The Attachment ConferenceWe just attended the sixth annual attachment conference here in Los Angeles. A similarly themed conference will be held later in Boston. Attendance is growing rapidly from year to year, indicating that Attachment Theory is on a path to becoming one of the central organizing schema for mental health. Presentations at this conference were highly congenial to our worldview. The theme of the conference was “The Embodied Mind,” with an emphasis on the role of the body. So talks variously took up the topics of self-regulation strategies, movement-based therapies, and mindfulness very respectfully. The impetus for this theoretical preoccupation traces back to the traditional psychoanalytic concern with infant and early childhood development as setting the stage for the quality of adult functioning. The themes here are unabashedly grand and encompassing, a worthy antidote to the highly compartmentalized thrusts of modern psychopharmacology. Admixed to this fundamentally psychodynamic perspective are now the findings of modern neuroscience, through the work of people such as Dan Siegel and Allan Schore. Dan Siegel In his leadoff talk, Dan Siegel set the stage by highlighting the need for a multi-disciplinary approach to an “interpersonal neurobiology,” one in which the “objective demands of science and the subjective domains of human knowing can find a common home.” How utterly refreshing. The affective development of the infant occurs in relationship, and hence cannot ultimately be understood apart from relationship. The sinews of connectivity that bind the nervous system of “Mother” to that of the child are essential to the neurophysiological development of the child from the earliest moments, and hence cannot be segregated in any scientific enterprise worthy of our attentions. Not only does the mind-brain dichotomy lose meaning in this context, but even the boundary of the self must be breached in our emerging developmental models. Siegel asked, “How do you awaken the mind to the wisdom of the body…” and then reported on his own venture into mindfulness exercise through a six-day retreat in the company of mostly neuroscientists who were also experienced meditators. The regimen allowed a mere ten minutes a day for verbal communication with a mentor—beyond that not even non-verbal communication or even eye contact. He found the experience rather unnerving (“I think I am going crazy…”). It was nice to see neuroscientists appreciating the virtues of meditation, but this is not the remedy for those less solidly put together than Siegel himself. Of course I could not help double-tracking while listening to Siegel, and reflecting on the fact that neurofeedback can also be considered as a mindfulness exercise in that it keeps you within the present moment, and gives you nothing to do except to be in the company of your own gently idling brain for the duration. The difference is that we conduct this little exercise as close as possible to the state in which the person functions best, and we don’t overload the circuits or overstay the course. The challenge is served up in manageable bites, and we assure that nothing distracts the person from the process. With the above as introduction, the audience was then led in a mindfulness exercise involving movement and the breath. The pacing appeared much too fast to me, and I realized that the room was probably populated by many rapid breathers and perhaps over-breathers. Who, after all, shows up at a conference of therapists where one of the leading topics is trauma resolution? Steve Porges Steve Porges, developmental psychologist from the University of Illinois, and co-Director of the Brain-Body Center there, spoke of his poly-vagal theory to model the regulation of social behavior through a process he calls neuroception. The latter refers to the neural processes that organize responses across the whole continuum of safe, dangerous, and life-threatening environments. The poly-vagal theory integrates a variety of regulatory functions that cover us over the whole continuum from safety to danger to threat, and involving in particular the autonomic regulation of the heart and gut. “The neuroscience of experience is at the level of the brainstem.” The unmyelinated old vagus nerve mediates the life-preserving immobilization of the system in the presence of extreme threat, and in absence of an ability to execute the flight/flight response. This mechanism was bequeathed to us by our more reptilian ancestors, where it was more clearly functional. For the mammalian brain, it may be catastrophic. And at the time of birth, we come into the world with our reptilian brain engaged. With fight/flight options foreclosed, it is here that our early responses to threats are physiologically encoded. This is the trauma response, which then eventuates in a disregulation cascade that can cast its shadow over the rest of life. Moreover, programmed responding is characteristic of much of the neuro-regulatory system of social interacting, with the consequence that “social behavior does not fall very well under the laws of learning.” “We find this out as parents…” We must therefore have a neurophysiological remedy for what is in essence a neurophysiologically encoded dysfunction. Porges seemed to be yet another psychologist with the heart of a clinician and the mind of a scientist. He is developing therapies based on his poly-vagal theory. One clinical approach that emerged out of this work is a listening program for autistic children in which they were given to hear voices with exaggerated prosody. The theoretical basis is the existence of an efferent auditory system that actively selects the human voice out of background sounds. Because of common neuro-developmental pathways, it is assumed that the gentle challenge to that system will generalize to improved state regulation overall. The result in short order was a change in the localization of their gaze when it came to faces. The avoidance of eye contact typical of autistics was in fact substantially resolved in two of the case histories presented. In his work, he is confirming the principle that “less stimulation is more effective for a challenged nervous system,” a principle on which we also operate in neurofeedback. A second principle is that the intervention must take place in a safe environment. This again sounds familiar to those of us in neurofeedback, as our work is conducted under the most benign circumstances imaginable for any nervous system. Porges acknowledges the difficulty of bringing science into clinical practice. “We cannot allow clinical research to be gatekeepers of new methods into practice…..” he pronounced, without fear of contradiction from this audience. Other gems poured off his tongue: “Medicine does not respect the body.” And finally, “The billing code for healthy medical practices will not make it.” It is just amazing to see the degree of convergence taking place between ourselves and someone like Porges who has taken such a very different path. Brainstem regulation is looming increasingly larger in our conceptions. It is the centrality of the most basic arousal-related (and defense-related) functions (read brainstem) that allows our key training methods to be so utterly simple and straight-forward. Brainstem regulation is the foundation for everything else that matters in the self-regulation regime. And it is with respect to brainstem regulation that the traditional (psychodynamic) approaches fall most tragically short. No alternative exists but for us to learn the language of the body. Ed Tronick Ed Tronick, developmental psychologist at Harvard, talked on the social and emotional development in normal and compromised infants. He showed imagery from “still-face” experiments with infants to demonstrate the strong negative emotional reaction of infants to the lack of responsiveness from the mother. The infant’s distress was immediate and persistent. Tronick’s postdoc employed galvanic skin response (GSR) and heart rate variability (HRV) measurements on the infant to document the susceptibility. “Developmental researchers have not used these systems for thirty years because they thought they were inactive. My post-doc didn’t know that, so he used them anyway…” The GSR measurement swung widely and wildly during the ‘still-face’ epoch, and rose even further during the reunion phase. This was one of a number of times during the conference when I felt that those of us involved in applied psychophysiology must be living in some parallel universe. Two observations follow: The infants’ behavioral neurophysiological and somatic capacities are overwhelmed in the short term by such unmanageable stress, and become dysfunctional and toxic to development in the long run. Further, the failure of self-regulation in general is self-amplifying. The hazard to infant development is particularly grave if the caregiver is the source of the threat in the early phases. Tronick observes that there is no diagnosis appropriate for the traumatized infant. Forty years ago this was referred to as Trauma X because it was difficult to conceive of it actually happening. By now it is clear that the mechanisms of implicit memory are accessible at birth, and recent memory research has elaborated a larger capacity even for explicit event memory in the pre-verbal infant. One way or another the causal influences of trauma in mental health need to be acknowledged—either by carving out a distinct category, or by recognizing that the trauma model has considerable explanatory power across a wide range of the canonical disorders. Onno van der Hart Onno van der Hart concentrated his talk on dissociation. “Personality at its best is highly integrated. Should that not also be the case for a science of the personality?” Indeed, but how is that to come about? If the integration of the personality can be described in psychological terms, the disintegration of the personality certainly cannot be adequately described without a neurophysiological model. Fortunately, the dissociated personality that has been identified since the turn of the last century (Pierre Janet) has its direct mirror in the language of neurophysiology through the theory of networks. It is networks that organize integration and dissociation. And it is the theory of networks that allows us to understand how different personalities can be organized on the same cortical real estate, and using the same neuronal resources, and yet be completely unaware of one another in one person and yet coexist simultaneously in another. The “integration” between them runs on a complete continuum from one extreme to the other. The organization of the momentary engagement and disengagement of neuronal networks will turn out to be the heart of self-regulation in the mental health perspective. And as we already know, it is through neurofeedback that the connectivity between such networks becomes directly accessible to us. As it happens, the word network was not used once in this entire conference. That will surely be different in coming years. Onno spoke of “life lived at the surface of consciousness” as the available option for the traumatized person. Erich Maria Remarque said of traumatic memory: “It is too dangerous for me to put these things into words. I am afraid they might become gigantic and I may no longer be able to master them” (All Quiet on the Western Front, p.165, 1929). A member of a family of Holocaust survivors said: “The moment any Holocaust memory or shred of a memory would come up we would fight it…” The implication for us in neurofeedback is that the “constricted life” carved out as a modus vivendi by the traumatized brain prescribes for us the very zone of provisional safety that is required for productive work to proceed on the agenda of self-regulation. This is where it all has to start. The work must largely be done without awakening the defenses, and without tossing the individual back into the maelstrom of his own disregulations. We would not do psychotherapy with a person while tossed on the high seas in a perfect storm. Similarly, we must work with trauma to the degree possible without reawakening it. Onno also discussed whether dissociation might be the underlying issue in some cases of other disorders. He recalled for us the following vignette on the denial of dissociation. A visiting professor from a university in the USA, lecturing in Norway on his research on bipolar disorder in children, presented a case in which there was obvious polarity in the child. Onno was reminded of working with a person with DID. The child would switch between being a very good and a very bad person, and he would switch very quickly. He suggested to the lecturer that this might be a dissociative condition rather than a case of bipolar disorder. The lecturer dismissed the thought: “That does not exist,” and cut off further discussion. At the end of the lecture it became apparent that the audience agreed with the lecturer. “We are still very obedient to authority in our country…” lamented Onno. Beyond being another illustration of that fateful combination of “arrogance and naiveté” that is so commonplace among professionals whenever established science has not yet displaced the aura of personal authority, there may be less difference here than meets the eye. In the language of networks, the state shifts we see in bipolar disorder may not be very different from the ones we see in dissociation. More importantly, the remedy may be essentially the same in both cases. In neurofeedback, we would approach both in first instances as instabilities to be remedied. Pharmacologically both perspectives might lead to the same set of remedies as well. That, however, is only the “Ansatz” to complete resolution. Network stability is only the first minimal condition to be met on the road to progress. In the end the bipolar model would not lead one to consider a trauma etiology, and that would be the significant downside from an improper diagnosis. This leaves us where we already are in our society: Trauma remains the largely unacknowledged stealth diagnosis, without a label to reify the condition and to organize our thinking. “The level of suffering that we work with [has been] historically denied…” Speaking also in the voice of a clinician, Onno said that one clearly needs a specific treatment
here. “There is no placebo response.” And he quoted Richard Kluft to the effect that “…the
slower you go, the faster you get there…” Indeed, we are not in Euclidean space here. This
again mirrors our experience in neurofeedback, where the challenges are so subtle and miniscule
that in some instances they almost defy detection. The brain reacts differently to such a
subtle, covert provocation than it does to a larger, overt challenge. Bessel van der Kolk Bessel van der Kolk spoke to the theme of Mind/Body integration by highlighting the connection of the trauma response to the failure of the fight-flight mechanism in particular, and to our agency through the control of movement in generality. “The worst form of PTSD may be waking in the course of a surgical procedure and being unable to tell the surgeon that you are awake.” So a partial remedy may be sought in movement-based or other body-based therapies. Van der Kolk came to this also through a personal experience. Having observed that his own heart variability measure was flat-lining, he found yoga practice helpful in restoring the proper dynamics. But things did not start there. He had been in China at about the time of the Tienanmen massacre, and despite all the tumult he could see people gathering at the local park in the morning doing Tai Chi. “Why weren’t they in their therapists’ offices talking about their mothers?” he asked rhetorically. So at the same time that van der Kolk was getting interested in movement-based therapies,
he remained somewhat skeptical, even contemptuous, of the psychodynamic approach to trauma
resolution, one that he himself had relied upon for years as a psychiatrist. “The rational
brain does not have pathways to the emotional brain.” “Action patterns and hormonal responses
are mobilized by the emotional brain, impervious to conscious control.” Hence that must set
the agenda for a strategy of remediation. Van der Kolk pointed out that every Nobel Prize in physiology in the twentieth century reflected the understanding of the centrality of movement in brain organization: Pavlov, Sherrington, Tinbergen, Lorenz, von Frisch, and Edelman. He personally ranks Pavlov almost at the level of Darwin as a scientist, and recalled Pavlov’s report from when his laboratory was once flooded by a rising Dnieper River. His dogs were traumatized, and subsequently engaged in immobility, or in irrelevant behavior. “They had lost their reflexive purpose.” This occurred just one year after Pavlov sustained his own trauma, as his son had been killed fighting the Bolsheviks. At the end of his talk, van der Kolk showed video of a drama and dance production involving inner-city youth---perhaps to suggest a kind of unification of movement-based and psychodynamic work. Of course I had seen his whole prior talk as leading up to neurofeedback as the final resolution, and therefore saw his crisp scientific presentation somewhat dissipated in the final “soft” message. After all, van der Kolk talked of the breakdown of cortical timing in PTSD. He said that PTSD is all about the integrity of brainstem functioning, through its management of autonomic arousal. That all sounded very promising. This matches up very well with where we are in neurofeedback, where matters concern brainstem functioning first and foremost, and where our methods are directly and explicitly targeting the integrity of brain timing. If truth be told, trauma is not resolved through movement per se, but more fundamentally through the organization of movement---that is to say, through the honing of regulatory control. The objective is enhanced self-regulation, and the most accessible pathway may be through movement. As we have found also, when one trains the brain in such a central function as the organization of movement, other regulatory faculties such as emotional regulation and pain threshold are influenced as well. From the standpoint of regulation, we are constituted of a network of nested regulatory networks, and it is no more possible to affect them in isolation than it is to vibrate only one portion of a spider’s web. The field of traumatology and of affect regulation has reached the point of recognizing the centrality of physiological self-regulation in the resolution of trauma. Isolated data are being attended to, such as the helpful quality of movement therapies and of massage, and including the utility of techniques such as EMDR. However, none of this yet fits an over-arching model. Whereas movement takes one out of the immediacy of trauma, EMDR ushers one into it. There is no coherency to the separate agendas. From our perspective, EMDR is a window into one part of the EEG frequency spectrum. It represents no more than a small part of the story when it comes to the domain of time and frequency in the organization of brain function. At the end of his talk I suggested to van der Kolk that a whole discipline already existed around the scientific investigation and systematic training of self-regulation. It is called biofeedback. Why is this emerging community of professionals now reinventing the whole field step by laborious step, when in fact an organized community of professionals has been continuously engaged with this topic for decades? How is it possible that these two professional communities can coexist with essentially no cross-talk? Affect regulation should be a dominant theme in the biofeedback community, and in turn biofeedback and neurofeedback should be the dominant theme in the treatment of trauma specifically, and of affect regulation generally. Allan Schore Allan Schore carried forward and elaborated the theme of the “embodiment” of trauma. Early infant trauma disrupts not only the developmental pathways toward affect regulation, but more generally. “What you have is an organism that no longer has available the mechanisms by which the infant normally organizes the body. They don’t create the body…” Hence, there must be bodywork as well as relational work. And when Allen refers to the body, it is not just to motor function. He includes interoception, our sensation and awareness of our interior selves, and the smooth muscle system. Allan Schore reminded the audience that seeing the process of dissociation in emotional terms is rather recent. It has traditionally been described in strictly cognitive terms, and is so described to this day in the DSMIV. The ICD10 in Europe is moving toward more of a body focus. “At the psychosomatic core of self, trauma is experienced as psychic death.” He quotes Weinberg: “When the right hemisphere collapses, the person lives in the self-sufficient, detached world of the left hemisphere. This mode of experience is determined by narrow-mindedness and search for new evidence supporting existing beliefs coupled with inability to verify them critically and reject them following contradictory feedback.” Summary The above paragraph holds a lot of explanatory power. In a positive and survival sense, the refuge of left-hemisphere functioning allows unremediated trauma to survive and navigate this world. On the positive side also, this zone of functioning is our preferred point of departure in neurofeedback. We start with where the person already functions competently, and proceed from there to enlarge the scope of functioning incrementally and gently. Movement therapies do the same. They may get to the heart of things to some extent, but they are distanced from the trauma itself. By placing the body-based therapies first, the trauma itself need never to be touched until it is already transformed. We can also recognize in this paragraph a pathology in the world at large. Does this description not characterize our current Administration? On the larger scale, does it not characterize our Judeo-Christian religion, both in its Judaic origins among a nomadic people—unmoored from emotional ties to place on mother earth—and in its present beleagurement? Closer to home, does it not characterize our own field of biofeedback? For many years I have tried to understand the self-deprecations of our professional organizations in terms of a trauma model, in view of the “near-death experience” neurofeedback suffered in the mid-seventies. What has emerged since that time is an almost unbelievable rigidity of mind, of constriction of vision, of reduction to stereotypic action, of the abandonment of autonomous mental activity, and of the abject capitulation and collapse in the face of threat. Biofeedback organizations reflect the pathology of dissociation everywhere one looks—both in its cognitive and affective aspects. Maybe it is our own organizational trauma that prevents us from recognizing our need for the very methods of recovery that we have developed for others. We may have collectively taken refuge in our rational left hemispheres. We are suspicious of the passionate commitment of the clinician. We delight in a withering skepticism that levels all. Maybe the Winter Brain Conference got off the ground so well in the early nineties because of that hot tub in Key West, so lively most years that the police were sometimes summoned to quiet us down. We are, finally, confronted with the paradox that trauma can only be resolved through the agency of those mental health professionals who actually understand the issue, and are prepared to engage with it. On the other hand, those same professionals are universally psychodynamically oriented and understandably find themselves challenged by the traumatized patient. They are reinforced in their interventions because these tend to put the clinician at the center of the drama. How can they be persuaded that engaging the trauma experience head-on, whether through traditional analytic techniques or even with EMDR, may be a mistake? For the most abject of trauma histories, a stealth strategy is needed that builds self-regulation
from the ground up, a kind of recapitulation of the developmental processes that is available
even at a relatively late stage. All the neuronal pathways are available for the learning
or re-learning of self-regulation in the affective and arousal domains. Any living brain
exhibits the requisite functional plasticity to make this possible. Not only that, but techniques
of self-regulation adequate to the task of trauma resolution are by now well known within
the domain of neurofeedback. Siegfried Othmer Healing Trauma: Attachment, Mind, Body, and Brain |
