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The development of self-identity and consciousness, interpreted as a relational construct: this is the new, overall topic of the next “Attachment and Trauma” Congress in Rome, which is being held on May 22nd-24th, 2020. When the developmental process is disrupted by inadequate caretaking, insufficient attunement or experiences of abuse within the caregiving relationship, the child’s inner sense of continuity and consistence can be severely affected, thus leading to a fragmentation of the Self. Human consciousness is structured in the intersubjective dimension that characterizes mirroring experiences with others. When such experiences are missing, this may lead to a dissociation of the Self and, in the presence of complex trauma, dissociative symptoms may involve extreme rigidity. During their talks, Speakers will explore a multitude of complex aspects related to the development of consciousness. At this respect, brain studies will be a starting point to get a deeper insight into human interactions and go beyond the mere distinction between top-down and bottom-up processes, thanks to a more integrated and comprehensive analysis of social dimensions. In addition, Speakers will highlight the most effective therapeutic approaches that can be adopted in order to create an integrative intervention system, based on specific aspects of the therapeutic relationship. From this perspective, the latter is understood as an opportunity to heal Self-fragmentation, as well as a space where both the therapist and the client can engage with each other in a safe way. Besides this, a series of intervention methods aimed at treating complex trauma and preventing its intergenerational legacy will be discussed. The Congress will also be a unique opportunity to explore new treatment perspectives in Psychotherapy, such as Mirror Therapy and, last but not least, specific interventions based on the use of prosody, music and voice to activate the client’s engagement system within the therapeutic setting.
SEMANTIC ATTACHMENT TRAUMA AND NARRATIVE CONSTRUCTION OF THE SELF
Severe dysregulation of archaic defence systems, characterised by the chronic activation of alarm mechanisms, can be generated by the simultaneous activation of the interpersonal motivational systems (SMI) of caregiving, rank and social sexuality by attachment fgures perceived by the child as a source of danger and threat instead of safety and relational well-being. Such traumatic interpersonal experiences, often early in the developmental history, can only be partially integrated into the body/feelings/memory/consciousness system and generate serious interference with the organisation of attachment, with the structuring of internal operating models, with the maturation of mechanisms for regulating emotional responses and with the acquisition of metacognitive skills. The brain forced to operate under such extreme conditions often manifests dissociative pathologies and constructs controlling strategies to manage interpersonal relationships through a compulsive and improper use of attachment, rank and sexuality. At the same time, as soon as the acute truncatedencephalic phase of neurovegetative and behavioural responses (attack, flight, freezing, fanting) has passed, the autobiographical component of consciousness is biologically driven to construct a meaning and significance also for the fragmented, confused and distressing experiences connected to traumatic memories and cannot help but generate around them and the controlling strategies a part of the narration from which the idea of the Self emerges and takes shape. In this way, complex relational trauma takes on the characteristics of the semantic trauma that characterises personal identity and becomes ontologically connotative of the Self through the use of radical and irrefutable assumptions about certain essential properties of the individual. The attempt to generate a cohesive, coherent and continuous personal narrative is paralysed, disorganised syntactically, emptied of coherent content, compartmentalised, rendered powerless and chaotic in the act of generating agreements between parts of the self. The unlovability, the absence of personal value, the sense of powerlessness, the pervasive feeling of shame, the sense of emptiness, the inconsistency of being oneself, the lack of inner freedom become the prevailing semantic cores around which the narration of one's traumatised relational history develops. Such dramatically sobering semantic nuclei and the dissociated parts of the self that bring them to the stage create continuous, dangerous opportunities for retraumatisation and activate recursive mechanisms of emotional dysregulation, dissociation of consciousness, and sudden re-emergence of fragments of traumatic memories. In many cases, therefore, the treatment plan cannot be limited to the regulation of dysfunctional somatic, relational, emotional and metacognitive mechanisms nor to the mere reactivation of the brain's self-repair mechanisms. Following the stabilisation of the patient and the consolidation of the therapeutic alliance, it is often necessary to include in the therapy of attachment trauma a narrative treatment aimed at working with the parts, strongly connoted on the semantic side, conducted also through relational and sensorimotor access routes. Bibliography Damasio A., Lo strano ordine delle cose, Adelphi, Milan, 2018. Di Fini G and Veglia F (2019) Life Themes and Attachment System in the Narrative Self-Construction: Direct and Indirect Indicators. In Front. Psychol",10:1393. doi: 10.3389/fpsyg. 2019.01393 Liotti G., Farina B., Traumatic developments: etiopathogenesis, clinic and therapy of the dissociative dimension, Rafaello Cortina Editore, Milan, 2011. Panksepp J., Biven L., Archaeology of the mind, Rafaello Cortina Editore, Milan, 2014. Porges S. W., The Polyvagal Theory. Giovanni Fioriti Editore, Rome, 2014 Veglia F., Di Fini G. (2017). Life Themes and Interpersonal Motivational Systems in the Narrative Self-construction. in Frontiers in psychology, 8, pp. 1897, 2017.
COMPLEX TRAUMA, ITS HISTORY AND TREATMENT: THE PRISM META-MODEL
Since its introduction in the early 1990s, the term 'complex trauma' and the diagnosis of Complex Post-Traumatic Stress Disorder (CPTSD) have been the subject of much controversy. Recently, however, an increasing number of experts agree that repetitive and imprisoning early forms of attachment and other forms of chronic interpersonal trauma can often have multiple, layered, and interconnected efects that infuence and undergo the infuence of maturational processes. Such effects interfere with the traumatised child's personal development in many different areas and can literally last a lifetime; they can also cause developmental regression in adults.
Since the 1990s, such after-effects have been the subject of various studies that have led to a much more sophisticated understanding of the subject, with applications to a wide range of fields, including evolutionary studies, attachment studies, emotion studies, and neuroscience. At the same time, in the words of Judith Herman, the field of complex trauma research has undergone a 'forensic clinical innovation' that has led to the development of new approaches and a wide range of treatment options applicable to the treatment of trauma. Today, there are a number of short-term evidence-based approaches whose efcacy in treating post-traumatic symptoms has been proven by scientific research. These findings have led some researchers and clinicians to consider these treatments applicable to any traumatised individual, regardless of clinical status. However, mental health professionals specialising in the treatment of complex trauma and dissociation have questioned the universal applicability of such treatments in several respects, arguing in favour of more sequential, nuanced approaches that go beyond mere posttraumatic symptoms and allow for work on disorders of the self, relationships with others, and the various comorbidities often caused by complex trauma. This intervention will focus on three main areas: The historical evolution of the conceptualisation of complex trauma/posttraumatic stress disorder (CPTSD) and the resistance in the field of traumatic stress research, as evidenced by the decision not to include it as an independent diagnosis within the Diagnostic and Statistical Manual (DSM) nor within clinical practice guidelines. The criteria for 'classical' PTSD are derived from studies of war trauma and post-traumatic reactions manifested in late adolescence or early adulthood, predominantly in male subjects. In contrast, criteria for complex PTSD derive from studies on childhood trauma, domestic violence and other repetitive and imprisoning forms of trauma, areas that more often - but not exclusively - affect female subjects. Significant differences were also identified between the two clinical populations: while traumatised children show clear post-traumatic symptoms, these manifest themselves differently in adults, due to age and the specific stage of the disorder. If the trauma occurs in the course of the child's development, this means that it affects, compromises and intersects with that developmental process, leading to the onset of symptom patterns quite different from those related to classical PTSD. These differences have recently been codified with the inclusion of complex PTSD - as an independent but 'related' diagnosis to traditional PTSD - within the 11th International Classification of Diseases (International Classifcation of Diseases-11). Based on research findings on various classes of after-effects, this diagnosis specifically highlights Disorders of Self-Organisation (DSOs), which are considered the most profound symptoms of complex PTSD. These disorders have also been identified as criteria for the diagnosis of Developmental Trauma Disorder, a diagnosis proposed but not yet accepted. The after-effects identified by the diagnosis of complex PTSD and the conceptualisation of Developmental Trauma Disorder. The complexity and multiple, layered and interconnected origins - both at the physiological and psychological levels - of these efects, which manifest themselves over time in various forms, including dissociative responses, will be analysed in depth. Symptoms will be analysed as efforts made by the individual to adapt to the trauma that, over time, become maladaptive if used outside the original context. In addition, a possible interpretation of symptoms as "secondary elaborations of the original untreated [and often unrecognised] efects of trauma" (Gelinas) will be presented, in relation to the often concomitant mental health illnesses and diagnoses. All of these aspects will be further analysed according to complexity theory, in order to help clinicians gain a deeper understanding of the wide range of symptoms presented by patients. The development of suitable treatment models for complex post-traumatic stress disorders, capable of intervening on their multiple manifestations. Following the publication of the updated version of our book on the treatment of complex trauma, I have developed, together with Julian Ford, a treatment meta-model and guidelines designed to help clinicians manage what may turn out to be one of the most complex and least clear-cut treatment processes of all. The acronym for this model is PRISM: Personalised, Integrative, Sequential, Relational and Multi-component. Each of these features will be presented in detail, together with its rationale and sub-components. At the end of this talk, participants will be able to recognise how the different treatment models presented during the Congress "Attachment and Trauma" are in line with this meta-model.
COMPLEX (ATTACHMENT) TRAUMA MEETS MEMORY RECONSOLIDATION: FACILITATING THE NEURAL PROCESS OF UNLEARNING TO BRING ABOUT TRANSFORMATIVE CHANGE
In the course of the intervention, videos of therapeutic sessions will be observed that show how emotional learnings derived from severe attachment trauma can be profoundly unresolved through memory reconsolidation, with the complete erasure of both extreme post-traumatic symptoms and the underlying reactivation of traumatic memories - a transformative change. Mnestic reconsolidation is an innate brain process that consists of the direct correction, at the level of neural coding, of existing learnings. For two decades, neuroscientists have been investigating how it works. It is an experience-driven process of neurological change. Since 2006, Bruce Ecker has been primarily engaged in translating these research findings into therapeutic methodology. Participants will acquire a clear map of the process steps necessary to induce reconsolidation and transformative change at the brain level, and also a vivid demonstration of the same steps applied to cases of severe complex trauma within attachment relationships. Both the emotional depth and the empathic quality of the facilitation intervention will become evident. Furthermore, the fundamental diference between transformative change, which eliminates the very existence of the target learning and the possibility of its re-emergence, and counter-active change, by which positive resources are developed that compete with the target learning but without actually replacing it and thus allowing for possible relapse, will be clarified. The therapeutic methodology of reconsolidation is entirely based on empirical, transtheoretical knowledge of the neural process of unlearning. The main steps are defined in terms of internal experiences, not external procedures, so that therapists are free to use any suitable experiential technique to facilitate the process. Such steps have, for example, been found in published clinical cases of transformative change in which different psychotherapeutic systems were employed, suggesting that they may be common universal factors that can serve as a framework for integrating psychotherapies. This process represents a significant confirmation and refinement of the corrective experience paradigm, and a serious challenge to the theory of non-specific common factors.
CLOSED SYSTEM, ATTACHMENT AND DISSOCIATION
Ronald Fairbairn considered the closed system of the patient's inner world to be the main source of all resistance; in this regard he wrote: 'to open up openings within the closed system that constitutes the patient's inner world - and thus make it accessible to the infuence of external reality - becomes [an] objective of psychoanalytic treatment' (1958, p. 84). The psychotherapist-patient dyad, just like the mother-infant dyad and dyads in other intimate relationships, is ideally characterised by mutual regulation and should constitute an open system. An open system presupposes, in fact, an interaction with the external reality, whose influence it undergoes. However, in histories of traumatic attachment, in which the attachment fgure fails to offer a protective shield against perceived dangers or threats, or itself constitutes a source of danger or threat, the individual's attachment system undergoes considerable distortions; this causes the self to become increasingly self-sufcient (paradoxically, precisely in order to maintain an aphective bond with the attachment fgure). In the presence of overwhelming emotions and in the absence of an external source of secure support, the psyche becomes, by necessity, increasingly self-referential and closed. Consequently, the individual becomes intensely hyper-vigilant to the dual danger triggered by external threats and the internal sense of overwhelm. This means that self-regulation - and, in particular, aphective regulation - becomes a problem. In the context of dissociative psychopathology, the reciprocity of relationships, both interpersonal and intrapersonal, is considerably reduced. The closed system, therefore, precludes interpersonal inter-subjectivity, as well as the mutual recognition of others, who are separate from the individual and distinguished by their own experiences, as well as their own sense of agency.
HOW TO IMPROVE ONE'S RELATIONSHIP WITH SELF AND OTHERS BY BRINGING UNRESOLVED TRAUMAS TO AWARENESS AND USING PRACTICAL STRATEGIES OF PROVEN EFFECTIVENESS WITH WHICH TO CREATE A SAFE AND EMPOWERING ENVIRONMENT THAT ALLOWS FOR PERMANENT HEALING
The biggest problem for survivors of childhood trauma is the inability to recognise the triggers derived from the traumatic experience and not knowing how to release them in order to deactivate the attack, flight or freeze response. We know from neuroscience that this is an automatic response that for trauma survivors is also one of the most important causes of behavioural and emotional problems.
Experts in the field confirm that healing must come from the right dominant hemisphere, the unconscious Self. The HFL model is successful because it safely accesses the unconscious Self to release suppressed emotions at the time of the traumatic event. The release of trauma enables clients to develop a new Self, free from the constraints of trauma. The model recognises the importance of the clients themselves guiding and controlling all treatment processes. The model is unique in that it was developed by trauma survivors, who integrated neuroscience findings and their own inner knowledge and experience. In the more than 20 years that it has been offered, it has been refined by incorporating the experiences and feedback of other childhood trauma survivors. The HFL model enables participants to recognise that they possess the knowledge and ability to heal, and promotes autonomy and self-efficacy. It also enables them to observe their relationship with themselves and others with a new awareness. Participants are then supported by therapists who have experienced the healing process themselves: they are highly trained and supervised to provide psycho-education and therapeutic support. During the practical, experiential presentation, a survivor will offer her perspective on effective treatment of complex trauma, including a video presentation with which to reinforce this client-centred, peer-developed programme for use in private practice. In this way, Congress participants will be able to expand the therapeutic modalities and thus more effectively and confidently support clients affected by childhood trauma on their journey to healing.
INSIDIOUS TRAUMA AND EMOTIONAL RELATIONSHIPS
The term 'insidious trauma' refers to all those episodes in daily life that can be traced back to marginalisation, objectification, dehumanisation and intimidation experienced by individuals belonging to groups affected by forms of oppression that can be traced back to racism, heterosexism, age discrimination, sexism and more. In the course of their clinical work, therapists are confronted with various forms of suffering (symptoms), often wrongly attributed to internal factors. In most cases, the insidious trauma is neither recognised nor adequately expressed, remaining mostly invisible. During this intervention, the insidious trauma will be the subject of an in-depth analysis, with particular attention to the different effects on aflective relationships. In particular, the analysis of the specific dynamics of heterophobia and homophobia within society, as well as their transmission through the father-child relationship, will serve as an example of how insidious trauma is "staged" and re-experienced within the afective relationships. Finally, the main clinical implications of the therapeutic treatment of this type of trauma and its effects will be illustrated.
DESENSITISATION AND REPROCESSING THROUGH EYE MOVEMENTS (EMDR) AND TRAUMATIC ATTACHMENT
EMDR therapy is an evidence-based therapeutic approach for the treatment of trauma. According to the adaptive information processing model, which guides the EMDR approach, the symptoms presented by the client originate from painful experiences that are maladaptively stored in the brain, without having been fully processed and integrated within the larger network of memory (Shapiro, 1995, 2001, 2018). EMDR therapy is an eight-step method that involves the processing of past memories at the origin of the problems manifested in the present, as well as the triggers that activate the client in the present; this method also involves the creation of a future model (or template) of adaptive behaviour. EMDR can be used not only to treat severe traumas, but also to treat those ubiquitous 'seemingly small' but rather impactful memories (e.g. a mother's angry look, a father's ignored call for help). These memories are the basis for a variety of negative beliefs: 'I am not enough', 'I do not deserve to be loved', 'I am powerless' or 'I am not safe' are just a few examples. Disorganised attachment takes place when the caregiver is both a source of safety and of terror; this form of attachment is at the origin of complex PTSD and dissociative disorders (Brown and Elliot, 2018). Trauma (the abuse or neglect suffered) is not the only aspect to be treated: traumatic attachment to the abuser must also be adequately treated. EMDR can be used to treat both trauma and traumatic attachment. This presentation will outline the basic principles of EMDR therapy and examine the therapeutic treatment of traumatic attachment in clients who have experienced sexual abuse. The principles of treatment will also be illustrated through specific clinical examples.
THE ROLE OF BODILY SENSATIONS IN THE TREATMENT OF DISSOCIATIVE CLIENTS: RISKS AND BENEFITS
During the presentation, a series of strategies will be illustrated to help dissociative clients become more aware of their body sensations as a source of self-knowledge and change. In addition to analysing body phobia, Dr Ogden will describe various interventions aimed at supporting clients in overcoming this phobia. Topics covered will include: the risks and benefits of therapeutic work with bodily sensations; interventions to use when clients end up being dysregulated by their sensations; and practical suggestions to help clients 'befriend' their bodily sensations and mitigate avoidance of the somatic experience. Pat Ogden will also explore the inherent risks and challenges of therapeutic work with positive emotion and 'good' memories, focusing on what to do when these experiences act as triggers on the client. Another aspect examined during the intervention will be the powerful impact of the client's use of self-touch: in this regard, the potential of this technique both in terms of positive outcome and as a useful tool to reduce dysregulation and re-experiencing will be highlighted. Participants will learn how to use positive emotions and self-touch to modify the body's procedural tendencies and foster the integration of different parts of the client's Self.
MINDFUL INTERBEING MIRROR THERAPY: BEYOND OVERCOMING TRAUMA
The Still Face paradigm and the mirror neuron mechanism represent two of the pivotal principles underlying MIMT, as they have scientifically emphasised the relational dimension intrinsic to the process of self-construction and the attribution of existential meaning proper to every human being. The use of the mirror in psychotherapy makes it possible to explore from the outset the subject's relationship with his or her own Self, objectifying the conception of the Self as an Other with whom to interact. This makes it possible to experience the intersubjective dimension of the human being in a new way in which the processes of change are accelerated. MIMT makes it possible to make targeted and conscious use of the activation of neurobiological circuits connected to the recognition of one's own face and the emotions linked to facial expressions, at the service of psychotherapy, understood as a process of self-reconstruction. The therapeutic objective is to re-establish a sense of connection and profound belonging to one's own reflex image, in which the patient can experience that self-compassion that stands at the antipodes with respect to the self-loathing and shame typical of traumatised subjects.
MINDFUL INTERBEING MIRROR THERAPY: BEYOND OVERCOMEING TRAUMA The Still Face paradigm and the mirror neuron mechanism represent two of the cardinal principles at the basis of MIMT, as they have given scientific emphasis to the relational dimension intrinsic in the process of self-construction and attribution of existential meaning proper to every human being. The use of the mirror in psychotherapy makes it possible to explore from the outset the subject's relationship with his or her own Self, objectifying the conception of the Self as an Other with whom to interact. This makes it possible to experience the intersubjective dimension of the human being in a new way in which the processes of change are accelerated. MIMT makes it possible to make targeted and conscious use of the activation of neurobiological circuits connected to the recognition of one's own face and the emotions linked to facial expressions, at the service of psychotherapy, understood as a process of self-reconstruction. The therapeutic objective is to re-establish a sense of connection and profound belonging to one's own reflex image, in which the patient can experience that self-compassion that stands at the antipodes with respect to the self-loathing and shame typical of traumatised subjects.
THE ROLE OF THE NEUROBIOLOGICAL CORE SELF AND ITS FELT SENSE IN THE TREATMENT OF TRAUMA AND DISSOCIATION
Diana Fosha, Ph.D., will focus her presentation on the dyadic, moment-to-moment monitoring of the felt sense of the neurobiological Core Self in the context of trauma and dissociation treatment. Drawing on neuroplasticity research, aphrophysical neuroscience, attachment theory, evolutionary studies related to caregiver-infant interactions, as well as transformational studies, Diana developed AEDP, whose clinical practice is essentially experiential, dyadic, and healing-oriented. This presentation will show you how to use, in the clinical setting, the important construct of the neurobiological Core Self, introduced by Jaak Panksepp and Antonio Damasio. Through the use of clinical data, the clinical work, of an experiential nature, conducted by the therapist at the upper edges of the patient's tolerance window, aimed at amplifying the patient's relational, emotional, receptive and aphotic capacities, will be clearly illustrated. Diana's intervention will focus mainly on techniques based on affirmation and recognition through the use of the therapist's aphective self. The clinical work will also illustrate moment-to-moment monitoring guided by the concept of the neurobiological Core Self formulated by Jaak Panksepp. Specifically, the occurrence of the neurobiological Core Self in a patient with complex post-traumatic stress disorder will be monitored from the first moment of the first session until the end of treatment. The presentation will include clinical video recordings.
CARING FOR THE TRAUMATISED SELF: HOW TO MANAGE COMPLEX CLINICAL SITUATIONS IN THE TREATMENT OF TRAUMA
In the course of the talk, we will discuss complex clinical situations that regularly occur in the treatment of trauma. Integrative therapeutic interventions aimed at restoring the self through the resolution of core symptoms will be discussed, which include: dissociative flashbacks, tonic immobility, auditory hallucinations ("hearing voices") associated with the dissociative phenomenon, out-of-body experiences, fragmentation of the self, self-mutilation, aphective dysregulation (high intensity emotional states, intolerance of positive aphective states, emotional dulling). In addition, therapeutic approaches focusing on restoring interpersonal functioning and preventing intergenerational transmission of trauma will be illustrated. In the course of the talk, clinical case examples will be used and treatment strategies based on neurobiology will be discussed. We will also explore recent research advances, particularly in the neurobiology of traumatic stress and its treatment.
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