Memory, Trauma and Representation in Psychotherapy

An intersubjective psychodynamic model uses the therapeutic relationship to facilitate relational and neurological changes in patients with trauma histories.

This paper explores the role of explicit and implicit memory in therapeutic action. Taking Freudian psychoanalysis as his starting point, the author summarizes the findings of neuroscience research into explicit or declarative memory and implicit or non declarative memory. From an interdisciplinary perspective, the author examines the role of trauma and dissociation and the reemergence of trauma-related childhood memories.
The paper illustrates the development of representational models from an intersubjective/attachment perspective and explores the processes that maintain sub optimal ways of experiencing and relating. The author suggests that such clinical issues are particularly pertinent for psychotherapy, arguing that an understanding of the dynamic nature of memories, and of the way in which the two major memory systems operate and interact, is salient to these issues and to a concomitant understanding of the process of therapeutic action. The author contends that an intersubjective, psychodynamic model can use the power of an emotionally meaningful therapeutic relationship to gradually facilitate both relational and neurological changes in patients with trauma histories.
Introduction
Recent advances in research in the fields of attachment, traumatology, and neuroscience are helping to deepen our understanding of the process of change in psychotherapy. In this paper, I draw on this research to inform an integrated model of clinical practice. Whereas earlier clinical models emphasized a largely verbal, interpretative technique in the explicit domain, newer models focus on a nonverbal, affective understanding of communication in the implicit/enactive domain, as manifested by the behavioural enactment of nonconscious procedural memories. I argue that therapeutic change consists of a dual process and needs to proceed in both of these domains. Given this, I contend that a neuroscientific understanding of the dynamic nature of memory processes, and of the way in which the two main memory systems operate and interact, is salient to a concomitant understanding of trauma, personality development and therapeutic action.
Memory and Freudian Psychoanalysis
The way in which traumatic memories of childhood sexuality influence experience and behaviour in later life has been a concern of psychoanalysis since its inception by Freud in the 1890s. Freud first conceptualized repression as a form of voluntary dissociation from consciousness of memories associated with emotions that were threatening to the person’s values and ideals. According to Freud’s theory, such memories became dynamically unconscious. His original therapeutic model was one of lifting repression and recovering memories into consciousness. In this context, Freud assumed that the conscious and pre-conscious representation in internal mental space of an object, person, or event in the external world may become subject to repression. He further assumed that some trace of the external reality would be retained in memory; that a ‘memory trace’ preserves its relation to the object represented through its resemblance to it (Freud, 1894a). In a letter to Wilhelm Fliess in 1896, Freud used the term Nachträglichkeit to describe a form of deferred action by which the patient’s clinical material, in the form of memory traces, may be revised and rearranged at a later date to fit in with new experiences and thus be endowed with a new meaning.
Reflecting on childhood memories in particular, and on the origins of conscious memories in general, Freud (1899a, in Gay, 1995) suggests that perhaps we do not have “memories at all from our childhood”, but rather that what we possess are “memories relating to our childhood” (p. 126, italics in original). Indeed, in Inhibitions, Symptoms and Anxiety, Freud (1926d) refers to ‘primal repression’, conceptualizing this as a fixation that exerts a continuous after-pressure on repression proper or secondary repression. He considered it unlikely that primal repression is derived from the superego, as this psychical agency develops subsequent to primal repression. Rather, primal repression should probably be sought in very intense archaic experiences, which, by their very nature, have broken through the protective shield against stimuli. Lacan (1993) subsequently theorized primal repression as a form of memory that remains inaccessible to the person. In this sense, primal repression, and the theory that repetitive actions are a form of unconscious memory (Freud, 1914g, 1926d), may be seen as having certain phenomenological features in common with the performative and enactive features of implicit memory (Reis, 2009a). Moreover, Fonagy and Target (1997) argue that the ‘repressed’ aspects of childhood ‘screen memories’ (Freud, 1914g) may be conceptualized as a manifestation of the implicit/procedural memory system “which can achieve no other phenomenal representation” (p. 215)
The Two Main Memory Systems: A Neurological Perspective
Recent findings from neuroscience suggest that memory is composed of a variety of distinct and dissociable processes and systems. Each system depends on a particular constellation of networks in the brain that involve different neural structures, each of which plays a highly specialized role within the system. It is generally accepted that brains deal in meaning rather than merely processing information, and that emotion is as important as cognition in encoding experience in memory (Brothers, 1997; Damasio, 1999, 2003; Gallagher, 2008; Ledoux, 1994, 1996; Mancia, 2006; Panksepp, 1998, 1999; Rose, 2005; Schacter, 1996). Moreover, cognitive-affective memories are subjective records of how we have experienced events and not replicas or facsimiles of the events themselves. The experiences we have are encoded by brain networks whose connections have already been shaped by previous encounters with the world. Thus, this preexisting knowledge powerfully influences how we encode new memories (Mancia, 2006; Schacter, 1987, 1996). However, memory is not only about learning but also about subsequently recalling or retrieving what has been encoded and committed to memory. As part of this process, we classify what we see and experience as ways of discriminating between various possibilities. Without the ability to discriminate, predict and classify we would experience the world as chaotic and confusing and thus would not survive (Rose, 2003). Indeed, neuroscience research emphasizes that prediction is one of the brain’s most fundamental functions (Pally, 2005).
Linked to processes of classification, prediction and discrimination, memory researchers have found that we possess an elaborate mechanism called ‘perceptual filtering’. This ensures that we select and commit to memory salient information from the outside world and that we block information not deemed salient. Such filtering processes are largely nonconscious, but the information is, nonetheless, classified in accordance to its importance to us. These classifications about how we perceive and what we remember are based on experience and permeate our adult life (Rose, 2003).
The Explicit and Implicit Memory Systems
Following Tulving (1983), psychologists and cognitive neuroscientists who specialize in memory research broadly agree that there are two main forms of memory: explicit or declarative memory and implicit or non declarative memory. Declarative memory has two aspects, being comprised of episodic memory, that is memory of autobiographical events in our own life history, and semantic memory, which refers to conceptual and factual knowledge of the world. Autobiographical memory allows us explicitly to recall personal events that uniquely define our lives (Damasio, 2003; Schacter, 1996). However, memories undergo a complex process of reconstruction or recontextualization during retrieval. Therefore, memories of some autobiographical events may be reconstructed in ways that differ from the original, or may never again see the light of consciousness. Instead, such memories may promote the retrieval of other memories which then become conscious in the form of other facts or emotional states (Damasio, 2000; Mancia, 2006).
Implicit memory includes a type of memory in which previous experiences aid in the performance of a skill or task, such as learning to play a musical instrument or to ride a bicycle. Significantly, implicit memory also comprises emotional memory, which influences current thoughts, feelings and behaviour in a relational context without conscious awareness of those previous experiences. Research into implicit memory indicates that it operates through a different mental process from explicit memory and is automatic in operation and not accessible to verbal report. Indeed, studies of brain-damaged patients have shown that implicit memory involves emotion-laden action and can be recontextualized in the absence of any capacity for explicit memory (Damasio, 2000; Mancia, 2006; Rose, 2005; Schacter, 1996). Implicit memory, then, is principally perceptual, nonconscious, and non reflective and allows us to learn new skills and acquire habitual ways of acting outside of conscious awareness. In daily life we rely on implicit memory in the form of procedural memory (Schacter, 1987, 1996; Mancia, 2006; Pally, 2000, 2005). Research findings confirm that implicit, nonconscious, emotionally-laden learning occurs and is available to reconstruction in the light of new experience (BCPSG, 2008). Moreover, a person’s ‘character’ and ways of interacting with others may be mediated and supported by procedural memory systems (Grigsby & Hartlaub, 1994; Schacter, 1996).
The brain structures that support implicit memory are in place before the systems needed for explicit memory and are used by pre-linguistic infants to learn from experience (Schacter, 1987, 1996; Pally, 2000, 2005). For example, face recognition occurs within hours of birth, with even day-old babies being able to distinguish between their mother’s and another woman’s face. Similarly, olfactory recognition, based on pheromone chemical signalling, contributes to the mother-infant attachment, with babies being able to discriminate between, and showing a preference for, the mother’s smell to that of a stranger (Rose, 2005).
Unlike explicit memories, implicit memories do not seem to become forgotten (Rose, 2003; Schacter, 1996). Indeed, while our sense of self and identity is highly dependent on explicit memory for past episodes and autobiographical facts, our personalities may be more closely tied to implicit memory processes. Appreciating the pervasive and invisible influence of implicit memory on our thoughts, feelings, and behaviour provides an essential insight into the fragile nature of human memory, as well as its powerful effect on our mental life (Grigsby & Hartlaub, 1994; Schacter, 1996).
Implicit Memory, Repression and the Dynamic Unconscious
The nonconscious world of implicit memory revealed by cognitive neuroscience differs markedly from Freud’s conceptualization of the dynamic unconscious (BCPSG, 2008). The dynamic unconscious consists of what was once consciously known and has then been subject to repression. Given this, repression can only act on events experienced at a developmental/neurobiological stage that allows encoding into autobiographical memory (Fonagy, 1999; Mancia, 2006; Schacter, 1996). By contrast, implicit memories arise in early development as a natural consequence of such everyday repetitive and habitual experiences as perceiving, relating, and acting. Implicit memories of a traumatic or non traumatic nature may then be enacted in behavioural terms in the form of emotional/procedural memories in contexts that cue the retrieval of such memories.
From the vantage point of neuroscience, primal repression, as conceptualized by Freud (1926d), and theorized by Lacan (1993) as an inaccessible form of memory, may, in phenomenological terms, be seen as having certain features in common with implicit memory. This may also be the case with Bollas’ (1987) formulation of the ‘unthought known’, Stolorow, Atwood and Brandchaft’s (1992) realm of the ‘prereflective unconscious’, and D. B. Stern’s (1997) concept of ‘unformulated experience’. Indeed, the BCPSG (2008) posit that D. B. Stern’s (1997) concept of unformulated experience is a form of ‘implicit relational knowing’ (IRK), that is, a non symbolic, nonconscious form of ‘knowledge’ that operates outside of focal attention and conscious experience. IRK is not necessarily dynamically repressed into the Freudian unconscious; rather, it is a form of ‘knowing’ that “has never been put into words, has never had to be, or never could be” (p. 129). The BCPSG (2008) point out that non-language-based knowing “is the only form of knowing in infancy by developmental default” (ibid).
On discussing the unthought known, Bollas (1987) links Winnicott’s concept of the true self and Freud’s concept of the ego to the notion of primal repression. He argues that the primal repressed must be the inherited disposition that constitutes the core of the personality. Indeed, he argues that: “At the very core of the concept of the unthought known, therefore, is Winnicott’s theory of the true self and Freud’s idea of the primary repressed unconscious” (p. 278). However, Bollas (1987) avers that: “The concept of primal repression does not address early intersubjective contributions to the infant’s knowledge of being and relating” (p. 280). Given this, he suggests that the term primal repression should be replaced by the concept of the ‘unthought known’, a term that he uses to stand for everything that on some deep level is known, such as moods, somatic experiences and personal idiom, but which has not yet been thought, in that the phenomena have remained unavailable for mental processing. For Bollas (1987), the unthought known becomes thought through object relations: “It is only through the subject’s use and experience of the other that mental representations of that experience can carry and therefore represent the idiom of a person’s unthought known” (p. 280).
This aspect of Bollas’s (1987) theory has resonances with D. B. Stern’s (1997) concept of ‘unformulated experience’. Unformulated experience is composed of vague tendencies and refers to “content without definite shape” (p. 39). Stern (1997) suggests that: “The way in which each of us shapes moment-to-moment experience is the outcome of our characteristic patterns of formulation interacting with the exigencies of the moment” (p. 38). Given this “the resolution of the ambiguity of unformulated experience is an interpersonal event” (ibid).
I would suggest that the phenomenological description of implicit/procedural memory may also be seen in Winnicott’s seminal (1974) paper Fear of Breakdown. Here, Winnicott speaks of ‘primitive agonies’ and “a fear of a breakdown that has already happened” but which has not been “experienced” and is thus prone to being repeated at an unconscious level of mental functioning (p.107). His thinking in this regard is clearly influenced by Freud’s notion of the ‘compulsion to repeat’, whereby the subject repeats old, unconscious experiences under the strong impression that his or her actions are fully determined by the circumstances of the present moment (Freud, 1920g). However, Winnicott (1974) makes it clear that he is not referring to Freud’s dynamically repressed unconscious, but rather to unconscious phenomena that the ego was too immature to encompass and gather “into the area of personal omnipotence” (p. 104). He contends that “the original experience of primitive agony cannot get into the past tense unless the ego can first gather it into its own present time experience and into omnipotent control” (p. 105). In the absence of such a resolution, the patient must “go on looking for the past detail which is not yet experienced. This search takes the form of looking for this detail in the future” (ibid, italics in original). If the patient can accept this “queer kind of truth, that what is not yet experienced did nevertheless happen in the past, then the way is open for the agony to be experienced in the transference, in reaction to the analyst’s failures and mistakes” (ibid). Via the transference, “the past and future thing then becomes a matter of the here and now, and becomes experienced by the patient for the first time” (ibid). Significantly, Winnicott (1974) argues that the transference experience “is the equivalent of remembering, and this outcome is the equivalent of lifting of repression that occurs in the analysis of the psychoneurotic patient (classical Freudian analysis)” (ibid).
Winnicott (1974), then, is drawing a distinction between the repressed unconscious on the one hand and unremembered unconscious phenomena from early childhood on the other hand. From the vantage point of neuroscience research, I am suggesting that the fear of breakdown, the unthought known, unformulated experience, the prereflective unconscious, and the compulsion to repeat, may all be understood, at least in part, as phenomenological descriptions of the functioning of implicit/procedural memory. As noted above, Fonagy and Target (1997) hold a similar view in respect of Freud’s (1914g) concept of ‘screen memories’. I would also see the phenomenological description of implicit/procedural memory as pertaining to Bion’s (1984) ‘elements theory’, specifically, to the subjective experience of ‘nameless dread’. By extension, I would argue that the similarities between implicit/procedural memory and ‘elements theory’ may be found in the writings of those influenced by Bion, for example, Ferro (2011) and Ogden (2009.
Bion (1984) argues that we all have sense impressions and emotional experiences. He suggests that there is a specific function of the personality which transforms sense impressions and emotional realities into psychic elements. These then become available for mental work by such means as thinking, dreaming, imagining and remembering. Bion (1984) terms the latter ‘alpha elements’, and the process by which they are transformed, ‘alpha function’. This process requires the mother to enter a state of calm receptiveness - a state of mind Bion (1984) terms reverie. The mother is thereby amenable to containing the infant’s inchoate state of mind and thus able to give meaning to the anxiety and terror inserted into her in unconscious phantasy by means of projective identification. ‘Beta elements’, on the other hand, consist of untransformed sense impressions and emotional experiences. These elements are experienced as split off, unintegrated ‘things-in-themselves’ and are therefore evacuated by means of projective indentification, leaving the self feeling depleted, fearful of persecution, and in a state of ‘nameless dread’.
I am arguing, then, that the infant’s experience of ‘nameless dread’, in the form of split-off, untransformed ‘beta elements’, is encoded in the systems of implicit/procedural memory as a traumatic emotional state. In this sense, ‘nameless dread’ may be seen as having much in common with Winnicott’s (1974) conceptualization and phenomenological description of unremembered, yet to be experienced, ‘primitive agonies’ that generate an ever present subjective ‘fear of breakdown’. Similarly, Stolorow, Atwood and Brandchaft (1992) argue that trauma encountered in early development is preserved in the domain of the ‘prereflective unconscious’ in the form of a never-to-be-forgotten traumatic memory system. “The enduring effect of this is to impart an aura of danger and a quality of “immanence” to the background of experience”, (Brandchaft, Doctors & Sorter, 2010, p. 226).
Similarly, and consonant with neuroscience research and an attachment theory perspective, Sandler and Sandler (1997) regard the past unconscious as a system of implicit procedures embodied in “rules of functioning” (p. 177). Procedural rules are expressed in repetitive behaviour patterns, and in the reactivation of object relations in the transference. The transference is understood in terms of the patient attempting to get the therapist to play a particular role in the present which accords with the rules laid down in the patient’s past.
It is argued, then, that implicit/procedural memory becomes an integral part of the transferential experience. Indeed, Clyman (1991) contends that procedural memories formed in early childhood are a fundamental constitution of the transference. In this context, Mancia (1993) argues that transference enactments are not so much a reactivation of historically definable experiences as a “facilitation of the comparison and integration of present and past experience, as reactivated by the transference” (p. 164, italics in original).
The Dynamic Nature of Memory
More generally, memory is seen as an emergent property of the brain which, as an open, dynamic system, is continually in interaction with the natural and social worlds outside, both changing them and being changed in their turn (Rose, 2003). Indeed, Edelman (1987) critiques a computer model of mind, arguing that the developing neural system has the capacity to change its properties as part of a process of continuous selection of pre-existing groups of neurons and their synaptic connections in response to environmental challenges and demands. Edelman (1987) calls this process ‘neural Darwinism’. From this perspective, explicit memory is viewed as a dialectical and highly dynamic phenomenon. Each time we remember, we work on and transform our memories; they are not simply called up from store and, once consulted, replaced unmodified. Rather, our conscious memories are re-created each time we remember. Thus, when we remember an event, we are actually not remembering the event itself, but the last time we remembered it (Rose, 2003, 2005).
The dynamic nature of memory is an example of brain plasticity. Respecting the brain as an open learning system avoids reductionist thinking and helps to create order out of chaos (Damasio, 2000, 2003; Edelman, 1989; Schacter, 1996; Rose, 2003). From a neurobiological perspective, and consonant with the concept of brain plasticity, Rose (2003) contends that learning evokes a biochemical cascade that permanently alters the brain. A similar biochemical process occurs when a memory is reactivated. However, Tulving (1989) suggests that although the brain has been lastingly changed, the resulting engram of the encoded experience only exists when it is activated and the memory is retrieved.
A Contemporary Perspective on Psychological Trauma
The word trauma derives from the Greek meaning penetration and wounding. Psychological trauma is linked to a pathological form of dissociation, a term coined by Pierre Janet, who undertook a systematic study of dissociation in the 1890s, seeing this concept as the crucial psychological process with which the person reacts to traumatic experiences. Janet also showed that traumatic memories may be expressed as sensory perceptions, affect states, and behavioural re-enactments (van der Kolk & van der Hart, 1989).
Psychological trauma results in feelings of intense fear, helplessness, loss of control, and threat of annihilation. Such feelings overwhelm the adaptations that ordinarily provide people with a sense of self-agency, emotional connection and meaning (Herman, 1992). Traumatic affect is therefore viewed as having a disorganizing effect on mental functioning and as being a significant motivating factor in the manifestation of psychopathology (de Zulueta, 1993; Schore, 1994; Tyson & Tyson, 1990; Wilkinson, 2010). Given optimal development, affects come to serve a signal function, enabling the child to regulate his or her own affects instead of being overwhelmed by their disorganising effects (Freud, 1926d; Tyson & Tyson, 1990). However, where there is a failure of parental empathy or traumatic interference of one form or another this process is disrupted. Hence, the development of a coherent sense of self is compromised, leading to fragmentation of experience and personality and to the manifestation of psychopathology in later life (Kohut, 1971; Tyson and Tyson, 1990).
Findings show that it is often not the traumatic event in and of itself that is salient in personality development and adult psychopathology, but rather the characteristic intersubjective/attachment system within which the child experiences the trauma (Lyons-Ruth & Block, 1996; Lyons-Ruth & Jacobvitz, 1999; Lyons-Ruth, Bronfman & Atwood, 1999; Lyons-Ruth et al., 2005; Renn, 2003; Rutter, 1997; Settlage et al., 1990). Of relevance to the link between cumulative developmental trauma and disorganized attachment, Lyons-Ruth and Block (1996) found that subtle aspects of the relationship seemed to be involved, rather than gross abuse, neglect, or abandonment. Cumulative trauma was manifested as profound disruption in patterns of caregiver-infant verbal and nonverbal affective communication, with repeated infant communication of distress, anger, or contact-seeking being entirely overridden by repetitive non responsive behaviours by the caregiver. Moreover, there was little or no attempt by the caregiver to repair the derailed interaction. Schore (1994, 2011) argues that relational trauma deriving from dysregulated preverbal attachment experiences of these kinds is imprinted in the right brain and associated with the child’s use of dissociation. He cites findings showing that an impaired ability to regulate the intensity of affect is the most enduring consequence of early relational trauma and, moreover, is strongly associated with psychopathology in adulthood.
Similarly, Panksepp (2001) found that early emotional experiences can profoundly influence the development of the brain, since it causes a change in the infant’s mental economy, as described by Edelman in terms of ‘neural Darwinism’ (1987). Findings confirm that the infant’s attachment to the caregiver is promoted by the interactive regulation of emotion (Sroufe, 1996). Early trauma, such as loss and abandonment, and physical, sexual and emotional abuse, can create the conditions for a lifelong tendency to sadness, depression, anger and resentment (Mancia, 2006; Wilkinson, 2010). Significant disruptions in caregiver-infant affective communications are associated with disorganized and ambivalent-resistant forms of child attachment. Such disruptions may consist of clearly dramatic trauma – sexual or physical abuse - or be correlated with more subtle parental behaviour, for example, withdrawal, dissociation, role-reversal, frightened and/or frightening behaviour, and hostile, critical and intrusive attitudes (Lyons-Ruth & Block, 1996; Lyons-Ruth et al., 2005). These kinds of caregiver orientations thwart the child’s psychological integration and are characteristics of cumulative developmental trauma.
A Neuroscienence Perspective on Dissociation
As noted above, the current view from neuroscience holds that memory is composed of parallel, interacting systems. This is seen as providing potentially fertile ground for the operation of dissociative processes (Schacter, 1996). With regard to adults, dissociation in reaction to a traumatic event represents a negative expression of brain plasticity resulting from an uncontrolled cascade of stress-related neurochemicals which may lead to the failure of the explicit memory system. This is reflected in the disruption of learning, memory, and neural network organization (Cozolino, 2002, 2006; De Zulueta, 1993; Herman, 1992; van der Kolk, 1989, 1994). However, dissociation does not erase traumatic memories, but severs the links among the different memory systems. As a consequence, aspects of the past, or periods of ongoing experience, become detached from conscious awareness and the dissociated traumatic experience is encoded in the systems of implicit/procedural memory as sensory fragments with no linking narrative (van der Kolk, 1994; Schacter, 1996; Schore, 2001; Pally, 2005).
Dissociation, then, and concomitant altered states of consciousness, make a traumatic experience difficult to recall consciously. Indeed, the most common post-traumatic symptom is unbidden recollection of the trauma in the form of flashback memories, which occur in the context of emotional disturbances. The amygdala and stress-related hormones play a special role in emotional memories. The amygdala is an almond-shaped structure located deep within the medial temporal lobes of the brain that form part of the limbic system. Evidence suggests that the maturation of the limbic system is experience-dependent and directly influenced by the caregiver-infant relationship (Schore, 1994). Moreover, research indicates that the amygdala is particularly involved in the fight/flight fear response and in emotional processing and implicit memory (Ledoux, 1994, 1996). Given these factors, memory for trauma differs in important ways from ordinary memory. Indeed, findings suggest that flashback and somatic memories are heavily influenced by expectations, beliefs, and fears which are not recognized as past memories activated in the present. Rather, they are experienced as happening in the here-and-now. Given this, the contents of a flashback memory may say more about what a person believes or fears about the past than about what actually happened (Pally, 2005; Schacter, 1996). The difficulty in consciously recalling traumatic memories makes it more likely that a person will manifest behaviours and symptoms that reflect implicit memory for dissociated experience (van der Kolk & van der Hart, 1989). As an example of this, Schacter (1996) cites Terr (1981), who found that children who had been traumatized in a violent school bus kidnapping enacted the trauma in their play, fears, and other nonverbal behaviours.
The Reemergence of Trauma-Related Childhood Memories
As has been well documented, we are all subject to childhood amnesia, in that we remember nothing prior to the ages of two or three, and little prior to the ages of five or six. As noted above, this is because the neural networks that support explicit memory, the hippocampus and temporal lobes, develop more slowly than those that support implicit memory, the basal ganglia, cerebellum and amygdala, which are almost fully developed at birth (Pally, 2000; Rose, 2005). As previously noted, the amygdala is at the centre of the fear regulation system and is particularly involved in implicit learning of intense, emotionally charged experiences (LeDoux, 1994, 1996).
I would argue that there may be an evolutionary reason for this, in that for survival purposes infants need to possess the capacity to experience fear and anxiety in order to signal danger, distress and their urgent need of protection. However, in consequence of the amygdala being centrally involved in implicit learning and emotion regulation, the infant is born not only with the capacity to learn and remember enacted experience, but also with an exquisite vulnerability to being overwhelmed by frightening experiences. Such experiences are encoded in the systems of implicit memory and may reemerge in emotional contexts that cue the retrieval of traumatic memories (Perry et al., 1995; Mancia, 2006; Schacter, 1996; Schore, 1994, 2001; Turnbull & Solms, 2003; van der Kolk, 1989, 1994; van der Kolk & Fisler, 1995). Farhi (2010) and Milner (1969) go so far as to argue that trauma may be experienced in the womb and be carried into adult life. Neuroscience research supports the idea that preverbal, pre-symbolic experiences in infancy become represented in adult brain systems and affect the person’s functioning throughout life (Damasio, 2000, 2003; Mancia, 2006; LeDoux, 1994, 1996; Pally, 2000, 2005; Siegal, 2001; Turnbull & Solms, 2003). Indeed, findings indicate that vulnerability to, and resilience against, adult post-traumatic stress is vitally affected by early traumatic experiences that have been indelibly imprinted in the infant’s implicit memory (LeDoux et al., 1989; Perry et al., 1995; Schore, 1994, 2001; van der Kolk & Fisler, 1995). Moreover, as previously noted, implicit effects of past experiences may shape our emotional reactions, preferences and dispositions – key elements of personality (Grigsby & Hartlaub, 1994; Schacter, 1996).
Findings, then, show that the amygdala plays a specific role in both fear conditioning and implicit learning, and that the later developing hippocampus plays a specialized role in the neural networks that support explicit memory (LeDoux, 1994; Mancia, 2006; Pally, 2005; Rose, 2003; Schacter, 1996). Given this, fear and anxiety experienced in early childhood are subject to a form of amnesia and thus may lay dormant for years (LeDoux, 1994). However, the procedural and emotive aspects of such experiences are still working within us and may suddenly be reactivated when we are exposed to a new traumatic stress. Typically, we have no meaning for how we initially acquired the fear. Again, this reflects the operation of implicit memory and the normal amnesia characteristic of the first years of life (LeDoux et al., 1989; Pally, 2005; Schacter, 1996; Turnbull & Solms, 2003).
Informed by research, Schacter (1996) speculates on the neurochemical reasons for the sudden reemergence of childhood trauma in later life. Accepting that early trauma is encoded in implicit memory in brain circuits outside or dissociable from the hippocampal system, as the latter system develops, the childhood fears may recede into the background. When, however, we experience a new psychological trauma, our brains release an uncontrolled cascade of glucocorticoids, excessive exposure to which can temporarily suppress the hippocampus, which has a high number of glucocorticoid receptors, thereby contributing to memory-related abnormalities. The suppression of the hippocampus by the bombardment of stress-induced glucocorticoids enhances amygdala activity. As a result, non-hippocampal systems may become more active, allowing hidden implicit memories, such as long latent childhood fears, to suddenly resurface (LeDoux et al., 1989; LeDoux, 1994; Mancia, 2006; Schacter, 1996).
Indeed, research shows that the dysregulation of fear-states in early life results in a permanent sensitivity to even mild stress in adulthood, with the individual being unable to terminate a stress response in time to prevent an excessive reaction (Perry et al., 1995; Schore, 2001). Moreover, it is now thought that traumatic early life events predispose certain individuals to later psychiatric disturbance when they are re-challenged with a matching event, or experience a recurrence of the original stressor (Perry et al., 1995). Schore (1994, 2001) argues that these findings reflect a trauma-induced deficit in the brain’s right orbitofrontal systems and concomitant difficulty in inhibiting responses related to orbitofrontal dysfunction. He suggests that as a result of such dysfunction, affective information implicitly processed in the right brain is inefficiently transmitted to the left hemisphere for semantic processing. Thus, the individual is more likely to behave impulsively and aggressively in situations of stress and arousal (Bradley, 2003; Schore, 1994, 2001). The way in which the individual subjectively interprets traumatic and abusive experiences is, needless to say, central to the modulation of affective arousal and to the development of symptoms and disorders (Herman & van der Kolk, 1987; van der Kolk & Fisler, 1995).
From a neurobiological perspective, then, trauma-related childhood memories are encoded in the systems of implicit/procedural memory and may re-emerge in stress-inducing social contexts in adulthood such as separation and loss that cue the retrieval of these indelibly imprinted emotional memories (LeDoux et al., 1989; LeDoux, 1994, 1996; Pally, 2000, 2005; Schacter, 1996; Schore, 1994; van der Kolk & Fisler, 1995).
Intersubjectivity, Attachment and Implicit Memory: The Development of Representational Models
Representation
The development of object relations theory challenged the Freudian view that instinctual drives of sexuality and aggression are the major determinant of the nature of the representational world. As a result of this paradigmatic shift it is increasingly accepted that external reality plays a key role in the formation of psychic structures, and that what is represented internally are self-other relationships. Indeed, empirical research supports the view that cognitive-affective schemas or mental models deriving from actual relationships are internalized and generalized as representations of past experience (Bowlby, 1973, 1988; Bucci, 1997; Schacter, 1996; Stern, 1985). It also shows that adaptive responses to repetitive caregiving patterns in early life reinforce particular neural networks that form the neurological substrate of representational models, together with sets of nonconscious expectancies about the behaviour of others that are likely to be activated in later life in similar relational contexts (Grigsby & Hartlaub, 1994). Informed by these findings, contemporary psychoanalysis holds that representational models of self-other relationships are encoded in implicit/procedural memory and organize interpersonal behaviour largely outside of conscious awareness (Bruschweiler-Stern et al., 2002, 2007; Fonagy, 1998, 1999; Fonagy & Target, 1998; Stern et al., 1998b). These findings have obvious clinical implications for understanding transference/countertransference enactments (Divino & Moore, 2010; Ginot, 2007; Mancia, 2006; Sandler & Sandler 1997; Schore, 2011).
The Intersubjective Motivational System and the Mirror Neuron System
More generally, findings from developmental studies, cognitive neuroscience, and attachment and intersubjectivity theory show that, excepting serious birth complications, we are all born with an innate capacity to engage in collaborative and mutually regulatory social interactions. This, in turn, indicates the existence of a sophisticated intersubjective motivational system that compels us to seek companionable shared experiences (Trevarthan, 2001, 2009; Seligman, 2009). Preliminary research suggests that the neurobiological substrate for the innate capacity to read and empathically share emotions, intentions and sensations with others is the mirror neuron circuitry, the systems of which are present at birth (Rizzolatti, Fogassi & Gallese, 2006). It is thought that the mirror neuron system is activated when we observe the other’s actions, intentions and emotions, taking the form of what Gallese (2009) terms “embodied simulation”. In essence, the same neurons fire in the brain of the person observing the actions or emotional display of another as if he or she was performing the observed action or experiencing the same feelings (Cozolino, 2002). Mirror neurons, then, permit us to participate in the other’s actions without having to imitate them (BCPSG, 2008), and help to elucidate the complex process by which nonverbal emotional communication occurs (Cozolino, 2002; Divino & Moore, 2010).
Preliminary findings suggest that the capacity for neural mirroring is the neuro-physiological substrate for empathy, as well as for our ability to meaningfully appraise the actions, intentions and emotions of others. Given this, the mirror neuron system would seem to be linked to the capacity for mentalization (Fonagy et al., 2004; Fonagy, 2008), as well as to the capacity for experiencing shared, intersubjective states of mind (Balbernie, 2007). Children diagnosed with autism have been found to lack activity of the mirror neuron system, suggesting that dysfunction of neural mirroring may be responsible for the relational deficit observed in autism (Ramachandran, 2011). However, ascertaining whether the cause of such a deficit is genetic or a result of a traumatic environment is an extremely complex and sensitive issue that requires further extensive research (Mancia, 2006).
Gallese (2009) emphasizes that our natural tendency is to experience our interpersonal relations first and foremost at the implicit level of bodily interaction. The development and maturation of neural circuitry occurs primarily in response to the infant’s own interactions with the environment, the most salient factor of which is the emotional relationship with his or her caregivers (Edelman, 1989; Bowlby, 1988; Schore, 1994). Elaborating on the aetiology of maladaptive ways of being and relating, Gallese (2009) argues that mirroring processes display neural plasticity and dependence upon the personal history and situated nature of the mirroring subject. He therefore suggests that mirroring mechanisms are likely to play an important role in the constitution of the implicit memories that constantly accompany our relations with internal and external objects. In line with attachment research in general, and Grigsby and Hartlaub’s (1994) findings in particular, Gallese (2009) contends that the internalization of specific patterns of interpersonal relations leads to the development of characteristic attitudes towards others, and towards how we internally live and experience these relations. Mancia (2006, 2007) emphasizes the importance for psychoanalysis of implicit memory, arguing that presymbolic and preverbal experience is encoded therein. He suggests that such early experiences are not lost, even though they cannot be remembered. Moreover, he argues that they form the pillars of an early non repressed unconscious that conditions the emotional life of the individual across the life-span, and that these aspects of personality are likely to emerge in the transference relationship.
The Boston Change Process Study Group
The BCPSG is in the vanguard of developing and promulgating many of the new ideas discussed in this paper. The Group argues that findings from recent developmental studies and cognitive psychology can, when harnessed to dynamic systems theory, help us to understand and model change processes in psychodynamic treatment. Dynamic systems theory (Thelen & Smith, 1994), as applied to psychodynamic therapy, holds that relational events are unpredictable, nonlinear, and emergent properties of the particular therapeutic relationship that change over time. Therapeutic action rests on the unfolding of an emergent intersubjective process characterized by the movement towards self-organization in a context of destabilization and perturbation. The Group argues that change in the implicit domain derives from ‘now moments’ and ‘moments of meeting’, which may be progressive or sudden and dramatic, and which may come about without the necessity of interpreting the experience in the explicit, ‘verbal-reflective domain’ (BCPSG, 2008). Somewhat paradoxically, Stern (2004) contends that the therapeutic process “leads not only to moments of meeting, but also to moments that are propitious for interpretive work or work of verbal clarification” (p. 188).
Commenting on the ideas of the BCPSG, Fonagy (1998) considers it likely that “the schematic representations postulated by attachment and object relations theorists are most usefully construed as procedural memories, the function of which is to adapt social behaviour to specific interpersonal contexts” (p.348). Given this, he suggests that patterns of attachment are stored as procedural memories which themselves are organized as representational models. Consonant with neuroscientific findings relating to the mirror neuron system (Gallese, 2010), Fonagy (1998) argues that knowledge of these procedures is accessible only through behavioural performance, that is by the direct observation of the individual’s manner or style of relating. Previously it was assumed that such knowledge was accessed through the verbal report of ideas or memories.
The BCPSG’s therapeutic model is similar to that proposed by Beebe and Lachmann (1994), which is also informed by developmental studies and systems theory. However, in contrast to the BCPSG, Beebe and Lachmann (2002) emphasize the interaction between the implicit, nonverbal domain and the explicit, verbal domain, arguing that: “A theory of interaction for psychoanalysis must ultimately address the nonverbal or ‘implicit’ (procedural/emotional), as well as the verbal or ‘explicit’, dimensions of the interaction” (p. 33).
A Developmental Perspective
As we have seen, our innate tendency from birth onwards is to seek sociable engagement with others, and socio-emotional relations play a central role in organizing our personality and psychic reality. Given this, the question arises as to what occurs to interfere with such hard-wired tendencies, and what processes maintain sub optimal ways of experiencing and relating. These would seem to be particularly pertinent questions for psychoanalysis. I would argue that an understanding of the dynamic nature of memories, and of the way in which the two major memory systems operate and interact, is salient to these questions and to a concomitant understanding of the invisible process of therapeutic action (Renn, 2010; 2012). Indeed, findings from the disciplines noted above have led to a burgeoning interest in contemporary psychoanalysis into the nonverbal, implicit/enactive dimensions of the therapeutic process with individuals and couples (Beebe & Lachmann, 2002; Beebe, Knoblauch, Rustin & Sorter, 2005; BCPSG, 2008; Bruschweiler-Stern, et al. 2002, 2007; Fonagy, 1999; Lyons-Ruth, et al., 1998; Reis, 2009a, 2009b; Ringstrom, 2008; Shimmerlik, 2008; Seligman, 2009; Stern, et al., 1998a, 1998b; Teicholz, 2009).
From a developmental perspective, the processes involved in the internalization, representation and intergenerational transmission of discrete patterns of interactive regulation have been illuminated by infant research. This has demonstrated that subtle, fine-grain interactive micro-behaviours are related to intersubjectivity, attachment and the transmission of emotion from one generation to the next. Such micro-behaviours operate at the level of implicit relational knowing (BCPSG, 2008; Stern et al., 1998a) and include the rhythmic co-ordination of gaze direction, vocal inflections, body posture, and facial expressions. The infant perceives and remembers the caregiver’s repetitive subtle behaviours in the form of pre-symbolic interactional expectancies. Thus, the cumulative impact of repeated interactions that are consistently matched or mismatched creates a structuring effect on the infant, for good or for ill, who then generalizes these presymbolic representations of interactional expectancies to other interpersonal contexts (Stern, 1985; Beebe, Jaffe & Lachmann, 1992; Knox, 1999; Peck, 2003; Teicholz, 2009). The caregiver’s timing, tracking and coordination of interactive regulations occurs in the implicit/enactive domain. Secure attachment is facilitated when the coordination is neither too low (avoidant) nor too high (enmeshed). Mid-range coordination that is contingent and predictable, yet flexible and variable, is optimal as it promotes a sense of felt security and thus the capacity to experience new information and relationship transformations (Beebe et al., 2000).
Patterns of interactive regulation, then, emerge moment-by-moment and are mediated by the caregiver’s attachment state of mind and level of reflective functioning (Beebe et al., 2005; Fonagy & Target, 1996; Fonagy & Target, 1998; Fonagy et al., 2004; Fonagy, 2008; Hurry, 1998; Slade, 2008). These repeated patterns of interpersonal experience are encoded in implicit/procedural memory and conceptualized as self-other representational models. A salient aspect of these mental models consists of generalized beliefs and expectations about relationships between the self and key attachment figures, not the least of which concerns one’s worthiness to receive love and care (Bowlby, 1973, 1988). Research using the Strange Situation procedure (Ainsworth et al., 1978) and the Adult Attachment Interview (George, Kaplan & Main, 1985) is designed to induce a degree of stress and thereby activate the attachment system and concomitant representational models. In effect, this research taps into implicit/procedural memory, the dynamics of which are manifested in infant attachment behaviour and adult discourse style (Crittenden, 1990; Fonagy, 1998, 1999b; Goldwyn & Hugh-Jones, 2011; Slade, 2004).
From a relational/intersubjective/attachment perspective, psychopathology is seen as arising from an accumulation of sub optimal interactive patterns that result in enduring character and personality traits and concomitant difficulties in interpersonal relationships (Bradley, 2003; Grigsby & Hartlaub, 1994; Mitchell, 1988; Spezzano, 1993; Stern, 1985, 1998). In neurobiological terms these findings reflect a trauma-induced deficit in the brain’s right orbitofrontal systems, as a result of which affective information implicitly processed in the right hemisphere is inefficiently transmitted to the left for semantic processing (Schore, 1994, 2001). Thus the psychological meaning of problematic emotional experience does not become organized into an explicit, coherent narrative and sense of self (Boulanger, 2007; Holmes, 1999; Main, Kaplan & Cassidy, 1985; Main, 1991; Roberts, 1999; Terr, 1981; van der Kolk, 1994; van der Kolk & Fisler, 1995). The resultant representational models of the self as bad and endangered are indelibly held in mind (LeDoux et al., 1989) and may be enacted at the procedural level in subsequent interpersonal contexts that cue the retrieval of traumatic memories (Ginot, 2007; Mancia, 2006; Schacter, 1996; Schore, 2011).
We see then that representational models developed in early life mediate experience of actual relationships and guide and direct feelings, behaviour, attention, memory and cognition out of conscious awareness. Nonverbal, implicit processes may therefore be viewed as providing a measure of continuity from childhood to adulthood, and as organizing transference expectations in everyday life, as well as in the therapeutic encounter (Beebe & Lachmann, 2002; Beebe et al., 2005; Clyman, 1991; Divino & Moore, 2010; Lyons-Ruth & Block, 1996; Lyons-Ruth et al., 2005; Mancia, 2006; Sander & Sander, 1997; Schore, 2011). Moreover, early childhood experiences in the form of cumulative developmental trauma have life-long effects on our functioning at the implicit, nonverbal level of behaviour, emotion, and arousal (Beebe, et al., 2005; Damasio, 2000; Mancia, 2006; Pally, 2005; Perry et al., 1995; Schore, 1994, 2001; van der Kolk & Fisler, 1995). Indeed, findings indicate that once patterns of interpersonal interaction are established they tend to become actively self-perpetuating because potentially disruptive signals are countered by the deployment of perceptual and behavioural control mechanisms. Thus, non optimal representational models are resistant to change because error-correcting information is being defensively and selectively excluded from consciousness (Main, Kaplan, & Cassidy, 1985). This nonconscious process may be equated with the perceptual filtering mechanism described by Rose (2003) from a neuroscience perspective, as detailed above. It may also be seen to partly account for the stability of character and the perseverance of maladaptive ways of experiencing and relating that are maintained by the procedural component of implicit memory (Beebe & Lachmann, 2002; Beebe et al., 2005; Fonagy, 1999; Grigsby & Hartlaub, 1994; Knox, 1999, 2003; Lyons-Ruth, et al., 1998; Mancia, 2006; Stern, et al., 1998a, 1998b; Wilkinson, 2010).
The Role of Explicit and Implicit Memory in Therapeutic Action
I have written elsewhere about the complex and multifaceted nature of the process of therapeutic change using an integrated therapeutic model (Renn, 2010; 2012). The purpose of this concluding section is to focus on one, albeit salient, aspect of therapeutic action - the role that memory plays in both the maintenance and modification of self-other representational models.
If we accept that the internal world of subjective experience is encoded in the systems of implicit/procedural memory (Schacter, 1996; Pally, 2000, 2005; Fonagy & Target, 1997; Fonagy, 1999), as conceptualised as relational configurations; self-states; object relations; emotion schemas; or self-other representational models (Bowlby, 1973, 1988; Bromberg, 1998; Bucci, 1997, 2011; Davies & Frawley, 1994; Fonagy, 1999), it may be argued that implicit modes of interaction, particularly as these relate to verbal and nonverbal emotional communication, become a central focus of the therapeutic process. This is particularly the case if we also accept that such nonconscious experience is enacted in our most intimate relationships, and is most readily accessed in the context of those relationships (Fonagy 1998; Stern et al. 1998a; Ringstrom, 2008; Shimmerlik 2008; Renn, 2010, 2012; Wachtel, 2008). From this integrated perspective, it follows that what we communicate to others, and register from others, both in everyday life and in the therapeutic encounter, often occurs out of awareness and in an enactive mode of relating. Findings that support this argument emphasize the fact that emotional communication is complex and at times highly ambiguous and that our experience is mediated by implicit, nonverbal representational models (Bowlby, 1973, 1988; Fonagy & Target, 1997; Fonagy, 1999; Shimmerlik, 2008). Therefore, accessing and making explicit invisible procedural ways of experiencing and relating so that implicit memories can be subtly changed and encoded within modified representational models becomes a crucial aspect of therapeutic action. In this conceptual framework, pre-symbolic, implicit/enactive encounters form the basis of intersubjective relatedness and promote the establishment of a secure-enough base from which to explore, express and elaborate new forms of agency and shared experiences (Lyons-Ruth, et al., 1998; Stern et al., 1998b). In this sense, psychoanalysis may be seen as the active co-construction of a new way of experiencing self with other (Fonagy & Target, 1998; Fonagy, 1999), and as identifying problematic patterns of organization (Fosshage, 2011; Wachtel, 2008).
The perspective outlined above contrasts sharply with classical psychoanalysis which, as previously noted, is more concerned with the verbal, symbolic aspects of the therapeutic encounter than with the nonverbal, implicit/enactive elements. From a traditional perspective, interpretation, the lifting of repression and the recovery of dynamically repressed childhood memories are key aspects of therapeutic action (Chused, 1996; Fonagy & Target, 1997). Whilst psychoanalytic therapy of all persuasions encourages the patient to tell his or her story, and therefore to talk about childhood memories, a contemporary approach argues that therapeutic action is largely unrelated to the actual recovery of such memories, as in most cases these will have occurred too early to be consciously and accurately remembered. Given this, the events that have led to deeply pathological ways of experiencing and relating to the other are likely to antedate the development of the explicit memory system. Therefore, working only with the verbalized element of therapy fails to take into account core developmental and intersubjective aspects of personality embedded in representational models and enacted at the implicit level in the transference/countertransference matrix, as well as in everyday life (Beebe, et al., 2005; Chused, 1996; Emde, 1990; Fonagy & Target, 1997; Fonagy & Target, 1998; Ginot, 2007; Hurry, 1998; Pally, 2005; Teicholz, 2009; Wachtel, 2008). As Bucci (1997) notes, the struggle to symbolize the implicit/enactive level of interaction in adult dyadic life is one of the major goals of psychoanalysis. This is made all the more difficult because of the invisible nature of implicit/procedural memory (Schacter, 1996). In the light of these factors, Fonagy and Target (1997) argue that the lifting of repression in order to recover previously unavailable memories needs to be reconceptualized as a process that facilitates change in the way the patient understands and feels in relation to a childhood experience. Conceptualizing therapeutic action in these terms would appear to be consonant with Freud’s thinking about early childhood memories, as noted above, viz., that perhaps we do not have “memories at all from our childhood”, but only “memories relating to our childhood” (Freud, 1899a, in Gay, 1995, p. 126, italics in original).
From a contemporary perspective, then, memory is important not as an account of history, but as a means of communicating the nature of internal representations of self-other relationships. Representational models are the invisible psychic structures that organize behaviour and experience in the present, mediating our expectations and predictions of self-other relationships deriving from the silent past (Bowlby, 1973, 1988; Fonagy & Target, 1997; Fonagy & Target, 1998; Fonagy, 1999; Fosshage, 2011; Renn 2012; Stern, 2004; Wachtel, 2008). Indeed, neuroscience has found that the brain organizes interpersonal interactions in accordance with implicit predictions rather than actual events (Pally, 2005). It follows, therefore, that it is these structures themselves that need to be the focus of psychoanalytic work and not the events that might have contributed to their development. In the light of these findings, therapeutic work needs to focus on helping the patient to identify, and thus make visible, repetitive patterns of behaviour for which explicit memory can provide no explanation. Therefore a key aspect of therapeutic action consists of the modification of implicit memories and the expression of dissociated emotions that motivate the procedures underpinning habitual ways of experiencing self with other (Fonagy & Target, 1998; Fonagy, 1999; Wachtel, 2008). Many of these procedures may be highly dysfunctional but be based on powerful, yet outdated and largely nonconscious expectations generated by past experience of a cumulatively traumatic nature (Knox, 2003; Renn, 2003, 2006, 2008, 2012; Wachtel, 2008; Wilkinson, 2010). Given that such emotional procedures are not readily accessible for verbal report they may only become explicitly knowable when enacted in the experiential realm (Fonagy, 1999; Lyons-Ruth, et al., 1998; Pally, 2005; Reis, 2009a, 2009b; Ringstrom, 2008; Shimmerlik 2008; Stern et al., 1998b; Teicholz, 2009). The modification of implicit/procedural memories encoded within representational models would seem to have certain features in common with Freud’s description of Nachträglichkeit, which, as observed above, is a process by which memory traces are revised and rearranged in the light of new experience.
As previously noted, explicit memory is not a static archive, but rather an open, dynamic and interactive system undergoing continuous recategorization (Mancia, 2006; Rose, 2005). In the light of such findings, Mancia (2006) argues that the transformational processes that occur in the therapeutic encounter indicate that the implicit memory system can be stimulated by the transference and undergo dynamic interactions with the explicit memory system. The interaction of the implicit and explicit memory systems leads, in turn, to a recategorization of memories during the therapeutic process. Indeed, although contemporary psychoanalysis, informed by the ideas of the BCPSG, emphasizes the role of implicit, nonverbal factors in the process of change, I would argue that learning new ways of experiencing self with other in the implicit/enactive domain needs to be elaborated in the explicit, verbal-reflective, and conscious domain. Thus, therapeutic change consists of a dual process, one implicit and one explicit, and needs to proceed in both of these modes (Beebe & Lachmann, 2002; Fonagy, 1999; Fosshage, 2011; Pally, 2005; Wachtel, 2008). Becoming consciously aware of new procedural ways of interacting is crucial if these are to be available as an inner resource in other relationships, or in contexts that are particularly stressful, for example when experiencing separation and loss.
From a clinical perspective, then, engaging focal attention and bringing the consciousness system to bear on implicit/procedural expectations and patterns of interaction is a vital therapeutic tool. Consciousness of previously nonconscious procedures, expectations, emotions and predictions facilitates choice, enhances behavioural and emotional regulation, and promotes therapeutic change (Fonagy & Target, 1998; Fonagy, 1999; Fosshage, 2011; Pally, 2005; Schore, 1994; Shimmerlik 2008; Wachtel, 2008). In time, consciousness of the beliefs and expectations generated by emotional memories leads to changes in procedural rules and to the creation of a second-order representational model of their inner experience (Eagle, 2003; Fonagy, 1999; Sandler & Sandler, 1997). From a contemporary perspective, then, psychoanalysis works by modifying procedural mental models and the accompanying emotions that are generated and enacted in particular self-other relationships (Bowlby, 1988). Therefore, bringing implicit/procedural structures into conscious focus in an emotionally meaningful way is a critical component of therapeutic action (Eagle, 2003; Fonagy, 1999; Fosshage, 2011; Orange, 1995; Pally, 2005; Renn, 2010, 2012; Schore, 1994; Sandler & Sandler, 1997; Shimmerlik 2008; Wachtel, 2008).
Given the implicit and explicit dimensions of therapeutic action, it is, of course, important that the therapist becomes aware of the implicit/procedural aspects of his or her own affect and behaviour, as well as that of the patient, so that implicit/enactive aspects of the exchange can be spoken about and reflected on. The dual aspect of therapeutic action suggests that the therapist functions both to enact and reflect on the interaction (Fosshage, 2011; Pally, 2005; Reis, 2009a, 2009b; Wallin, 2007). From a neuroscience perspective, utilizing the explicit, declarative system of the hippocampus allows optimal implicit/procedural interactions between patient and therapist to become more strongly encoded in the patient’s amygdala and basal ganglia of the implicit memory system with the outcome that these more optimal procedures are activated automatically and habitually (Pally, 2005). As previously noted, this process links the nonverbal and verbal representational domains of the brain, thereby facilitating the transfer of implicit/procedural information in the right hemisphere to explicit or declarative systems in the left. Thus, body-based visceral-somatic experience is symbolically transformed into emotional and intentional states of mind that then become available for reflection and regulation (Damasio 2000; Schore 1994). Optimally, these new forms of agency and shared experiences become encoded in the systems of implicit/procedural memory as second-order representational models (Fonagy, 1999).
Conclusion
It is, of course, enormously heart-warming and gratifying when our patients change, finding new ways of experiencing themselves and relating to others, seemingly as a result of their work with us. But I think that we need to be realistic, too, and acknowledge the limits of therapeutic action and that psychotherapy cannot bring about a complete cure. Thus, while the findings from neuroscience have revealed the ongoing plasticity of the brain, with new neural connections being made in response to novel environmental challenges and demands, such data also indicate that the traumas we have experienced do not disappear as a result of treatment, but live on within us and may, therefore, re-emerge in certain stressful contexts that cue the retrieval of trauma-related implicit memories (Pally, 2005; Schacter, 1996). At such times, silent representational models from the past may be activated, and old implicit/procedural ways of functioning become dominant once again in the present. In this more limited sense, therapeutic action consists in helping patients to have meaning for their traumatic experience and to enhance certain capacities, specifically affect regulation and mentalization. The goal here is to provide the patient with the resilience, self-agency and inner resources to recognize the activation of sub optimal representational models and the ability to transition out of a traumatic psychobiological self-state into a more coherent, organized and reflective self-state. To this end, I have argued that an intersubjective, psychodynamic model can use the power of an emotionally meaningful therapeutic relationship to gradually facilitate both relational and neurological changes in patients with trauma histories.
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Paul is a qualified Psychoanalytic Psychotherapist, based in Twickenham, United Kingdom.
With a commitment to mental health, Mr Renn provides services in English, including Psychoanalysis.
Mr Renn has expertise in Abuse (Emotional / Physical), Anger Management Issues, Anxiety Disorderss (Panic), Anxiety Disorders (Phobias), Attachment Issues, Behavioural and Emotional Problems, Bereavement and Loss, Depression, Dissociative Difficulty and Divorce and/or Separation.
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