THE SELF IS FUNDAMENTALLY ASSOCIATIVE and its development relational, thus mechanisms such as transference (whereby past experience of relating is transferred on to new relationships), and countertransference (where the therapist intuits within his or her self something of the patient’s transference process), are inevitably rooted in the very earliest experience of mind. Implicit memory is the source of the deeply founded ways of being and behaving that govern an individual life and the ways that person seeks to relate to others. Lichtenberg (2004) notes that in infancy “experiences are categorized and generalized into maps of feeling states or very basic affect stories” (p. 137). These early established maps or neural networks are held in the implicit memory store of the early developing right hemisphere.
As we have seen in Chapter 2, the interactions that occur between mothers and babies have been closely studied and basic types of attachment have been identified. These are then manifest in patients’ ways of being, feeling, and behaving in the consulting room. Through the transference/countertransference experience the therapist can become aware of the nature of a patient’s earliest attachment pattern. Part of the task of the therapy will be to help that patient explore and become aware of his or her early attachment style and become able to look at the way this may be mirrored in his or her current relationships.
Unconscious or implicit aspects as well as conscious, explicit aspects of experiencing together play a fundamental part in the therapeutic relationship. Interactions in the consulting room express affective experience arising from implicit early memory; such interactions occur because of the affective reexperiencing that occurs within the transference. Through the transference relationship with the analyst, the patient is able to explore his or her own deeply established patterns of reacting to another, patterns which are formed by earlier experience. Through the countertransference the therapist is first able to live them with the patient, then through the therapeutic process to examine these recurring patterns with the patient. Acute attention to the unique interactive experience between therapist and client is crucial for understanding the underlying patterns in the individual patient’s mind that affects his or her understanding of relationships. The processes of patterning and pattern completion are fundamental to the way in which we use the past to help us to integrate new experience and to predict future experience. Although they have been studied most thoroughly in the sensory modalities, some researchers are now concentrating on thalamo-cortical pattern-completion and others on hippocampal systems of pattern-completion. Hershberg (2008) notes that “These organizing patterns are developed in relational contexts, through lived experience, and are experienced at implicit and explicit levels of awareness” (p. 28). Javanbakht and Ragan (2008) suggest that these kinds of processes may “occur with conceptual and affective patterns of related-ness” and understand them as vital tools for understanding transference and countertransference experience (p. 259).
Such patterning, both explicit and implicit, is perhaps more common in life that we realize. “Pass it on to the next generation” is a characteristic remark that I remember my maternal grandmother making when I would thank her for some thoughtful gift or treat. I remember with great clarity the first time she said this to me, on our return from my first holiday abroad. It was 1953, the postwar period of austerity when people in England still rarely had the luxury of a trip to Europe. From my early childhood my grandmother had nurtured in me an understanding of the wider world and the viewpoints of a wide range of peoples. Some of the first stories that she told me were of her childhood spent in India. One of the first books she read to me was about the Kon-Tiki expedition, and another was about Scott of the Antarctic; National Geographic magazines abounded in her otherwise spare home. It came as no surprise that this grand old lady, then living in relative poverty, chose to use the proceeds of an insurance policy that had matured to take my aunt, my cousin, and myself to Switzerland, a country she had visited many times as a young woman, had come to love, and wanted to share with us. It was a wonderful holiday, full of new sights, sounds, and ways of being. It gave me a love of travel and of Switzerland that has remained throughout my life. The way of being with another, as my grandmother was with us, might be said to encourage a quality of mindful awareness of the being and needs of another. In turn I have taken two generations of young family members to Switzerland for their first holidays abroad, telling them the adage of their great-grandmother and great-great-grandmother, respectively, as I did so.
So much that matters, that is of special value, and indeed that contributes to the essence of who we are, is passed from generation to generation, not in an explicit way, as this principle of generous living was, but at an implicit level. Both my mother and grandmother were born in India; both loved their ayahs (nurses) very much and always spoke of them with great affection. When my mother was with her sisters or her mother, they would talk together in a certain way that I have also taken in “with my mother’s milk.” On my first visit to India, several years ago now, I sat idly on a low wall enjoying the beautiful garden of a palace while my friend lingered to take some photographs. I watched as a group of Indian women, dressed in colorful saris, sitting close to me, talked together. The moment was full of color and the musicality of the women’s voices. As I watched I suddenly realized that I was seeing and hearing women talking in exactly the way my grandmother did with her daughters and, indeed, most surprisingly to me, how I can often be with friends in moments of enthusiasm, friends who do not necessarily communicate in the same style themselves but who greet it in me with warmth. In short, I recognized a fundamental way of being and relating that my most English grandmother and mother had both acquired in the nursery from their much-loved ayahs who were their primary caretakers, and that I, in turn, had acquired from them.
The inferior colliculus (where the imprint of the mother’s or primary caretaker’s voice is thought to be stored) is also close to the zones of convergence that receive and integrate inputs from many different brain areas and produce a “virtual map” of the inner and outer being. It may be that our very being is in part sculpted by our earliest experiences of our mother’s voice and the voices of the loved ones who sculpted her very being; indeed, within our very makeup are voices from the far past echoing down the generations in this very particular way. What I saw and recognized so vividly and celebrated on this occasion were happy voices, but what about those whose earliest encounters were with frightening, hostile, or disinterested voices?
The Realm of the Implicit
Now I want to turn specifically to the transgenerational transmission of ways of being and behaving, and, in particular, to a sadder aspect of what a child may take in “with his or her mother’s milk”--—the transgenerational transmission of trauma. We will bear in mind its effect on the individual’s extrapolation of how future relationships may be and how this may be explored in the consulting room. Bromberg (2006) comments that developmental trauma matters so much because “it shapes the attachment patterns that establish what is to become a stable or unstable core self (p. 6). Bromberg warns that unintegrated affect from psychic trauma”, threatens to disorganize the internal template on which one’s experience of self-coherence, self-cohesiveness, and self-continuity depends…. The unprocessed ‘not-me’ experience held by a dissociated self state as an affective memory without an autobiographical memory of its origin ‘haunts’ the self (p. 689).
Stein (2006) emphasizes that the quality of containment offered to the baby is “highly dependent upon the attitudes and resources that happen to be available to the adult caregivers” and is also “crucially dependent on their emotional stability and maturity”(p. 201). Early traumatic interpersonal experience affects what is available to be encoded, as well as the processes of encoding and recall of the memories associated with it. The earlier in life and the more sustained the traumatic experience the more likely it is to be held in the realm of the implicit. Jung explains that affectively toned memory images are lost to consciousness and form an “unconscious layer of psychic happenings” (Jung, 1951, par. 231, emphasis in the original). Such experience becomes encoded in implicit memory, unavailable to the conscious mind. Implicit or procedural memories are readily acquired without intention and remain in the mind but without entering conscious awareness; thus they can be understood as underlying patterns of being and behaving, which, although outside conscious awareness, nevertheless affect our ways of being and behaving thereafter.
The actual hardwiring of the emotion-processing circuits of the baby’s developing right hemisphere, which are dominant for the sense of self, is determined by “implicit intersubjective affective transactions embedded in the attachment relationship with the mother” (Schore & Schore, 2008, p. 12). Woodhead (2009) points out that, in parent-infant psychotherapy, where the therapist works with both mother and child to help to redress very early relational trauma, “neuroaffective touch and holding may form an important tool to bring about change” (p. 145) and to allow the development of new more benign patterns of being in the infant. She suggests that this “facilitates the emergence of the infant self” (p. 145). Watt (2003) emphasizes that children who grow up with trauma at the heart of their experience will go down what is “not just a bad psychological pathway but a bad neurological pathway” (as cited in Schore & Schore, 2008, p. 12). Experience of actual trauma retained in implicit memory is known yet inaccessible to thought; as such it hardwires what become the deeply held ways of being and behaving that set the scene for the transference that will be experienced later in analytic work.
The limbic system as a whole plays a significant part in processing and enabling our response to trauma, a response that originates from rapid processing of danger signals with immediate effects on body and emotions. Our initial response is so fast that only later does information reach the cerebral cortex, where it can be recognized, felt, and pondered. Modell (2005) draws our attention to the ancient association between motility and emotion:
The limbic system appears to be present only in those animals who are motile, which suggests that the origin of emotions may be related to the need for the individual animal to mobilize bodily responses as a whole, to respond to the requirements for homeostasis that provides the appropriate internal signals that mobilize the individual to either fight or flee…. Emotions or protoemotions—internal signals that monitor homeostasis—existed for millions of years before the advent of consciousness and feelings, (p. 39)
Considerable interest has also focused on what has come to be known as the default system. Particular regions, including the posterior cingulate cortex and ventral anterior cingulate cortex, are thought to constitute a network whose activity is ongoing during resting states and suspended during tasks that require active cognitive processing. Greicius et al. (2003) remark:
Taken together our results demonstrate that a distinct set of brain regions, whose activity decreases during cognitive tasks compared with baseline states, shows significant functional connectivity during the resting state, thus providing the most compelling evidence…for the existence of a cohesive, tonically active, default mode network. (p. 256)
Although some have argued that the notion is valueless (Morcom & Fletcher, 2006), functional brain imaging studies have nevertheless yielded a considerable amount of research evidence (Gusnard et al., 2001; Greicius et al., 2003; Raichle & Snyder, 2007) indicating that this default network is active in the task of sorting and storing memories, thereby helping to create a narrative of the past that may be used to inform future thinking. Both self-referential mental activity and emotional processing may represent elements of the default state (Gusnard et al., 2001, p. 4,259). Raichle and Snyder (2007) comment: “Intrinsic activity instantiates the maintenance of information for interpreting, responding to and even predicting environmental demands” (2007, p. 9, emphasis in the original).
Bar-Yam (1993) suggests that the temporary subdivisions that occur in the brain during sleep also enable a selective relearning process to take place that, in turn, permits the development of these predictive patterns in the mind. The fundamental motivation for such subdivision of the brain is the need to generalize patterns that may recur in life by identifying those aspects of the day’s experience that may recur in other contexts. Here we have the grounding for the experience of the unconscious patterns that occur in the transference and countertransference.
The realm of the implicit, as the resting place of emotional experience, especially early emotional experience, gives rise to much that we experience in the transference and countertransference. It also produces the trigger responses that engender intense transference behaviors. It is from the realm of the implicit that such mechanisms of projection arise and become manifest in therapy. Fowler et al. (1996) note that “viewing projective data as a communication to an ‘other’ has broadened the interest of researchers” and assert that this approach “shifts the primary focus from assessing a one-person psychology to the assessment of a two-person interactive paradigm of transference and countertransference” (Fowler et al., 1996, p. 400). Schore emphasizes the importance of the capacity to “feel the emotional processes both between and deep within each member of the therapeutic dyad” (Schore, 2007b, p. 754). Schore and Schore (2008) stress the value of focusing treatment on “the affective dynamics of right brain insecure internal working models that are activated within the therapeutic alliance” (p. 10).
The Impact of Trauma
As danger threatens a young brain-mind-body being, the brain’s initial response takes place in the brainstem, midbrain, and thalamus long before it gets to the cortex, where it can be thought about. In the face of such threat an infant’s body immediately responds in an intensely aroused way. When this response is to no avail, a sense of hopelessness and helplessness overwhelms the baby, his or her systems shut down, and the dissociative response reigns supreme as a last ditch attempt to conserve life in the face of overwhelming trauma. Janet (1889), Jung (1912, 1928, 1934a), Schore (1994, 2003a, 2003b), Cozolino (2002, 2006), and many others acknowledge that when, in Bromberg’s (2006) words, “a chaotic and terrifying flooding of affect…can threaten to overwhelm sanity and imperil psychological survival, the mind’s normal capacity for dissociation is typically enlisted as a primary defense” (p. 33).
The Dissociative Continuum
The mind’s normal capacity for dissociation, and the continuum that runs between normal and pathological use of the dissociative strategy as a young person responds to varying degrees of trauma, has been brought home to me by several patients. The continuum ranges from the kind of dissociation in which we all engage when we concentrate so hard on one thing that our awareness of what is happening around us is diminished, through to the extreme end of the pathological defense which is resorted to initially in the face of overwhelming trauma and then becomes a habitual response, a way of escaping from the immediate that may be resorted to unconsciously in a wide range of circumstances.
At the normal end of the continuum might be:
• The rather lonely boy who, in therapy as an adult, explains that he always made up stories in which he was the hero at the times when he felt particularly alone. The habit of retreating into this other world where he was special and surrounded by friends had gradually spread into much of the time when he was alone and had spare time to think. The time during which he traveled to and from school had become a regular period of retreat from reality to the world of make-believe. He might go on to tell that although he had a lively social life and was well liked in adulthood, the habit of entering another world still persisted, especially on the long solitary drives in the car that business trips required. In times of difficulty it might become something of a consolation. In therapy such a patient might become able to think about this habit and decide to make sure it did not dominate his or her life in an unhelpful way.
A little further along the continuum may be:
• A patient who reports that in her childhood, as she became ever more deeply aware of the unhappiness that reigned in her home because of the difficulties that each parent had with the other, she would retreat from the parental quarreling by going into another downstairs room. In that room there was a standard floor lamp, which had seemed to her to be very old and which she felt might have been in the house for a long time. She had thought to herself “Happy people must have lived here once—maybe if I stand on the base of the lamp and cling tightly to it, I will be able to get back in time to them.” She would step up onto the base, curling her toes around the slippery curved surface, cling tightly to the lamp, shut her eyes, and imagine flying back in time. Later, in therapy, she explained rather ruefully that she felt she must have had in her mind a rather mixed-up version of a magic carpet and Aladdin’s lamp. She concluded: “It was a rather unsuccessful attempt to do what Harry Potter was able to do when he found Platform 9 and three-quarters and could enter another world” (Rowling, 1997).
Much further along the dissociative continuum would be:
• A 12-year-old girl poised between latency and adolescence, with a much more fragmented internal world who spoke of her regular retreat to the world of Doctor Who, where she felt protected and safe in a way that was not her experience in the real world. She told of hiding behind the sofa, timidly peeking out from time to time to watch the world of Doctor Who (which unknown to her, mirrored her frightening and fragmented intrasubjective reality formed from the scary world that she had known as a very young child). In therapy she recounted that she had heard the Doctor say to her “If you are frightened in your world, come into ours and I will protect you.” For much of the time this girl was living in this other world of which she spoke as “in pretend.” Her use of this phrase indicated that there was the possibility of helping her to distinguish between “in real” and “in pretend” and over time enabling her to feel more comfortable in the world of reality. My first step toward facilitating this shift was to quietly underline her first use of the word pretend simply by repeating “in pretend?” with a slightly questioning note in my voice. When she was not taking part in adventures with the Doctor, then she might find that she had, in imagination, cast herself as the principal boy in pantomime. British children are often taken to the pantomime at Christmas. The story (usually a fairy tale) centers not only on the heroine but also on the hero (e.g., Prince Charming or Aladdin) who is always played by a woman dressed as a man. This role offered a retreat into a world where she did not have to be a girl; as principal boy she escaped in imagination to a safer role where she would no longer have to contend with the possibility of sexual abuse.
The imaginary material from these patients demonstrates how both in the immediate aftermath of adverse experience and later in childhood the dissociative response becomes the default mode for dealing with life. Although some of the material here may seem almost delusional in quality the defense operating in each case was primarily dissociative—that is, an attempt to escape where there is no escape. Schore (2007) cites Allen and Coyne’s conclusion that while such patients may have originally “used dissociation to cope with traumatic events, they subsequently dissociate to defend against a broad range of daily stressors…pervasively undermining the continuity of their experience” (p. 759). This defense may manifest itself in the consulting room in the most hidden, subtle ways: the averting of the gaze, the turning of the head, the momentary closing of the eyes, a glazed look manifest in an otherwise usually alert and engaged patient, the dulling of mind—and not only the patient’s mind but also that of the therapist, caught in a transferential experience of the dissociated state.
Kradin (2007) has made an interesting exploration of the effect on development of being constantly subjected to interactions that lack adequate information from the caregiver. Kradin believes that such experiences are revealed through the projected complexes that become manifest in the consulting room. He has focused attention on those projections that indicate lifelong styles of response to early informational absences. He points out that “when an early caregiver fails to provide adequate information of either a factual or affective nature…[or is physically absent it] can potentially lead to the development of crude parental imagos that the psyche will attempt to flesh out with archetypal images” (2007, p. 3). Here Kradin offers a key to understanding the effect on a child’s development of what must be understood as an affective lack, as only the right hemisphere, which deals with affective rather than factual information, is fully online at this early stage. The dominance of archetypal imagery in the absence of a good-enough experience of the human can be seen in material that emerges from many patients, such as Holly’s illustrations of her journey (see paintings in Chapters 5 and 11) and Clare’s comments concerning her inner world experience (Chapter 3). In considering a patient’s response to such informational deficits, one must bear in mind that pattern completion comes into play when information arriving in the present is vague. How difficult this must be when there are early informational deficits that have given rise to inadequate and incomplete patterns of reference in the mind.
It is no surprise that intrapsychic experience that arises out of such interpsychic lacunas gives rise to uncertainly about how the other person actually is, and results in the transferring onto others characteristics of distance and disinterest, as well as sometimes more scary feelings that may have rushed in to fill the inner void.
Those adult patients whose early experience was dominated by fear, anger, and abuse tend to transfer the patterns of expectation of the other that have been formed in response to that poor early experience onto the therapist. The expectation may be of anger, cruelly, or rejection. This will happen especially at moments of uncertainly and is often described as “negative transference.” The emotions may indeed be negative, but they inform the therapist about the patient’s inner world in a powerful way. Their emergence gives the therapeutic dyad a chance to explore them and ultimately, through different experiencing of the other in the consulting room, a different expectation of the relationship may be forged. The therapist must take care to regulate the patient’s level of arousal and, through relating in a different way as well as offering interpretation, help the patient to modify the expectation of relationship.
In turn the therapist may find that he or she feels that he or she is being cruel and abusive or disinterested and switched-off. The therapist will ask him- or herself “Is this my stuff?” and indeed sometimes that may be the case. Further self-questioning along the lines of “But why with this patient? Why now?” may lead to fresh insight about the patient, a modified way of being with the patient, and will keep the work on track.
At this point I will look at the neurological substrates which underpin these processes and then close with case examples and some technical considerations that are helpful to keep in mind.
Neurological Substrates of the Transference
The right hemisphere is equipped to enable us to perceive different qualities in experience, particularly frightening experience, and to react accordingly. Therefore it must hold the key to the modification, even the resolution, of transference phenomena. The right hemisphere, it has been found, is “particularly sensitive to the affective semantic content of emotional stimuli” (Atchley et al., 2007, p. 145); that is, the right hemisphere plays a key role in processing early emotional experience and in determining the patterns of response to others that will arise out of such experience and that will be transferred to all subsequent relationships that stimulate similar feelings in any way. The right posterior association cortex also plays a particular role in “processing novel input, guiding reactions to emergencies, and anticipating consequences” (Schutz, 2005, p. 11). Panksepp (2008) notes that the affective “intensity of fear emerges from convergence on central nuclei of the amygdala.” In contrast, corticomedial regions of the amygdala “promote aggression and sexuality” (p. 48).
The sophisticated response system of the right brain’s for dealing with threat and negative emotions such as hostility, dread, and fear means that “such emotion interrupts other, ongoing activities…and seizes the whole brain’s focus…compelling the mind to handle urgent matters without delay” (Schutz, 2005, p. 15). Schutz explains that the “most complex imagery of prediction and anticipation of what might come to be is also the product of right-brain activity…. The right posterior cortex not only previews failures and disasters but feels their emotional impact in advance, stiffening resolve to avoid them” (p. 16). Some of the intensity of felt experience in the therapeutic transference may reflect these aspects of right-brain activity.
Schore stresses the central role of the right hemisphere, especially the prefrontal cortex and limbic areas, in the dissociative response (Schore, 1994, 2003a, 2003b, 2007a, 2007b) and notes the dense reciprocal interconnections “with emotion processing limbic regions as well as subcortical areas that generate both the arousal and autonomic bodily based aspect of emotions” (2007a, p. 760). He summarizes with great clarity the conclusions of a mass of research that indicates that “the infant’s psychobiological reaction to trauma is composed of two separate response patterns—hyperarousal and dissociation,” which depend on “two parasympathetic vagal systems in the brainstem medulla” (2007a, p. 757). The ventral vagal complex rapidly enables fluid engagement and disengagement with the social environment and rapid response to pain, in contrast the dorsal vagal complex, which is “associated with intense emotional states and immobilization and is responsible for the severe hypoarousal and pain blunting of dissociation” (2007a, p. 758). He draws attention to Porges’s (1997) work, which describes the prolonged and involuntary nature of the dorsal vagal response and links this to the gaps in patients’ ongoing experience of reality at such times (Schore, 2007a).
Schutz (2005) notes that the right posterior association cortex is larger in the right hemisphere than in the left, with “denser association fibers…greater interconnection of neural columns (identified in the temporal lobe)…and larger integrative structures” (p. 13). He observes that “right-brain problem-solving generates a matrix of alternative solutions, as contrasted with the left brain’s single solution of best fit” (p. 13). I remember, as a trainee, being struck by Klein’s (1975) capacity to wonder with her young patient, Richard, in a sensitive way about a number of possibilities of emotional meaning in what they were experiencing together. The right brain specializes in the processing of negative stimuli and is at work in situations where the negative transference predominates (Kimura, 2004; Sato & Aoki, 2006). To respond by using its capacity for examining alternative solutions in the way Klein advocated is therefore likely to be more effective than any head-on or either/or approach to a particular manifestation of the negative transference.
Imprinted patterns of neural excitation give rise to ways of being and behaving in the present in anticipation of future happenings based on past experience. Bar-Yam (1993) summarizes:
In theoretical models an imprinted pattern of neural excitations can be recovered if a sufficiently large part of the pattern is re-imposed on the neurons. Evolving the activity pattern then causes the complete original imprinted pattern to be recovered. This is an associative memory which associates the restored pattern to the part-of-it that was imposed. Such neural networks are also considered to be capable of generalization. This capability arises because the region of “possible experiences” near a particular memory evolves by neural dynamics to the memory. (p. 2)
Perhaps we have here a description that can be helpful in thinking about the process of first experiencing and then understanding elements of the transference, as it arises in response to emotional exchanges that in some way trigger implicit memory of earlier traumatic experience. Pally (2007) describes such patterns as the product of the predicting brain; she suggests that at a nonconscious level the brain “predicts what is most likely to happen and sets in motion perceptions, emotions, behaviors and interpersonal responses best adapted to what is expected” (p. 861). In life this can lead to a bringing about of what is most feared, as the person who adopts a response in anticipation of being hurt may bring about just that. In therapy the therapist must identify the feared response and seek to avoid responding in that way. Over time he or she may help the patient to identify and abandon, rather than continue to repeat, such maladaptive reactions. Pally (2007) gives weight to the cognitive as the curative element, whereas Schore favors the role of relational-emotional contact in the therapeutic dyad as the crucial factor in achieving lasting change (Schore, 1994, 2003a, 2003b, 2007a, 2007b).
Neurological Substrates of the Countertransference
Although still speculative and as yet poorly understood, it appears that a body of evidence may now be emerging that establishes a neural basis for empathy in that the perception of emotion in another activates the neural mechanisms responsible for the generation of emotions. If this should prove to be the case, it will provide an understanding of the depths of the transference-countertransference process and will establish an indissoluble link between those processes and the development of mind.
The countertransference is a very particular form of musing about one’s own body-brain-mind response as part of the experience of being with the patient; it is a musing that brings creative knowledge of oneself and the other via the unconscious communication of self states and relational patterns from the patient to the therapist. These states are absorbed by the therapist at the level of the implicit, below the threshold of consciousness. Perry (1997), following Samuels (1985), suggests that both therapist and patient “contribute to and are part of a shared imaginal realm, in which bodily responses, feelings and phantasies can be viewed imagistically” (p. 160). Many describe the countertransference experience as being rooted in bodily experience; Sidoli (2000) described her experience of countertransference in the following way:
The analyst must pay a great deal of attention to the subliminal messages conveyed by the body. The unintegrated emotional fragments are located in the body. Thus one must listen with a “third ear” and observe with a “third eye.”…My countertransference with these patients is rooted…most of all in my experience of observing young infants and their nonverbal way of relating…. I have to make my way toward making the hopeless infant inside the patient trust…. When the attachment sets in, the patient will slowly use me to make up for the mirroring experience he or she missed. (p. 102)
Modifying Past Patterning
Case Example: Jill
Jill, a woman in her forties, whom I describe more fully in Chapter 6, had an effective, well-adapted coping self that stood her in good stead in most situations, most of the time. The often unpredictable, impulse-driven behavior of her alcoholic mother and resentment of her very existence that emanated from her stepfather together combined to provide a particularly acute state of what Kradin (2007, p. 3) terms “informational absence.” These parenting failures persisted throughout her childhood and into adolescence, which, although it might have offered a second chance to experience a meaningful affective relationship with either parent, passed without much change in either’s parenting style. The intense affective informational absence that resulted was partly modified by an aunt’s warmer way of relating and attempts to explain factually the parents’ shortcomings. This information enabled the patient to develop enough resilience and intellectual understanding of her dilemma so as not to be destroyed completely, though she used the mechanism of projection defensively, in a rather rigid and inflexible way, particularly the projection of her own destructive anger. This could affect her transference to me at difficult moments in the therapy.
Transference phenomena are perhaps seen most clearly when they are manifest in the consulting room; that is, when difficult feelings which are the product of poor early relational experiences get transferred onto the therapist. With time and patience such feelings may be recognized, understood, and worked though so that it becomes more possible for the patient to relate to others in a different way. However the patterns that build in the mind of how relationships with others develop will also get transferred onto others; they may become manifest in relations with friends, family members, or co-workers. It may take very little to trigger such transference phenomena in someone whose early experience has been full of fear and uncertainly.
Hidden deep within Jill, unknown to her for much of the time, was a much younger hurt and frightened aspect of herself that was evoked when, as an adult functioning well in the workplace, she hit a difficult patch. As she told me the story she looked at me in a defensive way as if she was sure I would criticize her. It felt as if a senior colleague were pulling out the rug from beneath her feet, in a way that posed a very serious threat to her continued well-being and success at work. Jill told how she had gone home from work the previous evening uncertain of how the situation would develop. As she thought about it at home, she suddenly felt herself becoming overwhelmed by an anxiety that developed into a full-blown panic attack accompanied by a sudden and very vivid memory of an occasion from the eighth summer of her life. She had been out with young friends, unaccompanied by any adults. They had chosen to walk into the bottom of an old quarry, knowing that they would have fun, climbing up the steep side of it. Jill was overwhelmed by a sudden and intense flashback of how when she was halfway up this climb, she had suddenly found that her feet were slipping; she had felt the soil surface slipping away beneath her feet. She had made an abortive attempt to grab at some low-growing bush as she began to slip and slide. The memory was so vivid she felt that she was actually reliving the experience again. Somehow she had managed to save herself by clinging to a ledge with her legs trembling, until she became calm enough to finish the ascent. She never climbed that quarry again.
Although the incident had seemed long forgotten, if remembered at all, the actual moment of slipping had returned, as if it were happening to her all over again in an intensely vivid way, even as she retold it in the consulting room. She felt that she had been very lucky to have managed to save herself from what would have been a very dangerous fall from a considerable height. After we had worked on lowering her level of arousal, grounding her in the room and in the present (see Chapter 2 for a fuller explanation of this process), we were able to speak briefly about the way the brain remembers previous danger, stores such experience implicitly as “the old present,” is able to recognize similarities in contemporary experience, and then pattern-matches in a rather general way in an effort to protect from further distress. We went on to make the links to her workplace, her difficult early experience, and her fears that I would not understand but would blame her. We discussed how frightening the situation there felt, how it mirrored some of her very painful early experience as a child. I then asked about strategies that might help her to manage the work situation. She became much more able to think about what steps she might be able to take to deal with the current threat to her well-being once she had laid to rest the ghosts from the past. Such unresolved traumatic transference experience poses a constant challenge for the therapist when, through enactments in the therapy, the dynamics are replayed again and again, not in the workplace as on this occasion, but in the therapy itself, as the patient unconsciously seeks an experience not only of the rupture, undergone so frequently in childhood, but also a new experience of healthy repair.
Kradin’s Patient B.: Using the Reality of the Analyst to Compensate for Early Patterning
Kradin (2007) describes a patient, B., whose parents alternated between unwelcome impingement and emotional abandonment. Kradin highlights one of the limitations of working in a psychoanalytically abstinent way (i.e.,) with such patients. He suggests that although abstinence may foster projections, it may also unwittingly contribute to the “domain of informational absence” (Kradin 2007, p. 4). He realized that such a stance for this patient, although it might be operationally neutral, was not analytically so, understanding that it was “too close to the informational void that [the patient] had experienced with his father” (p. 5). He began to work cautiously in a way that allowed his patient to have more sense of an actual person in the room. Cozolino (2002) also stresses the difficulty that working in a silent, abstinent way poses for such patients, pointing out that “silence is an ambiguous stimulus that activates systems of implicit memory” (p. 99). Kradin (2007, p. 5) concludes: “Once B. realized that I was a person in my own right, his reliance on transference projections diminished.” Kradin makes clear that an abstinent evoking of projections accompanied by a left-brained interpretational approach is not only an inadequate way of working on this occasion but also actually unhelpful for such patients whose early affective distress is enacted again in the room. The rough pattern matching that goes on in the brain-mind can become particularly intense as a patient relives traumatic experience.
“A kind of novelty that is useful, valuable and generative” (Stokes, 1999) and a kind of unfocused attention (Mendelsohn, 1976) seem to me to be the hallmarks of creative countertransference experience. Concerning the process of creative thinking, in particular, it has been argued that the right hemisphere:
• Operates in a more “free-associative, primary process manner, typically observed in states of dreaming or reverie” (Grabner et al., 2007, p. 228).
• Works “in a more parallel or holistic processing mode, in contrast to the sequential, logic-analytical processing mode commonly assigned to the left hemisphere” (Grabner et al., 2007, p. 227). (It is this holistic processing mode that I believe enables the experience that we describe as the countertransference.)
• Has an increase in its alpha power in the subjective experience of insight (Jung-Beeman et al., 2004; Bowden et al., 2005; Grabner et al., 2007).
Gallese’s work, although speculative as yet, emphasizes our capacity to directly understand the inner world of others without recourse to complex sophisticated mentalizing abilities. He suggests that such direct understanding is arrived at by means of an “embodied simulation” mechanism resulting in the activation of chains of related neurons that enable not only low-level mechanisms such as empathy but also “more sophisticated aspects—like the attribution of mental states to others.” He further suggests that “this mechanism enables attentional attunement with the observed agent” (Gallese, 2007, p. 661, emphasis added).
Carr et al. (2003) explain empathy as arising from a mechanism of action representation that enables emotional understanding. They stress the role of the inferior frontal cortex because of the role of empathy in understanding the goals of the other. They also observe the part played by activity in the amygdala in the right hemisphere (rather than the left amygdala) in the imitation of facial expressions. I have come to think of the bodily experiencing that occurs as part of countertransference phenomena as embodied empathy.
Pally (2007) emphasizes the way in which nonconscious brain predictions that arise from earlier experience actually alter brain activity and suggests that this process offers a biological mechanism by which the unconscious repetition of transference phenomena occurs. It is just this activity that I believe is picked up in the rapid processing that occurs at levels below consciousness that we have come to describe as counter-transference. Cowan and Kandel argue that affective arousal increases neurotransmitter activity, which in turn fosters neural learning and development (as cited in Ginot 2007). Pally (2007) stresses the involuntary nature of nonconscious responses and emphasizes the importance of conscious self-reflection as an agent of therapeutic change; indeed interpretations, arising out of both transference and countertransference experience, have their part to play in effecting change.
In a groundbreaking summary of the literature concerning therapeutic change, Schore (2007a) emphasizes that for patients who have experienced early relational trauma, affective processes that lie beneath levels of conscious awareness are of critical importance and occur through the “ultra-rapid transactions of nonverbal facial expressions, gestures and prosody between the patient’s and therapist’s right brains” (p. 8). Schore also draws our attention to work that shows that only the right hemisphere, and not the left, is attentive to, and dominant in processing, negative emotional stimuli (Kimura et al., 2004; Sato & Aoki, 2006). Much of transference and countertransference phenomena is concerned with negative emotion, as the predictive patterns established in the mind-brain are patterns established in response to earlier trauma.
Apparent Absence of Empathic Countertransference
Early notions of lack of empathic countertransference were attributed to the intrusion of the analyst’s own concerns, sometimes as a defensive strategy against overintrusion by the patient or otherwise unbearable states of mind evoked by the patient. However, sometimes sleepiness or mind-wandering states may be dissociative effects induced in the therapist by the patient, and as such are an informative countertransferential response that may mirror dissociative states of mind that threaten to overtake the patient. I have often found that to ask myself “Why this state of mind with this patient at this moment?” can be extremely informative. For instance, one young female patient might have experienced early relational trauma in the form of hospitalization without her mother at 2 weeks old, which was then followed by removal from mother to be with a foster carer from 3 months to 18 months old, and then by a return to mother and total loss of the foster carer to whom she would by that time have become very attached. In the consulting room it might appear that this patient had dealt with the most painful moments of her early experience by disengaging, by blotting out what would have otherwise been unbearable feelings and retreating into almost completely switched-off states. Perhaps there would be moments in the consulting room when, without knowing why, I would find myself increasingly switched off and struggling to remain alert and engaged. Eventually I might learn that at these times it helped to say something open-ended along the lines of “I think there’s something quite difficult around.” My patient might then be able to get into touch with some new aspect of this painful, well-nigh unbearable, early experience.
Ginot (2007) argues that complex “mutually reactivated dissociated memories and self-states” can occur, containing within them “entangled implicit relational schemas,” and giving rise to enactments in the consulting room (p. 318)—perhaps better termed reenactments—because they arise out of the entanglement of the past experience of both members of the therapeutic couple. Ginot values such occurrences as providing a unique understanding of the patient’s relational patterns, held in dissociated self states that result from early relational trauma and that, as such, cannot yet be verbalized. Stern (2008) regards enactments as an essential, indeed the only means, of encountering dissociated aspects of the patient. For him the value of enactment lies in the opportunity it offers to “understand the unconscious impact of the patient on him, and then to use his knowledge of this impact, and of his own disequilibrium, to grasp parts of the patient’s experience that the patient has no way to put into words” (p. 402). Here it becomes clear that affective attunement based on empathic countertransference is the only medium that will enable understanding in the therapist and may lead to change in the patient’s mind.
A useful distinction is drawn between enactment and acting out by reference to Lebovici’s definition in which enactment is understood as something “achieved in a truly extraordinary moment in which the analyst feels in his own body an act which remains experienced and not acted out” (as cited in Zanocco et al., 2006, p. 148). Enactment concerns just these primitive elements of experience that have not yet entered the conscious mind and become nameable for the patient. The authors comment: “Enactment by contrast [to acting out] is related to primitive unconscious elements which find in the act their first expression” (Zanocco et al., 2006, p. 150).
Hart (2008) discusses the particular kind of countertransference enactment that Lebovici describes based on her work with a patient who moved into a state of hypoarousal (following overarousal), when reexperiencing extreme helplessness that she felt resulted, almost, in metabolic shutdown. Such a state of hypoarousal cuts the sufferer off from both internal and external stimuli in order to prevent cell death and damage that might otherwise result from a continuing state of overarousal. She argues that the effect on the therapist who is in the presence of such extreme manifestations may be a sense of having what feels like a lack of countertransference, which initially seems to diminish the possibility of meaningful reflection. She describes what seems to have been a flight into pseudo-thinking that she experienced as she worked with a severely traumatized child, a 3 1/2-year-old little boy, whom she calls Zack, who had been removed from his family because of neglect, violence, and suspected sexual abuse. The flight into thinking occurred in her at moments when he moved into severely dissociative states. Hart describes the state she was experiencing as a defended sort of thinking about her patient’s difficulties. On these occasions it seems that what she experienced was an involuntary shift into left-brain cognitive activity, perhaps as an unconscious protective dissociative strategy that matched her patient’s dissociative state, while avoiding a mirroring experience that would have led to the extreme and damaging right-brain manifestations that were being demonstrated in her patient.
What I find so moving about her account of the vicissitudes of Hart’s (2008) countertransference experience is the shift she describes to a right-hemispheric body-, image-, and feeling-based empathic counter-transference as the child became more able to be in touch with his bodily experience and also became able to cry. She describes her countertransference response on one occasion as consisting of sharp pain in her abdomen, which then emerged in “images of daggers” (Hart, 2008, p. 65). Linking with the left hemisphere occurs as she then begins to ponder the unthinkable—that is, she finds herself thinking of the sexual abuse that the child may have experienced. In thinking about this processing, she is reminded of Schore’s (2003a) observation that projective identification is “a very rapid sequence of reciprocal affective transactions within the intersubjective field that is constructed by the patient and the therapist” (p. 73).
Closing Thoughts
A patient toward the end of her treatment chose to sit cross-legged on the couch during one session, looking at me pensively as she explored the transference patterns in her mind that had caused her such difficulty early in the therapy—patterns that had so easily made her feel as if I might be a monster, or that she might be something monstrous, that she would fall into the abyss, that I must hate her, be bored by her, be always wishing the session would end, just waiting for her to leave. She tentatively mused about how it might have felt to be me at some of those times and about how it distressed her now to think of how it might have affected me then. As she spoke I was reminded of the difficult counter-transference feelings that I had experienced—feelings of anger, rage, uselessness, failure, even despair. With gentle warmth she reflected on how gradually but inexorably the deep affective engagement that had occurred between us had allowed those old patterns, based on fear and distrust and rage, to slowly change into a new way of experiencing as she began to know something of containment and security within the analytic dyad. The reader will meet Holly and will experience something of the changes in her inner world over the course of her therapy in the next chapter.