NARRATIVE NEUROSCIENCE IS A RELATIVELY NEW AREA of exploration, but a significant one. Just as metaphor lights up more centers of brain activity than any other form of human communication, so too does story; story gives shape to emotional experience and often relies on metaphor to develop aspects of the narrative. The Concise Oxford English Dictionary (Sykes, 1976) offers a definition of narrative as that of “story told in first person.” Therapy is so concerned with the personal story of the client that the neuroscience underpinning the development of story is an exciting area of development for the therapist to explore: “What fundamentally constitutes our consciousness is the understanding of self and world in story” (Young & Saver, 2001, p. 73). Currently the study of the neuroscience behind narrative draws principally upon imaging studies of volunteers responding to various kinds of narrative material as well as on studies of patients’ brain lesions. However, what is yet to be fully explored is just how narrative develops in the consulting room and how personal story may emerge in a way that enables minds to change.
Ferro (2005) suggests that therapy can be understood as bringing about transformations by grasping the emotions underlying patients’ narrations “in such a way that they feel it is understood and shared, thus progressively activating their narrative competence” (p. 100). The right hemisphere is, in this respect, the master of the left: The affective experience, meaning-making process, and emergent sense of self that are the hallmarks of coherent narrative as it develops in the consulting room, all arise in the right hemisphere and draw upon the linguistic capabilities of the left to produce the story. Let me elaborate: The right hemisphere processes visual, tactile, auditory, and olfactory experience and is the original source of much of our experiencing in the broadest sense of the term. Given its central role in affective experiencing, the right hemisphere enables much of the affective engagement and communication that occurs within the therapy session. Only then are the analytic and linguistic processes of the left hemisphere able to begin to formulate personal story in the more fully developed form that we more usually describe as narrative. A striking aspect of the research on narrative for the therapist is the degree of hemispheric integration that is required for story production and the stimulus toward such integration that secure relating, which includes coconstruction of story within the therapeutic dyad, offers.
Coherent narrative is characterized by a causal event structure, a lack of superfluous or tangential information, and a depiction of events in an imagined world that parallels the world of real experience (Mar, 2004). In contrast, patients’ initial trauma narratives may have confusing and distracting elements, a disjointed rather than coherent quality, and be intruded upon by flashbacks. Early story, generated out of the relation to the mother, lays down the patterns of being in the world that give rise to ways of being and behaving in it in relation to others. Such patterns of being and behaving manifest themselves afresh in the therapy room, but may become modified through the development of a secure attachment. “We need to tell someone else a story that describes our experience because the process of creating the story also creates the memory structure that will contain the gist of the story for the rest of our lives” (Schank & Morson, 1990, p. 115).
Our Earliest Stories
From the very earliest days of life, inner experience is organized out of interactive experience with the primary caregiver. Schore (2008a) notes that “it is a fallacy that all language is in the left hemisphere, for the right hemisphere is dominant not only for prosody but also for processing of emotional words, the detection of one’s first name, social discourse, metaphor and the organization of information at the pragmatic-communicative level.” Mother and baby, in their earliest, right-hemisphere-based affective exchanges, engage in proto-conversation that leads to what I call proto-narrative, which arises “from our emotional nature through a musical-prosodic bridge” (Panksepp, 2008, p. 49). Ultimately this proto-narrative develops into one’s personal story and makes possible a sense of self. Bollas (1987) observes that “a generative respect toward every representation in thought of the origins of the true self, and of the countless speeches mother and infant make through their curious dialect, enables us to face that knowledge we possess but cannot think” (p. 282).
From how early can experience be available to us as we engage in this process? To begin to examine this question I would like to explore some of the earliest memories that have been recounted to me, the difference in their quality, and the significance they may hold for understanding the individual’s earliest life. Such memories illustrate the integrity of the individual mind–brain–body because they tend to center on bodily and sensory experience. One patient told me a very early memory of being left outside in the stroller, cold, white flakes falling from the sky onto her face and hands, and her dislike of this. She remembers her anger and sense of helplessness as she experienced it beginning to snow and still being left outside. This patient’s mother suffered from an enduring postnatal depression, and one can assume that the patient may well have been left unattended for long periods of time, the advent of the snow gone unnoticed by her mother. Another patient recounts her earliest memory of being in her stroller in the garden near the hedge. She remembers her surprise when the green hedge with its white flowers gradually started to move and to turn upside down. She does not recall any fear. Her mother later told her of her own anxiety and horror at coming into the garden and finding her baby hanging upside down in the stroller—the old-fashioned, high-backed stroller had turned right over. The patient would have been about 15 months old and perhaps rather too active to have been left in the stroller unsupervised in this way. This same mother forgot her baby on more than one occasion; another time she left her outside a shop and arrived home (half an hour away) before she missed her, another time she went off to work, forgetting her. On that occasion the child’s crying alerted neighbors to her plight. The same child fell into a lake at 3 years old and into the fire that burned in the living-room grate not long after. This mother’s ambivalent care for her child affected my patient deeply; gradually it formed a part of her internal world with which she had to struggle for the rest of her life, as she sought to become an adequate caregiver for her own self.
In contrast, another woman describes a fleeting but very happy memory of preparing for a photograph on her second birthday: “We were going for my second birthday photo; I have a sense of my parents’ overwhelming pleasure as they got me ready in my special dress…there was a cake.” Another remembered, in a very tactile way, her dress that was a present for her third birthday:
I have a lovely pale blue silk dress made for me by my grandmother. I remember the slippery feel of the silk. I loved to trace with my fingertips the outlines of the embroidered farmyard animals that go around the hem. I remember what the goose looks like. I think there was a duck with little ducklings, following in a line behind her. I don’t remember what else.
These happy memory fragments may have been preserved through, and will certainly have been affected by, the later encounters with the photo and the dress.
Two female patients dealing with the arrival of their first sibling recount–– and, in so doing, seem to explore–– memories that carry the first inklings of experience in the world of the feminine. Again the sensory qualities of the memories are dominant. The good smells associated with Mother, for one, and Grandmother, for the other, remain into the present.
The first commented:
I remember my maternal grandmother coming to stay and plaiting my hair when my mother was in the hospital and my sister was born. I remember on my mother’s dressing table a bottle with the perfume of Devon violets with ‘made in London’ written on it. London was clearly a wonderful place. [In later life this woman was to travel halfway across the world to make London her home.]
The second recalled:
I remember going to spend the day at my grandmother’s house because my mother had gone to the hospital. My grandmother’s dressing table was so pretty and there was the wonderful smell of her spilled powder, the ‘untidy mess’ (my mother’s words about it) on top which, as a child, seemed to me to be a veritable treasure trove of perfume, lipsticks, brooches, and bracelets. I can still smell her powder. I can smell it now.
It is interesting to note that the narratives highlight smells, colors, and emotions associated with the experience being recounted: products from early implicit memory are from the right hemisphere where emotion and visual, tactile, and olfactory experiences are processed. (The process of memory making is discussed more fully in Chapter 2).
Neurological Substrates of Narrative Communication
Recent advances in cognitive neuroscience suggest that the creation of narrative communication is mediated by a regionally distributed neural network. Mitchell and Crow (2005) highlight the importance of right-hemisphere functions for successful social communication. Beeman et al. (2000) emphasize the cooperation between the hemispheres for story comprehension and development; they attribute to the right hemisphere initial predictive inferences concerning the development of story and to subsequent activity in the left hemisphere the coherent inferences that follow. Components of these regionally distributed networks include the amygdala–hippocampal system, responsible for initial encoding of episodic and autobiographical memories, the left peri-Sylvian region where language is formulated, and the frontal cortices and their subcortical connections, where individual experiences are organized into real and imagined narratives (Young & Saver, 2001, p. 75). Young and Saver (2001) cite Bruner’s (1991) assertion that narrative is the instrument of mind that constructs our version of reality and gives meaning to our experience of life. However, they suggest that this explanation is only partial because Bruner “fails to address the neurobiologic underpinning of the centrality of narrative in human cognition” (p. 75). They argue that it begs the question of how the brain determines that such experience should be organized with narrative as the core structure that gives meaning. Here Bruner and Young and Saver seem to get caught once again into the old Cartesian split, Bruner emphasizing mind and Young and Saver stressing brain. It is not a question of either brain or mind as the sole source but rather a series of interactive processes between not only mind and brain but also body.
My view is that mind responds to the changes that occur in the brain as a result of mind–brain–body interactions with another mind–brain– body experience; brain is modified again in response to mind, and so on. Intrasubjective experience arises from earliest intersubjective experience and is, in turn, modified by further intersubjective experience and reflected in the narrative that emerges. Schacter and Addis (2007a, 2007b) emphasize the constructive adaptive nature of memory processes. The brain is able to learn from experience and to modify future expectation in the light of what was learned.
Networks within the brain connect in a multiplicity of ways, permitting the most complex patterns of information processing. Examination of functional imaging in volunteers and clinical reports of the changes in individuals who have suffered focal brain injuries provide “a convergent view of how the brain narratively organizes experience” (Young & Saver, 2001, p. 75). The development of narrative is a dynamic, variable, and vulnerable process; experience processed in the right hemisphere becomes the determinant of the narrative that is developed into its final form in the left. Addis et al.’ s (2007) research using fMRI scans draws attention to the activation of the right hippocampal region that takes place when an individual constructs a narrative concerning the future that is novel and of a personal nature. They note that the right frontopolar cortex is also uniquely recruited in prospective thinking, which is characterized by intentionality, and the right ventrolateral prefrontal cortex in planning.
Research using fMRI scanning has demonstrated that both an intact left hippocampus and left amygdala are required for optimal encoding of emotional material in retrievable form (Richardson et al., 2004, p. 283). Further research highlights the complex specialization that takes place within the hippocampal region and that provides evidence of a specific role for the anterior hippocampal region in the successful associative encoding of memory that inevitably underpins the development of a personal narrative (Chua et al., 2007). These complex neural activity patterns and interactions provide the elements by which imagining and meaning-making occur. Episodic memory is thought to be extremely well adapted, drawing on past experiences to facilitate the imagining of what may happen to us in the future. Other researchers emphasize the meaning-making function of episode memory “to help us make sense of the past and the present” (Schacter & Addis, 2007a, p. 778). Much of the forward-looking, imaginative, relational exchange between therapist and patient depends on these aspects of the mind–brain relationship.
Mar (2004) notes that cross-temporal and cross-modal processing are necessary for effective encoding, retrieval, and expression in words, with the right-hemisphere networks enabling global coherence. The corpus callosum, the major highway between the two hemispheres, forms from right to left at about 20 months old, enabling interaction and integration of such inter-hemispheric activity. Mar reviews the available evidence and concludes by summarizing the five main regions that appear to be the neurological substrates of narrative. He stresses that it will most likely be the pattern of interaction among these, yet to be explored, that will prove most enlightening concerning the central role that narrative plays in the human being’s interior world and interaction with others. He suggests the following associations between functions of mind and brain structures:
• Comprehension, selection and theory of mind—medial prefrontal cortex bilaterally
• Narrative understanding and expression—lateral prefrontal cortex in the right hemisphere
• Story comprehension and production via the attribution of mental states and mental inferencing—temporoparietal region bilaterally
• Many aspects of story production, but possibly especially theory of mind and propositions—anterior temporal region bilaterally, including the temporal poles
• The imagery and episodic memory processes associated with story-making that are affective in nature—posterior cingulate cortex
Basic “memory packets” or storage forms are created without our conscious awareness; “one such packet organizes scenes and since we remember in scenes, these…allow us to travel from scene to scene” (Schank summarized by Ekstrom, 2004, p. 669). Another more complex group of memory packets deals with themes: These enable the processing and bringing together of scenes along with the integration of more abstract information. Such stories are encoded in neural patterns that the brain matches against new experience. The right hemisphere, dominant for novelty, particularly notices new deviations from the expected (remembered) pattern and creates new refinements of the pattern based on the new experience that has been noted. Such knowing consists not only of cognitions and emotions, but also that which is bodily and for the most part unconscious. Young and Saver explain that “To be without stories means in Schank’s telling to be without memories, which means something like being without a self” (as cited in Young & Saver, 2001, p. 74). Not surprisingly Mar (2004) reiterates that “both lines of evidence, imaging and patient, indicate the importance of the right hemisphere areas in sharp contrast to the traditional portrayal of left lateralized language processes” (p. 1,429). As Schore (2001) stated so cogently: “The center of psychic life shifts from Freud’s ego, which he located in the ‘speech area on the left hand side’ (Freud, 1923) and the posterior areas of the verbal left hemisphere, to the highest levels of the right hemisphere, the locus of the bodily based self system” (p. 77, emphasis in original).
Emergent Narrative
Affinity for narrative emerges at a very young age (Mar, 2004). It seems that the earliest narrative emerges initially out of the proto-conversation that occurs between mother and child and then develops as does the relationship between mother and child. The mother’s face is “the most potent visual stimulus in the child’s world” (Schore, 2002, p. 18). Ferro (2005) cites Bion’s view that every mind, at birth, needs another mind in order to develop and suggests that proto-emotions and proto-sense impressions are transformed into visual pictograms that carry the emotional qualities of primitive feelings. Such elements then “undergo further operations in order to attain the status of thought and narrative image” (p. 2). Thus Ferro describes the processes whereby “a narrative fabric is woven” (p. 2). Mar (2004) also notes the contribution of the processing of affective experience in the story-making process.
In good-enough circumstances, patients will have experienced warm exchanges with the mother, such as empathic looking, touching, and being held. Out of these emerge proto-conversation and the exchanges that lay down the neural patterns for later developing speech and social exchange. In less fortunate circumstances the baby may experience indifference, anxiety, ambivalence, terror, or hate, in which case very different neural patterns are laid down in the baby’s developing brain. In such exchanges the baby mirrors “the rhythmic structures of the mother’s dysregulated states [in the] stress-sensitive corticolimbic regions of the infant’s brain that are in a critical stage of growth” (Schore, 2003a, p. 251).
Traumatic experience can be an overwhelming single event but also may be composed of “a synergetic accumulation of repeated traumatic micro-experiences” (Ferro, 2005, p. 104). The therapist’s ability to engage in what I might describe as a containing or holding way will (1) contribute to the patient’s ability to draw on painful experience in the reconstruction of his or her story, (2) allow for the experience of implicit relational knowing (Lyons-Ruth et al., 1998), and (3) provide the best opportunity to test the old patterns of expectation against the reality of experience today.
In the same group, mentioned earlier in the chapter, who offered early memories, there were several accounts of a first memory, from around the age of two to three years, that contained scary moments wherein the central experience of the memory was a sense of separateness and loneliness.
Woman: “Our new house was being built…a neighbor fetched me and took me to her house. She was minding me. We were in the garden; her son and I were in the stroller together. They were talking and thought I didn’t understand. I knew they were saying that they shouldn’t have to mind me. I felt that I wasn’t wanted there…. I could see our house across the garden. I felt I wasn’t wanted there either. I didn’t belong anywhere.”
Woman: “I was in bed, and it was shadowy dark. I had been put to bed as it was my bedtime. Across the hall there was the warm yellow glow of light from the room where my parents and their friends were. I felt alone.”
Man: “My parents were in their bedroom. I was alone in my room. I thought ‘What is going on? Why am I not in the room with them?’ (After pausing and seeming to explore the memory for a few minutes) I used to press my face into the pillow…I could see pictures…each time I wondered ‘What will I see?’”
The first of these extracts may contain within in it a sense of loss for the first house leading to a sense of loss of the first container, mother. The last memory recounted hints at primal scene material. Each child has a sense of separateness, a sense of what it is to be a separate self.
Such stories can be recalled freely, as these were, or they may be hidden, only to emerge over time in the context of the therapeutic relationship. But why might they be hidden? It may be that they are formed from very early experience or it may be that they arise from experience so traumatic that it is inassimilable to the conscious mind. It seems that early autobiographical memory may arise in the right hemisphere and be transferred to the left, where it reaches its fullest development. The capacity of the high right hemisphere (i.e., the orbitofrontal cortex and the anterior cingulate) to regulate the right amygdala and to enable the transfer of information across the corpus callosum from right to left becomes very significantly diminished in patients with severe early relational trauma. When the different elements of an unbearable experience get dissociated or split off from one another, there can be no proper memory of the event. It will not be processed by the hippocampus, which tags time and place to memories, and so it cannot be stored as explicit or narrative memory. It cannot be recalled in the ordinary way because it has not been stored in the ordinary way. Instead it is encoded implicitly in the emotional brain and the body to remind and warn if similar danger should threaten again. In a sense the person may have lost a substantial part of who he or she is, of what constitutes that person’s unique self. The memory of such trauma may be stored implicitly in the patient for many years until mind and psyche are strong enough to integrate the unbearable experience. Sometimes the trauma is made manifest via narrative material or a dream narrative that seems to point to the earlier traumatic experience.
Porges (1997) describes three levels of neurological response with which a child may react when afraid. The optimal response is a social one mediated by the ventral vagal system and available to the child with good-enough early experience; such experience enables a turning toward others for help at such moments. Children with poor early experience may turn away from others when they become afraid relying on the sympathetic nervous system and its alternatives of fight or flight. As early as 1980 Fraiberg’s research showed that when a baby’s distress reaches intolerable limits, a cutoff mechanism comes into play analogous to that associated with intolerable physical pain. Schore (2002) makes clear how when both flight and fight fail, the parasympathetic nervous system comes into play, allowing a shutdown, frozen state to ensue—the way of escape when there is no escape.
Many who sustain trauma over time lose memory of it. If the trauma occurs prior to when the child is about 3 years old, the hippocampus will not be fully online and capacity to remember is not yet available. Terr’s paper (1996) “True Memories of Childhood Trauma: Flaws, Absences, and Returns” seeks to grapple with the problem that confronts both patient and therapist as each struggles with what is not remembered, half remembered, remembered only in patches, retained only in body memory yet portrayed in the transference and experienced by the therapist in the countertransference. For patients whose trauma memory is held in the body, the body becomes “a kind of stage upon which the unfelt psychic pain can be dramatized” (Sidoli, 2000, p. 97). It seems to me that this is particularly difficult for the therapist to think about because it is an indicator of the slow drip, drip of suffering that may have occurred in a vulnerable child’s early life.
As a child, Harriet used narrative defensively and for survival purposes as a place of escape. She was able to immerse herself in story and in so doing evaded something of the harsh reality of her childhood. However, she was also able unconsciously to begin to process something of the traumatic experience of her early years. Harriet became a child who was always “lost in a book.” Some stories that remained with her were the ones that had secretly terrified her, reflecting as they did the frightening aspects of her internal world; others were more nurturing and carried the hope that enabled her spirit to survive. She explained that Snow White was terrifying because the Witch [mother] gave the girl poisoned fruit. Alice in Wonderland terrified her because Alice fell into a world she couldn’t understand, where she almost drowned in a pool of her own tears. Bambi was horrifying as the hunter killed the mother and left Bambi alone with the father. The Wizard of Oz was the most frightening of all because there the girl encountered a man without a heart. There were more gentle nurturing themes but significantly in these books someone other than the parents cared for the children (Wilkinson, 2006a, pp. 49–50).
In the consulting room I sometimes felt that she still used narrative defensively, just as she had in childhood; she would tell of events at work or with friends, bombarding me with words, allowing me no chance to communicate with her, avoiding eye contact and keeping difficult feelings at bay.
Trauma and Narrative in Therapy with Adults
Creation of a coherent narrative has been suggested to be of fundamental importance in working with patients who have experienced trauma (Covington, 1995; Beebe & Lachmann, 2002; Cambray & Carter, 2004). It is the adequate regulation of emotional arousal that allows the creation of such narrative. “A traumatized patient with an abuse history including an intrusive, critical and abandoning mother may experience…through voice, intonation and expression [of the analyst], acceptance and connectedness” (Cambray & Carter, 2004, p. 132). The regulation of emotional arousal that can occur through such interactions permits the creation of a new narrative.
There are divergent views in cognitive neuroscience as to the exact nature and extent of the limbic system within the brain and the centrality of its role in the regulation of emotion, the way in which trauma-induced memory loss occurs, and what sort of remembering is possible. Traumatic experience and the associated endorphins that are released, along with raised cortisol levels, may interfere with the efficient functioning of the hippocampus and therefore with effective explicit memory consolidation. Amygdalar activity, however, is stimulated by experience that is traumatic, leading to enhanced emotional, implicit memory storage. Negative arousal seems to cause a narrowing of the attention so that negative, visually arousing encounters appear to be remembered more strongly and with more awareness of the central emotional elements (i.e., gist) as well as the visual detail of the event, than nonemotional ones. There is a consistent memory tradeoff: Central emotional events are retained over peripheral or background nonemotional elements of visual memory that occurs (Kensinger et al., 2007). Across a number of these studies emotion has been shown to enhance gist memory but impair memory of detail; thus emotional memory becomes dominant in the recall of past distressing events. The fluctuating degree of connectivity between the amygdala and the hippocampus, between the implicit and explicit memory systems, in the contextual processing of fear means that if the degree of emotional arousal is moderate, then explicit, declarative memory formation is strengthened, but when arousal is strong and highly stressful, then explicit memory formation may become impaired. However, the implicit becomes highly charged and operates adaptively. In experiences of extreme distress, feeling, sensation, behavior, image, and meaning may become dissociated from one another (Levine, 1997). The earlier in life and the more sustained the traumatic experience, the more likely this dissociation.
The adaptive constructive aspects of memory (and therefore of work with personal story) are being extensively explored (Addis et al., 2007; Kensinger et al., 2007; Schacter & Addis, 2007a, 2007b). Inevitably, the coconstruction of narrative becomes an integral part of therapy for patients who have experienced early severe relational trauma, but it must be undertaken with an understanding that the nature of such recall is primarily emotional rather than an accurate snapshot picture of the trauma. The high right hemisphere holds the key to emotion regulation and indeed much of the learning that will take place occurs through the emotional regulatory qualities of the transference experience in the therapy. Bohleber (2007) discusses what he terms “the battle for memory in psychoanalysis.” He understands, on the one hand, that “trauma is a brute fact that cannot be integrated into a context of meaning at the time it is experienced because it tears the fabric of the psyche” (p. 335), but nevertheless he feels that a search for the truth concerning trauma is necessary in order to recognize adequately what has been suffered. He deplores earlier psychoanalytic attitudes that privileged psychic reality and devalued external reality. He argues that today’s emphasis on the relational also tends to discount the value of reconstruction. He also fears that an emphasis on narrative may mean that “the real world goes unmentioned” (p. 377). In raising these issues Bohleber draws our attention to the complexities of working with narrative, with past and present, inner and outer realities.
I would argue that an emphasis on coconstructing narrative may play a vital part in assisting the patient not only in coming to terms with the reality of his or her internal world, but also in the process of mourning what was and what might have been, which then enables a greater capacity to live life as it is now in the real world. This mourning process, essential to work with those who have experienced early relational trauma, can be undertaken only if there is respect for the fact that “real traumatic events…happen to children and that these real events exert a strong developmental influence” on the way children experience the world and relate to others in the future (Eagle, 2000, p. 126). Indeed, Bohleber (2007) himself argues that it is necessary to appreciate fully the causative traumatic reality in order to distinguish between fantasy and reality and to avoid retraumatizing the patient; in this he seems to be reacting to the earlier overemphasis on fantasy rather than developing a cogent argument against the development of a coherent narrative as an important aspect of psychotherapy. Ferro (2005) draws attention to the complexity of the therapeutic task, suggesting that “the psycho-analyst’s entire ‘art’ lies in knowing on which angle to focus…the locations of the infantile history, those of the internal world and the transgenerational field, and those of the present relationship in the present field” (p. 47). Bohleber (2007) warns that the appalling aspects of trauma may arouse defensive repudiation, not only in the patient, but also in the therapist, and give rise to the danger that the traumatic aspects of the patient’s story will not be given sufficient space in the therapy.
Narrative, Meaning, and a Sense of Self
There has been a plethora of publications, books, and plays of what one might term “survivor narratives,” some of which have become popular bestsellers. Why should this be so? The search for meaning, for making sense out of suffering, of giving shape to emotional experience, is perhaps such a fundamental need in us all that the public responds warmly to those who attempt to process and make something out of their experience in this way. Positron emission tomography (PET) scanning has been used to show that access to effective deductive logic depends on a right ventromedial prefrontal area devoted to emotion and feeling, demonstrating that emotion and feeling have a part to play in effective thinking (Houdé et al., 2001). Young and Saver (2001) stress the need to “create a notion of the self that is understandable.” I have sought to recreate something of the experience of working with patients with early loss through the vehicle of a case study of someone whom I call Rachel. In this composite I emphasize the effect of the death of a father on childhood experience and beyond.
Case Example: Rachel
Rachel’s father died suddenly when she was only 6 years old. She felt that their mother had been unable to recognize or cope with her children’s need to mourn or to understand the difficulties that they were experiencing. The mother was overwhelmed by her own difficulties and by trying to provide for her young family. Rachel blamed herself for what had happened to her father. She felt that if she had been a good girl, her daddy would not have died. Her brother, in his raging, became the epitome of the difficult teenager, whereas Rachel became the good girl who sought to do well at school and to try to reconcile the warring members of her family. She became a doctor but, after a while, found that she was often exhausting herself by offering extensive help to dying patients; suddenly in her early 30s she lost part of her field of vision in one eye. After investigation her consultant concluded that it was a stress-related illness, and she came to see me. The physical symptom pointed to the trauma and in a sense represented an attempt to process it; up to that point the symptom had acted as a protective barrier that helped to keep the traumatic attachment loss “out of mind.”
Her transference, not surprisingly, was characterized by an instant awareness if I felt under par, accompanied by quite an intense need to protect me. Underlying this response was a much more difficult-to- access rage that I might become ill and leave her. Unconsciously she always feared that if she loved, she might lose the loved one again. Gradually over time in therapy we became able to piece something of her story together. She talked a little to her mother about her father’s death after she had been in therapy for some time. Her mother told her that she had “fixed on a remark” of her mother’s which she had heard as “the ambulance did not come on time” (her mother had actually said “the ambulance did not come in time”). Rachel had just kept asking whether, if Daddy was dead, that meant that he would not be coming home in an ambulance. Probably she was actually trying to ask, in a rather indirect way that mirrored her mother’s way of dealing with the distress of her children, “Will Daddy ever come home again?” It was a question that her mother, struggling with her own shock and grief, could not bear to hear, much less to answer. Rachel thought she and her older brother had been sent away immediately after the death. In fact, when she talked to her mother and brother, she found out that that had not been the case. She came to understand that she had felt shut out, “sent away” in a symbolic sense. The children had not been allowed to go to the funeral; Rachel’s brother remembered that they had stood at the school railings and watched the hearse and their relatives arrive because the school was next door to the church. Rachel had no memory of this.
It was only very late in therapy that she gained some inkling of a memory of this small fragment of very emotionally charged experience, which still felt quite dissociated and which she experienced as her brother’s memory rather than her own. Her “memory” of the events around the death and the funeral shows clearly how emotional gist is privileged over background detail. The emotional gist of her memory was accurate but the detail was flawed or absent.
After working on the emotional aspects of her early story, she became more able to see how her medical practice had become a constant and draining enactment of her early trauma. As she came to this realization, the pattern began to change and she no longer felt compelled to act out her early loss. Rachel had always enjoyed food and eaten well and continued to do so during the therapy, but at stressful times in her life, particularly those that involved a close personal relationship with a man, she had a real struggle to keep at a healthy weight; seemingly the weight just dropped away from her, a reaction to stress that she had experienced all her life. Partly it seemed to represent her unconscious fear that she herself might just fade away, but it was also partly a feeling that if she had been bad and that made Daddy die, then she herself should not thrive. “Her sight gradually returned to normal over the first two years of therapy and she became able to conceive a child, something that had eluded her for many years. It seemed that working through her grief and guilt had made it safe enough for her to conceive of being a parent” (Wilkinson, 2007a, p. 327).
Young and Saver (2001) stress the primary role of narrative in organizing meaning and a sense of self, concluding that “the potent adaptive value of narrative accounts for its primacy in organizing human understanding (as opposed to pictorial, musical, kinesthetic, syllogistic, or multiple other forms)” (p. 78). In this they perhaps ignore patients such as Holly and Sophie, who accessed their ability to think about their experience by means of vivid visual images rather than narrative, or those whose access tends to be through music—indeed, all of them would find words a much more difficult medium to use as an initial way of experiencing and thinking about meaning. Each of these patients also experienced significant early relational trauma that disturbed their primary attachment to their mother and early proto-conversations with her. In therapy each not only has used the initial therapy sessions but also has explored her inner world at home using her own medium, bringing artwork or experience of music back into the session as a way of communicating about and exploring early trauma. Gradually in the therapeutic relationship it has become more possible to access words and to build narrative for both early and current relational experience. Bucci (2001) describes conscious processing as “the tip of the psychic iceberg” (p. 45). She stresses the use of multiple modalities of unconscious mental processing and emphasizes the human being’s capacity for verbal and nonverbal modes of symbolization. Citing examples from art, music, and dance, she argues that information may exist “in a form that could not be fully captured in words” (p. 48). Persinger and Makarec (1992) suggest that intensely meaningful moments of experience may be the result of accessing nonverbal representations that are the right-hemispheric equivalents of a sense of self; they argue that this probably occurs as a result of enhanced firing in the left hippocampal–amygdalar complex. Early processing, especially of negative emotion, may well be captured only in implicit, amygdalar memory and may emerge most easily in vivid visual or prosodic forms of expression, linked to the earliest forms of experiencing and processing of emotion. Ferro (2005) suggests that one function of the analyst may be to “facilitate the creation of affective- climatic coordinates so as to activate the patient’s ‘imaginopoietic capacity.’” He stresses that whereas narrations create images, they are in turn derived from them (p. 101).
Case Example: Sophie
When she entered therapy, Sophie was in her late thirties. She gradually began to use painting as a way to develop a coherent narrative of her life; such stories have the power to change our understanding of our personal world, both past and present.
Early Stage of Therapy: Encountering the Burden of Sophie’s Depression
Sophie came to therapy in a state of depression. She had been off work for some weeks and had reached the point where she felt unable even to get up and prepare breakfast for her children before they went off to school. Early in the therapy she brought a picture that she came to call “dream sandscape”; she felt that it reflected the intolerable burden of trudging through the years of her life. In the picture are a series of images of herself, each trudging after the other much like prisoners in a chain gang (Figure 7.1). She could feel no hope at all at this time; even when she determinedly painted two images of herself as breaking out of the line and dancing, the feeling of the movement portrayed was heavy and despairing.
Second Stage of Therapy: The Emergence of a Coconstructed Narrative and a Coherent Sense of Self
Much later she came with another picture which she titled “The years of my life” (Figure 7.2). This time the overall effect of the picture was that of a stained-glass window, full of light. She used several sessions in therapy to discuss the significance of each of the tiny paintings that occupied one pane of the window and which represented 1 year of her life. We found we were reviewing the narrative that had gradually become her story as we had worked together in therapy. There were early years of appalling pain and sadness, latency pictures that showed her engaged in those interests that have always brought her consolation, particularly her love of the natural world, and later panes pictured her engagement with therapy. There were empty panes for the years that stretched before her; they were full of light, blazing her new-found hope.
These pictures provide a useful portal into understanding just how much Sophie’s inner world had modified and just how much any patient’s mind and perception of earlier experience can change as narrative is worked with in the context of an enabling relationship. Images, painted seemingly randomly by her at the time, gradually began to reveal the emergence of a changed sense of self that developed in response to therapy. She moved from feeling trapped in a sarcophagus whose walls were made of her painful early experience, to a dawning awareness of the difficulty that there had been in the mother–child relationship and the way in which this had been internalized. Once this work had been accomplished, she gradually became able to portray a softening of the walls, leading to a gradual emergence, an awakening of her true self to the possibilities of what life might hold for her (Wilkinson, 2006a, plates 4–9). I have included a new one here because it symbolizes the emergence of a coherent sense of self (Figure 7.3). It shows her centered position in a labyrinth, a symbol that had great meaning for her as representing her life journey.
Conclusion
Emotional security fosters the coconstruction of an individual’s self-narrative. This is what one might expect, given that the earliest encounter with narrative is often experienced safe on Mother’s lap, or listened to last thing at night while the child looks sleepily into a loved parent’s face. The secure therapeutic relationship, with its reliable affective tone over time, enables the affect regulation that makes possible the development of a coherent narrative. This in turn allows “the old present”—the trauma that may have recurrently seemed to be “now” to the patient—to be placed firmly as “then,” in turn encouraging the development of neural circuits that enable more effective affective regulation. It is the plasticity of the brain that permits such therapeutic gains throughout life. Within the context of an affective engagement with another mind, the part that narrative has to play in changing minds should not be underestimated. In Cozolino’s (2006) words, “The simultaneous activation of narratives and emotional experiences builds neural connection and coherence between easily dissociable networks of affect and cognition” (p. 306). In so doing, narrative construction fosters both hemispheric integration and neural integration at all levels.