Early Attachment
THE INITIAL ENGAGEMENT IN THERAPY with trauma patients requires an understanding of the earliest ways of relating that give rise to patterns of feeling, being, and behaving that persist throughout life unless another meaningful relationship can harness the plasticity of the brain to bring about lasting change. It is in the context of relationship that healing change can occur.
From birth, and even before birth, the provision of a nurturing environment is the key to emotional well-being and the realization of the full developmental potential of an individual because genetic potentialities can only become activated by actual early experience of secure and loving care-giving. Hart (2008) notes that first relationships influence the internal hormonal environment of the infant and that these hormones in turn influence the way in which the baby’s genetic material manifests itself. Thus the early development of mind is dependent on each individual’s experiences of relating to others. I summarize below Gergely and Unoka’s (2008) list of the species-specific characteristics of human mother-baby interactions:
• A “proto-conversational” turn-taking contingency structure
• Baby’s preference for eye contact, contingent reactivity, and “motherese”
• Baby’s attention to and gaze-following activities
• Frequent exchanges of rich and varied facial-vocal displays of emotion
• Empathic affect-mirroring displays of emotion
• Baby’s capacity to reenact parents facial-vocal displays of emotion
Schore (2003b) explains that in such face-to-face interactions the child uses the output of the mother’s emotion-regulating right cortex as a template for the imprinting of his or her own right cortex that will mediate his or her own expanding abilities. Bucci (1997) notes that as “repeated observations of an object form functionally equivalent classes and prototypic images, so repeated episodes with a common affective core, involving other persons in relation to the self, also form functionally-equivalent classes” (p. 195). The baby internalizes models of emotion schemas for self in relation to others based on his or her particular experiences of interactions with the caregiver. The care offered will reflect, to a great extent, the parent’s own early experience of being cared for and his or her own attachment style. Cozolino (2006) notes that poor early experience may have an adverse effect on the development and organization of the spindle cells in the anterior cingulate, with lifelong consequences for cognitive and emotional functioning. These consequences will include the child’s own future parenting style—which means that poor early experience may be passed on from generation to generation.
In good-enough circumstances caregivers establish a warm, empathic way of being with a child that forges a secure attachment, from which the growing child steps confidently into the wider world. The very rapid form of learning that occurs through the holding and smiling and vocal exchanges of the first months of life “irreversibly stamps early experience upon the developing nervous system and mediates attachment bond formation” (Schore, 2003a, p. 277). In good-enough circumstances this earliest emotional learning happens naturally as mother and baby begin to get to know each other. Such an experience inevitably includes the sensitive regulation of affect that an attentive and secure mother is able to offer to her baby and which leads, in due time, to the development of the ability to self-regulate affect.
Neural Substrates of Early Attachment
Relating to another in this healthy way is an early right-hemisphere activity that stimulates the growth of the centers for speech and language in the later developing left hemisphere of the brain, leading ultimately to the development of the child’s own mind (Tzourio-Mazoyer et al., 2002). In this respect the affectionate interaction with caregivers literally “grows” the baby’s brain (Gerhardt, 2004). Research with infants shows that the brain tissue where language is localized begins to develop as early as 3 months of age, that the functional cortical specialization involved in face recognition and processing is “online” at 6 months of age (de Haan & Nelson, 1999), and that by 1 year it is possible to identify the significant role played by the orbitofrontal cortex in positive exchanges between a mother and her infant (Minagawa-Kawai et al., 2008).
As the right brain is online from birth, it is a key player in these early emotional learning processes. Right-brain learning is primarily relational in nature; therefore, successful learning will inevitably be personalized. Patterns of expectation of how relationships will go begin to accumulate in the young child’s brain; they are stored in implicit or emotional memory and have a lasting effect on the way a young person begins to expect interactions to be with another, indeed all others. The sparse connections in the infant brain—mind mean that the child is much like a play about to be written: to a certain extent the content is already determined (genetically), but the drama that will emerge is as yet unknown and will be shaped by environmental influences. The baby’s brain responds to healthy interaction with another brain—mind by growing more neuronal connections than will ultimately be needed, so a neural pruning takes place in which cells without inputs die. The “use it or lose it” principle of learning is at work from the very beginning: appropriate levels of stimulation and interaction with another are key in this crucial developmental process (Wilkinson, 2006a).
The new “non-invasive neuroimaging techniques that allow three-dimensional spatial mapping of metabolic activity (which reflects level of neuronal activity) in real time” (Sherwood, 2006, p. 63) allow us “to measure in vivo subtle inter-individual differences in brain structure and to assess activity in distinct neural circuits from birth to adulthood” (Paus, 2005, p. 60). Knickmeyer et al. (2008) carried out a large-scale study using functional magnetic resonance imaging (fMRI) on brain development in the first 2 years after birth. They reported earlier work that identified a dramatic increase in overall brain size with, by age 2, the brain reaching 80–90% of adult volume, rapid elaboration of new synapses, an increase in overall gray matter volume, and myelination of white matter. Their own study revealed the following:
Total brain volume increased 101% in the first year, with a 15% increase in the second. The majority of hemispheric growth was accounted for by gray matter, which increased 149% in the first year; hemispheric white matter volume increased by only 11%. Cerebellum volume increased 240% in the first year. Lateral ventricle volume increased 280% in the first year, with a small decrease in the second. The caudate increased 19% and the hippocampus 13% from age 1 to age 2. (p. 12,176)
Early Attachment and A Robust Sense of Self
Further research has indicated that securely attached mothers are more able to match their babies’ moods than those with less secure or disorganized attachments (Haft & Slade, 1989). Researchers also observe the importance of therapeutic intervention in the first year of life for those most at risk, citing data from the Bucharest Early Intervention Project, which is studying a group of Romanian children in foster care who had earlier experienced extreme deprivation in orphanages. They note that children placed in foster care before 2 years of age appear to be making far better improvements in cognitive development than those placed in foster care after the age of 2. Chugani’s earlier study of Romanian orphans had shown that these children, “cut off from close bonds with an adult by being left in their cots all day, unable to make relationships, had a virtual black hole where their orbitofrontal cortex should be” (as cited in Gerhardt, 2004, p. 38).
What is becoming more and more evident from research in both contemporary neuroscience and attachment is that a young person’s brain and mind will owe a huge amount to the infant’s and growing child’s experiences of nurture with the mother, with the father, and with significant others, and later with the world of school and the wider world beyond it. It is much more than merely the young person’s brain that is the outcome of successful affect regulation and the development of emotional competence in the earliest years. Rather it is the interactive development of an ever-increasing connectivity resulting in the complexity that is mind, which in turn gives rise to varied but interlinked self states. Ultimately it is on issues around attachment and affect regulation that a person’s capacity to experience a sense of self that is, as noted previously, “simultaneously fluid and robust” depends (Bromberg, 2006, p. 32).
Research indicates not only that the right hemisphere is dominant for face recognition and sense of self throughout life but also that even 2-month-old infants looking at their mother’s face utilize what, in the left hemisphere, will later become their language network. Tzourio-Mazoyer et al. (2002) note that “co-activation of the face and the future language network sustains the facilitative efforts of social interactions, such as looking at the mother’s face, on language development” and establishes a sense of self and others (p. 460). The capacity of the young child to develop a secure and robust sense of self and of personal identity as well as of the identity of another was brought home to me recently in a rather charming way by Naja, the young daughter of close friends. This young family spoke a language that I had struggled (rather unsuccessfully) to acquire. Naja had seen me every month or so since she was born and almost always greeted me with delight, gurgling away as I lalled to her in English. She was about 1 year old when I began using some words of her own language to speak to her, and the look of recognition was clear to behold in contrast with our encounters in English, which relied heavily on affect for our sense of being in touch with one another. At 15 months her father spoke to her in English on one occasion when I had not been there for several weeks. To his surprise Naja immediately smiled broadly and exclaimed “Maggie!,” demonstrating that both receptive and expressive language have their roots firmly in relationship (Figure 2.1).
Early Patterns of Attachment and Their Effect on Affect Regulation
Given that the mind is fundamentally associative and its development based on psychological identification, these early patterns of relating are inevitably transferred to significant others in the outside world. The teacher who looks after children in their first year in school may hardly recognize herself in the eyes of a frightened or angry child who is reacting to her so badly on the basis of earlier traumatic experience. In contrast, the boy or girl whose early experience has led to secure attachments will go forth confidently into the world, aware of how to engage with others in a comfortable way. In other words, in the important new relationships that they make, children mirror ways of being with others and expecting others to be that are already firmly established inside. These processes are early, implicit, and emotional in nature. Emotional competence is achieved through healthy interaction with another mind, which provides a secure base from which further emotional learning may take place. When a mother is depressed or withdrawn, she may not be able to respond adequately to her baby’s needs, and her baby’s state of distress will escalate. When the mother repeatedly responds in a fearful, angry, terrifying, or inconsistent, unpredictable way, then the child that baby becomes will be affected throughout his or her whole mind-brain-body.
When a mother is unable to protect a child from abuse, the world becomes a terrifying place, and secure attachment moves out of reach without skilled intervention. If sustained trauma is experienced at the hands of those closest to the child, then there are far-reaching effects on the development of mind. Fonagy (1991) suggests that “the parent’s abuse undermines the child’s theory of mind, so that it is no longer safe for the child…to think about wishing, if this implies the contemplation of the all too real wishes of the parent to harm the child” (p. 649).
Case Example: Harriet
A little girl of about 4 years old, whom I will call Harriet, was part of a happy group of children in short-term fostering going to a son et lumière show in the local park. Harriet was in care while her mother was in the hospital and her father was working abroad. She chattered happily to her foster carer who was pushing her in her buggy, enjoying the colored lights, strung through the trees, which came on as they passed them. Harriet enjoyed music and sang along happily to some tunes that were familiar to her. Suddenly the park darkened and the first few notes of some rather scary music came out of the darkness; a sense of urgency and foreboding in the music grew rapidly. Suddenly bright lights flashed out of the darkness at about the height of the child’s face. Harriet became absolutely rigid; the change was noted instantly by the foster carer, who knew that the child had a history of early relational trauma. The group walked away as quickly as possible, rapidly making their way to the well-lit area around the cafe in the park. As they walked, the foster carer leaned forward, touched Harriet’s head gently, and soothed her saying, “It’s all right, you’re with me now and John and Alice are here, and we’re all going to get a drink of hot chocolate.” Slowly the rigidity left the child’s body and gradually she began to relax once again. The foster carer had regulated the level of arousal and averted what appeared to be the beginning of a catastrophic reexperiencing of trauma, triggered by the sudden flashing of bright lights in the darkness and the music that was frightening to the child.
The next day when they were in the car on the way to nursery, Harriet said to the foster carer, “What happened to me when we went to the park?” The foster carer thought for a moment and replied calmly, “I think you were reminded of scary times.” “Yes, what did you say?” asked Harriet. “I said that you were safe, and you were with John and Alice and me,” replied the carer. “Mmm…and?” “And we went to get the hot chocolate.” Enough had been said for the moment and the child moved on to talk about school. The careful way the carer responded to the child’s rather frightened questioning regulated the affect that the child experienced at the transition moment of leaving the carer and going into nursery. This intervention would help her create a coherent narrative of her immediate experience without foreclosing on the exploration of more painful aspects when the child became ready to do so. Later the social worker told the foster carer that new evidence had emerged that the child had been abused in the illicit video industry. Sadly the reasons for Harriet’s intense reaction to the sudden bright light and music were now all too apparent.
The vivid visual and emotional “pictures,” such as may have come to Harriet’s mind in the park revealing aspects of early traumatic affective experience, are products of right-brain activity, recorded in implicit memory. The early traumatic experience is not encoded as part of an autobiographical narrative that is easily accessible because the hippocampus that tags time and place to memory would not have been online yet. Rather the experience would have remained as part of Harriet’s implicit memory, only to emerge when a stimulus such as similar feeling tone, sight, or smell awakens it, much in the way her traumatic experience was reevoked by the light and music in the park.
The method that the foster carer demonstrated will resonate with those who look to regulate levels of arousal within therapy.
• She was alert to the child's level of arousal.
• She sought to regulate that level.
• She used the rhythm, lilt, and melody of her voice to calm the child.
• She moved the child's attention away from the environmental triggers rather than allowing the triggering to continue, leading to further arousal.
• She steadied the child by returning her to positive present sensory experience and to current nurturing relationships.
• Later she steadied the child again by answering her questions in a way that enabled the child to remain regulated at a moment of transition when reengaging with the outside world of school.
• She sought to help the child to think about her experience in a manageable way so that the processes of mentalization were assisted rather than discouraged.
Overview of Memory Systems
Encoding
Memory processing consists of encoding and retrieval, and plays a vital part in allowing us to develop a sense of self as well as a sense of self in relation to others over time. Memory makes possible the pattern-matching and meaning-making processes that allow us to build on earlier experience in a creative way, that enable us to make sense of current experience, and to regulate our affect in the light of past experience. LeDoux (2002) describes memory as the maintenance and stabilization of changes in synaptic connectivity over time. Patients who, due to neurological deficits or damage, are unable to remember, live in an endlessly present moment without the benefits that memory may bring to bear on the capacity to regulate affect arising out of current experience. Let’s first review briefly the nature and making of memory. The asymmetries in the two hemispheres of the brain give rise to two very different systems for processing and recording different types of experience. One is known as explicit or declarative memory, which can be accessed and spoken about. The other is described as implicit, nondeclarative, or procedural memory and is not dependent upon conscious processes. Understanding the nature of these two systems is fundamental to our appreciation of the connection between relational and interpretational aspects of the therapeutic process. The earliest form of memory is unconscious, implicit, emotional, and inaccessible, arising out of right-hemisphere processing of early relational experience; it is online from birth. This memory system stores procedural information such as acquired skills, the “how to” of memory conditioned and emotional and unconscious responses that manifest in fundamental ways of moving through the world. This memory system also stores emotional memory, which derives from emotional responses to stimuli and is processed by the amygdala. Negative or traumatic feeling responses are particularly associated with the amygdala. Appreciating the existence of implicit memory allows the concept of the unconscious to include anatomical structures where emotional, affective, sometimes traumatic, presymbolic preverbal experiences are stored (Mancia, 2005, p. 83). LeDoux (2002) points out that many different systems in the brain engage in implicit learning. He notes that these are not specifically memory systems as such, but were designed for specific functions such as perceiving stimuli, controlling precise movements, and maintaining balance. He adds that “plasticity (the ability to change as a result of experience) is simply a feature of the neuronal structure of these systems” (p. 117).
Later memory is conscious, explicit, informational, and accessible, arising from predominantly left-hemisphere processing and online by the time a child is about 3 years of age. Explicit memory consists of episodic, personal, biographical memory—the “this is my life” type of memory—and semantic factual memory—the “what” of memory. Explicit memory content is processed by the hippocampus, which tags time and place to memory (the “where” and “when”) ensuring the memory’s accessibility to consciousness in an identifiable form. Once the hippocampus has consolidated the memory in the cortex, each individual element that comprises the memory is stored at the cortical site where it was originally received (Wilkinson, 2006a).
Retrieval
The retrieval of memories is “not the simple act of accessing a storehouse of ready-made photos in a stable neural album” (Young & Saver, 2001, p. 79). The different elements of a particular memory are “distributed widely across different parts of the brain, such that no single location contains a literal trace or engram that corresponds to a specific experience” (Schacter & Addis, 2007a, p. 774). Retrieval requires a complex assembling of these constituent elements that have been stored at the various cortical sites. When recall has taken place and its use is over for that occasion, then the memory is disassembled, so to speak, and stored again in its individual elements at the original cortical sites. Those elements remain ready to be reassembled should they be required, but with the overlay of the most recent experience of remembering. Synaptic plasticity plays a significant part in “the organizational basis of long-term memory, implicit and explicit” (Mancia, 2005, p. 86). The actual reexperiencing of the memory and the context in which that takes place will affect the process. A memory of fear is not necessarily permanent and can change when retrieved: “The reactivation of a consolidated [fear] memory can return it to a labile, supposedly protein synthesis-dependent state, a process that is referred to as reconsolidation” (Kindt et al., 2009, p. 1). The working through of fear memories in the safely of the therapeutic relationship may help to weaken their destructive power in just this way. It may be necessary to regulate the process of the return of memory, slowing it down and helping the patient toward self-regulation of affect, so that the trauma is processed in small manageable amounts.
In this realm it is not a question of true or false, belief or disbelief, but of respecting the emotional integrity of the process while appreciating that what is held in implicit memory is, by definition, unthinkable and therefore will not provide what may be thought of as accurate snapshots of a particular traumatic experience.
Memory and Affect Regulation in Therapy
Emergent Memory
A patient remembered vividly her “Bunnikins” plate from which, in her earliest years, she ate every day (Figure 2.2). In one session she seemingly recounted each detail of the picture and her memory of being told to “eat up, then you will be able to see the little rabbits” or “have another mouthful, then you will be able to see the pretty blue and white china on the dresser” or “where is Mrs. Rabbit? Can you find her?” She remembered that Mrs. Rabbit was bathing her little rabbits in a tin bath by the fire. They looked up into her face, enjoying the moment, just as the child must have looked up into her mother’s face, enjoying the story of this moment in the little rabbits’ life as she ate the inviting food provided for her. Another rabbit child was playing with a red and blue train. Above the window hung big bunches of bright orange carrots and white turnips, presumably to be eaten by the rabbit family at a later time. In the background was the dresser and on the shelves was a beautiful set of blue and white plates of different shapes and sizes. At one level a happy moment of family life was indissolubly linked to food forever for the patient who came to like nothing better than an informal meal with close friends.
After recounting this material in one session, the patient went home and looked again at the picture on the plate. The next day she commented that all was much as she had remembered, except for two rather significant differences: There were several rabbit children playing with toy horses, not one with a train, and the father rabbit was sitting peacefully close by reading his newspaper. The patient had one sibling, a younger brother who loved to play with his toy train and would usually have been “in the picture,” in contrast, her father was often absent and when present had found it difficult to accept his eldest child. The patient’s memory and telling of the story had accurately represented her own inner world experience, rather than the actuality of the picture on the plate. The original memory of the picture becomes overlaid with personal affective experiences with significant others, leading to a memory that privileges emotional truth over accurate physical detail.
How the therapist engages with the patient will contribute to the emergence of such memories. As aspects of earliest affective experiencing, the tone and musicality, the rhythm and lilt of the therapist’s voice—the ability to speak in “pastel not primary” colors (Williams, 2004)—may help to access the patient’s early experience. It is not only the words but also the right-hemisphere “processing of the ‘music’ behind our words”—the emotional right-brained engagement with the other—that enables the patient to explore traumatic early experience. Psychotherapy is not only the “talking cure” but perhaps rather the communicating cure (Schore & Schore, 2008, p. 14). Andrade (2005) suggests that often what is said is immaterial because “it is the affective content of the analyst’s voice—not the semantic content—that has an impact on the patient’s implicit memories” (Andrade, 2005, p. 683). I think this disregard of semantic content is to confuse, at least in part, the state of the baby mind where only implicit experiencing is possible, with the adult mind-brain, where both implicit and explicit memory reside. Furthermore, it is not only the voice but also the posture and especially the facial expression of the therapist that play a part in all this. Bucci (2001) argues that “subsymbolic indicators, such as vocal tone or body movement or reports of intense feelings, provide evidence that an intervention has connected to an emotion schema…. At some point, the analyst will call on verbal formulation…to test her understanding” (p. 65). Such work calls for “a profound commitment” by both and “a deep emotional involvement on the part of the therapist” (Schore & Schore, 2008, p. 16). Indeed, I would add a deep emotional involvement is needed by both, which is inevitably difficult to achieve adequately in a very limited number of sessions. When possible, I argue for treatment in depth over time, at least for those who, although significantly traumatized, reveal enough resilience to be able to make good use of such an approach.
Affect Regulation
Harriet, our little 4-year-old from the park, was fortunate in that therapy was arranged for her quickly, which enabled her to process much of her early trauma. Sadly for many that is not the case. Let us imagine for a moment that Harriet had not received help but had recently come into therapy some 20 years later, that difficult life events—such as the break up of a marriage, an incident of rape, or the loss of a child—have called forth her early experiences from the implicit memory store and they threaten to overwhelm again. Perhaps she finds herself easily upset, describing it in an initial interview as “crying with no reason,” or alternatively increasingly worried by the fact that she finds herself inclined to switch off, drifting into states of “no think” and “no hear,” so that her loved ones, friends, and work colleagues all begin to comment on how they are constantly having to try to regain her attention. She may need considerable help with affect regulation, and the therapist will see this focus as an integral aspect of the therapy. In an early session she may tell just how frightened she was of some of the films that she saw as a child. It might be that she remembers Bambi, and the hunter that killed the mother deer and left Bambi with the fierce stag father, or she might remember her horror in the Wizard of Oz when it became clear that the tin man hadn’t got a heart. Slowly and painfully they begin to do some more work on the patient’s story. It is not until much later in the therapy that Harriet recalls something of the incident in the park with its very close links to her forgotten early trauma. Patients with experiences such as Harriet’s may struggle with affect regulation throughout their lives, especially at times of emotional stress. As adults it may be most helpful to reengage in shorter periods of supportive therapy during periods of major stress throughout their lifespan rather than assuming that one long period of therapy will resolve the problem forever (McQueen et al., 2008).
Therapists help patients such as Harriet learn to regulate their mood. As patient and therapist work, the therapist pays attention to changing levels of affect. “Like the securely attached mother, the empathic psychobiologically attuned clinician’s regulation of the patient’s affective-arousal states is critical to transforming the patient’s insecure nonconscious internal working model that encodes strategies of affect regulation” (Schore, 2007a, p. 12). Regulatory processes are fast, often below levels of consciousness; they are intuitive, empathic responses to the other in the room. As he or she reflects on the session when it is over or in supervision, the therapist may ponder his or her own responses and wonder whether they were helpful to the patient or whether they were the effect of some unconscious defense. It is the continual integration of right-hemisphere responses with left-hemisphere understanding and discernment that enables effective affect regulation by the therapist. Eventually patients become able to internalize this affect regulation for their own well-being.
The therapist can utilize four broad foci for regulating affect in the therapy session: the body words, timing, and the analytic frame.
• The body as a regulator. The therapist is aware not only of changes in mood communicated via words but also of mood changes revealed by fluctuations in the rhythm, lilt, and prosody of the voice; in breathing; skin tone/flushing; looking away, looking down, looking intently into the eyes of the therapist; turning away or turning toward the therapist; and in the tension or rigidity in the body versus states of floppiness. In response the therapist may lean forward and engage the patient’s eyes to bring him or her back. Or the patient might find him- or herself leaning back and looking slightly away, unconsciously creating a degree of disengagement. If the patient becomes distressed and overaroused, it will be reflected immediately in her breathing; he or she may become breathless, may hold the breath, or may breathe too rapidly, which, if unattended, could result in a panic attack. If the therapist breathes slowly, calmly, and deliberately, the patient’s breathing may soon follow the therapist’s rhythm—such are the powers of mirroring, resonance, and empathy. Schore and Schore (2008) describe interactive psychobiological regulation as the fundamental purpose of nonconscious attachment dynamics and note that this regulation acts as an “essential promoter of the development and maintenance of synaptic connections during the establishment of functional circuits of the right brain” (p. 11).
• Words as a regulator. The therapist’s words can draw the “switched off” patient back into the room and the therapeutic engagement. Sometimes as he or she reflects on her intuitive response to a particular patient, the therapist will notice that he or she used short sentences or brief open-ended questions. At other times he or she may have slowed her speech or modified the tone.
• Timing as a regulator. The therapist holds the stage of the session in mind, knowing that it is safest to deal with the most traumatic experience in the middle portion, so that the patient has time to recover and regulate his or her affect before leaving. If a patient has been unduly distressed, the therapist can become most active in helping him or her to regain equilibrium toward the end of the session, so that the patient leaves in a more regulated state of being. Simple remarks can help the patient to look around and refind familiar safe aspects of the room. The patient also may have found soothing inner images to hold on to that he or she can recreate to stabilize his or her mood.
• The frame as a regulator. As therapists we guarantee regular sessions that begin and end on time to provide continuity of time, space, and environment. We seek to provide a room that is not overstimulating, that is containing and protected from intrusion. Within the analytic frame we respect confidentiality and aim to work in a way that facilitates trust. We seek to behave in an absolutely predictable way around management of breaks, holidays, and fees. We regard boundaries as playing an essential part in the therapy itself.
Attachment and Its Effect on Affect Regulation in Adolescence
Goleman (1996) comments that “emotional intelligence is a master aptitude, a capacity that profoundly affects all other abilities, either facilitating or interfering with them” (p. 80). Emotional executive competence facilitates effective learning in every aspect of life and relationship. It is the socialization experiences of the early years and adolescence that play a vital role in the maturation of the orbitofrontal regions, the executive control centers of the brain. This control center of the brain, located in the cortex, the “thinking cap” of the brain (which is the latest part of the brain to develop in evolutionary terms and which is most highly developed in humans), has direct connections to virtually every other part of the brain.
In the earliest years one of three problematic responses to relationship may develop and, in later years, will be clearly identifiable in adolescence. The teenager who is affected may well not realize it but will operate in a certain way with regard to others: as avoidant, ambivalent, or disorganized.
• The avoidant adolescent. If the adolescent could make a conscious statement about how he or she operates in relationships, it might be this: “I must avoid people’s anger by avoiding knowledge of my own difficult feelings, pushing them down, switching them off.” This pattern may lead to a distant, switched-off attitude to all that is offered by adults, in particular. It is an attitude that may well be exacerbated in adolescence because of the natural urge toward separateness that is part of growing up. As such, it leads to a defended attitude toward the adult world and will interfere with emotional learning that requires cooperation with others.
• The ambivalent adolescent. This adolescent might say: “Sometimes people are okay, sometimes not; I must watch carefully and modify my mood and feelings to theirs.” In adolescence some of young people become distant and avoid others, some become overanxious and clingy, overeager to please, unable to think and function independently, in their efforts to solve their dilemma of how to relate to others.
• The disorganized adolescent. This adolescent might say: “People are so unpredictable, I just don’t know what to do for the best, whether to cling to others or to avoid them; I’m afraid all the time—sometimes I manage to pretend I am not, but it’s there, deep down all the time.” This last group of adolescents, who oscillate between clinging to and avoiding others, has the most complex response to relationship, these youngsters will find it most difficult to relax their guard enough to be able to relate empathically to others and to fully utilize learning opportunities. The plasticity of the brain may lead these young people into rapid dependence on alcohol, street drugs, or self-harm that may manifest in forms such as cutting. Alternatively, their anger may easily overwhelm them and lead to dysregulated behavior that results in antisocial activity.
These problematic attachment styles are not the problem of just a few of our young people. Holmes (1996) suggests that “in average populations about one-fifth of children are avoidant, one-sixth ambivalent, and one in twenty disorganized” in their attachment style (pp. 7–8). Without the provision of a different experience of relating made available in adequate therapy, these damaging patterns of attachment will become long-lasting, affecting the sense of self, in the deepest aspects of being, in a lasting way. Adolescence is further complicated by a second wave of nerve cell development, which results in the uneven development of emotional competence as emotional experience outpaces executive control. As the frontal cortex, responsible for reasoning and judgment, lags behind the limbic system in development, the availability of a good-enough parent or teacher who knows of when and how to say “no” may be of crucial importance in helping a young person to develop the internal ability to control impulsive behaviors. However, myelination of the axons is thought to increase at this time, making them into more effective transmitters that enable an increased capacity for communication and increased plasticity, which then permits rapid learning. Unfortunately, eating disorders, self-harming, and suicidal behaviors may emerge at this stage as the brain becomes as easily programmed to patterns of abuse as to patterns of achievement. Plasticity means that the young person very quickly becomes attached to the overwhelming pleasure that drug abuse seemingly brings.
If a different, more consistent experience of healthy relating is provided then these young people may be able to move into a “learned secure” attachment style. Schore and Schore (2008) note that providing experiences of secure attachment is the very heart of the therapeutic endeavor—“the essential matrix for creating a right brain that can regulate its own internal states and external relationships” (p. 17).
The Neurobiology of Attachment and Affect Regulation
Noriuchi et al. (2008), in an fMRI study of 13 mothers watching video clips of their own and other 16-month-old babies smiling and crying, found that a limited number of brain areas were specifically involved in recognition of their own infant, namely, the orbitofrontal cortex (OFC), the periaqueductal gray, the anterior insula, and the dorsal and ventrolateral parts of the putamen. They also demonstrated the strong and specific response of a mother’s brain to her own infant’s distress and the fact that a mother responds most strongly to her infant when it is in distress. A mother’s own infant’s distress cry activated multiple brain areas: the dorsal region of the OFC, the caudate nucleus, the right inferior frontal gyrus, prefrontal cortex (PFC), the dorsomedial prefrontal cortex (DPFC), the anterior cingulate, the posterior cingulate, the thalamus, the substantia nigra, and the posterior superior temporal sulcus.
A second study used fMRI scanning to explore the capacity of 16 mothers to understand and imitate their infant’s facial communications, on the premise that in the their first year together, exchanges and communication between a mother and her infant are exclusively preverbal and are based on the mother’s ability to understand her infant’s needs and feelings in an empathic way (Lenzi et al., 2008). The mothers were scanned while watching and imitating faces of their own child and that of someone else’s child. The researchers “found that the mirror neuron system, the insula and amygdala, were more active during emotional expressions, that this circuit is engaged to a greater extent when interacting with one’s own child, and that it is correlated with maternal reflective function”; furthermore, “joy expressions evoked a response mainly in right limbic and paralimbic areas” and “ambiguous expressions elicited a response in left high-order cognitive and motor areas, which might reflect cognitive effort” (p. 1, 24) (Figure 2.3).
Panksepp (2008) argues that adequate early affective communication promotes the development of linguistic prosody within the developing right hemisphere. Here he echoes the work of Schore, who has long emphasized the key role of attachment communications between mother and infant in the development of the early maturing right hemisphere (Schore, 1994, 2003a, 2003b). He emphasizes that “the affective intensity of the emotions arises more from the lower subcortical reaches of the brain than the various conditional, secondary-process routes that enable control over emotional urges” (p. 48). He goes on to stress the central role of the right hemisphere in the early affective mother-infant interaction that allows “the programming of prosody,” that is, “the lilting, singsong emotional-communicative dance between mothers and infants, where high-pitched melodic ‘motherese’ prevails” (pp. 48-49), which, in turn, enables the development of language. Panksepp warns against the premature overlocalization of certain brain functions in certain brain areas. He also makes clear that no hard and fast boundaries can be discerned, for instance, in relation to the margins of the amygdala or indeed the boundaries of the limbic system. Panksepp prefers the use of terms such as the “extended amygdala” and the “extended limbic system.”
Emde (1999), too, notes that the affective core depends on multiple experiences with significant others that become internalized in the course of early development. He acknowledges the importance of what Damasio (1994, 2003) conceptualizes as “background feelings”—that is, complex representations of current body states that are distributed over a number of cortical and subcortical brain locations. He comments: “Such feelings, Damasio emphasizes, contribute to our ongoing sense of identity, anchoring our ‘illusory sense of sameness’ in the midst of change” and adds that “since emotions are linked to specific relationship experiences in the past, they are likely to be activated by circumstances in the present that are similar” (Emde, 1999, p. 326).
The Effects of Trauma
It has become even clearer that early stress and maltreatment produce a cascade of events that have the potential to alter brain development in a far-reaching manner that has consequences not only for current development but also for the later development of the slowly maturing brain. Many studies have investigated the effects of trauma on the young developing brain and its implications for future mental well-being. Let’s take a bird’s-eye look at some of the papers emanating from one researcher, Teicher, undertaken with various colleagues. Teicher et al. (2002) studied the developmental neurobiology of childhood stress and trauma and noted that the first stage of the cascade of responses evoked by trauma involves the stress-induced programming of the glucocorticoid, noradrenergic, and vasopressin—oxytocin systems to augment stress responses. They concluded that these then affect neurogenesis, synaptic overproduction and pruning, and myelination during specific sensitive periods. Major consequences include “reduced size of the mid-portions of the corpus callosum, attenuated development of the left neocortex, hippocampus, and amygdala,” along with “abnormal frontotemporal electrical activity, and reduced functional activity of the cerebellar vermis.” They stressed that such changes form the neurobiological framework through which “early abuse increases the risk of developing posttraumatic stress disorder (PTSD), depression, symptoms of attention-deficit/hyperactivity disorder, borderline personality disorder, dissociative identity disorder, and substance abuse” (Teicher et al., 2002, p. 397).
In a further study of the neurobiological consequences of early stress and childhood maltreatment Teicher, et al. (2003) reported that “early severe stress and maltreatment produces a cascade of neurobiological events that have the potential to cause enduring changes in brain development.” They stress that these changes occur on multiple levels, from the neurohumoral (especially the HPA axis) to the structural and functional. They also stress that there are gender differences in vulnerability and functional consequences (Teicher et al., 2003, p. 33).
Teicher, et al. (2004) explored the relation between childhood neglect and reduced corpus callosum area. Magnetic resonance imaging (MRI) scans were used to compare the corpus callosum area in 26 boys and 25 girls admitted for psychiatric evaluation (28 with abuse or neglect) with 115 healthy control subjects. Neglect was the strongest experiential factor and was associated with a 15—18% reduction; sexual abuse seemed to be the strongest factor associated with reduced corpus callosum area in girls. Animal research has led to similar conclusions.
An overall view of research into the neurobiological and behavioral consequences of exposure to childhood traumatic stress and its significance for later development is offered by Teicher, et al. (2006). Emphasis is placed on the vulnerability and plasticity of the developing brain, which allow it to be sculpted by postnatal traumatic experience in far-reaching ways as the system attempts to adjust to what is perceived as a threatening, hostile environment. They conclude that “in essence, stress response systems are programmed by experience to respond more drastically to events in later life” (Teicher et al., 2006, p. 191). Alterations occur in the amygdala and other limbic regions as part of readying for the flight or fight response in the face of further threat.
Such stress-induced changes affect the trauma victim’s capacity for engagement and affect regulation. Fonagy and Target (2008) point out the effect of early relational trauma on the child’s attachment system: “Trauma normally causes a child to seek safely by gaining proximity to the attachment figure. This generates a characteristic dependency on the maltreating figure, with the real risk of an escalating sequence of further maltreatment, increased distress, and an even greater inner need for the attachment figure” (p. 27).
The more slowly developing left hemisphere is not left unscathed: “Diminished left hemisphere maturation, reduced corpus callosum size and attenuated left hemisphere integration may substantially increase an individual’s capacity to react rapidly and to shift into an angry aggressive state” (Teicher et al., 2006, p. 202). Lastly, Teicher et al. (2006) emphasize the “enduring alterations that occur in messenger RNA levels for vasopressin and oxytocin…[that] may predispose to patterns of sexual behavior and mating practices that foster reproductive success in a malevolent world” (p. 203). Indeed, overall, such hair-trigger reactions equip the individual with capacities necessary for survival in a hostile world. However, such reactions do not equip the individual for intimate relating in a more secure environment.
Other researchers reached similar conclusions. Shin et al. (2006) emphasize that amygdala responsivity is heightened and positively associated with symptom severity in PTSD. However, the medial prefrontal cortex is reported to be volumetrically smaller and hyporesponsive during symptomatic states, whereas medial prefrontal cortex responsivity is inversely associated with PTSD symptom severity. They summarize that “the reviewed research suggests diminished volumes, neuronal integrity, and functional integrity of the hippocampus in PTSD” (p. 67).
In a recent and significant study researchers (Heim et al., 2008) explored the neurohormonal consequences of childhood abuse in adult men and found that early emotional distress can have long-lasting consequences on the emotional well-being of such victims. They recruited 49 healthy, medication-free men, ages 18—60 years, without mania, psychosis, active substance abuse, or eating disorder, and four study groups of normal subjects: (1) those with no childhood abuse history or psychiatric disorder (2) those with childhood abuse histories without current major depression (3) those with childhood abuse histories with current major depression, and (4) those with current major depression and no childhood abuse history.
When tested, men with childhood abuse histories exhibited increases in adrenocorticotropic hormone (ACTH) and Cortisol responses to dexamethasone/ corticotrophin releasing factor (CRF) compared with nonabused men, and abused men with current major depression showed increased responsiveness compared with control subjects and depressed men without childhood abuse experience. The researchers concluded that childhood trauma increases HPA axis activity and is a risk factor for depression later in life.
Schore (2003a) points out that trauma in early life results in “permanent alterations in opiate, corticosteroid, corticotropin releasing factor, dopamine, noradrenaline and serotonin receptors” (p. 290). He notes that such changes may have a permanent effect on physiological reactivity in the limbic system and stresses that “elevated corticotrophin releasing factor is known to initiate seizure activity in the developing brain” (p. 290). He concludes that this circuit hyperactivity may continue to give rise to psychogenic nonepileptic seizures, or partial seizures.
Panksepp makes a further point, one that is in a sense more fundamental, relating as it does to the earliest interaction between mother and child. He argues that when right-hemisphere prosodic and reality testing functions are damaged, the left hemisphere’s story lines are affected. He suggests that the story lines become “more superficial and disconnected from the deep affective needs and life-stories of people” and that left-hemispheric propositional language is compromised when it becomes “decoupled from affective values” (Panksepp, 2008, p. 50). Thus early healthy right-brain to right-brain relating is essential to the development of sound language, reasoning, and coherent narrative in the left. This point makes an even stronger case for the fundamental importance of a healthy early prosodic relationship between mother and child out of which all higher functioning ultimately emerges. Teicher et al. (2006) cite research that indicates that young adults who were exposed to early and severe parental verbal abuse had significant and selective reduction (15%) of gray matter volume (GMV) in the right superior temporal gyrus, an area believed to be a key anatomical substrate for speech, language and communication (Teicher et al., 2006, p. 196). Gray matter areas are “relatively enriched in nerve cell bodies” (Crossman and Neary, 2000, p. 4).
Panksepp (2008) speculates that the left hemisphere may mediate the expression of defense mechanisms more than the right, especially in those defensive processes that use words to manipulate and control others. He goes so far as to conclude that healthy right-hemisphere functioning is absolutely essential to the development of healthy left-hemisphere functioning, commenting that “when the left hemisphere is less grounded in subcortical/right hemispheric emotional ‘soil’ it becomes more adept at self-serving rationalizations” (p. 50). He goes on to say that “this emerging understanding of higher brain development, whereby most cortical functions are epigenetically promoted by powerful subcortical processes, is rapidly approaching an established fact” (p. 52). I find in this perspective a confirmation of my argument that for therapy to produce effective integrated functioning of the whole mind—brain—body being it must be right-brained, relational, and emotionally engaged rather than merely left-brained, interpretational, and emotionally distant (see Chapter 5). Nowhere is this truer than in the case of rather schizoid patients who use left-brain intellectual functioning as a defense against affective engagement with life.
Case Example: Bill
In his late 40s, Bill was referred to me by the psychiatrist of the emergency inpatient psychiatric unit to which he had been admitted when he suffered what appeared to be a breakdown when his wife left after 20 years of marriage. She had become unable to tolerate his controlling behavior, which had reached into every aspect of their life together, and into his daughter’s life as well. When his wife and daughter left, he described himself as initially unable to stop crying and completely at a loss as to how he was going to manage even the simplest aspects of living alone.
One of Bill’s earliest memories was of wanting to go to the party of the child who lived a few doors down the road. He thought he was about 5 years old. He remembered that he was dressed in his best clothes and when the time came, he set off excitedly with his mother. However, when the door was opened and he went to step inside his mother gripped him tightly by the hand. She took the present out of his other hand and said to the other child’s mother, “I’d better give this to you now. I know he won’t stay—he’s far too shy.” He felt his face change color and his heart sink as he thought to himself “Maybe I won’t manage.” Only a moment later, it seemed, he found he was leaving with his mother. On another occasion, watching a Punch and Judy show with his grandfather, he was frightened by the shouting and violence that occurred between the two puppets, and only in therapy did he realize that this reminded him of the fright he felt on the rare occasions when his parents quarreled.
These early memories, recalled in therapy, seemed to encapsulate his experience with his parents and demonstrated how the intersubjective affects the intrasubjective, which then affects the intersubjective. It appeared that his parents, especially his mother, had been unable to help Bill regulate his emotional response to fear in a way that would have helped him to develop an ability to go out into the world with confidence. Only in therapy was he able to perceive how much his mother lacked confidence and kept herself and him within the four walls of their home. His father was not able to help him build his confidence either. If he got less than full marks for a test, there would be no pleasure in what his son had achieved, just a postmortem over his shortcomings—in particular, over the pieces of knowledge that he had not retained.
In secondary school Bill experienced some bullying. When he tried to speak to his mother about what was happening, she replied dismissively, “All boys get bullied at school—often much worse things happen to them.” He went away even more fearful of what the “worse things” still to come might be, and feeling totally alone. He could not internalize a feeling of confidence and empowerment that would have helped him to cope in difficult moments because his parents were not able to model those attributes. As an adult, in reaction to his early experience, Bill set out to try to become invulnerable. He would be master of all available knowledge. Much later in therapy he was able to realize that both his parents had feared the world and kept it at arm’s length as far as possible.
Bill became an information technology (I.T.) expert in an industry where I.T. skills, combined with specialist knowledge of the technical base used by his particular industry, were at a premium. He had made himself virtually indispensable in the office because every member of staff knew that, when in doubt, he or she could ask Bill and he would know. He explained that he felt safe only when he was in possession of every scrap of knowledge concerning his work and the world in general. That was the only way he felt he could protect himself from making a mistake, from being found wanting in some respect. He had little or no awareness of the power and indeed control that he exerted through this stance. Over the years that we worked together, it became clear just how much he was valued in his workplace, and he began to internalize that valuation. It was still difficult for him to have any sense of being in control.
He remained an isolated man, often fearing rejection and retreating from relationship. However, what was apparent was that colleagues liked and valued him and on occasion sought out his company. Very gradually he became more able to notice and appreciate this positive attention and then to accept invitations to social gatherings. A highpoint came when he arrived at therapy announcing that he would be away for two weeks because he was going on holiday with friends from the office.
Conclusion
Appropriate affect regulation may remain tantalizingly out of reach for some patients, who may face the condemnation of “always overreacting” or being “far too sensitive for your own good” or “getting uptight far too easily” or “sleeping around.” These are all expressions that patients have ruefully brought to therapy as they struggled to deal with their vulnerability to intense and immediate hyperarousal in the face of mild stressors. It is the reaction born of early trauma that gives rise to negative transference reactions, even in the benign therapeutic setting. Such reactions may gradually be identified as belonging to the patient’s past, which has shaped the brain—mind body to respond as if to a hostile world. Such extensive change argues for relational therapy conducted over a significant period of time, therapy that is long enough and engaged enough to permit the internalizing of a very different experience to the early trauma that established such difficulties. It will be a therapy that permits the patient to experience sensitive regulation by another as a bridge to the difficult task of self-regulation.