ALL HUMAN BEINGS, FROM INFANTS TO ADULTS, require an effective social engagement system in order to build attachment and affiliative relationships (Porges, 2004, 2005). In turn, early attachment experiences influence the development of the social engagement system and teach us how to regulate internal and external stimulation (Beebe & Lachmann, 1994; Bowlby, 1973, 1980; Fonagy, Gergely, Jurist, & Target, 2002; Hofer, 1984; Schore, 1994; Siegel, 1999). Born with limited capacities for self-regulation, human infants are dependent on the externally mediated interactive regulation of their primary attachment figures to maintain their arousal within the window of tolerance. Whether that attachment relationship is consistent or inconsistent, secure or insecure, it provides the context within which the infant develops lifelong tendencies for regulating arousal and affect. Early disruptions in attachment have enduring detrimental effects, diminishing the capacity to modulate arousal, develop healthy relationships, and cope with stress (Sable, 2000; Schore, 1994; Siegel, 1999).
Available to the full-term infant, the social engagement system is evident as the baby vocalizes, cries, and grimaces to signal distress, or smiles, gazes, or coos to interact with the caregiver (Porges, 2004, 2005). This “neural regulation of [facial] muscles that provide important elements of social cueing are available to facilitate the social interaction with the caregiver and function collectively as an integrated social engagement system” (Porges, 2005). These kinds of behaviors serve to increase proximity between infant and caregiver. Through the repeated experiences of attuned dyadic interaction with the mother or primary caregiver, the child becomes increasingly effective at signaling, engaging, and responding to the other (Brazelton, 1989; Schore, 1994; Siegel, 1999; Stern, 1985); these responses, in turn, shape the social engagement system. The activation of this system leads to experiences of safety and helps maintain or return arousal to a window of tolerance by dampening both sympathetic and dorsal vagal activation. A competent social engagement system that effectively regulates these neural circuits fosters a wider window of tolerance and ultimately provides the child, and later the adult, with the capacity to tolerate, process, and even transform difficult experiences into opportunities for growth.
The social engagement system is initially built upon a series of face-to-face, body-to-body interactions with an attachment figure who regulates the child’s autonomic and emotional arousal; it is further developed through attuned interactions with a primary caregiver who responds with motor and sensory contact to the infant’s signals long before communication with words is possible. This interactive, dyadic regulation facilitates the development of the part of the brain responsible for the self-regulation of arousal: the orbital prefrontal cortex (Schore, 1994).
The capacity to self-regulate is the foundation upon which a functional sense of self develops (Beebe & Lachmann, 1994; Schore, 1994; Stern, 1985). The sense of self is first and foremost a bodily sense, experienced not through language but through the sensations and movements of the body (Damasio, 1994, 1999; Janet, 1929; Krueger, 2002; Laplanche & Pontalis, 1998; Mahler & Furer, 1968; Stern, 1985). The primary sensations at the very beginning of life are physiological and tactile, and the primary form of communication immediately after birth between parent and newborn is through touch, with visual and auditory stimuli having a stronger role as time goes on (Krueger, 2002). The physical experience of the caregiver’s gentle, attuned ministrations to the infant’s signals pertaining to sensation, touch, movement, and physiological arousal, as well as to his or her sensitivities/vulnerabilities regarding sensory input and other physical needs (e.g., food, warmth, fluids) establishes the infant’s initial sense of self and sense of his or her body (Gergely & Watson, 1996, 1999). Thus, “the close and careful attunement to all the sensory and motor contacts with the child forms an accurate and attuned body self in the child” (Krueger, 2002). When this occurs, social engagement, secure attachment, and regulatory abilities are adaptively supported.
Early interpersonal trauma is not only a threat to physical and psychological integrity, but also a failure of the social engagement system. Moreover, if the perpetrator is a primary caregiver, it includes a failure of the attachment relationship, undermining the child’s ability to recover and reorganize, to feel soothed or even safe again. The child’s opportunity to effectively utilize social engagement for care and protection has been over ridden, and he or she experiences overwhelming arousal without the availability of attachment-mediated comfort or repair. Without adequate attunement and development of the social engagement system within a secure attachment relationship, “[c]hildren…are not able to create a sense of unity and continuity of the self across the past, present, and future, or in the relationship of the self with others. This impairment shows itself in the emotional instability, social dysfunction, poor response to stress, and cognitive disorganization and disorientation” (Siegel, 1999).
Understanding how self-regulatory capacities are formed through early attachment relationships is helpful to therapists, who also provide a similar relational context in which dysregulated clients can develop adaptive regulatory capacities (Beebe & Lachmann, 1994; Schore, 1994). In therapy, fostering clients’ social engagement and regulatory abilities is a top priority. Nonverbal cues are typically the first indicators of the client’s experience of safety or danger in response to the therapeutic relationship, the environment, and internal cues (Lanyado, 2001). The therapist’s attuned response to these nonverbal expressions is imperative in developing the client’s social engagement system. For example, if a client’s face expresses fear and his body tenses and pulls away, the attuned therapist may gently inquire about these non-verbal cues and take action to restore safety. If the client feels unsafe in the relationship, these actions might include increasing or decreasing physical proximity or other actions that give clients a sense of safety. Through these interventions, social engagement is reestablished and arousal is returned to a window of tolerance.
ATTACHMENT, SELF-REGULATION, AND RECIPROCAL INTERACTION
The primary caregiver, usually the mother, modulates her child’s arousal by both calming the infant when arousal is too high and stimulating the infant when arousal is too low, thus helping the baby remain in an optimal state (Schore, 1994). The caregiver is attuned to the infant’s need for stimulation as well as for disengagement via gaze aversion, which allows the infant to go to the edges of his or her window of tolerance without becoming hyperaroused. Or when, despite his or her best efforts, the infant experiences regulatory ruptures, the relationally attuned caregiver provides the interactive repair that enables the infant to return to a zone of optimal arousal (Beebe & Lachmann, 1994; Schore, 1994; Siegel, 1999; Stern, 1998; Tronick, 1998).
Because attachment needs are initially experienced and expressed primarily as body-based needs, the quality of the attachment relationship is originally founded on the caregiver’s consistent and accurate attunement and response to the infant’s body through their reciprocal sensorimotor interactions. The caregiver’s ministrations, sensory joining, and quality of physical handling of the infant links body and mind experiences in the child and forms the basis for self-regulation (Krueger, 2002). This reciprocal interaction between the attuned caregiver and the infant is reenacted again and again (Schore, 1994; Siegel, 1999; Stern, 1985), expanding the child’s internalized template of safe relatedness and consequently solidifying his or her ability to regulate, manage, and predict the environment.
Bion (1962) used the term containment to describe the primary caregiver’s provision of a psychological environment that fosters the infant’s self-regulating capacities. Winnicott’s “holding environment” describes a similar concept that includes details about the type of physical care and environment that promote “the mental health of the infant” (1990). By containing the child and providing a holding environment, the mother is able to hold the child both literally and in her mind in such a way that demonstrates her recognition of the child’s physiological and affective states and also her ability to deal with them effectively. She can tolerate and “stay with” the child through his or her dysregulated states (Schore, 2003a).
Containment is communicated by the mother’s holding and physical soothing of her infant’s body with her touch and voice, which thereby modify the baby’s physical sensations and motor activity (Brazelton, 1989). As the child develops, he or she acquires the capacity to experience security and comfort by means other than direct physical ministrations. Eye contact and words eventually “bridge the gap” between mother and child, and the child learns to calm down as the mother walks into his or her line of vision or is conjured in fantasy by the child as a comforting, calming presence.
The “good enough” mother/caregiver (Winnicott, 1945) is able to “mentalize” (Fonagy et al., 2002) her child. The caregiver who recognizes the child as a separate person with his or her own motivations, desires, and needs demonstrates a capacity to mentalize. This capacity in the caregiver enables the child to develop a secure sense of self and understand his or her own and others’ motivations, desires, and needs as separate but negotiable.
One of the skills that enables mentalizing is the ability of the mother to perceive the child’s world, identify with it, and align with it, while simultaneously realizing that the child is a separate person. Alignment—the empathic matching of one’s own state to that of another Siegel (1999)—is a sensorimotor event that promotes social engagement communicated through prosody, voice tone and volume, touch, expression, pace, gestures, and so on. As the mother “gets closer to the child’s state and then brings the child ‘down’ to a calmer state” (Siegel, 1999), through sensorimotor and emotional alignment, both mother and child experience a sense of calm and relaxation (Jaffe, Beebe, Feldstein, Crown, & Jasnow, 2001; Schore, 1994; Siegel, 1999; Stern, 1985). In psychotherapy, attuned therapists need to provide alignment for clients, conveyed through voice tone, body language, and emotional “resonance” (Siegel, 1999), and containment, by helping them maintain arousal within the window of tolerance. As one client said, “I need to know that you won’t let me go there [to the memories of the abuse].”
An Ever-Changing Body-to-Body Dialogue
At the beginning of life, the newborn is dependent on its sensorimotor capacities (e.g., vocalizing, movement) to interact with the environment. However, social and emotional capacities quickly develop so that, by the end of the second month, the infant is able to engage in face-to-face interactions with the mother via intense and prolonged eye contact (Schore, 2003a). At this time, interactive play also begins, a highly arousing emotional and sensorimotor exchange in which the infant’s rhythms and vocalizations are mirrored and elaborated by the mother (Schore, 2003a; Trevarthen, 1979). This body-to-body, brain-to-brain dialogue, described as “affect synchrony,” is a give-and-take somatic exchange during which the mother facilitates the infant’s information processing by “adjusting the mode, amount, variability, and timing of the onset and offset of stimulation to the infant’s actual integrative capacities” (Schore, 2003a). As the infant’s affective body “language” is responded to in a pleasure-enhancing manner by an attuned caregiver, the positive experience of nonverbal communication fosters the development of the infant’s sense of self and conditions his or her future relationship to somatic expression as a means of communication.
For this development to occur, caregivers must adapt to the infant’s ongoing development: The “maturation of the nervous system, accompanied by increasing differentiation of skills, drives infants to reorganize their control systems. At each step, parents must also readjust, finding a new more appropriate way of reaching out” (Brazelton, 1989). The caregiver’s empathic discernment of the child’s changing physical and emotional needs ensures a balance between an environment that is safe and secure and one that is sufficiently enriching to simulate the child within his or her developmental capacity and to provide experiences of both enjoyment and mastery (Bradley, 2000; Emde, 1989).
Regulation of Positive Affect
The infant’s developing experience of regulating a wide range of arousal states is facilitated by the mother’s sensitivity to both positive and negative affective states. The good enough mother (Winnicott, 1945) actively engages in playful experiences with her infant, repeatedly pairing high arousal states with interpersonal relatedness and pleasure, thereby helping the child learn to tolerate rapid shifts in arousal: “During the imprinting of play episodes mother and infant show sympathetic cardiac acceleration and then parasympathetic deceleration in response to the smile of the other, and thus the language of mother and infant consists of signals produced by the autonomic, involuntary nervous system in both parties” (Schore, 2003a). These interactions teach the infant to tolerate joy and excitement and encourage a “positively charged curiosity that fuels the burgeoning self’s exploration of novel socio-emotional and physical environments” (Schore, 2003a). Thus, “affect regulation is not just the reduction of affective intensity, the dampening of negative emotion. It also involves an amplification, an intensification of positive emotion, a condition necessary for more complex self-organization” (Schore, 2003a). When the window of tolerance is restricted and the child cannot regulate affect effectively, he or she will have little tolerance for both pleasant and unpleasant sensations.
Good enough caregivers are inevitably somewhat inconsistent in their attunement with their children, but they promote recovery from breaches of attunement by providing interactive repair (Tronick, 1989). For example, when parents must interrupt the child’s play for bedtime, they provide support to manage the frustration. When the child falls and bruises a knee, good interactive repair provides both comfort and reorienting of attention to play. Upon reunion with the caregiver following separation, a “source of joy” (Bowlby, 1980) to both parties, the caregiver responds with, and encourages, the child’s pleasure. This transitioning between negative and positive affect helps the infant develop resiliency and, later, flexible adaptive capabilities. As Schore stated: “The process of re-experiencing positive affect following negative experience may teach a child that negativity can be endured and conquered” (2003a).
ATTACHMENT PATTERNS AND THE BODY
Ainsworth, Belhar, Waters, and Wall (1978) identified prototypes of three attachment patterns in children: secure attachment, insecure-avoidant attachment, and insecure-ambivalent attachment. In 1990 Main and Solomon (1990) identified a fourth pattern: disorganized-disoriented. Subsequently, various additional researchers and authors in the attachment field have elaborated on how these four patterns reflect the habitual regulatory tendencies observed in children in an interpersonal context (Lyons-Ruth & Jacobvitz, 1999; Sroufe, 1997; Van Ijzendoorn, Schuengel, & Bakermans-Kranenburg, 1999). Attachment patterns, formed in infancy, usually remain relatively stable throughout childhood and adulthood (Brennan & Shaver, 1995; Cozolino, 2002; Hazan & Shaver, 1990). A child’s primary attachment pattern is usually formed in relationship to the mother, and this pattern is usually generalized to subsequent relationships. However, if the child forms different attachment patterns with each attachment figure, those patterns that are not primary may be also be triggered by similar situations or relationships in the future. Procedural triggering of these latent, non-dominant attachment patterns can lead to specific action tendencies relevant to a particular person but not generalized to all relationships.
Although attachment is described as “patterns of mental processing of information based on cognition and affect to create models of reality” (Crittenden, 1995), attachment patterns are also held in place by chronic physical tendencies reflective of early attachment. Encoded as procedural memory, these patterns manifest as proximity-seeking, social engagement behavior (smiling, movement toward, reaching out, eye contact) and defensive expressions (physical withdrawal, tension patterns, and hyper-or hypoarousal). It is important to remember that these patterns are stereotypes, describing clusters of behavior, and that there are wide variations within each pattern (Bowlby, 1980; Fonagy, 1999b; Main, 1995; Sable, 2000; Slade, 1999).
Of particular interest in a sensorimotor approach are the physical tendencies of each pattern observed in infancy, versions of which are evident in our adult client population. Although each attachment pattern translates uniquely in each client on a somatic level and any attempt to stereotype these tendencies is only generalization, understanding the attachment patterns and their corresponding possible physical tendencies can help therapists devise somatic interventions to challenge them and repair attachment disturbances.
Secure Attachment
Bowlby (1982/1969) emphasized that the basic task of the first year is forming attachment, and Schore wrote that this is a “bond of emotional communication between the infant and the primary caregiver” (submitted). As we reviewed previously, the good enough mother accomplishes the task of creating secure attachment through reciprocal, attuned somatic and verbal communication with her infant. The child engages in exploratory behavior in the presence of the parent, shows signs of missing the parent upon separation, approaches the parent without ambivalence upon reunion, and often initiates physical contact. Quickly soothed upon distress, infants with secure attachment patterns return easily to exploratory activities. A secure attachment is both a psychological and physically mediated achievement that provides the “the primary defense against trauma-induced psychopathology” (Schore, in press; see also Ainsworth et al., 1978). These children have a relatively wide window of tolerance, are able to mentalize, form effective social engagement systems, and achieve overall adaptive functioning of parasympathetic and sympathetic systems. These attributes enable them to sustain arousal in the optimal zone or quickly return to that zone when arousal is momentarily excessive. As adults, these individuals can generally seek proximity to others with little or no avoidance or angry resistance and can tolerate relational frustrations and disappointments (Cassidy & Shaver, 1999). Their physical tendencies reflect integrated, tempered movements of approach that are context-appropriate, such as actions of moving toward, reaching out, or otherwise seeking contact. When their arousal exceeds the window of tolerance, they are able to seek and receive soothing and calming, without ambivalence, and are also able to self-regulate.
Congruence between movement and internal states is observed in the behavior of the child who has experienced secure attachment. The match between the child’s interior psychological need and physical goals are congruent, and demonstrated through harmonious movements of the body. For example, when the attachment system is aroused, the child’s movements are geared to unambiguously secure sufficient proximity with the parent to bring arousal back within the window of tolerance. In congruent behavior, the cognitive, emotional, and sensorimotor levels of information processing are aligned. When these children are observed, their intention for proximity to the mother, exploration away from the mother, desire for play, and so forth are easily detected and seen in the harmonious, cohesive movements of the child’s body. These congruent behaviors are noticed in adults as well. Children with secure attachment patterns usually become adults who are comfortable being autonomous as well as comfortable seeking help and support from others. Clients who have experienced a secure attachment can use their therapist as a secure base once rapport is established, and their external physical movements match and reflect their internal state. They can unambiguously and congruently display their intentions, mood, desires, and even motives on cognitive, emotional, and sensorimotor behavioral levels.
Insecure Attachment
The two insecure patterns, insecure-avoidant and insecure-ambivalent, contain clear deficits. However, they, like secure attachment, are considered to be relatively adaptive and organized and predict future capacity for more or less adaptive behaviors (Ainsworth et al., 1978; Bowlby, 1920; Main, 1995; Siegel, 1999).
INSECURE-AVOIDANT ATTACHMENT
Mothers of insecure-avoidant infants actively thwart or block proximity-seeking behavior of the infant, responding instead by withdrawing or even pushing the child away (Ainsworth et al., 1978; Schore, 2003a). These mothers appear to have a general distaste for physical contact except on their terms and may respond to the infant’s overtures with wincing, arching away, or avoiding mutual gaze (Cassidy & Shaver, 1999; Schore, 2003a; Siegel, 1999). The child adapts to this affectively laden somatic communication of unavailability by expressing little need for proximity, and apparently little interest in adult overtures for contact. And, when contact is made, the avoidant child does not sustain it, focusing instead on toys and objects rather than on the mother. He generally avoids eye contact with her and shows few visible signs of distress upon separation, although some researchers (Fox & Card, 1999; Main, 1995) have found evidence of autonomic arousal in these toddlers even when they appear behaviorally indifferent to the mother. Upon reunion, they actively ignore or even avoid the mother by moving or leaning away when picked up (Main & Morgan, 1996). They generally do not seek proximity with caregivers and are reserved emotionally.
Children with insecure-avoidant attachment patterns are described as having a dismissive stance towards the importance of attachment in adulthood. They often distance themselves from others, undervalue interpersonal relationships, become self-reliant, and tend to view emotions with cynicism. Clients with insecure-avoidant attachment histories tend to withdraw under stress and avoid seeking emotional support from others. With a compromised social engagement system and limited access to internal states, these clients typically minimize their attachment needs. Preferring autoregulation to interactive, they may find dependence frightening or unpleasant and avoid situations that stimulate attachment needs. The body tendencies vary; through muscular tonicity or rigidity these clients might show that they are more comfortable with defensive movements than with reaching out or moving toward. For example, one adult client found it unfamiliar and uncomfortable to reach out with her arms and did so awkwardly and stiffly, saying that it was easier to push away than to reach out for contact when no one had ever responded. As they are approached, these clients may pull back or become more armored. Others withdraw through a demeanor of passivity, often reflected in low muscular tonicity, and lack of response to relational overtures. Many clients demonstrate mixed tone: high tone in certain areas of the body, and low tone in other areas, as in the client who was strong and muscular through her legs but weak and flaccid through her arms. A lack of emotional expression and eye contact and a lower level of overall arousal are also correlated with this attachment group (Cozolino, 2002). In a sensorimotor approach, somatic interventions that strengthen interactive regulation and social engagement (reaching out, seeking proximity, eye contact) provide effective avenues of exploration.
Children with insecure-avoidant attachment histories have a more complicated balance to attain between their need for caregiver proximity and their tolerance of anxiety; this adaptation may be subsequently reflected in a disjunction or disconnection between their interior needs and their external behavior. These incongruent patterns are apparent in our adult clients, too. For instance, the client who sits on the couch, visibly uncomfortable, may respond to the question “How are you doing?” or “How are you feeling in your body” with a smile and “Fine.” This client’s disconnection between her physical or emotional discomfort and her reported psychological state demonstrates an incongruence or mismatch between her inner psychological and somatic states, of which she is frequently genuinely unaware. Treatment for these clients includes becoming aware of internal states and practicing physical movements that accurately correspond to these states.
INSECURE-AMBIVALENT ATTACHMENT
The mother of the infant who develops insecure-ambivalent attachment patterns is inconsistent and unpredictable in her response to the infant. She may either over-arouse the infant or fail to help the infant engage. Because her interactions are often a response to her own emotional needs and moods rather than the infant’s, this caregiver might stimulate the infant into high arousal even when the infant is attempting to down-regulate by gaze aversion. Thus, when the mother’s own emotional need for engagement overrides the infant’s need, her behavior intrudes on the infant causing dysregulation of the infant’s arousal. Because the caregiver is inconsistent in her availability, sometimes allowing and encouraging proximity and sometimes not, the child is unsure of the reliability of the caregiver’s response to his or her somatic and affective communications (Belsky, Rosenberg, & Crnic, 1995; Carlson, Armstrong, Lowenstein, & Roth, 1998; Main, 1995). This uncertainty results in infants who appear cautious, distraught, angry, distressed, and preoccupied throughout both separation from, and reunion with, the mother. Upon reunion, they typically fail to be comforted by the caregiver’s presence or soothing (Main & Morgan, 1996), often continuing to cry. These infants characteristically appear irritable, have difficulty recovering from stress, show poor impulse control, fear abandonment, and engage in acting-out behavior (Allen, 2001). One example of the ambivalence such infants show with the unpredictable parent is to alternate between angry, rejecting behaviors and contact-seeking behaviors upon reunion with the mother after separation. Children with insecure-ambivalent patterns have a “difficult temperament” with “tendencies to intense expressiveness and negative mood responses, slow adaptability to change, and irregularity of biological functions” (Schore, 2003a).
Children with insecure-ambivalent attachment histories are described as having a preoccupied stance toward attachment in adulthood. They are preoccupied with attachment needs, overly dependent on others, and might have a tendency toward enmeshment and intensity in interpersonal relationships, with a preference for proximity. They focus excessively on internal distress, often pursuing relief frantically (Cassidy & Shaver, 1999). With a compromised social engagement system, these clients are often unable to recognize safety within the relationship. Preoccupied with the availability of attachment figures (including the therapist), they frequently experience increased affect and bodily agitation and increase or loss of muscular tone at the prospect of separation. A sensorimotor approach would facilitate autoregulatory capabilities through a development of grounding, boundaries, and core internal support as well as promote adaptive interactive regulatrory abilities (see Chapter 10).
Children with insecure-ambivalent attachment patterns may demonstrate more congruency between internal states and external physical movement than insecure-avoidant children, but their behavior is often dysregulated. Their physical movement may be uncontained, geared more toward discharge of high arousal than toward the purposeful achievement of a specific goal. For example, a child may frantically cry and flail when the attachment system is aroused, rather than execute directional, purposeful movement toward the caregiver. The movement may take the form of agitation that does not translate into a tempered, purposeful movement that accomplishes a particular goal. In a sensorimotor approach with adult clients with insecure ambivalent attachment histories, learning to tolerate high emotional and physiological arousal and execute thoughtful, purposeful action rather than dysregulated, non-directional movement is essential.
Disorganized/Disoriented Attachment
Main and her colleagues (Main, 1995; Main & Hesse, 1990; Main & Solomon, 1990) observed a group of children who had puzzling and contradictory sets of responses to their mothers upon reunion after separation. The researchers also observed the mothers, whose behavior they evaluated as “frightening” (e.g., looming behaviors, sudden movements, sudden invasion, attack postures) or “frightened” (e.g., backing away, exaggerated startle response, retraction in reaction to the infant, a fearful voice or facial expression) (Main & Hesse, 1990). In addition, these mothers may exhibit role confusion (e.g., eliciting reassurance from the child), disorientation(e.g., trance-like expression, aimless wandering in response to the infant’s cries), intrusive behavior (e.g., pulling the child by the wrist, mocking and teasing, withholding a toy) or withdrawal (e.g., not greeting the infant, not interacting verbally, gaze avoidance) (Lyons-Ruth, 2001). These caregivers often provoked sudden state switches without providing interactive repair. Sometimes the caregivers (usually the mother) of these children may be abusive or neglectful or both. Such a caregiver
induces traumatic states of enduring negative affect. Because her attachment is weak, she provides little protection against other potential abusers of the infant…. This caregiver is inaccessible and reacts to her infant’s expressions of emotion and stress inappropriately and/or rejectingly, and shows minimal or unpredictable participation in the various types of arousal-regulating processes. Instead of modulating, she induces extreme levels of stimulation and arousal, either too high in abuse or too low in neglect, and because she provides no interactive repair, the infant’s intense negative emotional states last for long periods of time. (Schore, submitted)
Because this misattuned caregiver shows little or no attempt to recognize or repair breaches in relatedness, the infant is left in hyper-or hypoaroused zones for extended periods of time.
Main and Solomon (1986, 1990) named the attachment pattern that developed from such caregiving the disorganized/disoriented style and identified seven categories of behavior indicative of this style:
Main and Solomon observed that these infants’ “approach movements were continually being inhibited and held back through simultaneous activation of avoidant tendencies. In most cases, however, proximity-seeking sufficiently ‘over-rode’ avoidance to permit the increase in physical proximity. Thus, contradictory patterns were activated but were not mutually inhibited” (1986).
Versions of these incongruent behaviors are observed in traumatized adults, especially in the context of discussing past relational trauma or past or current attachment relationships, including the relationship with the therapist. In clinical contexts, therapists often are confused by what seem like paradoxical responses to contact and apparent relational discontinuity. For example, Lisa frequently complained that “no one is there for me” and begged her therapist for more contact: to sit closer, to hold her hand if she cried, to call to see how she felt during the week. Yet, in sessions, Lisa consistently seated herself in such a way that she was facing away from the therapist and orienting toward the floor and sofa, and her body stiffened when the therapist moved her chair closer (at Lisa’s request). Proximity seeking emerged in her verbal communication, whereas avoidance was communicated physically: her body held back the approach, avoiding even eye contact.
The often confusing incongruent and contradictory behavior observed in these infants, and in clients such as Lisa, can be understood as the result of simultaneous or alternating stimulation of two opposing psychobiological systems: attachment and defense (Liotti, 1999a; Lyons-Ruth & Jacobvitz, 1999; Main & Morgan, 1996; Ogawa, Sroufe, Weinfield, Carlson, & Egeland, 1997; Van der Hart et al., 2004). An infant predictably seeks proximity to the caregiver when distressed, but if the caregiver further distresses the infant instead of providing comfort and safety, an irresolvable paradox ensues (Main & Solomon, 1986). The infant cannot satisfactorily approach, flee, or reorient his or her attention. When the attachment system is aroused, proximity-seeking behaviors are mobilized. But when the defensive system is aroused, flight, fight, freeze, or hypoarousal/feigned death responses are mobilized. The disorganized/disoriented infant experiences the alternating or simultaneous stimulation of these two opposing psychobiological systems.
Steele, Van der Hart, and Nijenhuis (2001) have challenged the notion that this attachment paradigm is, in fact, “disorganized” (see also Jaffe et al., 2001). They have proposed that, in the context of frightened and/or frightening caregiving, disorganized/disoriented attachment is actually an organized, logical response caused by the concurrent activation of both the defensive and attachment systems: the social engagement system and the sympathetic and dorsal vagal systems are thought to be simultaneously or alternately stimulated. In childhood trauma and neglect, disorganized/disorientated attachment as a strategy is a logical outcome. The ongoing threat of frightened and frightening caregiving evokes the action tendencies of both proximity seeking and defense. This attachment behavior has been demonstrated in 80% of maltreated infants (Carlson et al., 1998) and is a statistically significant predictor of both dissociative disorders (Carlson et al., 1998; Liotti, 1992) and aggressive behavior (Lyons-Ruth & Jacobvitz, 1999).
The therapist notes the physical manifestations of relational tendencies that reflect this attachment pattern in adults and works with them directly. For example, Kathy presented in therapy with a profound distrust of the therapist, expecting betrayal and even attack. Her body was stiff, her eyes never wavered from the therapist’s face, and she exhibited little movement. Whenever the therapist moved, Kathy’s arousal increased. Yet she had sought therapeutic help, wanted to tell her story, and even called her therapist between sessions. She reported a childhood of extreme abuse from a primary attachment figure, which naturally evoked the alternation or simultaneous stimulation of attachment and protective or defensive impulses characteristic of disorganized/disoriented attachment. Her conflict between social engagement—seeking therapy, telling the therapist her story, calling the therapist for contact between sessions—and defense—fear, “frozen” body, and hyperarousal—reflects the early attachment disturbances from childhood trauma. The therapist, understanding this dynamic, worked first to increase Kathy’s ability for social engagement by helping her have more control of her interactions in therapy. Because Kathy often felt threatened when the therapist moved, the therapist encouraged Kathy to notice when she felt her arousal begin to increase, and request that she (the therapist) sit still at those times. The therapist also told Kathy when she was about to move, so that her unexpected movements would not surprise Kathy. As Kathy’s sense of control and safety increased, her arousal remained more often within the window of tolerance. The therapist then worked directly with both of Kathy’s tendencies (defense and proximity seeking) by first discussing them with her, then asking her how her body would demonstrate both tendencies simultaneously. Kathy reached out toward the therapist with one hand while putting her other hand up in a defensive position. With this gesture, she took a deep breath, saying, “This is exactly how it is. I need both in all my relationships—I need contact, and I need to be on guard.” Throughout Kathy’s treatment, she and her therapist tracked when proximity-seeking, social engagement tendencies were prominent (through approach movements) and when proximity-avoiding tendencies were prominent (through defensive movements) and explored options for integrated action appropriate to current context.
ATTACHMENT PATTERNS AND SELF-REGULATION
The hierarchical relationship between social engagement, sympathetic, and dorsal vagal parasympathetic systems is established early in life and forms enduring overall arousal tendencies, reactions under stress, and even vulnerability to psychiatric disorders (Cozolino, 2002; Lyons-Ruth & Jacobvitz, 1999; Schore, 2001, Sroufe, 1997; Van Ijzendoorn et al., 1999). As the infant’s affect regulatory structures develop through attuned interactive regulation, they progress from dependence on external regulation to the capacity for internal regulation (Schore, 2001). For the infant in a secure attachment relationship, interactions with the caregiver “[facilitate] right brain development, promote efficient affect regulation, and [foster] adaptive infant mental health” (Schore, 2001). The child’s immature brain is continually stimulated in ways that “prune” the neurons of the orbitoprefrontal cortex, a structure that is especially important because of its profound effect on self-regulation. We depend upon the right orbitoprefrontal cortex for its ability to regulate emotional and autonomic arousal (Schore, 1994; Siegel, 1999), and this area of the brain depends reciprocally upon interactive regulation in infancy for its development. The early socioemotional context directly influences the prefrontal areas of the right brain that are “dominant for the unconscious processing of socioemotional information, the regulation of bodily states, the capacity to cope with emotional stress, and the corporeal and emotional self” (Schore, 2003).
Self-regulation comprises two strategies—auto and interactive—described by Schore as, respectively, “autoregulation in autonomous contexts via a one-person psychology” and “interactive regulation [via social engagement system] in interconnected contexts via a two-person psychology” (2001). With both auto-and interactive regulatory abilities, a person can observe, articulate, and integrate emotional and sensorimotor reactions in solitude and can equally utilize relationships to achieve a similar end. These capacities are founded upon early attachment dynamics: “Early interactive experiences determine whether, in later times of crisis, the individual can allow himself to go to others for interpersonal support, that is, to avail himself of interactive regulation within an intimate or psychotherapeutic relationship when his own autoregulatory mechanisms have temporarily failed” (Schore, 2001).
Secure Attachment and Regulation
Each of the four attachment patterns reflects specific tendencies of self-regulation and autonomic dominance. In the context of secure attachment, the child develops increasingly sophisticated autoregulatory abilities appropriate to his or her developmental age. Concurrently, the child is able to seek others for regulation, as needed, and has little or no resistance to utilizing interactive regulation to bring arousal into the window of tolerance. In a secure attachment relationship the child learns a balance of autoregulatory and interactive regulatory strategies that are internalized via the development of regulatory areas of the orbital prefrontal cortex. These regulatory areas of the orbital prefrontal cortex support social engagement and condition a balanced relationship between sympathetic and parasympathetic arousal (Schore, 1994). The child has an optimal ability to evaluate safety, danger, and life-threatening situations and can shift adaptively between the three arousal zones.
Insecure-Avoidant Attachment and Regulation
The child with an insecure-avoidant history may depend upon autoregulation and parasympathetic (dorsal vagal) dominance (Cozolino, 2002; Schore, 2003a) to self-regulate, most likely experiencing increased dorsal vagal tone characterized, in the extreme, by feelings of helplessness and lower levels of activity (i.e., a state of conservation and withdrawal) (Schore, 2003a). With a tendency to curtail the expression of emotion (Cassidy & Shaver, 1999), this “overregulation” indicates a reduced capacity to experience either positive or negative affect and may contribute to a low threshold of arousal in socioemotional contexts and to modulation imbalances(i.e., difficulty shifting out of low arousal states and moderating high arousal) (Schore, 2003a). This child, in the relative absence of an available caregiver, is robbed of the opportunity for satisfying social engagement and typically develops a preference for autoregulatory tendencies that do not depend on another’s presence. He or she may learn to modulate arousal in solitude, turning inward through reading, daydreaming, and worlds of fantasy. Although generally compliant, the child may express frustration in peer relationships where avoidant attachment behaviors are sometimes associated with hostility, aggressiveness, and conduct problems (Allen, 2001; Crittenden, 1995; Sroufe, 1997; Weinfield, Stroufe, Egeland, & Carlson, 1999). Interactive regulatory and social engagement abilities necessary for resolving interpersonal conflicts are often underdeveloped in such individuals.
Insecure-Ambivalent Attachment and Regulation
On the other hand, children with insecure-ambivalent attachment patterns tend to have a sympathetically dominant nervous system (Cozolino, 2002; Schore, 2003a) with a low threshold of arousal and concurrent difficulty maintaining arousal within a window of tolerance. The inconsistent responsiveness of the primary caregiver has taught the child to increase signaling for attention, escalating distress in order to solicit caregiving (Allen, 2001). These children are biased toward undercontrolled high-arousal states, with increased emotional reactivity combined with an inability to modulate distress, leaving them vulnerable to underregulatory disturbances (Schore, 2003a). Less able to autoregulate, as adults these individuals find isolation stressful: Because they have trouble tolerating solitude, they cling to relational contact, becoming overly dependent on interactive regulation but simultaneously experiencing a lack of ability to be easily calmed and soothed in a relationship. Although social engagement is sought, the person remains biased toward hyperarousal, in part due to hypervigilence developed from previous experience of intrusive behavior by the primary attachment figure.
Disorganized-Disoriented Attachment and Regulation
Hyper-and hypoarousal are both involved in the infant’s psychobiological response to frightened or frightening caregivers, with whom the social engagement system is functionally off-line for much of the time. Disorganized/disoriented attachment patterns in children has been associated with elevated heart rates, intense alarm reactions, higher cortisol levels, and behavior that may indicate increased dorsal vagal tone, such as stilling, going into a brief trance, unresponsiveness, and shutting down (Schore, 2001). In the initial stage of threat, infants demonstrate sympathetic activation accompanied by startle reactions, elevated heart rate, respiration, and blood pressure, and usually crying or screaming (Schore, submitted). However, when sympathetic arousal cannot be regulated, a quick shift to hypoarousal may occur. The body undergoes “the sudden and rapid transition from an unsuccessful strategy of struggling requiring massive sympathetic activation to the metabolically conservative immobilized state mimicking death associated with the dorsal vagal complex” (Porges, 2001a).
Thus sympathetically mediated responses quickly change “from interactive regulatory modes into long-enduring less complex autoregulatory modes” (Schore, submitted). During these hypoaroused conditions, observed in newborns (Bergman, Linley, & Fawcus, 2004; Spitz, 1946), the infant is unresponsive to interactive regulation (Schore, submitted). Early relational trauma generates prolonged negative affective and physiological states in the infant, which, in turn, “generate immature and inefficient orbitofrontal systems, thereby precluding higher complex forms of affect regulation” (Schore, submitted). These negative states also leave the child with a compromised social engagement system.
Tramatogenic environments that produce disorganized-disoriented attachment behaviors in children typically include both neglect and abuse: Children living in conditions of neglect are often at the mercy of abusive and/or unprotective adults, and abusive environments usually include neglect. Whereas physical, emotional, or sexual abuse typically produces either chronically heightened autonomic arousal or biphasic alternations between hyper-and hypoarousal states, neglect typically leads to a flattening of affect (Gaensbauer & Hiatt, 1984), which has a more negative effect than abuse alone (Cicchetti & Toth, 1995) due to the decreased arousal and behavior associated with chronic increase in dorsal vagal tone. Whereas over-stimulation and inadequate repair are inevitable outcomes of trauma, inadequate stimulation, insufficient mirroring, and a lack of responsiveness by the caregiver accompany neglect. Such inadequate stimulation can be life-threatening to an infant, forcing the child to autoregulate by becoming disengaged and hypoaroused (Carlson et al., 1998; Perry et al., 1995; Schore, 2001). In chronic and extreme hypoarousal, the child may even enter persistent conditions of conservation and withdrawal, with profoundly reduced affect, loss of postural and muscular tonicity, and disengagement from the environment. Individuals who have experienced chronic childhood trauma characteristically suffer from a compromised social engagement system, underdeveloped or ineffective interactive regulatory abilities, as well as impaired autoregulatory capacities; they remain in, or alternate between, hyper-or hypoarousal zones for extended periods of time.
SENSORIMOTOR TREATMENT
Attachment to the therapist “serves as a base from which to explore both the inner world and the outer environment, offering a haven of refuge at times of fear and anxiety, and a source of information for understanding the underlying meanings of troubling symptoms” (Sable, 2000). Each attachment pattern poses particular challenges for both client and therapist.
Treatment of Insecure-Avoidant Attachment
As we stated above, individuals with insecure-avoidant attachment histories have a dismissive stance toward attachment in adulthood, and may have a tendency toward a parasympathetically (dorsal vagal) dominant autonomic nervous system as well as a tendency to autoregulate. Therapeutic goals for these individuals include fostering interactive regulation and the ability to engage in social interaction when their arousal is higher than they are used to. The clients often turn away from social interaction when they are anxious, and practice managing this higher arousal state during interpersonal interaction fosters a wider window of tolerance. These goals are approached in a titrated manner because pushing too quickly for change may trigger both psychological and somatic defenses and cause the client to feel more withdrawn and possibly less open to treatment and change. Therefore, a slow collaborative approach is taken, using a combination of psychoeducation about the client’s attachment history and the creation of a collaborative atmosphere of exploration about the way the elements of the attachment group are experienced in movement and sensation.
Sally demonstrated dismissive attachment patterns and behaviors that indicated unresolved trauma. She came to her first session complaining about “intimacy problems” with her partner. She said that she had always felt emotionally remote in relationship to her partner, though she loved and appreciated her. The therapist immediately noted the affective “flatness” with which Sally discussed these concerns. Her body was slumped and showed little spontaneous movement. The therapist asked Sally to choose a pillow that could represent her partner, and to notice what happened in her body as she imagined her partner in the room with her (a typical starting point with a client with an insecure-avoidant attachment history). Sally said that she felt nothing in her body whatsoever, which is common for such individuals. The therapist asked Sally to notice what happened in her internal experience as he moved the pillow closer to her. Sally found that she felt “claustrophobic.” The therapist asked her to notice how “claustrophobia” related to her body. Sally said she felt as if her whole body tightened, and she reported feeling smaller and more distant as the therapist moved the pillow closer. Over the course of several sessions, Sally became more aware that her body would spontaneously tighten and that often her emotions would become unavailable to her when her partner approached her. She and her therapist explored this in the therapeutic relationship as well, and Sally discovered the same response when the therapist increased proximity. Sally described this as a “numbing of her emotions” and inability to feel her body in response to physical closeness. To work on this, the therapist encouraged her to openly discuss these physical and emotional feelings as they arose, thus utilizing the social engagement system and creating links between cognitive, emotional, and sensorimotor levels of processing.
Sally also learned to pay attention to times she felt uncomfortable in the therapy hour, and to ask her therapist to stop when he came close physically (by leaning forward) or verbally/emotionally (by asking questions), and to request more time to explore and report her internal experience. Over the course of many sessions, Sally began to trust that she could control the physical and psychological proximity to the therapist and began to feel like she was “less numbed out” for longer portions of the session. She said she felt like she was able to sense her body and her emotions and be in a relationship for the first time. Eventually, Sally became more comfortable “being in her body” while relating emotionally and exploring closer psychological proximity to her therapist, and eventually her partner.
Treatment of Insecure-Ambivalent Attachment
The wounding of the child with a history of insecure-ambivalent attachment also disrupts intimate capacity and interactive regulation, but through different somatic mechanisms and for different reasons. The person with this attachment history is “ambivalent” because of the inconsistent attunement and unpredictable intrusiveness of the caregiver and the undeveloped capacity for autoregulation. As noted, these children develop a preoccupied stance toward attachment in adulthood. The emotional lability and irritability of this attachment pattern (which was distinctly absent in the insecure-avoidant attachment pattern) often manifest as dysregulated behaviors that may be an attempt to “discharge” strong affect and arousal.
Tom demonstrated a preoccupied stance toward attachment needs, and also behaviors that indicated unresolved trauma. He was unable to regulate his emotions and expressed an inability to trust his wife. As he spoke, the therapist noticed that he moved around in the chair and nervously jiggled his legs. He spoke quickly, in an impulsive rather than thoughtful manner, and was emotionally labile and intense. Over the course of several sessions, the therapist intervened by 1) helping Tom feel more grounded physically, and therefore emotionally (see Chapter 10); 2) working directly with the physical sensations of emotional and physiological activation and stress by bringing his mindful awareness to them and encouraging him to refrain from behaviors that served to discharge this arousal; and 3) tracking these sensations as they slowly progressed through his body, allowing the sensations of arousal to manifest, build, autonomically discharge (through trembling, shaking, temperature changes, etc.), and eventually come to rest—rather than utilizing behavior, such as aggressive outbursts and excessive exercise, to dissipate it. As Tom became more proficient at recognizing his own physical and emotional discomfort during the therapy session, he learned to contain his feelings of anxiety by remaining aware of his body sensation, grounding himself, and practicing other physical actions that helped him develop his capacity to contain his emotional experience and calm down. Over time he found that he could talk about very intimate aspects of himself and his relationship while feeling more grounded and comfortable with physiological and emotional arousal. This allowed him to interact with his therapist (and his partner) without displaying uncomfortable emotional outbursts.
Treatment of Unresolved Disorganized-Disoriented Attachment
In the context of trauma treatment, the unresolved disorganized-disoriented attachment pattern poses the most extreme challenge for both client and therapist: Attachment to the therapist in the context of the therapeutic alliance inevitably mobilizes the client’s defensive system, whereas distancing by either client or therapist inevitably mobilizes the client’s attachment system. Unresolved trauma results in a “blockage in the flow of energy and information between two minds” (Siegel, 2001). With a compromised social engagement system, clients suffering from childhood relational trauma understandably have great difficulty utilizing relationships, including the therapeutic relationship, for interactive regulation. Herman (1992) pointed out that although traumatized individuals desperately need to form a trusting relationship, they are beleaguered by fears and suspicions learned from, and relevant to, their traumatic past. These fears and suspicions often prevent clients from engaging in adaptive relational behavior. As much as the therapist might wish to provide good interactive regulation for the client, an interpersonal trauma history disrupts the client’s ability to experience the therapist as safe and reliable. In the words of Hedges, “Contact itself is the feared element because it brings a promise of love, safety, and comfort that cannot ultimately be fulfilled and that reminds [the client] of the abrupt breaches of infancy” (1997). One of the first tasks of therapy is to strengthen the social engagement system by helping clients overcome “the phobia of attachment to the therapist” (Steele et al., 2005b).
With this challenge in mind, the therapist, like an attuned caregiver, attempts to keep the client within the window of tolerance by taking a number of precautions to assure that the information evoked in the therapy hour is within the client’s ability to integrate. Like the good enough mother who observes and contains the child through psychophysiological dyadic regulation, the sensorimotor psychotherapist observes or “tracks” the subtle movements and somatic “expressions” that accompany the client’s words and emotions, linking body and mind experiences and helping the client to down-regulate hyperarousal and counteract the numbing effects of hypoarousal. Understanding the crucial importance of nonverbal, bodily cues in regulating the client, the therapist experiments with changes in pace, tone, and volume of voice, body posture, movement, and physical distance from/ closeness to the client, tracking closely for dysynchrony and reestablishing synchrony. Therapists must consistently employ techniques facilitating interactive repair to keep clients’ arousal within a window of tolerance.
It bears repeating that as clients attempt to manage states of overwhelming negative affect, their recognition and experience of positive affective states is inevitably impaired. Most traumatized clients lack the capacity to experience pleasure and joy in their lives. Overwhelmed by negative affects and triggered by reminders of trauma, these clients invariably find that even their capacity to become aware of pleasurable experience is compromised. In addition, positive affective states often have become associated with danger in tramatogenic childhood environments: Pride in accomplishment may have been shamed; laughter may have been punished; relaxation may have meant a loss of hypervigilence leading to exploitation. This phobia of positive affect can be gently challenged by the therapist by facilitating experiences of curiosity, exploration, humor, empowerment, and play (see Chapter 12).
With the help of the therapist’s thoughtful interactive regulation of both positive and negative affect, the client’s social engagement system is stimulated and developed. As the availability of the social engagement and attachment systems facilitates successful experience of regulatory repair, clients learn the autoregulatory capacities of observing and tracking their own emotional, cognitive, and sensorimotor reactions. Paradoxically, the therapist’s ability to interactively regulate the client’s dysregulated arousal creates an environment in which the client can begin to access his or her own ability to regulate arousal independent of relational interaction. As Schore (2003b) explained: “Over the course of the treatment, the therapist’s role as a psychobiological regulator and coparticipant in the ‘dyadic regulation of emotion’ (Sroufe, 1997), especially during clinical heightened affective moments and episodes of projective identification, can facilitate the emergence of a reflective capacity and an ‘earned secure’ attachment”. Additionally, the therapist is cognizant of the fact that both the client’s attachment and defensive systems will be evoked within the therapeutic relationship and tracks for the behavioral indicators of both of these systems.
Louise and Frank came to sensorimotor psychotherapy because of marital problems, which both reported as stemming from Louise’s recurrent history of sexual abuse between ages 5 and 8. Louise and Frank had not had sexual relations in over a year, and Frank complained that Louise’s behavior was “unpredictable.” He described how painful it was for him when Louise invited him to be close, then suddenly and unexpectedly pulled away physically—behaviors that may indicate sequential arousal of attachment and defensive systems. Though Louise generally seemed well adjusted and able to modulate her arousal level, the topic of sex immediately evoked autonomic arousal and emotions that would swing from high to low, with little ability on her part to self-regulate. Demonstrating conflicting action tendencies typical of disorganized-disoriented attachment, she engaged in attachment-related, proximity-seeking behavior at the thought of intimacy with her husband (evident in a soft, open, inviting facial expression, eye contact with Frank, slight smile, open body posture and movement toward him), but then quickly experienced two different defensive responses: accelerated heart rate and tension in her body, especially her legs, which Louise described as indicating that she wanted to “run away;” as well as “spacing out,” vacant eye contact, and losing interest in the exchange.
Evoking Louise’s social engagement system, the therapist, a male, helped her notice her physical tendencies of attachment and defense and the extremes of autonomic arousal she experienced, and he asked her to pause when arousal became high until it was back within the window of tolerance. Louise became curious about these physical tendencies and learned to notice when her defensive reactions usurped her desire to be close to her husband. The therapist helped her assemble several strategies to use both during therapy and with Frank at home. In the initial session interventions were focused on helping Louise experience control and choice: She was encouraged to stop the discussion when any topic (including the topic of sexuality) triggered her defensive reactions. Once Louise realized she had this control, she no longer felt the need to “withdraw” or “run away,” and she observed that her autonomic arousal began to stabilize, enabling her to socially engage. She reported that her body sensations became less overwhelming and turbulent, and also less numb. She could feel her feet literally touching the ground.
Louise’s therapist encouraged her to become aware of other stimuli that were triggering to her and to notice her physical reactions to them. Louise reported that being in the presence of two men (her male therapist and her husband) was frightening for her, and she correlated the fear with stiffness in her neck, trembling throughout her body, and tension in her legs. Louise, Frank, and the therapist decided that Louise could try moving her chair closer to the door and open the door slightly. Her therapist suggested that she would have the option to leave the room if she became more triggered and afraid. As she sat near the door, Louise slowly stopped trembling and her stiff neck began to relax.
In this initial session, Louise continued to feel somewhat distressed and unable to fully calm herself. A third intervention was suggested by her therapist and proved useful. When Louise experimented with holding a large square pillow that covered her entire torso and genitals, she felt more relaxed. Her therapist encouraged her to use the pillow when she experienced autonomic arousal or defensive strategies, thus facilitating Louise’s closer observation of her bodily experiences—which in turn enabled her to self-regulate during the session with greater competence. With the addition of the pillow, Louise experienced a returning sense of physical calmness and greater capacity for social engagement.
Through understanding her defensive tendencies and learning these somatic strategies that calmed her physiological arousal, Louise began to experience greater trust in the therapist and the therapeutic process. Through her social engagement with, and the interactive regulation of, her therapist, combined with her use of these strategies, Louise’s capacity to self-regulate during the sessions was enhanced. She mentioned that she felt able to find the words to tell the therapist about her internal experiences and that she actually liked working with him. Thus the first session enabled the formation of a therapeutic alliance. Additionally, Louise and her therapist designed homework to help her notice her defensive tendencies and to engage in conscious, adaptive behaviors, such as verbalizing her needs or placing a pillow in front of her body when physically close to her husband. These strategies enabled her to increase her contact with Frank without becoming physically aroused or defensive.
During a later session, the idea of physical and sexual contact between Louise and Frank was explored. The therapist suggested that they imagine physical (nonsexual) touch between them. Prior to the onset of treatment, Louise had been having startle responses any time she even imagined Frank touching her without her explicit permission. No contact during sleep and little contact around the house was tolerable. Work with this issue began slowly. The therapist asked them both to think of a place that might foster their exploration of physical, sensual, but non-sexual contact. When Frank suggested the bedroom, Louise physically braced and pulled back, triggering her into what she called a “freeze” and then “shutting down” mode. Despite Frank’s frustration at her reaction, they began to brainstorm other possibilities. Frank suggested the couch. Again Louise found her body bracing instinctively. Finally, Louise suggested somewhere public, such as a park. When she visualized this scenario, it still seemed “like a lot,” but it led to another idea: “How about when we’re in a park watching something else, like a game or something, and we start holding hands and touching each other (non-sexually).” She closed her eyes and noted that her body relaxed when she imagined this interaction. Frank was disappointed but agreed to give it a try.
The following week, Louise was pleased. She was beginning to work with these “sensual” exercises in a way that did not provoke her defensive tendencies, and she reported that she could keep her arousal within a window of tolerance. She and Frank had gone to a park to watch children play and were physically affectionate there, hugging, holding hands, and occasionally kissing. The therapist asked Louise if she actually felt pleasure. The first week her answer was “No,” leading the therapist to suggest that Louise initiate and direct more of the contact. As the weeks progressed, Louise felt increasingly greater control over their physical contact and gradually began to feel pleasure. As time passed and her ability to interactively (by talking with Frank) and autoregulate increased, Louise was able to maintain her autonomic arousal within a window of tolerance as her trust and enjoyment of Frank’s closeness became greater and more pleasurable. Strategies, boundaries, and structure were essential ingredients to Louise’s developing sense of attachment and ability to modulate her arousal.
CONCLUSION
Because the ability to modulate arousal and develop healthy, adaptive relationships requires sophisticated mental and physical abilities that are dependent on early attachment and social engagement experiences, clients with histories of neglect, abuse, and attachment failure are often challenged relationally, especially when faced with unexpected reminders of their trauma. Autonomic dysregulation evoked by trauma-related relational stimuli drive intense hyper-and hypoarousal responses and fixed action tendencies, such as hypervigilance, fight, flight, freeze, or submit responses, associated with early experience. Misinterpretation of their own responses and those of others results when procedural survival-related learning from the past usurps awareness of the present. Social engagement suffers as sympathetic and dorsal vagal responses predominate over ventral vagal responses. In treatment, sensorimotor therapeutic interventions address habitual action tendencies and practice to establish more adaptive capacities. As the therapist facilitates an attuned, collaborative “dyadic dance” with the client, the experience of interactive psychobiological regulation allows the individual to modulate his or her arousal and achieve states of pleasure and calm, rather than extremes of arousal. Practice of new actions in the context of attuned social engagement with the therapist leads to the development of more adaptive relational capacities and the strengthening of both interactive regulatory skills and autoregulatory abilities. Through the successful accomplishment of previously feared or unfamiliar actions, as illustrated in the case of Louise, feelings of mastery emerge. Finally, as the attachment and social engagement systems become more accessible to the client, other transformations begin to occur in the orienting and defensive systems.