The Disintegrative Core of Relational Trauma and a Way Toward Unity
IN THIS CHAPTER I discuss what I believe to be the central pathological effect of relational trauma and how it might be overcome. A gathering body of evidence suggests that a fundamental feature of those who have suffered repeated traumas during their early years is a relative failure of the integration of mental life. This failure is associated with a loss of coordination among brain systems that normally function together. How integration might be restored is a principal problem facing psychotherapists. No accepted therapeutic approach exists. The proposal put forward here, and in previous publications (Meares, 2000, 2005, 2012; Meares, Bendit, et al., 2012), is that unity of mind is fostered by a specific kind of conversation between the patient and therapist: a conversation that has the quality of analogical connectedness. In its adult form, this kind of conversation has the feeling and “inwardness” that are the cardinal features of intimacy. The feeling involves “warmth,” whereas a relationship that is distant is “cold” or “cool.”
Intimacy is used here in a quasi-technical way, without confessional or sexual connotations. It refers to a reciprocal sharing of emotional states that leads to a sense of connection between the conversational partners, in turn, generating pleasure. This kind of relationship has a characteristic doubleness that is both psychic and relational. Hobson (1971, 1985) called it “aloneness-togetherness.”
Disrupted Rhythms of Psychic Life
Allan Schore introduced the term relational trauma in 2001 to refer to what Freud had called, in pondering the bases of intractable nonpsychotic illness, “alterations of a rhythm of development of psychic life” (Freud, 1937, p. 242). Trevarthen (1974) has termed the normal rhythm a “proto-conversation”—that is, a dynamic interplay of expression and response, a continuing iteration between presentation, representation, re-representation, and so on—in which the continuity depends upon fine-tuning and harmony between the expressions of the dyadic partners, in the manner of music (Malloch & Trevarthen, 2009, Trevarthen et al, 2009).
In 1992, in our first outcome study of the treatment of borderline personality disorder, Janine Stevenson and I suggested that at least some cases of this apparently intractable illness have their basis in the disruption of such rhythms when the caregiver makes responses to the infant’s expression that “do not connect with the child’s immediate reality and so seem to come from outside” (Stevenson & Meares, 1992, p. 358). In short, such responses have an effect like a loud noise. Winnicott called them “impingements” (1965, p. 86).
At that time no adequate evidence existed that could support the hypothesis that relational trauma—that is, the infant’s experience of repeated impingements—might lead to so serious a disruption of personality development as borderline personality disorder. Support, however, soon came from a series of publications from Giovanni Liotti (e.g., 1995, 1999, 2000, 2004), which reported on the outcome of disorganized attachment in childhood. The typical caregiver responses that produce disorganized attachment behavior in a child are those that “do not connect with child’s immediate reality” (Stevenson & Meares, 1992). These responses have the effect of a shock. The parent or quasi-parental figure making such responses is likely to be frightening, sometimes frightened, and often unpredictable. The disorganized child may appear as if stunned, as if unable to know which way to turn. The child is manifesting behavior that in the adult is an experience of dissociation. Liotti found that disorganized attachment in children may be the precursor of dissociative disorders and borderline personality disorder in later life.
The Therapeutic Field
When we enter into a therapeutic conversation, we find ourselves in a field governed by two main opposing forces: one positive and the other negative. The first force is toward health and well-being; the second is an effect of unconscious traumatic memory, overthrowing the first, the ordinary sense of existing, the state that Winnicott (1965) called “going-on-being,” which is the basis of self. The system of unconscious traumatic memory is a record of inflictions occurring repeatedly, perhaps day after day, some severe, like sexual or physical abuse, and some apparently minor, like those of infancy—“little emotions, each one insignificant in itself, which have left no distinct or dangerous memories” (Janet, 1924, p. 275).
The traumatic memory system is likely to be made up of a number of subsystems relating to traumas of different kinds, at various stages in life, and in different forms of relatedness. Important among them are those that involve “attacks upon value” (Meares, 2004b), in which the individual is subjected to continuing devaluation, humiliation, disparagement, and relentless criticism, usually in a familial context. Such a background has also been associated with intractability as conceived in terms of depression (Meares, 2004b; Kaplan & Klinetob, 2000; Murphy et al., 2002; Kendler, Hettema, Butera, Gardner, & Prescott, 2003; Brown, Harris, & Hepworth, 1995; Farmer & McGuffin, 2003).
Although each subsystem can be conceived as discrete and autonomous, multiple subsystems can connect and trigger each other. Every major therapeutic system approaches interpersonal trauma with its own language. Whether addressing transference phenomena, distorted cognitions, or maladaptive schemas of interpersonal transactions, the approaches are all focused on the negative aspect of the therapeutic field. I do not speak here of this important issue, which has been considered elsewhere (e.g., Meares, 2000, 2005; Meares, Bendit, et al., 2012). Instead, this chapter concerns that which has been neglected, the “self” that has been damaged, distorted, and stunted by trauma. In the case of relational trauma, at least, it must be the primary concern of the therapist. Such trauma is not approached by strategies, techniques, interpretations, and so forth, dictated by the agenda of a particular theory. Rather, it is through the establishment of a specific kind of relationship, which is not artificially imposed or manipulated but is allowed to emerge in conversational interplay. The propensity for it is given to all of us through our biological heritage. A consideration of the form of this relationship necessarily begins with what we mean by self.
The Concept of the Self
Self is an elusive concept. It is hard to define since it is often merely a background sense, a feeling of existing going-on-being. Lévi-Strauss put it this way: “I never had and still do not have, the perception of personal identity. I appear to myself as the place where something is going on” (1979, p. 3). This vague idea, this background feeling, became a highly developed concept in the work of William James (1890, 1892), who can be considered the main descriptor of self. In recent years, he has been reinstated as a cultural hero after a period of neglect during the mid-20th century. James’s ideas are now used by the foremost proponents of a neural basis of self: Gerald Edelman (1992) and Antonio Damasio (2012, p. 7). James’s description allows us to track the waxing and waning of the experience of self during the therapeutic conversation by the use of linguistic analysis. At least 12 salient features of this experience, which I have noted elsewhere, can be derived from his account (see Meares, 2004a; Meares, Bendit, et al., 2012).
This leads to the idea that we can, to an extent that is useful, observe and measure that which cannot be seen. Words—or more particularly, words as they are spoken and as they fit together syntactically—provide a kind of window into the movements of inner life. In this way, self becomes a subject accessible to scientific inquiry, which, in the past, had not been considered possible (Meares, Butt et al, 2005; Meares & Jones, 2009).
Integration and Conversation
The notion of being able to “observe” psychic change is important. Language gives us a way of testing hypotheses concerning integration and disintegration. Proper “observation” of this kind, however, requires us to go beyond James’s work. Although his concept of self implicitly contains a sense of the other—he tells us that, at its heart, is the feeling of “warmth and intimacy”—this idea is not developed.
James’s description is of a one-person system. Such a view is an abstraction. Self, as a form of consciousness, cannot exist in isolation. It arises from a brain state. But a brain, seen as a system isolated from the world, is also an abstraction. It is always interacting with the environment, of which, when speaking of self, the social environment is the most important part. This interplay determines the brain state that produces a particular state of mind. The interplay, speaking again of self, is conducted by means of conversation. A particular kind of conversation is associated with a specific form of consciousness. The conversation and the state of mind are aspects of single system of function, made of self and other. The form of the relatedness (i.e., the conversation) both reflects and constitutes the form of consciousness. It is important to note here that integration is not judged by the language of the subject alone but primarily by the linguistic structure of the conversational unit created by both partners.
This main idea is the basis of the Conversational Model (Hobson, 1985; Meares, 2004b; Meares, Bendit, et al., 2012) the project for the development of which was launched by Robert Hobson in 1971. Writing from his experiences with intractable illness, which today would be called borderline personality disorder, a condition we now know to be associated with early trauma, he suggested that “much of the work of psychotherapy is concerned with establishing the state of aloneness-togetherness” (Hobson, 1971, p. 97) out of a prior state of disconnection. Aloneness-togetherness is part of the Jamesian duplex self. The duplex self is one of unified duality.
The simultaneity of relationship and state of consciousness provides a way not only of treating disintegration but also of testing the proposed method of treatment. This theory of self predicts that its main features arise, and can be identified, in a relationship that also has the qualities of connectedness.
Jacksonian Theory of Self and Trauma
The notion that trauma produces disintegration of the mind–brain system requires a fleshing out that takes us beyond James in a second way. He implied that integration of mental function and self are almost the same thing. He wrote: “Thoughts, connected as we feel them to be connected are what we mean by personal selves” (James, 1892, pp. 153–154). Connection is the cardinal quality of self. But James does not tell us what is connected. How can it be conceived?
James’s famous image of self as a “stream of consciousness” is not enough to answer this question. This phrase describes the background feeling of existing that is most prominent in reverie. This is not the whole of self. For much of the time, our consciousness in directed toward tasks and events. Our attention is focused on the outer world. Our state of mind, in this circumstance, is quite different from that of the “stream.” Can this form of consciousness be thought of as not-self? Such an idea makes no sense. In these moments we also feel our existence.
In order to find an answer to the puzzle presented by these phenomena, we turn to the legendary English neurologist, John Hughlings Jackson. James cited Jackson and spoke of him respectfully. Yet, he was apparently unaware of Jackson’s important concept of self, published in 1887, 3 years before the Jamesian magnum opus. Although a neurologist, Jackson had an abiding interest in the concept of mind, or self, and how it might help in the understanding of mental illness. He believed himself to be the first person in the medical literature to use the term self. As he saw it, self is identified by the reflective function of introspection, the capacity to be aware of “inner” events. Such a capacity, however, as he said, is not self itself. This is a more complex conception of a consciousness consisting of paradoxical unity and doubling.
Jackson conceived self as comprised of two coordinated kinds of consciousness. “Each is only half itself” (1887a /1958, p. 93). The first of these he called “subject consciousness;” it is the background feeling, present to a greater or lesser degree all the time. Compared with the second kind of consciousness, which he called “object consciousness,” it is comparatively unchanging. Object consciousness is engaged by attention to objects, either external or internal. Although the two kinds of consciousness work together in the creation of self, he believed that subject consciousness (which is akin to Winnicott’s [1965] “going-on-being”) is the more fundamental. “It is us,” he said, emphasizing the verb “to be” (1887a/1958, p. 96). Jackson considered that self arises in development, and arose in evolution, not through any new structures or tissue being added to the brain, but through an elaboration of existing structures, notably the prefrontal cortex, which makes possible a higher coordination of brain systems than previously existed. Self emerges in a hierarchical fashion, each notional tier of the hierarchy decreed by stages in evolutionary history. The appearance of self reflects the culmination of an evolutionary passage from lowest to highest levels of coordination of all elements in the brain, from automatic to voluntary function and from simplicity of organization to complexity. Complexity is reflected in the relationship of the organism to the environment. At its simplest, it is a single stimulus, a sound perhaps. At its highest, it is the relationship of intimacy, which arises out of, and is compounded with, earliest forms of relatedness, most importantly, attachment. This late stage of evolution and development is fragile, the least “hard-wired.” It is overthrown by trauma, in which the mind–brain system operates at a lower level of coordination, as if at an earlier level of evolution. Self and intimacy are lost. Attachment becomes exaggerated (Meares, 1999, 2000).
Default Mode Network
Jackson’s concept of subject consciousness might have once seemed speculative and without physiological basis. Recently, however, a plausible neurophysiology has been established for this background state of “going-on-being” (Winnicott, 1965), called the “default mode network” (Raichle et al., 2001). This system is active when the mind is apparently at rest, when the “stream of consciousness” becomes salient (Raichle et al., 2001). It is organized around cortical midline structures, with two principal nodes, one prefrontal and the other posterior cingulate/cuneus. Its activity is associated with markers of self such as autobiographical memory (Gusnard, Akbudak, Shulman, & Raichle, 2001; Buckner & Carrol, 2007), “mentalizing” (Frith & Frith, 1999, 2003), and tests of false belief (Gallagher & Frith, 2003).
It is a reasonable hypothesis to suppose that the central pathophysiology induced by relational traumas is a disruption of the connectedness of Jackson’s (1887b/1958) “subject consciousness.” Bluhm and colleagues found diminished connectivity in the default mode network in a group of subjects with traumatic backgrounds similar to those of patients with borderline features (Bluhm et al., 2009).
Failure in the coordination of brain systems in those subjected to cumulative traumas, of which the archetype is borderline personality disorder, is not limited to the default mode network. Systems that usually operate together no longer do so. Initial evidence of this came from a study of subjects with a history of dissociative disorders and a long history of unexplained medical illness, a condition once called hysteria but that now is called borderline. Typically, the individuals had histories of trauma and in some cases, severe disruptions of the early life through, for example, institutionalization in infancy. These individuals showed a failure of coordination in excitatory and inhibitory activity; in the normal case, one rises while the other falls. This failed coordination was reflected in electrodermal evidence of disturbed coordination between sympathetic and parasympathetic nervous systems, primarily related, the researchers suggested, to disturbance in the parasympathetic, or inhibitory, aspects of autonomic function (Horvath, Friedman, & Meares, 1980). Similar findings have been reported by Linehan (Kuo & Linehan, 2009) and Porges (Austin, Riniolo, & Porges, 2007).
Autonomic activity occurs at an unconscious level. Failure of coordination has also been shown in conscious function, specifically in the simple matter of the response to a novel stimulus. Such a stimulus produces a large component of the event-related potential, that record of the electrical passage, through the brain, reflecting the processing of a stimulus, called the P3. P3 occurs at about 300 milliseconds after the presentation of the stimulus. It is a single peak, suggesting a lone generator. However, it is produced by two main generators: one a largely prefrontal network generating the first part of P3, called P3a. The second part of P3, P3b, is generated by a mainly parietal network. In normal circumstances, the function of the two generating networks is coordinated, leading to the unified output of a single peak. In borderline patients, the coordination is lost, resulting in a double peak, a biphasic wave. Onset times of P3a and P3b no longer correlate (Meares et al., 2005; Meares, 2012, pp.63-85).
Later evidence, which I and my colleagues are about to publish, suggests that these abnormalities are markers of dissociation.
Integration and the Right Hemisphere
The observations made thus far in this chapter suggest that a prime therapeutic aim, when treating those who have suffered cumulative traumas, is toward integration of mind–brain function. How is so complex a task to be achieved? A hypothesis derives from Jackson’s (1887b, 1958) notion of “coordination.” Two systems become coordinated when they somehow “fit” one another, as if their shapes resemble each other, or a part of one also becomes a part of the other. I am suggesting that this coordination first occurs in the outer world in a special kind of conversation that has the characteristic form of “analogical connectedness.” An analogue is something that resembles another thing.
The earliest appearance of this kind of conversation is the game mothers play with their babies, which Colwyn Trevarthen (1974) has called a “proto-conversation.” In this game the mother portrays, in her face and in the contours of her voice, the “shape” of her baby’s immediate experience. In other words, she creates analogues of this experience.
Allan Schore has argued that this interplay between mother and child is essentially one between two right hemispheres (2002, 2003, 2009, 2010). Following this idea, the kind of relatedness that fosters integration and the generation of self depends upon a kind of language that is loosely conceived as right-hemispheric.
Ordinary conversation consists of the coordination of two kinds of language, which Vygotsky (1962) identified in a study of young children. He called them “social speech” and “inner speech,” the latter observed during symbolic play. They reflect two different thought forms, which, again following Jackson, depend upon the left and right hemispheres, respectively. Left-hemispheric function, Jackson (1874/1958) pointed out, allows us to “proposition.” The right hemisphere cannot construct propositions, but it has a potential language that is abbreviated and emotional.
It would seem that the right hemisphere is particularly suited to the establishment of the proto-conversation, the first form of analogical connectedness (Meares, Schore, & Melkonian, 2011, 2012). It has the functions of “shaping,” of rhythm, and of the recognition of faces, especially the emotions they represent. The hypothesis now arises that, since the proto-conversation is likely to be ill-developed in those who have suffered relational traumas, the right hemisphere will have been insufficiently activated, leading to a deficiency in its function. The idea can be tested in the following way.
During the investigation of P3 in patients with borderline features, previously mentioned, we studied the amplitude of P3a and P3b. We found that P3a was greatly enlarged in the borderline individuals, a reflection of deficient higher-order inhibition. This finding is consistent with what Jacksonian theory would predict following trauma. It is found in dissociated patients, but not in those suffering another kind of psychic disintegration: schizophrenia. In a study published with Allan Schore (Meares, Shore, & Melkonian, 2011/2012), we showed that this deficiency, the exaggerated P3a in borderline personality disorder, is confined to the right hemisphere. Consistent with this observation, Bluhm and colleagues (2009) found that disconnections of the default mode network in traumatized people was particularly right-sided.
Analogical Connectedness
Finally, we consider the nature of therapeutic responsiveness that facilitates the integration of consciousness necessary to the experience of self. What follows here is a very simplified attempt to summarize the main elements of a complex matter that is approached in various ways, and in more detail, elsewhere (e.g., Hobson, 1985; Meares & Hobson, 1977; Meares, 2000, Meares, Butt et al., 2005, 2016; Meares et al., 2005; Meares & Jones, 2009; Meares, Bendit, et al., 2012).
First of all, the language is natural and familiar. The response is a refinement and amplification of the innate ability possessed by the typical mother who plays with the baby when the infant is in a state that is free of distress. (She does something different during distress.) Nobody instructed her to do so or taught her how to do it. We might say the behavior is “instinctive.”
The behavior, however, is not “instinctive” when it comes to therapy, wherein the therapist is the recipient of quite different interpersonal and emotional signaling. Nevertheless, certain therapists can adapt themselves, without much instruction, to the different situations and are able to respond in a manner that follows the principles implicit in a proto-conversation. Such therapists, in our experience, are the most effective. They may be (linguistic studies are required to verify) those “super therapists” who have been shown, in a number of reports, to have the best results whatever kind of manualized therapy they are applying (e.g. Luborsky et al., 1986; Lambert, 1989).
Although a therapist can foster beneficial change by means of natural talent, this propensity must be trained, honed, and enhanced. It involves a kind of responsiveness that is consistently engaged, in interchange after interchange, in a disciplined way. Change is seen to occur as a result of this continuing relational milieu, rather than as an outcome of intermittent contributions to the therapeutic conversations, such as “interpretations.”
The therapist experiences the therapeutic exchange in a particular way by means of empathy. Empathic imagination is the basis of the stereotypic therapeutic response, which has a “picturing” function. It is a “form of feeling” (Hobson, 1985) that shows the “shape” and feeling of the patient’s immediate reality. This is not a replica but a second “view” of that reality. It may be merely a vocalization or as large as a story. It is usually brief, having the structure of analogy/metaphor. A positive shift in the conversation often follows a “cascade” of such “analogical representations,” each one larger than the one before.
Such “pictures,” or “analogues,” however, have no positive effect unless they achieve a sense of connection with the reality they attempt to depict. Following this achievement is a positive feeling of a subtle kind. “Fit” is not achieved when the depiction comes as if from an observer, outside the patient’s subjective space. In order to achieve the feeling that the therapeutic conversation is going on in shared subjective space, a certain kind of language is required.
A language of connection is likely to have two main qualities. First, it “couples” to that which is essential to the patient’s expression. Secondly, it is of a right-hemispheric kind. In the first case, coupling involves a language that resembles that of the patient’s in its style, lexicon, and syntax. It is not a copy, however. For example, a patient begins the session with: “Here I am,” speaking in a tiny voice. The therapist’s response is firm and positively toned: “Here you are.” It seems simple, even banal, yet it is skilled and it works. The sense of “fit,” and the pleasure that comes with it, is evident in their laughing together after the response. Whether a therapist’s remark is “correct” is judged not in terms of a theory but by “what happens next” (Meares, 2001).
“Right-hemispheric language” is of the kind described by Vygotsky (1962). It is “inner speech,” referring to the life of the self, an inner world. It is abbreviated, condensed, emotional, and lacks normal syntax. Sentences are often incomplete. Subjects of sentences may be missing, even verbs may be omitted. It is contrasted with “social speech,” which is cast in the form of propositions.
The sense of shared subjective space is enhanced by a language that suggests that the conversational partners are sitting side by side, gazing out at a space, like an invisible screen, where their depictions are jointly cast, in a combined attempt to “visualize” a personal reality (Meares, 1983). This third element of the conversation tends to be referred to as “it.” Pronouns are likely to be omitted.
Establishment of connection is evident in a conversation in which the partners finish each other’s sentences, speak in unison, use the same words, and utter frequent, non-verbal, emotional vocalizations. An example of a session finishing in this way, showing, in linguistic terms, a high level of connection, will be presented in detail in a later publication. During this conversation, markers of self appear: reflection, mentalizing, and autobiographical memory. These markers are consistent with the main principle of Vygotsky (1978): that higher-order functions have their first form in the outer world as a shared activity between two people. Since the principal characteristic of the mental function we are calling self is cohesion, the shared activity that is a necessary precursor to its appearance will also be cohesive. Vygotsky wrote: “Any function in the child’s cultural development appears twice, or on two planes. First it appears on the social plane, and then on the psychological plane. First it appears between people as an inter-psychological category, and then within the child as an intra-psychological category” (1978, p. 163). The intrapsychological category includes, at is core, a remembrance of its origin, the “warmth and intimacy” of which William James spoke so often.
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