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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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