ATTACHMENT, AFFECT REGULATION, AND AWARENESS of early patterning have become increasingly accepted as the basics of good therapy because they underpin each individual’s capacity for successful relating. My concept of therapy is something like a double helix, in which interactions involving left-brain and right-brain processes intertwine in order to make a whole. One aspect of therapy deals with the implicit, arising from the right hemisphere; it is predominantly affective, composed of the affective encounter between therapist and patient. The other deals with the explicit, arising from the left hemisphere; it is predominantly cognitive, manifest in interpretation. With Stern et al. (1998), Cambray and Carter (2004) note two similar strands of therapeutic action. One strand is “explicit through verbal, content-oriented interpretation of the transference, the other is implicit through nonverbal, process-oriented knowing in the context of the shared current relationship” (p. 133). They conclude that the focus of therapy should be on “facilitating a coordinated integration of explicit and implicit relational memory and knowing as manifest in images, dreams, stories, and narratives, as well as the analytic relationship” (p. 144). Cozolino emphasizes that “the blending of the strengths of the right and left hemisphere allows for the maximum integration of our cognitive and emotional experience with our inner and outer worlds” (Cozolino, 2002: 115). No therapy is complete without both and I find that interpretations, particularly those that involve putting feelings into words, arise out of the experience of relationship as it unfolds and brings about increasing connectivity, making possible healthy and integrated functioning of both hemispheres of the brain. M. L. Miller (2008) argues that “with each successive advance in our theoretical understanding of emotion the analyst’s emotional participation becomes more central to the analytic process, opening new avenues of therapeutic relatedness and intervention” (p. 4). There is now a growing consensus that left-brain interpretational work is simply not enough and that right-brain empathic relating is essential, especially for patients who have experienced early relational trauma. Haven (2009) points out that “people process their trauma from the bottom up—body to mind—not the top down” and concludes that “if trauma is situated in these subcortical areas, then to do effective therapy, therapists need to do things that change the way people regulate these core functions, which probably can not be done by words or language alone” (p. 212). The second half of this book explores some of these avenues. The American Psychological Association’s Presidential Task Force on Evidence-Based Practice (2006, p. 277) asserts that clinical expertise is characterized by “interpersonal skill, which is manifested in forming a relationship, encoding and decoding verbal and nonverbal responses, creating realistic but positive expectations, and responding empathically to the patient’s explicit and implicit concerns.”
Integrating Cognitive and Affective Approaches
For those who have experienced early relational trauma, it seems that only this dual approach of empathy and interpretation will enable clients to address the point of pain while staying “in mind” and able to work, rather than retreating into defensive dissociative states of mind. Interpretation alone is simply not enough to redress damage to early implicit structures in the mind. Haven (2009) comments: “Trauma does not sit in the verbal understanding part of the brain but in the much deeper regions—the amygdala, hippocampus, hypothalamus, brain stem” (p. 211). Our task is not merely that of making the unconscious conscious but rather of restructuring the unconscious itself (Alvarez, as cited in Schore, 2007a). Lane (2008) points out that the adaptive value of primary emotional responses is the reason for their survival in the evolving organism that is the human being. Schore (2008b) argues that “emotional processes lie at the core of not only early developmental processes, but also in the re-evocation of these processes in the psychotherapeutic relationship” (p. 22). Stern (2008) emphasizes the unconscious aspects of the therapeutic process, explaining “Just as inevitably as the patient unconsciously affects the analyst, the analyst unconsciously affects the patient. From this point of view, the relationship is understood to take place between two unconsciously intertwined subjectivities” (pp. 404–405).
Whereas the explicit can be thought about in words by the therapist and client together, the implicit is most effectively addressed through the actual quality of the relationship that is established in therapy. I argue in favor of an approach that regards both affective encounter and interpretation as vital and complementary aspects of therapy. I have come to take what I think of as a “double helix” approach to therapy, one that pursues increasing neural integration of right- and left-hemispheric activity.
Jung consistently emphasized the dual aspects of the encounter between two beings. He regarded the meeting of minds at both conscious, explicit and unconscious, implicit levels as necessary for change and transformation. I have utilized Jung’s (1946b) exploration of one of the images from the Rosarium Philosphorum, in order to better illustrate the levels at which this transformation occurs (see Fig. 5.1).
Jung understands the joining of the left hands as representing “the unconscious side…the affective nature of the relationship” (Jung, 1946b, par. 410). The left side of the body connects to the right hemisphere of the brain, and the right side of the body connects to the left hemisphere. The joining of the left hands in this image may be understood to signify right-hemispheric, implicit interactions and emotional responses, and the crossing of the flowers held in the right hands (which Jung understands as compensatory) to signify the exchange of ideas or cognitions arising in the left hemisphere. Both figures are standing in a way that permits gaze and gaze-away exchanges to take place between them, reminiscent of the earliest ways of relating between mother and infant. The way the gaze of each engages the other points to the importance of the “language of the eyes” for the understanding of the other (Baron-Cohen et al., 1997; Baron-Cohen, 2001; Hirao, Miyate, et al., 2008). For a considerable time analytic theory privileged left-hemisphere functions over those of the right. However, each has a part to play. As M. L. Miller (2008, p. 11) argues, “our brain is as much, if not more, an emotional organ as it is a cognitive one,” and he notes that “cognitive schemas organize our declarative knowledge whereas emotional schemas organize and interpret our subjective and interpersonal worlds” (p. 8).
The Right Hemisphere and Cognition
Recent research has focused attention on the process by which the unconscious is made conscious, seemingly an essentially cognitive process. However, both fMRI scanning and electroencephalography (EEG) recordings have detected increased activity in the anterior superior temporal gyrus of the right hemisphere, where new insights involved what might be termed the “aha” factor. Researchers describe this as the activity that reflects the moment at which “the unconscious becomes conscious” and note that “this right anterior area is associated with making connections across distantly related information during comprehension” (Jung-Beeman et al., 2004, p. 506). They further observe: “It is striking that the insight effect observed in the RH [right hemisphere] in our experiments occurred when people solved verbal problems, which traditional views suggest should involve mostly LH [left hemisphere] processing with little or no contribution from the RH.” They conclude that such insight solutions are associated with “early unconscious solution-related processing, followed by a sudden transition to full awareness of the solution” (p. 507).
Inadequate development of the left hemisphere is the result of early relational trauma and prevents adequate processing of information (Panksepp, 2008). For the mind-brain to function effectively the two hemispheres need to function in an integrated way. Both are linked through the corpus callosum, the midsection, which has been identified as the brain region most severely reduced through early traumatic experience (Teicher et al., 2006). It seems likely that such linking and integrating of the two hemispheres is best able to develop in a therapy that embraces the affective as well as the cognitive dimension. Beaucousin et al. (2006) stress that emotional verbal communication has a fundamental part to play in human relating and that emotional comprehension emerges from the processing of both linguistic and pragmatic information, thus being the product of the integrated functioning of both hemispheres.
Recent research has also highlighted the importance of the ventrolateral prefrontal cortex (VLPFC) in the integration of cognitive and emotional information from one’s own internal states, both in normal subjects and in patients with a diagnosis of schizophrenia. The VLPFC, “in addition to cognitive information on external object identity through the ventral visual pathway…also receives motivational and emotional information from the OFC [orbitofrontal cortex] and subcortical areas such as the mid-brain and the amygdala” (Hirao, Miyuta, et al., 2008, p. 172).
Other researchers focus attention on the integrative role of the cerebellum, “a vastly complex structure…[with] almost as many neurons as the cerebral cortex” (Cozolino, 2006, p. 285). This complexity, in conjunction with its dense connectivity into surrounding areas, suggests that the cerebellum may play a significant role in “the modulation and timing for language and affective communication” (p. 286). Levin (2009) further highlights the importance of the functioning of the cerebellum in relation to the processing of emotion and the linking of implicit and explicit memory. I would speculate that the cerebellum ultimately can the integration of affect and cognition that is mediated by the cerebellum ultimately can lead to therapeutic change and development of mind.
It must be clearly acknowledged that from a therapeutic viewpoint, words have limitations. Words can be used defensively in the consulting room by either member of the dyad. A patient may use a stream of words or may report rather meaningless life narrative material in an attempt to shut out the analyst. Words are rarely neutral, and words spoken by the analyst may be experienced by the patient as attacks that harm the fabric of the self. Knox (2008) notes that at the wrong stage of psychic development, even the lightest interpretation can be experienced by a patient as “inadvertently taking away a whole world” (p. 31). She goes on to argue, both sensitively and cogently, that “interpretation is about words which, by the fact we need to use them, convey the separateness of one mind from another and so may be unbearable to someone who cannot yet be sure that he or she can be allowed to have a much more direct emotional impact on the analyst, that the analyst is not afraid of the patient’s need for close attunement” (p. 35).
I am aware that much interaction in the twosome will be fast, automatic, and below the threshold of consciousness. Cozolino (2006) observes that “when it comes to the processing of facial expressions we have a wide span of attention, a low threshold for detection and obligatory and automatic processing” (p. 177). Such research makes clear that to “watch what we say” will not be sufficient on its own; equally vital will be to attend to “how we are.” A shrug of the shoulders, on its own, or with a certain look or sound may indicate disdain; a shrug of the shoulders, again on its own, or with a slightly different look or sound accompanying it may rather indicate despair. A smile which does not reach the eyes may have the quality of a grimace—sometimes this will reveal itself as annoyance, at other times the therapist may be instantly aware of underlying fear. Watt identifies two routes for perception of the feelings of another person. One is very fast and he terms it the contagion route; it is essentially a right hemisphere, affective process occurring below levels of consciousness. The other is a slower process involving left hemisphere, cognitive processing; that is, thinking about what a sound, a look, a gesture might mean. Fear may be identified almost instantly. Thinking about why the patient might have become afraid is a slower but equally important process for the therapist. Quiet attentiveness from the therapist can help the patient to feel safe enough to reveal the material that has come to mind, which may well be very frightening, and short, open-ended questions can invite further exploration of the feeling and encourage the patient to attend to the affect.
Mundo (2006) points out that “when patients are asked to remember the significant moments inducing change during their treatment they usually remember affect-charged moments of interaction with the therapist” rather than the interpretations that were offered (Mundo, 2006, p. 684). Indeed Fonagy and Target (2008) point out that “as arousal increases, in part in response to interpretive work, traumatized patients cannot process talk about their minds” (p. 29). The Boston Change Process Study Group emphasize the importance of the implicit realm as the facilitator of therapeutic change, of the experience of “moments of meaning” within the dyad rather than moments of insight or intellectual understanding (Lyons-Ruth et al., 1998).
“Moments of meaning” are processed by the prefrontal cortex of the right hemisphere, the emotional executive of the brain, which is densely connected vertically into the limbic system, the brain stem, and into the body, just as the body, the brain stem and the limbic system are richly connected to the prefrontal cortex. Such connectivity enables the prefrontal cortex to process, organize, and inhibit, feelings, impulses and bodily emotions. It also has strong horizontal connections into the left hemisphere, via the corpus callosum, which enables more cognitive processing. Such connections are reciprocal. There are horizontal connections at the limbic level from right to left and vice versa. Cozolino (2002) notes “transcortical networks in both hemispheres feed highly processed sensory-motor information forward to the frontal cortex. Simultaneously, multiple hierarchical networks, which loop up and down through the cortex, limbic system and brainstem, provide the frontal cortex with visceral, behavioural and emotional information” (p. 132). Cozolino concludes that factual and affective informational development layered upon early experience requires “simultaneous re-regulation of networks on both vertical and horizontal planes” and observes that much of this is mediated “through interactions among regions of the prefrontal cortex, our primary executive system” (p. 30). Such reregulation can only be the product of a therapy that addresses movement between and within each hemisphere. As a result of their exploration of fMRI scans, Beaucousin et al. (2006) concluded that the accurate affective communication involves activity in both hemispheres in that semantic, affective prosody and mind-reading neural networks are activated (Beaucousin et al., 2006). Chused (2007) suggests that in such circumstances “the communication that takes shape back and forth between patient and analyst may have more mutative power than an explicit communication” and argues that “in some instances such implicit communications lose their power to alter a patient’s inner world if they are made explicit” (p. 875).
Locking on to an emotional understanding of another via pattern completion (see Chapter 4) allows a quick response to present experience based on past experience. When past relational experience has been seriously flawed, familiar pain in relating is privileged over fear of the unknown. Javanbakht and Ragan (2008) point out that “such a neuropsychological template fit offers abeyance of the insecurity of the unknown in favor of…easily accessible pattern-completion” (p. 270). When early experience has been very difficult or present circumstances have given rise to very stressful relational experience, then such locking in of a past pattern may result in a very powerful negative transference that may destroy the unique opportunity that therapy offers to experience something other. Left-brain interpretational work will prove to be ineffective when confronted with such a negative affective engagement based on past early, right-brain experience. The solution lies in the relational approach: Lewis et al. (2000) point out that “people do not learn emotional modulation as they do geometry or the names of state capitals”; rather they learn it implicitly from “the presence of an adept external modulator” (as cited in Dales & Jerry, 2008, p. 305). The therapist must be sufficiently present to mitigate the too intense transference that would paralyze the patient and lead to a stalemate in the treatment.
Promoting Neural Integration as a Means to Achieve a Learned Secure Attachment
Images associated with early trauma may be called forth through the powerful affective engagement that may occur in therapy when the core work is understood as affective and relational in nature. Lichtenberg (2004) notes that “through words, images, gestures, metaphors and model scenes, analysts and analysands forge linkages between presymbolic, procedural, verbal, symbolic and imagistic symbolic encodings of experience” (p. 140). Such images, if characterized by novelty and creativity, are often metaphorical, and as such stimulate brain activity and facilitate change and development in the mind-brain-body being. Zabriskie (2004) comments “images carry our analysands beyond their here and now toward their could and would be. Images give form and shape to the mutual vibrations of the emotions, as they move back and forth along the highly charged connections between analyst and analysand” (p. 240). Such images are conveyed not only through the patient’s story but also through the evolving symbolism in dream sequences and in paintings. Insight arising out of exploration of the symbolic as it presents in image and metaphor facilitates the development of a secure attachment, adequate affect-regulation, and a more coherent sense of self. Because some metaphorical material may represent an early state of emergence from the implicit, it may be difficult at first for patient or therapist to get hold of in a meaningful way. A measure of a deepening capacity for trust can be seen in the ways in which such images change over time, as the patient becomes more able to process early experience on both cognitive and affective levels. The patient’s inner world becomes more benign as a result of intersubjective experience within the analytic dyad. Holly (whom we met in Chapter 1) worked in therapy with difficult experiences of relating to her mother. Holly’s images, often taken from dream images, were remarkable in that they played a transforming role by functioning as the steppingstones by which she became able to put difficult feelings into words. Hartmann (2000) notes that as we move from focused waking thought to dreaming, “our mental processes become increasingly metaphoric” (p. 70). When a patient brings a dream, I often ask when during the night he or she thought it had occurred. Holly’s reply was that it usually felt as if she had dreamt just after dropping off to sleep or just before waking. Holly described these dreams as “snippets.” I have found that such dream snippets, despite their fleeting nature, are often highly significant precursors of change, particularly changes in the analytic attachment.
Throughout the course of therapy, Holly and I worked with cognitive and emotional schemas, the exploration of which offered an opportunity to reshape her understanding of her intrapsychic and interpsychic worlds. Holly had experienced quite severe early relational trauma (Wilkinson, 2006a, pp. 149-150). Her mother had had a difficult early start herself and found it difficult, if not impossible, to mother her children. She had returned to work soon after the birth of each baby, leaving the children with a succession of carers. She would disappear from time to time totally unexpectedly. Holly has hardly any memories from her earliest childhood and few that include her mother. She felt that she always displeased her mother, who left her in no doubt about this, attacking her verbally and occasionally physically. She remembers her mother as an angry person and would often lie awake in bed at night listening to her parents quarreling, particularly her mother’s raging. Holly was sent away to school and was desperately unhappy there. At school her elder sister seemed to take on her mother’s mantle. To Holly it seemed that, together with her friends, her sister used seniority as an excuse to persecute Holly, bullying her at every opportunity. Holly failed dismally at school, left as soon as possible, married young, had children, and only much later, with the help of therapy, was able to embark on higher education and a career.
First Phase of Therapy: Acknowledging Terrifying Feelings. Material arising from the implicit that indicates a disorganized attachment and that is dominated by subcortical, amygdala-driven states of fear and aggression.
Holly came to see me for the first time in the middle years of life. She was in a state of seeming numbness and confusion, impelled by a recent overwhelming loss that had occurred in her life. Her underlying rage and fury were expressed in her first remark. She experienced the rocky millstone grit moor edge, which has towered high above the village in which I work from time immemorial, as threatening and fearsome. She commented: “Isn’t it frightening to be here? Isn’t it dangerous? It was frightening driving along beneath the edge.” She continued, “I thought that the huge black rocks would come crashing onto my car. They don’t look safe; it looks like they could crash down on us.” Often when she became fearful of me, she would build a pile of pillows on the couch between her and me so that she could not see me and I could not see her. She experienced the rocky edge on her way to that first session, much as she had often experienced her mother and would come to experience me at times in the “rocky edge” of the transference.
Symbols express underlying emotional schemas. For Holly the black rocks and the pillows represented an opportunity for either a repetition of old patterns or a chance to form new patterns of connectivity in the mind, based on the new experience of relationship that the therapy would provide. I have been struck not only by verbal material brought by patients as they attempt to process trauma, but also by the visual images that they bring and the enactments that occur. All become of great significance as the patient slowly painfully and with great difficulty seeks to put words to the emotional schemas that the images represent. The countertransference experiences of the therapist may be acutely painful and difficult to bear at these times, but they are but a tiny amount of the pain felt by the vulnerable, hurt, and raging child aspects of the patient. Hart (2008) has described similar states of being as “a mirror neuron dance of the affective transference” (p. 275).
In my work with Holly I frequently asked myself a series of questions:
• How will I deal with Holly’s fear, which she experiences as overwhelming?
• How will I approach her towering anger?
• How can her actions be translated into words?
• How can her underlying emotional schemas be transformed into cognitions that we may then think about together?
• What is the most appropriate way for me to be with her?
• How am I feeling?
• How does Holly make me feel?
• What am I not feeling?
• What is it appropriate to say?
• How can I open this moment up?
In the therapeutic encounter the matter of timing is everything, and therefore the empathic engagement of the therapist will be crucial: Too much or too soon and the trauma patient may feel unsafe, confused, intruded upon, and even penetrated against his or her will; too little or too late and the patient may feel unsafe and uncontained. For some time our work was dominated by Holly’s experience of me as the hostile, persecuting, destructive mother-analyst, as I carried the projection of her internalized destructive and persecuting mother. As we worked together, she would suddenly change in a moment, it seemed; her face would show fear and then would become hard as she closed off completely from me. For Holly, sometimes just too strong a tone in my voice—the use of what has been termed as “primary not pastel colours” (Williams, 2004) in my way of speaking would remind her of her strident, overintrusive, and fearsome mother within. Almost a whole session would pass wherein Holly would struggle with her experience of me as the bad mother.
A turning point came when Holly went home after one such session and dreamt a dream with one terrifyingly vivid image that she felt compelled to paint. She brought the picture to her next session: It was of a fearsome black cat mauling a baby cat (Figure 5.2). It filled her with fear. Haltingly she was able to discuss her uncertainly about whether I was the bad black cat mother attacking her, or whether she was the bad black cat tearing me to shreds. So through this image we became able to talk about experiences of aggression long past being experienced in the relationships of today. Toward the end of the session we noticed a little cream cat curled up in the center of the picture. For me this seemed like a symbol of hope in that it was uncannily like a much-loved, happy little cat I had once had, that Holly had never seen or known about consciously (Wilkinson, 2006a). The meaningful image of the little cream cat may be understood as the product of her unconscious imagination (Decety & Chaminade, 2003; for an explanation of this concept, see Chapter 4). It was an indication of a softening in her primitive splitting mechanism that brought me hope that her anger would no longer be experienced only in projection. For Holly the image brought the possibility of putting her angry feelings into words as we looked at the image together; for the first time Holly became able to speak about her anger. This was the first of many pictures that Holly was to make at home and bring to therapy. Some, such as this one, she would bring immediately; others would arrive after several months had elapsed since their making. Lyotard (1993) reminds us that the primary motivation for the artist is a search for truth. Sometimes it may be a visual image that assists the patient in moving from a wordless state of rage and terror to a state that permits the unthinkable to enter the mind.
Second Phase of Therapy: From Image to Mind. Fostering neural integration by verbal interpretation of images arising from the implicit and symbolizing cingulate-driven, dyadic attempts to connect
One day some months later Holly came into the room saying “Some people dream vividly with long stories. I can never bring dreams, I only dream in snippets.” I replied, “Perhaps if you had a book and kept a record of those snippets they might begin to make some sense for you.” Here I was hoping that the act of writing might help to stimulate memory and lead to meaningful links that would assist the meaning-making process and ultimately enrich her personal narrative.
Dream: “Why was I trying to clean the outside?”
She thought for a moment or two and then said, “Well, last night I dreamt of a vase and that I was trying really hard to clean it. What meaning could there possibly be in that?” I replied more directively than I would ordinarily because I sensed the importance of making sense of the image for her. “Well, for starters what does the vase symbolize?” After a while I added “Is it something to do with it being a container?” “Mm, maybe,” she replied. I continued, “Well, yesterday we were talking about the difficult relationship that you had with your mother and how she made you feel you were a no good, bad baby from the beginning. It’s been so difficult to know whether you were a bad baby or whether it was actually your mother who was having difficulties.” Holly asked anxiously, “I was trying to scrub the outside—why the outside?” “But isn’t that what you are often trying to do, wanting to look good on the outside, trying to please the other person, just as you so longed to please your mother and for her to see you and to love you?”
There were some moments full of sadness, then our dialogue continued. I pondered aloud, pausing between my thoughts to give her time to follow the thread; “I wonder whether the container might be this relationship where you also want to have an experience of being seen as a nice, clean container. Because of what we were talking about last time we met, I do think it probably has to do with your mother.” We sat in silence for a while then I added, “What about the vase? What was it like?” Holly replied, “Oh, I know it well—it was a glass vase, cut in a rather modern way. It was something my sister gave me.” We talked more about the early dynamics of the family and what her sister had given her in terms of negative feelings about herself when her sister acted the bossy goody-goody at boarding school. Like her mother, Holly’s sister always made her feel that she had got it wrong, that she was bad rather than good, that her outward way of being with others was inadequate, that she needed to “clean up her act.” In her therapy we often worked at the edges of this sort of experience and I had to tread carefully at first so that I did not provoke massive projections that would have been too overwhelming for her to process. Gradually we began to be more able to relate implicit to explicit, to explore our current experience of relating in light of the patterning that she brought with her from the past. The next session Holly felt confident enough to bring another dream, which she still called “a snippet,” but it was slightly fuller and involved her current attachment relationships.
Through her engagement in the therapeutic relationship Holly sought to process her experience of another in a different way to that portrayed in the dream. She had longed to be a loved and valued child. Perhaps she might not always be seen as “bad” or “dirty.” She made many images that conveyed the plasticity of her mind and the uncertainly she experienced about me at this time.
Painting: “Is It Safe to Trust Her? How Does She Feel about Me?”
The painting in Figure 5.3 showed Holly sitting on the couch with two images of me sitting side by side in the room; in the more dominant image in the foreground I had a clock face, as my face and the time it showed was the time that our sessions ended. “Was I sitting there longing for her to leave?” Holly wondered. Sitting behind but yet leaning forward and so appearing to be in front of the clock-face analyst was a fainter picture of me with a real face listening attentively but also rather anxiously. That this figure was fainter seemed to indicate that it was an aspect of me that was still in the shadows of her other experience of me. The picture reflected the uncertainly of her experience but also indicated her hope, for there was not just one possibility of how another might be with her, but two. Was I similar to her mother? Did I see her as “no good”? Was I just waiting to get rid of her at the end of each session, just as her mother had packed her off to boarding school? Would she prove to be too much for me? Might she actually become able to experience and internalize someone who sat with her and listened to her attentively? As Holly looked at this picture she was able to explore what it said about her way of relating to me at that time. She felt that she was portrayed by the child sitting hunched up, withdrawn, and alone and also by the simple line drawing of a figure lying close to death; both were encased in a protective bubble (representing her dissociative defense in the face of possible intimacy). The cushions from the couch were piled up around her, adding further protection, and were also represented as the wall that she so often built between us. In those early months of therapy she would almost always accidentally dislodge one of the tassels from one particular cushion, a cushion in exactly the same blue material that covered my chair. She would then work really hard to repair it and to reattach it to the cushion, acting out in a vivid way her fear of the damage that might come from her attachment to me and her wish that there might be a possibility of an experience that was reparative. She thought the child in the bubble might be trying to repair the blue cushion. The little cream cat, which had also come to stand for her, was shown as taking the risk of being outside the bubble, struggling in a frenzy of motor activity, arms and legs flailing, with two heads, one with a grimace of a smile, the other with mouth open, possibly in a silent scream. This reminded her of rushing off into a frenzy of physical activity when things became too much for her both at home and later at school.
Painting: “What Do I Feel about Therapy? How Do I Feel about Her?”
In the next painting (Figure 5.4) we are sitting together in an imaginary garden; I am sitting in a relaxed way and listening attentively to her. This time there are two images of Holly, not me. One Holly lies comfortably and listens attentively, half-turned toward me, but another, a darker figure, also recognizably her, lies alongside, turned away from me with her face toward the wall. Again her picture reflected her uncertainly. Could she trust me? Could she engage in a relationship? What about her hurt, angry self that really only wanted to turn away to avoid the risk of being hurt again? This picture was not brought until much later in the therapy. Significantly, these two pictures (in Figures 5.3 and 5.4) were brought to therapy together.
Holly looked again at this picture with me much later on in the therapy and began to explain that the fountain in the shape of an egg that sometimes played in my actual garden had been very important to her. She felt that it had come to symbolize “the breast” for her; if the water was flowing then there could be a hope of a feed. She would feel very sad if it was switched off. Holly had said nothing of this to me at the time. It was as if her internal struggle to risk relationship had been symbolized in the availability of the life-giving fountain but in the very concrete way, that characterizes the thinking of those who have experienced early relational trauma. For her at that time there was no certainly that another would be reliably there for her in a life-giving way and she found herself unable to risk putting such painful feelings into words. While the notion of meeting together in the garden was symbolic in the second picture, I was reminded of its power as a symbol when I read Martha Bragin’s (2007) account of her work with a survivor of torture, with whom she actually met in an enclosed garden, which she felt conveyed safely, freedom, life, and nurturance—all of which were crucial to the ability of her patient to engage in the treatment.
Painting: “To Try to Relate Feels Dangerous”
Because the making of mind is an implicit, emergent, and relational process, traumatic complexes, or splinter psyches (Jung, 1934a: par. 203), form when the psyche is presented with inassimilable experience, resulting in undigested contents. Sometimes a vivid image such as Holly brought next may emerge that helps to move the patient from a wordless state of rage and terror and enables the beginning emergence of such split-off feeling-toned, archetypal experiences into mind (Figure 5.5).
In this complex metaphorical picture Holly was struggling again with her perception of our relationship. The most significant point for me about this image was that the bad black cat mother had begun to become more human in a somewhat Picasso-esque way. There is a mouth that is open and can speak, albeit a rather fierce mouth that might bite, much as her mother’s remarks had been biting. The meat cleaver of her/her mother/her mother-analyst’s anger is held behind her back. As I look closely at the picture with Holly, I note to myself with horror that the cleaver is about to fall on the little cream cat that has now taken on human form, albeit an emaciated one, bearing a crown of thorns. The theme of victim, abuser, and the need for a rescuer was to play out over many, many sessions in the transference and countertransference relationships.
Stern (2008) stresses that whatever content is discussed will also be expressed through the medium of the analyst’s unconscious way of relating, which is evoked by a particular patient out of the dissociated content of his or her mind. It is clear that the analyst who remains unaware of this process is in danger of making interpretations that reinforce, rather than illuminate, the transference. Stern (2008) notes the probable outcomes: “The analyst of a masochistic patient makes sadistic interpretations of masochism; the analyst of the seductive patient who is nevertheless fearful of sexuality makes seductive interpretations of the patient’s fear; the analyst of a narcissistically vulnerable patient interprets the narcissism in a way that wounds the patient’s self-regard” (p. 403). Such ways of interpreting can trigger early unconscious memory and leave the patient feeling “as though a layer of my skin had been peeled off”—in these words of one patient describing an earlier assessment interview in another setting in which far too much had been said too soon, ultimately leaving the patient in a more defended state of mind. Another patient described an earlier attempt he had made to engage in therapy as feeling “as if the therapist had opened the top of my head surgically without anaesthetic, and was sitting behind me poking about with wires inside it.” That patient persisted with the therapist for some time before deciding it was actually a sadistic process. It was years before the patient risked embarking on therapy again, this time choosing a therapist who always sat where the patient could keep an eye on her if he wished.
Final Phase of Therapy: Learned Secure Attachment. Material indicating state of neural integration and more complex cortical development and capacity for self-regulated affect.
Painting: “I Can Feel Safe”
The next picture that Holly brought was of another twosome, but a very different one (Figure 5.6). It was an image of an attachment from which a child might begin to look out at the world a little more confidently, the beginnings of a coherent sense of self within. Perhaps we may infer that the new relational experience in the therapy and the evolving symbolizations to which it gave rise had assisted the development of new neural pathways in the brain, enabling the beginnings of a change in attachment style for Holly. As we looked at this painting together, I noticed that it was painted on a paper that had a rather rough, raised surface. I wondered aloud why Holly might have chosen that paper. Holly replied, “Oh, it was the first piece of paper that I pulled out of my drawer.” Almost instantly her mood changed from being companionably at ease to feeling criticized and a failure. She said, “Oh, I’ve spoiled it, it’s no good…well, maybe I will do it again.” In turn I quickly felt that I was an insensitive, no-good therapist-mother who had, with a few words, managed to spoil for my patient what had been a good experience of making something. As she left Holly murmured, “Oh, well, maybe I’ll do it again.” She arrived the next week and almost immediately said, ‘“You know that picture?” I simply said “Yes,” remembering well my previous mistake and also knowing that she found it hard to believe that I might keep her in mind. She continued, “I decided I wouldn’t do the picture again. It’s on rough paper but I thought to myself that it was actually an appropriate choice because it’s been a rough road.” Once again I marveled at both the pertinence and the healing power of the symbolic.
Painting: A Learned Secure Attachment
It was with joy a year or so later that Holly painted another picture (Figure 5.7) that portrayed the new attachment she found as a result of the repeated experiences of rupture and repair in therapy, an attachment that I call “learned secure” (Wilkinson, 2006a, pp. 182-83). Holly spoke of this picture in relation to the last one. She said that, although in some ways she experienced the new one as quite primitive and the colors quite crude, she felt that that this one marked the completion of the process. She felt both mother and child had become more human. She had become able to experience and speak freely of these images from her internal world as symbolizing aspects of herself. She liked it that the child was able to reach out and touch the mother’s face in a loving way, and she felt that her inner child might, at last, begin to feel more secure. She felt it was significant that the two aspects of the mother’s face again become important as they reflected the different moods she was able to experience within herself: sometimes feeling smiling and joyful, sometimes feeling pensive and sad. She felt that it was important that her anger was still in the picture, in the form of the little black cat, but that it was now in manageable proportions. She said that “the little black cat” was how she thought of the picture, that it reminded her of a cat they’d had when she was a teenager that had been a really nice cat.
She remembered that it had been called Togo. Earlier in the same week that she brought this picture, she had said for the first time she could actually conceive that the therapy might be able to end at some time. On reflection I found I was not altogether surprised that the little cat who represented her ability to contain and use her anger constructively happened to remind her of a cat called “to go”…perhaps Togo signaled the arrival of self-regulation, which would permit the possibility of termination. Holly said she had wondered whether the heart in the picture might be a bit naive, but then she had felt it was the way people ordinarily spoke about love and affection. I found myself thinking about the baby’s earliest experience of the warmth of the mother’s body, the comfort of the rhythm of her heart beat and the warmth that had grown between us. She spoke last about the snowdrops that were blooming in the bottom left corner of the picture. It seemed that in the realm of the unconscious hope had flowered, that the bitter winter ruled over by the wicked ice queen no longer had her in its thrall.
Conclusion
Mancia (2005) suggests that “the defining element of the therapeutic action of current psychoanalysis appears to be that of transforming symbolically and putting into words the early implicit structures of the patient’s mind” (93). Mancia makes clear that such experiences cannot be remembered in the ordinary way but can be accessed only when they are “re-experienced emotionally and enacted in the intersubjective relationship” (p. 93). Therapeutic experience acts as a “bridging function” that enables the patient to find his or her own way, as Holly did, to process the unconscious traumatic experiences of the past. It is deep emotional engagement that makes this process possible and enables the patient to heal.
The making, bringing, and discussing of these pictures, representative of the symbolic work that is the stuff of analysis, made crystal clear to me that, for Holly, it was the relational style of psychoanalysis, with its capacity to address early trauma deep in the implicit memory store of the developing right hemisphere, that was crucial to the successful process of change—that assisted in the integration of the mind-brain hemispheres that then permitted the self to emerge more fully through the process of individuation.