A CENTRAL CONCERN OF THIS BOOK HAS BEEN with what Schore (2007b) termed “the current paradigm shift from not only cognition to affect but also from repression to dissociation” (p. 753). Young (1988) suggests that dissociation is an “active inhibitory process that normally screens internal and external stimuli from the field of consciousness” (p. 35, emphasis added). We dissociate all the time as we allow our mind to concentrate on one particular experience and effortlessly filter out what might otherwise be distracting stimuli. As I write this, I have suddenly become aware of the washing machine at work in the next room, the wind rustling the leaves of the trees outside the window, the interaction of wind with the sunlight making subtle changes in the light reflected on my keyboard. As I concentrated on the task in hand, I had completely eliminated all these stimuli until this moment.
The dissociative response resulting from traumatic experience is also purposive. The Diagnostic and Statistical Manual of Mental Disorders—Fourth Edition (DSM-IV) identifies dissociation as disrupting the usually integrated functions of consciousness, memory, identity, or perception of the environment (American Psychiatric Association, 1994). The International Classification of Diseases—Tenth Edition (ICD-10) (World Health Organization, 1992) makes reference to partial or complete loss of the normal integration between memories of the past, awareness of identity and immediate sensations, and control of body movements. I understand the dissociative response to be an adaptive defensive structure developed to protect the nascent or traumatized self. Bromberg (2008) describes traumatic affect as not merely “anxiety with its volume turned up,” but rather “affective flooding intense enough to disrupt thought because it is inherently chaotic” (p. 416, emphasis in original). He suggests that “defensive dissociation shows its signature through disconnecting the mind from its capacity to perceive that which feels too much for selfhood to bear” (p. 416).
Overview of Dissociation and Regressive States
Teicher et al. (2006) regard the “consistently reported hippocampal volume reduction, particularly on the left side” in research populations who have experienced early relational trauma as a significant factor in the development of the dissociative defense, noting the consistent reporting of such diminished hippocampal volume in studies of adults who have experienced early sexual abuse whereas those of sexually abused children do not show such marked changes (p. 193). Earlier animal research (Andersen & Teicher, 2004) investigated delayed effects of early stress on hippocampal development in rats. The results of the more recent study (Teicher et al., 2006) suggested that early maternal separation produces a regionally specific delayed effect on the structure of the hippocampus by attenuating rates of synaptic development. The researchers concluded that “early life stress may affect a brain region in a way that is not immediately apparent on a gross morphological level, but may become apparent with continued maturation” (p. 194).
Mundo (2006) notes that the excessive stimulation of the amygdala, such as that associated with traumatic experience, “would interfere with the correct functioning of the hippocampus, thus affecting the possibility of proper symbolic representation and conscious awareness of the experiences.” He observes that several studies have shown that “under stressful conditions the amygdala is hyperactive while the hippocampus may show reduced activity” (p. 684). Thus dissociation may become increasingly significant in individual lives as those who have been traumatized begin to struggle with the demands that face a young adult and which are manifest again in later life as the ageing mind struggles with the difficult emotional and bodily experience associated with the latter phase of life.
Jung (1934b) appreciated the significance of the dissociative defense arising from early trauma; he described disturbances caused by affects as phenomena of dissociation. He appreciated the possible time lag before the tendency to dissociate is fully recognized, observing that “the real emotional significance of that experience remains hidden all along from the patient, so that not reaching consciousness, the emotion never wears itself out, it is never used up” (Jung, 1912, par. 224). It is often such experience that brings a new patient into therapy, and part of the work may well be to deal with the pressures from within that are perhaps leading to the possibility, first of painful awareness of emotional suffering, and then of the development of a more integrated experience of the self. Jung warned that dissociated content, which he described as a traumatic complex, may suddenly return to consciousness: “It forces itself tyrannically upon the conscious mind. The explosion of affect is a complete invasion of the individual. It pounces upon him like an enemy or a wild animal” (Jung, 1928, par. 267). It is for patients with just such extreme experience as described by Jung that the new research provides insight for therapists to enable a different, more benign experience of dissociated states of mind. Issues of empathy arousal and affect regulation become crucial to successful therapy and are discussed later in the chapter.
Regression has been a much debated part of analytic tradition and technique. But to what and where do patients regress? Where are they in their minds at such a time? Is the process helpful or unhelpful in regard to the psychodynamic process of changing minds? How do we avoid the dangers of drowning in a regressive fusion with a patient, on the one hand, or being destroyed by the unbridled forces of primitive rage, on the other? How do dissociation and the dissociative defense relate to regression? Should we allow regressive states of mind? If so, how may such experience in the consulting room help the dissociative patient? The goal of therapy for dissociative clients is to promote integration within the personality. This integrative process inevitably involves overcoming dissociative defenses in order to explore dissociative states of mind so that maturation, full integration, and affect regulation can take place.
Dissociation is a defense that is employed as a means of surviving and adapting to the effects of traumatic experience, and for some it is the means that makes it possible to adapt to life in a hostile environment that involves repeated traumatic experiences that are inescapable. As such, dissociation inevitably involves regression to primitive states of mind. It is to these dissociative states of mind to which a patient, overwhelmed once more by psychic pain, may regress and that the therapist will of necessity seek to engage. The words of Emily Dickinson (c. 1862) both evoke the unbearable mental pain associated with terror and point to the dissociative defense that alleviates distress but at a price.
There is a pain—so utter—
It swallows substance up—
Then covers the Abyss with Trance—
So Memory can step
Around—across-upon it—
As one within a Swoon—
Goes safely—where an open eye—
Would drop Him––Bone by Bone
What are the hidden hazards of treating this client group? Both therapist and supervisor at one remove may experience secondary traumatization from repeated exposure to a patient’s experience of abuse through the overarousal of the patient’s highly sensitive limbic system. Such patients bring complex issues, not the least of which is the need to work through earlier abusive ways of relating as part of their exploration of the past patterns lodged in implicit memory. Supervision offers the opportunity to reflect and helps to diminish the very real possibility of the therapist and patient becoming locked into unhelpful and prolonged reenactments of earlier abusive experience. Guidelines for the treatment of this group of patients note that “much of the material can be violent and shame inducing for the psychotherapist” and recommend that “psychotherapists need professional support to acknowledge the impact of the patients’ material on themselves” (McQueen et al., 2008, p. 86).
The romantic, amusing, and deeply moving film Eternal Sunshine of the Spotless Mind (2004) highlights some of the hopes and fears of traumatized patients as they seek to deal with past experience. In the film Dr. Mierzwiak’s clinic offers “The Lacuna Procedure,” which guarantees permanent erasure of particular distressing memories from which the patient would like to be freed. The central character, a young man called Joel, is horrified to discover that his girlfriend has had her memory of their intense, turbulent, and painful relationship erased by this technique. He seeks the same course of treatment but then rejects it as he realizes he still loves her, and together they then move on to struggle with early memories of his that it feels important to work through rather than forget.
(“The stuff of science fiction” you may be now be muttering, but as I write I discover Nature’s section on neuroscience carries an article entitled “Beyond Extinction: Erasing Human Fear Responses and Preventing the Return of Fear” [Kindt et al., 2009]. The researchers found that oral administration of the b-adrenergic receptor antagonist propranolol before memory reactivation erased the behavioral expression of the fear memory 24 hours later and prevented the return of fear. The researchers concluded that disrupting the reconsolidation of fear memory in this way opens up new hope for patients with hitherto recalcitrant emotional disorders. This research has been greeted by some as a psychopharmacological breakthrough for patients for whom conventional treatments have failed to bring relief, but others see such a treatment as potentially damaging and emphasize the importance of preserving the integrity of memory. They value the warning aspect of traumatic memory, which is much like the early warning system provided by the pain response.)
Symbolically, we can understand Eternal Sunshine of the Spotless Mind as highlighting several of the dilemmas that face the therapeutic dyad: how to deal with dissociated trauma experience, how to process distressing memory, how to modify the trauma response, how to manage levels of arousal, how to develop new patterning, how much to help the patient let go of and what to retain in a manageable form. Every patient who has experienced early trauma has to deal, one way or another, with the patterning that such difficult experience provides. To work through a portion of the trauma in a safe relationship may help to remove something of the “here-and-now” quality of such memory that leads so easily to states of overarousal and dysregulation, and which will then permit something more of a “there-and-then” quality to emerge, which frees the patient to live life more in the present. The empathic relationship is the therapeutic measure that facilitates such change and development.
Dissociation Up Close
Pierre Janet (1889) first used the term dissociation to refer to the uncoupling of the mental processes, the splitting apart of psychological functions that normally go together. Dissociative patients may complain of absences, amnesia for patches of recent time or for trauma experience, depersonalization, and derealization. Such patients may be either easily aroused and overcome by flashbacks to traumatic experience or “dampened down” or “switched off.” In such states of mind (i.e., hyperarousal or hypoarousal), the past is not yet truly the past because it has not been possible for such unbearable experience to be processed in the normal way. It has not passed into explicit memory via the hippocampal memory system of the left hemisphere, which would have tagged time and place to it, enabling the sufferer to gain some distance from it. Such unbearable experience, in which psychic contents get dissociated or split off, inevitably cannot be properly remembered. Rather it remains as part of the individual’s “implicit knowledge” that is associated with the amygdaloidal memory store of the early developing right hemisphere. In early relational trauma occurring before the age of 3 years, dissociation may reflect an earlier stage of mind structuring wherein the cognitive flexibility to be provided by the later developing left hemisphere was not yet fully developed. Indeed Teicher et al. (2006) argue that it is the impairment of the development of the hippocampus as a result of early relational trauma that may generate such dissociative states of mind (p. 193). Once again our concern is with processing that occurs in the right brain rather than the left. When early attachment experiences are traumatic in nature, they become, as Schore (2002) comments, “burned into the developing limbic and autonomic systems of the early maturing right brain, and become part of implicit memory, and lead to enduring structural changes that produce inefficient stress coping mechanisms” (p. 1).
In revisiting aspects of early trauma in the consulting room later in life, the right hemisphere may inhibit the activity of the left when a patient enters a state of high arousal. Decreased activation of Broca’s area may inhibit the patient’s ability to articulate what is felt as overwhelming at that moment. The deeply dissociative defense mechanisms that may emerge as a result may mean that traumatic experience becomes available only in flashbacks; such dissociative manifestations have been described as primary by Dutch researchers Nijenhuis and van der Hart (1999). When different aspects of experience become dissociated from one another (e.g., affect from meaning), presenting as memory fragments that may be visual, verbal, a smell, a sensation, or a feeling unattached to narrative, they are classified by Nijenhuis and van der Hart (1999) as secondary. Tertiary dissociation is their term to describe dissociation in individuals who manifest several dissociated identities. Patients whose traumatic experience has led to any of these dissociative defenses have found some aspect of their experience unbearable; a dissociative response enables intolerable pain to be kept at bay, out of mind.
Trauma patients may come for help because some aspect of the amnesiac defense is failing, and as their trauma is beginning to emerge into mind, it feels too much to manage alone. For some, manifestations may emerge as scary bodily experience or overwhelming emotion.
Case Example: Jennifer
A patient whom I call Jennifer lived in a war zone in early childhood, a place where it was dangerous for people of her race to be seen on the streets. As a child she was sent out in the fog to fetch supplies because a child in the fog just might go unnoticed, whereas in broad daylight she might have been stopped. Jennifer and her immediate family escaped and came to England when she was 7 years old. She has virtually no memory of any experiences before they arrived here. Jennifer arrived asking for therapy because she’d had a terrible panic attack on the street. She told of being taken to hospital in an ambulance, whose siren had sounded weirdly terrifying as it echoed in the fog. Only gradually, in the safe context of the emotionally engaged relationship provided in therapy, did she haltingly become able to make the links to her terrifying early experience. In the safety of the therapeutic relationship, in a series of rather regressed experiences, dissociated states of mind were felt by Jennifer and gradually the unthinkable became able to be thought, the unbearable to be felt, just a little at a time. Jennifer began to explore her terror of being caught, which had had to be buried at the time, and had remained buried until the tendrils of the fog reached into her hidden memory store. In time we both came to understand how the panic that had been so long denied had overwhelmed her and had become a full-blown panic attack, when the trigger of the fog stimulated the old neuronal pathway.
Working with Dissociative Processes
When faced with overwhelming trauma, the dissociative defense––by which feeling, sensation, behavior, image, and meaning became split off from one another––acts as a protective maneuver that preserves the integrity of each area (Levine, 1997). Such experience may not have been processed by the hippocampus, which, as noted several times, tags time and place to memories, and so it cannot be stored as explicit or narrative memory. Rather it will be encoded in the emotional brain and in the body, experienced only in implicit ways. For such patients the body becomes “a container and signifier, as a kind of stage upon which the unfelt psychic pain can be dramatized and eventually relieved” (Sidoli, 2000, p. 97).
Establishing Emotional Connections
If an adult is troubled by early relational trauma, it is “because as a child he or she extracted patterns from early attachment relationships and these patterns form attractors in the limbic brain” (Dales & Jerry, 2008, p. 285; the pull toward pattern completion in these circumstances is discussed more fully in Chapter 4.) Lewis et al. emphasize that “when a limbic connection has established a neural pattern, it takes a limbic [i.e., a new, powerfully engaged emotional] connection to revise it” (as cited in Dales & Jerry, 2008, p. 285). The affect regulation that occurs through a relationally based psychotherapy, supported by supervision that encourages such meaningful affective engagement, is the key to treatment in these circumstances.
Regulating Levels of Arousal
In the consulting room such patients can be easily triggered into states of hyperarousal that affect both psyche and soma and that blot out the ability to think. Such states may escalate very fast, eliciting fight, flight, or freeze responses when even a minor element of current experience, such as a feeling, a noise, a color, a shape, a touch, or a smell, elicits a dissociated fragment of previous trauma. Cozolino (2006) points out that words are problematic at such times of terror because decreased activation in Broca’s area occurs in such states and the patient literally finds it difficult to speak. Afterward patients cannot always recall what happened because the encoding for conscious memory may also be affected in states of extreme arousal. This means that both patient and therapist struggle with the task of constructing coherent narrative. In states of overarousal the secretion of endogenous opioids may come to the rescue, calming the amygdala, which has a high proportion of opioid receptors, and thereby calming the patient (Cozolino, 2006).
However, frequent experiencing of extreme states of arousal in therapy may lead to overdependence on the release of opioids as a way of self-calming. The therapist must find ways to help the patient return to a more regulated state of arousal without this sort of extreme escalation occurring. Should the therapist fail to achieve this then the patient may move to the further state of hypoarousal, wherein disengagement (the escape when there is no escape) and the rag-doll-like state of collapse may ensue, accompanied by the release of endogenous opioids. An understanding of the intensity of projections that may emanate from these patients at such times and be received by the therapist is central to adequate understanding and supervision of what one might term the inner workings of the therapeutic alliance in these circumstances. The way in which the therapist may also get pulled into an enactment is particularly relevant here. Stewart (2002) comments: “The supervisor can provide a cathartic holding experience, a space to think, or in Schore’s (1996) terminology the opportunity to co-regulate or recover to a more mature mode of functioning” (p. 76).
Processing Affect
A young child or even an adult may communicate with noises. Here the therapist may wish to resist the temptation to respond merely in noises but perhaps will follow the rhythm and lilt of the patient in speaking phrases such as “What is it that you want to tell me?” or “I know” or “I see.” With a child, identifying the state as hypoarousal or hyperarousal and therefore responding appropriately may come through an exploration of the way in which the room and the objects in the child’s box are used. Are they attacked, squashed, pushed, pulled? Are they collapsed onto or not touched at all? What do the sounds evoke in the therapist? What is the therapist’s bodily countertransference?
Dissociative episodes in the consulting room and dissociative states of mind can be unnerving to the onlooker and can become counterproductive for the individual once the trauma is past. Bromberg (2003) 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(s) held by a dissociated self state, or by several dissociated self states in the case of patients with DID, as an affective memory without an autobiographical memory of its origin ‘haunts’ the self. (Bromberg, 2003, p. 689)
At the time of the original trauma(s), when meaning was unbearable and experience unthinkable, the dissociative defense may have been a mind-saving one. Because of the way the “unformulated” (Stern, 2008, p. 402) traumatic experience is remembered in the body rather than held in mind, many clients struggle to engage with such psychic pain. As we have seen, experiencing these states arises from the realm of the implicit and as yet there will be no encoding in explicit memory for such trauma. Stern (2008) explains that such experience is “highly charged with affect. Sometimes, in fact, that experience is virtually nothing but affect, affect that can feel completely inchoate to the patient” (p. 402). Research has already shown clearly that the experience of emotional pain “lights up” the anterior cingulate cortex just as actual physical pain does (Eisenberger et al., 2003). By contrast the recall of trauma in the context of the holding, containing therapeutic relationship can do much to modulate the intolerable nature of previously unbearable memories and thereby to modulate the associated affect, in turn modulating the quality of the remembered experience. When such states of mind are addressed in a relational and affect-regulatory manner, a greater integration may gradually take place that enables an explicit memory, at least of the experience in the consulting room, to be held in mind.
Regression in Psychoanalytic Literature and Its Relation to Affect Regulation
Regression work, used as part of the therapeutic technique, was initially associated with Breuer’s work with his patient Anna O and developed by Freud after Breuer renounced it in reaction to his patient’s extreme hysterical response (Breuer & Freud, 1895). Its use as a psychoanalytic technique became a contentious issue for two reasons: The first relates to Freud’s renunciation of his early use of hypnosis to achieve altered states of mind, which for him were an integral part of working with regression, and the second relates to the profession’s understandable renunciation of Ferenczi’s (1988) later unboundaried exploration of regression in the service of therapy, which may best be explored in his clinical diary.
Despite these difficulties, I would like to highlight certain aspects of this early work that still have relevance for us as clinicians today. First is the understanding of regression as involving altered states of mind that are primitive in nature; second is Ferenczi’s understanding that what was provoked by the use of too abstinent a technique on the part of the therapist was not a therapeutic improvement but rather “a replay, a reenactment of original traumatic experiences that the patient as a child had undergone at the hands of adults resulting in an under—or over-stimulation of the child” (Stewart, 1992, p. 104). Third, I would draw attention to the current concern that interpretation used alone and in the context of an abstinent approach may actually be antitherapeutic for some patients at certain stages of treatment.
Lastly Stewart (1992) also notes Ferenczi’s interest in exploring the degree of tension that a patient could tolerate and his assertion that to work at the edge of what was bearable could bring about therapeutic results. If we look at the work of Ogden, Minton, et al. (2006) and of Schore concerning the appropriate level of arousal, we find that this latter assertion of Ferenczi has a curiously modern ring to it. Schore explains the neurobiology of working with such states of mind by means of the following diagram (see Figure 8.1). He notes that the “self-destabilization of the emotional right brain in clinical enactments can take one of two forms: high arousal explosive fragmentation versus low arousal implosion of the implicit self” and argues for work to be done at “the edges of the windows of affect tolerance.”
Affect regulation while working at the edge of what may be tolerated is desirable in most therapy once the relationship is secure enough to work with traumatic experience. Such work requires caution to avoid states of hyperarousal; when the clinician strays into methods of working that stimulate overarousal, frequent states of hyperarousal and the emergence of flashbacks may overwhelm the patient’s capacity to think and reflect on the emotional state and aggravate the kindling process. The cautious therapist will watch carefully for signs of psychological kindling, that is, the changed pattern of neuronal responses in the brain, subsequent to emotional trauma, whereby they fire in response to internal stimuli rather than external stimuli. This changed pattern of neuronal response was first identified by animal researchers (Goddard et al., 1969) and has since been explored more fully by researchers, particularly in relation to posttraumatic stress disorder (Charney et al., 1993; Post et al., 1995) and posttraumatic illness (Miller, 1997; Scaer, 2001). Scaer notes that psychological kindling is most likely to affect the amygdala, leading to high levels of arousal and resulting in flashbacks and states of terror and dread. The goal is to avoid the development of the kindled state in the patient, with its inevitable misplaced release of powerful chemicals into the brain, chemicals designed to enable adequate response to life-threatening emergencies (Scaer, 2001). The kindled state, once aroused, may linger for some considerable time with detrimental effects to the patient’s state of mind and general well-being. Cortisol levels may be raised, resulting in damage to the hippocampus and the thalamus.
Various ways of being in the room with the patient may help counteract such states of overarousal. For example, there is a need for caution in the use of lengthy silences with these patients; “silence is an ambiguous stimulus that activates systems of implicit memory” (Cozolino, 2002, p. 99). Such systems may be so persecutory that they lead patients to depths of affective despair. The therapist’s aim is not reassurance or avoidance of the trauma, but rather to address the point of pain while enabling the patient to stay “in mind” and engaged in the therapeutic process (Wilkinson, 2006a). To this end the therapist should avoid sustained states of both overarousal and underarousal in the patient in order to work effectively (Ogden, Minton, et al., 2006).
Affect regulation, therefore, must be central to any therapy. A lowering of tone and slowing of speech help to counteract overarousal, triggered in the patient by the sudden flow of adrenaline. It may be possible to help the patient modify his or her experience by use of a simple phrase such as “It was then, not now.” Cozolino (2002) suggests that this kind of verbalization is effective because it stimulates Broca’s area and encourages the functioning of right and left hemispheres in a more integrated way. This overview endorses Ferenczi’s understanding that interpretation solely in the context of abstinence is unhelpful for certain patients and introduces the relational perspective that implicitly underpins Ferenczi’s thought about technique with regressed patients. Both Balint and Winnicott, who went on to develop theory and practice concerning regression, understood that the altered states of mind involved in regressive experiences in the consulting room covered a wide spectrum of arousal, from the numbing, switched-off mood of states that we would now recognize as dissociative to the more highly aroused dissociative states of mind often linked with flashbacks and kindled states of mind when traumatic experience is reawakened.
Regression in the Light of an Attachment Perspective: Balint
Balint (1968), the first to revive Ferenczi’s work, proposed two types of pathological character structures that might be encountered in this group of patients, which he categorized in terms of their relation to the object. He described “ocnophilia” as a state in which there is a desire to cling to the object, and “philobatism” as a state in which the spaces between objects are preferred to the object. Here he describes, on the one hand, an anxious, clinging attachment style and, on the other, an avoidant attachment style. This aspect of his theory resonates with Bowlby’s (1958) groundbreaking work on attachment and, indeed, Balint (1968) himself makes this link explicitly, as well as links to studies in ethology.
In his exploration of the therapeutic aspects of regression, Balint, in a clear-sighted way, did not restrict his perspective to merely the positive aspects of regression (a method that had led Ferenczi into substantial difficulty and the use of regression as a therapeutic technique into disrepute), but urged caution concerning what he termed “malignant regression,” which he categorized as “regression aimed at gratification” (1968, p. 144). Balint understood the difficulties encountered in the regressive state of mind to be connected with the earliest relation to the mother and the experience of the inevitable frustration of what he termed “primary object love.” He understood a benign regression as “a regression for recognition” and suggested that the analyst “must accept and carry the patient for a while, must prove more or less indestructible, must not insist on maintaining harsh boundaries, but must allow the development of a kind of mix-up between the patient and himself” (1968, p. 145).
Balint placed at least some of the responsibility for the type of regression that ensued in a session firmly in the psyche of the therapist. He argued that once a malignant type of regression is established, “the analyst will find it very difficult to resist its power, to extricate the patient and himself from it” (Balint, 1968, p. 140). Stewart (1992) notes that “The more the analyst’s technique was suggestive of omniscience and omnipotence, the greater is the danger of malignant regression” (p. 123). Chu (1998) also warns that “passivity and withholding on the part of the therapist allow traumatic transferences to flourish” (p. 122). Chu continues: “Such transferences have their origins in a past reality and can rapidly become functionally psychotic” (p. 122).
A staged approach to the work within a session is important for patients with trauma histories (see Chapter 1) and may go some way in avoiding the development of a malignant regressive experience. For such patients the last part of the session devoted to recovery is essential to maintain so that they may leave in a safe state of being.
Winnicott
Winnicott (1965) also understood the need for regression, emphasized its value, and described two types that he felt occurred in the consulting room. The first he described as a thorough-going regression that some patients needed to achieve what he described as “unit status” with the therapist (Winnicott, p. 44). He understood the wound to these patients to be a primary one, just as in healthy early development “the infant becomes a person, an individual in his own right.” This occurs in the earliest relation to the primary caretaker, which means that “the personal structure is not yet securely founded” (Winnicott, 1975b, p. 279). Winnicott’s and Schore’s work both seamlessly integrate an understanding of the mother–baby couple as the source of the secure attachment and the unit status and also as the stimulus for, and definer of, the quality of the newly developing baby mind–brain and the baby’s ability to self-regulate. Deep-seated early relational trauma requires sustained treatment in depth to effect change, thereby requiring a dependent experience over time for these patients.
The building blocks that establish attachment in the beginning of life are activated again in the very special kind of regression that may develop in the consulting room. The voice of the therapist may come to be extremely important to the patient as he or she begins to regress, and seeks to form, perhaps for the first time, a deep affective attachment that will give the confidence to move forward into a fuller experience of life. The inferior colliculus which stores the imprint of the mother’s voice is the part of the brain which also becomes active when affective encounters occur throughout life. Panksepp and Bernatzky (2002) describe sound as “a special form of touch…built upon the prosodic mechanisms of the right hemisphere…[that] allows us affective emotional communication through vocal intonations” (p.136), and emphasize that sound is “an excellent way to help to synchronize and regulate emotions” (p. 140).
Winnicott felt that a thorough-going regression with a view to establishing a reliable attachment was of particular help to those patients whose attachment had been what would now be characterized as insecure, avoidant, or disorganized. Such patients, Winnicott felt, had developed what he termed a “false self” as a protective barrier against unbearable impingement and as a means of coping with the need to interact with the external environment. In Winnicott’s exploration of what he described as the strain put on mental functioning that is organized in defense of a tantalizing environment––that is, an environment in which the mother does not manage to respond to the baby’s needs in a “good enough” way––he noted that, in some patients, a method of managing emerges in which mental functioning becomes a thing in itself and acts as a substitute mother within the psyche but inevitably proves to be no replacement for real mothering.
Such a defense is reminiscent of Kalsched’s (1996) identification of a powerful protector/persecutor figure, a split-off aspect of the self that develops in response to trauma (the protective aspect) but then comes to dominate the psyche (the persecutor aspect), reflecting the patient’s internal attempt to regulate arousal and to manage the debilitating effects of lingering traumatic states of mind. Winnicott (1975c) warns that such false caretakers within the psyche will always prove inadequate, and breakdown may threaten or occur. He uses the term “freezing” to describe the effect on the developing psyche–soma of the failure of the early environment to provide adequate nurturing (Winnicott, 1975b, p. 281). We know that part of an initial response to a trauma experience is the freeze response and that after the threat is past, the healthy reaction is relaxation. What Winnicott suggests parallels our knowledge of the effects of an unresolved traumatic experience: that is, the sufferer may become fixed in the freeze response with detrimental effects on mind, body, and emotions (Levine, 1997; Scaer, 2001). Winnicott understood a regression that takes place within supportive psychotherapy, inevitably involving altered states of mind, to be a major therapeutic tool for such patients.
Winnicott (1975d) also understood that patients might move into altered states of mind in a less thorough-going but equally helpful way. In therapy with these patients he suggests that at the moment a patient becomes withdrawn, in an altered state of mind, if the analyst can manage to “hold” the patient metaphorically, then “what would otherwise have become a withdrawal state becomes a regression” (Winnicott, 1975d, p. 261). A quality of healthy dependency then characterizes the therapeutic relationship and enables the deep affective engagement that may bring about change in the patient’s mind. Winnicott (1975d) concludes: “Danger does not lie in the regression but in the analyst’s unreadiness to meet the regression and the dependence which belongs to it” (p. 261). Today, as we consider the value of such a relational stance, the added knowledge is available to us that affectively focused treatment alters the frontal lobes of the brain, which in the right hemisphere is the emotional executive of the brain, in a way that is detectable by functional imaging studies (Solms & Turnbull, 2002, p. 288).
Regression and Aggression
One of the reasons that Ferenczi brought working with regression as a therapeutic tool into disrepute was his failure to acknowledge the levels of aggression that can be uncovered through the engagement of primitive states of mind. Writing about traumatic experience in general, Grossman (1991) suggested that pain and painful affects stimulate, and are the sources of, aggression, and that fantasy formation may be damaged by trauma, leading to an ability to transform the traumatic experience through mental activity. Fonagy (1991) comments on the child’s psychic response to parental abuse: “The parent’s abuse undermines the child’s theory of mind, so that it is no longer safe for the child…to think about wishing, if this implies the contemplation of the all too real wishes of the parent to harm the child” (p. 649). Inderbitzin and Levy (1998) note that “Destructive and self-destructive behaviors are prominent if not central, whether the source of trauma is a primary caretaker or external circumstances (illness, surgery, etc.) requiring help from an important adult” (p. 44). They argue that trauma gives rise to “intense frustration and ensuing aggression” and that the opportunities for aggression provided by “reexperiencing trauma” should not be underestimated (p. 40). We begin to have intimations of the quality and complexity of the transference–countertransference relationship with these patients.
Bragin (2003), in her discussions of the effect of terror on symbol formation, emphasizes the problems that occur when the natural destructive internal fantasy that is an inevitable part of the process of the development of mind seems suddenly to come into its own in external reality and points out that the “exposure to extreme violence may inhibit the ability to mentalize in order to protect against the knowledge of internal destructive capacity” that becomes too painful to bear (pp. 60–61). It seems that similar processes affect the nascent mind confronted with prolonged abuse at the hands of the primary caregiver.
Bragin also suggests that those who are afflicted by “survivor guilt” may regress to the state of early infantile omnipotence that acts as a defense against terrifying helplessness by seeing “themselves as the cause of the violence not its victim” (p. 64). In another paper she argues cogently for the need to enable the patient’s awareness of the therapist’s capacity for knowing terrible things very early on in therapy if the patient is to engage successfully in the incredibly painful task of undergoing treatment for the effects of extreme violence. In particular, she emphasizes that omnipotent guilt can be understood as “a defense against something far worse—being helpless and alone in the face of murderous rage within and the torturer without,” adding “one is not then the helpless victim of someone else’s nightmare but the author of one’s own” (Bragin, 2007, p. 231). Knox (2001) developed a similar idea in relation to the patient who has experienced early relational trauma when she considered the effects of a child’s dawning awareness of parental cruelty: “For any child to feel this is unbearable and…it might feel preferable in that situation for the child to construct a belief or fantasy that (s)he has done something to cause the parent to behave in this sadistic way; such an imaginative belief would allow the child to retain some sense of cause and effect” (p. 626).
Bragin (2007) argues that in the face of such internal pressures, regression to the earliest states of infantile omnipotence becomes inevitable, and the victim is “thrown back to an experience of early aggressive fantasy” (p. 231). She suggests that torture promotes regression to the preverbal defensive stage of the earliest months of life and intimates that identification with the aggressor may well be the ultimate outcome of abusive experience. Schore also concludes that the “spatiotemporal imprinting of terror, rage and dissociation is a primary mechanism for the intergenerational transmission of violence” (Schore, 2003a, p. 287).
Eigen (2001) delineated vividly the etiology of rage arising out of early relational trauma and argued for a similar effect to that described by Bragin and Schore:
The individual was born into a frightened and frightening world, a world in which being frightened plays a significant role…. Personality [is] congealed or collapsed around or into the fright…. It spreads through body, the way it feels to be a person, through character…. Once personality is set in the mould of terror, it is difficult to move on…. Rage is fed by terror. (pp. 24–25)
It is essential for the therapist to help the patient understand that these terrible states of mind are not unthinkable but in fact knowable and that, as such, they can be acknowledged and worked with, especially in therapy. Bragin (2007) elucidates the central dilemma that such states of mind pose for the clinician: “how to convey the capacity to know terrible things without being destroyed by the survivor, while at the same time not conveying that one is dangerous oneself” (p. 229). It is only by acknowledging the aggressive fantasy that lies buried in us all that the patient can be helped to move on and to engage in the “struggle to reshape what relationship can mean” (Orbach, 1998, p. 70). Indeed Fonagy (1991) had already made clear that “the ability to represent the idea of an affect is crucial in the achievement of control over overwhelming affect” (p. 641). But how can this control be achieved in relation to aggression? For the answer I believe we have to return again to the earliest relationship, that between the baby and the primary caregiver, and allow the implicit relational knowing that occurs in that earliest dyad to inform our way of working in the consulting room. Regression, therefore, has a crucial part to play in treatment. One may summarize the process that Winnicott (1975b) conceived as:
• Providing containment in a way that gives the patient a sense of security
• Allowing regression to dependence
• Enabling a discovery of the self through the unfreezing of the early environmental failure
• Enabling an ability to feel and express anger
• Enabling a steady return to independence
• Validating a new quality of liveliness
The path of the therapy does not necessarily feel like a steady upward climb; more often than not, the struggle is more of a forward and backward motion, a struggle between progression and regression. Maybe a spiral staircase is a better metaphor, as both therapist and patient often seem to find themselves back at the same place again, but perhaps on a higher level of the spiral. In work that involves an encounter with younger self states that contain more regressed or frozen parts of the self, dependency is an integral part of the patient’s experience. A patient described her need of her analyst over a short break in therapy as a need for her kangaroo mother. She knew that they were separate but still longed to be able to be kept close in a kangaroo pouch, much as neonates on a premature baby ward are “kangarooed” or snuggled by the parent close to his or her body inside a large sweater. At this stage the analyst’s implicit acceptance of the patient’s dependency at a nonverbal level is crucial. Of course, the acceptance could be put into words and no doubt later will be, but at this stage a much more fundamental sort of nonretal-iatory holding is what is required. Chused (2007) emphasizes the analyst’s capacity to allow him- or herself to be used symbolically in the role of “idealized care-provider,” that is, to “accept the role of the all-important other has a significant impact on patients” (p. 878). Such dependency can be very difficult for the analyst to bear, and this difficulty gives rise to the danger that a premature attempt at separation will be initiated, with disastrous consequences, just as Stern (1985) noted that a misattuned mother can ask too much separation of her child too early. Later, the way in which analyst and patient are able to engage in the tasks normally associated with the second year of life will be crucial for the patient, who has needed to regress to earlier states of being. The inner child must also learn about a less than perfect fit to be able to manage in the world. Stern (1985) has described in depth the way in which well-attuned mothers gradually enable their children to accept this reality.
Chused (2007) notes that when a child patient is in the pretend mode which is a feature of imaginative play in the therapy room, “the defensive hyper vigilance and guardedness felt to be necessary in the ‘real world’ relax and the child is much more available for meaningful interaction” (p. 877). It is just so with the child part of the adult patient, and the wide range of therapeutic techniques that has developed attests to this. Perhaps what is most important about the playful, imaginative aspects of therapy—whether with child or with adult, and whether using toys, words, images, dreams, or imaginative interactions between patient and therapist—is what Chused describes as an exchange between patient and analyst, “where meaning is not fixed, [and through which] the implicit communication of availability, containment, accompaniment, and tolerance allows for both the emergence of unconscious fears and conflicts and their eventual transformation” (p. 877). Chodorow (2006) observes that “the imagination creates symbolic images and stories that express the mood or emotion in a way that may be more bearable, [reminding us that] this completely natural process occurs in the symbolic play of children” (p. 223). The capacity for imaginative play helps patient and therapist together find a way through the defensive stance that hypervigilance would demand of the adult parts of the patient in response to regressive states of mind.
The Neuroscience of Changing Self States
Dissociation, such as these regressed patients may experience, involves the maintenance of effective defensive systems in protection of the self, on the one hand, alongside a separate system geared to managing the ordinary events of a daily life, on the other. Van der Hart et al. (2006) identify the “apparently normal personality” as an aspect of the patient’s psyche that is “fixated in trying to go on with normal life…while avoiding traumatic memories” (p. 5). The apparently normal personality may be equated with Winnicott’s adaptive, coping, or false self with which the patient manages the ordinary demands of living. In this sense Winnicott’s term “false self” extends far beyond his original meaning. The apparently normal self state is false in that it fails to recognize the experience of the traumatized self as its own; it is not able to identify with it and remains unable to feel its pain.
Van der Hart et al. (2006) understand the “emotional personality” to be stuck in the traumatic experience that persistently fails to become a narrative memory of the trauma. They note that the domain in which the emotional personality lives may be characterized by vehement emotion that is overwhelming and nonadaptive. In the hyperaroused states that occur in a regressed patient, the emotional personality is in the ascendance. In such states patients may unconsciously seek retraumatization in the consulting room in order to experience an endorphin “high” to which they have become accustomed from early and repetitive experiences of trauma. “Children abused by their caregiver will experience increased levels of endorphins as part of the traumatization and freeze response” (Scaer, 2001a, p. 88). Patients who had this type of early experience may continually seek to reexperience trauma in what may be thought of as an addictive state of mind. Such a pattern may also occur when a patient attaches to a therapist who unconsciously works in an abusive way, or is experienced as doing so in the transference. In each situation the patient unconsciously seeks the endorphinergic effects, with ensuing opiate-like reward, of the abusive situation. Reexperiencing or reenactment of this kind in the consulting room will become addictive rather than therapeutic. Thus the therapist must consider carefully the appropriateness of any reexperiencing or reenactment in the consulting room.
When dissociation has become the way to manage the trauma initially, it persists as a way of coping with stresses in life generally, and in the consulting room, in particular. Traumatized patients may find themselves escaping from reality by old familiar routes: When the going gets tough, they may enter states in which they believe “I was not abused”; in other states they may feel weak, helpless, and easily become a victim, whereas at yet other times they may find themselves unduly aggressive in an unconscious identification with the abuser. “Exposure to subsequent stress tends to reactivate not only traumatic memories, but also trauma-based schemes about self and others” (van der Kolk et al., 1996, p. 432).
Memories of the earliest trauma relating to the primary caregiver are held only in emotional and bodily memory. As such, when they are reexperienced there is a strong emotional and bodily quality to the “memo-ring,” as one patient chose to describe the experience. When she used this term there was always a vivid here-and-now quality to the memory fragments that emerged, which would give rise to an experience of what I term “the old present.”
Using EEG, Schiffer et al. (1995) observed activity indicative of left-hemisphere processing when patients were engaged with neutral memories, but a marked switch to activity indicative of right-hemisphere processing when they were engaged with trauma memories. Two small studies have explored the discrete regional cerebral blood flow (RCBF) patterns that are identifiable when patients listen to their emotionally neutral versus trauma focused scripts. The first study by Rauch et al. sought to explore the neurobiology of intense fear in eight patients with a diagnosis of PTSD. Cozolino (2002) reports this research and emphasizes their findings that, when listening to trauma scripts, the RCBF was greater in right-sided structures associated with intense emotion, “including the amygdala, orbitofrontal cortex, insular, anterior and medial frontal lobe, and the anterior cingulate cortex” (as cited in Cozolino, 2002, p. 273). Reinders et al. (2003), in a study of 11 female patients with DTD, used PET scanning to explore the possibility of one human brain being able to initiate two autobiographical selves. The results demonstrated that “these patients have state-dependent access to autobiographical affective memories and thus different autobiographical selves.” Furthermore:
The Traumatic Personality State (TPS) of the patient was identified as being able to store a traumatic memory and able to acknowledge that its reactivation affected them emotionally while the Neutral Personality State (NPS) reported to be emotionally unresponsive to that memory and had no awareness of having been exposed to that event. (Reinders, cited in Wilkinson, 2006a, pp. 169–70)
Areas that play a role in regulating emotional and behavioral reaction to pain were activated when the TPS listened to the trauma script but not when the NPS heard the same script. The existence of different RCBF patterns for different senses of self was observed in the medial prefrontal cortex (MPFC) and the posterior associative cortices. The right MPFC, thought to play a crucial role in the representation of the self-concept, was significantly deactivated when the NPS listened to the trauma script (Reinders et al., as cited in Wilkinson, 2006a, p. 170). Although the results of small-scale studies should be approached with caution, at the least they indicate possible lines of research that may profitably be pursued in larger studies or complementary studies.
Conclusion
Teicher’s research into the aftereffects of trauma has shown that the effective functioning of the corpus callosum, which is the major highway between the two hemispheres, can be reduced through trauma (Teicher, 2000; Teicher et al., 2006). As therapist and patient affectively engage with one another and together develop words for the patient’s experience, particularly for his or her previously inaccessible affects, greater interhemispheric connectivity is fostered in the mind–brain of the patient, helping to mitigate the earlier effects of trauma.
While researchers pursue the nature of dissociative states of mind and the way in which unintegrated affect may be integrated and unnecessary fear and negative affect modulated, what is clear is that therapy that addresses these issues will involve the circuitry of both hemispheres. Hugely important will be the therapist’s capacity to foster an understanding that omnipotent fantasy is both an illusion and, as Bragin (2007) emphasizes, “the rage it is defending against” (p. 231). How can this level of therapeutic understanding be realized in the consulting room? Krowski (1997) comments: “It is only when a containing maternal object has been internalized [in therapy] that rage and hatred…can be faced” (p. 171). I conclude that it is the internalizing of the containing maternal object that is at the heart of a regressive process in treatment that emerges as truly therapeutic.