I CLOSE AS I BEGAN, by musing again with Ian McEwan’s (2006) character of Henry Perowne:
A man who attempts to ease the miseries of failing minds…is bound to respect the material world, its limits, and what it can sustain—consciousness no less…the mind is what the brain, mere matter, performs. If that’s worthy of awe, it also deserves curiosity; the actual, not the magical, should be the challenge. (from Saturday by Ian McEwan, published by Jonathan Cape. Reprinted by permission of The Random House Group Ltd., p. 67)
Those of us who engage with minds that have become unduly stressed also need great curiosity if we are to assist others who seek to explore their intra- and interpsychic subjectivity. It is a curiosity that is now presented with a plethora of sources of satisfaction as research into attachment, trauma, and the neurobiology of emotion burgeons.
As I was writing this final chapter, thinking about the many sources of information and how they might integrate with any one of the traditional schools of psychodynamic therapy, I dreamt the following dream.
I was visiting a country house that belongs to very close friends of mine, Sally and Alan. It is a very old and beautiful thatched cottage that has been carefully restored and modernized in a way that is in keeping with its original features. As one goes in the front door the large kitchen is off to the right down a few steps. On the left is the dining room, so often a hub of conversation and discussion of ideas. As my dream opened, I was in the kitchen with a large group of seemingly rather distinguished guests. All were busy preparing their favourite soup, using tried and trusted recipes. Then Alan entered the kitchen carrying a very large pan with some new ingredients in it, which he set on the kitchen range. He carefully began to mix and blend quantities of the other soups into this, tasting as he went along to ensure that he had just the right mix to produce just the right flavor. When all was ready, we trooped out of the kitchen up a beautiful traditional dark oak staircase to the dining room, which in my dream had moved to the left at the top of the stairs. Some of the guests were still clutching the spoon they had been using to taste their favorite old soup.
The scene changed and I was sitting in the middle of one side of a long oak dining table. All the guests were sitting around the table, Alan was just across from me, and the old inglenook fireplace was just behind him. I thought the room had a rather Jacobean feel to it. Some people had chosen to bring the soup of their own old original recipe in the spoons they had brought with them from the kitchen, wanting at that moment only to conserve the soup with the old, familiar, much loved taste. Naturally with this already in their spoons, they found it difficult to taste the new flavor. A tall distinguished man, who reminded me of a very well respected American psychoanalyst who has blended the old established psychoanalytic teaching with the new insights from affective neuroscience, asked for a clean spoon. Alan brought fresh silver soup spoons, and several people took one and more readily began to appreciate the new flavor that had been mixed, blending the best of the old with the new ingredients that Alan had added.
As I woke and thought about the dream, I realized almost instantly that Alan, a much valued friend and the master chef of my dream who blended the old with the new with such care, stood for Allan Schore, who has made such an outstanding contribution to the consideration of how minds are changed in therapy by blending together for us the best of affective neuroscience, attachment theory, infant research, evolutionary psychology, and ethology—just as, in my dream, the new is blended with the old to produce something of outstanding worth, both in renovation of the house itself and in the delicious soup that has been concocted.
We very much need a theory and practice where the best of the old is conserved yet where the new can be integrated and used, just as in my dream. We need to go into the creative kitchen on the right—that is, to discover the riches of the right hemisphere that can then be taken and tasted, thought about, in the upstairs dining room that is the information-processing center of the left cerebral cortex. As in my dream it is in a sense a Jacobean atmosphere we wish to prevail, if by Jacobean one understands an atmosphere of enlightenment, of grounding ideas in the best experimental science of the day. The dream also warns that those who cling only to the old familiar soup, the old familiar ideas, may miss the new flavor that is made possible by the use of new ingredients, supped from a new spoon, ingredients that have now become available to us.
Psychodynamic psychotherapy stands at the interface of what might be termed the cognitive–affective divide. Traditionally this school of therapy has emphasized words, interpretations, and the changing of cognitions; currently we have come to a greater appreciation of the affective, relational aspects of our work and the way in which they relate to the early right-brained experience of the child in relation to the primary caregiver. Like so much in life, it is not a case of either/or but both–and. It is the capacity for integration and interconnectivity, both within and without, that gives rise to a mature mind. Regarding research, Panksepp (2003) warns against what he terms “cognitive imperialism” and argues that “if affective organic processes, ancient adaptive solutions that they are in brain evolution, are to a substantial degree distinct from those that mediate cognitive deliberation…then we must develop special strategies to understand them in neural terms” (p. 6). In effect, Panksepp rejects approaches that merely apply cognitive “information-only strategies” to research concerning affect, concluding that “emotions are not simply informationally encapsulated brain processes as some cognitively-oriented investigators seem to believe.” He adds, “to succeed in this journey we must cultivate deep neuro-evolutionary points of view” (p. 12).
Not only does current thinking make clear that psychotherapy stands at the crossroads between the affective and the cognitive, it also directs our attention to the mind–body continuum, especially where trauma is concerned, in stark contrast to earlier practice, which seems to have envisaged a chasm between mind and body, in keeping with the old Cartesian dualism that dominated thought and practice. Sinason (2006) argues that in the past “to cope with the privileged access to the mind of the client a split has been made that excludes the body” (p. 51). Recent large-scale studies of the effects of adverse childhood experiences on later health in the United States and the United Kingdom (Felitti et al., 1998), involving more than 17,000 patients, identified a significantly increased risk of developing serious organic diseases, including cancer, heart disease, asthma, diabetes, and chronic obstructive pulmonary disease. Kendall-Tackett and Klest (2009) point out that trauma gives rise to health problems along five possible pathways: (1) physiological—affecting the catecholamine system, the hypothalamus–pituitary–adrenal (HPA) axis, and the regulation of cortisol and the immune system; (2) behavioral—high-risk behaviors may ensue; (3) social—affecting the capacity for successful relating; (4) emotional—leading to depression, anxiety, and PTSD; and (5) cognitive—via “hostility—or framing the world as a dangerous place” (p. 132). They note that just as trauma affects health adversely, so poor health can reactivate the symptoms of trauma, such as flashbacks and dissociative symptoms. Haven (2009) concludes: “It is not enough, and is actually misguided, to focus exclusively on the cognitive and emotional meaning of the experience…. Past traumatic experiences…imprinted in the deeper regions of the brain that are only marginally affected by thinking and emotion…are embodied in current physiological states and sensations” (p. 216). The way forward in treatment must incorporate a holistic approach.
A major concern in this book has been to explore the nature and role of empathy in the therapeutic encounter. M. L. Miller (2008) offers a significant review of the psychoanalytic literature concerning this and concludes that the emotional participation of the therapist has become the major focus in recent years. He stresses the relevance of a dynamic systems theory approach to understanding emotion, noting that emotions are self-organizing products of psychological and physiological processes that arise out of interpersonal experience. In so doing he rejects a solely cognitive appraisal approach, which stresses arousal and cognitive response to arousal and understands emotions as “an ever-present, constantly changing set of processes that influence and are influenced by the social context within which they occur” (p. 15). He understands all social interaction, including therapy, as a process “coordinating emotional-adaptive responses between participants to a social interaction [which] occurs automatically, nonconsciously, and continuously” (p. 17). Three systems, the subcortical arousal system, the cortical interpretive system, and the motor system, mutually regulate each other in response to the social environment. Miller emphasizes that “emotional processes, like all dynamic systems, have a tendency to settle into a finite number of stable patterns” (p. 16). It is these established patterns in both patient and analyst that affect the dynamics of the emotional experience within the dyad and produce change. The ventromedial prefrontal cortex, located at the interface of the cortex and subcortex, enables the necessary mind–body connections and permits emotional regulation. Miller concludes that “dynamic systems theory casts emotion in a truly interactive context, enabling analysts to appreciate the co-constructed nature not only of the meanings attributed to the analytic interaction but also of their own and the patient’s emotional states as well” (p. 20).
Although stressing his own view as one in which the emotional engagement of the therapist is paramount in therapy, M. L. Miller (2008) nevertheless voices the concerns of some who have suggested that an analyst’s emotional engagement in therapy with a patient may be “an expression of the analyst’s unconscious emotional conflicts” or may lead to “a traumatic reification of the patient’s unconscious fantasies and fears” (p. 4). What also needs to be acknowledged is that the converse may be equally likely to be true: The disengaged, distant, abstinent therapist may be adopting that style of working because of his or her own unconscious conflicts, and it may just as likely lead to a reification of the patient’s unconscious fantasies and fears. Indeed, it could be argued that the use of silence, in particular, can be extremely persecutory for the patient, as it allows so much space for persecutory fantasy and fear to flood into the room and into the relationship. Such difficulties can be guarded against only by adequate self-understanding on the part of the therapist, most fruitfully achieved through the therapist’s own personal therapy, reflection, and supervision.
The field of epigenetics, which studies the effects of environmental experience on genetic expression, is yielding much information that may encourage a more proactive approach to those who have experienced early relational trauma. Inheritance and experience both play vital roles, and “parental care is revealed as a critical agent of natural selection that influences the stabilization or elimination of corticolimbic connections” in early childhood (Bradshaw & Schore, 2007, p. 429). Boes et al. (2008) suggest decreased volume in the right ventromedial prefrontal cortex as a cause of heightened impulsivity in boys and pose a host of questions that arise from the possibility of identifying neural “endophenotypes” for impulse control.
How does one’s environment interact with susceptibility genes to impact brain development in this circuit? Can therapeutic intervention be optimized if tailored to one’s unique genetic vulnerability? Will biological markers of vulnerability someday be utilized to initiate preventative efforts for high-risk individuals? (p. 7)
Panksepp (1998) makes clear that maternal behavior during early childhood (e.g., rat mothers licking their pups or sea otter mothers providing for their pups) has a profound effect on the epigenetic marks on specific genes and on behavior in ways that are sustained throughout life.
In humans the earliest environments, both prenatal and postnatal, have been shown to have a profound effect on gene expression. This, in turn, has implications for our understanding of patients who have experienced early childhood trauma. A study by McGowan et al. (2009) compared a particular aspect of hippocampal gene expression (NR3C1) in brain tissue samples from suicide victims with a history of childhood abuse with samples from two control groups—victims of sudden, accidental death, and those who had committed suicide but who had no history of abuse. They found no differences in glucocorticoid receptor expression between suicide victims without a history of childhood abuse and controls, but found that this particular aspect of hippocampal gene expression was decreased in samples from those who had experienced childhood abuse. Their research indicates that “changes in glucocorticoid receptor expression are closely associated with a developmental history of familial adversity, in this case a history of childhood abuse, rather than with suicide completion” (p. 4). The researchers stress that these results, which are in keeping with earlier studies in which childhood abuse in humans and disruptions in mother–infant interactions in rodents and nonhuman primates were linked to an increase in pituitary adrenocorticotropic hormone (ACTH) responses to stress. (See Chapter 2 and the work of Shin et al., 2006, and Teicher et al., 2006, for a fuller discussion of this point.) McGowan et al. conclude that “pituitary ACTH directly reflects central activation of the HPA stress response and hippocampal glucocorticoid receptor activation dampens HPA activity” (p. 4). Stress inevitably results in symptoms that may bring the patient in search of help. Regulation of arousal levels brought about by stress becomes a central feature of work with this group. Body therapy, sensorimotor therapy, and bodily relaxation techniques have a significant part to play in the achievement of stress regulation. Psychotherapy work that focuses on affect regulation within the context of a secure relationship with the therapist will provide a different learning experience and, if underpinned by real affective engagement, will enable patients to manage their stress levels more efficiently as well as work toward some modification of their stress responses.
Panksepp (2003) encourages us to make “the evolutionary working-assumption that internally experienced affects are universal capacities of brains in all mammals” (p. 5). From a similar neuroethological stance Bradshaw and Schore (2007) emphasize the importance of early attachment and social learning and the far-reaching effects of poor early experience. They explore the abnormal behavior of the wild African elephants; these elephants have been affected by changes that led to infants “largely being reared by inexperienced, highly stressed single mothers” instead of the more traditional extended matriarchal elephant society. They note that such an upbringing impairs normative and socially mediated neuroendocrinological development and causes psychobiological dysregulation, which, if experienced “during critical periods of infant female brain growth[,] alters the developmental trajectory of successive generations.” They note that new data from brain imaging, along with an understanding that “cortical and limbic structures responsible for processing and controlling emotional and social information…are all highly conserved evolutionarily across species,” lead inevitably toward “species-inclusive models” and the emergence of “trans-species models of brain and behavior” (pp. 427–428). Such trans-species models of brain and behavior will inevitably encompass the trans-generational transmission of trauma. Changing minds in therapy will inevitably seek to break the chain by enabling patients first to experience and then to explore different ways of relating that enable affect regulation, rather than dysregulation, for them and, in turn, for their offspring. It also behooves professionals to identify as early as possible those babies and young children most at risk, and governments to have training, funding, and provision of parent–infant psychotherapy as priorities.
Turning specifically to the field of imaging, one can claim, without doubt, that it has transformed research in the field of mind–brain–body relationships. Used in conjunction with knowledge drawn from work concerning neural activity in monkeys and other species, fMRI offers the best possibility of exploring information processing in the human brain. Newer techniques are also being used to complement the findings of fMRI research. Diffusion tensor imaging, a new form of MRI, is being used to explore the axon tracts that connect regions in the human brain. Transcranial magnetic stimulation (TMS) is being used to explore whether links between a brain region and a particular behavior identified by fMRI hold true. When neural activity in a particular region is disrupted by the use of TMS, then the behavior, thought to be associated with that region on the basis of fMRI, will also be affected (G. Miller, 2008).
Of course there are limitations. Logothetis (2008) has given a masterly summary of both the strengths and weaknesses of research using fMRI. He stresses the huge amount of research that is being conducted and notes that somewhere in the region of eight papers per day have been produced in recent years. As to its value as a research tool, he asserts:
fMRI is not and will never be a mind reader, as some of the proponents of decoding-based methods suggest, nor is it a worthless and non-informative “neophrenology” that is condemned to fail, as has been occasionally argued. Perhaps the extreme positions on both sides result from a poor understanding of the actual capacities and limitations of this technology, as well as, frequently, a confusion between fMRI shortcomings and potential flaws in modelling the organizational principles of the faculties under investigation. (p. 869)
Watt (2005) also makes several points concerning the limitations of the use of fMRI for research purposes:
• It tends to “minimally accent ventral brain areas” (p. 191).
• It produces “correlative pictures with uncertain causal connections” (p. 192).
• Emphasis on very small hot spots may be misleading and ignore the reality of “widespread and highly distributed networks in which many structures may be variably activated or inhibited, some more so than others” (p. 193).
• Studies “typically gloss over individual variations, often quite large.”
Logothetis argues that, nevertheless, fMRI is the most important discovery since the X-ray and a powerful tool at our disposal, if used appropriately, for “gaining insights into brain function and formulating interesting and eventually testable hypotheses, even though the plausibility of these hypotheses critically depends on used magnetic resonance technology, experimental protocol, statistical analysis and insightful modeling” (p. 876).
From our profession’s particular point of view we must also realize that time frames involved in fMRI studies are vastly different from the time frames of therapy. Modell (2005) notes the difficulty that occurs in attempts to incorporate and directly transfer information regarding emotions and feelings derived from an experimental context, such as fMRI scanning or PET imaging, into the knowledge base generated from psychoanalysis. He observes that “it is essentially a problem of the very different contexts in which feelings are experienced, and feelings are very sensitive to the context of the environmental surround” (p. 37). He further notes that “we must be mindful of the fact that named feelings and their neural correlates evoked in the context of the controlled conditions of a laboratory experiment may or may not be identical to comparable feelings evoked during a psychoanalytic session” (pp. 37–38). Others highlight the dangers of false positives and the complexities of accurate interpretation of information gained from scanning. Miller (G. Miller, 2008) notes Aron’s suggestion that information accessed from fMRI should be used as “one tool in a toolbox, as a way of testing hypotheses where you have converging techniques and evidence” (p. 1414).
With all these caveats in mind, research based on imaging techniques nevertheless provides rich material for the therapist to explore in relation to clinical work, especially when used in conjunction with the complementary insights emerging from research in the fields of attachment and trauma. How links are made between these fields regarding the making of mind and how insights are used is an area that careful research, rather than speculation, will reward. In the process of changing minds, of course, our minds as therapists are also changed. While much attention is now being directed to the scanning of particular patient groups, there is also fruitful territory for research in the exploration of the effects of the therapeutic process on the mind of the therapist, particularly when there is a high risk of secondary traumatization.
I suggest that an interdisciplinary approach that values the insights from the fathers of psychoanalysis alongside insights from attachment research, parent–infant psychotherapy research, and the neurobiology of emotion should no longer be considered an optional “extra” in the world of psychotherapy for a few to pursue as a special interest. Our training venues must now embrace an interdisciplinary approach rather than shy away from one, or use it merely to bolster up outdated scientific concepts in an artificial way. Strachey (1950) notes that in 1895 Freud was at the frontier of brain science with his discovery of what he termed “contact barriers” and which Sherrington (1906) later named “synapses.” Jung (1946a) pointed out that “natural science combines two worlds, the physical and the psychic, [and that] psychology does this only in so far as it is psychophysiology” (par. 162, emphasis in original). In the discussion that followed Jung’s Second Tavistock Lecture, Bion asked Jung whether he thought there was a connection between mind and brain. Jung replied: “The psychic fact and the physiological fact come together in a peculiar way…We see them as two on account of the utter incapacity of our mind to think them together” (Jung, 1935, par. 135–136).
Although it can be argued cogently on the basis of empirical evidence that neuroimaging and lesion studies now make crystal clear the neural basis for theory of mind (Hirao, Miyata, et al., 2008), sadly, to a certain extent, Fonagy’s (2003) argument that failure of analytic theory as a scientific theory has resulted in a failure to link theory to practice in a creative way still holds. It behooves us as a profession to seek to use the new knowledge available to us so that our discipline may truly come of age and prove even more beneficial to our patients.
Freud himself recognized this need in his own day. He observed that “a scheme of training for analysis has still to be created. It must include elements from the mental sciences, from psychology, the history of civilization and sociology, as well as from anatomy, biology, and the study of evolution” (Freud, 1959, p. 252). Many of our trainings still fall far short of Freud’s breadth of vision. In arguing the importance of neurobiolog-ical teaching to underpin training, both in dynamic psychotherapy and psychiatry, to address this shortcoming, Lacy and Hughes (2006) suggest of such an approach that “rather than an attempt to justify a belief or theory, it is the establishment of core concepts that inform psychological reasoning and understanding” (p. 47). Whitehead (2006) argues that “our problem is now the true integration of two complementary scientific disciplines” (pp. 609–610, emphasis in the original).
The clinical process of changing minds in therapy is the central concern of this book. Emde (1999) observes that we need to “give more theoretical and empirical attention to questions regarding what kinds of emotional availability are appropriate within the professionally guarded psychoanalytic situation.” He points out that “this may or may not lead to changes in technique with consequences for outcomes that can be studied” (p. 330). The positive affective aspects of intersubjective relations, rather than interpretation, appear to impact most effectively on the patient’s store of implicit memories (Andrade, 2005). Research indicates that healthy interaction with others results in “increased metabolic activity, mRNA synthesis, and neural growth” and that “relationships can create an internal biological environment, supportive of neural plasticity” (Cozolino, 2006, p. 299). We have noted the effects of trauma as hypervigilance and heightened activity in the HPA axis, heightened sensitivity of the amygdala, damage to the hippocampus, and failure to develop adequate inhibitory cortical controls. However, brain plasticity and affective engagement with the therapist hold out hope for change. Such a perspective is endorsed by the body of research that points to the quality of the relationship rather than the theoretical orientation of the therapist as the effective agent for change.
In closing I would like to return to the meaning-making process at work in the clinical setting. I have been fortunate to have some patients who have chosen to express some of their trauma narrative so vividly in artwork, and I wish to thank them for their generosity in sharing these images with us. These patients have seemed unconsciously compelled to explore as yet unrecognized early trauma through the making of these visual images. Only on later reflection does the symbolic meaning become apparent. The making of such pictures indicates the dawning of the ability to move from the concrete acting-out of old trauma through the transference to a more symbolic way of experiencing. When the pictures are brought to therapy and the patient begins to talk about them, the shift from the visual to the linguistic heralds a new capacity for symbolization. It is this capacity to integrate early right-hemisphere traumatic experience, which often emerges in visual fragments, with the later developing left-hemisphere capacities that marks recovery. The shift from the visual to the linguistic that occurs not only explains why the “talking cure” has been so highly valued but also acknowledges the need for trauma to emerge from the implicit into a realm where it can be initially experienced, in this case by looking at it, and subsequently be thought about so that it can move from the “here and now” to the “there and then.” Toward the close of her therapy Holly made a collage, which she then used to describe how she had come to feel about the therapeutic process ( Figure 10.1). This last picture of Holly’s is an extended metaphor of her experience of herself and her experience in analysis. It is rich in symbolism associated with the self. The picture, painted in glowing colors, is of a glacial, alpine lake surrounded by dark peaks under a vivid azure-blue sky. Deep in the water are hidden treasures made out of sparkling, jewel-colored sequins, stars, and glitter. Holly talked freely and easily about the picture; this was in such marked contrast to her earlier difficulties in voicing her inner world. She felt that she and I were like the two swimmers in the picture who were diving into an alpine lake to find the treasures that were in it. Tall dark mountain peaks surrounded the lake, reminiscent of the rocks that she so feared on her first visit; they spoke to her of teeth and the biting, death-dealing anger that she associated with her mother and had feared to explore in herself and in me. The glacial alpine water reminded me of the appalling chill accompanying her attachment losses, which she so feared she would experience again with me. She continued:
I like the sheep standing near the water and in the distance. Sheep are such timid animals, and these are me; they suggest something of my feeling of fear in letting what I want to be seen. The figures struggling up the sides of the mountains are me too, on a difficult journey and not yet able to reach the water with all it can hold. There are two fishes swimming in front of the two people. They seem involved—perhaps they are like guides for us in the watery environment, perhaps they just want to be with us.
I was reminded of Jung’s view of the fish as a symbol for the self. Holly continued:
There are streams of bubbles coming from the swimmers. They are breath, oxygen, giving life and strength and endurance so that the swimmers can spend time exploring together. You said, “The picture perhaps is telling us about the journey of therapy.” It’s right, I have found many treasures in therapy, and the feeling of attachment is the most beautiful.
Holly’s words reminded me of van der Hart, Nijenhuis, and Steele’s (2006) remark that “overcoming the phobia of intimacy is perhaps the pinnacle of successful treatment” (p. 18). What was noticeable for me in the picture was that the two of us were separate, yet companionably engaged in a worthwhile and enjoyable activity, albeit with the element of challenge and uncertainty that is inherent in life. It seemed that the picture reflected Holly’s approaching arrival at what Orbach (2007) has termed a “separated attachment,” an attachment style characterized by connected autonomy. The making, bringing, and discussion of this picture, representative of the symbolic work that is the stuff of analysis, made crystal clear that it was the relational experience in therapy that enabled change to take place in Holly. It is this that assists the integration of activity throughout the right hemisphere and between the hemispheres of the patient’s mind–brain and which then permits the development of the individual mind and of healthy attachment.
Gambini (2007) says of Jung: “He followed the silk thread that united the physical and the psychic, he fought to envisage the unity that underlies perceptible diversities and dualities” (p. 364). It is that same silk thread that we must follow as we seek to bring the best of 21st-century thinking and research to bear upon the process of changing minds in therapy.