CPPNJ - The Center for Psychoanalysis and Psychotherapy of New Jersey


Scientific Research Validates Treatment: Brain Studies Reinforce Psychoanalytic Knowledge

By Debi Roelke, Ph.D. and Harlene Goldschmidt, PhD.

This article will look at psychological and interpersonal aspects of relational trauma, as well as explore some basic aspects of the neurological underpinnings of such trauma. Patients who have suffered relational trauma have emotional requirements that are often challenging to the therapist. Seeing these requirements and challenges through the lens of neuropsychoanalysis and attachment theory supports therapists' efforts in providing a safe and structured holding environment in which therapeutic change may occur. The intention is to offer therapists a comprehensive and concrete model of relational trauma to serve as an aid in providing psychotherapy.

The more we understand about trauma, the more we know about its ongoing impact on the brain. “Relational trauma” is the term used to refer to the accumulation of misattunements, non-availability and failure to repair attachment interactions on the part of early caretakers. When these interactions occur at critical developmental periods or reach an intolerable threshold, the resulting insecure attachment history shapes the way the brain is wired to experience future interactions. These internal working models are the primary focus of therapeutic action. The child who suffers from relational trauma has greater difficulty learning to regulate her affective responses. In the absences of a good model for affect regulation, the child is more easily dysregulated in relationships, and has less ability to extract regulating experiences from caregivers.

One of Alan Schore’s core assumptions is that early attachment interactions are central in building an implicit sense of self and the capacity for affect regulation. This sense of self is mostly unconscious, in part being molded before language and linear thinking has developed. Schore sees attachment interactions taking place at a biological level, right brain to right brain, and as such they “wire” into place as implicit, procedural memories about the act of relating – i.e., internal working models. Early in life, this process forms the underpinnings of “experience-dependent maturation” in the right brain, especially the orbitofrontal cortex (OFC). The OFC is part of a complex system of higher and lower brain regions that allow for affect regulation and self observation. The upshot is this: according to Schore, high-affect interactions with our earliest attachment figures are encoded at the biological level as relational memories, and this very process affects the ongoing development of key structures in the social brain.

Attachment interactions including separating to explore and returning to secure base to “refuel” are fundamentally all about attunement and affect regulation. Optimally, the attuned caregiver matches herself to the experience of the infant, backing off when the infant desires to separate, and making herself available when the infant needs to return to secure base. Attuned caregivers can still miss an infant’s cues, briefly rupturing the interaction in a moment of mismatched internal states: for example, infant wants to separate and caregiver wants to comfort. The mismatch is quickly repaired, though: caregiver gets back in tune and reorients herself, and their rhythmic rapport is back in place.

Schore points out that this rhythm of attunement, misattunement and repair is not just emotional and behavioral but is occurring on a biological level as well. Each partner uses a myriad of nonverbal cues that are communicated at a non-conscious implicit level: for example, Schore discusses the dilation of pupils as both an expression of positive, excited affect and a response to that affect in the partner. Attunement, then, is both psychological and biological: interactive partners (parent and infant, therapist and patient) are responding to and matching (or mismatching) each other on arousal level, activation of both brain and body at the neurochemical and hormonal level.

The clinical implication of this is that we attend more to the rhythmic patterning of the interaction, the mutual regulation of arousal and affect in an arc of crescendo and descrescendo, and begin to think about how these patterns speak to the dialectic of approach and withdrawal (e.g., Tatkin) that establish our ways of connecting when we feel safe enough and withdrawing/disconnecting when we do not. This is the stuff of Internal Working Models, “wired in,” Schore argues, as established neural pathways representing self-in-relation-to others. Schore then describes how these “wired-in” relational models form the basis of affect regulation - how aroused and activated we are, how safe it is to get close and/or separate, what the quality is of the subjective experience – in relation to the other.

These interactive patterns follow one of four types: (1) self with attuned other; (2) self with misattuned other when the mismatch is repaired; (3) self with misattuned other when the mismatch is not repaired; and (4) self with nonattuned other. Positive attunement allows for a smooth rhythm of connecting and separating: shared sadness or anger that is soothingly contained, joyful excitement enhanced by its mutuality but downregulated or tempered before the onset of overstimulation. Misattunement that is repaired provides an internal working model of connection as a means to re-regulating and revitalizing oneself.

Misattuned failure to repair and nonattunement – i.e., the complete absence of a responsive and available other – are the hallmarks of relational trauma. With lack of repair, the high levels of negative arousal created by the relational mismatch are sustained or even escalated for painful lengths of time. Schore describes this internal working model as self-interacting-with-misattuned-and dysregulating-other. Pervasive “wiring in” of such interactions leads to the inability to regulate oneself, affectively and otherwise, either inter- or intrapersonally. Finally, an internal model of self-with-nonattuned-and-nonregulating-other leads to what Schore and others describe as “dead spots” – dissociative states of affective self-experience which lack any sense of aliveness or bearable subjective awareness.

Therapists who have worked with patients that exhibit relational trauma often describe the emotional and physiological discomfort involved in attempting to remain empathically connected. Therapists may reexperience their own relational trauma and sometimes lose the ability to respond therapeutically. Schore discusses the need at times for “reparative withdrawal” on the part of the therapist when the toxic effects of the patient’s relational trauma are too great. Following this reparative withdrawal the therapist knows how to self regulate and reconnect with more positive self states. This internal process is implicitly modeled to the patient. It takes many such cycles for the patient to begin to experience a more hopeful sense that overwhelming emotions are only temporary and may be managed with greater skill in the therapeutic relationship.

We may look a little more carefully at this regulation-dysregulation-regulation cycle in terms of the underlying psycho-neurophysiological events. This additional information helps further inform therapists regarding the patient’s process in overcoming relational trauma and developing earned secure attachment. Let’s start by looking into the limbic system, a central region of the brain involved in processing emotions. At birth, parts of this system are wired up and ready to respond to the environment. Of particular interest are small almond sized bi-lateral areas called the amygdala, referred to as the smoke alarm of the brain.

In a recent study looking at children adopted from orphanages, there were measurable differences in the size and activity level of the amygdala between infants placed in homes after 15 months compared to those placed before 15 months. Most children were placed by the age of two. The larger amygdala volume correlated with higher ratings of anxiety in these children. Measures of self-regulation were also problematic for children adopted after 15 months as they had exaggerated responses to negative faces. The relational trauma appeared to be due to neglect and lack of attunement rather than to any abuse.

Another region in the brain involved in re-working trauma is the hippocampus. The hippocampus is important in the development of explicit autobiographical memory. This sort of memory helps contextualize our implicit, unconscious sense of ourselves. The hippocampus turns off when a person is stressed, and prolonged stress has been shown to kill off neurons vital to regulating centers of the brain. Preliminary research shows that therapy serves to stimulate the growth of the hippocampus.

In patients diagnosed with borderline personality disorder, 90 % report early abuse or neglect. As discussed earlier in this article “the most significant consequence of early relational trauma is the loss of the ability to regulate the intensity and duration of affects, especially negative affects" (van der Kolk & Fisher 1994). In conjunction with problems regulating affect, we also find an increased tendency for dissociation, which further compounds relational trauma by preventing reparation. Other parts of the brain and nervous system are involved. To the extent that our left hemisphere is able to provide words and verbal understanding, this will help regulate emotions. If arousal due to emotional stress is particularly intense, the left hemisphere shuts off, placing us back to right hemisphere coping strategies. Hyperactive nervous system may trigger us to try to run away or fight. In this case our sympathetic nervous system is flooded with adrenalin in addition to our inability to think clearly. If hyperarousal peaks into a panic for an extended period of time, the nervous system will shift to hypo-arousal to shut out the external threats, and prevent organ damage from toxic surges of adrenalin. Dissociation is the mechanism of last resort when all other forms of regulation have failed.

As therapists, we know how important it is to help our patients understand that the therapeutic relationship is safe. Understanding the powerful forces at work within a patient when they are dissociating can help us remain patient and calmer knowing that the physiological and psychological process are operating. There may be times to explain this reaction to a patient to help them understand more about their experience and mitigate self blame when in they are in throes of re-experiencing relational trauma.

The therapy moves forward as the patient and therapist live through episodes of relational trauma with different and more positive outcomes. Rather than being completely immobilized by the re-experiencing of relational trauma, the patient learns to stay more connected with the therapist, able to listen to and experience the therapist as a calming person, and develops an ability to reflect on what is occurring and talk about the experience in a more contextualized manner. Part of this shift can be understood as moving away from a more primitive, early developing system in the parasympathetic nervous system to a later developing “mammalian” parasympathetic system. This more developed part of the autonomic nervous system has the ability to communicate via eye contact, facial expression, vocalization, and gestures.

As mentioned earlier in the article the OFC, orbital frontal cortex is one of the most important neural regulating centers in the entire brain. OFC turns on around 12 months of age, and integrates the central emotional limbic brain with the higher cortex and lower brain stem areas. Through the therapeutic relationship, a new internal working model is created that serves to regulate affect and re-wire the brain as a result of the deeply humanizing experiences within the therapeutic relationship.