A Whole-Person Approach to Dynamic Psychotherapy
HOW DO PEOPLE change? This question is one that therapists think about in two ways with every patient. Firstly, we need to consider how each patient became a distressed person in need of help. Secondly, we need to decide how we may bring about effective change in that person, change that means our client will leave therapy with a more robust sense of self and a confident approach to living.
Change That Is Destructive to the Developing Mind
The question of how our clients’ personalities have developed preoccupies all of us who seek to work with those who have experienced early relational trauma. It may be trauma that arises from inadequate early caregiving, from abuse, from bullying, from an accident, from necessary but intrusive medical procedures, or from sudden, overwhelming loss experienced at an early age. Change in these individuals may take the form of dissociative processes. Dissociation as a defense becomes most severe in those for whom the experience of trauma is persistent, continues over time, and is caused by someone close to them. Moreover, recent studies have shown that the “drip-drip” process of verbal abuse may be just as damaging and lead to neurobiological change within the individual just as much as physical or sexual abuse does (Teicher et al., 2010).
Research into attachment, especially early attachment, has been crucial in developing our understanding of how we change and develop the capacity to relate to one another in a meaningful way that builds a secure sense of both self and other. Research into neurobiology and epigenetics has given us a fuller understanding of how nature and nurture work together for good or ill in the way the individual changes and develops. Kessler observes that “Brains, and in fact, all nervous systems evolved as predictors, as creators of inner narratives of future events, for the purpose of the safe navigation of the environment” (2011, p. 202). The plasticity of the brain enables change by using learning from past experience to determine responses to future events. Crucially, how people change will depend on their experience. Inevitably, those whose early experience was distressing will develop defensive patterns in their minds; those minds will adapt to help them survive in what is unconsciously perceived as a hostile environment. Our task is to mobilize the plasticity of the human brain to enable therapeutic change.
The accumulated wisdom of years of in-depth psychotherapeutic work with people who have experienced early trauma shows that sexual, physical, verbal, and emotional abuse or neglect in childhood can have profoundly disruptive effects on the development of the mind, on the capacity for affect regulation, alongside long-term effects on the body’s well-being. Schore’s seminal work on attachment trauma and affect regulation has enriched our understanding of much that occurs in the clinical encounter—in essence, how people may change and develop a more secure sense of self and a more robust way of relating to others (Schore, 1994, 2003a, 2003b). Some of the research conducted by Lanius and her team at the University of Western Ontario has focused on patients who dissociate some aspects of their early traumatic experience and has confirmed that mind, body, and emotions may all be affected in such patients. It also makes clear that, “In addition to its core affective components, PTSD is associated with poor cognitive functioning across multiple domains, including declarative memory, short-term memory, attention, and executive functioning” (Lanius, Frewen, Tursich, Jetly, & McKinnon, 2015). Therapy that emphasizes “putting into words” and “meaning-making” can do much to address these deficits.
Research in the scanner (Lanius, 2012) reveals that some 70% of patients become overaroused when listening to their own trauma narrative. These are the patients who struggle to control and contain feelings, easily becoming dysregulated. In the consulting room such patients may be easily triggered into states of hyperarousal that affect both psyche and soma and blot out the ability to think. One such patient, whom I call “Holly,” and have written about in detail elsewhere, painted a frightening image of what she came to call the “bad black cat mother” holding a baby cat that was covered in blood (Figure 5.2 in Wilkinson, 2010). She explained haltingly, with great difficulty as she struggled to find words, how she did not know whether she was the bad black cat attacking me or whether I was the bad black cat mother attacking her. The image spoke volumes about her early experience of her mother and how that had affected her as a person: how it had affected her core sense of both self and others. Such states of mind may escalate very fast in the consulting room, eliciting fight, flight, or freeze responses when even a fragment of current experience, such as a feeling, a noise, a color, a shape, a touch or a smell, reminds the client of previous trauma.
Cozolino stresses that words are problematic at such times of terror because decreased activation in Broca’s area occurs in such states and the patient literally finds it difficult to speak (2006, p. 29). Afterward, patients cannot always recall what happened in the session because the encoding for conscious memory as well as unconscious patterns of expectation may be affected in states of such extreme arousal, as it would have been in childhood. This means that patient and therapist struggle with the task of change within the individual and in the relationship. Understanding the way past experience intrudes into present reality helps to explain the intensity of projections that emanate from these patients at these times and the likelihood of the therapist getting pulled into an enactment. The value of consultation or supervision at such times is clear.
In contrast, other patients become detached, “switched off,” deadened, and dissociated from their feelings, unable to express or experience them. Some young people today may dissociate by retreating, as much as possible, into the virtual world, “a parallel world where you can be on the move in the real world, yet always hooked into an alternative time and place” (Greenfield, 2014, p. 1). Some will find other ways to switch off from unbearable experience. One patient, whom I will call “Sophie,” painted a picture just before the beginning of her therapy (plate 4 in Wilkinson, 2006) that expressed her feeling of being as if entombed. In the picture the layers of her coffin express the layers of her early trauma. The outer layer consists of pointing, slapping hands and clenched fists and represents her early experience with her mother. In the image her hands are clenched, a mirror image of her experience with her mother. She had become frozen as if protected by a layer of wood, but in that very layer of wood she saw her mother’s eyes. She commented, “It was as if I needed a skeleton on the outside,” and so she painted just that. Inside the body, which is her entombed self-image, is a young child trying desperately to free herself. Thirty per cent of trauma patients, scanned while listening to their trauma narratives (Lanius, 2012), demonstrated deadening dissociative defenses. These defenses also challenge the therapist in the search to help the patient toward greater well-being, and are often reflected in the therapist’s countertransferential response in a session. Similar states of mind may be experienced again by therapist and supervisor as the mirroring process informs their work together. For the therapist, the dissociative quality of the patient may be experienced as a struggle to consciously keep the material and the patient in mind, and in supervision to present the material with clarity. For both, there may be a difficulty in following the material and in making the links that are so shunned by the patient. These difficulties may present as bodily reactions, including numbing, distancing, switching off, and drowsiness; all will represent defenses that keep trauma out of mind and hinder meaningful change within the personality. Such trauma does not always consist of what has been traditionally considered active abuse. If early in life, when relationships with meaningful others are simply absent, or the caregiver is too distant or switched off emotionally, the result may be rage, despair, and finally switched-off, dissociative reactions.
In both groups of patients, trauma may affect hippocampal functioning and explicit memory and may leave patients with a highly sensitized amygdala and a storehouse of painful emotional memories held in the body. Haven concludes: “It is not enough, and is actually misguided, to focus exclusively on the cognitive and emotional meaning of the experience. . . . Past traumatic experiences . . . imprinted in the deeper regions of the brain that are only marginally affected by thinking and emotion . . . are embodied in current physiological states and sensations” (2009, p. 216). We should also be aware that there are specific windows of change and vulnerability in brain development in a young life. The hippocampus (the storehouse for explicit memory—the why, when, where, and how of memory) and the corpus callosum (the major link and route between the left and right hemispheres of the brain) are maximally affected at ages 3–5 and 9–10, respectively, and the gray matter volume of the frontal cortex is maximally affected by abuse at ages 14–16 years old (McCrory, DeBrito, & Viding, 2010). McFarlane stresses the difficulties connected with trying to create coherent narratives, and reminds us that traumatic events disrupt the capacity for word formulation and “impact on the areas of the brain concerned with expressive language” (2010, p. 46). Working with cognitions and meaning-making are thus integral to the therapeutic process in dynamic psychotherapy. However, it is the experience-dependent plasticity of the human brain that enables all change in therapy.
Patients who have experienced early relational trauma often carry the marks of that experience in their bodily states of being. Felitti comments that “traumatic events of the earliest years of infancy are not lost but, like a child’s footprints in the wet cement, are often preserved lifelong” (2010, p. xiii). He emphasizes that “time does not heal the wounds that occur in those earliest years; time conceals them. They are not lost; they are embodied” (p. xiii). He warns that if we do not explore how to work with these wounds, we ignore “that which is actually the somatic inscription of life experience on to the human body and brain” (p. xiv, emphasis added). The importance of the contribution of radiology to assessing the well-being of vulnerable children has been highlighted by researchers: “To the informed physician, the bones tell a story the child is too young or too frightened to tell” (Kempe, Silverman, Steele, Droegmueller, & Silver, 1978, p. 18). The changes in the bones of a patient, whose therapy I will describe as the chapter progresses, documented only too well the effects of adverse early experience on a developing human being.
As a child, this patient, whom I will call “Ella,” experienced pervasive early relational trauma. Sadly, it was not until she was an adult that doctors observed and commented on this patient’s multiple early fractures. This patient had never forgotten some of her difficult experiences at the hands of her impulsive, volatile, alcoholic mother and the need never to cry or to show her distress. All too easily her mother would respond to such distress with “If you’re going to cry, I’ll give you something to cry for”—and the violence would escalate, as the mother pulled the child around by her hair or slapped her around the head, at the same time shouting, “If you’re hit on the wrong part of your head, you could die!”
For patients such as Ella, it is not just the mind that is radically affected but also the whole person. Those of us whose training is to work with the mind have to grapple with the now urgent question of how to work within the area of our specialty or competence while also taking into account, as much as possible, the complex and sophisticated understanding of the three main elements of mind, brain, and body that constitute our basic humanity. Therapies that focus only on the mind will continue to promote the now outdated Cartesian split.
Fostering Therapeutic Change
Plasticity of the Brain
It is the plasticity of the brain and the importance of the enriched environment evoked in relational styles of therapy that give me hope that meaningful change can come about in our patients. At first, it was thought that we do not make new neurons later in life and that it was only our already established neuronal connections that were open to change. Now we have become aware just how extraordinarily plastic the human brain is (Begley, 2008). Not only do we make new connections when we are stimulated by change, newness, and difference, we also continue to make new neurons throughout our lives. Those new neurons make greater plasticity possible: “New neurons, because they are structurally plastic, are highly susceptible to changes in the environment and to different life experiences (Gould & Gross, 2002, p. 622).
Underpinning my thinking in the whole of this chapter are these research findings concerning plasticity:
• Genes only shape the broad outline of how a living being develops.
• Inheritance may bias us in certain directions, but many other environmental factors, including traumatic early experience. affect how our genes are expressed.
• New neurons continue to be made throughout life; these immature neurons learn easily.
• New connections and patterns of connectivity develop in response to new experience.
• Enhanced environmental stimuli enable change, and (we may infer), the emotionally attuned therapist may provide such an enriched environment.
It was originally assumed that the central nervous system (CNS) became stable soon after birth and remained that way throughout life. Research into plasticity has highlighted the importance of new neurons and new neuronal patterns of connectivity, as just mentioned. Gage and Muotri (2012) investigated the significance of exercise in neurogenesis and in particular genes. Genes known as transposons—one kind in particular, known as long-interspersed or LINE-1 (L.1) retrotransposons—have sometimes been described as “jumping genes,” because they have the capacity to “paste” copies of themselves into other parts of the genome, thereby acting as promoters that can alter the level of gene expression. These alterations change the way in which the affected cell will go on to develop, with good or bad results, promoting healthy development or the onset of disease. Such cells are active in the human brain, enabling the ability to adapt quickly to change but with the possibility of affecting behavior, cognition, and risk of disease (Gage & Muotri, 2012).
This research has led to exciting new insights about the way in which DNA may become altered in the embryonic stage of life (particularly in the embryonic forebrain) and in later life when changes occur in the hippocampus, an area where neurogenesis (the creation of new neurons) occurs. Animal studies have revealed that exercise make retrotransposition twice as likely to occur. Because novelty and challenge are also known to stimulate neurogenesis, the same researchers are now questioning whether L.1 jumping increases because “individual brains and the neuronal networks that make them up are constantly changing” in response to new experience, thus making us each unique manifestations of what it is to be a human. The research of Gould and Gross highlighted the importance of the earliest phases of life for the well-being of the whole individual, stressing the activity of these jumping genes. These researchers suggested that “much of the jumping had to have occurred during the brain’s development” (2012, p. 24).
What is the significance of all this scientific research for our work in the consulting room? The plasticity of the brain gives us hope for our patients and their ability to change as they experience the emotional engagement that occurs in therapy. Greenfield (2014) stresses the importance of imagination along with her concern that the dominance of the digital technologies may be changing brains, and in particular, eliminating the ways in which children have developed their imagination in the past. Therapy offers an opportunity to remediate this growing lacuna, to explore and develop imagination, whether through the exploration of the patient’s unconscious imagination expressed through dreaming or through the transference. Both reveal the unconscious expectations, based on past experience, that affect the way the patient relates to the therapist and to others. Equally important are the novel metaphors that emerge, the new pictures formed in the mind in response to therapy. Some, like Sophie, are able to produce visual images that reflect their inner world experience; others use words to convey their changing emotional world. Gradually, patient and therapist co-construct a narrative that “may play a vital part in assisting the patient not only in coming to terms with the reality of his or her internal world, but also in the process of mourning what was and what might have been, which then enables a greater capacity to live life as it is now in the real world” (Wilkinson, 2010, p. 133). Plasticity is what makes such change possible.
Attachment
Some time ago I spoke in Los Angeles for a Jungian group at the 25th anniversary celebration of the Hilda Kirsch Children’s’ Clinic. A dinner was kindly given for me by one of the organizers, Harriet Friedman. She asked whether there was anyone I might especially like to be there. I asked if she would invite Allan and Judy Schore because I so appreciated the generous way Allan had encouraged me to develop my thinking and therefore practice. As the group chatted before dinner that evening, we began to speak about the Jungian practice of using sandplay trays as a way to help patients explore their inner world. For some in the group, Jungian sandplay therapy was a new concept, so a small group of us trooped downstairs to look at our hostess’s beautiful sandtray room.
One by one we began to choose an object from the shelves and put it into the tray. There was a tree with shimmering gold leaves, a horse running wild and free, a cottage, and an exotic eastern figure, to name but a few. As time went on it became clear that everyone except Allan had made a choice. Then Allan turned to the shelf and carefully chose a little sculpture of a nursing mother and child, saying quietly “It has to be this.” As he put it down in the center of the tray, suddenly all the seemingly disparate elements came into relation with one another. For me, it was a vivid expression of the way in which a focus on the quality of early attachment through the lens of neurobiology makes sense of so much that I encounter in the consulting room and, most importantly, guides the way I understand the transference, the countertransference, and the therapeutic response evoked in me. If I keep what I know about early attachment in mind, it all begins to make sense to me. It is for this reason that early attachment has become by far the most important thread in my clinical work.
Let us just consider for a moment the nursing mother and child that Allan placed in the center of the sandtray as surely as he has emphasized the centrality of the nursing couple in our understanding of our clinical work. In order to change and develop in a robust way, each baby needs to experience a meaningful relationship with its primary caregiver (usually, but not necessarily, the mother) in order to make sense of his or her new world. The way the baby is able to achieve this is through the powerful affective engagement that occurs between mother and baby. From the very beginning the warmth of the mother’s body is the first experience an infant has of the warmth of human relationship. Also, Schore reminds us that “the mother’s face is the most potent visual stimulus in the baby’s world” (2002, p. 18), and as such, it becomes the most powerful affective stimulus for the baby’s expectation of what relating to another will mean.
The polyvagal system mediates social engagement (Porges, 2007). If activated in its most primitive form, it immobilizes the person in the face of danger. In its more evolved form, it is able to initiate social engagement when it is safe to do so, and, in association with the hypothalamus–pituitary–adrenal (HPA) axis, to mobilize fight and flight strategies when it is not. Porges (2007) suggests that this social engagement system is “online” from birth. In tandem with attachment researchers, he notes that the young baby attempts to elicit interaction with the caregiver through smiling and vocalization. Avoidance of eye contact may be a significant indicator of a baby’s very early developing fears about attachment. In Dr. Amanda Jones’s video Help Me Love My Baby (2007), a mother struggles with her difficulty in attaching to her baby. There is a moving scene where the mother is struggling with feeling very down while they are on a train journey to the therapy. The baby is sitting in her babychair, which is placed on the table facing her mother. The mother stares at her baby with a blank, almost unseeing expression. The baby repeatedly turns away from her mother and breaks eye contact rather than encounter her mother’s emotional absence, which is writ large for all to see. We may also conjecture that the baby’s newly developing salience network comes into play as she instinctively avoids experiencing or developing such negative feelings directly from her mother. The price paid is a setback in the development of a robust and secure attachment that would provide a healthy foundation for the building of later relationships.
Even such simple things as the arrangement of our room may be informed by this research. What do I mean? Well, it is important for such patients that the chairs or chair and couch used in the therapy room permit the natural gaze and gaze-away sequence favored in early infant–mother interactions. Such an arrangement encourages the development of direct gaze, which stimulates cortical pathways and facilitates the development of mentalizing processes without forcing it in a way that might be threatening to the patient who has experienced early relational trauma. It can only be counter-productive to positive change if the subcortical alarm system is activated in patients with posttraumatic stress disorder (PTSD).
Affect Regulation
Affect regulation in the consulting room is the key to positive change for patients such as Ella who had difficult early experience. At first, Ella told me of some of her remembered traumas but in a monotonous, switched-off way that made me want to intervene with “Yes, but how did you feel?” If I had asked this question, it would have been far too much for her because it quickly became apparent that as soon as she began to relax, to let her guard slip and to be more in touch with her feelings, she would all too easily descend into the abyss. True affect regulation had never become established for this patient. Ella had achieved an outward appearance of self-control by an almost total denial of her feelings, a survival strategy learned in response to her mother’s way of managing her child. The only alternative to this denial of her feelings was a falling into the abyss, much as she must have done at the times when her defense of denial broke down in the face of hostility from her irascible, alcoholic mother. Any early signs of beginning to fall apart by Ella as a child provoked a further attack from the mother, which then overwhelmed her daughter completely.
One might ask, “How did this patient survive well enough to even begin therapy?” Sroufe, Egeland, Carlson, and Collins draw our attention to the importance of the cumulative history of care as “a more powerful predictor of outcome than quality of attachment alone” (2005, p. 112, emphasis added), and they identify other emotionally supportive caregivers in childhood as one of three protective factors against an adverse outcome (as cited by Szajnberg, Goldenberg, & Harari, 2010). Some such as Ella may have been protected from the worst effects of abuse by the presence of a loving other—in her case, an aunt—but it was not sufficient to lead to an adequate sense of inner well-being that could sustain a robust sense of self.
Rereading my first draft of this paper, I noticed that I had not yet given a name to the patient in this narrative. This is perhaps in itself an indication of just how much her sense of identity was damaged. I decided to call her Ella because it was the name her beloved aunt once used in addressing her and which she never forgot. This aunt, who had one son but no daughter, used to look after her at least once a week (sometimes more frequently) in her first 7 years of life. Ella knew that her aunt loved her, and she loved her in return; she was the source of fun, stories, laughter, warmth, and love. For example, her aunt bought her a doll and together they made clothes for it; then there were visits to the beach with her cousin and sleeping soundly in her aunt’s house at night at the end of a happy day spent with that family. Her aunt taught Ella how to read and introduced her to the world of books; she made Ella a puppet theatre, and they had fun making up plays together. Ella began to do well at school and even loved being there.
At 8 years old, disaster struck for this child. Her father, also an alcoholic, had worked away from home for much of the time, but now lost his job, and she moved with her parents to a different part of the country where he had managed to secure another job. She found herself many miles away from her aunt, alone in a strange place and school, with alcoholic parents who were at war with one another. She would lie in bed at night and listen to the escalating violence; her father would assault her mother verbally, and her mother would then come upstairs and, instead of protecting her child, would drag her into the fray. In the morning neither parent seemed to remember what had happened, but the repeated experience etched a pattern of expectation concerning relationships deep into the mind of their child.
Somehow Ella managed to experience school as a good place where she could achieve in the relative peace that reigned there. When she moved to secondary school, Ella’s dramatic ability was encouraged by an empathic drama teacher to whom she became much attached. She filled her life with acting in school productions and those of a local youth theatre group. This way she could dissociate from her own painful feelings as she concentrated on portraying the life of someone else. This acting work helped her to know in some way that there were other ways of being, keeping alive her hope that change might still be possible for her. She went to stay at her aunt’s house for as much of the school holidays as she could.
Ella worked hard academically and saw going away to university as offering the beginning of a new life. Just as she left school, her aunt died unexpectedly of a heart attack, and her parents would not let her travel to the funeral. Still grieving, Ella nevertheless escaped, as she thought, to university but then realized, to her horror, that her warring parents had come away with her as part of her internal world. This realization, coupled with the loss of her aunt, led to acute anxiety attacks and to psychosomatic illness that limited her ability to fulfill her potential; her past was fast catching up with her. Her burning desire was to remain independent of her parents and not to have to go home. Sadly, the relationships she made at university seemed to be ones in which she became the victim as she was driven unconsciously by the compulsion to repeat and reexperience the quality of her earliest relationships. Siegel and Sieff explain: “The attachment relationship . . . is the medium through which the infant creates top-down models about how people will behave towards him. In time, these internal models color our perceptions of everybody we meet” (2014, p. 145). As van der Kolk remarks, “Being traumatized means continuing to organize your life as if the trauma were still going on” (2014, p. 53).
Empathy
I believe empathy is what makes possible appropriate understandings and responses in the therapist in the face of such pain. Ella came into therapy in her late 20s to try to resolve her difficulties around anxiety. At the beginning, empathically I experienced her as in a prison with a high stone wall that kept everyone out and kept her safe inside but very alone. Quite early in therapy she described herself as trapped behind a huge glass wall; she could see others and reach out toward them, but she could not touch them. If she tried to do so, it would always end in disaster.
Just as the baby’s earliest affective experiencing depends on the tone and musicality, the rhythm and lilt, of the mother’s voice, so too does the patient’s meaningful affective experiencing of the therapist depend in part on the therapist’s ability to speak in “pastel or primary colors” as required (Williams, 2004). This level of attunement involves working in the “right-brained” empathic way advocated by Schore (2002) but also requires a “left-brained” reflective approach, the mirroring of which enables the development of the reflective capacity within the patient. Greenfield directs our attention to studies in the United Kingdom and the United States that suggest that the younger generation may have greater difficulty with empathy because there may be a correlation between amount of time spent interacting with smartphones, iPads, and computers and a reduction in empathy (2014, pp. 36–37). This finding has particular relevance for the generation described as “digital natives” (Prensky, 2001). All these insights are of crucial significance for our understanding of ways to foster change in our patients. I believe that change in Ella came about partly through her coming to understand the significance of her early experience but much more through the quality of the relationship established between us: that is, her freedom to explore and express her feelings, and the opportunity our time together offered for the emergence of the implicit and the chance to reflect upon it together. Many years ago, while working with young people with emotional difficulties in an educational setting, I learned to work from their strengths rather than their weaknesses. Van der Kolk describes reaching a similar conclusion when, as a young intern, he realized “how little attention was paid to their [his patients’] accomplishments and aspirations” (2014, p. 24).
As clinicians we have come to appreciate the importance of attachment and know that therapy will demand a relational approach rather than an impersonal analytic blank screen. Traditionally, we have emphasized words, interpretations, and meaning-making. Over the years that we worked together, slowly I learned from Ella that wordy interpretations did not help her. Brief verbal interventions were easier for her child-self to grasp and to hold on to. Currently, we have come to a greater appreciation of the affective, relational, embodied aspects of the analytic encounter and the way in which they relate to the early right-brained, embodied experience of the child in relation to the primary caregiver—in particular, to the early interactive experience that is held in implicit memory (i.e., in the memory store of the right hemisphere), unavailable to the conscious mind. Shedler, in his discussion of the efficacy of psychodynamic therapy, indicates that the quality of the relationship established with the therapist—the working alliance or the therapeutic alliance—along with the capacity for gaining of “awareness of previously implicit” experience, are the best predictors of “patient improvement on all outcome measures” (2010, p. 104).
Meaning-Making
I understand meaning-making to be both a cognitive and an affective process. Today as analysts and therapists, we work at the interface of what might be termed the cognitive–affective divide. Schore (2002) has made clear that for those whose earliest patterns are derived from relational trauma, therapy must seek to alter responses by providing a different affective experience through relating with another at the deepest levels. Crucial are the unconscious affective exchanges between analyst/therapist and patient, and patient and analyst/therapist, in the service of remaking the patient’s experience of relationship. Although interpretation and verbal response to interpretation are the left hemisphere’s very necessary contribution to a therapy, they are never enough in themselves. Nevertheless, the left hemisphere enables meaning-making and facilitates our understanding of symbolic material and of the complexity of self and self-states.
When problems occur in treatment, Tymanski (2011) suggests that we consider whether the therapy has become unhelpfully “lateralized,” privileging one side of brain functioning over the other. He comments that “this state could lead to miscommunication, empathic failure, and misinterpretation—the long list of therapeutic missteps that occupy nearly every therapist’s daily work.” Van der Kolk (2014, p. 128) warns that “visiting the past in therapy should be done while people are, biologically speaking, firmly rooted in the present and feeling as calm, safe and grounded as possible” (p. 70). Allen, Fonagy, and Bateman highlight further dangers that may plague the analyst/therapist, such as the danger of confidently imputing to patients “states of which they are unaware” (2010, p. 251); of dealing with the transference in a way that inadvertently stimulates overly intense affect, which then undermines the therapeutic process; of allowing an intense countertransference experience to lead to a distant and avoidant stance in the therapist, which then recapitulates the core trauma in which “the patient feels abandoned . . . in a state of intense distress” (p. 250). Allen et al. see our main task as “to promote a sense of agency” in patients and to help them “become aware of their unwitting re-creation of past trauma in current relationships” (p. 252).
Neurobiological Substrates of Change: Key Intrinsic Connectivity Networks
I would like to highlight some of the key intrinsic connectivity networks and their relevance to any consideration of the processes of change in therapy. Looking from the point of view as a lay analyst/therapist, I observe how researchers have become increasingly able to identify systems or networks that affect the mind–brain–body system. Studies of such “intrinsic connectivity networks” (ICNs) in individuals (Seeley et al., 2007, p. 2349) have led to an understanding of the brain as being composed of multiple, distinct, and interacting networks that support complex cognitive and emotional functioning. Thinking of brain functioning in this way provides a systemic framework for understanding how people change in therapy. “Three major networks have been identified as critical to our healthy mental functioning” (Menon & Uddin, 2010; Lanius, Wilkinson, & Woodhead 2013; Lanius et al., 2015), all of which are at work in the therapeutic process of change.
The chief executive control network (CEN) deals with both cognitive and emotional decision-making, integrating effective functioning of right- and left-hemisphere activity. The CEN is vital for cognitive decision-making, for maintaining working memory, and for initiating and sustaining goal-directed behavior. Much of our work with every patient involves the functioning of this network in each partner in the therapeutic alliance, as day-to-day aspects of living as well as more crucial decisions get discussed. Some patients are in a flight from thinking. For them to think is to have to confront the unthinkable: the experience of abuse in their earliest relationship. Yet these patients often bring their concerns about relationships in the present, perhaps a flight from the other, maybe a fear of all intimacy, perhaps a retreat into neuter gender identity or a tendency to be repeatedly drawn into relationships that are abusive. Helping patients to think must be an integral part of any sustained process of change.
The salience network can be thought of as the network for meaning-making of the cognitive, emotional, and bodily aspects of experience. The insula, its hub, is unique in that it lies at the interface of “the cognitive, homeostatic, and affective systems of the human brain” (Menon & Uddin, 2010, p. 656) and mediates “dynamic interactions between other large-scale brain networks involved in externally-oriented attention and internally-oriented or self-related cognition” (p. 655). In addition, the insula facilitates the processing of the “physiological condition of the body” and the development of “subjective feelings from the body” (Craig, 2010, p. 395). It comes as no surprise that meaning-making is at the heart of the therapeutic endeavor.
Damasio (1994, 2003) understands signals from the autonomic nervous system to be the source of our emotions, and feelings to be the mental representation of those emotions; the insula stands at the interface between mind and body: Research demonstrates a strong association between the right anterior insula and the “perception of one’s own bodily states and the experience of emotion” (Menon & Uddin, 2010, p. 658). If the degree of connectivity within this network is damaged, then “how one thinks and feels in daily life” may be compromised (Seeley et al., 2007) and there is the potential for the occurrence of pathological difficulties. Links have been made to autism in the case of underactive functioning of the right insula (Di Martino et al., 2009) and to the anxiety disorders when hyperactivity of the right insula is the problem (Stein, Simmons, Feinstein, & Paulus, 2007). It has also been observed that individuals with a high degree of connectivity within the salience network may show a greater degree of anticipatory anxiety, and that an individual’s anxiety trait “is coded, to some degree, in the underlying neural architecture of the salience network” (Seeley et al., 2007, p. 2354).
The meaning-making network is inevitably stimulated by the therapeutic encounter. Awareness of both self and others can occur at levels that are less than conscious. For example, “if the size of the pupils of the observed subject change in a way that is discordant with the changes in pupil size in the subject, both anterior cingulate and anterior insula are activated” in the observer (Allman et al., 2010, p. 497). The therapist may experience momentary awareness of this discordance at the first interview and then become increasingly aware of such moments as a therapy progresses. With an extremely gaze-avoidant patient who demonstrates an avoidant attachment style, it may become very marked early in a therapy.
Another patient, who I will call “Melanie,” arrived in my consulting room for the first time and stood looking away and down as she entered. She turned out to have an extremely avoidant attachment style born of difficult early parenting from a mother who had repeated psychotic episodes and a father who was away or involved with another woman rather than there to support his children. In the early years, care for the children was provided by a succession of rather strict nannies, none of whom stayed very long. No wonder my patient could not bear to look into the eyes of yet another caretaker. This woman was extraordinarily courageous; she had undergone an analysis with an analyst who had required her to use the couch and who sat at some distance behind her throughout the whole of the therapy. She knew in her heart of hearts that this avoidant, rather abstinent style of analysis did not reach her deepest difficulties but rather colluded with them. When she was a qualified therapist and had been working for a while, she sought out a different style of therapy for herself. It took several months, but eventually she was able to come into my room and take part of the time to rearrange the pillows on my couch at the far end so that she could lean comfortably against the wall and gaze at me, albeit from a safe distance!
Lanius et al. (2015) suggest that in patients with PTSD, altered connectivity within the salience network may result in a change in threat-sensitivity circuits, which then aggravates the symptoms of hypervigilance and hyperarousal. Steuwe et al.’s (2012) research was illuminating concerning an averted or avoidant gaze. The team noted that “healthy controls react to the exposure of direct gaze with an activation of a cortical route that enhances evaluative ‘top-down’ processes underlying social interactions. In individuals with PTSD, however, direct gaze leads to sustained activation of a sub-cortical route of eye-contact processing” (p. 1), which is an innate alarm system (involving the superior colliculus and the underlying circuits of the periaqueductal gray). The clinical implications for us in terms of how we experience and use gaze in the consulting room are of considerable interest. PTSD seems to be associated with heightened threat sensitivity. Lanius et al. note that “during a virtual reality paradigm, participants with PTSD showed enhanced coupling of the amygdala and the insula within the SN [salience network] as compared to healthy control subjects, providing evidence for an increased sensitivity of the salience network in individuals with PTSD related to prolonged childhood abuse” (2013, p. 6). Van der Kolk observes that “almost every brain-imaging study of trauma patients finds abnormal activation of the insula,” the part of the brain that generates a sense of being embodied (2014, p. 247).
“Holly” had such problems with her experience of anger and rejection in her mother’s face that for a long while, she would pile the cushions on the couch between her and me in such a way that all I could see was the top of her head, and she did not have to risk looking at my face. Much later, she was to paint a picture (Figure 5.3 in Wilkinson, 2010) of how she had felt at this time. It revealed a very sad little girl, shut away in a bubble, with the pillows as her shield against the all too painful relational reality of her inner perception of herself that had resulted from her early punitive interactions with her mother, with the face and eyes of a caregiver who could not build a bond with her daughter. This patient had a pronounced startle reaction and commented that although sometimes she could not remember someone’s name, she always knew the color of his or her eyes. The picture also gives a graphic description of her fears about what might be in her analyst/therapist’s mind, and shows her desperate need for a secure attachment.
The right anterior insula mediates awareness of both positive and negative feelings: empathic and dishonest responses to others, feelings of admiration and of disgust, and the capacity for emotional discrimination and judgment (Menon & Uddin, 2010). It deals with uncertainty and risk as well as intuition and those “aha” moments, characterized by “immediate effortless awareness” (Allman et al., 2010, p. 497). Such moments form the stuff of experience when the process of therapy has engaged both client and therapist at the deepest level. Craig surveyed the now extensive literature and concluded that the “anterior insula engenders human awareness” (2010, p. 395). Its role is crucial in that it enables links between outer and inner awareness and cognitive and affective experiences: all vital aspects of the individual personality engaged in the process of change and development.
The default mode network (DMN) also plays a key role in that it is centrally involved in self-referential processing, in building a robust sense of self that is engendered from within. The insula facilitates a switch over to this network when it is no longer necessary for the CEN to be in active mode, when we might be said to be relaxing. The DMN uses past experiences to plan for the future and utilizes moments when we are not otherwise engaged by the external world to do this. This network comes into play when the brain, seemingly at rest, actually uses massive amounts of energy to process experience at an unconscious level.
Some therapists favor an approach to a session that is to be without memory or desire, to seek to be in a seeming resting state out of which a very creative engagement with the material presented by the patient emerges. Although such a notion can only be speculative, it might be that in this unique resting state the DMN is activated, along with its connections into the hippocampus, which allows the creative connections between past and present to emerge and be thought about in the session. As a therapist I find myself wondering about the relationship between the DMN, the salience network, and those underlying pervasive states of fear, sadness, or anger that may affect our patients who have experienced early relational trauma. One patient said that for her, the baseline position that she always felt deep down was one of fear; another said that sadness was always there and only with great difficulty could she keep it out of mind.
Conclusion
I will end on a personal note. I am reminded of the dream I dreamt when finishing my last book, and which was included in it. I want to look at it again here, as I think it perhaps illustrates what we need to take into consideration as we seek to develop our understanding in order to help our clients to change:
I was visiting a country house that belonged to very close friends of mine called Sally and Alan. It is a very old and beautiful thatched cottage that has been carefully restored and modernized in a way that is in keeping with its original features. Through the front door the large country kitchen is off to the right, down a few steps. On the left is the dining room, so often a hub of conversation and discussion of ideas. As my dream opened, I was in the kitchen with a large group of rather distinguished guests. All were busy preparing their favorite soup, using tried and trusted recipes. My old friend Alan entered the kitchen carrying a very large pan with some new ingredients in it, which he set on the kitchen range. He carefully began to mix and blend quantities of the other soups into this, tasting as he went along to ensure that he had just the right mix to produce just the right flavor. When all was ready, we trooped out of the kitchen up a beautiful traditional dark oak staircase to the dining room, which in my dream had moved to the left at the top of the stairs. Some of the guests were still clutching the spoon they had been using to taste their favorite old soup.
The scene changed and I was sitting in the middle of one side of a long oak dining table. All the guests were sitting around the table; Alan was just across from me, and an old inglenook fireplace was just behind him. I thought the room had a rather Jacobean feel to it. Some people had chosen to bring the soup of their own old original recipe in the spoons they had brought up with them from the kitchen, wanting at that moment only to conserve the soup with the old familiar much loved taste. Naturally, with this already in their spoons, they found it difficult to taste the new flavor. A tall, distinguished man, who reminded me of a very well respected American psychoanalyst (actually, Philip Bromberg) who has blended the old established psychoanalytic teaching with the new insights from affective neuroscience, asked for a clean spoon. Alan brought fresh silver soup spoons, and several people round the table took one and more readily began to appreciate the new flavor that had been mixed, blending the best of the old with the new ingredients that Alan had added.
As I woke and thought about the dream, I realized almost instantly that Alan, a much valued friend and the master chef of my dream who had blended the old with the new with such care, stood for Allan Schore, who has made such an outstanding contribution to the consideration of how minds are changed in therapy by blending together for us the best of affective neuroscience, attachment theory, infant research, evolutionary psychology and ethology, just as, in my dream, the new is blended with the old to produce something of outstanding worth. (Wilkinson, 2010, pp. 184–185)
As in my dream, it is the Jacobean atmosphere of scientific enlightenment that we need to cultivate in ourselves as therapists if we want to facilitate effective change in those who choose to work with us. The first scene in the dream invited me down into the kitchen on the right of the door: the realm of implicit memory and of sensory experience, the realm of the right hemisphere we will always find ourselves exploring as we work with our traumatized patients. In our work it is also necessary to move up and to the left, to the information-processing center of the left cerebral cortex, to the realm of conscious awareness, of meaning-making, of decision-making, of chief executive control, just as in the dream we moved to the upstairs dining room. The dream warns us that those who cling only to the old familiar “soup”—the old familiar ways of thinking—will not be sufficiently open to change in their own thinking and ways of working. As therapists, we can enjoy a new flavor in our work through the inclusion of new ingredients, blended with the old and supped from a new spoon, but only if we explore the new advances in understanding attachment, affect regulation, and the amazing plasticity of the human brain. It is this extraordinary plasticity that facilitates change in the individual.
References
Allen, J. G., Fonagy, P., & Bateman, A. (2010). The role of mentalizing in treating attachment trauma. In R. A. Lanius, E. Vermetten, & C. Pain (Eds.), The impact of early life trauma on health and disease: The hidden epidemic. New York, NY: Cambridge University Press.
Allman, J. M., Tetreault, N. A., Hakeem, A. Y., Manaye, K. F., Semendeferi, K., Park, P., . . . & Hof, P. R. (2010). The von Economo neurons in frontoinsular and anterior cingulate cortex in great apes and humans. Brain Structure and Function, 214(5), 495–517. doi: 10.1007/s00429-010-0254-0.
Begley, S. (2008). The plastic mind. London, UK: Constable & Robinson.
Cozolino, L. (2006). The neuroscience of human relationships: Attachment and the developing brain. New York: Norton.
Craig, A. D. (2010). Once an island, now the focus of attention. Brain Structure and Function, 214(5–6), 396–396. doi: 10.1007/s00429-010-0270-0.
Damasio, A. R. (1994). Descartes’ error: Emotion, reason and the human brain. New York, NY: Putnam.
Damasio, A. R. (2003) Looking for Spinoza. Joy, Sorrow and the Feeling Brain. London, UK: Heinemann.
Di Martino, A., Ross, K., Uddin, L. Q., Skar, A. B., Castellanos, F. X., & Milham, M. P. (2009). Functional brain correlates of social and nonsocial processes in autism spectrum disorders: An activation likelihood estimation meta-analysis. Biological Psychiatry, 65(1), 63–74.
Felitti, V. J. (2010). Foreword. In R. A. Lanius, E. Vermetten, & C. Pain (Eds.), The impact of early life trauma on health and disease: The hidden epidemic. New York, NY: Cambridge University Press.
Gage, F. H., & Muotri, A. R. (2012). What makes each brain unique. Scientific American 306(3), 26–31.
Gould, E., & Gross, C. G. (2002). Neurogenesis in adult mammals: Some progress and problems. Journal of Neuroscience, 22(3), 619–623.
Greenfield, S. (2014). Mind change: How digital technologies are leaving their mark on our brains. London, UK: Random House/Penguin.
Haven, T. J. (2009). “That part of the body is just gone”: Understanding and responding to dissociation and physical health. Journal of Trauma & Dissociation, 10(2), 204–218.
Jones, A. (2007). Help me love my baby: Part 1 [Channel 4 TV documentary, made in conjunction with the Anna Freud Clinic].
Kempe, C. H., Silverman, F. N., Steele, B. F., Droegmueller, W., & Silver, H. K. (1962). The battered child syndrome. Journal of the American Medical Association, 181, 17–24.
Kessler, R. J. (2011). Neuropsychoanalysis, consciousness, and creativity. Neuropsychoanalysis, 13(2), 202.
Lanius, R. A. (2012). A social and affective neuroscience approach to complex PTSD. In P. Bennett (Ed.), Facing Multiplicity: Psyche, Nature, Culture. Proceedings of the XVIIIth Congress of the International Association of Analytical Psychology. Einsiedeln, Switzerland: Daimon Verlag.
Lanius, R. A., Frewen, P. A., Tursich, M., Jetly, R., & McKinnon, M. C. (2015). Restoring large-scale brain networks in PTSD and related disorders: A proposal for neuroscientifically-informed treatment interventions. European Journal of Psychotraumatology, 6, 27313.
Lanius, R. A., Wilkinson, M. A. & Woodhead, J. (2013). Report and clinical reflections on the research carried out by Dr. Lanius and her team at the University of Western Ontario. Paper presented at the triennial congress of the International Association of Analytical Psychology, Copenhagen, Denmark.
McCrory, E., DeBrito, S. A., & Viding, E. (2010). Research review: The neurobiology and genetics of maltreatment and adversity. Journal of Child Psychology and Psychiatry, 51(10), 1079–1095.
McFarlane, A. (2010). Part 1: Synopsis. In R. A. Lanius, E. Vermetten, & C. Pain (Eds.), The impact of early life trauma on health and disease: The hidden epidemic. New York, NY: Cambridge University Press.
Menon, V., & Uddin, L. Q. (2010). Saliency, switching, attention and control: A network model of insula function. Brain Structure and Function, 214(5–6), 655–667. doi: 10.1007/s00429-010-0262-0.
Porges, S. W. (2007). The polyvagal perspective. Biological Psychology, 74, 116–143.
Prensky, M. (2001). Digital Natives, digital immigrants: Part 2. Do they really think differently? On the Horizon, 9(6), 1–6.
Schore, A. N. (1994). Affect regulation and the origin of the self: The neurobiology of emotional development. Hillsdale, NJ: Erlbaum.
Schore, A. N. (2002). Dysregulation of the right brain: A fundamental mechanism of traumatic attachment and the psychopathogenesis of posttraumatic stress disorder. Australian and New Zealand Journal of Psychiatry, 36(1), 9–30.
Schore, A. N. (2003a). Affect dysregulation and disorders of the self. New York, NY: Norton.
Schore, A. N. (2003b). Affect regulation and the repair of the self. New York, NY: Norton.
Seeley, W. W., Menon, V., Schatzberg, A. F., Keller, J., Glover, G. H., Kenna, H., . . . & Greicius, M. D. (2007). Dissociable intrinsic connectivity networks for salience processing and executive control. Journal of Neuroscience, 27(9), 2349–2356.
Shedler, J. (2010). The efficacy of psychodynamic psychotherapy. American Psychologist, 65(2), 98–109.
Siegel, D. J., & Sieff, D. F. (2015). Beyond the prison of implicit memory: The mindful path to well-being. In D. F. Sieff (Ed.), Understanding and healing emotional trauma: Conversations with pioneering clinicians and researchers. New York, NY: Routledge.
Sroufe, L. A., Egeland, B., Carlson, E., & Collins, W. A. (2005). The development of the person: The Minnesota study of risk and adaptation from birth to childhood. New York, NY: Guilford Press.
Stein, M. B., Simmons, A. N., Feinstein, J. S., & Paulus, M. P. (2007). Increased amygdala and insula activation during emotion processing in anxiety-prone subjects. American Journal of Psychiatry, 164(2), 318–327.
Steuwe, C., Daniels, J. K., Frewen, P. A., Densmore, M., Pannasch, S., Beblo, T., . . . & Lanius, R. A. (2012). Effect of direct eye contact in PTSD related to interpersonal trauma: An fMRI study of activation of an innate alarm system. Social, Cognitive, and Affective Neuroscience, 9(1), 88–97.
Szajnberg, N., Goldenberg. A., & Harari, U. (2010). Early trauma, later outcome: Results from longitudinal studies and clinical observations. In R. A. Lanius, E. Vermetten, & C. Pain (Eds.), The impact of early life trauma on health and disease: The hidden epidemic. New York, NY: Cambridge University Press.
Teicher, M. H., Rabi, K., Sheu, Y.-S., Seraphim, S. B. Andersen, S. L., Andersen, C. M., . . . & Tomoda, A. (2010) A neurobiology of childhood trauma and adversity. In R. A. Lanius, E. Vermetten, & C. Pain (Eds.), The impact of early life trauma on health and disease: The hidden epidemic (pp. 116–120). Cambridge & New York, NY: Cambridge University Press.
Tymanski, R. (2011). The substrate of transformation in psychotherapy and analysis: Review of changing minds in therapy by Margaret Wilkinson. Jung Journal: Culture and Psyche, 5(2), 128–132.
van der Kolk, B. (2014). The body keeps the score: Mind, brain and body in the transformation of trauma. New York: Allen Lane, Penguin.
Wilkinson, M. A. (2006). Coming into mind: The mind–brain relationship—a clinical perspective. New York, NY: Routledge.
Wilkinson, M. A. (2010). Changing minds in therapy: Emotion, attachment, trauma, and neurobiology. New York: Norton.
Williams, G. P. (2004, October 4). Response to “Bodily states of anxiety: The movement from somatic states to thoughtfulness and relatedness.” Paper on B. Proner presented at the scientific meeting of the Society of Analytical Psychology, London.