ATTUNEMENT—BEING AWARE OF AND RESPONSIVE TO ANOTHER—is absolutely fundamental to meaningful human interaction and therefore also to the therapeutic process. Perception and emotional learning in the area of attunement arise out of earliest relating to another. The human being, in common with other primates, demonstrates a capacity and facility for this from the earliest days of life.
Interest has snowballed in the role of attunement in the therapeutic process; research in the field has been stimulated by a number of studies that concluded that it was the quality of the relationship between therapist and client, rather than the theoretical orientation, that brought about a successful therapeutic outcome (see Chapter 1). McCluskey et al. (1997) explored the part played by attunement, in particular, in adult psychotherapy. In a study that involved the rating of therapists as attuned or nonattuned on the basis of clinical extracts, the rating was carried out first by senior clinicians and then by trainees. From the results it became clear that four primary characteristics were identifiable in each of the categories of attuned and nonattuned. The descriptors of the attuned therapists were “engrossed, modulates response, provides input, and facilitates exploration” (McCluskey et al., 1997, p. 1,268, emphasis in original). These researchers concluded that further research might enable the development of more appropriate training programs for therapists.
Therapeutic Attunement
Driver (2006) identifies the fundamental issues related to attunement that I seek to address in my work, namely:
How do we understand and touch the deep structures of the mind which are formed of implicit and embodied memory and which have formed patterns in the mind from early infancy but are unavailable to conscious memory especially in patients with early relational trauma? What relational dynamics do we need to consider, such as affective attunement and empathy, in relation to the restructuring of the connections of mind? (p. 5)
I have come to understand the therapist’s mind-brain-body attunement to the patient’s mind-brain-body being to be something that is fundamental to the process of changing minds through therapy.
The capacity for empathy is described by Fonagy et al. (2004) as arising in the second year of life. They make it clear that, in early development, healthy attunement consists of the mother mirroring the baby’s affect in such a way that the baby is reassured and calmed. This process is fundamental to the baby’s ability to develop self-regulation and a healthy sense of self. Fonagy et al. suggest that “affect expressions by the parent that are not contingent on the infant’s affect will undermine the appropriate labeling of internal states, which may, in turn, remain confusing, experienced as unsymbolized, and hard to regulate” (p. 9). In response to repeated experiences of the mother’s attunement, the baby in turn develops a capacity for awareness of and sensitivity to the other. Thus attunement and empathy are two sides of the same coin. It is the therapist’s capacity for empathy—acquired through his or her experience of being related to in an attuned way—that enables him or her to attune, that is to respond empathically, to the patient.
Stern’s (1985) work on attunement and misattunement in mother-baby interactions confirms earlier research findings that mothers naturally match and modulate their babies’ affect, but that in moments of misattunement the mother may become the unknown, or the stranger, and the child will experience himself as deficient. Researchers understand such experiences of misattunement to be shame experiences. They warn that “unrepaired shame experiences result in a self defined in shame” (Spiegel et al., 2000, p. 25), a self that becomes focused on the needs of the other, a self preoccupied with feelings of shame. If such misattunement goes unrepaired then they suggest that the false self comes to be born. However, in good-enough circumstances, where an experience of misattunement is something that the parent addresses through empathic reengagement with the child, the self “developing within mutual empathic attunement and the experience of repaired misattunement will develop with integrity and a reliable capacity to accurately read the interpersonal environments” (Spiegel et al., 2000, p. 25).
While attunement offers opportunities for effective engagement in the therapeutic process, misattunement—with the opportunities it offers for effective repair—may be even more vital to equip the patient who has experienced early relational trauma adequately for the vicissitudes of relating in everyday life. Spiegel et al. (2000) noted that while empathic attunement gives rise to positive emotions and states of joy and excitement, misattunement has exactly the opposite effect. Repair is therefore a key concept for the working through of experiences of rupture that occur in therapy. Fonagy et al. (2004) suggest that psychotherapy with these patients will seek to “regenerate the connection between the consciousness of an affect state and its experience at the constitutional level” (p. 14), thus developing the capacity to become aware of feelings and to make meaning out of bodily emotional experience.
As I consider how attunement actually occurs I am aware of the growing number of researchers who show substantial interest in how the neurobiology of emotional body language affects emotional understanding of the other and influences decision making. Schore (2008b) stresses how much more than words is involved in therapy and endorses the view of Hutterer and Liss (2006) who emphasize the need for nonverbal variables such as tone, tempo, rhythm, timbre, prosody, and amplitude of speech, as well as body signals, to be considered as crucial aspects of the therapist’s interaction with the patient.
In Galton’s collection of essays concerning touch in the psychoanalytic space, I was struck by the number of clinicians who did not use touch routinely but who spoke of definitive moments of meeting with patients that involved touch. Those definitive moments enabled patients to deal more effectively with poor early experience, acting as a “bridge between ‘somatic’ and ‘psychic’ modes of experience” (Totton, 2006, p. 160). Totton points out that touch enables us to reach back into the “infant world of the patient in very powerfully effective ways” but also urges caution because “the passage through the Oedipal field takes up and transforms infant eroticism into adult sexuality” (p. 159).
What is brought home to me as I engage with the varied experience of a wide range of practitioners is that we have to consider the unique multilayered developmental experience that each patient brings to the relationship, and how that is affecting, and being experienced in, the current therapeutic relationship.
Both therapist and patient have undergone a series of attachment experiences, past and current, that affect the capacity for attunement that they bring to the therapeutic relationship. In each, autoassociative pattern-matching processes will take place beneath the level of conscious awareness. These patterns in the mind-brain develop from an individual’s earlier experience. The patterning, discussed more fully in Chapter 5, dictates the individual’s expectations of how relationships with others will be. As the work together progresses, both will also be affected by any significant changes in their current attachment experiences caused by stress, loss, or positive occurrences. The therapist’s ability to do this work successfully will depend very much on his or her capacity for empathy. In order to develop this ability, therapists must be aware of their own early and current attachment styles and the way these aspects of their inner world affect their capacity for attunement to each particular patient at any particular time. For example, therapists whose early attachment style was avoidant and whose current personal circumstances have suddenly plunged them into emotional pain may find themselves wishing to avoid the dependency needs of the baby part of an adult patient who comes to a session in a state of distress and who presents in a regressed state (Wilkinson, 2007b). They must also be wary of the hidden hazard of secondary traumatization that may afflict the therapist faced with very severe trauma in the patient’s material through the mechanism of empathy (see also Chapter 9).
Case Example: Steve
When Steve, a man in his 40s, called to make an appointment, I encountered a seemingly very experienced and articulate patient. While we only spoke briefly it quickly became clear that he had had therapy from an analyst in a school of analysis very different from that to which I belonged and that he was used to working with his inner world in a very different way from the way I worked. While I thought in developmental and relational terms informed by attachment theory, my new patient thought and talked in mythological terms which at first I found quite difficult to relate to and which left me feeling inadequate. As I sought to attune to my would-be patient, my countertransference was to feel small and helpless in the face of the archetypes, an inner feeling that actually deeply echoed my patient’s inner sense of a small and helpless self that had been almost overwhelmed by life-threatening earliest experience.
The first thing I was aware of when Steve arrived for his first session was of this very large man who was rubbing his hand slowly but firmly over his close shaven head as he walked toward me. Was he caressing it, rubbing the thinking cap of his brain or comforting some old injury, I pondered? While there was no visible damage of significance, I found myself wondering whether he had been the victim of a car accident. My engagement with the gesture, made first as he passed the window on his way into the room and then as he sat talking, was immediate and intense. Little did I know how symbolic a gesture it was, containing reference to both early and current experience. In the first session I felt sometimes as if I was with a newborn baby; in later sessions I would sometimes see a willful toddler or a confused and acting-out adolescent; and much of the time I was in the presence of a sensitive and caring man.
Soon I learned that Steve’s arrival into the world had been most hazardous for both him and his mother. He recounted that his final forceps-assisted emergence into the world had damaged and deformed his head so badly that his mother had not been allowed to see him until he was 4 days old. He had been told this along with the fact that he had not been expected to survive. The utter loneliness and desolation of his earliest experience lying in an incubator rather than cradled in his mother’s arms was something to which he returned many, many, many times. I was often filled with a sense of utter desolation just at the moment before he would begin to speak afresh about his earliest hours and days of life, but perhaps the experience weighed most heavily on me that first afternoon. Sometimes in our early sessions it seemed like Steve was hanging on to me, for grim death, just with his eyes. I guess that life-giving eye-contact with nurses, when he fought to stay alive, whose eyes expressed care and concern arising out of an understanding of something of his very earliest distress, was being reexperienced by us both in the room. As I sought to attune to him in his distress, I wondered about the mother who had not been there for him, and a system that had not allowed, or indeed enabled, her to be with her baby in his earliest hours of pain and distress.
Steve was a survivor; he had survived those early days of isolation, alienation, and despair, and he had survived unhappy experiences of bullying at school, the reason for which he did not understand. His parents proved unable to help him deal with, or understand, the bullying. His need for attunement, which went for the most part unmet, left him feeling shamed and vulnerable to bullying from outside, which matched the condemnatory voices that clamored from within. He and his parents (he had no siblings) lived in a rather barren, isolated, rural area until he was 11 years old. He survived the loneliness of this isolation by turning to animals for comfort, for example, riding for miles alone on his horse. Later came the greater loneliness of an inner-city secondary school where he felt out of place, a misfit who did not know what “streetwise” meant. He felt frequently let down by his rather absent father, who was an ex-army officer and a successful businessman, and whose interaction with his son seemed to be as if with a young and rather recalcitrant subordinate. However, Steve felt supported and encouraged by his grandfather and his grandmother who, in spite of the generation gap, were much more aware of how he felt. He went to live with them while he studied for his first degree.
He went on to have a successful career in the law, which involved prosecuting men in positions of power (fathers, bullies) who failed to act as they should. He became the attacker who could bully and shame the bully. That way he could for a while escape knowledge of the helpless, hurting little one within. Fonagy et al. (2004) observed that many patients who have experienced early relational trauma develop a survival strategy in which they use “the alien, dissociated part of the self to contain the image of the aggressor and the unthinkable affect” (p. 13). After working with a therapist whom he described as a rather gentle man, he was able to shift to a career that had a more nurturing component to it and that required and used his new-found capacity for control rather than bullying and dominance. In his (Jungian) terms, the opposites had begun to come together in him in a wholesome way. He married and felt more settled. His new career flourished and he managed to develop it in ways that were satisfying to him. His mother remained, as she had been from the beginning, a shadowy figure. His early therapy had enabled him to deal with some of his pain by providing a secure relationship, but a curiously impersonal quality clung to the way in which he talked to me of archetype and myth; somehow it felt as if life had barely begun to be a human existence for him.
Yet there was a sense in which I felt a larger-than-life quality in this man, a quality that I felt might threaten to overwhelm both of us. At these times I was aware of the need to remain separate rather than to allow his regressive state to overwhelm the two of us. At such moments I felt a need to think about the continuum of need from attunement to detachment. When he went to sit on the floor, I asked him to sit on the chair; when he moved the chair in a way that blocked the door, I asked him to move it back. I was surprised at my own directiveness. Internally I questioned myself about my defenses. What was I defending against? What was going on? In the first instance I felt he was not yet ready to confront his infant self so directly; in the second I was simply not comfortable that the route out of the room for either of us was blocked. A breakthrough came when Steve arrived with a pen-and-ink drawing (Figure 3.1) he’d done at home. In a way it seems that he was attempting a symbolic reconciliation of his objective understanding of the brain with his subjective experience of early birth and postbirth trauma and how his early experience had determined his sense of self and his journey through life. The drawing was a line drawing done on brown paper. He described the paper as fibrous and said he had chosen it for that quality. It seemed that somehow the texture made the paper feel alive, in some way related to the fiber of the human body, in particular, his head. He felt that, in some way, the drawing reflected his head. He began to talk about the drawing in a strangely inarticulate way for a man who had earned a living through the skillful use of words for much of his life. The drawing appeared to be an attempt to reconcile what had happened to him with the life he had subsequently lived. He had written:
• My inner landscape is changing…the making of mankind
• Head games…head injuries…where do they come from?…A man?…The birth canal? A doctor?
• The top of my head feels vulnerable…Ow! Ow! Ow!…Cover your head
• Careful—careful—burning down the house, but I’m scared of fire. I burnt myself trying to light the heater.
The drawing represented his life’s journey, my patient slowly explained. As I looked at it I was struck by its uncanny resemblance to a brain. I said, “In some ways it reminds me of a brain.” He looked and agreed with surprise that that was indeed just what it looked like. He felt that the drawing was somewhat like a map with contour lines but that it was also very much in the shape of a brain, with something being pulled off at the top. He brought a drawing of the brain in a subsequent session and we looked at the similarities that he saw between his drawing and the illustration.
Hirao, Naka, et al. (2008) explore the use of sandplay therapy, that is, the use of a sandtray with figures and objects with which a patient may express him- or herself, as one possible nonverbal clinical method of helping patients to integrate objective and subjective experience. In the example they offer, they combine neuroimaging and images from sandplay therapy to explore the objective and subjective view of a male patient’s self in conflict following the onset of nonfluent aphasia. They chart his recovery through the series of images that he makes and in a process they call “mind-imaging.” It seemed to me that a rather similar process of mind-imaging occurred for Steve when he unwittingly made an image of the brain that had references all over it of the painful journey that had been his early experience of life. Interestingly, Steve chose to call this drawing The Sandpit; perhaps he had devised his own version of the sandtray experience!
In looking at his representation of his mind-brain he found himself beginning to be able to remember more detail of his mother’s account of his very early days of life. He told me that his mother had not been allowed to see him for the first 4 days of his life and that the staff had kept saying to her “We’re praying for him” when she asked to see her baby. His fantasy was that he had been appallingly bruised, that his mother must have felt that she had given birth to a monster, and that he had been that monstrous baby. I made an intervention that spoke of the effect that such an early, painful experience must have had on his life’s journey. From that moment the quality of our work changed—the focus became relational. Now there could be a “good enough” mother in the room, one who had been able to look at and understand what his hurt head symbolized, that is, the traumatic trajectory of the development of his very early mind. He struggled with issues of blame for his suffering. As I sought to work in an attuned way I felt as if I suddenly caught sight of the small boy who somehow thought what had happened was his fault and who feared his own destructive rage. Just as the corpus callosum links the two hemispheres of the brain, so as my patient looked at his image and the representation of the human brain that he had found he became able to begin to make links between his affective experience (the domain of the right hemisphere) and his capacity to think about his early experience (the task of the left). He spoke about the links between affective and cognitive experiencing and commented that it would be helpful to identify the corpus callosum on the illustration.
The therapy seemed to enrich Steve’s understanding of his inner self states, his inner attachments, and his attachments in the wider world. What seemed quite extraordinary about him was not only his ability to allow me to help him with some of his difficult encounters with the parental figures that he came across in his world of work, but also his increasing ability to identify, care for, and contain more primitive self states within his inner world. He would speak of “the little fellow,” say “He’s been having a hard time,” and then make a gesture such as a Mum might make as she sits her baby on her lap to burp him. He would speak of the teenager within and the way in which he had helped and managed that part of himself that might have turned to alcohol as a way of escape. As I worked with him I was aware that I always had to have the very young parts of him in mind, even though I might be having a very erudite discussion with a very grown-up part of him. I remained impressed by his capacity to parent these needy parts of himself and finally came to wonder whether my attuned way of working had enabled him to allow them into mind in such a nurturing way.
During his time in therapy with me he studied for a higher degree and achieved distinction at every stage. His determination to overcome all difficulties was impressive. It was as if being “determined” was determined in him by his earliest experience. I don’t understand yet quite how that determination comes about with such difficult early experience, although I have seen it in several patients with early relational trauma, where the very issue of survival has been in question. It may be that determination is a way of escape, a survival strategy. I find myself wondering about the neural circuits of survival. Steve’s determination may have been a useful by-product of the hypervigilance that is occasioned by such trauma. It may have been the process of pattern completion at work, of locking on to the familiar in the face of uncertain stimuli. Maybe there was an echo of the way in which some, despite his trauma, had fought very hard for his life at the very beginning. As I reflected on our experience together I realized that:
For the patient:
• Attunement from therapist overcomes isolation.
• Attunement from therapist provides a route to greater awareness of earlier painful states.
• Attunement from therapist leads to containment of difficult early feelings.
• Attunement from therapist and with therapist leads to greater attunement to changing inner self states.
• Attunement from therapist enables maturational processes.
For the therapist:
• Attunement requires attention to the separation-attachment continuum.
• Attunement requires awareness of the need for affective engagement or disengagement.
• Attunement requires the ability to catch fleeting emotional states in the other; an openness to allow experiences, as yet unconscious, belonging to the other, to be known through one’s own experience; a knowing of the other not only from outside (observation) but from inside (countertransference) as well.
• Attunement requires an opening of the self to the self of the other.
Neurological Substrates of Attunement
Early attunement from mother to baby has been widely studied. Lenzi et al. (2008) undertook an fMRI study of 16 mothers with babies between 6 and 12 months of age, the stage when 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. The mothers underwent fMRI scanning while observing and imitating pictures of their child’s face and the face of someone else’s child. The researchers discovered that “the mirror neuron system, the insula and amygdala were all more active during emotional expressions, that this circuit was engaged to a greater extent when interacting with one’s own child, and that it is correlated with maternal reflective function (a measure of empathy)” (p. 1124). When the researchers compared single emotions with each other, they found that joy expressions evoked a response mainly in right limbic and paralimbic areas, suggesting an empathic response characteristic of maternal reflectiveness or attunement, but that ambiguous expressions elicited a response in left high order cognitive and motor areas, which might reflect the greater cognitive effort involved in recording expression that is less easy to read. Attunement will be not only to mind but also to facial and bodily expressions. Emotional communication depends as much on posture, gesture, movement, facial expressions, tone, syntax, rhythm of speech, and the pauses and silences that punctuate it as on verbalization itself (Jacobs, 2005). From the earliest days the young mind appears to be aware of the human body just as it is of the human face. De Gelder (2006) reports research indicating that “three-month-old human infants can discriminate point-light displays of human movement from random patterns” (Bertenthal et al., 1987) and at the same age infants presented with distorted bodies react significantly in areas of “brain potential that is typically evoked by the sight of faces and bodies” (Gliga & Dehaene-Lambertz, 2005).
Such attunement occurs rapidly at levels that are both conscious and unconscious. In the first minutes of life infants are attracted by face patterns; by two months they are able to recognize their mother’s face among others (Morton & Johnson, 1991). Martin et al. (as cited in Harrison et al., 2007) found that individuals who score highly on scales that rate social empathy need less time to identify emotional expressions even when seen very briefly. Both right and left amygdala show greater activity in response to faces with big rather than small pupils, and researchers in the area conclude that “amygdala sensitivity to pupil dilation is usefully conceptualized as an alerting response to the wide range of biological outcomes that this signal can predict” (Demos et al., 2008, p. 2,732). The amygdala plays a central role in this area and is vital to the processing of threatening faces.
Davis and Hadiks (as cited in McCluskey et al., 1997) set out to explore whether nonverbal behaviors were indicative of changing states of mind in therapy and concluded that body movement patterns at levels below the threshold of consciousness were indicative of intrapsychic and interpsychic changes during the therapeutic session. Concerning emotional body language, de Gelder (2006) posits a two-system model of attunement: a rapid reflex-like system that functions from subcortical structures involving the superior colliculus, pulvinar, striatum and amygdala, and a second system consisting of a cortical network involving “the fronto-parietal motor system, and connectivity between the amygdala and the ventromedial prefrontal cortex” (de Gelder, 2006, p. 247). Again the amygdala plays a major part in such processing, as it has reciprocal connections to both cortical and subcortical structures and, as such, acts as the crossroads in the interactions emanating from these structures.
Cozolino (2008) also stresses the integrative role of the insula, blending outer and inner sensation and linking cortical, limbic, and visceral experience. The right insula becomes activated when a face is judged to be a threat; it also becomes activated in relation to the experiencing of emotions. Both the insula and the anterior cingulate become activated when we experience pain or see others in pain (Cozolino, 2008). Again, the involvement of structures within the right hemisphere is seen to be crucial in the processing of painful emotion in relation to self and other. Because the right orbitofrontal cortex controls the regulation of emotional and bodily feelings, it has become known as the emotional executive of the brain, acting as it does “in concert with the amygdala and somatosensory cortex” (de Gelder, 2006, p. 244).
The role of mirror neurons in the realm of empathy and attunement is much debated currently. It was established in the 1990s, “the decade of the brain,” that action observation involves neural regions in the observer similar to those engaged in by the active participant during actual action sequences. A new group of neurons, described as “mirror” neurons, were discovered in the ventral premotor cortex of the macaque monkey. It was observed that these neurons are activated when a monkey intentionally performs hand and/or mouth acts and that the same neurons also become activated in the brain of a monkey observer as it passively watches this event. Further work on parietal mirror neurons indicates that single motor acts depend on each other, combining to form “pre-wired intentional chains, in which each motor act is facilitated by the previously executed one” (Gallese, 2007, p. 62). Some argue that mirror neurons play a part in the perception of emotion as well as action. Cozolino (2006) notes that “mirror neurons lie at the crossroads of the processing of inner and outer experience [and are] most likely involved in…the evolution of gestural communication…and empathy” (p. 187).
Harrison et al. (2006) point out that until recently empathy research had not identified convincing neurobiological substrates. They summarize recent developments, stressing that discovery of mirror neurons within the premotor cortex has provided a potential neural mechanism that mediates how we understand other people’s actions and intentions, thus providing a neurological basis for intentionality. They note concurrent advances that also take in the realm of feelings and emotions and observe that together these offer “a common neural representation for the perception of actions and feelings in others and their experience in self [and] basis for a neuroscientific account of intersubjectivity” (p. 5).
Many questions are being posed that may point to directions for fruitful future research. Hart (2008), writing as a clinician, is exploring whether “the recruiting of mirror neurons in the service of the developing processes of identification and empathy” is what actually underpins an attuned approach to working with traumatized and developmentally delayed children (p. 259). Recent research data suggest that autism is associated with an impairment of a basic automatic social-emotional process. It was found that autistic participants did not demonstrate the ability to mimic facial expressions automatically, whereas the control group of typically developing participants did. However, both groups showed evidence of successful voluntary mimicry. The researchers concluded that in development, such a mimicry deficit could impair a child’s ability to grasp others’ emotions. If such a deficit occurred early, it could impair the child’s ability to form self-other correspondences, affecting the sense of intersubjectivity and emotional correspondence so fundamental to a developing capacity for understanding other minds, perhaps even contributing significantly to the development of autism (Mcintosh et al., 2006). If this is the case it has profound implications for the study of attachment and affect regulation in children deemed to be on the autistic spectrum. As a result of a large-scale study of young children on the autistic spectrum, Greenspan (2000) observed that connecting affect to sequencing involves left and right-hemisphere connectivity and questioned whether between the ages of 12 and 30 months it may become possible to identify a particular metabolic or neurotransmitter system that plays a critical role in integrating affect or intent and sequencing functions.
Javanbakht and Ragan (2008) draw attention to the work of those who suggest that “frontoparietal and frontotemporal mirror neurons function as a bridge between self and others” and understand this mechanism as a possible substrate for the recognition of the intention and affect of the other (p. 260). De Gelder (2006, p. 244) points out that research into autism has demonstrated that people with the condition “show less activity in the mirror neuron system when passively observing or actively imitating facial expressions, consistent with reduced cortical thickness in mirror neuron brain areas,” which might point to a key role for mirror neurons in the processing of emotion. However, she strikes a cautionary note by observing that the reduced activity in the mirror neuron system might be caused by a deficit in the amygdala itself rather than in the mirror neurons primarily. The neurological substrates of attunement and empathy are explored further in Chapters 4 and 9.
Pattern completion is the autoassociative mechanism by which we lock on to familiar aspects of new experience and eliminate difference as seemingly irrelevant, in order to make best sense of the new in relation to past experience. The patterns in the mind that have developed as a result of early and subsequent experience and are stored in implicit memory, are discussed more fully in the next chapter in relation to the transference and countertransference, both of which (but especially the latter) may be understood as aspects of attunement.
Case Example: Marie
Imagine for a moment a patient, whom we will call Marie, who recently shared a traumatic experience of attunement from her childhood, which had continued to affect her bodily experience well into her therapy. An empathic therapist enabled Marie to feel secure enough in the relationship to explore the way in which she had become locked into an unconscious identification with a traumatic moment in the life of her young sister. She told her therapist that as a 10-year-old she had often been left with the responsibility of caring for her two younger sisters while her parents were at work. The children were allowed a great deal of freedom and spent much of the time swimming in a natural harbor. Marie was a strong swimmer and so was always charged with the responsibility of watching the other two. She remembered that on one occasion she was standing in the sea and watching them as they bobbed up and down, playing in the waves, some distance away in what was a seemingly safe situation. Suddenly she noticed something odd; one sister was now also watching as the other continued to seemingly bob up and down but disappeared into the water for longer and longer each time. As she retold the incident in therapy it was as if her memory cut off abruptly at this point for a moment or two, but then the scene she was recounting moved to a fully clothed man suddenly diving into the water near her sisters. Now there was another blank and her little sister was lying on the side and the man was thumping her chest. The scene changed again and the man was shaking Marie by the shoulders, shouting loudly “Don’t you know about cramp, surely you know about cramp!” She did not know what cramp was.
As she recounted this incident she remembered with distress that she had felt that she was castigated and punished by her parents because she had failed to take care of her sisters properly, and a sense of deep shame had lingered until she was able to begin to work with the experience in therapy. She did not go into the water again until she became an adult. Nobody noticed that as a result of the aftermath of their swim, she had actually become terrified of going into the water, especially if the sea had “white horses.” Much later she took swimming lessons to try to overcome her fear and after several lessons her coach became aware that she was not actually breathing at all as she tried to swim. In therapy she gradually realized that without knowing it, she was locked in an unconscious identification with her sister who had breathed in while under water and who had nearly drowned because of it. Her body had remained in a time warp of memory; her very attunement with her sister had left her traumatized. Woodhead (2004) comments that such a pattern formed out of a particularly traumatic experience of relating to another is “likely to be played out, outside of awareness, throughout her lifetime” (p. 146). Marie remained unable to break the spell until she gained insight, born of her transference experience in the consulting room, that enabled her to think about what had happened an how she had responded. She also became aware that she was trying to find a way to take care of her therapist just as she had sought to take care of her sisters and continued to do with others who mattered to her. Such thinking becomes possible within the context of an attuned relationship that offers new experiences and expectations of relating and thus enables new patterns to form within implicit memory.
Attunement in Relation to the Whole Mind-Brain-Body Being
Finally, I would like to reemphasize that attunement concerns the whole mind-brain-body being of the twosome in the therapeutic session. Sometimes the therapist will experience attunement primarily to emotional feelings emanating from the patient; at other times attunement to bodily states, as yet unrecognized by the patient, may be crucial for the work. Three times in 25 years I have worked with patients with serious, previously undiagnosed medical conditions, and all made good use of supportive psychotherapy. The following material is a composite based on work with all three of these patients. It is interesting to speculate how much my growing experience enabled an unconscious pattern-making process to occur, which I was able to “lock onto” at an unconscious level and which called forth the questions that helped us to bear soma (in this case, the brain-body) in mind as well as psyche.
Case Example: Lindsey
The patient, whom I will call Lindsey, was referred by her family doctor for depression that was keeping her out of work. As we spoke together I held in mind the series of questions that I ask myself about the patient and some of which I sometimes ask the patient directly (outlined in Chapter 1). Lindsey had recently become engaged, and the doctor wondered if this had awoken early difficulties of which the patient was unaware. Significantly she had also complained of some physical problems, and the doctor had already sent her for investigations, but no medical problem was identified. She was a very bright, scientifically trained professional woman, who was increasingly experiencing bouts of depression; she also complained of increasingly severe headaches. When asked to say more about the headaches, it became clear that sometimes they interfered significantly with her capacity to work, and although she had only recently stopped working she had self-medicated the headaches for a long time. As I heard this, I made a mental note to pay attention to the possibility of physical illness while also noting the need to try to understand the meaning that was attached to these headaches for my patient.
Lindsey moved on to explain that she had had a difficult relationship with her father all of her life; he had been dominant, demanding, scathing, and controlling. Nevertheless Lindsey had a significant degree of resilience, having done well at school and university and having entered successfully into her chosen career. For the most part she seemed to cope well socially and professionally but was having understandable concerns about what might be happening to her. I found a sense of unease within me that I couldn’t quite identify. The patient came for her fourth appointment and complained of more severe depression, accompanied by suicidal ideation. Something resonated deep inside me, and I found myself listening, with serious concern, to the patient’s description of how she had been feeing physically, feelings that she associated with her depression. I asked, “Is the increase in depression and headache related to your menstrual cycle?” She replied, “Oh, I don’t have periods, I haven’t had a period for years now.” Having ascertained that this amenorrhea was not because of any contraceptive choice she had made, I said firmly to this scientifically educated, young woman, “Then that is something you must go and talk to your doctor about. Will you do that before you come back to see me next week?” This step led to diagnosis and treatment of her hitherto unsuspected but serious physical problem.
Our work together had begun with an attuned awareness inside me of deep unease, which ultimately reflected my patient’s inner experience of disease. As one thinks about the patient as a mind-brain-body being it becomes increasingly clear how mind-brain and body are intimately and inextricably linked. As we worked together on her early trauma, the development of my capacity to experience the other in an empathic way was at the heart of our work. We sought to find each other and to work together in the today seeking to manage her depression, her difficult current life experience, the issues around medical and surgical options for her further treatment, and her hopes and fears around pregnancy and ultimately about becoming a mother herself. It seems that in those early sessions I was becoming deeply attuned to my patient’s inner being and was therefore able to sense in a right-brained empathic manner, through the countertransference, the level of deep malaise that she was experiencing.
Conclusion
While further research is needed to clarify the role of mirror neurons in the empathic process, the central role of attunement, achieved through the mechanisms of mirroring, resonance, and empathy is clear. The work with these patients brought home to me the need for attunement and the knowledge that such attunement will be to body as well as to mind. The working through of the insights that are made possible by such attunement is underpinned by right and left brain processing, by the capacity to feel with another while remaining able to think.