This is an amazing book. The title says it all. As a clinician, I found myself experiencing an “aha” moment on almost every page. I knew that a mother's inability to control the behavior of her unruly 3-year-old stemmed from her own childhood experience of severe physical trauma from a psychotic mother. But I wondered why she did not “identify with the aggressor.” Instead, she allowed her toddler to victimize her as her own mother had done. Another seemingly inconsistent example is the woman who, having been severely abused as a child, repeatedly chooses abusive, punitive partners.
I found the answers in Dr. Alexander's book: the cycle of violence can be interrupted if one can make sense of the past and reverse the narrative of past experiences and help reverse the effects of earlier trauma. Dr. Alexander achieves this by a thorough understanding of attachment theory as well as family systems theory.
The book is not an easy read. Of 384 pages, 120 are devoted to the references. That means every statement Dr. Alexander makes is fortified by a myriad of research studies on each topic. The comprehensive examination of intergenerational cycles of abuse provides the best compilation of data I have ever seen on the topic and is well worth careful scrutiny.
Although Dr. Alexander discusses other theoretical models such as learning theory and family systems of care, she devotes most of the book to the importance of attachment theory promulgated by John Bowlby as a way of explaining a range of human responses. Bowlby believed that many of the most intense emotions arise during formation, maintenance, disruption, and renewal of attachment relationships.
The concept of a bond involves at least 2 individuals. Under the care of a loving caregiver, usually the mother, the child perceives the world as loving and safe, but an emotionally unavailable mother may result in a child's perception of the world as dangerous and threatening. Dr. Alexander has studied Bowlby's attachment theory for more than 30 years and was influenced by the researchers Mary Ainsworth and Mary Main. Ainsworth developed a research paradigm called “the strange situation.” It describes a baby's response after a brief separation from the mother. The responses are labeled “secure attachment” (parents who respond to their babies' emotional needs); “avoidant attachment” (parents emotionally unavailable); “resistant or ambivalent attachment” (parents emotionally unavailable or rejecting), and in addition, a group of children Main described as “disorganized and disoriented.”
Moreover, Main developed a research instrument that predicted which children would be securely attached versus those exhibiting a form of insecure attachment. She called it “The Adult Attachment Instrument”—AAI—that consists of parents' subjective accounts of their own relationships, traumatic events, and overall development. Bowlby attempted to make a synthesis between the 2 systems, attachment and trauma, and Alexander notes that in the case of insecure attachment or ambivalent attachment as with individuals who have a history of violence or trauma.
“The AAI reveals the systemic distortions of memory and emotion that potentially confound most self-report questions of attachment. For these reasons, this book focuses primarily on research grounded in the developmental psychology paradigms of the strange situation and the AAI” (p. 25).
The book is replete with clinical vignettes that describe victims of sexual abuse, partner violence, and family triangulation. A mother who had been abused as a child experienced dissociation and avoidance of caregiving that led to role confusion. Abandonment was often worse than punishment, according to Alexander, who describes the effects of an absent, disinterested parent on children and spouses.
She discusses other risk factors that may lead to disorganized attachment, such as low income, substance abuse, low level of education, and teen pregnancy. Exposure to family violence may lead to both internalizing and externalizing behavior in middle school children. Both bullying and victimization have been associated with a history of maltreatment and exposure to violence in the family. Callous-unemotional traits and bullying may be precursors to adult psychopathology, Alexander concludes.
Several chapters deal with special populations such as foster care and adoption, military trauma (posttraumatic stress disorder), and cultural variations. One chapter reviews the current neurobiological research findings, particularly genetics and epigenetics.
For each example of disorganized attachment, Alexander offers implications and treatment recommendations specific for a particular individual, whether the therapeutic intervention is for the single patient or the family as a whole.
On the whole, I found the Alexander work compelling and greatly informative. At the end of her fascinating book, she writes:
“The effects of maltreatment, emotional neglect, family stress and societal disruption on children can be immense. However, they occur within the context of attachment and family relationships.… Just as individuals differ in their response to stress, they also differ in response to interventions. Therefore, given our limited resources, prevention and treatment efforts should be firmly grounded in an awareness of the many sounds of variation in children's experience. This way, we can be successful in interrupting intergenerational cycles of trauma and violence, which is the best form of prevention for future generations.” (p. 222).
Clarice J. Kestenbaum, MD
College of Physicians and Surgeons
New York City, NY
The author declares no conflict of interest.