Seeing the Invisible

The Role of Recognition in Healing from Neglect and Deprivation

By Kari A. Gleiser, PhD

Abstract:
Attachment experiences between caregiver and child are powerful sculptors of personality, and become key determinants in how an individual relates to self, other and emotions over a lifetime.  When a child’s early attachment relationships are characterized by recurrent “errors of omission” ­– neglect, deprivation, misattunement, and lack of affection, recognition and/or affirmation — that child can develop areas of psychic darkness or invisibility, in which parts of the self that are not seen and mirrored become dissociated.  Such children, and later adults, may struggle with chronic and profound feelings of emptiness, detachment, unbearable aloneness, identity diffusion and avoidant attachment patterns.  Because such attachment wounds are, by their very nature, absences, they can easily go undetected, leaving individuals who have lived through them with incomplete life narratives.  Such “invisible” traumas are hard to heal because they are hard to see, and left unrecognized, can become self-perpetuating, both relationally and intra-relationally.  In this paper, we will explore the case of a woman who grew up in a family rife with errors of omission.  In addition to struggling with an avoidant attachment style, she also lived through cycles of re-enactment — both with others and within herself — in which her emotional needs went unrecognized and unmet.  Relational and intra-relational interventions aimed at forging new attachment bonds between 1. therapist and client, and 2. the client and an “invisible” part of her are illustrated. Recognition plays an essential role in creating these bonds and sparking deep emotional processing of grief.

“What is essential is invisible to the eye.”

(The Little Prince, Saint-Exupery)

“The existential need for recognition and the functional need for effective action on behalf of the self are powerful motives; they are both manifestations of transformance.”

(Fosha, 2008, p. 3)

Attachment relationships wield considerable influence over a child’s emerging sense of self (Bowlby, 1980).  A primary force in the “nurture” half of the “nature/nurture” dialectic, attachment experiences mold, reinforce and even transform personality, for better and for worse.  When the relational field between caregiver and child is rich and fertile, it features elements of  “empathic recognition of the self” (Fosha, 2002), including comfort, protection, and delight, thus fostering a sense of ongoing connection and responsivity, even the face of ruptures and misattunements.  This allows the child to grow in climate of feeling seen, understood, supported and appreciated.  These elements are also, not coincidentally, essential to the co-creation of secure attachment in psychotherapy, which becomes the foundation for the deep emotional processing that promotes healing from attachment trauma.

When the relational field is, by contrast, barren, parched, or rocky, it can be characterized by a range of errors of commission, such as physical, emotional or sexual abuse, high levels of conflict, criticism and shaming; or errors of omission, such as neglect, deprivation, misattunement, and/or lack of affection, recognition and/or affirmation (Fosha, 2000).  While errors of commission may leave more visible wounds and scars, errors of omission can also wreak destructive havoc on the developing mind, with the added twist of being invisible and often unrecognized by self or others.  This paper will focus on the deleterious effects of the more insidious errors of omission, and how recognition is a cornerstone of the healing process (see also Fosha, 2013, in press).  We will explore the sequelae of emotional neglect in the case of a high-functioning woman with an entrenched avoidant attachment style, and witness how, in a single session, therapist and patient are able to co-create new, more secure attachment patterns.

On Neglect

Because early caregiver relationships lay down the initial templates for a child’s relational patterns and sense of self across the lifespan (Bowlby, 1980), they wield a formidable and enduring formative influence.  From the very first moments of life, an infant is assailed by a tumbling cascade of external and internal stimuli, which create a variety of basic needs such as hunger, fatigue, temperature regulation, and proximity to a caregiver.  Unable to regulate any of her own states or meet any of her own needs, the infant is entirely dependent upon caregivers to 1. recognize her needs as they arise (i.e. know that the baby is hungry); 2.  mirror these needs back to the baby (i.e. cooing, “Oh, you’re hungry, time for some milk”), and 3. respond appropriately to these needs (i.e. by nourishing the baby in a peaceful, pleasant, satisfying way).  As the infant grows into a child, adolescent and adult, these needs evolve, growing more complex and nuanced; however, the need for accurate recognition and reflection of who she is and what she needs from others, remains a constant throughout the life cycle.  These relational dynamics form cornerstones of identity as well as create templates for future relationships and attachment style (Bowlby, 1980).

When caregivers are not able to execute this crucial sequence of recognition-mirroring-responding, this failure can create a “dead spot in experience” (Kestenberg in Schore, 2002) in which “both the subjective self and intersubjective field instantly switch off and do not exist” (Schore, 2002, p. 454).  Parental vulnerabilities and defenses (e.g. trauma, dissociation, denial, projection, narcissistic personality structure) can interrupt this delicate sequence of attunement, and essentially ‘drop’ the infant or child in moments of distress, acute vulnerability or painful neediness.  If the child’s internal resources are exceeded, and they have no access to succor, this can lead to a sense of desperate dysregulation, blind panic, and ultimately, unbearable aloneness (Fosha, 2000).  Often, the only refuge left is dissociation, cutting oneself off from intolerable emotion, experience, and, tragically, vital parts of the self.  In addition to dissociation, such experiences create templates of insecure or even disorganized attachment to others (Lyons-Ruth, 2006).

For individuals who have endured ‘invisible’ childhood traumas of chronic misattunement, deprivation or neglect, but do not yet have the perspective to identify or label them as such, these templates assume additional damaging power as they become deeply threaded into the fibers of personality with little or no awareness of their historic or relational roots.  These emotional and behavioral grooves then give rise to endless, unconscious re-enactments that feed a vicious cycle of stigma, shame, stuck-ness and confusion. Furthermore, victims of the hidden trauma of neglect often shoulder the burden of blame, attributing their deprivation to an internal flaw in their own natures.  For a child who has had impoverished mirroring in his primary attachment relationships, his capacity for internal recognition is often compromised, with his vision of himself distorted or frail. This internalized invisibility, in turn, can forge an incomplete life narrative, pocked with gaps, “dead spots,” and chronic feelings of alienation and emptiness.

On Recognition

The idea of recognition as a key ingredient of the healing process threads through decades of therapeutic theory and practice: from Carl Roger’s (1949) notion of “emphatic listening,” which entails not only taking in the other through active listening, but also empathic reflection back, to Winnicott’s classic paper on the mother’s face as mirror to her baby.  Winnicott (1971) writes, “What does the baby see when he or she looks at the mother’s face?  I am suggesting that, ordinarily, what the baby sees is him or herself. In other words, the mother is looking at the baby and what she looks like is related to what she sees there.”

(Winnicott, 1971, 112)

Winnicott goes on to say that when the mother is unresponsive, the baby will withdraw in order to avoid the threat of chaos, and will stop seeking out reflections of him or herself in others around him or her (ibid.)

Bowlby (1980) built on these ideas, theorizing that repeated emotional exchanges with caregivers are basic building blocks that, over time, construct reliable (if not always accurate) templates of self and other; in other words, how important others in child’s life perceive, respond to and mirror that child are formidable sculptors of personality.  Schore (1994) translates this into the language of neuroscience, saying that an infant’s right brain is actually hardwired by affectively charged interchanges within in the caregiver/baby dyad.  Finally, research into the function of mirror neurons has implicated them in the recognition of actions, intentions and feelings of other, as well as in the phenomenon of empathy (Iacoboni, 2009).  In fact, Iacoboni asserts that mirror neurons are the neural substrates of primary intersubjectivity between an infant and caregiver and that the mirror neuron system is actually created and nourished by these interactions.  He presents compelling research supporting the notion that “mirror neurons – through a simulation mechanism – map the actions of other onto the self”  (Ibid, 147).  This seems to suggest that mirror neurons are responsible not only for recognition of the actions and intentions of others and for self-recognition, but also for recognition-as-emotional-process that we will explore below and in the clinical transcripts to follow.

While all of these theories imply or allude to the vital role of recognition, Fosha (2009) examines head-on recognition as a developmental and healing process.  She views recognition as, at once, a transformative and an integrative process: “recognition is the internal experience we have when something clicks into place” (2009, 178).  She goes on to say,

“Recognition is always ‘dyadic’ in that it involves two things fitting together, but it is not necessarily relational or interpersonal:  the fit can be between self and other, but it can also be between self and self, or self and process, or self and experience.  The ‘click’ occurs between what is felt as ‘me’ and ‘not me,’ in a way that feels right and allows what was felt as ‘not me’ to eventually become integrated into ‘me.”

(Fosha, 2009, 179)

Recognition, when occurring between two people, or even two parts of the self, can be conceived as a process that can be deconstructed into various sub-processes.   A necessary precondition is a sense of openness or receptivity (Fosha, 2000) in both parties.  Next, at least one member of the dyad  (i.e. the therapist) must accurately perceive and receive the other; a level of attunement has to be, at first, unidirectional, then bidirectional as the two members of the dyad move into synchrony with one another.  For this to happen, the other member (i.e., the patient) also has to be in a state of heightened receptivity to take in what is being reflected back. Then, when the therapist communicates back, either non-verbally or verbally, and often with a healthy dose of emotional self-disclosure (Prenn, 2009), the patient is able to receive it and respond in turn.  The patient is, in a sense, both being met and coming forward to meet, and in that moment, the process becomes deeply mutual.  

In therapy, this experience tends to be not only a cognitive, but also an emotionally charged moment [1], which may unlock negative affects such as grief, as well as waves of positive relational affects (Russell & Fosha, 2008) related to (finally!) being deeply seen, known, affirmed (Fosha, 2000).   It is inherently pleasurable to be deeply seen and resonated with, aside from any trauma, grief or anxiety that may be associated with this experience.  Attending to both positive and painful emotions associated with the experience of recognition creates an opportunity to not only heal past relational trauma, and process emotions associated with such trauma, but also to lay down new relational templates.  This process is especially crucial in the aftermath of the invisible traumas of neglect and deprivation, the hallmark of which is the absence of essential developmental, life- and growth-sustaining experiences.

AEDP identifies the culmination of a full wave of emotional processing as core state, in which patients are calm, peaceful, open, engaged, in touch with deep founts of wisdom and clarity (Fosha, 2000).  In this expansive state, transformations are consolidated and the lens of perspective on their lives is widened.  In core state, patients often begin the process of re-writing their life narrative, integrating the emotional and relational experiences they have lived and processed during the session.  One could argue, therefore, that this is yet another facet of the process of recognition:  weaving in the new insights, emotions, and understandings illuminated by various external recognitions (i.e. between therapist and patient) and/or internal recognitions (i.e. parts of the self coming to know and understand each other), leads to a higher order recognition that has to do with reconstructing one’s life narrative.  Having articulated and filled in the gaps of absences and invisibilities, dropped moments, dead spots, what emerges is a more cohesive, complete, integrated and compassionate recognition of the long swath of their personal history.

The following, very brief fragment from a therapy session with a long-term patient (not the same patient in the extended clinical case below) poignantly and succinctly conveys the many layers of dyadic interplay of recognition.

Th: (interrupting a flow of patient narration; with tears in my eyes) I’m having a private moment of deep admiration for you. [self-disclosure of my emotional experience of seeing qualities of the patient]

Pt: (surprised, smiling, a little self-consciously) Why? 

Th: For the sensitivity and care and mindfulness that you bring to understanding your relationships. [naming and affirming positive qualities that I see in her]

Pt:  (Her eyes fill with tears and she cries softly.) 

Th: What’s it like to hear me say that?  I can see that it touches something deep inside. [gently nudging her to put into words the emotional reaction that the recognition creates in her]

Pt:  It’s the way that I’ve always wanted to be seen in the world, the values I’ve always wanted to live by and what I’ve always longed for others to see in me.  And you see them.  And what’s sad is that I’ve always longed for my parents to see that in me, but I’m not going to deny myself that experience just because they are not capable.  Because you see it, and I see it in myself, and it feels amazing.

This brief exchange illustrates what I’ve come to think of as ‘resonant recognition,’ wherein a dyadic process of recognition unfolds in such a way that it is difficult to tease apart the separate elements.[2]  In this dialogue, I notice and name something that is not, per se, new to the patient – she clearly knows this about herself.  She can even identify an age-old longing to have it seen and affirmed by others, and the lack of this in her life thus far.  Something about my recognizing, articulating and feeling appreciation for her deep relational capacity allows it to click into place (Fosha, 2009) in a new way.  The fact that recognition is not merely a cognitive process, but also a deeply emotional one, for both parties, is clearly highlighted here.  I am moved to tears by what I see, and I think that paves the way more so than my words.  In turn, the patient is able to feel both the grief about past deprivation, but also how “amazing” it is to have it seen by me and by herself in this moment.  It is almost as if this dyadic process of recognition allows her to possess these qualities in a more integrated, felt and secure manner.

Clinical Case

Sami is a 42 year-old, single, White female, who lives split between a New England city, where her boyfriend of one year lives, and a Midwestern city, where she is developing a work project.  She sought therapy with me after a number of unsuccessful therapies, in which she always ended up feeling more like a friend of the therapist than a patient.  She expressed frustration that her previous therapists couldn’t help her plumb the emotional depths; they saw her as high functioning and healthy and ultimately not in need of therapy.  Indeed, Sami presented as dynamic, charming, intelligent, highly successful in her work (she started a nonprofit to build schools in impoverished locales). Yet Sami struggled with close relationships: most of her friendships were long distance, and had never had a long-term intimate, love relationship.  She was chronically lonely.

Sami grew up in an intact, middle class family, the only child of parents who had unresolved trauma from their own childhoods.  In this session, she connects with painful emotions related to what she had always intellectually known:  that her parents were chronically misattuned to her, did not recognize her distress, and ultimately failed to see that she was being sexually abused by an older boy in the neighborhood.

This was our second, three-hour session.  Since Sami was commuting two hours each way to do monthly sessions with me, we chose the format of longer, block therapy sessions.

The following session embodies three aspects of recognition, i.e., recognition as 1. a relational core affective experience, that initiates an emotional cascade of grief; 2. a self-to-self encounter, in which the adult patient recognizes and responds to a child part of herself in a moment of unbearable aloneness and 3. a process of integration and re-writing of life narrative.

Part One:  Invisibility and First Light of Recognition

In this first segment, Sami recounts, initially in a detached, factual manner, her sense of not being seen or known by her parents.  She speaks poignantly of her experience of feeling “invisible,” in a tone of disbelief, but remains distant from the pain and grief associated with the deprivation.  The transition to core affect comes via a moment of recognition by me, which seems to serve as a flint, igniting in Sami a more feelingful connection to her experience.

Th: Well, if your parents weren’t yet able, if they hadn’t gotten to the place where they could help you…

Pt: (matter-of-fact) Oh, no, they knew nothing about me, I was invisible.

Th: So that…

Pt: …completely invisible. All my childhood, until I was over the age of 22, I was completely invisible . . . .

Th: How do you feel saying that, ‘before I was 20 I was completely invisible?’ (drawing attention to emotions connected to this observation)

Pt: (speaking with emotional emphasis in the form of mock outrage; still detached from feelings) It was tragic, it was an awful. It was an awful childhood, you know. The person my parents really perceived me being such a distortion of who I was. And they gave me plenty of feedback, telling me who they thought I was, and I thought, ‘isn’t this amazing. You don’t have a clue, do you?’ My mother, in particular, didn’t have a clue. She used to say to me that problems rolled off me like water off a duck’s back. Nothing could have been further from the truth.  (patient is describing a chronic misattunement by primary attachment figures)

Th: Oh my God, here you are, like, holding, carrying… right.  (raising the emotional bar)

Pt:  I was a very lonely, sad kid, I had no friends… (naming a core pathogenic emotional state of unbearable aloneness, but still detached from feelings)

(a few minutes later)

Pt: [My parents] never asked me questions, never, never sought to understand my point of view on anything. Now the rare times when I wanted them to understand something, to get it, (shakes head) I met a wall. They didn’t want, they didn’t want to hear anything.

Th: So when you sit with that right now, just know how that feels…

Pt: It’s awful. (laughs; defensive affect) It’s just horrible, what a childhood I had, oh… It stunk. (pause, resumes with slower speech, more thoughtful tone; this pause is the marker of a state shift, dropping down into more connection with past experience) Somehow though I had this vision of, me, one day, doing something in the world. Like, I always had that. Always. I had this weird sense of, “this too shall pass.”

 

Th: Mmmm.

Pt: I remember saying to myself, unh, I’m, I’m gonna win this one day. You know, my… This is gonna change, I’m gonna make it change.

Th: It’s an amazing strength, I mean the picture that kind of emerges… (affirming resilience)

Pt: I don’t know where it came from, though!

Th: …is this incredible resilience, right. Like, okay, no one’s helping me, I will teach myself social skills, and I will adapt. And, no one is seeing me and giving me positive, and I will… (stops as patient begins crying) (Putting her strength in the context of chronic deprivation — having to do for herself what no one was doing for her — unlocks a well of grief)

Pt: (cries for several seconds and nods) It’s true…

Th: (softly) Yeah, just let it go…

Pt: (crying and wiping eyes) I didn’t see any other options, unh, there’s no… I don’t know…what other kids who face this same thing, what they end up doing. I don’t know… I mean, what do you do, you just give up, and, I don’t know. Commit suicide, or something?  (beginning to allude to and connect with the desperate emotional reality of the situation)

Th: Well, there’s so many maladaptive options, turn towards drugs… (I think I made a mistake her by taking her question literally instead of as an emotional statement, and answering it; we get off track for a few exchanges until I realize the digression and bring us back to the emotional material)

Pt: I did that. In my teens. I didn’t enjoy it, that was a big part of the problem, like I couldn’t even enjoy it. It just so isn’t me to, you know, take a substance and feel deranged. (laughs) So I felt, I really hated it.

Th: I mean you didn’t, you had that clarity, too, and clearly didn’t lose yourself into that.

Pt: I tried to, I did…

Th: ‘I tried to, I wanted it to work!’

Pt: I did, I really did! It was partly defiance, it was partly wanting to escape. It just made me feel awful, and it scared me. So, you know, me and drugs were not a good mix… at all. Um…

Th: So there was something, I just want to back up for a second, something about me seeing that resilience in you, (the moment of recognition; Patient begins to cry again) and that grabbing on, and, you know, just hanging on for your dear life, and making it through, that really touches something so deep and painful… (the recognition by an Other brings her back to the pain and grief)

Pt: (crying quietly) Yeah… I see it in myself every day.  (She is clear that she knows her own strength; what is new here is that it is being recognized by an Other in the context of the emotional deprivation of her childhood.) 

Th: Mm-hm…

Pt: I never worry anymore that anybody’s gonna take me down, or outsmart me, or … or break me, or… I, I know…

Th: Amazing security, yeah.  (The benefit of avoidant attachment and hyper-self-sufficiency….)

Pt: Right…

Th: But, there’s a painful side to it. (And the liability….)

Pt: Yeah, because I didn’t know then. I didn’t know anything, I just knew I had to keep going. I mean, what can you do, there’s no… I had to find my way out of… very tough situations. And in silence. (pause) Yeah. It was tough. (sighs)

Pt: My parents were so unaware…

Th: They were so…

Pt: Unaware. Like, I worked with kids as a teacher for years, I could see, I could see in a child’s face when something was wrong, and, would talk to them about it.

Th: But no one was seeing it, no one to talk to…

Pt: But nobody ever did that with me when I was kid, like how many years, we’re not talking like days or weeks or months but years of never perceiving my pain, my reality, my struggles, never asking a question, like never seeing my face and asking a question. How weird is that?  (really beginning to apprehend the gravity of the situation;  re-constructing a piece of her life narrative)

Th: It’s, it’s tragic, it’s so tragic, it’s so…

Pt: I mean, I guess a lot of parents don’t ask questions, but…

Th: But to say you felt invisible, that is such a profound level of not being seen.

Pt: I was invisible. My world was completely secret. (looking down) My father, when I was an adult, you know, has shared with me some things that he perceived and was worried about. And so, it was… you know, that was a partial kind of seeing… 

Th: Yeah… but you didn’t know it then.

Pt: I didn’t know it. He didn’t help me with it, he didn’t…

Th: Name it, you know, draw closer around it…

Pt: Have any empathy around it, if anything…. He, I think, was afraid was gonna debilitate me, so he’d…give me these really harsh kind of lessons that were supposed to help me. Like I was very afraid to go to grade one. I didn’t wanna go. And… (moving into a specific memory)

In the first part of this session, Sami moves from a disengaged, story-telling, “as-if” defensive stance to full-bodied connection with genuine affect about her caregivers’ deficits and the effect these had on her as a child.  The key moment that brings her into contact with her feelings is a moment of recognition between us; I see something in her that no one saw then, and, for the most part, something that no one sees now, and this puts her in touch with a deep well of grief.  This moment is also significant relationally; Sami moves into a state of vulnerability and openness in sharing her emotions with me.  I have shown myself to be different from her caregivers.  I’m not buying the tough kid façade; I’m seeing underneath it to what is hidden, and saying what I see.  This is a window into the early co-construction of secure attachment. From this connection, and the cascade of deep emotion from Sami, emerges a specific experience that gives us even more access into her internal world.

Part Two: Beyond Mirroring:  Seeing into Being

In this second segment, Sami moves into a specific memory that exemplifies the misattunement and emotional neglect she experienced from her parents and, in this case, also from a teacher.  This memory allows us to initiate a portrayal with a young, dysregulated, distressed part of Sami.  

Th: Grade one, meaning like, six [years old]?

Pt: Yeah, age 6, first day of school. And, um, I was just, I was scared, I didn’t wanna go, I knew it was, I’d seen the building, I’d seen the assembly area, it was enormous. Uh… there were gonna be a coupla hundred kids there, it was an open concept school, where each classroom was, had no walls, it opened onto a large assembly area, that was carpeted that everyone could sit in at once, and it was huge and overwhelming for me socially… (Sami is already somewhat empathically connected to the feelings of her six year-old self in this memory).

Th: Six is so little, for two hundred people, and many open spaces, and… (matching her empathy, seeing it through the six year old’s eyes)

Pt: Right. So I didn’t have, and we were in a new neighborhood so I didn’t know anybody, um, so it wasn’t like I had any friends I could go with, or anything. Um, and so, you know, I’m dressed in my uniform, and he’s, he’s walking me to school, he’s holding my hand, and I’m resisting, you know, and I’m like, I don’t wanna go, and I was crying. And he’s like, and he said to me, pull up your socks and act like a… man, is supposed to be the word, right? And here I am, little six year-old girl. And I just, you know, I just cried all the way to school. And I cried when I got there, and I cried when I was assigned to my teacher, Mrs. Dodd, I think was her name. And, she had enough of my crying after about, I don’t know, half an hour or something, and she told me to lie under her desk. Like a dog, as far as I was concerned. (laughs) Because I wasn’t behaving appropriately, or something like that. And that was that. I was under there, for most of the first day, I’m gonna say. It was terrible! (In this memory, Sami was shamed for her distress, first by her father, who minimized and pushed aside her feelings, and then by her teacher, who banished her to under her desk, “like a dog.”  Sami’s laughter is a defense against feelings she is not yet connected to.)

Th: That sounds awful! (Perhaps, too, Sami was waiting to see my reaction – would I shame her as well, or minimize her distress?)

Pt: (laughs, and then cries) It wasn’t good.  (When I validate the awfulness of the situation, she is able to connect with visceral distress and cry.)

Th: That’s the last thing a little six year old needs, is to be like, banished.

Pt: (sobs, nods) Yeah. Uh huh… (sobs)… I didn’t know my parents saw me as little. (cries)

Th: And that little six year-old, what did she really need?

Pt: (sobs, exhales) You know, it’s interesting. It’s… you know, I was a teacher for many years, and… I didn’t teach kids that young, but, um, it is kind of a hard question to answer, like how do you… (Sami appears to be tempted to seek cover in the defense of intellectualization and generalization.)

Th: What would you have done, if you could go right into that classroom and see this little six year old you just crying, crying, crying, crying, and so scared… (Bringing her back to the specifics of this portrayal, and her needs as a dysregulated six year old.)

Pt: (small sigh) It’s hard to say what would have been the right thing. I mean, some things are clear, like, ah, you know, certainly comforting her, taking her away from the scary situation. And, sitting outside the classroom with her in a quieter space, um…

Th: Uh-huh. So let yourself see that, that you just take her out of that big room, and you say let’s go somewhere, just you and me…(Sami cries) Already just responding to what she needed.

Pt: Yeah. (cries, eyes closed) I don’t think I would have been easily reassured, I don’t think I could have gone off to, a little quiet room, and, and I would have snapped out of it in ten or fifteen minutes, I don’t think that would have happened, I think…

Th: That’s okay. Let’s just stay with what you needed.

Pt: (eye contact, nods, cries) (Having permission to stay with what she needs brings another wave of core affect)

Th: Maybe your fears were big and your stress was big, yeah. Yeah. (I am speaking directly to the little girl).

Pt: (closes eyes, sobs, nods)

(cut)

Th: …so beautifully responsive, like what do you need to feel safe? And no one was asking that to you. (S. rubs chair with hand, nods, cries…) Right? They’re kicking you under the desk, like, here, just hide, so we don’t have to see you cry. What a horrible, horrible banishing.

Pt: (whisper) Yeah.

Th: And leaving you all alone with your distress. (S. sobs) Like that’s gonna make it better. And it didn’t. (Restating the emotional error of omission here, emphasizing and amplifying the emotional abandonment)

Pt: Eventually it did.

Th: Well, you were eventually able to stop crying…

Pt: … But you just reach inside yourself, and (gestures, both sigh) kinda will yourself out of it.  (Planting the seeds of avoidant attachment style: the message being,“ no one is going to help with these feelings, so you better learn how to turn them off on your own.”

Th: Right. But what does it teach you about the world?

Pt: Nothing good.

Th: Yeah, no one’s going to be there to help you. (S. gesture of agreement, nods, crying quietly) Crying doesn’t get you support.

Pt: God, no. Ridicule.

Th: Yeah.

Pt: I mean she, I think she, in her mind she was being nice to me, allowing me to go under her desk and hide from the ridicule that, you know, I must be feeling in the room. I don’t think she thought of it as, ah…

Th: Right, right. But it’s another one of those, like, just complete misses, right?

Pt: Oh, completely. Completely.

Th: May have been well-intentioned, but, it was so not what you needed.

Pt: Right. Well, it’s . . . symbolically, to be under somebody’s desk, like a dog, that’s how I described it, I always describe it to myself as, you know, like a, a lesser creature, you know. So. It was awful.

Th: So being so in touch with these feelings, with the aloneness, with the distress and the fears. If we could go back to this little six-year-old you, so you take her off to a smaller room with you, and bringing that same spirit of creating safety for her that you did with this little third-grader in Bulgaria (referring to a situation in which she was a teacher of a little boy who was upset and she comforted him), what happens next? (Re-orienting to the portrayal, so we can have a sense of completion)

Pt: (sighs) Ah.

Th: What do you see in her as you’ve taken her away?

Pt: Relief.

Th: Uh-huh.

Pt: Relief. (nods) Understood.  (Post-breakthrough affects in this little part of Sami)

Th: Uh-huh.

Pt: (looks away listening)

Th: So just let her know that you see that — that it feels better to be out of the big classroom. So she can feel you seeing her. (small sigh)(emphasizing the internal seeing and recognition, that unleashes another wave of emotion – grief for her little self)

Pt: Yeah. (tears begin; spends a full minute tearing up and crying)

Th: What does that touch inside of you, to see her?

Pt: (talking through her tears) I just wish an adult had been there for her.

Th: Yeah, yeah. But you…

Pt: Any adult, really.

Th: Right. It was such a deprivation.

Pt: And then the teacher, the principal, a parent, heck it coulda been another kid’s parent, it coulda… she needed that. And she came… the experience taught her that something was wrong with her. That she was somehow defect… deficient. Not okay. (scars of internalized shame)

Th: Mm. So just let her know that you see all those things, that you get what that meant to her, so she can feel seen by you.

Pt: (nods looking down. pause)

Th: Now what else would you want to say to her about all of that, if you were to speak to her from your heart? (Working intra-relationally, strengthening the bond between Sami and this little girl part of her)

Pt: (looking down, gaze moving) That I… I know how scary it is. … all those different people around you. And it’s… it’s okay, take your time.

Th: Yeah.

Pt: Don’t need to jump in all at once… and that I’ll be there for her (face expressing pain and crying as she talks).

Th: Yeah, yeah. Just let yourself feel that, on both sides. How do you see her responding, this little six year old you, to hearing you say, I will be there for you.  (Intra-relationally, helping her micro-track the reactions and emotions of this little part)

Pt: (small sob, deep breath) Tearful. And relieved. Trusting… I don’t ever remember having that experience, with an adult.  (Sowing the seeds of secure internal attachment.)

Th: I see that, I see that. I see the profoundness…

Pt: It was horrible! (cries)

Th: of the deprivation. Yeah. You needed that so many times.

Pt: (cries) Yeah.

Th: To be seen, and reassured, and comforted.

Pt: Just never happened… ah… (deep sigh) I don’t know, I, like I don’t know how I made it, through to adulthood, without becoming all messed, like… Wow.  (appreciating her own resilience in the context of emotional deprivation)

Th: So a sense of wonder…yeah…  [wonder and self-appreciation as emergent transformational affect: the realization affects of State 3]

Pt: Yeah really, in some ways… I don’t know. I did not feel comforted. I’m trying to think of an instance. … (deep breath, looking at floor) I don’t know. I used to flee into a world, like an imaginary world, it was comforting. Used to spend a lot of time there.

Th: Uh-huh… What was your imaginary world? Or one of them?

Pt: There were many of them. There was one in which I had lots of brothers and sisters and wonderful parents, and life was happy.

Th: Do you know that there’s a whole kind of therapy that has people do that intentionally? (Here I was referring to Dan Brown’s hypnotic ideal parent intervention) So I think you were kinda intuitively as a kid, intuitively creating in an internal world exactly what you needed …

Pt: Really? Huh. interesting. … friends…

Th: So emotionally resilient.

Pt: Really! See, I thought it was weird, I would say I lived in my imaginary world, seventy-five percent of the time?

Th: I think it was your salvation.  (validating her emotional refuge and resilient brilliance)

Pt: I think so too. I even kind of knew that… because I felt safe, happy, part of something bigger than me, in that world. It was the only time. But, it was most of the time! I just pretended that that was actually my life, and that my life was just like this little shadow, that… It was a… I spent most of my time in an imaginary world. It helped…

Th: I mean, I feel so much wonder, and appreciation, but then when you say my life was like this shadow…

Pt: My real life was like a shadow, and I didn’t connect with it very much. As little as I could, as little as I could, you know, possibly…

Th: It just is more of an acknowledgment and, and, an understanding of how deprived that life was and that world, how emotionally deprived of, all the things that kids need, comfort, support, recognition, like being deeply seen and known and responded to.

Pt: Yeah, I didn’t have any of that… I did not have any of that from anybody. So I just lived in my own world.

In this segment, errors of omission that Sami was describing earlier in the abstract become concretized and located in time and space.  Her specific memory allows us to achieve another level of recognition – our both laying eyes on an actual small “t” traumatic event in Sami’s childhood.  Here we are deeply in the throes of State 2 work, processing the pain, grief, shame and aloneness of the little girl banished under her teacher’s desk, crying inconsolably.  These feelings are moving through and being simultaneously re-experienced, recognized, comforted by both Sami and by me.  This allows for an emotional processing that leads to a transformational shift: Sami feels a sense of wonder at her own resilience and touches into her own adaptive action tendencies of self-salvation through her happy, connected imaginary world.  From here, we move into the realm of formal metaprocessing of the experience.

Part Three: From Recognition to Re-writing a Life Narrative

In this final segment of transcript, we reflect on Sami’s experience of being seen, receiving recognition from me and also giving it to the little girl inside, who, in parallel, received it from Sami.  With this swath of emotional landscape now illuminated, Sami begins to perceive and articulate a new version of her life narrative, both the emotional neglect she endured and the resilience that allowed her to cope with such a depleted and sparse attachment environment.

Th: Well, what does it mean now for us to see beneath that, I mean to both…(Starting to meta-process the experience of receiving recognition, both externally and internally —  State 3 work.)

Pt: (sighs) It, it, it, it kind of shocks… I mean, I’ve always known these pieces, but I’ve never seen it as a whole, I’ve never, like, seen it.

Th: Uh-huh, so let’s spend some time just hanging out here.

Pt: It’s kind of shocking. It’s kind of shocking, kind of amazing. (realization affects)

Th: Let’s create lots of space to just keep looking at it together, and letting it sink in.

Pt: Yeah… its funny, I, um, I, I’ve always thought of my childhood as being not particularly good, but this, like, as I look at this, like ooh, this is really bad. This is almost  like… yeah. (deep inhalation)

Th: Tell me what happens inside when, as that sinks in, as you, like, take this unflinching look at it – well, you actually flinched, I can’t say unflinching because your face…(facilitating a re-writing of her life narrative)

Pt: Enh, enh, yeah. Not good.

Th: So what does that mean to you, to see it for what it was?

Pt: You know, um, I, oh, it’s, it’s hard, because you know, I’ve heard from both my parents how horrible their early lives were. I’ve heard it millions of times, and I, you know, when people ask me about my parents and my past, I think, yeah, I didn’t have a great childhood, but boy, my parents, they had awful… you know I think of theirs as being terrible and mine as being a much a lesser degree, you know, not, not so bad… not great, but not so bad, but I look at it and I’m going, well, what exactly did I get from adults, like what? Not much! Almost nothing.

Th: Right. And, you know…

Pt: I mean it took…

Th: That kind of deprivation and neglect, it’s invisible trauma, because it doesn’t leave marks on your body, or physical injuries, but it is so wounding, so painful. (seeing the invisible wounds and scars)

Pt: (emphatically) Yeah! Yeah. Yes. It’s true.

Th: And nobody sees it. Or, nobody saw it, I should say.

Pt: And not even… like, I’ve always looked at it in terms of its little parts, instead of a seeing it as a holistic picture of, a sorta gr … it’s a grim picture, really. Um… I was aware that my parents loved me. I didn’t feel like their love did me any good, though. Like it didn’t…  it, it in no way even interacted with my problems and issues, it just… it was just a devotion that they felt.  (state 4 work: re-writing the narrative)

Th: Right, right. Right right right. I mean, the, the love may have been there, but the connection to you…

Pt: Me, as a person.

Th: …and like, your true self, wasn’t there.

Pt: Yeah.

Th: Like, you can have love in the air, you know…

Pt: And that’s what it was, it was love in the air…

Th: …they can have love inside of them, but…

Pt: …love inside of them…

Th: …if it’s not meeting you, in a deep way, if they’re not seeing who you are,

Pt: …if they’re not seeing me, at all, yeah…

Th: …I mean, how do you profit from that?

Pt: I didn’t. I didn’t. I… it’s amazing. I, I think it’s all the more amazing I ended up… it came out okay. I taught myself what I needed to know. I figured it out.

Th: Yeah. It is amazing, it really, really is…

(cut)

Pt: …in my life, so many therapists just can’t get past the confidence and the capable… it just can’t, like… I mean, this therapist I see in Amherst.  (One of the domains of re-enactment: therapists not seeing the distress and emotional need)

Th: Right.

Pt: Last time I saw her she said to me, well, I guess the only thing you didn’t really work on so much was, and she mentioned something from my childhood, and I’m thinking, if you only knew… 

Th: So tell me, let’s stay there for a minute, and tell mean what it means…

Pt: That’s good, it’s a relief…

Th:  …that I can see both…the resilience and the amazing confidence, and all of the pain…

Pt: It’s a relief because, ach, you know, I can LIVE in the confidence side of me forever. I would think that some of my fears as an adult, some of my, yeah actually some of my choices, you know… go back to some of what happened to me when I was young and the better I understand that…I can work through that pain…

Pt: (tears up, tracing fingers on the couch) Yeah. Yeah. Nobody ever asked. (looking down) I mean, ah, a friend who… what they know of the story, you know, like my friend Stephanie, but I don’t let her know that much because she’s my friend, you know…

Th: So this is the first time that really anyone has laid eyes on this in this way.

Pt: Oh yeah. I mean, I’ve had boyfriends who knew much more about me than most people but no, nobody… I’ve done a fair amount of therapy… years…

Th:  And no one saw any of this.

Pt: Some… Some. But… you have to have that ability to see beyond, you know, what lies on the surface. And believe that its there. Cuz I’ve said to plenty of people, you know, my childhood wasn’t… I give pretty honest, clear signals that there’s stuff there to be probed, but nobody…

Pt: Still there, and it still hurts

Pt: yeah…

Pt: I find it really easy to be really open with you, you just… open the doors! Others… I guess, for therapists, if the patient seems to be okay, why stir the pot, I mean, I don’t know what the heck is in their minds…

Th: Yeah… I don’t know either, I don’t know, what about this made it right, but thankfully, its right and you, you know it seems like you have brought that courage, to other people before, and that readiness…

Pt: I have, and they just walk right away from it! And I think, well, they let me down, they can’t handle it, and I don’t wanna give it to anyone who can’t handle it. That’s what it is.

Th: Yeah. That’s wise, and self-protective.

Pt. They can’t… I see their unwillingness to go there, which tells me they can’t really handle it, that they would be like (grunts)… And I don’t need that. It’s not gonna help.

Th: So it just feels so…(sigh) it’s hard to find the word, its… more than special, it feels sacred to me, that I could be part of this with you. So I just wanted you to know that I’m feeling that. Because this has needed…(honoring what Sami has shared with me and allowed me to witness)

Pt: …(whispers) to come out…

Th: to be seen, for a long long time.

Pt: Yeah. So many years. Yeah. So many years. Yeah.

Th: So there’s a way that even though its so painful, and so tragic, and has been waiting so long, that it feels like this kind of precious thing to hold.

Pt: I can see that… (deep sigh) Yeah. It’s really important for me to… let it out, you know? Not keep it hidden. It’s been hidden for so long. Sometimes I tell people some of the facts, in a cold sort of a way…

Th: Uh-huh, detached from…

Pt: It’s completely meaningless. And then, and then they say, oh yeah, I’ve had really bad… you know, and it just…yeah. (deep breath)

Th: It doesn’t do it justice, right, it doesn’t honor what’s actually, what the experience is.

Pt: No, there’s… and there’s no processing of it, there’s no… I’d… it’s almost like I’m telling a story about myself or about somebody else, like it… there’s no feeling, I don’t feel it, I’m not connected to it, it’s not even real… so. (undoing the affective constriction that is the hallmark of avoidant attachment)

Th: So just, you know, spending just a couple more minutes here before we… cuz I feel that readiness, we wanna, definitely want to give you the space to do that, to see, just kind of on the other side of this wave of acknowledgment and recognition, and processing of a lot of this pain, and this neglect. You know, I mean kind of… very courageously, let yourself experience it, with me. (lots of affirmation)

Pt: Yeah… never thought of it as neglect before.  (Sami is still in re-writing narrative mode, making the most of the recognition/understanding/discovery process.)

Th: Total emotional neglect.

Pt: It is. It is. And that’s why… my heart has always gone out to children, where… Wha – it’s been many years of, dedicating, you know, my work life to, to helping kids, and working with kids.

Th: That makes so much sense.

Pt: … the kids in the middle, I’m fine with them, and they like me, but there isn’t the same bond…

Th: There’s not that resonance, right, right.

Pt: …that I have with the kids who really struggle in different ways.

Th: And now, it feels like, the kid in you that experienced all that, is finally getting, you know, identification and recognition, and getting to feel some of that bond with you, and my hope is also with me, you know, as a participant in this…

Pt: Yeah. Yes. (breath) (whispered) Yes.

Th: So how does that feel? (pause) And so… you are so, full of emotion as we, even as we reflect on that, I just want to honor that

Pt: Yeah.

Th: …each moment of it…

Pt: It’s very different from, seeing another child’s pain. There, you, you know, I’m aware of my own in… situations – but I’m the one who’s in a position to give and to hold a hand, and this is… a rare chance for me, to receive.

Th: Yeah.

Pt: It’s very rare.

Th: So what does that receiving feel like? How’s it feel like in your body, and your heart…

Pt: It feels good. It feels good to me. See, and, acknowledge, it hurts…

Th: Mm, yeah, yeah. I’m right here with you, it’s a pain, too.

Pt: (sighs)

Th: It hurts, but it feels good.

Pt: Uh-huh.

Th: Does that make sense?

Pt: Yeah. (sigh) I don’t find myself looking for, for the answer, for a solution. (relinguishing some of the rationalizing, intellectualizing, cognitive defenses)

Th: Ah-hah.

Pt: I don’t find myself under any pressure to, um, solve, a problem. Most of the time everything is about solutions.

Th: Right. Right. But not this.

Pt: No. And I do allow myself moments where, I allow, you know, the pain to bubble up. I’ll cry and I’ll kind of wrestle with it intensely alone, for an hour, two hours sometimes… I do that pretty regularly in my life. Nobody ever sees that.

Th: Ah, right.

Pt: Nobody knows about that. That’s a secret!

Th: Right. That’s you under the teacher’s desk again, right, in a way. Upset, and alone.

Pt: It’s hard to… there’s another me that’s standing there, though, when I do it. (She has been able to maintain some internal presence with the pain – more of her spontaneous corrective resilience)

Th: Uh-huh, well, that’s good. That’s good…

Pt: There’s another me that knows it’s okay.

Th: Yeh. That’s more of that amazing resilience.

Pt: I allow myself to go into that.

Th: Yeah… 

Pt: Um… but I need to do it, like I desperately need to go into it, and process it, just by myself, but it’s always by myself.

Th: Yeah. So it’s like, that was such an amazing, and important piece of it, but this is another p… a different piece, right…

Pt: Yeah, well this is, that grownup part of me doesn’t actually have to be there. (She can let go, surrender into an attachment relationship with a perceived “older, stronger, wiser” who can hold her through the experience.  This is a newly, co-constructed secure attachment experience, both outside between she and I and inside between her and the little girl part.)

Th: Right.

Pt: I don’t, I don’t have to play two roles, in the same way. And it’s good. And I don’t feel scared at all, I feel completely trusting, and safe, and… ah… relieved, you know, it’s time…

Th: To feel me doing some of that.

Pt: Right, yeah. And me just, having the experience.

Th: Right, which is how it always should have been.

Pt: God, yeah… Ah… but it’s so bad … But, oh my God, it gets so much worse. It’s like… it’s funny, cuz I try not to… it’s interesting, I don’t think of myself as denying a lot of it to myself, but I think in some ways I have denied just how big it is.…

Th: I think you had to.

Pt: Yeah.

Th: I think you have had to. Cuz there’s only so much someone can deal with alone. I think you have done a… an amazing, like, almost unbelievable job of holding yourself through this. Like, to the maximum someone can.

Pt: Right.

Th: And, there’s always a point where it’s just not enough. We all have that threshold, right.

Pt: Right, right. And I think it comes out in, in strange ways. Um, you know I certainly think my relationship history has something to do with some of this. (laughs) Or should I say, my lack of relationship history, and the ease with which I’ve moved on in life, a lot.

Th: Mm-hm, mm-hm. Cuz you learn you have to do it by yourself, right?

Pt: Sure, yeah, I don’t, I don’t think I’ve ever… that’s not true. In Bulgaria, Jason and I started a school, that was probably now the only time in my life when I’ve ever really, really counted on somebody else, because I had to.

Th: Ah-huh.

Pt: There’re brief moments where I’ve had to, like, literally like live-or-die kinds of moments, but other than that, I don’t count on other people a lot.

Th: I can see why. (Pt laughs) I can see why you would have gotten there!

Pt: Yeah, there’s nothing new, there’s nothing new in not counting on anyone, you know? Yeah, and I guess the good thing is, you don’t get disappointed, you don’t expect, you… if your expectations are low and they’re met… I honestly never even question it, I never think about it. So…

Th: And yet there’s something in you that has been so adamant about continuing the search, right…

Pt: Oh yeah, absolutely.

Th: And you, right, eight therapists later…

Pt: (laughs) I know. It’s crazy.

Th: …and many disappointments, you’re like, you are driving two and a half hours…

Pt: (laughing) I know – each way! 

Th: …you know, sick!

Pt: I know…

Th: …you know, and sleep-deprived the first time after, what, your flight back from Chicago and like, you are really…

Pt: Uh huh.

Th: …clear…

Pt: …I…

Th: …about what you want for yourself!

Pt: Yeah. I just think it’s time.

Th: … and transforming your situation into that.

Pt: It’s… yeah. So… ah.

(cut)

Th: Before we go to scheduling…

Pt: (looks up) Yes, ah?

Th: … I just wanna check in with you, just give you another minute to, you know, kind of, let go of all content and just, kind of, have another moment for you and I to connect. On the other side of such deep work.

Pt: Yeah.

Th: You know, and then this…painful disclosure, you know…

Pt:  (rolls eyes, nods)

Th: …. letting me know something so big and so painful.

Pt: Yeah.

Th: But letting go of all the content, just seeing where you’re at… 

Pt: I’m a little tired. (laughing)

Th: Yeah…

Pt: I do feel tired.

Th: I’m not surprised.

Pt: I feel okay… but I feel tired. (big sigh) I feel safe. I hope it stays with me while I’m on the road. (laughs)

Th: (laughs) Take a little satchel of safety right out with you.

Pt: Yeah…

Th: Pack a safety to go…

Pt: I need, I definitely need to be alert. Yeah.

Th: I’m so glad that you can feel safe, in here.

Pt: Yeah.

Th: Safe enough to go to all these places.

Pt: Yeah. I do. (nods, eye contact) I feel very safe. That’s a relief. You know, it’s a relief to go there, a relief to talk about it.

Th: I can see it in your breath, you know…

Pt: (deep breath) Yeah. It’s been a long time.

Th: Mm, I know, you’ve waited a long time.

Conclusion

The healing trajectory of this session is catalyzed by a moment of recognition:  my seeing and affirming Sami’s strength in the context of chronic misattunement and emotional neglect in her childhood.  Although Sami already held many disparate pieces of her life in awareness, they were fragmented and disjointed:  she knew she felt “invisible” as a child, that her internal life was a “secret” from her parents, who didn’t see or truly know her, and that she was a strong, self-sufficient person.  Because Sami’s parents were blind to her emotional life and needs, they could not provide protection, comfort, a holding environment or lively reflection of Sami’s deep, true self.  These basic building blocks of secure attachment were missing from Sami’s history, so she learned, from an early age, to tough it out, stop her tears, not rely on others, take care of herself.  In other words, she resorted to the protective bubble of an avoidant attachment style.  My recognition of her strength and resilience, arising from a barren landscape of deprivation and lack of connection, opened up a well of grief and pain inside of Sami.  This grief and pain led her to a scared, shamed and dysregulated young part of her, with whom Sami was able to connect, comfort and understand.

This sequence of recognition, first between me and Sami, and then between Sami and this young, abandoned part of her is a hallmark of AEDP intra-relational interventions (Lamagna & Gleiser, 2000; Lamagna, 2011; Schore, 2002). An evolving, multi-tiered foundation of secure attachment was laid down in the course of a two hour session:  Sami had an experience of being deeply seen and understood by me in moment of recognition that bridged her strengths and her traumatic deprivation.   She was able to let go, surrender into both the grief and the attachment experience of being held through intense emotion.  Later, in a wave of meta-processing, Sami reflected on how good it felt that the “grownup part of me doesn’t actually have to be there” to take care of her through the distress.  She, thus, co-created with me, a curative experience to her avoidant attachment style – she didn’t have to block emotion or remain in a counter-dependent stance.

The irony of Sami’s statement above is that the grown-up her was present – deeply present and engaged with the emotional life of the distressed little girl crying uncontrollably under her teacher’s desk.  She was able to build on the foundation of her secure attachment experience of being seen, led and believed in by me, in order to do the same for the little girl inside of her.  One key component of secure attachment is the faith that one can push oneself to the absolute limits of personal strength, knowing that when internal resources are exhausted, there is a reliable and caring pair of outstretched hands to help and support.  Having a lived and felt experience of exceeding one’s internal resources and being able to rely on the support and care of an Other without shame or anxiety is a cornerstone of building a secure attachment bond in the therapeutic relationship.

Some therapies, which over-emphasize the development of internal resources and autonomy run the risk of neglecting half of the equation of secure attachment.  This colludes with the Western cultural myth (especially rampant for men) that emotional health and strength means being able to cope with and overcome most anything alone.  This stance, whether explicitly or implicitly embedded in a therapeutic model or arising from an unconscious bias of a therapist, can be very damaging for people with avoidant attachment styles such as Sami’s.  Her frustration with failed therapy attempts and her inability to get help healing from a painful history of emotional neglect and deprivation attests to the destructive re-enactments that can stem from approaches that do not possess a specifically articulated set of interventions to build secure attachment.

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