Healing Trauma, page 35
The probability that individuals will experience happiness and the opportunity to grow to their full human potential can be dampened, or even extinguished, through the effects of unresolved negative experiences. While the processing of these memories liberates the individual and allows the experiences to be appropriately assimilated, if the memories remain unprocessed, they will be dysfunctionally stored. Then the person’s potential is constrained by static brain states, resulting in the activation of stored perceptions, cognitions, and affects, with related maladaptive behaviors. These effects are detrimental, not only to the individual; they can cascade onto others and into the next generation. Whatever the cause—the unhealed traumas of disasters or war, the disruptions born of poverty and violence in the inner cities, separations of parents and children due to natural or manmade disasters, genocide or ethno-political violence—people who are hurting are likely to hurt others, whether deliberately or unintentionally. Whether this transmission of pain is caused explicitly or implicitly, this process must be addressed by our profession.
Those that have been healed can open up to life and they can open up to service. Therefore, one of the goals of psychotherapy is undoing, on all levels, the effects of trauma. Large-T trauma events can cause the obvious symptoms of PTSD. These symptoms are generally so disruptive and make life so unmanageable that clients come into therapy and can be healed. Not only are the symptoms of PTSD eradicated in treatment, the underlying configurations that have caused lives of “quiet desperation” are also healed. These are individuals like Lynne who, without awareness, married men who were duplicates of her father.
Victims of small-T traumas may not seek treatment because their symptoms do not appear to interfere with their function. We do not give them a diagnosis; their lives are not unmanageable, and they remain mostly unaware of the deleterious effects of these experiences. These are individuals like Maura, who was unaware of the repercussions of unhealed loss, individuals who reenact their traumas with their children through automatic behaviors, movements, and expressions, and thus transmit their pain to the next generation.
Given all we know about the psychological and physical effects of unhealed trauma, we must help the underserved become aware of how they are affecting each other and the next generation. This knowledge must be presented to the general public, and information should be provided in both education and comprehensive treatment programs. Research is needed to identify precisely what experiences are necessary to foster the development of a healthy, happy adult who is capable of love, joy, and service. Then we can improve our educational programs to encourage these types of interactions and experiences with the natural family setting. We also need to develop procedures to orchestrate this development within a clinical setting when it has not occurred naturally. To this end, we must integrate our many tools and the wisdom of different psychotherapeutic orientations to develop methods to efficiently engender the appropriate developmental stages for these parents and children alike.
It is clear that the healing of trauma victims is of supreme importance and must be multidimensional in scope. Treatment for individuals must comprehensively address cognitive, somatic, and affective elements, to achieve changes in both understanding and implicit reactions. Treatment for traumatized families must address both parents and children. At a societal level, it must address both perpetrators and victims. The multidimensional approach is absolutely essential to ensure that the negative effects and the cycles of interpersonal abuse, regardless of their origin, are ended within one generation. What better goal can we have as a profession than to extend these benefits not only to any one family, such as Maura and Ashley, but to the underserved populations worldwide?
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* This paper is based on a talk by the first author presented at Cutting Edge Conference, University of California, San Diego, March, 2001.
6
Dyadic Regulation and Experiential Work with Emotion and Relatedness in Trauma and Disorganized Attachment
Diana Fosha
Introduction
Mary Main ended her talk (2001) with a plea and a mandate: “Effective interventions effect change. Study and document that process.” Precisely. In the unfolding conversation between clinicians and affective neuroscientists, the data of clinical change processes can spur the next wave of progress in neuroscience, namely the elucidation of the psychobiology of plasticity.
Emergent understandings based on advances in affective neuroscience (Damasio, 1994, 1999; LeDoux, 1996, 2002; Panksepp, 1998, 2000; Porges, 1997; Schore, 1994; Siegel, 1999), attachment theory and research (Ainsworth, Blehar, Waters, & Wall, 1978; Bowlby, 1973, 1980, 1982, 1991; Fonagy, Steele, et al., 1995; Main, 1995), and developmental research into mother-infant interaction (Beebe & Lachmann, 1994; Emde, 1988; Jaffe, Beebe, Feldstein, Crown, & Jasnow, 2001; Stern, 1985; Trevarthen, 2000; Tronick, 1989, 1998), are increasingly informing and transforming how we do clinical work (Beebe & Lachmann, 2002; Fosha, 2000b, 2002a; Hughes, in preparation; Lachmann, 2001; Rothschild, 2000; Stern et al., 1998; van der Kolk, 2001). Clinicians can make this a truly two-way conversation by putting forth their privileged understanding of how change occurs, and what change looks like when it occurs. Accompanied by a descriptive phenomenology of the healing process, the data documenting change in psychotherapy can then shape future questions in neuroscientific and developmental research. What clinical experience reveals about the mind can thus contribute to the further unlocking of the secrets of the brain and of the developmental processes by which the brain is molded; such scientific advances can, in turn, only further enhance the effectiveness of therapeutic intervention.
For instance, it appears that (a) the right brain and subcortical structures like the amygdala, the periaqueductal gray, and the brainstem are centrally involved in emotional processing, that (b) the prefrontal cortex plays a major role in affect regulation and secure attachment, and that (c) trauma and emotional neglect—which lead to disorganized attachment—compromise the structure and function of right hemisphere, subcortical structures and the prefrontal cortex. But it also appears that therapeutic interventions that involve emotion, the body, somatosensory activation, and bilateral information-processing mechanisms (see Fosha, 2000b, 2002a; Levine, 1997; Neborsky, this volume; Rothschild, 2000; Shapiro, this volume; Siegel, this volume) are effective in functionally reversing the effects of trauma. How does neuroscience explain such therapeutic results? What mechanisms operate in the brain when lifelong patterns of behavior, emotion regulation, and relatedness are rapidly transformed?
The Paradox Between Continuity and Plasticity
Questions such as these reveal a paradox between continuity and plasticity, between structure and state, between vulnerability and resilience, between intransigence and transformation.
CONTINUITY OF PSYCHIC ORGANIZATION OVER THE LIFESPAN AND ITS INTERGENERATIONAL TRANSMISSION
On the side of continuity, we have powerful evidence that affect-regulating experiences with caregivers become immortalized in the psychic organization of the child (Cassidy, 1994; Fonagy et al., 1991; Hesse & Main, 1999, 2000; Main, 1995) and shape the landscape of the brain, particularly the right brain (e.g., Schore, 1996, Siegel, 1999; Trevarthen & Aitken, 1994). For example, neglect and emotional deprivation in the first years of life lead to left hippocampal shrinkage, corpus callosum damage, and dendritic burnout (Schore, this volume; Siegel, this volume; Teicher, 2002). The characteristics of affect-regulating relationships, or lack thereof, are also immortalized through their transmission to future generations (Fonagy, Steele, et al., 1995; Main, 1995). The intergenerational transmission of attachment states of mind is an extraordinarily robust finding, with wide-ranging implications. Witness the continuity of the Adult Attachment Interview (AAI) ratings over time (Main, this volume), and its uncanny capacity to predict the attachment status of babies yet unborn (Fonagy et al., 1991). We have evidence of the stability of attachment classifications over time and their power to predict academic and social functioning, predisposition to pathology, and vulnerability for trauma (see Main, 1995). Such evidence strongly supports the psychoanalytic axiom that early experiences with caregivers determine lifelong patterns (Seligman, 1998), which makes the possibility of effecting change seem quite daunting (Fosha, 2000b, pp. 55–56).
