| 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.
References
Bion,
W. R. (1962). Learning from experience. London:
Heinemann.
Bion, W. R. (1990). W. R. Bion Brazilian lectures.
1973. Sao Paulo,
1974. Rio de Janeiro/Sao Paulo. New York, Brunner/Mazel.
First published 1990 London, Karnac Books.
Jones, J. M. (1995). Affects as process: An
inquiry into the centrality of affect in psychological
life. Hillsdale, NJ: The Analytic Press.
Krystal, H. (1978). Trauma and affects. Psychoanalytic
Study of the Child, 33, 81-116.
Lichtenberg, J. (1989). Psychoanalysis and motivation.
Hillsdale, NJ: The Analytic Press.
Robbins, M. (1993). The mental organization
of primitive personalities and its treatment
implications. Journal of The American Psychoanalytic
Association, 44, 755-785.
Schore, A. N. (1994). Affect regulation and
the origin of the self: The neurobiology of
emotional development. Hillsdale, NJ: Erlbaum.
Schore, A. N. (1996). The experience-dependent
maturation of a regulatory system in the orbital
prefrontal cortex and the origin of developmental
psychopathology. Development and Psychopathology,
8, 59-87.
Schore, A. N. (1997a). Early organization of
the nonlinear right brain and development of
a predisposition to psychiatric disorders. Development
and Psychopathology, 9, 595-631.
Schore, A. N. (1997b, March). Psychobiological
affect regulation: An essential mechanism of
both development and psychoanalytic treatment.
Paper presented at American Psychological Association
17th Annual Division 39 Meeting, Denver, Colorado.
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