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.

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.

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:

Witness
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

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?

Using Winnicott, Part I

I find no writer more felicitous to read than Winnicott. Immensely prolific, it is as if he is speaking to me spontaneously about things about which he is passionate. He is relatively jargon free, and he relatively rarely refers to other authors. His many ideas are original and profound. My favorite two Winnicottian concepts, because I find them so clinically useful, are survival and transitional space.

In The Use of the Object... (1971, Playing and Reality) Winnicott refers to the necessity of the mother surviving (that is, neither retaliating nor withdrawing) the attacks of the infant if the infant is to see her as an external subject outside his omnipotent control, thereby allowing the infant both a capacity for concern as well as a mitigation of guilt about his aggression. Likewise, in the psychoanalytic situation, the analyst surviving the analysand’s attacks (of the analyst, of the process, and of hope itself) is necessary.

In Transitional Objects and Trsansitional Phenomena (1951) Winnicott notes that a good enough mother never falls to one side of the question of whether the infant created the transitional object or found it external to himself. So, too, he intimates that the good enough analyst does not close the transitional space by imposing the analyst’s reality on the creations and observations of the patient. It is into this transitional space that play is sometimes invited, a play with words, though much like the squiggle game, to imagine together what if.., what would it be like if… and sometimes to enjoy wistfully together what has come into being through pretend.

My great admiration for Winnicott and the enormity of usefulness I have derived from his ideas made my criticism of Chap 4: Playing: Creative Activity and the Search for the Self in Playing and Reality (1971) when re-reading it with students in the TBIPS Development Course, a bit of a surprise to me. I will post next time on the use the class made of his Case Illustration.

Deconstructing what we read

Nothing pleases an instructor more than when students learn to read and think critically. How pleased was I then when the first year class at TBIPS was able to take the clinical vignette from an assigned journal article, deconstruct the reported interaction, and come up with additional points of view.

In the assigned artice, the author began with some background: a young woman of a withdrawn, depressed mother and a hostile, accusatory father was described as being opaque to others, unable to be vulnerable and emotionally intimate with others, operating from a paranoid-schizoid position, distrustful of men, found it difficult to bond with women, and experienced interpretations as intrusive and insulting. The analyst complained that his attempts at empathy were rebuffed.

Then followed from the author/analyst a brief portion of process notes:

The patient was indignant about a male colleague who had made advances; the male analyst responded by giving an explanation for the colleague’s behavior. [The class easily recognized the analyst as defending the other’s, not the patient’s, point of view, in essence an attack on the patient’s reality. ] The patient responds derisively, accusing the male analyst of being like all those other men who think they can say or do anything with women.

The patient continues, talking about being professionally excluded by an Old Boys’ Club at work. The analyst, attempting empathy, lands on interpreting her feeling alone, without female colleagues. The patient says she thinks the analyst really think she is a bitch and she accuses her analyst of phony empathy. [The analyst does not consider here his own contribution to his patient’s rebuff, that perhaps the patient perceives accurately what is in her analyst’s heart. The analyst, after all, had only moments before attacked her point of view.]

The patient then complains about her very bad day and asks her analyst if he has ever had such a day. The analyst asks for her thoughts. [Here the analyst is the opaque one, being with his patient exactly what he, in his description of her, accused her of being, and he is likewise being unknown to her, just as her depressed mother had been. Is this an enactment?, the class asks.] The patient then insults the analyst, accusing him of being uncaring and, as a man, without compassion.

Vignettes from the literature and from our own clinical experiences are often used in classes to improve our skills. And where the medium is the message, we deconstruct who we are alongside what we say and think, leaning in the direction of hope, empathic attunement, and opening the third space. Next time I will post on how the Intro. class used Winnicott.

Useful Relational Intersubjective Inferences

Having recently attended a conference where the speaker read a paper which leaned heavily toward inferring, from the psychoanalytic situation, particularly the narrative, infantile drives and fantasies, I was much relieved to find myself once again in the Tampa Bay Institute’s Study Groups and classes discussing inferences from infant research and attachment theory. Specifically discussed was the 1999 paper The Two-Person Unconscious: Intersubjective Dialogue, Enactive Relational Representation, and the Emergence of New Forms of Relational Organization by Karlen Lyons-Ruth.

Lyons-Ruth reminds us that meaning systems are organized by more than the symbolic (words and images): “meaning systems are organized to include implicit or procedural forms of knowing.” As such, a primary engine of change is “new enactive ‘procedures for being with’ [which] destabilize existing enactive organization…” Moreover, “procedural forms of representation are not infantile” for “development does not proceed only or primarily by moving from procedural coding to symbolic coding.” She states that “‘internalization’ is occurring at a presymbolic level...[thus] representation [is] not of words or images, but …of enactive relational procedures…”

One such procedure is parent-infant dialogue and, when flexible and collaborative “is about getting to know another’s mind…” A coherent, open dialogue requires openness of the parent, not in the form of “unmonitored parental self-disclosure, but by parental ‘openness’ to the state of mind of the child...” [And] “intersubjective recognition in development requires close attention to the child’s initiatives in interaction…” Likewise, the parent seeks “active negotiation and repairing of miscues, misunderstandings, and conflicts of interest;” It is from these ideas of Lyons-Ruth and others that clinicians infer the importance in the analyst-analysand dialogue the need for flexible and collaborative openness to the state of mind of the other, with attention to initiatives of the other, and a responsibility to seek repair of ruptures.

Valentine's Day Musings

"When the satisfaction or the security of another person becomes as significant to one as is one's own satisfaction or security, then the state of love exists" (Sullivan, 1940)

“Such mutuality, however, seems clearly an ideal, not a normative practice. No matter how mature and healthy, all love relationships are characterized by periodic retreats from mutuality to self-absorption and demands for unconditional sensitivity and acceptance.” (Mitchell, 1984)

Among its other important components, I still contend that the analytic relationship is one of love. And as Mitchell notes, and Benjamin reminds us, it is almost impossibly difficult to hold for long the tension between mutual recognition and negation of the other; instead we are always falling to one side (usually negation). This realization of how easily we fall, I think, is in sharp contrast to Orange and Levinas putting the (suffering) other above ourselves, making psychoanalysis, with this impossible ideal, once again the impossible profession. I think that love might just be in the striving, not the success, to recognize the other.

Is Addiction Inherited?

This past week the media (National Public Radio, BBC World News, for example) picked up a story from Science that addiction might be hereditary, based on a study out of Cambridge, UK, of 50 pairs of siblings, where one sibling had a cocaine addiction and the other did not, yet both had similar changes in the brain (in areas of impulse control). The conclusion that these similar brain changes indicate inherited traits may overlook the discovery that experience changes brain anatomy, chemistry, and function. As such, it might be equally plausible to conclude that siblings were similarly exposed to parents who were unavailable, misattuned, or abusive in ways that caused the brain to develop as seen in the touted study.

In the TBIPS course on Repetitive Painful States, in which a portion of the course is devoted to addiction, we consider the possibility that addictive behavior (whether substance abuse or self injurious such as cutting) is a way to manage untenable beliefs and affects. Having gone unrecognized and misunderstood, or worse, as often is the case, having had one’s reality attacked and one’s spirit nearly extinguished, a child is often without the opportunity to learn to regulate one’s impulses. Does this not affect the developing brain? [This is not to say that the myriad possible ways a child's brain might develop is not constrained by genetics.]

We go even further in class, presupposing that new experience in relationship with the analyst, repeated and protracted, also begins to change brain anatomy and function, encoding experience in such a way that impulse control is gradually developed, not by prohibition of behaviors, but by the shared experience of accepting a patient’s reality, bearing painful affects together, and reconfiguring belief systems about the self and the self with others. Differing with most treatment modalities for addiction, I expect that it would be a further misunderstanding of an analytic patient to base treatment on the contingency of abstinence while the patient has yet to have help with painful affects and untenable beliefs.

Mitchell's Developmental Tilt

This semester the TBIPS first year class is reading Mitchell’s Object Relations Theories and the Developmental Tilt. In it, Mitchell asks (doubts) whether so many diverse theories can go under one theory called Object Relations. But, more importantly, he notes that many Object Relations theorists maintain allegiance to the Freudian drive-conflict model (whose sine qua non of neurosis according to Freud is the Oedipus complex) by simply placing relational issues developmentally earlier than the oedipal stage. He asks, is Object Relations just an extension of drive theory? Or is it altogether new, substituting drive discharge as motivation and the structural theory (ego, id, superego) of mind with object-seeking as motivation and with relational configurations, “relations with others, past and present, real and imaginary” (mental representations of part/whole objects, in Object Relational terminology, and how they interact with each other) as the makeup of the mind?

Mitchell sees assimilation of Object Relations theory into drive theory as mixing apples and oranges. He says that assimilating Object Relations, through what he calls the” developmental tilt,” into drive theory risks designating lifelong needs of relationship as pathology:

“these innovations have been introduced into psychoanalytic theory via the developmental tilt; consequently, the dynamic issues they depict tend to get characterized as infantile, pre-oedipal, immature, and their persistence in later life is often regarded as a residue of infantilism, rather than as an expression of human relational needs extending throughout the life cycle.”

Mitchell believes contrivances such as regarding “relational issues as prior to drive issues”, were required by ego psychologists (who privilege drive and defense, ie the structural conflict model) in order to assimilate Object Relations. Mitchell does not conceive that relational issues “emerge sequentially over the course of early infancy, becoming progressively resolved” but says they instead persist throughout life.

Furthermore, the developmental tilt risks, Mitchell contends, infantilizing patients by casting the analytic relationship in an infant-mother dyad:

“…instead of conceptualizing these dimensions of the analytic relationship as providing the patient with a richer, more complex, more adult kind of intimacy that his previous psychopathology allowed him to experience, the developmental tilt leads to a view of these dimensions essentially as developmental remediations…”

Consequently, spontaneous gestures as evidence of new relationship (such as Balint’s somersaulting patient) are viewed not as a ‘forward edge’ [Tolpin], but as a regression to the old and are pathologized: their “evidence later in life is regarded as a regressive residue of very early disturbance.” When Object Relations theory is “positioned via classical theory” through the developmental tilt, psychoanalytic “interaction is collapsed into mother-infant terms.” Similarly “the need for tenderness throughout life”… is collapsed “into the infant's need for tenderness from the mother … depicted as regressive, unresolved residues from earliest childhood” [and] “depicted as [the] …only developmental forum in which such needs make sense.”

Mitchell agrees with contemporary theorists on the importance of the real relationship, as well as of what is new:

“the analytic relationship has been understood as more and more of a real and new relationship than previously. For Freud, the relationship with the analyst was a re-creation of past relationships, a new version struck from the original "stereotype plate" (Freud, 1912). The here-and-now relationship was crucial, but as a replication, as a vehicle for the recovery of memories, the filling in of amnesias, which cured the patient. Contemporary views of the analytic relationship tend to put more emphasis on what is new in the analytic relationship. The past is still important, but as a vehicle for understanding the meaning of the present relationship with the analyst, and it is in the working through of that relationship that cure resides.”

I find I agree with Mitchell’s ideas, especially the need for relationship and tenderness being lifelong (just as Kohut posited a lifelong requirement for self object experiences) and can dust off my previously long constrained (anonymous, abstinent) self to participate with my patients in the therapeutic endeavor toward new experience co-creating new ‘templates [Herzog].’

Mitchell, S.A. (1984). Object Relations Theories and the Developmental Tilt. Contemp. Psychoanal., 20:473-499.