-skin and the right brain-to-right-brain connection and attunements from the main carer makes the difference, as our limbic brain develops and learns to regulate in relation to the other (Costello 2013). 

Further to this discussion, Costello (2013) suggests that our early experiences will decide how much oxytocin we could produce, release and reserve in our bodies.  The dysregulation of oxytocin is transferred from one generation to the next. Considering that oxytocin is the love/bonding chemical, the mother who has less oxytocin in her system would have greater difficulty in the task of bonding with her offspring as she lacks the “love potion”.  This brings us to insecurely attached mothers, who would be, and understandably might have, attunement deficiencies.  

When there is an aggression/violence towards a mother at home, then the mother’s capacity to care for her children might also be reduced. Mothers who are in violent relationships might not be able to fully engage with their offspring due to PTSD symptoms, and feeling unsafe, which may stop them being fully present and attuned to their babies. A mother might be less available and more frightened in such a relationship and the child is then exposed to a frightened mother who is with a frightening partner. This might also contribute to intergenerational trauma transmission as there are proven impact on children who witness violence vicariously, such as behavioural, mental and attachment problems (Pamela C. Alexander, 2015).

Depressed mothers will be less attuned to their babies and less able to engage with their children as they will be hypo aroused which may mean less touch, less eye contact, less talking, less smiles, and/or less playing games, etc.. There may be too much space for the child that the child cannot fill. These kids will grow up lonely. On the other hand intrusive, anxious (hyper-aroused) mothers will be intrusive, mis-attuned, overly engaged, and controlling and which does not give any space to the child. However an insecure attachment style may add to the survival of a child, as Costello points out:

“…an insecure attachment style was not always a mistake. It depended on what the circumstances were in the developmental niche and which circumstances were to be later encountered in the wider world. In circumstances in which a mother is highly stressed, as has often been the case through human history, a child who was avoidant enough not to drive his mother away or who was anxious enough to successfully insist on attention might have a better chance of surviving and flourishing.” (Costello, 2013, p.52).

Before I delve into the attachment issues, I will briefly talk about attachment styles. To explain attachment theory basically I will ask you to think about the relational mirror a baby has, and which they start to look into soon after birth.

When a baby looks at this mirror, which is the face of their main carer, then the baby will internalize the picture that they see on that mirror as to whom they are themselves  – a reflection of the mother’s nervous system.  

If the baby sees a loving and caring face, which matches the behavior that they receive, then most likely they will think that they are loveable and that they do matter; which creates a secure attachment. Alexander (2015) further defines secure attachment in children as “The child’s use of the mother as a secure base from which to explore the environment as well as a safe haven from whom to receive comfort and reassurance is not only effective, but is internalized by the child in its ability to self-soothe and in the development of positive expectations of self and others.” (Pamela C. Alexander, 2015; p25).

However, if a child’s mirror shows that they are not safe; such as you are only loved when you are not demanding or needing me, then the child will learn that if they show any emotions they might not be viewed as likeable, or lovable; which creates avoidant attachment. “Avoidant attachment is associated with the parent’s insensitivity and rejection of the child precisely when the child is distressed or needy….. the child learns that the best way to maintain connection with this parent is through deactivating the attachment needs that appear to drive the parent away.” (Pamela C. Alexander, 2015; p28).

And at times, when a baby looks at the mirror, which reflects a mixed response, one day loving, the next day dismissive or angry; will be confusing for the child. The child might be preoccupied about how to get a consistent good response each time and might be anxious about getting it right each time; this creates anxious attachment. “Anxious attachment… This attachment category is associated with the parent’s inconsistency, ranging from neglect, on one hand, to over protectiveness or intrusiveness in the child’s play… an anxious/ambivalent child displays difficulty attending to the toys and instead seems preoccupied with the mother. In order to gain the attention of this inattentive parent, the child heightens the display of negative affect.” (Pamela C. Alexander, 2015; p30).

Or in some cases this mirror will be very scary to look at. Then the baby will get caught up in an impossible place; with nowhere to escape to but be stuck with this mirror: which creates disorganised attachment. “..we anticipate that the other to whom we would like to turn may create in us feelings of fear and of confusion…So we may fluctuate between urgently pursuing our attachment figure (in a way that looks like anxious attachment) and avoiding and distancing ourselves from the attachment figure (in a way that looks like avoidant attachment).” (Costello 2013, p.82) In this kind of attachment there will be fear without solution (Pamela C. Alexander, 2015).

A child with a sensitive system due to peri, and/or pre-natal stressors of the mother, might have more difficulty regulating their emotions, which in return may trigger the carer who is already struggling with his/her own affect regulation. This could then trigger the child further and heighten the child’s stressed response, which could in turn trigger their mother more. This chicken and egg situation might then transfer itself on to the next generation with regards to affect regulation; with a reminder again that changes in DNA expressions can pass through generations, which I mentioned earlier  (Pamela C.Alexander,2015). 

Child Sexual Assault-it’s dynamics and life impact.  

Herman stated that “Traumatic events are extraordinary, not because they occur rarely, but rather because they overwhelm the ordinary human adaptations to life” (Herman, 1992; p.33). As we know, sexual assault is not a rare event in our societies; Australian statistical data shows that one in every four girls and between one in seven and one in twelve boys are victims of sexual abuse (Bravehearts, 2015). Sexual assault overwhelms a person’s nervous system, which in return means they cannot integrate this event into their adaptive system.  Children who have been exposed to trauma at an early age are usually more vulnerable to be sexually assaulted as teenagers and adults (Alexander, 2015).  

Alexander (2015) states that sexually abusive families also operate differently from other types of families with other issues. Sexually abusive families exhibit anger, rigidity, and are more punitive, chaotic, less boundaried and more enmeshed, which gives us a lot of information about the attachment styles of these families. When a sexually abused child reaches puberty/adolescence then, often, they start acting out by re-enactment; such as over/under sexualised behaviour, substance abuse, and self harm etc. For example,  “CSA (Child Sexual Abuse) is a significant predictor of substance abuse… CSA increases the risk for heavy poly substance use in girls” (Pamela C.Alexander, 2015; p.158). Isolation, and normalised secretiveness also reduces the likelihood of disclosures. “Secrecy and silence are the perpetrator’s first line of defence. If secrecy fails, the perpetrator attacks the credibility of his victim.” (Herman, 1992; p.8) which usually works well with teenagers who also have behavioural problems due to CSA.

The term ‘complex psychological trauma’ has now been recognized in the DSMV and is used to refer to the impact of chronic, and/or childhood attachment abuse. Indeed, “… patients with Borderline Personality Disorder reported the highest rate of traumatic exposure (particularly to sexual assault trauma, including childhood sexual abuse), the highest rate of Post Traumatic Stress Disorder, and the youngest age of first traumatic events.” (Van der Hart, Nijenhuis and Steele 2006; p.113).

Understandably, victim/Survivor’s of childhood sexual assault are significantly more likely to be re-victimised further in childhood, adolescence and adulthood because the child’s relationship with their body and boundaries change; “…the child’s body invaded; the child is given confusing messages about the abuse; the child is often abused by a trusted person; the child is forced or encouraged to keep the abuse secret; and the abuse is often minimized if and when it is finally disclosed….Approximately 40-60% of patients with a diagnosis of BPD have a history of CSA” (Pamela C. Alexander, 2015;p.150).  When a person is exposed to sexual assault trauma early in life this adds more layers i.e. dissociation disorders and complexities to their attachment style, this makes therapeutic work more challenging and longer term.

When a child is sexually assaulted the message passed on to the child by the sexual offender is: your feelings, wants are not important but only my needs and sexual gratification are important. On top of this, children who were sexually abused may internalise I am not capable of stopping the sexual abuse, given that they were abused as children and were both physically, and mentally vulnerable and could not stop the perpetrator. This internalisation, I can’t stop them, makes them even more vulnerable to further abuse as teenagers and adults. 

When it comes to sexual assault the closer the relationship between the victim/ survivor and the perpetrator, the more complex and difficult the mental health problems will be, especially in teenage and adulthood years. Attachment betrayal is one of the predictors of negative outcomes for the victim/survivor as it adds further attachment injuries. (Pamela C. Alexander, 2015).  When there is sexual assault by a trusted adult, then the child’s nervous systems becomes overwhelmed, as their nervous system will be vulnerable owing to their developmental stage and reliance on the offender to have their emotional needs met.

My work experience as a sexual assault counsellor informs me that some mothers’ who were sexually assaulted as children had difficulty recognising sexual predators and therefore their children became vulnerable. One possible reason for this is that the need for attachment is stronger than other needs and the abuse material was dissociated. Alternatively, there may have been such a profound violation of boundaries and silencing that a survivor may not be able to have a voice for her experiences. 

In some cases mothers are overly protective; and do not let the child’s father get involved with their children as their fear of men in intimate relationships generalises. Whether mothers are over or under protective of their children there is an impact on their children.

Another impact of CSA is an increased risk of sexual offending against others by a small number of victim/survivors. In general, sexual offenders have a history of physical, sexual abuse themselves. (Pamela C. Alexander, 2015).  Sexual abuse may then become an intergenerational trauma and requires intentional and informed decision-making processes such as receiving family therapy to stop passing this trauma onto the next generation, to correct offending beliefs and cognitions. 

Alexander (2015) further reports people with a CSA history having higher dis-satisfaction rates in their intimate relationships; especially in regard to sexual intimacy, because of the increased emotional shut down experienced by survivors as a protective and survival mechanism.

Treatment implications

We now know that we can create new neural pathways and new connections because of the Neuroplasticity of the brain. Positive attachment experiences help in creating new adaptive pathways (Costello, 2013). Human beings have an amazing system that can, and is often able to, compensate and heal from attachment and/or trauma injuries. However, research also indicates that long-term attachment injuries and neglect can create permanent maladaptive behaviour (Hart, 2008). Our early experiences form how our brain is going to develop. When children are exposed to trauma at a younger age, the effect will be longer lasting and impact harder to ameliorate. Therefore, we may need to work long term to help our clients to make changes in their lives, and not necessarily to reverse the impact of trauma, but to improve the quality of their life. We are living in times of economic rationalism, which is irrational about the treatment of complex trauma and only funds short-term treatments in Australia.  

Working with clients with pre, peri and post attachment injuries and sexual assault trauma is often very challenging. When there is a trauma then there is an impact on Cognition (Frontal Cortex), Emotional (Limbic System), and Survival (Reptilian) brain functions. Because of this our trauma counselling needs to engage with all parts of the brain. The work then will be while engaging the trauma material (right brain), keeping the client in the here and now (left brain) (Ogden, Minton, & Pain; 2006).

Trauma is also not only what had happened to our clients but also what did not happen; for example, pre, peri and post-natal safe engagement –secure attachment-, not being able to integrate the left hemisphere’s input, and/or to discharge the stored energy, which occurs as a result of the traumatic experience. The release of this stored energy usually comes through the movement.

When there are pre-nates exposed to the trauma in this delicate and important time; their trauma coding will be done somatically. Therefore, our response to our clients’ needs to be somatically driven. As Van der Kolk (2014) states no amount of talking can change the body-based fear, as the fear is not the result of a lack of cognitive understanding. Therefore, the therapeutic work needs to engage a highly-strung nervous system, which needs to be soothed first, before change can occur. Down regulating by grounding exercises and creating safety within the body through pendulation are helpful tools.

Different frameworks are known to be helpful in order to engage with the nervous system such as Havening, Sensory-motor, Somatic Experiencing, the Theory of Structural Dissociation of the Personality with the combination of EMDR, Attachment theory and many more are too numerous to list here. An attachment framework will open the door to the work that we are aiming to accomplish. 

My experiences with these modalities are; 

• The Theory of Structural Dissociation of the Personality with the combination of EMDR is a great stabiliser when working with developmental trauma. In my experience, these modalities help clients to create self-compassion, which becomes the first casualty of attachment injuries and sexual assault trauma.
• Havening soothes the nervous system especially around memories such as sexual assault, family violence, which triggers trauma defence –flight, fight, freeze- response. 
• Somatic Experiencing and Sensory-motor engages with the nervous system where the trauma material got stuck. Therefore pre, peri and post- natal attachment injuries will be benefited from these modalities. Both modalities work with a bottom-up process and supports clients in order to create internal safety and resolve under and/or over coupling of trauma material. 
• Attachment Theory underpins all the above theories. When there is no therapeutic relationship then there won’t be successful outcomes for the therapy.

If/when a client does not feel safe with the counselling process then the client won’t be able to participate in his/her own healing. Therefore, with attachment work the counsellor creates safety in the room; so that the client can stay connected to their thinking (left) brain, whilst the client and the counsellor are engaging the emotions/trauma material, which is coded in the right brain. During the therapy, the counsellor’s attunement to the client’s attachment style will guide the pace and the level of engagement. For example, avoidant attached client may need more space and less emotional engagement as it might be destabilising for the client due to feeling unsafe.  

To enable this work the therapist uses their own body and felt sense as an information source to engage with the clients’ nervous system. Some clients may not be able tell what they are feeling or thinking, then there is only one source for the counsellor to work with – the nervous system. “Children who have been exposed massively to early neglect are often unable to put their emotions into words (alexithymia) and to correct their own behaviour, or, regulate their affects through language, and soothing words provide them with no comfort.” (Hart, 2008 p.48 &49). 

Sometimes working with this client group is hard and slow going. This sensing of what is going on between the client and ourselves is the therapeutic attunement. This means that we are going to potentially feel a lot in our bodies as counsellors, because we are connected and we know what is going on within, and between ourselves, and the client.  

Or, the line between ourselves and the client can be a bit fuzzy; dissociated, overwhelmed, or not attuned, which, by itself is important information for the counsellor to explore in their supervision session, focussing especially on the possibility of vicarious traumatisation, and/or transference/counter-transference, which may be played out in the counselling room. Regular supervision will create awareness regarding the counsellor’s own blind spots, and the attunement disruption patterns.  

My last point is that I have found that the most important aspect of this work is to keep a positive regard and compassionate eyes for the clients. What I have noticed, and read time and time again, is that the first casualty of trauma is the inability to feel compassion towards the self.  I find that it is imperative to educate clients of the importance of developing self-compassion. The use of Structural Dissociation of the Personality and the EMDR modalities are extremely helpful in order to create self-compassion.

Working with this group of clients requires systemic approaches in order to reduce attachment injuries, impact of sexual assault and other intergenerational traumas. Government funded programs, such as-

• Psycho educational programs for mothers, medical practitioners and teachers etc.
• Extensive history taking (in medical settings) inclusive of past and present traumas
• Intensive support and resources for mother and babies
• Government funded trauma centers which use a wide variety of modalities inclusive of somatic work, and
• More research

These are deemed to be helpful in reducing the intergenerational trauma and increasing securely attached children and adults.