Tuesday, March 20, 2012

Intergenerational Transmission of Trauma

Doris Brothers, author of The Shattered Self, spoke in Tampa March 10, 2012 on trauma,and briefly alluded to intergenerational transmission of trauma. I would like to elaborate on some of the neurobiological mechanisms that might illuminate how intergenerational transmission of trauma occurs. To that end, I utilize Alan Schore’s Advances in Neuropsychoanalysis, Attachment Theory, and Trauma Research: Implications for Self Psychology.(2002). Psychoanal. Inq., 22:433-484.

As we are aware from infant research and neurobiology, an infant requires the presence of an attuned other for its optimal development and to optimally organize its experience. Winnicott said there is no such thing as a baby, that is, there is a mutual (interdependence) influence (regulation) between infant and mother in which the two function as a unit, including unconscious communications that serve to develop the brain of the infant. [This bulwarks the relational theories which take psychoanalysis from a one-person (intrapsychic) to a two person (intersubjective) psychology.] The 'good enough' caregiver helps the infant maintain its homeostatic equilibrium and facilitates the emerging self. Instead of the Cartesian mind-body duality (or of self from the environment) regulation of physiological functions builds the brain (the mind, the self) in particular ways.

A mother who may herself utilize dissociation as a result of her own childhood trauma, or due to depression, may be unavailable to regulate her infant. The 'good enough' caregiver helps the immature (as yet unformed neuronal connections, and unmyelinated peripheral nerves) infant regulate through her gaze, soothing voice, etc). Ruptures in regulation affect the infant’s homeostasis, and negatively affect attachment. They may even threaten the infant’s survival. Additionally, the infant is unable to acquire experience for self regulation and restoration of its equilibrium. In an attempt to restore homeostasis, the infant must divert energy away from needed growth, development, and learning (sometimes leading to failure to thrive, to lower IQ, and lower socio-emotional learning). Because brain growth is experience-dependent, experience with dysregulation negatively impacts the developing brain, the self, and the sense of self in relation with others, particularly during the brain’s growth spurt in the first three years of life. It can lead to later psychopathology, e.g. affect dysregulation commonly found in certain psychiatric disorders.

The right hemisphere, larger in the first two years, and, more than the left, processes and stores early infant experiences. Resonant attachment experiences involve “synchronized and ordered directed flows of energy” in the primary caregiver’s brain and the infant’s brain. The right hemisphere, more than the left, also has extensive connections with the limbic system. The limbic system is the emotional processing center which helps to guide emotional expression and behavior and organize new, procedural learning. The right brain is central to “integrating and assigning emotional-motivational significance to cognitive impressions” and “the association of emotion with ideas.” The right brain, with its connections to the right prefrontal cortex, allows the sense of self continuous through time. The right hemisphere, with its bodily connections, analyzes signals from the body, and helps regulate appropriate survival mechanisms, through the autonomic nervous system (ANS)which, in turn, help maintain a cohesive sense of self.

An infant responds to traumatic chronic misattunement by hyperarousal or by dissociation. When attuned response is not forthcoming, a distressed infant initially increases its attempts (e.g. by crying) to engage the mother. Should this fail, the infant, hopeless to effect the other, conserves energy, and seems to implode, go limp, itself dissociate, becoming helpless. The ANS lends a physiological explanation for hyperarousal and subsequent hypoarousal. The sympathetic and parasympathetic systems work to maintain homeostasis. The sympathetic ANS prepares the body for fight-flight (increased heart rate, increase blood flow to the skeletal muscles, etc); and the parasympathetic, responding to elevations in stress-induced cortisol, is energy-conserving (going quiet, staring off in space, and becoming limp).

As Winnicott noted, “ If maternal care is not good enough, then the infant does not really come into existence, since there is no continuity in being; instead, the personality becomes built on the basis of reactions to environmental impingement.”
We know that dissociation affects one’s sense of subjectivity. A mother, or grandmother, who has suffered herself with unresolved trauma conveys her terror and dissociation to her infant via infant matching of the mother’s right corticolimbic firing patterns, inadvertently transmitting to the next generation her, or her mother’s, experience of trauma. Mother’s “regulatory strategy of dissociation is inscribed into the infant's right brain implict-procedural memory system.”

Maltreatment in childhood, then, is a growth-inhibiting environment for the developing brain and results in “structural defects of cortical-subcortical circuits of the right brain, the locus of the corporeal-emotional self.” “[D]issociation is associated with a deficiency of the right brain” and “early relational trauma is particularly expressed in right hemisphere deficits”. The untoward consequences include disorders in attachments, regulation of affect, and subjectivity and sense of self, with threats to going-on-being.

Monday, March 12, 2012

Reducing Uncertainty

Doris Brothers spoke to the Tampa Bay Psychoanalytic Society, Inc on March 10, 2012 on uncertainty and trauma. Brothers notes that people are motivated to reduce uncertainty--despite there is no certainty in the world-- by simplifying experience, accomplished by dissociation. We think, feel, fantasize, and make decisions, all regulatory processes created to have a sense that we will go-on- being [WInnicott]…until trauma shatters this sense.

Brothers defines trauma as that which threatens our going-on-being, threatens us with the fear of annihilation. Trauma threatens us with uncertainty. While her formulations about trauma are ongoing, she says a few ideas about trauma persist for her:

1. Trauma is relational, that is, trauma always has a relational meaning.

2. We always make restorative efforts, however faulty, that give us a sense of certainty that we will go-on-being, and that the relational surround will be there so we can go-on-being. We restore ourselves by clinging to convictions (certainties), from which we cannot be dissuaded.

3. Trauma goes hand in hand with dissociation. Brothers says dissociation is a restorative effort to reduce uncertainty by simplifying that which is complex. For example, while others purport that feelings are often too intense to be born, Brothers says it is the range of feelings, often contradictory, that we cannot bear. (As a colleague noted, perhaps all defenses, and all symptoms, are restorative attempts.) I agree with Brothers that therapists need to respect symptoms, which Brothers says allow for safety and certainty that otherwise would not exist. Therapists ought not seek to take away prematurely what is necessary to the patient to stave off terror of annihilation.

4. Shame is an inevitable companion of trauma.
On a note of self disclosure, such as therapists admitting to failures of empathy brought to our attention by our patients, Brothers notes an implicit ‘Ah, you notice my humanity, it may be safe to show me yours.’

Brothers also spoke of trauma as having a before, during, and aftermath, and what’s more, the before can have occurred before conception, as in intergenerational transmission of trauma. As Winnicott noted in The theory of the parent–infant relationship (1960, NY, IUP) “If maternal care is not good enough, then the infant does not really come into existence, since there is no continuity in being…” Winnicott (1958, IJP: The capacity to be alone) also noted that when a mother is depressed or dissociated (perhaps from her own past trauma or that of her mother’s) and unable to provide mutual regulation of experience, the infant, in matching its mother’s state, is devoid of subjectivity at a time critical in development. An infant who has extreme fluctuations in subjectivity, a traumatically dissociated infant, experiences discontinuity and threats to its going-on-being.

Friday, March 9, 2012

Poem: Witness

Having read the previous post (also found in the TBIPS Spring 2010 Newsletter) on Winnicott and the comment " ... to recognize that we all need, at times, the presence of the effected other to come into being", David Baker, PhD recently wrote this poem (after a party) with a thought to the analytic encounter:

I know you’ll know what I’m talking about.
You’ve walked out of the house
Into the yard
In the middle of your own party
And looked back through the living room window to see
The outlines of your friends
As they laughed and danced and drank
And you wondered
Among other things
If they knew you were missing
From your own party.
Wondered if they knew you were out there watching them,
If they would look back at you through the window,
Maybe set down their drink and ponder you
As you ponder them.
In the air just above you
Thoughts rise to meet theirs and from that ether is born
a knowing of each other.
It’s hard to know each other at a party.
We play at it, we like a party.
We like to see and be seen,
We like to be known,
Like to be missed.
But the almost-collisions of human-to-human
Never really allows for the deeper knowing.
It’s the depths we crave
Within ourselves and in others.
We need witnesses to our life, in order to really have our lives.
Perhaps that is why you walked outside,
Looked back,
Delighted in them.
In those few moments you were witness to their lives,
Held them, loved them into the eternity of your own memory.
How fortunate they were.
How they may never know about the gift you gave
By stepping out and away
To hold them closer than you ever could
Had you stayed in the room
Politely listening to their laments over real estate.

David Baker

Friday, March 2, 2012

Using Winnicott, Part II

In Playing and Reality (1971) Chapter 4: Creative Activity and the Search for the Self, Winnicott hopes to illustrate how, if the analyst would sometimes just get out of the way, the patient will come into a sense of self in her/his “search for the self.” In his clinical example, Case In Illustration (pp. 56-64), he allows a three hour session with a patient because she needs a lot of time to come into being, as it were. He believes he is allowing the patient freedom from his intrusions, impingements, derailments, [and cleverness] by his protracted silence. [Indeed, the patient may have felt Winnicott to have been palpably present by his demeanor, benevolent attitude, ability to hold her in his mind, etc., but the reader does not have this benefit.]

Upon rereading this case with the first year class at the Tampa Bay Institute for Psychoanalytic Studies, Inc, I was struck by the patient’s many attempts to feel Winnicott more significantly engaged with her. She says: “I’m loathe to come into this room…I feel of no consequence.” Winnicott adds that she cites “Odd details of my dealing with her, implying that she is of no consequence.” She states “I don’t matter.”

When the patient eventually speaks of positive feelings and activities, Winnicott takes this as evidence of her be[com]ing real as if this naturally unfolded by her creative play, alone in the presence of the other. What Winnicott does not acknowledge here is that this ‘positiveness of being’ followed both his interpretation (indicating he understood how withering and deadening it is when there is no one to give back to her her experience; no mutuality, as it were) and his responsiveness that she drink up the milk he had made available there for his patients.

Having reported more of her feelings and activities, she then asks, “Where are you? Why am I alone so?...Why don’t I matter anymore?” And, after talking about her birthday experiences, the patient says, “I feel as if I have wasted this session. I feel as though I came to meet somebody and they didn’t come.” [Here I think the patient is talking about Winnicott’s absence, as he tries to stay out of her way, from being in the space with her.] Winnicott speaks, reflects back, and the patient says, “I get a feeling sometimes that I was born.” [I take this as further confirmation that it is Winnicott’s participation which enlivens the patient.] Winnicott reflects for her what she may have always felt: that others were not glad that she was born, that they did not enjoy her. She confirms this with: “what is so awful is existence that is negatived” [negated]. She continues and asks [hopefully], “…is there a little soul waiting to pop into a body?”

Winnicott emphasizes, from the patient’s dream: “I might find a me—get in touch with a me,” that the patient is “trying to show you me” for the first two hours of the session. Winnicott writes: “The searching can come only from desultory formless functioning, or perhaps from rudimentary playing, as if in a neutral zone.” Yet I could not help noticing that the patient was only enlivened, came into being, when Winnicott spoke to her in such a way as to communicate his understanding of her, thereby giving her evidence of his having been listening attentively, and had done so because she was significant to him. Perhaps his patient felt his silence as an indication that she was insignificant to him.

In class, I was equally struck by one first year student who could so adeptly feel her way into Winnicott’s position, illuminating to the class a different point of view from mine, and imagine that his patient, having perhaps had demanding, intrusive parents, who forced compliance of her being to theirs (that she please them, say what they wanted to hear), would very much need an analyst who stayed out of the way, letting the patient say what she wanted, or say nothing at all, indicating she would not have to please the analyst. [Still, I thought, when Winnicott was pleased to let the patient give an interpretation that he would have made himself, that the patient was indeed saying something she thought he might want to hear, and doing so perhaps to keep him engaged with her.]

Had Winnicott lived today, would he now drop the ‘the’ of “the self” and characterize self as a more fluid, emerging entity? More importantly, would he have transformed his theory to view interaction through a slightly more contemporary lens, a lens which recognizes the need for all of us, including patients, to be seen, to have an effect, to feel significant to someone, even to one’s analyst, to recognize that we all need, at times, the presence of an effected other to come into being? Or would silence, as an indictor of respect for the patient's creativity and being alone in the presence of the other, still loom so large with a patient so desperate to feel significant to her analyst?