The Meadows Blog


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By: Jon G. Caldwell, D.O.

During my first meeting with Rebecca (as I will call her), I asked about her family history of mental and emotional difficulties, which can tell me something about her genetic susceptibilities, and about her early life experience with caregivers. These two elements of the evaluation often provide critical information about the unique way in which nature and nurture contribute to human development (see my previous article on this topic).

When I asked Rebecca these questions, an unforgettable look flashed across her face that was part shame and part longing as she explained to me that she was adopted and had no “valuable information” to offer on these topics. All she knew was that she had been adopted by an American family from a Romanian orphanage at the age of two. In fact, to her surprise, this little bit of information proved to be extremely valuable as we tried to better understand how her challenges in adulthood were related to her early childhood experiences.

In the last several decades, as geographic and political borders began to break down, the deplorable conditions of many orphanages around the world came to light, including those in Romania. In some cases this exposure led to policy changes, gradual improvements in orphanage conditions and a wave of adoptions by people from other countries. It also offered scientists a rare opportunity to study children who had experienced early deprivation and adversity and to follow these children as their environmental conditions changed after adoption.

Research of this kind has confirmed that early social experience plays a critically important role in human development. Indeed, we come into the world with a brain that has evolved to capitalize on the social environment, which under favorable conditions is full of rich opportunities for learning and completely embedded in a milieu of meaningful social relationships. Unfortunately, this doesn’t describe many orphanages around the world, where children are kept in cribs or cots for long periods with little access to toys or books and caregiver-to-child ratios can be as high as one caregiver for twenty children. This issue is terribly important because, for better or for worse, the early social environment appears to lay the foundation for cognitive, emotional and social development.

In fact, there appears to be sensitive periods early in life, during which time the brain has an overabundance of neurons that are just waiting to capture information from the outside world. During these sensitive periods, certain brain circuits are more easily shaped by environmental input and may also be more susceptible to environmental insult. After the sensitive period has ended, the brain actually “prunes” or cuts back those neural connections that aren’t necessary for success in the environment of upbringing.

However, as you might expect, children raised in deprived circumstances may not receive adequate brain stimulation during sensitive periods of development, and this is bound to negatively affect the neural pruning process as well. Fortunately, the brain’s mechanisms of neural pruning are balanced with its incredible capacity for “neural plasticity” – which is the brain’s ability to continually change in response to environmental demands. Thus, even when environmental conditions are suboptimal during a particular sensitive period, it doesn't mean that development can't or won't take place, but it can mean that development might proceed along a somewhat atypical trajectory, bringing with it some challenges for the child and the child's caregivers.

Early social experiences with caregivers and family members are important for the development of adaptive emotional and behavioral regulation (i.e., self-regulation). Children everywhere encounter stressful situations on a daily basis and typically they must rely on caregivers to help them resolve these situations and to aide them in regulating their nervous system so that the toxic effects of stress are ameliorated in a timely fashion. In typical rearing environments, children experience repeated cycles of nervous system activation and caregiver-facilitated deactivation and these cycles get written into the child’s neurobiology until it becomes a natural, self-regulatory response pattern for the developing child.

Individuals like Rebecca who were raised in adverse environments often do not receive the short- and long-term benefits that come with this kind of nervous system regulation and organization. Often, these children are forced into a sort of social hibernation where they must shut-down their natural impulses to seek closeness and security from caregivers. Some of these children will learn to sooth themselves, but these make-shift measures are by no means optimal and it is likely that many of these children do not experience the much-needed social-emotional brain development that comes through interacting with sensitive and responsive caregivers.

Despite these concerns, the research on Romanian orphans illustrates the power of neural plasticity and provides some degree of hope because many of these orphans show significant developmental gains in certain areas after they are adopted. The first area of development to show progress after adoption is often physical health; these children can rather quickly experience improvements in weight, height and fine and gross motor skills. In fact, many these children may not be physically different from their peers by the time they start school.

Somewhat surprisingly, these children often make gains in the cognitive domain too – they seem to catch up in terms of reading and writing, and general intelligence is often similar to their school-aged peers. Yet, a proportion of children who were in an orphanage have some lasting problems with attention, concentration, focus, distractibility, impulsivity, and poor organizational skills. It seems as though the neural circuits involved in “executive function” (i.e., attention, cognitive flexibility, planning, goal-directed behavior, etc.) are very sensitive to suboptimal rearing environments.

Of interest, the areas that seem to be most affected by early deprivation are the social and emotional domains. Children raised in orphanages frequently have challenges in terms of regulating their emotions, calming themselves, coping with difficulties, initiating and maintaining friendships, and negotiating close relationships. Because these children often make noticeable physical and cognitive gains after adoption, the lingering social-emotional issues can be confusing to the child and caregivers. Of course, these social-emotional issues can be compounded if the adoptive home environment is less-than-nurturing or if the child encounters any form of trauma later in childhood.

Even after leaving the orphanage, some of these children have difficulty learning to trust caregivers and to make their attachment needs known in adaptive ways. There can be a tendency on the part of these children to avoid showing vulnerable emotions and outward displays of affection and they may seem indifferent to, or afraid of, intimacy and closeness. On the other hand, some of these children may show signs of heightened separation anxiety, clingy and anxious behavior, and they might have strong fears of abandonment. Some children display signs of both of these extremes in their relationships with caregivers – the so-called “push-pull” pattern where they desperately want companionship but at the same time seem to fear closeness or fear that it won’t last. This sort of picture is sometimes referred to as “reactive attachment”.

That being said, it is important to stress that a warm and nurturing home environment will go a long way to buffering many of the social-emotional difficulties associated with early adversity. Over time, sensitive and responsive parenting practices, coupled with consistent and caring limit-setting, can gradually establish a sense of trust and security. Within the safety and security of the caregiver-child attachment relationship, the child’s nervous system can be re-organized in a way that supports greater self-regulation. This socially enriched environment can stimulate new brain pathways in the adopted child that will eventually underpin a greater capacity to regulate emotions and maintain close relationships.

Like Rebecca, some individuals who have experienced early social deprivation require additional support and treatment later in life. This may come as a result of ongoing issues from early childhood that were never quite resolved or previously resolved issues that resurface due to subsequent experiences of loss/death, abandonment, betrayal or traumatic experiences. While the resurfaced issues can usually be handled by traditional treatment methods, it can be very helpful if the treatment providers also have an understanding of how early social deprivation and trauma can influence social-emotional functioning late in life.

The Meadows treatment model is designed to specifically address the core developmental issues related to early childhood neglect and abuse. Treatment at The Meadow also helps individuals to understand how these core developmental issues are related to secondary symptoms, like shame, anger, low self-esteem, co-dependency, love addiction/avoidance, anxiety, depression and addictive behaviors of all kinds. Through various forms of expertly delivered treatment, individuals at The Meadows build on these insights by gaining actual experience in learning to esteem themselves from within and regulate their own nervous systems more effectively. Gradually, as individuals at The Meadows feel more comfortable with themselves, they are aided in forming safe and meaningful relationships with family members and significant others.

For many individuals who come to The Meadows, the experience of early social adversity starts to become a vital part of a broader life story that no longer carries with it the pain of the past, but instead offers the promise of a brighter future.

Jon G. Caldwell, D.O., is a board certified psychiatrist who specializes in the treatment of adults with relational trauma histories and addictive behaviors. Dr. Caldwell currently works full-time as a psychiatrist at The Meadows treatment center in Wickenburg, Arizona. For many years he has been teaching students, interns, residents, and professionals in medicine and mental health about how childhood adversity influences health and wellbeing. His theoretical perspective is heavily influenced by his PhD graduate work at the University of California at Davis where he has been researching how early childhood maltreatment and insecure attachment relationships affect cognitive, emotional, and social functioning later in life. Dr. Caldwell’s clinical approach has become increasingly flavored by the timeless teachings of the contemplative traditions and the practice of mindfulness meditation.

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By: Joyce Willis, MC, LPC

The Model of the Developmental Immaturity was developed by Pia Mellody. In the 1970s, Pia was working at The Meadows, a trauma and addiction Inpatient Treatment Facility. Pia found that she was encountering an increasing number of patients who identified less than nurturing, abusive family systems in their childhood - leading to adulthood behaviors of codependency. The codependency patterns translated into addictions, mood disorders and physical illness. Pia's continued work with patients led to the conclusion that people with codependence wind up in despair and actually die from the effects of codependence. Thus, the model was "born" to help patients understand the Family of Origin issues that brought them to the symptoms of their addictions, mood disorders and relationship struggles.

The Model of Developmental Immaturity
Valuable Self-esteem Issues Control Relational
Vulnerable Boundary Issues Resentment Enmeshment
Imperfect Reality Issues Spirituality Dishonesty
Dependent Dependency Issues Addiction
Spontaneous Moderation Intimacy Intensity

The Model of Developmental Immaturity is incorporated into every facet of treatment at The Meadows; from the week-long workshops to the intensive inpatient program.  At each level, patients receive education on The Model and learn how to identify the childhood roots of their adult behaviors. Therapists at The Meadows lead patients through understanding how their core issues, secondary symptoms and relational problems were set up in childhood, leading to codependence in adulthood. The biggest understanding that we want patients to leave treatment with is the belief in the Nature of the Child - which is the Nature of the Functional Adult; that we are inherently valuable and perfectly imperfect. We will further explore The Model in stages, beginning with understanding the primary symptoms of codependency and understanding The Nature of the Child.

The Model of Developmental Immaturity is a model that has to do with codependency. Codependency is defined as a disorder of immaturity caused by relational problems.  Understanding codependency is imperative to understanding The Model. There are five primary symptoms of codependency. These are:

1. We have trouble esteeming ourselves from the idea of inherent worth.
2. We have trouble protecting and nurturing ourselves.
3. We have trouble being real.
4. We have trouble attending to our needs and wants.
5. We have trouble living life with an attitude of moderation in all things.

The Model of Developmental Immaturity Issues is a model used at The Meadows to treat the effects of childhood trauma and issues of developmental immaturity. Childhood trauma and developmental immaturity can lead to addiction issues, mood disorders and physical issues.

To further understand the model, we will examine each column. The first column is the Nature of the Child. The Nature of the Child is the Precious Child Ego State.  Our precious child is the reality of who we are:

  • We are precious and valuable just as we are.
  • We are vulnerable and can expect protection.
  • We are human and make mistakes. We are perfectly imperfect.
  • We are dependent on others for our needs and wants.
  • We are spontaneous and open.

As children, we get relationally traumatized by enmeshment, neglect or abandonment in the “Nature of the Child” areas. Let's explore each of these terms:

  • Enmeshment is the inappropriate closeness of family members. In an enmeshed and overinvolved relationship, individuals get lost in the relationship. There is a lack of clear boundaries, thus each individual has difficulty having a clear sense of self. Examples of phrases that demonstrate enmeshment are, "You're my everything," "Without you, my life would not be worth living," or "You complete me."

  • Neglect happens when a child's basic dependency needs were not met. Dependency needs are our basic needs for food, clothing, shelter, safety and medical attention. Either the parent did not know how to meet these needs or the parent did not meet these needs well enough.  Neglect in childhood may lead to depression, anxiety, eating disorders, anger issues, or alcohol and drug abuse in adulthood.

  • Abandonment happens when the loss of one both parents occurs physically or emotionally. If the parent was not present in the child's life or the parent withheld affection or nurturing, the child was abandoned. Abandonment in childhood can result in adulthood difficulties with expressing and managing emotions, trust issues or a need to be in control.

Any behavior exacted upon us as children that was less than nurturing is defined as trauma in this model. Childhood trauma causes immaturity in the Core Issues (Column II of the model).

We will examine the Core Issues in Part II of "Breaking Down the Model."


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As Humans, we are intensely social creatures. Close relationships with other people are often the source of our greatest joy in life, but they can also be associated with tremendous pain and suffering. Early relationships with caregivers, siblings, and extended family are not merely a static backdrop to a mechanistic unfolding of human development - these relational experiences have profound effects on biological and psychological processes, for better or for worse. We now know that children come into the world with sophisticated neurobiological systems that are keenly attuned to the social environment and in turn these systems are shaped by the social milieu. This means that the narrative of the early social experience is written into the biology of the developing child, or in other words, nurture actually becomes nature.

Unfortunately, overt forms of childhood abuse and neglect are all too common and can result in serious long-term physical and psychological consequences. In fact, large research studies have shown that adverse childhood experiences can lead to serious health risks, including many forms of chronic illness and even shortened length of life. However, it is increasingly recognized that covert forms of relational trauma and emotional abuse can also lead to deleterious outcomes, particularly in the area of social-emotional development.

While the term "relational trauma" often connotes overt forms of maltreatment such as physical and sexual abuse, it can also be used to describe covert forms of maltreatment such as abandonment, enmeshment, parent-child role reversal, verbal abuse, love-withdrawal, and many other forms of emotional abuse. Relational trauma can be difficult for children, caregivers and outside observers to recognize, which means it can persist throughout much of childhood and even into adulthood. For this reason, relational trauma can have insidious effects on development through persistent, maladaptive interaction patterns. These social interaction patterns occur while the brain is developing and can therefore shape the way that individuals think and feel about themselves, others, and the world around them.

Attachment theory is a very useful framework for understanding how differences in the quality of close interpersonal relationships, particularly parent-child bonds and adult romantic bonds, influence health and well-being throughout the lifespan. In the mid-nineteen hundreds, John Bowlby proposed that an attachment behavioral system evolved in humans (and other animals) because it improved the chances of offspring survival and successful reproduction by fostering proximity to caregivers, protection and safety, and sense of security for the developing child. Bowlby argued that a secure attachment relationship between a parent and child doesn't lead to dependency, which was the contention of his psychoanalytic colleagues at the time, but instead creates a secure base for the child. In fact, he postulated that attachment security, and specifically a secure base, actually facilitates exploration and learning in childhood and ultimately leads to greater autonomy and social competence later in life.

According to attachment theory, when a child experiences conditions such as pain, sickness, loneliness, or fear, the attachment system is activated and there is a natural, even biological, drive to seek comfort and safety from an attachment partner. In a secure attachment relationship, the attachment figure is sensitive and responsive to the child's desire for closeness and safety. Moreover, a secure attachment relationship provides a safe haven where intense emotional states are co-regulated and the child is able to return to engaging openly with the environment. This cycle of attachment system activation, proximity and support seeking behavior, interpersonal interaction (with the possibility of co-regulation of affect), and a return to environmental exploration occurs repeatedly in the day-to-day exchanges between attachment partners. It is in the context of this repeated "dyadic dance" that patterns of attachment behavior take shape. In turn, these attachment-related patterns contribute to the organization of biological pathways in the brain and body that underlie emotion regulation capacities and mental representations of the self and others (i.e., internal working models).

Due to the attachment system's critical role in human development, it remains active even in adverse conditions, such as relational trauma, emotional abuse, neglect, and maltreatment. As suggested by Pia Mellody in her model of development, children are born "valuable, vulnerable, imperfect, dependent, and spontaneous". This precarious natural state of the child necessitates that he or she seek comfort and support from an attachment figure, even if that caregiver is ill-equipped to consistently provide a safe haven or a secure base. The child can't simply choose to not to attach - like the physiological drive to drink when thirsty, children are compelled to seek closeness and security when feeling threatened in some way. Thus, in the context of relational trauma, the child experiences an instinctive drive to find support and safety in an attachment figure who, often without malicious intent, may also be a source of fear, anger, shame, and pain.

This "double-bind" situation is emotionally and mentally confusing - the child is torn between the attachment-related drive to seek security and love, and the self-protective impulse to avoid pain and fear. It is no wonder that relational trauma often leads to an insecure attachment pattern where the child unwittingly adopts various mental and emotional strategies aimed at obtaining or maintaining a sense of relationship security, while also protecting against loss, pain, and fear. In this light, insecure attachment patterns represent the child's best efforts to negotiate incredibly complex relational circumstances and, at least in the short-term, can be seen as a successful adaptation to environmental adversity. However, in the long-run, the distorted mental representations and emotional processes that are often associated with insecure attachment relationships can have significant effects on core areas of development.

The elegant theoretical model used at The Meadows treatment centers, which is based on extensive clinical work by Pia Mellody and her colleagues, indicates that relational trauma leads to developmental immaturity by causing an individual to become polarized along five core dimensions of development: 1) self esteem (less than versus better than), 2) boundaries (too vulnerable versus invulnerable), 3) reality issues (bad/rebellious versus good/perfect), 4) dependency (too dependent versus needless/wantless), and 5) moderation (too little versus too much self-control). The model goes on to predict that relational trauma and the subsequent distortions of the core issues result in higher rates of addiction, mental health disturbances, and spiritual disconnection. Finally, the model describes how these cascading variables almost invariably lead to problems with intimacy and romantic relationships in adulthood.

While relational trauma can have direct effects on these core dimensions of development, it may be helpful to also consider the indirect effects that are mediated by the attachment relationship. For example, when a child experiences abandonment and neglect, it may be adaptive for the child to amplify or "hyperactivate" the attachment system to get proximity and support from an elusive caregiver. Under these conditions, the child may engage in energetic and insistent attempts to remain close to the caregiver out of a fear that separation will bring abandonment, loneliness, and insecurity.

As a way of making sense of a caregiver's repeated failures to be emotionally and physically present, the child often develops a deep sense of personal unworthiness - a belief that "something is wrong with me" - thereby assuming a "one-down" position. Additionally, the child may resort to mental rumination, perseveration, and fantasy about the attachment relationship as a way of keeping it alive and filling the internal void associated with its absence. These individuals often experience their own self-worth as being highly dependent on the actions of others. So, naturally they are hypervigilant and hypersensitive to possible relationship threats and can experience intense negative emotions when threatened with loss or separation. This "anxious" or "preoccupied" behavioral pattern represents one dimension of attachment insecurity and accurately describes some of the socioemotional challenges for individuals who have been exposed to relational trauma.

Another form of relational trauma is enmeshment or parent-child role-reversal, which paradoxically involves abandonment. Often, the enmeshed caregiver isn't able to meet the attachment needs of the child because he or she is getting their own needs met through the child. In contrast to attachment-related anxiety, under conditions of enmeshment, the child may find it most adaptive to suppress or "deactivate" their own attachment system so that he or she can effectively meet the caregiver's needs and thereby maintain closeness and support. In fact, over time, the child may tacitly learn that his or her own bids for proximity and security elicit disapproval, frustration, and anger from the caregiver, and actually threaten the attachment relationship.

Therefore, when the attachment relationship is marked by enmeshment, the child dutifully meets the caregiver's interpersonal demands by suppressing, avoiding, and down-playing their own attachment-related desires. This role-reversal can create a sense of false empowerment for the child and a "one-up" position. However, it can also foster an undercurrent of resentment and rebellion as the child yearns to be free of the expectations and roles given to him or her by the caregiver. Often these individuals feel unable to depend or rely on others to meet their attachment needs, so they avoid interdependence and instead resort to rugged self-reliance and a commitment to deal with adversity alone. This "avoidant" behavioral pattern represents the other main dimension of attachment insecurity. Like its counterpart, it is often associated with relational trauma and is thought to have long-term consequences for socioemotional functioning.

It should be noted that abandonment and neglect are not always associated with attachment-related anxiety, and enmeshment is not always associated with attachment-related avoidance. Certainly the reverse can be true for both types of relational trauma, and in some cases, individuals who have experienced relational trauma can show elements of both attachment-related anxiety and avoidance. Also, even though these two dimensions of attachment behavior are considered insecure, they are nevertheless organized patterns of mental and emotional strategies aimed at maintaining intra- and inter-personal equilibrium within the context of a suboptimal attachment relationship.

However, in recent decades it has been discovered that some children who are exposed to relational trauma exhibit disorganized attachment patterns involving contradictory approach-avoidance behaviors toward the caregiver. Disorganized attachment can involve various un-integrated elements of the anxious and avoidant dimensions, as well as more ominous signs such as "freezing" or trance-like expressions and coercive or controlling interpersonal behaviors. Of importance to clinicians, disorganized attachment in early childhood has been linked to later deficits in mentalization (i.e., understanding one's own and other's mental and emotional states), dissociation, and mental health disturbances.

The effects of relational trauma on the attachment system and on subsequent developmental trajectories are moderated by a number of contextual factors. For example, evidence suggests that genetic and temperamental factors play a role in how susceptible a person is to traumatic experiences. Children with the DRD4 variant of the dopamine receptor gene are more negatively affected by relational trauma than those children without the genetic susceptibility. Also, in light of the growing awareness of critical or sensitive periods in development, it stands to reason that the timing and type of relational trauma are important variables. In some cases, the negative consequences associated with an insecure attachment to a particular caregiver can be buffered to some degree by a warm and loving relationship with a different caregiver. The family system as a whole, with its intricate dynamics and various roles, is an important, but frequently overlooked moderating variable. Finally, it is important to remember that the child is an active agent in their own development, so how he or she perceives and formulates the experience of relational trauma will have considerable bearing on its developmental consequences.

There is mounting evidence that the effects of early relational trauma and attachment insecurity can reverberate across generations. Bowlby hypothesized that the attachment behavioral system remains active throughout the lifespan and that attachment-related patterns of thinking and feeling influence adult romantic relationships and parent-child relationships. It should be noted that attachment insecurity in childhood doesn't guarantee that an individual will experience significant problems in being able to bond with romantic partners or children in adulthood. However, consistent with the clinical model used at The Meadows treatment center, longitudinal research has shown that relational trauma and attachment insecurity in childhood are associated with disturbances in core developmental areas, which are in-turn related to higher rates of mental and emotional problems, addiction to mood altering substances and behaviors, and challenges in negotiating adult relationships. For practitioners who recognize and routinely encounter the intergenerational effects of relational trauma in their clinical practice, attachment theory provides an elegant framework that connects childhood attachment experiences to adult pair-bonding and parenting.

Adult attachment orientations, whether assessed by a semi-structured interview or a self-report questionnaire, generally fall on the previously noted dimensions of attachment-related anxiety and avoidance. In a series of research studies, my colleagues and I showed that adults with a history of childhood maltreatment, particularly emotional abuse, were more likely to have problems with emotion dysregulation (especially when facing fear), addictions, depression, and adult attachment-related anxiety and avoidance. Importantly, these two attachment dimensions are remarkably similar to the constructs of Love Addiction and Love Avoidance, which are an integral part of Pia Mellody's model and the clinical work at The Meadows. While more research is needed to understand how these two perspectives interface with each other, they are both extremely useful frameworks for understanding how early relational experiences influence cognitions, emotions, and behavior in adult relationships. Adult attachment will be discussed in greater detail in future articles.

Fortunately, individuals who have experienced relational trauma and attachment insecurity can receive treatment that leads to a path of true and lasting recovery. Certainly, early intervention with at-risk parents and children is ideal, but there is also much hope for adults who have experienced trauma in childhood or adult relationships. Indeed, recent findings indicate that the brain is more "plastic" or malleable than we once thought. In fact, research has shown that social experience, including therapeutic experiences, can have meaningful effects on gene expression, physiological processes, and brain function. This means that the neurobiological pathways that were sub-optimally organized in the context of relational trauma and attachment insecurity can be re-organized by the application of appropriate treatment techniques. Similar to a secure attachment relationship, effective treatment generally involves the creation of a secure therapeutic environment where raw, painful thoughts and emotions associated with past trauma can be safely explored and metabolized so that personal and interpersonal well-being can be restored. The Meadows has been offering this kind of treatment for decades and remains a world-leader in the treatment of trauma and addiction.

Jon G. Caldwell, D.O., is a board certified psychiatrist who specializes in the treatment of adults with relational trauma histories and addictive behaviors. He currently works full-time as a psychiatrist at The Meadows treatment center in Wickenburg Arizona. For a number of years he has been teaching students, interns, residents, and professionals in medicine and mental health about how childhood adversity influences health and wellbeing. His theoretical perspective is heavily influenced by his PhD graduate work at the University of California at Davis where he has been researching how early childhood maltreatment and insecure attachment relationships affect cognitive, emotional, and social functioning later in life. His clinical approach has become increasingly flavored by the timeless teachings of the contemplative traditions and the practice of mindfulness meditation.

Published in Blog

May 12, 2011

Ginnie Hartman, MA, LPC will be speaking at The Meadows Free Lecture on May 12, 2011, at 7pm at the Baronette Renaissance Detroit-Novi Hotel in Novi, Michigan. Mrs. Hartman will discuss Helping Heartbroken, Abandoned and Betrayed to Wholeness. The presentation will address the betrayal and abandonment partners of sex addicts face and provide a pathway to healing with a unique approach to wholeness. Contact Jenna Pastore at 815-641-2185 for more information. No registration required. We look forward to seeing you.

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