“The body remembers what the mind forgets”

J.L. Moreno

Abstract
The most important early interpersonal patterns are coded on subcortical neural structures which rapidly complete their development soon after the birth. Development of cortical structures takes a gradual process which continue across several years of life. Early mother-child attachment patterns (secure or insecure) develop mostly in the first year literally before the development of cortical neural systems which are necessary for explicit memory. Since the only memory system is implicit memory in the first year, early attachment experiences are far from conscious and declarative retrieval. Therefore, in order to work on insecure attachment patterns in psychotherapy, it is necessary to track the traces of senses, emotions and actions through a close contact with the body. Psychodrama is a psychotherapy system which fulfills this need because it enables us to work on somatic, psychic and social roles simultaneously. Affective and body reactions from implicit memory are integrated with episodic memory scenes and semantic clarifications of explicit memory on psychodramatic trips. This is at the same time an integration of memory systems which is possible by means of action insight. 

This presentation is about power of Psychodrama on integrating different memorial systems in relation with early attachment patterns. It is an interpersonal psychotherapy system which provides us with a secure base for restructuring insecure attachment patterns and forming new healing bonds with life.

As the Founder of the Attachment Theory, John Bowlby, criticized mainstream psychoanalytic viewpoint because of its overemphasis on drives/ fantasies and underestimation of real-life experiences. Even though he is coming from classical psychoanalytical background, he believes in critical value of early mother-child experiences. Bowlby believed that attachment had an evolutionary component; it aids in survival. "The propensity to make strong emotional bonds to particular individuals is a basic component of human nature" (Bowlby, 1980). The real nature of the attachment bond between mother and baby determines attachment patterns which are lifelong blueprints of close relationships.

 

Function of the Attachment System

 

Attachment behavior helps the baby to maintain closeness to a special person in order to feel himself as physically and emotionally secure. (Jellema, 1999; Page, 2001). Consistency in this secure position gives way to form positive mental representations of the  self and the other as part of the attachment relationship. Positive mental representations are potential self-regulating components in the future.

Mother’s sensitivity in response to emotional signals coming from the baby has a critically important role in terms of how the baby will organize his own emotional experiences.  If he feels that the mother is sensitive and responsive towards negative emotions, he will more likely to learn how to regulate distress with strategies that involve seeking comfort and support which facilitates the development of secure attachment. If distress signals are met with insensitivity and inconsistency by the care giver, the child is likely to associate distress with aversive consequences and will develop coping strategies contributing to insecure attachment (Brown and Wright, 2001).

Similarly, Moreno stressed the importance of mother-child relationship in the first psychic universe where the child needs a social placenta in order to survive (Moreno, 1953). Mother serves as the first double for her child and they walk with each other by being, doing and feeling together. Social placenta helps the child growing in a secure bond which forms the roots of his/her future self-confidence (Özbek & Leutz, 1987). Zerka Moreno (1975) views the period as critical for recognition and approval of the child’s existence.  Fulfillment of the needs of this developmental phase is a promise for future healthy sociometric choices in intimate relationships (Altınay, 2010). I think the wholeness between mother and baby in this stage is necessary for perceiving the world as a secure place to live for a baby who is not yet ready to cope with an anxiety of feeling himself as a separate being.

 

Attachment Patterns

 

According to Main, Kaplan and Cassidy (1985) every baby has a biologically based tendency to seek to maintain proximity to the caregiver. The possible caregiver responses to this infant proximity-seeking intention are limited. She either permits or blocks the attempt of the baby or behaves inconsistently. The type of responsiveness of the mother results in the corresponding organization of attachment. 

Ainsworth, Blehar and Waters (1978), developed a paradigm to classify attachment security, termed “strange situation”. Classification was based on the child’s response to a structured procedure, in which infants were exposed to two brief separations and reunion with their mothers. Ainsworth identified three different attachment strategies depending on infants’ reactions in this situation. Secure, avoidant and ambivalent attachment... 

Securely attached infants were slightly distressed after the separation. Upon reunion they sought contact with their mothers and could easily be comforted and were able to use the mother as a secure base from which to explore the environment. Mothers of secure children were available and responded consistently and sensitively. 

Anxious-ambivalent infants responded with heightened expressions of anger upon separation and were hard to settle when reunited. Their mothers were observed to be inconsistent and intrusive in their parenting.

Anxious-avoidant infants behaved in a detached manner when their mothers returned as if unaffected by the separation and were unable to use the caregiver as a base from which to explore. These mothers were observed to behave in a rejecting manner.

 

Internal Working Models

 

As a result of repeated interactions with the attachment figures infants develop organized representational structures which Bowlby called internal working models (IWM). Reflecting the systemic nature of behavior, internal working models are representations of appraisals of the caregiver’s responsiveness to the child’s expression of attachment goals and of the child’s own worthiness to deserve this care. IWMs function as mental maps in the brain. Some interpersonal information is processed by means of these maps. They are unconscious and assumed to be saved in the implicit memory (Bowlby, 1973; 1980; Hazan ve Shaver, 1994; Knox, 1999; Main ve ark., 1985; Page, 2001; Schore, 2000). While they are relatively enduring structures, they are at the same time open to new experiences for healthy survival.

Neurobiology of Attachment

and Stress Behavior

Brain systems dominating stress coping behavior grow in the early phases of development and affected by the quality of the primary relationship. As well as autonomic nervous system (ANS), limbic structures of central nervous system (CNS) are also important in affect regulation and stress reactions. Right hemisphere has deeper connection with both the limbic system (Tucker, 1992) and ANS than the later developing left hemisphere. It is therefore more dominant for the human stress response (Wittling, 1997).  Schore (2000, 2001) suggested that the limbic structures are intimately tied to attachment, because compared to the left “the right limbic system may be better connected with subcortical neurochemical systems associated with emotion”. Postnatal early phases have critical importance on growth of limbic-autonomic structures because they mediate stress-coping capacities for the rest of the life span.

Dayton (2005) summarizes the main implications of studies on neurobiology of early life experiences by saying that “Studies in neurobiology point to how critical the early environment is in laying down the neural wiring that becomes part of our emotional regulation throughout life” (p.160).

 

 

Attachment Experiences

And Brain Development

 

Orbitofrontal cortex is a corticolimbic area between cortex and subcortex which is thought to be strongly effected from the quality of attachment relationship.

It is known that its major maturational change begins at 10 to 12 months which completes the critical period of growth from middle to the end of the second year. This time frame is identical to maturational course of Bowlby’s  attachment system.

This prefrontal system has a capability of rapid evaluation of environmental stimuli which requires monitoring feedback about the current internal state in order to make assessments of possible coping resources. It updates the appropriate response outputs in order to develop adaptive adjustments to the environment. The integrity of orbitofrontal cortex is needed for acquiring specific knowledge about regulating interpersonal behavior.

The orbital prefrontal region is especially expanded in the right hemisphere which is specialized for inhibitory control and it comes to act as an executive control for the entire right brain.

Early Stressful Experiences

Early adverse developmental experiences may leave permanent physiological reactivity in limbic areas of the brain behind, thereby inhibiting its capacity to cope with future stressors. Cortisol (a stress hormone) can also be produced in response to a danger that has not been consciously registered, galvanizing implicit memory in the right hemisphere.

Once programmed in, the reactions that went with the initial period of abuse or neglect are immediately reactivated whenever a reminder occurs, whether or not the threat is real.

These surges of cortisol also cause cell loss in the hippocampus, damaging learning and explicit memory (which is why some trauma cannot be recalled, only restructured) (Balbernie, 2001).

At the same time extreme amygdala activity in the face of stressful situations also deteriorates hippocampal processes. These effects may impair cortical consolidation.

Early traumatic experiences that affect the formation of limbic and subcortical areas of the brain result in extreme anxiety, depression and a lack of ability to form secure attachment. On the other hand, secure attachment can promote resilience so that secure infants can cope with stressful events without their cortisol levels rising.

Attachment and Cognitive Processes

It is important to note that not just painful experiences but novelty itself is a stressor for babies. However, the capacity to approach, tolerate and incorporate novelty is fundamental to the development of cognitive processes. Naturally, babies prefer novelty. So effective coping with stress and ability to achieve affect regulation becomes important for healthy cognitive processing. A mind of a baby who has a “secure base” is ready to explore environment.

Information processing needs consistency in order to discard redundant information. Inconsistency increases loads of attentional system which has a restricted capacity. Overloaded attentional system has a difficulty in preference for novelty. Unstable representations in insecure anxious babies overloads attentional system which may impair novelty processing. Even though avoidant babies have more stable representations, negative rigidity and difficulty in emotional regulation may result in withdrawal of attention from the external world which is full of negative experiences.

Forms of Memory

There are two main systems of long term memory in human beings: Implicit and explicit.

Implicit memory relies on brain structures that are intact at birth and remain available to us throughout life. Implicit memory involves parts of the brain that do not require conscious processing during encoding or retrieval. When implicit memory is retrieved, there is no awareness of remembering. But it influences here and now feelings, perceptions and behaviors. It is mediated via brain circuits involved in the initial encoding and independent of the medial temporal lobe/hippocampus.

Explicit memory is a form of memory requiring conscious awareness for encoding and having the subjective sense of remembering. It includes semantic (factual) and episodic (autobiographical) memory. Explicit memory begins to develop by the second birthday following the maturation of hippocampal structures and orbitofrontal cortex. 

Attachment Patterns and Forms of Memory

Attachment patterns represented by internal working models are maintained in implicit-procedural memory which is assumed to be localized in orbitofrontal cortex.  Since early trauma experiences cause damages in hippocampal structures, explicit encoding and retrieval processes are expected to be deteriorated. Even though attachment relationship is represented in the implicit memory, there is an evidence that early experiences are indirectly effective on developing explicit memory system and its declarative functions (Türköz, 2007).

Research also indicated differences between insecurely attached groups dominant memory systems. Those who have insecure-avoidant attachment patterns repress disturbing emotional experiences and develop relatively strict semantic memory organizations. They have difficulty for recalling their childhood memories since parent(s) usually deny what happens. On the other hand, people having insecure-anxious attachment pattern mostly rely on episodic memories since they have a difficulty to integrate inconsistent experiential scenes to reach general semantic inferences (Page, 2001).

Those functional difficulties in information processing systems appear as constraints in therapeutic processes. Psychotherapy of persons who have any insecure attachment patterns should depend on restructuring semantic and episodic memory systems by appropriate methods and techniques. Because psychological healing needs to be integrative and narrative for our whole life experiences.

Psychotherapy in Restructuring

Attachment Patterns

It is known that effects of psychotherapy are not only psychological but at the same time neurobiological. Pioneers of this field suggest that psychological healing process at first changes the functional bonds between neurons which over time results in concrete structural changes on cerebral cortex. Psychotherapy facilitates recalling subcortical affective experiences. However there is a need for cortical activity to process them; namely awareness... In any powerful therapy technique integration between affect and cognition should be increased (Balbernie, 2001; Cozolino, 2002; Liggan ve Kay, 1999).

Bowlby stressed the importance of therapist’s role on exploring internal working models and restructuring them. According to this approach the therapeutic bond is itself an attachment relationship. In my opinion, if a therapist provides a secure base on which  the client  finds an opportunity to awaken his/her own implicit memories, it is possible to find a way to explore internal working models and actively work on them. We know that they are living structures which are subject to be reidentified with new experiences.

Alan Schore (2000) emphasized lifelong plasticity of orbitofrontal cortex and suggested that developmentally based and affect focused psychotherapy approach can change this brain structure together with attachment patterns.

I think for the clients with insecure attachment patterns, the therapy system in practice should be a containing nature, it should provide a secure base on which mind and body can interact freely so that episodic and semantic memory systems come across and find a way to be integrated by healthy affect regulation experiences.

Psychodrama

Moreno (1953) says, “The self emerges from the roles we play, rather than the roles emerging from a self that has not yet had the opportunity to be formed and integrated.”  This viewpoint interposes with Bowlby’s conceptualization of internal working models where baby develops a self-model depending on the nature of the relationship with the primary care giving environment. Both theories point out a necessity of developmental therapeutic approaches in order to heal wounds of the self and to complete the unfinished story of healthy growth.

Based on the role theory of Moreno, psychodrama as a developmental system of psychotherapy relies on role development by using creativity and spontaneity on the core functions of double, mirror, auxiliary ego and role reversal. Since all the roles whether somatic, psychic, social or transcendental are interactive while developing, the therapeutic environment should be welcoming to all the roles simultaneously and in touch with them.

Tian Dayton (2005) matches the core aspects of psychodrama with the stages of role development on the road to maturity. She called the first stage as “the double” phase where somatic roles are dominating the life and mother (primary care giver) is the first double of the baby. Moreno defines this as “the matrix of identity” in which the infant coexists with the mother. If the parent is an attuned double for her child, healthy dyadic emotional regulation is achieved in this coexistence which helps in developing capability of self-regulation. The deepest seeds of self-development are planted on this phase. The second universe is called “the mirror” where an experience and awareness of separate self gradually emerges. The child begins to perceive the beings in the environment no longer as the self but as reflections of the self. The surroundings still seem to be under her control where back reflections of the environment become important. The mirror period is critical for identifying and separating the self in secure circumstances and growing positive self-value. The third stage is “auxiliary ego” which is a developmental period whose task is separation/individuation of the self in relationship to others. The child begins to perceive others as separate beings, but she cannot distinguish inner worlds from each other. She imagines that they share the same feelings with her. Codependence is the main characteristics of this stage. I suppose healthy development needs supportive existence of significant others who are able to put empathetic interpersonal boundaries. The fourth developmental period is called “role reversal” where a true sense of separateness is achieved. The child has a capacity to perceive others as different beings with their own thoughts, needs, feelings, choices etc. Maturity of this stage teaches us the fact that the others are not as we wish they were but as they are. Eventually we become capable of having an encounter with another subjectivity which is completely different than ours’ where an intersubjective role reversal is possible without a need for compromise.

Comprehensive psychodramatic system of developmental theory and therapeutic techniques undoubtedly cover all these developmental phases where early rooted self-wounds can be identified and healed.

An Organisation of Memory on

Psychodrama Stage

Psychodrama as experiential and action-based system easily triggers subcortical implicit material which can also be processed on a cortical level in the same session and/or over the following sessions.  

Primary memory system of a baby is implicit procedural memory as explained above. Attachment related experiences are also collected and saved in this system far from later developed explicit (declarative) memory. So, activation of implicit memory does not sense as if it is a remembering process. It just creates some changes on the feelings and behaviors at the moment which deserves genuine effort to hold them and walk with them carefully. Remembering is a here and now active process and how to remember is as important as what to remember.

Intensive feelings on a psychodrama stage are usually not the results of conscious remembering but just the experiences of affective associations. In other words, they are artifacts of activated implicit memory. But if the psychodramatist tracks these affective reactions of the protagonist and contain them patiently, it is highly possible that some particular episodes come out to be enacted. This phase opens a way to form a stage, use several techniques, explore and identify discovered reality and reach action insight at the end. The critical thing here is being able to integrate episodic and semantic material.

As an example, during a warming up phase one of the group members suddenly begins to weep without any awareness. Then the therapist picks her as the protagonist, and they begin to work where a memory of an abuse of the mother comes out. By the help of auxiliaries and the leader she becomes aware of the fact that she denied deteriorating effects of this trauma and took this as an unordinary expression of love of her mother. In other words, the protagonist discovers her semantic distortion of episodic memory material. This gives an opportunity to correct the distortion and reidentify past painful experiences. Cathartic phase should focus on this pain which had been repressed. On the secure base of psychodrama stage, the protagonist can find a way to live and express her deep feelings with true doubling. Strong support of the group encourages self-regulation of feelings which is very important for secure attachment.

Since psychodramatic action is highly stimulating for episodic memory, it is ideal for insecure avoidant members who have a difficulty on recalling aversive past experiences. On the other hand, members with several semantic memory difficulties (ex. distortions, cognitive ambivalence, denial etc.) can also benefit from doubling, role reversal and mirroring as well as spontaneous action of auxiliaries in the enactment stage. After all, role feedback and sharing phases of the session is the best way to integrate episodic and semantic experiences for the whole group.

 

Moreno had introduced us a very comprehensive system defined as sociometry which is dialectical, dynamic and progressive including all the possibilities of interpersonal world. Moreno as an answer to his own question “who shall survive?” certainly points out those ones who are able to discover and use healing techniques of sociometry.

 

“Since we are wounded in interaction, that is where our healing should occur.”

J. L. Moreno

 

REFERENCES

Ainsworth, M.D.S., Blehar, M.C., Waters, E., ve Wall, S. (1978). Patterns of attachment: A psychological study of the strange situation. Hillsdale, NJ: Erlbaum.

Altınay, D. (2010a). Tangodrama. Psikodramada Çağdaş Yaklaşımlar. Ed. Deniz Altınay. İstanbul: Sistem yayıncılık.

Balbernie, R. (2001). Circuits and circumstances: the neurobiological consequences of early relationship experiences and how they shape later behaviour. Journal of Child Psychotherapy, 27(3), 237-255.

Bowlby, J. (1973). Attachment and Loss: Cilt 2. Separation: Anxiety and anger.  New York: Basic Books.

Bowlby, J. (1980). Attachment and Loss: Cilt 3. Loss: Sadness and depression. New York: Basic Books.

Cozolino, L. (2002). The Neuroscience of Psychotherapy. NewYork: W.W. Norton.

Dayton, T (2005). The Living Stage. New York: Health Communications. Inc

Dayton, T. Neuroscience and Psychodrama:Validating the Mind/Body Approach of Psychodrama. Opening Plenary at the 64th Annual Conference in San Francisco, CA

Dökmen, Ü. (1995). Sosyometri ve Psikodrama. İstanbul: Sistem yayıncılık.

Hazan, C. & Shaver, P.R. (1994). Bağlanma: Yakın ilişkilerle ilgili araştırmalar için bir çerçeve (Çev. Ali Dönmez). Türk Psikoloji Bülteni, 16-17, Mart-Haziran 2000, 29-50.

Holmes, P. (1992). The Inner World Outside: Object relations theory and psychodrama, London: Tavistock/Routledge.

Jellema, A. (1999). Cognitive analytic therapy: Developing its theory and practice via attachment theory. Clinical Psychology and Psychotherapy, 6, 16-28.

Kellermann, P.F. (1992). Focus on Psychodrama: The Therapeutic Aspects of Psychodrama. London: Jessica Kingsley.

Knox, J. (1999). The relevance of attachment theory to a contemporary Jungian view of internal world: internal working models, implicit memory and internal objects. Journal of Analytical Psychology, 44, 511-530.

Liggan, D.Y. & Kay J. (1999). Some neurobiological aspects of psychotherapy. Journal of Psychotherapy Practice and Research, 8(2), 103-114.

Main, M., Kaplan, N. ve Cassidy, J. (1985). Security in infancy, chilhood and adulthood: A move to the level of representation. E. Waters, (Ed.), Growing points of attachment and research. Monographs of the Society for Research in Child Development, 50 (1-2, serial no: 209), 66-103.

Moreno, J.L. (1953). Who Shall Survive? A New Approach to the Problem of Human Interrelations. Washington: Nervous and Mental Disease Publishing Co.

Moreno, Z.T. (1975). The significance of doubling and role reversal for cosmic man. Group Psychotherapy & Psychodrama, 28, 55-59.

Özbek, A. Ve Leutz, G. (1987). Psikodrama, Grup Psikoterapisinde Sahnesel Etkileşim. Ankara: Has-Soy Matbaası

Page, T.F. (2001). Attachment and personality disorders: Exploring maladaptive developmental pathways. Child and Adolescent Social Work Journal, 18(5), 313-334.

Schore, A. N. (2000). Attachment and the regulation of the right brain. Attachment and human development, 2(1), 23-47.

Schore, A. N. (2001). Effects of a secure attachment relationship on right brain development, affect regulation and infant mental health. Infant Mental Health Journal, 22(1-2), 7-66.

Schore, A. N. (2002a). Advances in Neuropsychoanalysis, attachment theory and trauma research: Implications for self psychology. Psychoanalytic Inquiry, 22(3), 433-484.

Tucker, D.M. (1992). Developing emotions and cortical networks. In A. Schore, (2001). Effects of a secure attachment relationship on right brain development, affect regulation and infant mental health. Infant Mental Health Journal, 22(1-2), 7-66.

Türköz Y. (2007). Okulöncesi Çocuklarda Bağlanma Örüntüsünün     Kişilerarası Problem Çözme ve Açık Bellek Süreçlerine Etkisi. Doktora Tezi, Ankara Üniversitesi.

Wittling, W. (1997). The right hemisphere and the human stress response. Acta Physiologica Scandinavia Supplement, 640, 55-59.