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Psychoanalytic Psychology
2014, Vol. 31, No. 1, 134 144
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implicit, right-brain pathways that are not always available for verbal expression and
insight, but can be reached through sensory, imaginal, and affective methods (Bucci,
2011a, 2011b; Fosshage, 2011; Schore, 2011; Schore & Schore, 2008). These authors
argue that nonverbal and implicit modes of communication between client and therapist
should be the initial focus of treatment before verbal and reflective modes are utilized.
However, both implicit and insight-oriented, verbal approaches should take place in order
for the trauma to be accessed and integrated. Eye movement desensitization and reprocessing (EMDR) is one among several treatment models that can help process traumatic
memories through systematic and gradual exposure to the original trauma via sensory and
affective pathways, culminating in cognitive shifts in perception and beliefs.
The implicit domain of communication is central in trauma work when verbal and
reflective capacities are not available and therefore, right-brain communication through
facial expression, tone of voice, and other physiological and sensory processes become the
main conduits of dissociated memories. Empathic sensing, attunement, and responsiveness by the therapist are important modes of understanding and relating. However, the
therapists own unresolved traumatic schema may be elicited during the treatment, and
because the therapists subjectivity is an inherent aspect of the intersubjective treatment
process, it is important to be cognizant of these affective responses and to work through
potential enactments that may occur during the treatment (Davies & Frawley, 1994).
Schore emphasizes the important function of right brain-to-right brain implicit and
unconscious communication between patient and therapist and differentiates the surface,
verbal, conscious, analytic, explicit self versus a deeper non verbal, unconscious, holistic,
emotional corporeal implicit self (Schore, 2011, p. 77). Bucci agrees with this formulation, but proposes a theory of greater interaction between what she calls the subsymbolic
and symbolic parts of the mind (Bucci, 2011a). The subsymbolic level includes sensory
and somatic representations that comprise the core self across different affective contexts and constitute an emotional and bodily memory system that is not easily linked to
verbal and cognitive processes. The symbolic level contains nonverbal processes, such as
visual, kinesthetic, and tactile functions (Hershberg, 2011). The subsymbolic level becomes activated during a traumatic event and in the subsequent interaction between
patient and therapist. Both Bucci (2011a, 2011b) and Fosshage (2011) assert that it is
important to integrate the subsymbolic with symbolic interactions in order to give
meaning to and negotiate interactions between patient and therapist. Buccis theory of the
mind is similar to Fosshages notion of organizing patterns of self and of self with others
(Fosshage, 2011). Fosshage asserts that imagistic symbolic thinking, or thinking through
images generated in sensory processes, is the earliest mode of memory and that organizing
relational patterns develop based on experiences of self and others that accumulate
throughout development. Like Bucci, Fosshage argues that therapeutic action is based on
the interplay between affective, sensory, and implicit processes, as well as on explicit
processes of reflection and insight. Therefore, he recommends that both explicit and
implicit processes be utilized during treatment so that sensory and affective processing
would be linked to reflection and cognition.
Therapists own emotional schema, which is based on their subsymbolic schema and
on past relational experiences, becomes activated in response to intersubjective interactions with patients. This may involve the therapists own unresolved traumatic experiences
culminating in their desire to save and protect the patient or may involve their feelings of
anger, fear, guilt, and shame elicited in response to patients traumatic narratives and
demands of or disappointment in the therapist. Enactments are inevitable based on the
interplay of traumatic schemas between patient and therapist and are an important
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childs hurt and disappointment, may then try to repair the rupture by proceeding to sooth
and comfort the child, acknowledging their misattuned behavior. These cycles of disruption and repair are instrumental in developing the childs sense of agency and security.
Ongoing interactions of incremental disruption and repair cycles contribute to the deepening complexity and sophistication of infants regulatory systems and are designed to
regulate arousal and create a pattern of better matching behaviors between infants and
caregivers in terms of gaze and vocalizing (Beebe, 2005).
The traumatic impact of the sexual abuse was exacerbated by Sandys grandfathers
pattern of promises and betrayals (to be elaborated on). Her mothers denial of the abuse
and her withdrawal from Sandy further contributed to the deep sense of abandonment and
rejection that Sandy experienced. She learned to regulate her untenable affects through
avoidance, isolation, and dissociation and later through angry and controlling behaviors
with her own children.
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139
visual stimuli, sound, or alternate tactile tapping. During the desensitization procedure, the
client is encouraged to reexperience aspects of their traumatic past and is then taught to
integrate these experiences into more adaptive cognitive structures. The protocol has been
adapted for adults with complex childhood trauma (Parnell, 1999). During the EMDR
procedure, the patient is asked to select a traumatic memory and an image associated with
it and to apply negative and positive cognitions associated with the memory. Along with
visual, affective, and cognitive focus, the EMDR therapist also prompts the patient to
attend to bodily sensations associated with the trauma.
EMDR includes a structured approach that seemed to offer comfort and security for
Sandy. However, the linear, directive model of EMDR contrasts with the unstructured,
spontaneous, and improvisational nature of our previous work in which Sandy took the
lead. As we progressed, the EMDR protocol gradually changed into a more spontaneous,
creative, and dynamic process where Sandy decided what she wanted to work through and
how, and I readily followed. We agreed on basic ground rules, whereby, for example, she
could stop at any time when the memories became too overwhelming. As discussed
previously, during the EMDR procedure, there is an emphasis on physiological and
affective experiences, and later on cognitive integration, and this is particularly helpful
with trauma patients who, like Sandy, do not always possess the language to describe their
experience. The EMDR process occurred twice weekly for approximately 2 months, when
we resumed our unstructured, dynamic format.
I encourage Sandy to describe to me the memories associated with the abuse and the
images that come to her mind. I ask her to experience her bodily sensations and the
feelings, thoughts, and negative cognitions associated with the memories. Many of her
experiences have no words or visual images, but her body remembers. She haltingly
reports the sense of pressure, the tastes, and her difficulty in breathing under a heavy
weight. She is longing for love and attention from her grandfather and would do anything
to please him, but she is also terrified and feels suffocated and trapped. The feelings of
disappointment and betrayal by her grandfather who she idolized and admired are
confusing and painful. He would promise her treats after she had been nice to him, but
never followed through, especially during the Christmas holidays, when the abuse usually
took place. During the Christmas season, Sandy typically disappears for weeks. When she
returns, she tells me that she had experienced flashbacks and that the only way to comfort
the betrayed and angry little girl part of her is to buy herself expensive gifts that she cannot
afford in order to compensate for this profound disappointment.
Gradually, I become acquainted with Sandys little-girl self state, which is usually in
hiding, fearful and resentful, and which refuses to come out. This little girl does not trust
anyones words and promises. Sandy is aware of the little girl self-state but feels helpless
to manage her when she becomes fearful, angry, or demanding. At those times, the little
girl self state takes over her still fragile adult self that she has worked so hard to develop.
Bromberg suggests that traumatized patients develop a mental structure of separate,
incompatible self states, and he notes that the dilemma for both patient and therapist is that
by developing the capacity for self-reflection and the resolution of internal conflicts,
patients experience a threat to the dismantling of their familiar and protective dissociative
structure that may render them more vulnerable for retraumatization (Bromberg, 1998,
2003). When Sandy feels threatened by our exploration of her dissociated self states, she
disappears for weeks and does not respond to my phone calls. Although this can be
frustratingand at times I am very concerned about herI try to be as flexible as I can
and let her know that I am available, that she is on my mind, and that she can return
whenever she is ready.
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Eventually, as the fear subsides, Sandy is able to draw on our connection and her
deepening trust in me and in our work, and we continue to forge on. I rely on Sandy to
be the facilitator with her younger self state and to let me know whether I am using the
right words and asking the right questions. Her little girl can be playful and lovable at
times, but she is also impulsive and stubborn. Sandy and I learn together how to comfort
and reassure her, how to play with her but also how to set reasonable limits. Sandy
recognizes that, like her mother, she had also abandoned this part of herself and that her
little girl self is still longing for attention and recognition. Although I validate (little)
Sandys outrage, fear, and sense of isolation and betrayal, I also encourage Sandy to listen
and communicate with the little girl part of herself and to invite her in as often as possible.
Her adult self is still fragile and tenuous, but she is starting to learn how to regulate and
comfort her childlike self. I experience loving maternal feelings, for both the adult Sandy
and the child. I know that in order for Sandy to love the child, she needs to feel loved by
me. When she disappears, I worry about her, and her disappearance triggers my own
vulnerability to abandonment. In this enactment, I recognize that my experience mirrors
Sandys memory of her mother.
At first, Sandy does not want to talk about what happened with her grandfather,
because it is too raw and painful, but she comes to recognize how constrained and boxed
in her life has become. She is afraid of people; she is isolated and unable to leave the
house. One day she finally decides that the time has come and that she needs to free herself
from his dark power, which has imprisoned her all of these years. I ask her to describe the
part of herself that she would like to enter. She describes a box, both safe and confining,
and how fearful it is to leave it, though staying there leaves her isolated and withdrawn.
She then envisions a wall she dares not look beyond. An old monster leers at her and
threatens to control and overpower her. He is in every stranger she meets and therefore she
cannot trust anyone. At this point, another self state emergesa powerful and angry
Sandy whose voice is loud and imposing, who confronts her grandfather, cursing and
enraged. Suddenly, he has lost his power, and he no longer matters. Tears, saliva, and
blood flow from Sandys nose and mouth, we are both startled as Sandy cries out, You
see what he has done to me, you see? Sandy seems much lighter as she leaves my office.
I, on the other hand, feel quite overwhelmed by Sandys unexpected physiological
response. Gradually, granddad loses his hold on Sandy and becomes more and more
distant.
We discover that as Sandy releases her fear and rage toward her grandfather other
affects emerge. She is angry at her mother who had ignored the abuse but was also critical
of and competitive with her. She experiences deep sorrow and regret regarding her
inability to love and parent her children, who have not spoken to her in several years, and
she longs to make amends. As the EMDR aspect of our work fades and we return to a
more spontaneous and improvisational mode, an element of play appears as well (Ringstrom, 2007). It is Halloween, and Sandy brings in a skull, a black wig, and a broom.
Together, we confront the mother/witch to try and loosen her hold over Sandy. In a
ceremonial ritual we set the objects on a chair and Sandy tells her mother/witch how
betrayed, disappointed, and abandoned she felt with no one to offer her support and
protection. As she talks to her mother, Sandy recognizes that her mother is terrified as
well and that she has rigidly held on to the organization and structure of her life in order
not to fall apart. She too may have been abused by her father (Sandys grandfather) but,
if so, she cannot tolerate this knowledge. This recognition about her mother seems to free
Sandy to view her mother in a new way. Her mother is no longer the powerful witch but
a fragile old woman for whom Sandy feels empathy and compassion.
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The EMDR procedure allows us to open up the therapeutic space to painful self states
that we were unable to access previously, but eventually Sandy no longer needs the safety
and security of the structured procedure. There is sufficient trust between us that she is
able to tolerate the uncertainty and open-ended nature of a more dynamic process. She has
started to trust herself and to trust me that we will figure out where we need to go and will
survive it. We spend a long time reflecting on what had happened and deepening our
understanding of the trauma and its impact on her life. Sandy realizes that she has built
protective masks around herselfthe Grandpa mask that is self confident, charming, and
arrogant and the Mother Mary mask that is kind, loving and caring but that she still
does not know who she really is. Sandy brings me a book she has designed that captures
some of her poignant self states: The frightened child cowering in a corner, the old crone
whose gnarly hands have become roots planted in the ground, and the wise woman who
sees everything but who is still quite fragile.
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another (Aron, 2006; Benjamin, 2004) or when the patient can hold conflicting self states
without the need to dissociate (Bromberg, 2011).
After working through early traumatic events that curtailed Sandys capacity for creative
and interpersonal expression, we gained a better understanding of how the traumatic events of
her past shaped the dynamics between the two of us. For example, Sandys habitual pattern of
frequently calling in sick, missing sessions, and not paying, which was initially understood as
a byproduct of her unpredictable attacks of fibromyalgia and other physical disabilities,
became more accessible for investigation and for mutual negotiation. Sandy admitted that she
preferred to go on spending sprees in order to sooth her emotional hunger and to distract
herself from flashbacks, rather than face me and discuss her painful memories and intolerable
feelings. She inevitably went deeper into debt, and at times could not pay for her sessions. At
times, I felt torn. I wanted to be the reliable, loving parent who provided Sandy with
unconditional love, but I also recognized that I felt manipulated and resentful. I acknowledged
and validated Sandys pain, but I realized that I had my own needs and that I felt dismissed
and victimized by her. In this enactment, I had become the victim, and I felt that it would be
important for us to process and understand together how Sandys past had shadowed our own
relationship. I told Sandy that I thought it was important that we discuss the implications of her
behavior on both of us. I expressed my disappointment, and at times resentment, while waiting
for her and when not getting paid. It was important for me, and for Sandy, to see that she had
an impact on me and that her actions held consequences for others who could also feel hurt
and dismissed. Sandy began to cry. She told me that she valued me and the work we were
doing, but that at times she was afraid to come to the session, afraid of me, afraid of the pain.
At times, she just wanted to act on her impulses and shop in order to avoid her feelings and
flashbacks, rather than face them with me. Eventually, we negotiated an arrangement that we
both felt was fair.
Conclusion
Attachment research indicates that disorganized attachment is transmitted from parent to
child and that the consequently children take on roles that helps them control, organize,
and manage chaotic, frightening experiences with caregivers who themselves are traumatized and helpless or are frightening and abusive (Hesse et al., 2003). The roles of
caretaker, aggressor, helpless victim, and helpless caregiver manifest between child and
caregiver and between patient and therapist and can be processed and worked through
during a relational treatment process.
A relational focus on the intersubjective process between patient and therapist, along
with EMDRs emphasis on the implicit, nonverbal aspects of traumatic experience, can
work well as complementary models in the treatment of trauma. This case suggests that
with adult survivors of sexual abuse it is important at times to utilize an approach that
integrates the uncertainty and fluid nature of a dynamic approach with a more structured,
linear model such as EMDR. Current neuroscientific data (Bucci, 2011a, 2011b; Schore,
2011) supports the notion that nonverbal, implicit processes within the patient, within the
therapist, and between patient and therapist are vital conduits of memory and experience,
especially in the case of early trauma that had occurred before cognitive and verbal
functions were well developed.
EMDR is one among several trauma-focused approaches including prolonged exposure (Foa et al., 2005) and sensorimotor therapy (Fisher & Ogden, 2009), all of which may
help to access traumatic experiences through physiological and affective channels. Subsequent reflective processing and insight can then help to integrate previously dissociated
143
traumatic events from the patients life. A relational treatment process based on the
intersubjective dynamics between patient and therapist elaborates on the interpersonal
aftermath of the trauma through the lens of the patient-therapist relationship. It therefore
provides an opportunity to elaborate on the meaning of the trauma and to enhance the
affective experiences that have been elicited.
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