The Use of the Dyadic Affective-State Relationship (ASR) in the Treatment of the Post-Traumatic Stress Disordered Adult Molested as a Child

Judy McLaughlin-Ryan

Schore (1994), whose research has highlighted the importance of right-brain communications in psychotherapy, notes that most research on psychotherapy focuses on what the patient says during session, often utilizing transcripts. Schore (1994) asserts:


Such samples totally delete the essential "hidden" prosodic cues and visuoaffective transactions that are communicated between patient and therapist. I suggest that the almost exclusive focus of research on verbal and cognitive rather than nonverbal and affective psychotherapeutic events has severely restricted our deeper understanding of the dyadic therapy process. In essence, studying only left hemispheric activities can never elucidate the mechanisms of the socioemotional disorders that arise from limitations of right hemispheric affect regulation. (p. 469)

In this paper, I will present an approach to therapy I use with adult patients who were molested as children (AMACs) who suffer from post-traumatic stress disorder (PTSD). This approach uses right-brain-to-right-brain communications that serve an affect-regulating function for the patient. Among the goals of this paper is to describe how trauma early in life may cause biological trauma to the brain, including the disruption of verbal encoding of experience. An additional goal of this paper is to describe a three-step technique that may, based on the current understanding that the brain retains some plastic capacities well into adulthood (Shore, 1994), alter this process. This technique will be illustrated with case vignettes.

It is my observation and belief that, most often, AMACs suffering from PTDS seek therapy primarily for an affect driven and state-regulated dyadic experience (which I am referring to as an affective-state relationship [ASR]) that addresses the affect and state dysregulated symptomatology of PTSD. These patients are seeking a relationship with an affectively responsive and intuitively involved "other" (the therapist) in which they will be able to explore their extreme, yet adaptive, emotional and psychobiological states, which emerged early in life in order to survive their trauma and which altered their natural drive responses. For effective treatment to occur, the therapist needs to navigate through many territories in which dysregulation occurs for both the therapist and the patient.

The PTSD/AMAC's problems with attachment and self-regulation stem from the type, severity, and timing of the trauma. Sexual abuse at the hands of caregivers early in life triggers conflicting emotions—arousal and interest in the caregiver paired with fear, terror, fight, flight, despair, humiliation—at a time when brain development is occurring. Additionally, natural temperamental systems of drive are altered. Unlike a singular experience that may result in PTSD, such as being at the effect of a bank robbery, for the AMAC, more often than not, the sexual abuse occurred frequently over a prolonged period and severely impacted right-brain development, thereby disrupting normal regulating and attachment-oriented responses and, as Schore (1996) has noted, disrupting the expression and processing of both emotional information and nonverbal communication.

A feature of PTSD, which may appear to the therapist initially as a symptom of problems with impulse control, is what I call the "impulsive adaptive function." This pervasive symptom of impulsivity is, I believe, how the patient adjusted to his original life supportive drives to survive the trauma. Although these same impulses in adulthood cause problems for the survivors, originally, I believe, their construction was adaptive and helpful.

Lichtenberg (1989) and Jones (1995) describe motivational systems that are relevant to working with traumatized patients. Lichtenberg (1989) defines five motivational systems: (a) physiological; (b) attachment; (c) exploration/assertion; (d) withdrawal, or antagonism in response to aversive events; and (e) sensual/sexual pleasure. Jones (1995) proposes a motivational system that he describes as the aggressive/competitive. Identification by the therapist and the patient of which motivational system a patient is using at any particular point provides a window both to the methods the patient used to survive his or her trauma and to the original (before trauma) motivational systems that lay dormant in the patient, ready for reclamation once he or she comes to understand the use of their current motivational systems as a reaction to trauma. I have observed in treatment the reduction of learned trauma-related responses and the emergence of natural drive responses.

When impulsivity manifests in the treatment dyad, particularly nonverbal impulsivity, it can appear as a surge of inappropriate and spontaneous reactivity. It can cause massive dysregulation for both the therapist and the patient. Yet if the therapist can ride this wave, he or she will have a peek into the survivor's internalized history.
I believe that the "impulsive adaptive function" is directly related to the dysregulation of the trauma and not particularly related to the patient's current environment and relationships. Survivors react to triggers that remind them of the trauma with both hyperarousal, as though they are in an emergency, and at the same time numbing, punctuated by hyperarousal, which result in an inability to use affect states as signals to respond effectively and efficiently. The response of survivors is to go from stimulus to response without assessing what is really going on (Krystal, 1978). These psychobiological trauma-based affects, states, motivational systems, and impulses are stored within the patient's nonverbal right-brain emotional systems and are communicated to the therapist nonverbally. The therapist needs to utilize this information as though it were a "word." This adaptive response, as I have observed its development throughout the course of treatment, initially appears as impulsive, by which I mean disruptive to the treatment due to how dysregulating its appearance or presence becomes to both the therapist and the client. Yet when the response is welcomed by the therapist, understood, and metabolized by surrendering to it through state, affective, and somatic experiences, eventually the adaptive response of the client is seen as a method whereby the patient adapted and altered his or her natural drive responses, which are unconscious, presymbolic, procedural, and somatic. These responses involve both affect and state to survive trauma and in adulthood traumatic triggers or signals. And their appearances in treatment need to be welcomed.

An example of how understanding impulsivity can be effective in psychotherapy is the case of Uma. She had been sexually abused by her father from infancy until age 10. The reoccurring ritual was for Uma's mother to get Uma interested in and excited about family outings or other exciting treats as a precursor to the abuse. Uma learned to dissociate and deny any and all feeling about her abuse. As an adult, she engaged in severe sadomasochistic relationships. After a period of abstaining from engaging in sadomasochism, she began to do very well in treatment. Her mood was more stabilized, she was less depressed, and she felt happy for the first time in her life. About 4 months later, all of a sudden, she became severely suicidal, enraged, and contemptuous of me. She humiliated me, shamed me, and blamed her suicidal feelings on me. She attributed them to my failure in treating her and said her demise would be my fault, a therapist's living nightmare. My dread increased. I did what was needed ethically and legally, but most importantly, I felt such a deep sense of helplessness and shock, as well as incompetence and shame. This event appeared so "impulsive," there were no apparent triggers. Only months later did I learn that Uma needed me to understand the state of helplessness she experienced before she herself could move from relationships based on aggression and sadomasochism to relationships based on attachment. Her capacity to physiologically respond to closeness with dissociation mixed with inflicting and receiving sexual pain was transformed into responses to closeness colored with responses of attachment. She became attached to me after effectively communicating to me her own underlying sense of helplessness, dread, despair, and massive confusion.

The therapeutic approach that I am proposing for the treatment of the PTSD/AMAC is in three steps. In Step 1, the therapist needs to be receptive to the patient's dysregulated states and affective experiences, thus visiting the patient's traumatically adjusted adaptive responses. In Step 2, the therapist needs to mobilize and regulate the dysregulated state by experiencing the dysregulation and then exiting those feelings and bodily experiences by responding with increased or decreased arousal and/or increased or decreased calming (i.e., soothing, restoration, conservation). Finally, in Step 3, the therapist needs to deliver back to the patient the regulated state through an interactive dyadic state and affectively regulated right-brain-to-right-brain communication. When I use the words "receive," "became a tenant or a resident of," "visit," "became a guest," "acquiesce," I am referring to Step 1, describing the fraction of a second wherein the patient communicates an internal experience to the therapist through soma and affect, using nonverbal right-brain communications (e.g., vocal rhythm tones and sounds; a variety of gazes and looks: gaze averts, still gazes, hypergazes, constricted pupils, dilated pupils; gustatory responses: stomach making noises, feeling like vomiting; muscleloskeletal responses: arching 90 degrees, 180-degree turns, posturing, jumping, running, hopping, feelings, or affects). If this experience is received by the therapist through a unilateral bridge of receptivity from patient to therapist through the medium of soma and affect, the right brain, the therapist will experience some of the patient's unconscious, fertile, and critical information including early adaptive impulsive responses and information about the patient's unedited, unfiltered internal experience. Therefore the therapist must receive it first and then begin to sort it out during and after experiencing it, while involving a bilateral affective-state exchange. This method of therapy embodies a template for the repair of the patient's primitive parts, which during this phase of treatment are unresponsive to symbolic or reflective thought. As Michael Robbins's (1993) paradigm so eloquently suggests, therapists cannot necessarily assume that their patients possess an internalized representation of cognitive-affective experiences or representations of self from representations of others. Furthermore, one cannot assume that the patient has the capacity for appropriate, adaptive self-regulatory functioning, let alone the ability to move from primary process to reflective or interpretive experiences. This requires that the therapist is attuned not so much to the overt behavior of the client as to the internal states of the client, as Schore (1996) points out.


With the advent of neurobiological studies, we are now able to support with neurobiological evidence a method of treatment that makes possible positive outcomes for primarily nonverbally equipped patients who have trauma stored in the right brain.

According to Schore (1994,1997a), in early development, the caregiver functions as a psychobiological regulator of the behavior and physiology of the developing brain of the infant. The maturation of homeostatic regulatory systems in the right frontolimbic cortex is dependent on the quality of the psychobiological attachment. If there is unregulated interactive stress and prolonged episodes of heightened levels of negative affect (fear, humiliation, shame, despair, anger, rage, intense excitement, and arousal)—which is the core of trauma and sexual abuse—this will result in a growth-inhibiting environment that disrupts the experience-dependent development of the prefrontal system.

The reason this information is critical in adult treatment, particularly with AMAC PTSDs, is that there is anatomical evidence that the prefrontal limbic cortex retains some of the plastic capacities of early development. Specifically, changes in the right orbitofrontal cortex and its subcortical connections have been detected in patients as a result of successful psychological treatment (Schore, 1997b). This finding provides support for the efficacy of psychotherapy, in particular therapy that focuses on the affect-state-regulated relationship of patient and therapist (which Schore, 1997b, describes as "reciprocal mutual influence") that mobilizes fundamental modes of development and continuance of previously interrupted developmental processes. Schore (1997b) asserts:


Experience-dependent plastic changes in the nervous system remain throughout the lifespan. In fact, there is now very specific evidence that the prefrontal limbic cortex . . . retains the plastic capacities of early development. The orbital frontal areas of the limbic system, even in adulthood, continue to express anatomical and biochemical features observed in early development, and this properly allows for structural changes that result from psychotherapeutic treatment. (p. 16)

Nonverbal interactions take place at preconscious-unconscious levels and are represented in the right-hemisphere-to-right-hemisphere communications that are involved in the expression and processing of emotional information and in nonverbal communications (Schore, 1996). This processing reads traffic of visual signals and prosodic auditory signals that effect emotions. This psychobiological communication system is a mechanism thought to be responsible for mediation of attachment. These informational systems occur as fast-acting, automatic, regulated and unregulated emotional states in relation to the patient and therapist. This right-hemispheric activity is dominant for the interactive transfer of affect and state.

To further illustrate this process as well as integrate the three-step process, I will describe the case of Jane. Jane entered treatment with acute PTSD. Not long after our work began, Jane started describing some explicit memories of her mother using toys to penetrate her while changing her undergarments when she was 3 years old. At one point, while I was listening to Jane, I found it impossible to move my arms (Step 1). I felt immobilized, paralyzed, and numbed. Then I began to notice my feeling state. I felt overwhelming helplessness. The patient began discussing horrifying images, and I wanted to run out of the room. I sat with these sensations. Jane kept talking. I noticed Jane was in a mildly dissociative state and appeared to feel very little about what she was describing. I (Step 2) stayed with the feelings I was experiencing. I did not talk, but instead I moved, groaned, grunted, sighed, squirmed, and experienced my feelings and my bodily changes. I did not interpret. Then, toward the end of the session, I began to implement self-regulating, self-soothing, containing behaviors, which served a grounding function. For example, I told her we would now get ready for her to go back into the world and would therefore discuss everyday events, like what time it was, what her daily plans were, and what she will wear that evening. At that point, I realized I still could not move. I was unable to get up, my forearms were paralyzed. I mentioned this, in a very soothing voice, "Oh my, Oh my goodness, my arms won't move. Hmmm, curious." The prosody of my voice indicated that all was well, as though a breeze had just moved over my face. I (Step 2) then calmed myself further (something Jane could not do during her trauma), began moving my fingers, slowly regaining enough movement to stand. All through this I was self-regulating. I said good night and so did Jane. This turned out to be a significant moment in the treatment, which later resulted in Jane's being able to affectively experience what in the session just described she had communicated to me through nonverbal process.

Jane was well aware of her ability to withdraw in response to trauma. She had no skills to self-regulate, or access to other adaptive responses (i.e., assertion, aggression, attachment). Soon after the session in which I became immobilized, Jane said that she had had a similar experience in her youth; she described an incident of her mother binding her arms when her father had oral sex with her. As a young girl, she had learned to paralyze her arms, and more generally, she learned how to play dead and deaden parts of her body. She referred to this adaptive self-regulatory, primary process, state-adjusting event as her "body game." I never responded to Jane's description of her "body game" with words. But at some point, it became apparent that Jane was aware that her state had a profound impact on me. Jane then felt safe enough to experience the helplessness and terror that she had stored in her adaptive unconscious state. After that point, I never experienced such immobility with Jane again. It had been mobilized and—in a dyadic-state-regulated manner experienced by me, the listener of her internal world—dysregulated, reregulated and dyadically communicated. The nonverbal, affective-state communication was not received as misattunement and polarization, but as an opportunity to better understand Jane's internal state and affective world. I was attuned within a millisecond of Jane's internal world of helplessness and immobilization.

Jane did not have the capacity to move from dissociation or negative states for prolonged periods of time. Oftentimes after sessions that included flashbacks or episodes of amplified negative states, she would remain for days in a somewhat dysregulated state. Sometimes autoregulation was only achieved by complete isolation and withdrawal. This gravely affected her ability to have relationships and or to work. But after this dyadic experience I had with her, whereby I attempted to autoregulate with her there in the room, Jane began to display behaviors that indicated that she had an increased ability to enter dysregulated states, receive regulatory responses from me, and then internalize and, after time, autoregulate within a shorter period of time. Her impulsive response to survive primarily by withdrawal began to shift to a more assertive/aggressive capacity with an increased ability to experience attachment.

As described earlier, Jane labeled her response to trauma her "body game." Interestingly, after the session in which I became immobilized, Jane's experience of the "body game" changed. Paralysis and freezing gave way to screaming, sweating, and a desire to fight the perpetrator. The latter was concretized as a metaphorical protector: the "body game buster," who took the form of a burly monster who would kill off the parents during the trauma. While she was experiencing the identification with the aggressor, this gave her access to a survival mechanism that she had not formerly experienced. It, most importantly, mobilized an amplification of the aroused state and deamplified for Jane her former response of playing dead (conservation and restoration as means of survival). At this point, her sessions were filled with laugher. Needless to say, her deep depression began to lift. Jane never acted out on the identification with the aggressor, but she did utilize this part of her newfound physiological capacity and brain chemistry to work creatively as a graphic artist. Additionally, she now had the ability to respond competitively and had the capacity to feel a modicum of attachment.

Jane was in therapy with me for six years, and upon leaving therapy had a profoundly positive life. The "body game" was transformed into horrific computer graphic images, which Jane created for a major film studio. She became involved in an intimate relationship. She continues to send me letters and photos, and computer images, of course.

The following case illustrates the ASR technique when treating PTSD/AMACs. The clinical phenomena presented below are nonverbal, right-brain communications that, while impulsive and affectively and physiologically extreme, are not responsive to reflection, left-brain word-driven communications, but need to be metabolized through the affective right-brain-to-right-brain dyad.

Jason's father was a seemingly good father, upstanding citizen, and businessman. But at night when Jason was 5-12 years old, his father would penetrate him anally. Jason's father would remind Jason that this was because he loved him and he had to teach him to "pay his debt," because he was a child, the only way he could pay his dad was by doing "his responsibility." Jason talked about this from the onset of treatment in a dissociated and numb state with flat affect.

Jason's "impulsive adaptive functions" manifested in enactments of withdrawal from his attachment to me surrounding payment of fees and keeping appointments. Regarding the former, he would have excuses for not paying at the end of sessions, such as forgetting his checkbook and wallet. Around the issue of keeping appointments, he would cancel less than 48 hours before appointments, even at times calling at the last minute, or he would forget his weekly scheduled time.

As treatment progressed, I (Step 1) began to be receptive to Jason's dysregulated states and affective experiences, and I thought that with time I would understand them as Jason's traumatically adjusted adaptive response to feelings of rage, anger, contempt, and helplessness, paired with states of numbness, exhaustion, flight responses, fight responses, and many others. Interestingly, all of these acquiescences to dysregulated states occurred during procedural exchanges regarding Jason's payments and appointments. I (Step 2) mobilized these states and affects in session without discussion. For example, when I told him he needed to pay as agreed, I was terrified, palms sweating. He did pay. Afterwards, I doubted my abilities as a therapist; I had fantasies of terminating the treatment or perhaps not charging him at all, in order to avoid feeling this thalamic dread (Bion, 1990), but I continued to mobilize these complex responses. And then, while addressing payment and scheduling, I made efforts to regulate my state. This required delivering (Step 3) mobilizing assertion, soothing my own withdrawal responses, and continued attachment to Jason instead of being frozen in the terror. The verbal content was not about my extreme reactions.

When acquiescing to Jason's states and affects, I understood that I was experiencing a sample of his experience. Therefore, I cherished and held the interactions in highest regard.

After about 6 months, Jason began to have an assortment of his own state and feeling reactions to payments and scheduling. Of note, this shift coincided with the mobilization of his state and affect when talking about his father's penetration of him. He manifested less withdrawal and hyperarousal and more interest, assertion, excitement, and aggression. His tone became loud; his eyes began darting back and forth; he stared at me with intense confrontation and anger. Concurrently, Jason learned to regulate his mobilized states as well as his feelings, and he developed an ability to self-sooth. Jason had stored these feelings that were triggered in regard to attachment with caring paired with torture. Had I not held to our original scheduling and financial agreements, I would have been unconsciously defending and colluding with Jason. Although this content area provoked acute terror in me, after this phase of treatment, its value was clear to me. It was apparent that Jason eventually trusted that his paying me did not mean one of us would be the victim and the other the perpetrator, but it enabled him caring and some healing instead. Therefore, there was an unpairing of terror and the therapy-related procedures of paying and scheduling. Finally, responsibility acquired a different meaning to Jason, freeing him from unconsciously and impulsively reacting to responsibilities from the perspective of his trauma.

The point here is: I (Step 1) momentarily became a tenant in Jason's depressed state and dissociation. I then (Step 2) moved and mobilized to a state of assertion, interest, and excitement, where I was able (Step 3) to regulate enough to take care of myself and my practice, enforcing fees and scheduling. This regulated state was apparent through the content of fee and scheduling. He then paid without conflict and showed up without problem. But I needed to reside in his state and affect in order to effectively receive the nonverbal content Jason was sending me.

In closing, I think that heightened dyadic state and affective levels need to take place in treatment to accomplish repair. It is my belief that if this is an element of the therapy, the treatment may serve as a reparative relationship in which the patient can further heal his or her trauma. The therapist needs to experience the patient's symptomatology from a secondary position because the original trauma happened to the patient not the therapist. From this perspective, the therapist can facilitate the growth of self-regulation for the patient through the therapist's alterations in physiological responses acquired by engaging in what Shore (1997b) describes as "reciprocal mutual influence," or what Bion (1962) refers to as "reverie," or what Marcus (1998) discusses as the analyst maintaining a state of reverie so the analyst's unconscious will be able to hear the patient's unconscious. This is possible because the therapist has a feeling for how it was for the client and can offer state and affective alternatives to reactions that the patient had to his or her trauma. Repair is done through the therapist's ability to self-regulate and then feed that self-regulation back to the patient through preverbal right-brain-to-right-brain experience. Finally, if the therapist can resist initially using words as a primary intervention, when affectively dysregulated and reregulated exchanges are occurring during the right-brain-to-right-brain communication, the therapist will have a greater understanding of how the trauma was internalized by the patient. For effective treatment, the therapist cannot deny the existence of these presymbolic experiences, only to have the client need to escalate with increased impulsivity, chronic acute dysregulation, and negative attachment styles in treatment, which are efforts by the patient to drive information into the therapist because the original sending of information was not received. The patient is concurrently hoping the experience will be repaired and the rupture will be noticed. The therapist needs to notice, experience, and, as an attuned caregiver, feed back only what is palatable to the patient through affect and state during periods of treatment where nonverbal communication is critical. I have utilized this process of treatment, implementing the affective exchange, and I have experienced it as a positive treatment modality with positive results. The usage of words has been secondary during these points of heightened affective-state communications.


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