Healing Trauma: Attachment, Mind, Body, and Brain, edited by Daniel Siegel and Marion Solomon. Norton Series on Interpersonal Neurobiology, W. W. Norton, 2003.
Reviewed by Peter C. van Tricht, MD (published in Ad Hoc Bulletin for STDP: Practice and Theory, 2005, Vol 9, No 2, pp 80-86)
The book “Healing trauma, attachment, mind, body, and brain” is an ambitious plan to make transparent the processes, occurring when a human being is traumatized, when he is cured from his trauma, and what processes can be followed in his brain when all this takes place.
I started reading this book with a certain dose of skepticism. Of course it is interesting, and scientifically important, to find the correlation between what happens in the brain and what happens in an interpersonal contact, but it remains to be seen, I thought, if neurobiology can add anything of value to our knowledge of psychotherapy and metapsychology.
Can we use the findings of neurobiology to understand mental processes and to improve or refine the working alliance with our patients? Can we use these findings for an actual mental health prevention program? With this premise in mind I started reading “Healing Trauma” and right away, on the second page of chapter 1, Daniel Siegel invited me to take “this seeming conceptual leap”.
In eight chapters, all of them written by different authors, we are guided through this interdisciplinary field, where three specialisms are exposed, each with its own scope, and with one purpose in common: to understand how human beings are traumatized and how they can be healed. And we soon discover (at least I did) it is a fascinating field. It’s like driving a tunnel from three sides: neurobiology, attachment theory and psychotherapy. The moment seems to have come that from each of the tunnels we can hear the other two.
Chapter 1, Daniel J. Siegel: An Interpersonal Neurobiology of Psychotherapy: The Developing Mind and the Resolution of Trauma.
One could say that when e.g. patient and therapist are sharing emotions one mind becomes (often non-verbally) connected to another. Neurobiological research findings suggest that such a sharing of non-verbal signals may be one way in which the right hemisphere of one person “joins” with the right hemisphere of the other.
Thus a right-to-right-hemisphere communication between therapist and patient might become a well attuned successful therapy session. Or it might become a thunderous speech. Herewith the Orbitofrontal cortex (part of the limbic association cortex) plays a decisive role. Our orbitofrontal cortex is involved in the neural integration of all information from the external (what we hear, see, smell) and internal environment and has an important function in the regulation of e.g. our emotions and their motor planning.
Siegel pilots us into the really complex world of brain activity. He gives us an introduction, to mention a few things, to the development of our brain, the cortical and subcortical structures of the brain, the functioning of some brain structures (and their interconnections), the processing and regulation of e.g. information and emotions, the anatomical asymmetry in the human brain, specific functions of the left and the right hemisphere.
It’s a world, the greater part of which we only learn to know by the facilities of high tech examinations, like PET- and MRI-scans: pictures on a screen. At the same time it is at the core of our own being alive, thinking feeling and behaving and it is as far away and difficult to reach, and as fascinating, as, say, the pictures of Titan, Saturn’s moon, more than a billion kilometers from here. These bizarre pictures and colors, do they tell what happens in my head? Siegel makes us feel at home in this world (unless, of course you already are at home with the grey and the white matter).
To give you some idea of what Siegel explains: The developing brain, during the first years of life, has many neurons and relatively few synapses and is relatively undifferentiated. The basic circuits of the brain are formed that are needed for processes as emotional and behavioral regulation, interpersonal relatedness, language and memory. Genetic information is important in this development, but so is a proper experiential stimulation. Experiences with the caregiver, and especially the kind of interaction, determine to a high degree how the synapses develop. The nurturing should be good, literally and emotionally.
And he introduces some principles of chaos theory or complexity theory into his working definition of mental health, which leads him to the conclusion: “A human being is a complex system, striving to complexity”. According to Siegel, mental health can be defined as a “self-organized process that enables a person, or a relationship or a group to continually move toward maximal complexity. Unresolved trauma creates impairment to this striving and leads to either chaos or rigidity”. To give an indication, I think chaos is associated with borderline structure, rigidity with character neurosis. (So – to make things clear – an unresolved Oedipus complex, being impairment to our striving to complexity, makes us less complex, in the sense of this theory). Psychotherapy is meant to help restore the potential to complexity and thus to greater adaptive capacity, flexibility and stability.
Chapter 2, Erik Hesse, Mary Main, Kelley Yost Abrams, and Anne Rifkin: Unresolved states regarding loss or abuse can have “second generation” effects: Disorganization, role-inversion, and frightening ideation in the offspring of traumatized, non-maltreating parents.
These authors lead us into quite a different world: the world of early attachment patterns, the role of fear in early attachment and all that can go wrong with it. They are building on Bowlby’s theory. They focus on “Second Generation” effects: what happens to the children as a result of their patterns of interaction with their traumatized parents, parents with unresolved states regarding loss or abuse. These parents may exhibit frightened, dissociative or threatening behavior (“FR behavior”). Examination of children has been made at different ages: one year, six year and at about eighteen years old. The behavior of the observed children shows a differentiation in two categories:
- organized attachment patterns, the majority, the low-risk samples
- disorganized/disoriented attachment pattern (D)
The organized attachment patterns are either secure (B) or insecure. The insecure attachment patterns are avoidant (A) or resistant/ambivalent (C). Fear of the parent, be it the result of FR behavior or of the parent being abusive leads to a situation in which the child, being afraid, has no one else to run to but the parent with FR behavior. This leads to “fright without solution” for the child, resulting in a D pattern of attachment. This is a diagnosis that easily can be overlooked, if and when only the parent him/herself seems to be the victim. The child is well off with a parent who is at home with his/her own life history, cognitively and emotionally. That is to say with a parent with a cohesive and coherent autobiographical narrative, which appears to be characteristic of mental health.
Chapter 3, Allan N. Schore: Early Relational Trauma, Disorganized Attachment, and the Development of a Predisposition to Violence.
In the first two years of our life, from three months before birth on, a spectacular growth spurt of the brain takes place, especially of the right hemisphere. In this period the creation of a secure attachment is an essential task, which occurs in a dyadic interaction. Learning to regulate the intensity of affects takes place in these early years of our life, in the contact with a caregiver who is a “good enough mother”. The maturation of the right hemisphere’s prefrontal area (one of the three major association cortices), the development of function of cortical and subcortical structures in the regulation of emotions and behavior is highly experience-dependent. Effects of early abuse and/or neglect are reflected in an enduring developmental impairment of the right brain hemisphere. When the learning process to regulate anxiety and/or aggression has not succeeded, the harm has been done in these early years of one’s life. Strong indications have been found that severe early trauma, be it abuse or neglect (the combination is worst), is at the root of later violent behavior. We then meet “The ghosts from our nursery”. Decisive to the extent of the developmental impairment is the presence or absence of one person in that nursery, not the primary caregiver, with whom the child can develop a better attachment.
Strikingly we are looking here at the period of the life cycle in which according to Davanloo superego pathology finds its origin. Schore suggests that aggression can become dysregulated by early relational trauma. He argues that the psychopathic personality is susceptible to “cold blooded” predatory rage, while the borderline personality to “hot blooded” impulsive rage. Schore elaborates on the development of an aggression regulation system in the orbitofrontal cortex.
Allan Schore pleads strongly for a prevention program, of which I think it is at the same time very difficult to realize (to actively intervene in families where children are abused/neglected) and highly necessary. How to track these families down? How to enter their system? How to create a working alliance? How to make a PET scan of an intractable child?
In several chapters the theme of Attunement – Disruption – Repair is at stake. In the process – first year of life – of learning to regulate the intensity of feelings, when the attunement between child and caregiver is all-important, there inevitably are moments of disharmony. The experience that a disruption of the harmony can be repaired is essential for this learning process. This theme comes back in the psychotherapeutic context (Diana Fosha, Robert J Neborsky, Marion F Solomon) as an important controlled intervention.
Allan Schore made us look at the brain in depth.
Chapter 4, Bessel A. van der Kolk,: Posttraumatic Stress disorder and the nature of trauma, offers the broad vision (+ statistics).
His chapter tells about PTSD and the nature of trauma. And he reminds us that already at the end of the 19th century Charcot, Janet and Freud understood the essence of psychotrauma, and its treatment. He states that, although many people who are traumatized by horrendous events do not seem to develop lasting effects, the human response to psychological trauma is one of the most important public health problems in the world. This concerns not only PTSD, but also depression, increased (self-) aggression, compulsive behavioral repetition of traumatic scenarios, etc. Dissociation during a traumatic event is an important predictor of the development of subsequent PTSD.
MRI scans and PET scans have revealed abnormal brain activity when PTSD sufferers have a traumatic recall: heightened activity of structures in the right hemisphere, especially in the structures, involved in emotional regulation such as the amygdala, the insula and the medial temporal lobe and under-activity of the left hemispheric cortical structures, mediating verbal communication. This corresponds with the finding that a traumatic recall makes the person feel, see or hear the sensory elements of the traumatic experience, not susceptible of correction by experience, but don’t have words to tell about this experience; may even suffer from speechless terror.
Effective treatment should focus on self-regulatory deficits. Should help the PTSD patient to find a language in which he can come to understand and communicate his experiences. Needed are: 1. a safe place to recover, 2. anxiety management and 3. emotional processing, which means, in a nutshell: creating the narrative of what has traumatized the patient. The narrative should emerge without eventual dissociation or avoidance. Bessel van der Kolk ends his chapter with the promise that the studies of trauma and neuroscience are beginning to open up entirely new perspectives on how traumatized individuals can be helped. As for me, these perspectives have not been opened up, yet. Regarding the study of trauma: yes; regarding the contribution of neuroscience: what’s really new in terms of therapeutic working alliance?
Chapter 5, Francine Shapiro and Louise Maxfield: EMDR and information processing in psychotherapy treatment: personal development and global implications.
EMDR: A peculiar technique. It may give one an idea of hocus-pocus: the eliciting of the eye-movement. But it isn’t! And how it originated also is a peculiar story, but this I suppose is well known. It was a nice case of serendipity.
The adaptive information processing (AIP) model was developed to explain and predict EMDR treatment effects. We read: The AIP model states that all memory is associated, and learning occurs through the creation of new associations. When an incident is not fully processed, the perceptions, thoughts, and emotions that were experienced during the traumatic event are generally stored in state-dependent form. This storage may be in an isolated memory network where the information cannot link up with more appropriate information and learning cannot take place. And, to jump to a conclusion, what EMDR does is linking, forging new connections between the unprocessed memory and more adaptive information that is contained in other memory networks, while the simultaneous eye-movement decreases the intense and painful emotions that are recalled. Again: creating the narrative, cognitively and emotionally.
EMDR, provided it is well indicated and correctly applied, seems to be a very useful technique, a real tool, without pretension. It provides what it offers if… the results last (do they?). The case studies described in this chapter are convincing, one of them with a 5 year old child with a D attachment pattern (disorganized/disoriented attachment pattern, see also chapter 2). Both mother and child treated with EMDR. What happens in the brain when we move our eyes from left to right to left while recalling a traumatic incident is not explained.
In chapters 6-8 we can read about the psychotherapy of traumatized people.
Chapter 6, Diana Fosha: Dyadic Regulation and Experiential Work with Emotion and Relatedness in Trauma and Disorganized Attachment.
What’s this? Diana, we’ve never met. But your chapter invites me to write in dyadic format and to say something personal. Even with your writing you seem to activate my right hemisphere. How do you do that? When I started my own learning process in the psychotherapeutic field, Carl Rogers (his writings) was there. Wandering through psychoanalysis, psychodrama and ISTDP (I’m an ISTDP-adherent) I’ve always kept him with me, like a compass in my pocket. And now I have a hunch that you, Diana, are his reincarnation, evolved and adapted to this era. So it’s back to the cradle.
But now back to business, back to the third person. Diana Fosha gives an introduction, which, in case you had to plough your way through the mound of the first half of this book, and your left hemisphere has become over-active, is a welcome integrative summary of chapters 1-4. It is followed by an introduction of her (A)ccelerated (E)xperiential-(D)ynamic (P)sychotherapy, and she reports of two sessions that illustrate the dyadic regulation of affective states. Both introductions are clear. The case is called “Fright without solution”, referring to the second chapter.
In the description of the two successive sessions the theme of: attunement – disruption – repair, so important in the first year of life, in the working alliance, and in life, is central. Clarifying for me was the differentiation of pathogenic versus core anxiety and shame. Where Diana Fosha describes how she makes a therapeutic disruption I’m not surprised that the disruption is not severe: it is obvious that her anger is meant to defend the patient’s ego, directed to the self-destructive tendency of the patient. We might call this ‘empathic anger of the therapist’ (well-known of Doctor H. Davanloo too). There is empathy throughout the sessions. We get the opportunity to follow a deeply felt and moving therapeutic process.
Chapter 7, Robert J. Neborsky: A Clinical Model for the Comprehensive Treatment of Trauma Using an Affect Experiencing-Attachment Theory Approach.
Most people who have been exposed to a major trauma do not develop PTSD. The “tendency to experience negative affects when exposed to a new event”, we read on the first page of this chapter, is a powerful predictor for PTSD. In each of us, Robert Neborsky says, there is an unconscious negative affect processing system that protects us from developing anxiety disorder and/or depression. This system is called the attachment system. In a preview first is outlined how trauma is processed with an integrated attachment system, and next how and why chronic disorders of stress happen. This is illustrated, with clinical know-how, by an appealing example.
The master at work!
Chapter 8, Marion F. Solomon: Connection, Disruption, Repair: Treating the Effects of Attachment Trauma on Intimate Relationships.
Marion Solomon gives us an exposé of couple’s therapy. In her pithy formulation: “To be in any relationship where one feels unrecognized, disconnected, and helpless to change things is deflating, and is the most salient feature of unhappy marriages”. And: “A defining factor in relationships that last is the ability to reconnect emotionally after an argument”.
She gives an example of therapy with two early traumatized partners, and explains: the internal model of attachment of each partner is used as the guideline for the therapeutic process. When both partners are traumatized to help the partners acknowledge their sense of vulnerability is an important (first) step. The regressive pull toward old, familiar (egosyntonic) interactional dynamics has to be tracked down. Marion Solomon elaborates on this topic in an inspiring way and gives a clear illustration. (But, contrary to what Marion Solomon does: I, myself, will not point out to my patients that “traumatic experiences are often processed in the non-verbal right hemisphere”).
There are several themes we encounter in every chapter of this book. To start at the beginning:
To acquire a secure attachment in the contact with a caregiver during the first year of life is of lifelong importance. An insecure attachment may be changed into an earned security (e.g. as a result of psychotherapy, or when the partner has a secure attachment). A disorganized attachment may result in an irreversible hot- or cold-blooded violent character.
During the process when the attachment is getting shape the sequence of attunement-disruption-repair is decisive for the outcome. When repair doesn’t take place, the evoked negative emotions cannot be “metabolized”, integrated.
A person with insecure/disorganized attachment doesn’t have a cohesive and coherent biographical narrative and if she/he is also a caregiver
This has an impact for the development of the attachment of the next generation.
In these cases there might be an impaired functioning of the orbitofrontal structures of the right hemisphere and their interconnections with other cortical and subcortical structures
The essence of trauma therapy is integration of defended emotions, which were elicited by the trauma.
The evolution of attachment theory is of direct value for the daily practice of psychotherapy.
Regarding the coherent narrative of traumatic events it is interesting what Freud wrote (in 1893):
…We must presume rather that the psychical trauma – or more precisely the memory of the trauma – acts like a foreign body which long after its entry must continue to be regarded as an agent that is still at work; and we find the evidence for this in a highly remarkable phenomenon which at the same time lends an important practical interest to our findings. For we found, to our great surprise at first, that each individual hysterical symptom immediately and permanently disappeared when we had succeeded bringing clearly to light the memory of the event by which it was provoked and in arousing its accompanying affect, and when the patient had described that event in the greatest possible detail and had put the affects into words. Recollections without affect almost invariably produce no result. The physical process which originally took place must be repeated as vividly as possible; it must be brought back into its status nascendi and then given verbal utterance. Where what we are dealing with are phenomena involving stimuli (spasms, neuralgias and hallucinations) these re-appear once again with the fullest intensity and then vanish forever”.
This book, Healing Trauma, could well serve as an introduction to neuroscience and to some principles of attachment theory. Resolution of trauma is amongst others rooted in neural integration, and from a viewpoint of pure science it is of great importance that we know which cortical and subcortical structures and their interconnections are involved in specific aspects of the regulation of our emotions, cognitions, behaviors and learning processes. And of course it is of great importance when the results of neuroscienctific research may lead to more effective psychotherapy.
But, when a therapist is “only” an expert at carrying out the dynamic diagnostic interview, therapist and certainly the patient, are very well off, I’m sure.
In neuroscience a lot of brainy work has been done. But the concrete contribution of neuroscience as an instrument to enhance effective psychotherapy is still in a process of growth, I think.