Holding up a Healthy Mirror – Therapeutic Parenting Training for Parents in the Rejected Position

The Neurobiology of Attachment-Focused Therapy: Enhancing Connection and Trust in the Treatment of Children and Adolescents by Jonathan Baylin and Daniel Hughes

Introduction
If we are to protect young children from harm … we will have to value more and give response to what children bring to human life—the eager spirit of their joyful projects beyond their seeking to survive.” —Colywn Trevarthen (2013, p. 203)

How can therapists and caregivers help maltreated children recover what they were born with: the potential to experience the safety, comfort, and joy of having trustworthy, loving adults in their lives? This is the topic of this book. The authors have been collaborating for a number of years now about the treatment of maltreated children and their caregivers. Both experienced psychologists, we’re committed to helping these children learn to trust caregivers and helping caregivers be the “trust builders” these children need. Our shared project is developing a science-based model of attachment-focused therapy that links clinical interventions to the underlying biobehavioral processes of trust, mistrust, and trust-building.

Our approach is embedded in the growing field of interpersonal neurobiology (IPNB) (Siegel, 2012; Schore, 2013), a clinical model that seeks to inform psychotherapy with the exploding knowledge from social neuroscience. In particular, we draw from (1) research showing how early exposure to poor care tunes the child’s brain for living defensively (Perry et al., 1995; Cushing & Kramer, 2005; Roth et al., 2006; Beach et al., 2010; Tottenham, 2012; Meaney, 2013) and (2) research showing that later in life, “enriched” social experiences can retune the brain and support a biobehavioral shift from mistrust to trust, reawakening and strengthening the child’s capacity for social engagement (Branchi, Francia, & Alleva, 2004; Weaver, Meaney, & Szyf, 2006; Curley et al., 2009; Dozier, Meade, & Bernard, 2014; Humphreys et al., 2015; Moretti et al., 2015).

Our earlier work on the development of a brain-based model of caregiving led to the book Brain-Based Parenting (Hughes & Baylin, 2012), in which we focused mostly on the neurodynamics of parenting, introducing the concept of blocked parental care, or simply blocked care. In this book, we turn our attention to children who are forced by poor care to develop what we call blocked trust: the suppression of inherent relational needs for comfort and companionship to survive neglect and abuse. How do infants, who are not aware of learning anything, learn to trust and mistrust adults? Once young children develop blocked trust, is this learned defensiveness reversible? Can their blocked potential for trusting in the care of a trustworthy adult be reawakened after years of living defensively? Can these children learn to feel the social emotions—separation pain, remorse, empathy, joy of connection—that they had to suppress to be asocial earlier in life? If so, how do they make this journey from mistrust to trust, and what needs to happen in their relationships with caring adults to facilitate this shift? How do their caregivers avoid the risk of blocked care from repeated experiences of being mindlessly mistrusted and manage somehow to sustain their compassion for these complicated hurt children? How can caregivers, therapists, and other adults send strong, consistent messages of safety and approachability deep into those mistrusting brains where safety and danger are first detected?

Children develop blocked trust in response to frightening and painful relational experiences with adults. Neuroscientific research reveals that these experiences sensitize a neural “alarm system” (Liddell et al., 2005) called the mid-brain defense system, laying the foundation for chronic defensiveness, the core of blocked trust. At the same time, maltreatment suppresses the development of the child’s “social engagement system” (Porges, 2011), the brain system that would normally be activated and strengthened by good care.

Maltreatment triggers chemical reactions in children’s brains that decrease subjective suffering from the pain of rejection and abuse (Lanius, Paulsen, & Corrigan, 2014) while enabling them to remain vigilant and defensive around uncaring caregivers. This combination of pain suppression and chronic, mindless defensiveness is at the heart of the deep emotional disengagement and mistrust we see in these children. Treatment for blocked trust has to target the mid-brain alarm system, disarm it, and remove the blockage that keeps the child from feeling the need for care and comfort from adults. To accomplish this, children need to have comforting, enjoyable experiences with adults, experiences that can awaken their brains to experience the safety they have never known. They need to hear the caring voices, see the shining eyes, and feel the loving touch of people who somehow manage to keep caring deeply about them in the face of their mistrust.

Dyadic Developmental Psychotherapy: A Brain-Based and Attachment-Focused Model

Dyadic developmental psychotherapy (DDP) is a model of treatment that is squarely focused on providing the kind of safe, trustworthy experiences with adults that can facilitate this brain-shifting process and help children with blocked trust move from chronic defensiveness toward open engagement (Hughes, 2006; 2007; 2011). DDP targets the heart of blocked trust: the social brain switch where the implicit process of appraising safety and danger begins. In this brain circuit, we use crude sensory information such as facial expressions to appraise trustworthiness at a preconscious level faster than we can be aware that we are appraising anything. This is where attachment-focused therapy needs to work; this, as Sebern Fisher (2014) so powerfully puts it, is the “epicenter” of the chronic defensiveness at the heart of blocked trust and developmental trauma. Crucially, the DDP therapist embraces the child’s defensiveness, putting connection before correction, knowing that the child had to develop this core relational strategy to survive poor care. This radical acceptance of the child’s mistrust (which can feel like hugging a porcupine) is essential to the process of helping a mistrusting child begin to trust.

Maltreated children who have never felt safe with caregivers need to experience safety on at least three basic levels: (1) safety to feel the pain of disconnection and to seek comfort from a trustworthy adult; (2) safety to engage a caregiver in positive, playful, rewarding interactions; and (3) safety to share inner experiences and enter an intersubjective relationship with a trusted adult. These are the three levels of safety children need to recover from blocked trust and the suppression of attachment needs.

In DDP, change is driven by relational and emotion-focused processes that work from the bottom up, creating new positive experiences with caregivers, and from the top down, promoting new meaning making and the development of more coherent narratives as the child awakens to the reality of being in a safe, trustworthy environment. The relational processes used in DDP are similar to the trust-building processes parents use with young children to develop secure attachments, processes that are now known to buffer the child’s defense system and foster healthy brain development (Tottenham, Hare, & Casey, 2009). The DDP therapist uses relational skills to help caregivers and mistrusting children revive the suppressed reciprocal processes of attachment and caregiving that were absent in the child’s earlier relationships with adults. DDP helps caregivers and therapists function as trust builders by being in the “right” mind to send safety messages deep into that hypersensitized defense circuit and switch on the social engagement system.

When a child’s alarm system is off, and the social engagement system is switched on, the child can begin to use the higher brain regions, especially the prefrontal cortex, that have to be activated to support the new learning to make the journey from mistrust to trust. We link the processes of DDP to the neurobiological processes of reversal learning, fear extinction, memory reconsolidation, reflection, and reappraisal, which depend on the awakening of the prefrontal regions. These processes enable mistrusting children to start learning from experiences with adults and gradually change their minds and their behavior based on new experiences, something they are not able to do as long as their brains remain in the shut-down state of blocked trust. Using such processes as PACE (playfulness, acceptance, curiosity, empathy), follow-lead-follow, co-regulation of affect, storytelling, co-creation of meaning, emotional state induction, affective/reflective dialogue, and relational repair, the DDP therapist establishes a rhythm of reciprocal nonverbal communication with the child. Then she blends this nonverbal engagement with words congruent with the traumatic events of the past, while remaining socially engaged with PACE, enabling the child to participate in this dialogue without defensiveness. This allows the child to experience care differently and start creating new meanings for past traumatic events, moving toward developing a coherent autobiographical narrative. PACE constitutes a therapeutic mind-set or “attitude” that helps ensure adults will send messages of approachability and trustworthiness into the child’s brain, helping prevent the mutual mistrust scenario that often develops between mistrusting children and adults. The attitude of PACE is the opposite of an adult’s frequently defensive approach toward these children.

By concentrating on the main agenda of creating a safe connection with the mistrusting child, the therapist learns in real time, constantly monitoring the child’s feedback, how to engage the child. Once some level of engagement is attained— what we call engagement light—the therapist concentrates on extending and deepening this dyadic connection while modeling the engagement process for caregivers and coaching them in becoming messengers of safety and trustability for the child. The therapist uses the engagement to help the child travel emotionally from a shut-down state to a state perhaps of light playfulness, toward a state of sadness, with the goal of helping the child safely remove the neurobiological block from the separation distress system that is a core component of attachment. This in turn enables the child to start feeling the need for care and seeking comfort from an adult who is ready, willing, and able to provide it—an adult who is not in blocked care.

DDP includes intensive work with caregivers to enhance their capacity to sustain a caring state of mind toward the child. In brain terms, this involves helping caregivers strengthen the brain circuitry that enables them to “keep their lids on” and regulate their emotions and actions when faced with oppositional behavior and defensiveness. By helping the adults learn to rise above their “low-road” instinctive feelings of rejection, DDP helps caregivers provide the enriched kind of care that is needed to undo the damaging effects of earlier exposure to adults who didn’t (for whatever reason) rise above their own defensive needs to be trustworthy caregivers for these children.

Good Care and Poor Care: The Neurodynamics of Attachment and Caregiving

Unlike reptiles, the mammalian nervous system did not evolve solely to survive in dangerous and life-threatening contexts, but it evolved to promote social interactions and social bonds in safe environments. —Porges and Lewis (2009, p. 256)

Experiential factors shape the neural circuitry underlying social and emotional behavior from the prenatal period to the end of life. —Davidson and McEwen (2013, p. 689)

Infants are born social, ready to engage with their world. They don’t have to learn to seek close connections with caregivers. They are ready to shine in their parents’ eyes, be a source of immeasurable delight even as they are also inevitably a source of stress, even for the most loving parents. Having already learned their mother’s voice before birth, they enter the world searching for her face, being especially attentive to her eyes. Their brains get excited when they find those eyes, especially when they widen and brighten when receiving this magical gaze (Guastella, Mitchell, & Dadds, 2008). It’s not an accident that human babies, along with other mammalian young, have big eyes and the ability to mimic the facial expressions of their caregivers from birth. Cuteness and sociability are all part of nature’s plan for ensuring that the brains of parents will be responsive to the infant’s signals and become obsessed in the loveliest way with taking care of them (Noriuchi, KiKuchi, & Senoo, 2008; Carter & Porges, 2013). (The authors can both attest that similar experiences await lucky grandparents, who also find it easy to fall in love with their new grandchildren.)

Infants bring energy and excitement to their interactions with receptive caregivers, expressing what Dan Stern (1985) calls the “vitality affects”: the capacities for feeling the pains and pleasures of being social, of needing comfort and companionship. When children are well cared for, they develop a deep, abiding trust in their caregivers, getting the benefits of a safe environment in which to play, express all of their emotions, and be exuberant, passionate, and curious.

What can suppress this natural vitality, this inherent readiness for social engagement? Fear of engagement. Children exposed to very poor care early in life learn to fear expressing the very needs for comfort and pleasurable companionship that normally lead to enduring emotional bonds with trustworthy caregivers. Poor care in the form of neglect, abuse, or lack of an attachment figure can force children to suppress their attachment-based needs, making them shrink from engagement with adults whom they would otherwise approach to get comfort, be playful, and share their thoughts and feelings. Instead of fully engaging with untrustworthy caregivers, they stifle their relational needs while learning to be as self-sufficient as they can be, keeping caregivers at a safe-enough distance. This process of living defensively results in what we call blocked trust, a complex developmental adaptation forced on children who cannot depend on caregivers to meet their emotional and social needs. Let’s meet Mavis and Danny, two inherently social beings who find themselves in radically different social environments early in their lives.

Experience-Adaptive Brain Development

Neuroscientists have learned that early in life, good care and poor care affect brain development by activating and silencing genes in brain systems or circuits that are under development (Weaver, Meaney, and Szyf, 2006; Champagne and Curley, 2011). This interplay between genes and environment is called epigenetics, a process earlier brought to light in the field of cancer research (Baylin and Ohm, 2006) and more recently taking center stage in the field of developmental neuroscience. This fast-growing research reveals how experiences with caregivers affect the way genes “behave” in the child’s brain, genes that are involved in building all of the key neurotransmitter systems, the dopamine, serotonin, opioid, and oxytocin systems that support the formation of secure attachments. Epigenetically, good care and poor care can either wake up or silence genes to orchestrate the structural development of the child’s brain in accordance with the nature of care the child is sensing. These epigenetic processes help build the key brain systems that make up the social brain (Callaghan et al., 2014).

The young infant’s brain, primarily the right hemisphere (Chiron et al., 1997), awaits input from experiences with caregivers to start adapting its structure and functioning for relating to the kind of care being offered (Belsky, 2005, 2013). Does the quality of early care presage a life of milk and honey where resources are plentiful and others delight in your being? Or is life going to be constantly stressful, a world in which everyone is looking out for number one, competing every moment for scarce resources, a world where no one can really be trusted, where no eyes are safe? Or will life be somewhere in between, with degrees of trust that gradually decrease from the world of family to neighborhood, school, and community to more distant social settings inhabited by strangers? Answering these fundamental questions about the nature of the social world and adapting accordingly is exactly what the child’s preverbal brain is doing, even though the infant has no conscious awareness of this social learning process. This is implicit, emotion-driven learning, perhaps the most powerful kind of learning humans experience in life, learning that sticks with us, literally embedded epigenetically in our brains and bodies. What kinds of messages from caregivers trigger epigenetic effects in a baby’s brain, and what brain systems are sensitive to these effects? Primarily nonverbal signals from facial expressions, tones of voice, and different kinds of touch, multisensory inputs to the baby’s brain that affect the construction of several brain systems which together make up the social brain.

Blocked Trust: Stress and Early Brain Development

The retreat into isolation can sometimes feel more controllable than being flooded with a sense of needing another person for comfort and connection. —Siegel (2012, p. 385)

When we begin to understand the nature of the separation distress system at the neurobiological level, we may learn how to disentangle the damage wrought by emotional misfortunes.
—Panksepp (2003, p. 237)

To survive very poor care, children learn to fend for themselves by developing a strategy to meet their physical needs for food, warmth, and protection from the elements (self-provisioning); protect themselves from untrustworthy caregivers (self-defense); and manage the emotional pain of being on their own in a dangerous world without a comforting other (self-regulation of social pain). In the process, the child must heighten those aspects of brain functioning that support chronic defensiveness while suppressing those emotions that normally support social engagement and attachment, including separation pain, pleasure of companionship, empathy, and remorse—emotions that would prompt the child to move toward an untrustworthy caregiver and get hurt even more. In the process of heightening defensiveness and suppressing social emotions, the child also has to suppress the development of his inner life, that inward-looking default mode system that eventually enables reflective functioning to emerge in typical development. Poorly cared-for children don’t feel safe enough in the presence of a caregiver to look inside; instead they are compelled to constantly monitor the external environment for threats. Blocked trust is the combination of these different processes that constitute the child’s survival strategy, his or her tool kit for getting by largely through self care, for maintaining a “me” orientation to life in the absence of a healthy “we” (Siegel, 2012).

Let’s look at how this developmental trajectory affects the five core brain systems we discussed in Chapter 1. Then we consider the processes of heightening self-defensiveness and suppressing social emotions and reflective functioning. Last, we describe three types of blocked trust strategies commonly seen in a clinical setting.

Blocked Trust and the Five Core Brain Systems

In terms of the core brain systems discussed in Chapter 1, the maltreated child has to suppress the social engagement system and the social pain system while activating and strengthening the self-defense system. To do this as an infant, the child has to rely on the bottom-up, primarily subcortical brain systems in which the amygdala takes the lead. The child has to use the amygdala-driven neuroception system to rapidly detect threats and keep the self-defense and the stress systems up and running, basically on 24/7 duty. The child also uses the ability to release pain-suppressing chemicals, mostly opioids, into the amygdala and the anterior cingulate cortex (ACC) to dampen the subjective pain of having to deal with poor care. This requires the child to use the social pain management system for self-defense rather than experiencing the co-regulation of separation distress by a trusted caregiver. This forces the child prematurely to develop a self-regulation strategy at a time in brain development when there is no other option besides the automatic, unconscious use of the opioid-driven pain suppression system, an emotion regulation strategy that promotes chronic disengagement and dissociation. Meanwhile, the need to stay hypervigilant toward the outer world interferes greatly with the development of the child’s inner life, making the child doubly unsafe: unsafe looking outside and unsafe being inside. This lack of external and internal safety underlies the disorganized style of attachment most of these children develop and goes to the heart of blocked trust. Understanding these dynamics informs us, as therapists and caregivers, that we need to target both levels of safety to help these children recover from this developmental trauma.

Heightening Self-Defense Processes Hypervigilance

Defensive living requires the ability to rivet attention on the signs of impending threats to safety in the behavior of other people. This includes the art of reading other people’s intentions, of “minding their minds” to see harm on the rise, catching threats emerging before they actually materialize in various forms of abuse, neglect, invalidation, or rejection.
Chronic mistrust requires a strong negativity bias, a constant hyperfocusing on the subtlest shifts in other people’s faces, voices, body language, and interactions that reveal anger, disgust, or apathy. This early threat detection process is sufficient in highly defensive children to trigger defensive action: evasion, preemptive aggression, a charm offensive, or some form of frantic excitement that distracts everyone, including themselves. Based on this quick appraisal of impending harm, some kids become tigers, others opossums, other chameleons, different styles of blocked trust all serving the function of keeping others at a physical and emotional distance.

Implicit Memories, False Alarms, and Over-the-top Reactions

Understanding how the amygdala helps create implicit, preverbal memories of exposure to maltreatment helps us understand why children with blocked trust react the way they do when caregivers (and therapists) try to engage them. When these preverbal memories are triggered later in life, they have the quality of coming up out of the blue, out of context to the realities of the new environment and triggering emotional reactions that are way out of proportion to what is actually occurring during an interaction with a caregiver. This is how those big feelings that we often see in mistrusting children get triggered and take over a child’s (and often a parent’s) brain while this brain storm is going on. This is the neurodynamic explanation for the many false alarms that mistrusting children get in their brains during their interactions with adults and peers, those moments when the children’s brains jump to the conclusion that the other person is having a negative reaction, getting ready to reject, abandon, or physically abuse them.

Early life experiences with being rejected, with experiencing, as one child expressed it, being “set aside,” are certain to trigger the amygdala–periaqueductal gray (PAG) defense system, that deep-brain primitive alarm system that can activate big defensive reactions in the blink of an eye. This is how rage, running away, or freezing in fear happen out of the blue in these children, the result of having their mid-brain defense system triggered in the absence of top-down regulation from the ventromedial prefrontal cortex (VMPFC) regions as we described in Chapter 1. Repeated experiences with being uncomforted, unseen, neglected, and/or abused sensitized the child’s quick emotional appraisal system in such a way that any future experiences that even hint at rejection, abandonment, or physical abuse can trigger these over-the-top defensive reactions. Think, for example, about the way adults with a diagnosis of borderline personality disorder react so dramatically to seemingly innocuous, subtle shifts in a therapist’s facial expression or tone of voice, as if these were the early warning signs that the therapist is abandoning them.
Think about the still face experiment when mothers are asked to put on a blank face and their babies decompensate within seconds, only coming back to life when the mother starts smiling and cooing again. In both instances, we are witnessing the power of perceived loss of safe connections to another person to make us “flip our lids” and fall into a dark, terrifying place, a black hole of disconnection that can even rob us of the will to live.

It is telling that wild animals who live in environments with much more uncertainty than their tamer relatives have larger amygdalas, particularly in the region that orchestrates the release of defensive behaviors (Kagan, 1994). Maltreated children are forced, in a way, to shift into a trajectory of brain development more suited for life in the wild than for living in very safe environments. Knowing this can help therapists and caregivers better understand the seemingly wild, over-the-top emotional reactions and behavior exhibited at times by maltreated children living in tame environments.

Blocked Care: The Parenting Brain and the Role of the Caregiver

Children who experience early adversity, such as neglect, abuse, exposure to domestic violence, and separations from caregivers, are at increased risk for developing disorganized attachments. These children’s caregivers need to provide nurturing, sensitive care, indeed even therapeutic care, if such children are to develop organized attachments. —Bernard et al. (2012, p. 623)

Young children are at the mercy of their caregivers’ states of mind toward them and have to adapt accordingly to survive. The ability of a parent to develop and sustain a compassionate state of mind or attitude toward the child—embracing the whole child—is, in our clinical experience, the most important factor contributing to a child’s recovery from blocked trust. Parents who can resist the natural tendency to respond defensively to a child’s defensiveness and can recover effectively from inevitable moments of losing empathy with a mistrusting child are the trust builders these children need to have.

Developing and sustaining this kind of resilient compassion is no easy task—far from a no-brainer. One parent described it as “hugging a cactus.” Indeed, parenting a chronically defensive child takes all of the brain power an adult can muster, demanding the use of instinctual aspects of caregiving we share with other mammalian parents and the highest executive powers we access by turning on our most uniquely human brain regions in our prefrontal cortex. To make it even more challenging, these higher brain regions are the very ones most likely to shut down when a parent is experiencing great stress.

In brain terms, the ability to be a nurturing parent over time depends heavily on the social engagement system (that smart vagal circuit we described in Chapter 1) (Porges, 2012), the brain–body system that enables people to stay open and engaged with each other even when there is tension or misattunement in the relationship. Parents who stay open, mindful, and engaged with their children over time in spite of the stresses and strains of parenthood are relying on their good vagal tone to stay parental in an enriched way that supports a child’s healthy brain development. Parents with good vagal tone can keep defensive reactions at bay and recover more quickly from lapses into defensiveness than can parents with poor vagal tone. Fortunately, a growing body of research shows that parents can strengthen their capacity to be open and engaged in their relationships with their children (Tang et al., 2010). (We discuss this in Chapters 8 and 11.)

As we discussed in our previous book, Brain-Based Parenting (Hughes & Baylin, 2012), parenting well actually calls on at least five different brain systems that enable us to (1) feel safe being very close to our children; (2) derive pleasure and joy from taking care of and interacting with our kids; (3) attune to our kids’ inner lives using our powers of empathy and “mindsight”; (4) construct positive, affirming stories or narratives about being parents; and (5) control our negative, uncaring reactions sufficiently to stay parental most of the time, to be the adult in the room. We call these systems the Approach, Reward, Child Reading, Meaning Making, and Executive Systems. When a parent can access all five systems and keep them up and running over time, a child gets to interact with an open-minded, empathic, attuning other in ways that we now know enhance a child’s brain development and build strong bonds of trust between parent and child. A parent’s ability to access and sustain this open state of engagement depends on the parent’s visceral sense of safety, physically and emotionally, in the relationship with the child. Having supportive, secure relationships with other adults and freedom from chronic stress over issues of daily survival are also essential for a parent to interact in an open, engaged way.

Normally, when parents go through the experience of pregnancy and then are present to be trust builders in a child’s first year of life, there is a mix of joy and stress in which the joy outweighs the stress, enabling the parents to hold on to their loving feelings and compassion for their child and gain the child’s deep trust in their care. The hormonal changes during pregnancy, especially the rise in oxytocin and prolactin levels around the time of birth, prime the caregiving system in the mother, while expectations of fatherhood may have similar priming effects on the father-to-be, including the suppression of testosterone and other hormones that would normally inhibit a dad’s more nurturing, empathic potential (Bridges, 2008). With the birth of the child and the beginnings of face- to-face, voice-to-voice, touch-to-touch interactions, oxytocin and dopamine are triggered in parents and children, helping create strong emotional bonds that pave the way toward secure attachment and sustained caregiving (Fleming & Li, 2002).

This emotional bonding process helps build a strong foundation of trust that enables parents and children to weather the inevitable tensions that accompany the next stage of development when the child is mobile and the parents have to engage in more socializing functions, including saying “no” and helping the child learn to accept limits and rules. Once children deeply trust their parents’ intentions in setting limits and directing behaviors, the children are free to turn their attention to what is really important to them—play, discovery, delight, adventure, learning interesting things. The parents can do the heavy lifting regarding basic issues of safety and the child is free to be a child.

Mutual Defense Societies: When Blocked Trust Meets Blocked Care

Having to be a socializer without the benefit of first being a comforter and trust builder has much to do with why foster and adoptive parents of older children experience great challenges as they try to combine trust-building with socialization, “connection with correction.” Under the inevitable stress of parenting hurt children, parents are at risk for blocked care (Hughes and Baylin, 2012). The concept of blocked care refers to a scenario in which too much stress suppresses the higher brain functions needed for caregiving, engendering a self-defensive stance toward a child. In blocked care, the parent’s nurturing capacities are suppressed, temporarily out of commission. Caregiving is supported by the social engagement system, not the defense system; defensive states of mind inhibit the caring process. When a parent gets stuck in a defensive state of mind, this puts the parent–child relationship in jeopardy because, in effect, there is no caring mind “in the room.”

We readily understand how an adult is likely to begin to experience “blocked care” when an adult partner does not respond to expressions of interest and care for a period of time. Rejection by our child is likely to trigger the same social pain system activated by adult rejection. Although we may be able to see the difference between our child’s and our partner’s hurtful actions, it is still challenging to manage feelings of rejection and sustain caring feelings for our child. The risk that our care will weaken and may even become blocked, is still present.

Common Characteristics of Blocked Care

Shifting between states of social engagement and self-defense is normal in the give-and-take of parent-child relationships. Blocked care sets in when the parent gets stuck in defensiveness and cannot shift out of this negative state of mind towards the child. In this scenario, the parent’s brain is using the defense system to protect the parent from the pain of perceived rejection.

Rejection Sensitivity and the Brain: It Feels Personal

Because parenting is such a demanding, emotionally meaningful process, parents have a strong tendency to take their children’s reactions to them personally. In brain terms, taking things personally is related to the activation of the limbic system, which is tightly connected to our hearts and the rest of our bodies. When we react to anything that moves us strongly, this system is turned on; when this system is on, we experience what is happening as highly personal, as happening to us, as being about us. This is why it is often difficult for us to deal with signs of rejection or invalidation when we interact with another person. Our first appraisal in these situations comes from our limbic brain, including our amygdala, not from our higher, more reflective regions of the brain, particularly the middle prefrontal regions, that can help us to step back from our immediate experience and gain a better perspective. We can easily get captured in this egocentric, personalizing part of our brain’s reaction, especially if we are interacting with someone whose reactions to us really matter. For parents, reactions from their children matter a lot and are very likely to stir up the limbic system, for better or for worse.

In many ways, the parents of children with blocked trust face the same dilemma that the children faced earlier in life when they had to protect themselves from the chronic pain of being neglected and/or abused. Just as the children turned to the pain suppression process, the parents are likely to use the same process to buffer themselves from having to experience the constant pain of feeling rejected by their children. This is how blocked care can set in—initially as an adaptive response that protects the parent from the pain of caring when it hurts to care. The risk here is that this process may suppress the caring process because the two are interlinked in the brain. That is, feeling caring and empathic toward a child and feeling the pain of being rejected by the child activate a very similar region of the brain, parts of the anterior cingulate cortex (ACC) (Eisenberger, Lieberman, & Williams, 2003). To suppress the pain of rejection, the parent uses the ACC to inhibit the pain system in a top-down way, using opioid receptors all along the way to the brain stem from where pain messages get relayed upward into the cingulate (Vogt & Sikes, 2009). Suppressing the pain of rejection, then, also suppresses the capacity for empathy, for subjectively caring about the child.

In short, the brain processes that underlie the development of blocked trust in maltreated children operate in the adult brain, as well, creating the potential for getting stuck in the same kind of limbic reactivity that is at the heart of chronic defensiveness in children with blocked trust. While adults have more brain power than do young children (increased prefrontal powers are associated with the transition from adolescence to adulthood), this does not guarantee that adults faced with intense stress will be able to access these higher powers and regulate negative, self-protective reactions toward a defensive child.

Blindsided by a Child’s Blocked Trust

Adults who are used to being trusted and to making people feel safe in their presence may experience being deeply mistrusted for the first time when they try to get close to a child with blocked trust. If these caregivers don’t see this coming, if they are blindsided by the child’s intensely negative reactions to their offerings of love, they may experience the intense pain of perceived rejection and recoil to protect themselves from this awful feeling. This can be the beginnings of a process in which a caregiver takes the child’s defensiveness personally, not understanding that this habitual defensiveness is really not at all personal but an overgeneralized, nondiscriminating response that lumps this adult together with all past adults who have mistreated the child.

When a child’s blocked trust meets a parent’s blocked care, the parent–child relationship becomes a mutual defense society that keeps reinforcing defensiveness in both parent and child. In blocked care, the parent tends to be in survival mode, parenting reactively rather than proactively. In brain terms, survival-based, defensive parenting is generated from the more primitive limbic and self-defense circuitry, without much use of higher brain functions that support the processes of reflection, mentalization, flexibility, and self-regulation. When the parent is in a “narrow-minded” self-protective state, the child and the relationship are at risk for chronic misattunement. Parents in this stressed-out state of mind do not respond empathically to the child’s distress, do not engage in repair operations, and do not reflect on their parenting to make changes and do a better job. Parents who enter parenthood with high levels of stress are more at risk for developing blocked care than are parents who embark on parenthood with emotional resilience, a secure adult attachment style, and a well-developed capacity for self-regulation and self-reflection.

Preventing blocked care, whenever possible, is a primary task in attachment-focused treatment. Addressing blocked care when it has already set in is also an essential component of treatment, because there is little possibility of helping a mistrusting child learn to trust if the adults trying to care for him are not able to approach him nondefensively, indeed, with compassion. Helping caregivers recover from blocked care and then strengthen their capacity for sustaining a compassionate state of mind toward their mistrustful child is a major part of the therapeutic process in attachment-focused treatment.

It behooves therapists to understand the dynamics of parental rejection sensitivity and to be prepared to work empathically with parents like Carol who are experiencing this distressing conflict between their personal reaction to their child’s mistrust and their goal of being a loving parent.

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