Book Review – Emotional Neglect and the Adult in Therapy: Lifelong Consequences to a Lack of Early Attunement

Stauffer, K. A. (2021)
W. W. Norton & Company

I believe it was during a conference in 2015 when I first heard Martin Teicher talk about the impact of neglect in young children; how there was growing evidence that in comparing the “neglect trajectory” and “abuse trajectory” for the deleterious impact on the developing brain, neglect may be more harmful than abuse. Since then, we have been watching the accumulation of further evidence to support this bold claim, coming out of various labs. As research in this area became more nuanced over the years, we started to see that “neglect” means something different than emotionally ignoring infants and young children. For a lot of trauma clinicians, this created a persistent question about what exactly this may mean in terms of what happens in the therapy room: How do these different experiences present differently in adulthood, and how may the various trauma-focused approaches and interventions result in different outcomes based on the nuances of the impacts of the experiences? Dr. Kathrin Stauffer’s Emotional Neglect and the Adult in Therapy: Lifelong Consequences to a Lack of Early Attunement (2021) provides a cohesive response to these questions by pulling together experience-informed effective theories, principles, and specific interventions for the treatment of adults who were emotionally neglected as infants and young children.

In the first part of the book, Dr. Stauffer wisely and helpfully presents the overlaps and nuances between emotional neglect and trauma experiences. She emphasizes that predictably, there is significant overlap between the world of trauma and emotional neglect, both in terms of situational and interpersonal risk factors and clinical presentations. On the other hand, in describing the emotional neglect cases, she emphasizes shame as the most prominent tell-tale sign of emotional neglect. To demonstrate both the clinical presentations and the suggested interventions, four different cases are used. The definitions, descriptions, theories, and interventions come to life in these case excerpts that Dr. Stauffer turns to regularly throughout the book. Using a developmental framework, emotional neglect is defined as the experience of not having a primary caregiver who is able to interpret and/or appropriately respond to the needs of the infant/young child. She uses the term “ignored children” throughout the book to describe individuals who have suffered emotional neglect. From this perspective, shame has two fundamental prongs: the shame of having needs (e.g. the need to be close to others) and the shame of being someone who deserves all the painful experiences of the past. “Deserving the painful experiences” comes from the common understanding that for the ignored children (and for those who have suffered early and chronic interpersonal traumas), it is safer to assume responsibility to preserve the “goodness” of others, to avoid the biggest threat of all: isolation.

In terms of clinical presentations, the author uses attachment theory and body psychotherapy as her guiding posts. She uses attachment theory to understand insecure attachment and body psychotherapy to understand self-regulation, and the “schizoid character style” and “oral character style.” She explains that in literature, schizoid character style is thought to develop from severe trauma in the earliest stages of life, and she claims that there are parallels with the ignored children. On the other hand, she claims that while “ignored children do not have a narrative for how unpleasant their experiences had been, schizoid characters may have more of an awareness of themselves as victims of some kind.” According to Dr. Stauffer, oral character style develops when the baby is misread and neglected by the caregiver. Consequently, the baby decides that they do not have the right to need anything, so they either experience an ever-present and aching need (collapsed oral character) or they will work hard not to need anything (compensated oral character). The “compulsive caregiver,” someone who connects with others by solely focusing on meeting the needs of others, with no regard for their own needs, develops from the compensated oral character.

Primarily, biodynamic theory in explaining “hypo-responsiveness” and relational trauma therapy (developed by Holm Brantbjerg, 2020) is used to conceptualize the ignored children cases. Admittedly, I am not familiar with these approaches, so I depended on the information provided in the book; it was easy to read and understand. Much like muscles that go flaccid when encountering a force that overwhelms their strength, hypo-responsiveness is described as giving up instead of engaging and attempting to rise to the challenge in psychological terms. The parallels of motor development and psychological development are described through the biodynamic theory. Dr. Stauffer also describes that much like the process of strengthening underdeveloped muscles, interventions that provide emotional challenges can only be psychotherapeutically effective, when they do not overwhelm the available resources. Given how hypo-responsive ignored children are, she strongly cautions against challenging and confronting in therapy, suggesting alternatives that are primarily designed to validate and support. Throughout the book, the relational and body/physical aspect of the psychotherapy process is emphasized to help improve available resources for the emotional experience of the clients. For example, Resource Oriented Skills Training (ROST), relational trauma therapy’s movement-based exercise schedule, is one of the primary components of therapy. Given the fact that emotional neglect and its impact starts early in development, the emphasis on physiology and relationship aspects of therapy made sense.

Using Stephen Porges’ Polyvagal Theory principles, Dr. Stauffer explains the approach she describes from a neuroscience perspective as well. I found it fascinating to read about the “toxic shame” that overwhelms the psychological apparatus in connection to the dorsal vagal complex that triggers the freeze response. The connection between attachment, internalized shaming, and stuck shamed states, and how these systems can be explained by the Polyvagal Theory, were also clearly laid out, suggesting an intervention roadmap based on these foundations.

The last two chapters are dedicated to principles and specific interventions for working with adults who were neglected as children. Using the amorous transference example provided earlier in this section, the author demonstrates how the emotional relational aspect of therapy can be used to strike a balance between the support of positive feelings and appropriate boundaries. The process also brings forth a countertransference reaction, as the client admits to needing something and articulates it (very critical aspects of treatment), the therapist is not able to reciprocate and meet the need of the client. “Dosing down,” the incremental engagement of challenges to “underdeveloped muscles” to be able to facilitate growth and increase capacity for “emotional muscles” is emphasized. Of course, as was the case throughout the book, shame mechanisms and addressing shame in the therapy room is brought up repeatedly during this section as well. The treatment process was laid out to show three aspects: using trauma treatment approaches, support for good feelings, and “nourishing the soul,” allowing in what feels good with no hesitation or shame. There is a significant emphasis on making sure there is a physical aspect to the treatment plan and biodynamic massage is one of the recommendations. Again, I was not familiar with this modality, so reading about it here and understanding how it would “fit with” using various other approaches such as attachment, humanistic, Jungian, and integrative therapies was intriguing.

Overall, I found this book valuable in presenting a comprehensive treatment approach for the hidden developmental trauma of emotional neglect. An integrative approach is evident that pulls together strengths of psychodynamic, humanistic, and interpersonal approaches, and incorporates neuroscience for trauma syndromes and ego state work. Clinicians who work with complex trauma cases and developmental traumas will find this book to be beneficial.

Reviewer bio:
Z. Benek Altayli, PsyD is the executive director of Wellness Center at University of Colorado Colorado Springs. She has been practicing as a psychologist for 15 years and has focused interest in psychological trauma assessment, diagnosis and treatment; more specifically, she is interested in complex traumatic stress and its treatment. Dr. Altayli has experience and expertise with disaster preparedness and response and is a part of APA’s Disaster Resource Network. Additionally, she works with and trains other professionals on behavioral crises and emergencies assessment and intervention. Currently, Dr. Altayli holds APA and Division 56 memberships. Dr. Altayli is currently serving as a Colorado State suicide prevention commissioner representing higher education, assessment task force member for the Colorado National Collaborative, and El Paso County suicide prevention collaborative member.