Inside Out: a Transactional Analysis Model of Trauma

Inside Out: A Transactional Analysis Model ofTrauma

Jo Stuthridge

Abstract leave her with Bill. During therapy, Annie be- This article presents a transactional analy- gan to realize that despite all her efforts to sis model of trauma located within a rela- avoid the past (by using alcohol, silence, and tional paradigm. It proposes that the Adult denial), she had been reenacting the story of ego state enables us to form a narrative self her own abuse over 30 years. She used the mar- or coherent sense of identity. Trauma inter- riage to project an abusive Parent ego state and feres with this integrative capacity, creating failed to protect her children as her mother had excluded ego states and a disorganized self. failed to protect her. The pain ofher own abuse The child's experience of abusive caregivers remained safely outside awareness in an ex- is internalized in a series of toxic Parenti cluded Child ego state. Child egostates. This inner world shapes the Annie's tragic story illustrates an incoherent child's view ofthe world outside, leading to self-narrative. This is evident in the telling of patternsof transferential enactment that re- her story and also in the way her life is lived. inforce a traumatic script. Therapy is con- This article argues that when trauma impairs cerned with developing the Adult capacity to the Adult capacity to create narrative, the unin- create a coherent narrative that allows the tegrated experience is reenacted in the person's client to move from enacting to reflecting. present life. Stories like Annie's have been explained in very different ways over the past 100 years. This article is based on years of clinical ex- Freud (1905/1953) argued that unconscious perience with adult survivors ofchildhood phy- fantasies, not child abuse, were the real cause sical and sexual abuse. Its title was partly in- of hysteria. During the 1970s, with research spired by my sons' preference for wearing their into posttraumatic stress disorder (PTSD) (see trousers "low-rider," revealing a gaudy slice of van der Kolk, 2000, p. 244) and the develop- satin boxer. It occurred to me that this fashion ment of feminism, the pendulum of opinion for wearing underwear on the outside is very like swung toward actual trauma as the cause of working with adult survivors of child abuse, pathology (Masson, 1984). This historical de- where intrapsychic "garments" are worn on the velopment can be seen as a dialectic between outside in the guise oftransferential enactments. the importance ofinside (fantasy and intrapsy- I offer the following example as an illustra- chic conflict) and outside (actual abuse and tion. Annie was sexually abused by her father parental failure). Thequestionbeingaskedhere from the age of5 until 15 years, when she ran is this: Does pathology arise from real life away from home. Later she married Bill and to- monsters or from monsters ofthe mind? gether they had four children. She never al- This article considers that question by using lowed Bill any physical contact with their chil- transactional analysis to bridge the divide be- dren, describing a feeling of disgust when he tween psychoanalysis and empirical psychol- went near them. She did allow the children to ogy. I begin with a reinterpretation of the ego stay with her parents, and when her teenage state model. I then offer a briefexploration of daughters disclosed that they had beensexually the impact oftrauma on development and sug- abusedby theirgrandfather, Annie reactedwith gest a transactional analysis formulation of angry disbelief. trauma. Finally, case material is provided to il- Annie was 49 when I met her; she brought lustrate a relational approach to therapy using her baby granddaughter to sessions rather than the model described.

270 Transactional Analysis Journal

Downloaded from tax.sagepub.com by Marco Mazzetti on February 3, 2014 INSIDEOUT: A TRANSACTIONAL ANALYSIS MODELOF TRAUMA

A StoryofSelf: Development of I, Me, and Self The internal structure ofthe self, then, arises This section offers a theory or story about the from a matrix ofrelationships. I use the phrase emergence ofselfwithin a relational paradigm; "Parent/Child ego state dyad" to stress that a it revisits ego state theory in light ofinfant re- whole relationship is internalized, not just an search and neurobiology. introject: for example, an anxious Child ego state Is it appropriate to begin writing about incest in response to a critical Parent ego state. Little with comments about my sons' underwear? (2005) refers to a similar concept as "ego state How did this happen? Me watching I. William relational units" (p. 136). James (1892, p. 176) made this distinction be- We might assume that the mind contains mu- tween a complex reflecting self-a"me"-and ltiple ego state dyads that reflect the child's ex- the simple experiencing "I." I propose that the perience ofthe caregiving environment. Fonagy selfin James'ssense ofa transient experiencing (2001, p. 165) and Schore (1994, p. 498) refer "I" is best conceived ofin transactional analy- to multiple sets ofself-other representations in sis terms as a multiplicity of discontinuous securely attached children. Relational psycho- ChildlParent ego state configurations that pro- analysts (Bromberg, 2001, p. 181; Mitchell, duce shifts in consciousness in response to con- 1988) describe multiple relational configura- text. A sense of"me" as coherent and continu- tions within the mind. Bromberg (2001, p. 244) ous over time develops with the Adult ego state suggests it is only with maturity that we attain capacity to link ego states through story, thus an adaptive illusion of self that overrides the creating a "narrative self." This concept ofself awareness ofdiscontinuity. encompasses the paradoxical experience of This ordinary phenomenological experience changing with time or context while knowing I ofbeing many selves is summed up succinctly am the same person. It also allows for the pos- by Virginia Woolf(1928/1993): "Abiography sibility ofan "I" that is not part ofme. is considered complete ifit merely accounts for Citing infant research, several authors (Beebe six or seven selves, whereas a person may well & Lachman, 1988; Lichtenberg, 1983; Stern, have as many thousand" (p. 224). 1985) suggest that an emergent sense of self Selfas Story: The AdultEgo State. One starts develops out of repetitive reciprocal interac- to wonder, how do we experience any sense of tions between infant and caregiver. Beebe and identity, a single "me" in the midst ofthis shift- Lachman (1988, p. 306) used empirical evi- ing milieu? dence ofthe infant's capacity to recognize, re- Berne (1961) referred to the integrative func- member, and expect these recurring interac- tion of the Adult ego state but acknowledged tions to suggest that the infant forms symbolic that "the mechanism ofthis integration remains representations ofselfand other. This process to be elucidated" (p. 213). I suggest that self- of internalization involves representations of narrative is the key mechanism for integrating both infant and caregiver, a dyadic system that disparate Parentand Child ego states into a uni- cannot be described on the basis ofeither part- fied sense ofselfor "me." The capacity to tell ner alone (Beebe & Lachman, 1988, p. 305; stories about the selfinvolves a reflective pro- Fonagy, Target, & Gergely, 2000, p. 104). cess. In transactional analysis terms, we might say Fonagy, Gergely, Jurist, and Target (2002) that repeated transactions between the child argue that the development ofsuch a reflective and his or her caregivers are aggregated and capacity is dependent on attunement in early internalized to form the basis of developing relationships. When the caregiver accurately Child, Parent, and Adult ego states. As Berne represents experience for the child, this pattern (1961) put it, the mind contains "relics of the ofrelatedness is internalized, and the child de- infant who once actually existed, in a struggle velops an ability to integrate experience into with the relics ofthe parents who once actually narrative. The child learns to name his or her existed" (p. 55). He emphasized that ego states internal states and those ofothers. Fonagy et a1. are phenomenological entities, not abstractrep- (2000, pp. 108-9) cite empirical evidence to resentations (p. 4). demonstrate a high correlation between secure

Vol. 36. No.4. October 2006 271

Downloaded from tax.sagepub.com by Marco Mazzetti on February 3, 2014 10 STUTHRIDGE

attachment, reflective abilities, and narrative "subsymbolic" refers to affective and somatic coherence. patterns oforganization (Cornell, 2003, p. 45). In transactional analysis terms, accurate at- Implicit memory remains outside of aware- tunement facilitates the Adult capacity for re- ness. These memories are stored in emotions, flective function and self-narrative. This con- sensations, and behaviors, with no sense of cept ofneopsychic function as a process ofin- conscious recollection (LeDoux, 2002). Stories tegration, reflective function, and narrative is stored in implicit memory systems might be consistentwith recenttheoretical developments associated with Berne's (1961, p. 118) concept in transactional analysis (Allen, 2003; Erskine, of protocol, which comprises the early rela- 2003; Tudor, 2003). Allen (2003) uses the term tional patterns that form the basis of script. "psychological mindedness" to refer to "peo- Allen (2003) suggests that experience stored in pIe's ability to think about their psychodynam- implicit memory creates "nonconscious organ- ics and to put their experiences into narrative izing principles" (p. 131) that underlie later script context" (p. 132). script decisions. Implicit storytelling is not re- The mind is experienced, then, as an unruly placed but continues to exist alongside later crowd ofChild-Parentego states with their own explicit story forms (Damasio, 2000). unique modes of relating and affective tones For example, when an infant's earliest inter- that are given meaning and shape by a narrator actions are experiences of being adored and -the Adult ego state. held snugly with a full belly, this set ofsensa- The Narrative Self. Accumulated evidence tions forms a subsymbolic narrative. These from neuroscience supports the idea that the wordless stories form an emotional background self does not start as an integrated whole but -setting the mood, tone, and broad themes- rather is nonunitary in origin (LeDoux, 2002). that defmes the world as safe or dangerous. LeDoux (p. 192) and Damasio (2000, p. 189) Simple symbolic stories about the selfemerge both argue that narrative provides the essential with the development ofexplicit memory at 18 glue that binds various neural networks to cre- months (Schore, 1994, p. 483). Explicit memo- ate a unified sense ofself. The brain uses stor- ry involves conscious recall, language, and ies to create a single "me" out of fragmented symbolic processes. These stories define the experience. Neurological research suggests that basic plot, the ending, and the goodies and bad- memory plays a majorrole in this process (Da- dies. This is the magical and concrete thinking masio, 2000). of Beme's (1961) Little Professor or AI neo- In transactional analysis language, script theo- psychic process. Al process tends to overgen- ry aptly describes the crucial role ofstoryin the eralize experience, thus forming injunctions development of self-identity. A life script is a story that arises out of interactions between a child and the world. It can either be life en- Table 1 hancing or self-limiting (Allen & Allen, 1997; The Narrative Self Cornell, 1988; Loria, 1995). Using a structural Ao Subsymbolic. affective. ego state model, neurological findings about sensorimotor stories of self. Present memory can be used to deepen our understand- at birth (Cozolino, 2002, p. 178). ing ofan integrating Adult ego state, the emer- Implicit memory systems. gence ofscript, and the development ofa narrative self(see Table 1). A, Simple symbolic. verbal stories of self. Present from 18 months Our earliest stories are wordless and arise (Schore, 1994, p. 487). Explicit from nonverbal transactions between infant and episodic memory. caregiver; they rely on sound, touch, and move- ment internalized as PriCo ego state dyads. This A2 Complex symbolic stories of self and experience is integrated into subsymbolic nar- reflective capacity. Present from 4-5 years (Fonagy, 2002, p. 245). rative by an early Adult ego state (An) that re- Autobiographical memory. lies on implicit memory systems. The term

272 Transactional Analysis Journal

Downloaded from tax.sagepub.com by Marco Mazzetti on February 3, 2014 INSIDE OUT: A TRANSACTIONAL ANALYSIS MODELOFTRAUMA

and core script beliefs. Explicit episodic memory captures highly charged emotional scenes PO' Pl , P2-Parent typical ofthe memories accessed using redeci- ego states en- sion therapy. These scenes provide evidence coded inimplicit, used to justify and reinforce early themes. explicit, and auto- Complex self-narratives (A ) are possible by biographical 2 memory 4-5 years with the development of autobiographical memory (Nelson, 1992) and reflec- Ao, Al , A2-Adult tive abilities (Fonagy, 2002, pp. 245-248). ego states en- Autobiographical memory makes it possible to coded in implicit, organize remote events into a verbal narrative, explicit, and auto- including aspects of both fact and fiction, im- biographical memory plicit and explicit memory (Damasio, 2000).

Siegel (1999) referred to the "narrativization of Co, C1, C2 -Child episodic memory" (p. 61) as a child learns to ego states en- coded inimplicit, string together episodes to create more com- explicit, and auto- plex coherent stories. These are the changing biographical stories I tell about myself, and they involve a memory conscious narrator. Autobiographical memory allows us to form a narrative self, a "me" who persists over time (Damasio,2000,p. 217).Coherentautobiographi- Figure 1 cal narratives connect the past, present, and fu- Second-Order Structural Model: An ture, thus allowing a person to make sense of Alternative Configuration of Ego States life (Siegel, 2003, p. 52). These narratives are fluid and flexible; they allow the integration of conflicting experiences into a coherent whole. I propose that trauma impairs the Adult ego This capacity is a developmental achievement state's capacity to form self-narrative, which associated with secure attachment (Fonagy et results in dissociated ego states. This is not a al.,2002; Siegel,1999).Autobiographicalmemo- new idea. Pierre Janet in 1889 (as cited in van ry can be modified by new experiences (Da- der Kolk, 2000, p. 238) suggested that trauma masio, 2000, p. 173), and this has important causes a failure of narrative memory. He de- implications for therapy. It means I can change scribed how the experience oftrauma is frag- the story I write about myself. mented into emotional and sensory elements The Adult ego state acts as a narrator, weav- that are split off from ordinary consciousness ing stories that bind various senses of "I" or dissociated. Contemporaryneuroscience has (Parent/Child ego state dyads) into a coherent begun to elucidate the underlying mechanisms "me": a narrated identity. Selfis located within for this breakdown. a story rather than an ego state-more like a Neurobiology and Childhood Trauma. The process than a structure. The narrative self, like absence ofa secure attachment figure is one of a good biography, contains diverse ego states, the most critical factors contributing to chronic or many selves, linked by story. The ego state effects ofchild abuse (Schore, 2003; Streeck- model described here might be diagrammed as Fischer & van der Kolk, 2000). Infants are de- shown in Figure 1. pendent on an attuned caregiver in order to develop a capacity to regulate emotional states Stories and Trauma (Schore, 1994). Traumatic attachments result in What happens when trauma interferes with an inability to regulate arousal and chaotic bio- the development ofthe self? This section brief- chemical alterations that can damage the in- ly explores the evidence from neurobiology, at- fant's brain (Schore, 2003; van der Kolk et al, tachment studies, and clinical research. 1996).

Vol. 36, No, 4, October 2006 273

Downloaded from tax.sagepub.com by Marco Mazzetti on February 3, 2014 10 STUTHRIDGE

Several studies indicate limbic system abnor- experiences; the abusive father/abused child malities and reductions in the size of the left and the good respectable father with the good hippocampus in adult survivors ofchild sexual child remain side by side. These incompatible abuse (Teicher, 2002, p. 71). What does this ego state dyads seem to alternate in Annie's mean? Van der Kolle(2000) argues that disrup- consciousness. tion to the limbic system-in particular, to the Attachment and Trauma. Child attachment hippocampus-results in a failure to integrate researchers describe a similar process using dif- traumatic experience into narrative. The hippo- ferent language and concepts. Numerous stud- campus is responsible for the contextualization ies (Carlson, Cicchetti, Barnett, & Braunwald, ofexperience in time and place. Impairment to 1989; Lyons-Ruth & Jacobvitz, 1999) verify a hippocampus functioning leads to the persis- high correlation between child abuse and dis- tence ofdissociatedmemory fragments, smells, organized attachmentpatterns. The child strug- images, and sensations that are not located in gles to integrate contradictory experiences of time and space. the caregiver as protective and hostile, leading To return to the example of Annie, she did to contradictory clinging and fight and flight not come to therapy with a neat story. She pre- behaviors. sented, instead, with a series ofsymptoms that Longitudinal studies show that disorganized made her feel crazy: disgustingsmells that would attachment in children predicts dissociative not wash away; nights lying awake in frozen symptoms in adults (Carlson, 1998). Fosha terror hearing footsteps in the hallway, and (2003, p. 250) explains this link by suggesting vivid images ofher father standing by her bed. that painful feelings and events are dissociated She slept with the light and TV on. The events in order to maintain the attachment to the abu- ofher childhood were not integrated into self- sive caregiver. This Faustian compromise cre- narrative; instead, the trauma intruded in the ates autobiographical narratives that lack emo- present in the form of sensory intrusions or tional coherence. flashbacks. Clinical Evidence and Dissociation. Adult Damasio's (2000, p. 235) work with brainin- survivors of intrafamilial child abuse present juries confirms that damage to the hippocam- with symptoms that meet a vast range ofDSM pus will halt the growth of autobiographical IV disorders (American Psychiatric Associa- memory. Memory research also suggests that tion, 1994). However, clinical evidence from under extreme stress, explicit memory can fail three key areas of research-sexual abuse while implicit memory is enhanced (LeDoux, (Briere & Runtze, 1988; Herman, 1992), PTSD 2002, p. 29; van der Kolk & Fisler, 1995). Sie- (McFarlane & Yehuda, 2000; van der Kolk & gel (2003) and Cozolino (2002) both argue that Fisler, 1995), and dissociative disorders (Put- trauma impairs neural integration in the devel- nam, 1989}-allconfirm a connectionbetween oping brain, resulting in a failure to integrate childhood abuse and the process of dissocia- implicit memories of trauma into autobio- tion. The evidence suggests that dissociation is graphical narrative. a critical mediator between child abuse and a In transactional analysis terms, these biologi- variety ofpsychiatric symptoms, including sub- cal changes interfere with the Adult ego state's stance abuse, self-harm, suicide (Kisiel & capacityfor integration through narrative. Feel- Lyons, 2001), somatization, borderline person- ing states, events, and relational patterns of ality disorder (BPD), and PTSD (Streeck- trauma can all be recorded in implicit memory. Fischer & van der Kolk, 2000). Dissociation In other words, whole ego state systems may be can be understood as a disruption in the inte- dissociated, not just the sensory elements of gration ofmemory, consciousness, and identity trauma. (American Psychiatric Association, 1994, p. For example, Annie's proud memories of 477). walking to church hand in hand with her father Braun (1989) described a continuum ofdis- sit alongside vivid sensory memories of the sociation from normal that includes "highway sexual abuse. There is no integration of these hypnosis" to PTSD and finally to dissociative

274 Transactional Analysis Journal Downloaded from tax.sagepub.com by Marco Mazzetti on February 3, 2014 INSIDE OUT: A TRANSACTIONAL ANALYSIS MODELOF TRAUMA

identity disorder (DID). The degree of disso- through the kaleidoscopic lens created by his or ciation in an adult survivor depends on the her unique ego state patterning. This ego state availability ofan adequate caregiver, age ofon- matrix determines affect regulation and rela- set, severity of trauma, and closeness of the tional patterns. Neutral cues are experienced as relationship to the abuser. With patients with signs of danger, while other people are per- DID, 95-98% of them have been victims of ceived as untrustworthy or abusive. The inter- severe child abuse (p. 308). nal world is turned inside out through projec- The evidence accumulating from empirical tions ofexcluded Parent and Child ego states. studies, like a braided river, seems to take dif- The unintegrated experience oftrauma is reen- ferent pathways to a similar destination. Neu- acted through these repetitive patterns oftrans- rology, attachment studies, and clinical re- ference, thus reinforcing the traumatic script. search all pointto the same conclusion: Trauma At this point we have an answer to the ques- interrupts the capacity to form self-narrative, tion posed at the beginning. The monsters were thus creating a division ofexperiences or dis- outside but they get inside via the internaliza- sociation. In transactional analysis terms, we tion ofearly relationships in Parent/Child ego might call this exclusion. states. The intrapsychic structure then shapes the view ofself, others, and the world outside Self without Story: A Transactional so that the adult survivor ofabuse continues to Analysis Model of Trauma see monsters long after they are gone. This section proposes a model oftrauma that The real tragedy for most survivors ofchild- integrates a relational theory of self with em- hood trauma is the struggle they have in form- pirical evidence about the impact oftrauma on ing satisfactory loving relationships as adults. development. Traumatic Script. The Disorganized Self. Trauma impairs the Subsymbolic narrative, Ao.. Physiological Adult ego state's capacity to organize experi- symptoms ofPTSD give voice to three corner- ence through narrative, which results in a fun- stones ofthe traumatic script using Ao sensori- damentally disorganized self, one without an motor language. These symptoms tell a story effective story to bind disparate Parent-Child without using words, ego states into a cohesive identity. The disor- 1. "Never forget" is the message expressed ganized self includes many different "I"s and through intrusive symptoms: flashbacks, no coherent "me." somatic symptoms, nightmares, and panic Inside Out. attacks, all relating to implicit memories 1. Outside gets inside. The experience ofchild oftrauma, abuse is internalized structurally as a kaleido- 2. "Never go this way again" is suggested scope oftoxic Parent/Child ego states stored in by avoidant symptoms: forgetting, emo- implicit memory systems (PoICo)' These relational numbing, denial, dissociation, and tional prototypes represent the child's diverse drug and alcohol abuse. emotional experience ofabusive and neglectful 3. "Be prepared" is the clarion call ofhyper- Parent introjects alongside abused and aban- vigilantsymptoms:agitation,anxietystates, doned Child ego states. and exaggerated startle reactions (Dalen- 2. The capacityfor self-narrative is impaired. berg, 2003).

In the absence ofsecure attachment, trauma im- Simple symbolic narrative, A J• AI process pairs the Adult capacity for complex self- gives rise to simple, overgeneralized, concrete, narrative (A2). The abuse survivor relies on or magical stories. A traumatic script is formed earlier forms ofneopsychic functioning (Ao or based on beliefs about the self as bad, mad, At), thus forming restrictive stories or trauma- unworthy, or unlovable, while other people are tic script. Incoherent self-narrative gives rise to depicted as malevolent, untrustworthy, or un- excluded ego states. caring. Bad things are attributed to a bad self. 3. The inner world shapes the view outside. The child without narrative has no buffer against The adult survivor continues to see the world external events.

Vol. 36, No.4, October 2006 275

Downloaded from tax.sagepub.com by Marco Mazzetti on February 3, 2014 10 STUTHRIDGE

For example, Nancy first knew she was bad image with the charming, friendly, quite hu- at age four when her mother suddenly aban- morous Sharon who turned up to subsequent doned the family, pinning a note to Nancy's sessions. At other times, she would walk out of back as she left. Nancy did not feel bad-she sessions in fits ofrage, quit her job, overdose, was bad. When her uncle, a priest, sexually cut herself, and binge eat. These diverse pre- abused her when she was five then threatened sentations reflected a series of alternating ego to shoot her father ifshe told, she knew this had states with no coherent self-narrative. happened because she was a very bad child. Sharon had beensexuallyabused by her fath- When her stepmother locked her in a dark cel- er from her earliest memories until she was 16. lar, Nancy knew she was as black and bad in- Her father disguised this exploitation with ap- side as the cellar was outside. Years later, the parent adoration and involvement in her activi- blackreturned, perceived as a sticky black sub- ties. Her mother never asked questions. The stance inside her body. Sometimes the black secret ofincest remained safely hidden behind would ooze out and stick to her hands. She of- the family's quietmiddle-class lifestyle. Sharon ten scrubbed them until they bled. Nancy was eitherpretendedthat things were fine or she got careful not to tell her husband about the black sick. She had no words to explain her distress. for fear he would see herbadness. She told him This childhood reality was reenacted during nothing of her past. He left one day after 20 her adult life. For long periods Sharon pre- years ofmarriage saying she did not trust him. tended, hiding the incest secret from her own Nancy knew he left because she was bad. awareness. She looked after her children and Exclusion. Exclusion is defined here as a worked in a supermarket. Alternately, she be- process of"dis-integration" due to a failure of came sick with depression, self-disgust, suici- the Adult ego state to integrate experience into dal thoughts, and flashbacks of sexual abuse. narrative. Parent/Child ego state dyads become Sharon had frequent hospital admissions over excluded from Adultawareness and eachother, 20 years, diagnosed with bulimia, BPD, and alternating in mutually exclusive patterns. PTSD. As she became aware of this process, Excluded Parent/Child ego states may in- she began to describe herself as a Jekyll and clude painful feelings related to trauma, unmet Hyde: "I have to be either one thing or the other." relational needs, and conflicted experience of During our work together over 6 years, these a caregiver as loving and abusive. Exclusion distinct ego state systems achieved some level results in a discontinuity ofself-experience but ofintegration. Sharon managed to attend both also preserves more adaptive ego states that al- work and therapy and learned to live in the Iowa child to cope. present, creating a narrative of self that in- Erskine (1993) suggests that trauma leads to cluded her past. "ego fragmentation and dissociation" (p. 38); however, the process he describes is very dif- Stories without Words: When Actions ferent from what I am suggesting here. He as- Speaker Louder . .. sumes that the selfbegins as a whole entityand The unfolding ofthe script is the substance fragmentation occurs with lack ofcontact. I am of the psychoanalytic process. The trans- proposing that self begins as a multiplicity of ference consists not merely ofa set ofin- ego states and integrationthrough self-narrative terrelated reactions, a transference neuro- is a developmental achievement. sis, but ofa dynamicallyprogressive trans- Sharon's story illustrates this model. During ference drama, usually containing all the her first few sessions, Sharon would sit, wring- elements and subdivisions ofa Greek tra- ing her hands, with her head lowered and her gedy. (Berne, 1961, p. 174) body shaking. Long silences, tears, and stam- The abuse survivor arrives in therapy with a mering attempts at speech dominated the hour. chaotic display ofsymptoms-the outer mani- Her whole presence powerfully evoked the festations ofa disorganized state ofmind. Intra- sense of a small, frightened child squirming psychic relationships betweenego states are ex- with shame. It was difficult to reconcile this ternalized through shifting constellations of

276 Transactional Analysis Journal Downloaded from tax.sagepub.com by Marco Mazzetti on February 3, 2014 INSIDE OUT: A TRANSACTIONAL ANALYSIS MODELOF TRAUMA

transference/countertransference enactments. relational patterns and excluded ego states. The term "enactment" refers to nonverbal ac- With this approach, the therapist becomes tions and interactions in the therapy setting both participant and narrator in the drama. Re- (Aron, 1996, p. 198). Abusive Parent intro- lational therapies recognize the inevitability of jects, terrified Child ego states, and fantasized participation and the need to observe the im- fairy godmothers are all brought to life in the pact ofthe therapist's participation on the pro- therapeutic arena. As these characters interact cess (Aron, 1996, p. 194). Through immersion with the therapist, exchanging roles in various in the client's emotional world, implicit rela- combinations, the traumatic script unfolds in tional patterns formed in the abusive context the therapy room. inevitably emerge in the therapy relationship. Berne's ego state model provides a theory of When therapist and client manage to repair selfthat sits squarely within a relational tradi- these disruptions, excluded experience such as tion as described by Mitchell and Aron (1999). shame, rage, or terror can be integrated into an The self is constituted through the internali- expanded self-narrative. As this process ofat- zation of interpersonal experience, with rela- tunement, rupture, and repair is repeated many tionalneeds (recognition)replacing drive theory times over, a new relational prototype develops as the key to motivation. Berne's methodology, within the client. Interpretations oftransference however, is closer to a traditional objectivist facilitate this transition from implicit memory approach than to a relational style oftherapy. to explicit story, thus ending the repetitive en- He encouraged the therapist to act as a Martian actments ofthe traumatic script. observer (Berne, 1966, p. 84) who detects the The model oftrauma outlined here provides client's discounts, games, and script from an a theory ofmind and a method that is consis- objective stance. Using a classical orredecision tent with principles of contemporary relational transactional analysis approach, the therapist psychoanalysis (Aron, 1996; Mitchell, 1988). confronts an enactment as a game, thus refusing These theories emphasize the importance ofre- the transference; the therapist remains safely on lationships, both internal and external, real and Mars, outside the relationship. imagined (Aron, 1996, p. 18). Here a dyadic Trends within transactional analysis over the structure ofmind (Parent/Child dyads) empha- past 10-15 years have begun to address this in- sizes internal relationships between ego states congruity between theory and method. Berne's derived from relational configurations. This method is a one-person approach, focused on inner world influences external relationships in the client as object with decontamination or in- the present, and therapy requires participation sight as the road to cure. Cornell and Hargaden in cocreated patterns of transference to bring (2005) trace the development ofa two-person about change. Transactional analysis provides relational transactional analysis approach that a bridge between intrapsychic and interpersonal focuses on the therapeutic relationship as a realms, including both fantasized and real rela- vehicle for change. Moiso (1985); Novellino tionships. (1990); Erskine, Moursund, and Trautmann Three Transference Patterns. Clinicians who (1999); and Hargaden and Sills (2002) have work with trauma from a psychodynamic per- been key contributors to this development of spective often describe predictable patterns of transactional analysis theory and practice. transference based on variations on themes of A relational approach is essential to therapy helplessness, hostility, and rescue (Davies & with survivors ofchild abuse. The experience Frawley, 1994; Gabbard, 1994, pp. 309-311). of trauma is often stored in implicit memories In my experience, three major transference pat- and excluded ego states, beyond words. This terns can be delineated (see Figure 2). Each in- story can only be learned through attention to volves a Child/Parent ego state dyad. relational dynamics in the present, not by dredg- 1. The good child in relation to an idealized ing for explicit memories oftraumatic events. parent, a Victim-Rescuer theme Using a relational approach, transferential 2. The abused child in relation to the abus- enactments provide a crucial voice for implicit er, a Victim-Persecutor theme

Vol. 36. No.4. October 2006 277

Downloaded from tax.sagepub.com by Marco Mazzetti on February 3, 2014 JO STUTHRIDGE

Uninvolved Fairy Parent Godmother Abuser

Internal dialogue

l4--'t-- Empty Child Abused Child

Figure 2 The Disorganized Self: Three Transference Patterns

3. The empty child in relation to the unin- dyad. The concept of transference used here volved parent, a Victim-Bystander (Clark- draws on Erskine's (1991) defmition-"exter- son, 1987) theme nalized expressions of internal ego conflicts" With intrafamilial abuse, there is almost always (p. 66)-and assumes that both Child and Par- an uninvolved parent who failed to protect the ent ego states can be projected. The transferen- child. Neglect plus abuse forms a particularly tial relationship is viewed as a mutual construc- toxic matrix ofParent/Child dyads. tion (Hargaden & Sills, 2002, p. 63). While the themes and characters are familiar, In the following sections, case vignettes illus- each ego state system is a manifestation ofac- trate a relational approach to therapy with adult tual relationships that have been internalized. survivors ofchild abuse. The emphasis is on phenomenology: finding 1. The good child and the fairy godmother. names and addresses for ego states involved in This transference pattern (see Figure 3) is a transferential transactions. Cinderella story and often marks the beginning A Parent/Childego state dyad may be experi- of therapy. Stories of a child being raped or enced as an intrapsychic impasse, as an active beaten easily tug on the heartstrings, thus in- Parent or Child ego state, or interpersonally voking the Rescuer ever present in many thera- when one aspect ofthe dyad is projected. Cli- pists with the desire to alleviate suffering by ent and therapist can find themselves experi- magic. From the client's perspective, feeling encing both aspects ofan internalized ego state believed and understood for the first time can

278 Transactional Analysis Journal

Downloaded from tax.sagepub.com by Marco Mazzetti on February 3, 2014 INSIDEOUT: A TRANSACTIONAL ANALYSIS MODELOF TRAUMA

a • internal dialogue b - projected ego state c - social transaction d· transference transaction

Figure 3 The Good Child/Fairy Godmother (after Moiso, 1985, p. 197) provide a powerful elixir that conjures up pain. She used glimpses ofme with my family unheard-of promises and the fantasized fairy in public as proofofher perception. godmother. This dynamic can be formulated as Over time,an entitledChild ego stateemerged. an expression ofCo longings for unrnet needs IfSharon truly was as innocent as I maintained, (Hargaden & Sills, 2002) or an attempt to find then surely she deserved a few phone calls? a symbiotic fusion through projection of the During suicidal crises, pleas for extra sessions fantasized Parent figure (P 1+) (Haykin, 1980; and phone calls escalated; somehow I was not Moiso, 1985). I believe there is no reason to doing enough. differentiate this fantasized introject from other Working through a fairy godmother trans- introjects (P2); both are real subjective experi- ference usually involves giving up hopes ofres- ences formed from a mix offantasy and reality. cue, acknowledging that the abuse did happen, For example, Sharon had a constant fantasy and mourning for a lost childhood. Instead of as a child that her kindly neighbor, an older waiting for the therapist to wave a magic wand, woman, would one day take her home. In thera- the client leams to tolerate the pain of never py, an idealizing transference emerged very having felt cared for. quickly in which I was viewed as the best 2. The abused child and the abuser. Fair- therapist she had ever seen, an all-loving, per- bairn (1952/1992) first noted in his work with fect mother who could magically remove her abused children that the abusive parent is

Vol. 36. No.4. October 2006 279

Downloaded from tax.sagepub.com by Marco Mazzetti on February 3, 2014 10 STUTHRIDGE frequently internalized and split off or disso- integrity, like sexual abuse. She began cutting ciated from consciousness. This sadistic Parent herself; memories and sensations of sexual ego state is evident in harsh internal dialogue abuse flooded her awareness. She phoned me at and persistent self-blame. It often seems intent home feeling desperate. I calmed her somewhat on a campaign oframpant self-sabotage, mani- and then suggested we talk further in the ses- fested in self-destructive behaviorlike Sharon's sion. Angry at my response, she immediately starving, purging, cutting, and overdoses. phoned my colleague and then her insurance This abused child/abuser ego state dyad ap- case manager, complaining about my lack of peared in therapy with Sharon during long stuck availability. The case manager phoned me, ac- periods when she would tell variations on the cusing me ofignoring Sharon's distress-guilty same story over and over (e.g., "People are cruel again. I received this call a day after my mother- to me"). She felt distressed and helpless (abused in-law died. I entertained a brieffantasy about Child), while everyone around her, including calling Sharon to cancel the next session beme, was seen as being hurtful (projected abuser). cause of the funeral. A retaliatory fantasy- Occasionally there would be a rapid switch "See how guilty you feel now." At this point I in ego states. During a period ofcrisis, Sharon realized the extent ofthe guilt Sharon had felt began asking me to hold her hand during ses- as a child and the way it was being tossed be- sions or to sit next to her on the couch. I gently tween us in the transference and countertrans- refused the physical contact, suggesting we talk ference. This time it was only a week before about her need for touch instead. Shortly after- she recognized the pattern. ward, I received a call from her psychiatrist; Sharon began to accept the depth ofher an- Sharon had complained that she felt abused by ger and to understand her guilt. With this Adult me. awareness, previously excluded feelings were Sharon had recreated her family oforigin in integrated into an expanded autobiographical this drama. The psychiatristrequested meetings narrative. and explanations, while I felt trapped and guilty. Using game theory and blanket labels of Sharon seemed to enjoyexercising some power "Kick Me" or "Now I've Got You, You Son of over me. My supervisor made an insightful a Bitch" to explain these events would miss the comment: "She's fucked you." This summed up subtle detail of the relational dynamics being the nature of the intrusion I felt-projective repeated in the transference.The sudden switches identification with an abused Child ego state. in Sharon's ego states resulted from disjointed Over several months, Sharon and I managed to self-narrative and unintegrated ego states, both unravel the tangle. She understood that her feel- characteristic ofBPD. ings ofguilt in coming to see me were much like In my work with Sharon, I found myself navi- the feelings she had about her relationship with gating an uneasy path between actual recapitu- her father. She felt guilty about being in ther- lations of past trauma and creating a stage on apy for several years and kept the relationship which these silent dramas, which have been ex- secret from her family. When she disclosed cluded from awareness, can be enacted, sym- abusive memories, she felt abused by me as she bolized, and integrated into conscious narra- was by him (projection ofthe abusive Parent). tive. My supervisor reminded me ofthe impor- She acknowledged the complaint was an ex- tance ofkeeping the doors to the "theater" shut pression of anger and eventually recognized (boundaries) while the "play" is in progress to her own behavior as being like her father's (ac- prevent fantasy from spilling out into the real tive Parent), an alien, excluded part ofherself. world. The enactment was repeated again some 3. The empty child and the uninvolvedpar- months later. On this occasion, Sharon had just ent. In therapy, Nancy was silent for long peri- been diagnosed with arthritis, a disease from ods, staring out the window. When I asked a which her father also suffered. She felt as question she seemed not to hear or asked me to though he was in her body again and experi- repeat it. Her mind seemed utterly discon- enced the arthritis as a violation ofher physical nected, like a computer that freezes. She was

280 Transactional Analysis Journal

Downloaded from tax.sagepub.com by Marco Mazzetti on February 3, 2014 INSIDE OUT: A TRANSACTIONAL ANALYSIS MODEL OF TRAUMA

on medication and had had many courses of Creating New Stories: Cure electroconvulsive therapy (ECT). Long before I believe the goal oftherapy is to strengthen this treatment she had perfected the art ofdis- the Adult ego state's capacity to create coher- sociation during countless incidents of sexual ent self-narrative. Within a relational therapy, abuse as a child by numerous offenders, includ- intrapsychic dynamics are externalized through ing brothers, cousins, and uncles. At these transferential enactments. As client and thera- times, Nancy would leave her body and view pist resolve these impasses in the relationship, the abusive scene from a third-person perspec- excluded Parent-Child ego state dyads can be tive. For long periods I felt as though I had integrated into an expanded self-narrative. At- completely lost contact with her. She came and tunement in the therapeutic relationship is used went from sessions with little change, appar- to develop the Adult capacity for reflective ently unreachable. During sessions I often function and self-narrative. glanced at the clock, feeling irrelevant. Adult attachment research shows that coher- In one session, Nancy and I had the follow- ent narrative in a parent is the most robust in- ing exchange: dicator ofsecure attachment in infants (Hesse, Nancy stared blankly. 1999). These findings suggest that integration Jo: Where are you now? within the mind fosters interpersonal connec- Nancy: I'm back in the cellar. (She goes on tions. In transactional analysis terms, this means to describe the wee square of linoleum she that coherent self-narrative can prevent the in- sits on, the cold and dark.) tergenerational transmission ofscript. Jo: What are you thinking about? To return to the story ofAnnie, one day she Nancy: That someone might find me ... arrived at the session with a broad smile and Jo: Your mum? without her baby granddaughter. We both knew Nancy: No. She didn't want me .... She's this meant she had left the baby with her hus- dead (said in a deadpan voice). band Bill, trusting him for the first time-ever. It slowly dawned on me during this session As she said, "It just feels so different. It's only thatI was experiencing myself as Nancy's "dead now talking to you that I realize how different mother." She had no investment ofhope in me I am. It's such a warm good feeling to see Bill at all. Nancy's mother had left when Nancy was holding the baby." We both share "the warm four, leaving her vulnerable to years ofsexual good feeling" in a moment ofeye contact-so and physical abuse. These feelings ofdeadness different from the furtive glances and shame or emptiness can be harder to cope with than that has permeated our sessions in the past. the drama ofthe abuser-victim dyad. Gabbard Coherent narrative integrates disparate ego (1992) suggested that the tenacity with which states into a continuous sense ofself. The client the incest survivor clings to the paternal trans- is free to roam in previously excluded parts of ference maybe an attempt to avoid this deaden- the mind. The stream of consciousness being void. comes deeper and widerrather than being forced This transferential dyad often appears as a down the narrow channels carved by the trau- perception that the therapist is uncaring or un- matic script. The client develops a broader, available-projectionofthe uninvolved Parent. more flexible story ofselfthat makes sense of A switch can occur ifthe therapist is inspired to the past and creates a new future. A client "go the extra mile" to prove caring, thus pro- summed this up for me during a final session. voking the entitled Child. Attempts to love the When I asked her what had changed, Jamie client more than the uncaring mother did might said, "It's like having a walk-in wardrobe in also lead to a sexual transgression ofboundar- your mind." ies wherein the therapist becomes the abuser, thus repeating the incest. A significant percen- Conclusion tage of clients involved in sexual relationships This article proposes that self-narrative is a with therapists have been incest victims as key function ofthe integrating Adult ego state. children (Gabbard, 1992). Trauma and neglect in early relationships impair

Vol. 36. No.4. October 2006 28/

Downloaded from tax.sagepub.com by Marco Mazzetti on February 3, 2014 10 STUTHRIDGE this capacity and result in a disorganized self- ofNorth America, 12(2),307-325. structure. The goal oftherapy, using a relation- Briere, 1., & Runtze, M. (1988). Symptomatology associated with childhood sexual victimization in a non- al approach, is to develop the client's ability to clinical sample. Child Abuse and Neglect. 12.51-59. create a coherent self-narrative. Bromberg, P. M. (2001). Standing in the spaces: Essays This transactional analysis model oftrauma on clinicalprocess, trauma and dissociation. Hillsdale, places the consequences ofchildhood abuse in NJ: The Analytic Press. Carlson. E. A. (1998). A prospective longitudinal study of a psychodynamic relational framework, high- disorganized/disorientated attachment. Child Develop- lighting the complex interplay between fantasy ment, 69. 1970-1979. and reality, inside and out. Carlson, V., Cicchetti, D., Barnett, D., & Braunwald, K. Trauma therapies that focus on outside, re- (1989). Disorganized/disoriented attachment relationships in maltreated infants. DevelopmentalPsychology, call ofevents, and abreactionare insufficient to 25, 525-531. bring about lasting change. It is essential to ad- Clarkson, P. (1987). The bystander role. Transactional dress internal ego state relationships to facili- Analysis Journal, 17,82-87. tate a reorganization of mind or cure (Berne, Cornell, W. (1988). Life script theory: A critical review from a developmental perspective. TransactionalAnaly- 1961, p. 246). As Bromberg (2001) writes, sis Journal. 18, 270-282. We do not treat patients . . . to cure them Cornell, W. F. (2003). Babies, brains and bodies: Somatic ofsomething that was done to them in the foundation of the child. In C. Sills & H. Hargaden past; rather we are trying to cure them of (Eds.), Ego states (Vol. I of Key concepts in transactional analysis: Contemporary views) (pp. 28-54). Lon- what they still do to themselves and to oth- don: Worth Publishing. ers in order to cope with what was done to Cornell. W. F., & Hargaden, H. (Eds.). (2005). From them in the past. (p. 237) transactions to relations: The emergence of a relational tradition in transactionalanalysis. Chadlington, Jo Stuthridge, MSc., is a Teaching andSup- England: Haddon Press. ervising TransactionalAnalyst (psychotherapy) Cozolino, L. (2002). The neuroscience ofpsychotherapy. New York: Norton. andmemberofthe New ZealandAssociation of Dalenberg, C. (2003, 28 April). Abuse as trauma. be- Psychotherapists. She is codirector ofthe Phy- trayal. loss and stigma: Deepening trauma treatment. sis Institute and maintains a private psycho- Seminar presentation, Doctors for Sexual Abuse Care, therapy practice in Dunedin, New Zealand. Dunedin, New Zealand. Damasio, A. (2000). Thefeeling ofwhat happens: Body She can be reached at PO Box 1205, Dunedin, and emotion in the making ofconsciousness. London: New Zealand; e-mail: [email protected] William Heinmann. Davies,J. M., & Frawley, G. M. (1994). Treating the adult REFERENCES survivor ofchildhood sexual abuse: A psychoanalytic Allen, 1. R. (2003). Concepts, competencies and interpre- perspective. New York: Basic Books. tive communities. Transactional Analysis Journal, 33, Erskine, R. G. (1991). Transference and transactions: Cri- 126-147. tique from an intrapsychic and integrative perspective. Allen, 1. R., & Allen, 8. A. (1997). A new type oftrans- Transactional Analysis Journal, 2I, 63-76. actional analysis and one version of script work with a Erskine, R. G. (1993). Inquiry, attunement, and involve- constructionist sensibility. Transactional Analysis ment in the psychotherapy of dissociation. Transac- Journal, 27, 89-98. tional Analysis Journal. 23, 184-190. American Psychiatric Association. (1994). Diagnosticand Erskine, R. G. (2003). Introjection, psychic presence and statistical manual ofmental disorders (4th ed.). Wash- parent ego state: Considerations for psychotherapy. In ington, DC: Author. C. Sills & H. Hargaden (Eds.), Ego states (Vol. I of Aron, L. (1996). A meeting ofminds: Mutuality inpsycho- Key concepts in transactional analysis: Contemporary analysis. Hillsdale, NJ: The Analytic Press. views) (pp. 83-108). London: Worth Publishing. Beebe, 8., & Lachman, F. (1988). The contribution of Erskine, R. G., Moursund, 1. P., & Trautmann, R. L. mother-infantmutual influenceto the origins of selfand (1999). Beyond empathy: A therapy of contact-in- object representations. Psychoanalytic Psychology, relationship. Philadelphia: Brunner/Maze!. 5(4),305-337. Fairbairn, W. R. D. (1992). Psychoanalytic studies ofthe Berne, E. (1961). Transactional analysis inpsychotherapy personality. London: Tavistock/ Routledge. (Original A systematic individual and social psychiatry. New work published 1952) York: Grove Press. Fonagy, P. (200 I). Attachment theoryandpsychoanalysis. Berne, E. (1966). Principles ofgroup treatment. New New York: Other Press. York: Grove Press. Fonagy, P., Gergely, G., Jurist, E., & Target, M. (2002). Braun, B. G. (1989). Psychotherapy of the survivor of Affect regulation. mentalization, and the development incest with a dissociative disorder. Psychiatric Clinics ofthe self New York: Other Press.

282 Transactional Analysis Journal

Downloaded from tax.sagepub.com by Marco Mazzetti on February 3, 2014 INSIDE OUT: A TRANSACTIONAL ANALYSIS MODEL OF TRAUMA

Fonagy, P., Target, M., & Gergely, G. (2000). Attachment Mitchell, S. (1988). Relational concepts in psycho- and borderline personality disorder. The Psychiatric analysis. Cambridge, MA: Harvard University Press. Clinics ofNorth America. 23(1), 103-121. Mitchell, S. A., & Aron, L. (Eds.). (1999). Relational Fosha, D. (2003). Dyadic regulation and experiential work psychoanalysis: The emergence ofa tradition (Vol. 14 with emotion and relatedness in trauma and disorgan- of Relational perspectives book series). Hillsdale, NJ: ized attachment. In M. F. Solomon & D. 1. Siegel The Analytic Press. (Eds.), Healing trauma: Attachment. mind. body and Moiso, C. (1985). Ego states and transference. Transac- brain (pp. 221-281). New York: Norton. tional Analysis Journal. 15, 194-201. Freud, S. (1953). Three essays on the theory ofsexuality. Nelson, K. (1992). Emergence ofautobiographical mem- In 1. Strachey (Ed. & Trans.), The standard edition of ory at four. Human Development. 35. 172-177. the complete psychological works ofSigmund Freud Novellino, M. (1990). Unconscious communication and (Vol. 7, pp. 125-243). London: Hogarth Press. (Original interpretation in transactional analysis. Transactional work published 1905) Analysis Journal. 20, 168-172. Gabbard, G. O. (1994). Psychodynamic psychiatry in Putnam, F. (1989). The diagnosis and treatment ofmul- clinicalpractice: The DSM-IV edition. Washington, DC: tiple personality disorder. New York: Guilford Press. American Psychiatric Press. Schore, A. N. (1994). Affect regulation and the origin of Gabbard, G. O. M. (1992). Commentary on "dissociative the self Hillsdale, NJ: Lawrence Erlbaum Associates. processes and transference-countertransference Schore, A. N. (2003). Early relational trauma: Disorgan- paradigms" by Jody Messler Davies and Mary Gail ized attachment and the development of a predispo- Frawley. Psychoanalytic Dialogues. 2(1),37-47. sition to violence. In M. F. Solomon & D. 1. Siegel Hargaden, H., & Sills, C. (2002). Transactional analysis: (Eds.), Healing trauma: Attachment, mind. body and A relational perspective. Hove, England: Brunner- brain. New York: Norton. Routledge. Siegel, D. J. (1999). The developing mind: How relation- Haykin, M. D. (1980). Type casting: The influence of ships and the brain interact to shape who we are. New early childhood experience upon the structure of the York: Guilford Press. child ego state. Transactional Analysis Journal. 10(4), Siegel, D. J. (2003). An interpersonal neurobiology of 354-364. psychotherapy: The developingmindand the resolution Herman, J. (1992). Trauma and recovery. New York: of trauma. In M. F. Solomon & D. 1. Siegel (Eds.), Basic Books. Healing trauma: Attachment, mind. body and brain Hesse, E. (1999). The adult attachment interview: His- (pp. 1-56). New York: Norton. torical and current perspectives. In 1. Cassidy & P. Stern, D. N. (1985). The interpersonal world ofthe infant: Shaver (Eds.), Handbook ofattachment: Theory. re- A view from psychoanalysis and developmental psy- search and clinical applications (pp. 395-433). New chology. New York: Basic Books. York: Guilford Press. Streeck-Fischer, A., & van der Kolk, B. A. (2000). Down James, W. (1892). Psychology: Briefer course. London: will come baby cradle and all: Diagnostic and thera- Macmillan. peutic implications ofchronic trauma on child develop- Kisiel, C. L., & Lyons, J. S. (200 I). Dissociation as a me- ment. Australian and New ZealandJournal ofPsychia- diator of psychopathology among sexually abused try. 34, 903-918. children and adolescents. American Journal ofPsychi- Teicher, M. H. (2002, March). Scars that won't heal: The atry, 158, 1034-1039. neurobiology ofchild abuse. Scientific American, 68- leDoux, J. (2002). Synaptic self: How our brains become 75. who we are. Middelsex, England: Viking Penguin. Tudor, K. (2003). The neopsyche: The integrating adult Lichtenberg, 1. D. (1983). Psychoanalysis and infant re- ego state. In C. Sills & H. Hargaden (Eds.), Ego states search. Hillsdale, NJ: The Analytic Press. (Vol. I ofKey concepts in transactional analysis: Con- Little, R. (2005). Integrating psychoanalytic understand- temporary views) (pp. 201-231). London: Worth Pub- ings in deconfusion ofprimitivechild ego states. Trans- lishing. actional Analysis Journal. 35, 132-146. van der Kolk, B. A. (2000). Trauma, neuroscience and the Loria, B. (1995). Structure determinism and script analy- etiology of hysteria: An exploration ofthe relevance of sis: A bringing forth of alternative realities. Transac- Breuer and Freud's 1893 article in light ofmodern sci- tional Analysis Journal. 25, 156-167. ence. Journal of the American Academy of Psycho- Lyons-Ruth, K., & Jacobvitz, F. (1999). Attachment dis- analysis, 28(2),237-262. organization: Unresolved loss, relational violence and van der Kolk, B. A., & Fisler, R. (1995). Dissociation and lapses in behavioral and attentional strategies. In 1. the fragmentary nature of traumatic memories: Over- Cassidy & P. R. Shaver (Eds.), Handbook ofattach- view and exploratory study. Journal ofTraumaticStress, ment theory: Theory. research and clinical applica- 8(4),505-525. tions (pp. 520-554). New York: Guilford Press. van der Kolk, B. A., Pelcovitz, D., Roth, S., Mandel, R., Masson, 1. M. (1984). The assault on truth. New York: Mcf'arlane, A., & Herman, 1. (1996). Dissociation, Farrar, Straus & Giroux. somatization and affect dysregulation: The complexity McFarlane, A., & Yehuda, R. (2000). Clinical treatment of of adaptation to trauma. The American Journal of posttraumatic stress disorder: Conceptual challenges Psychiatry, 153(7),83-93. raised by recent research. Australian and New Zealand Woolf, V. (1993). Orlando. London: Bloomsbury. (Origi- Journal ofPsychiatry. 34. 940-953. nal work published 1928)

Vol. 36, No.4. October 2006 283

Downloaded from tax.sagepub.com by Marco Mazzetti on February 3, 2014