Cognitive Neuroscience Encounters Psychotherapy
Lessons from Research on Attachment and the Development of Emotion, Memory and Narrative
by Daniel J. Siegel, M.D.
March 1996
(The following ideas were presented as a plenary address at the 1996 American Association of Directors of Residency Training Annual Meeting and in greatly expanded form in Siegel's forthcoming book, Memory Matters-Ed.)
The Decade of the Brain has offered psychiatry an opportunity to expand its identity by simultaneously reaffirming our roots in biology and discovering new insights into the social nature of brain development. Findings in cognitive neuroscience-the study of the neurophysiological basis of mental processes-have been exploding in recent years. Discoveries of how particular circuits interact as a whole system shed light on the clinical phenomena of illnesses such as obsessive-compulsive disorder, schizophrenia and autism. Integrative work across disciplines, the hallmark of the larger field of cognitive science, embraces developmental and neurophysiological studies that now point to particular regions crucial for emotional regulation, decision-making and the appraisal of meaning.
In this article, I will highlight some of these findings in cognitive neuroscience and relate them to nonclinical studies on attachment in order to provide a view of the developmental interdependence of emotion, memory and narrative. Clinical implications of this integration will be discussed briefly along the way, especially as they pertain to psychotherapy.
Child Development
Two central features of child development are the "hot" cognitive process of regulation of internal psychobiological states, or mental states, and the "cold" cognitive process of attempting to "make sense" of the world. From the first days of infancy, the child's brain is noting similarities and differences across experiences and across sensory modalities. The infant learns via these comparisons and generalizations in the form of mental models, or schema. These models are formed from events in the past. They shape present perceptual biases and aid in anticipating future action. Models can be about the external world, about relationships with other people and about the self. The patterns of neuronal firing within neural circuits and distributed in parallel fashion throughout the brain are believed to be the basis for these processes which represent external or internal entities. The term representation is thus used to describe a basic process of encoding within the brain/mind.
At least three flavors of cognitive representations have been described: symbolic linguistic (semantic, or words), symbolic prelinguistic (images, ideas, categories) and presymbolic (sensations, notions). [So, the "sensation" of Hakomi Integrative Somatics is "a presymbolic cognitive representation" laid down in the earliest perceptual stage of life!!!]
Even at an early age, children begin to associate these three levels with each other in what is called a dispositional representation (DR), which links memories for experiences with emotional states of mind present at the time of the event (see Damasio). Emotions can be conceptualized as being a part of a mental state determined by the physiological status of response of the body as registered in the brain as a representation called a somatic marker (SM).
For example, the words the Eiffel Tower are a semantic stimulus which may activate similar symbolic linguistic representations in many people, but the associated prelinguistic and presymbolic representations linked to the words within each individual's DRs will be quite unique. The personal meaning of the Tower will vary with the emotions which link much of what becomes associated within a DR. Recent reviews (see Damasio, Schore and Baron-Cohen) have suggested that a region of the brain resting just above the orbits of the eyes and at the apex of the limbic system, called the orbitofrontal cortex, is responsible for linking somatic markers to DRs, thus permitting the appraisal of meaning to stimuli, allowing rational decision-making processes to occur and facilitating emotional regulation and interpersonal communication.
The orbitofrontal cortex thus plays a central role in human relationships and its dysfunction may be evident in a number of psychiatric disturbances including disorders of mood, attachment or personality, and in autism. Sitting at the interface between the deeper limbic structures (including the amygdala) responsible for basic emotional reactions, and the higher cortical centers involved in associational thinking, the orbitofrontal cortex has, in this decade, become the focus of much research on normal and pathological emotional cognition. This region of the brain is able to monitor the physiological status of the body via the registration of somatic markers which directly influence mental states. In addition, the orbitofrontal cortex can regulate bodily states--and hence emotional states--via nucleii which directly control the sympathetic and parasympathetic divisions of the autonomic nervous system.
Emotional states are both a primary topic and mode of communication between infant and parent. In fact, the mutual "tuning" of psychobiological states between parent and child [and between client and therapist!!] appears to be a necessary experience for the neuronal maturation of the orbitofrontal cortex (see Schore). Established via eye contact and the mutual attunement of states of mind between infant and caregiver, this alignment of mental states appears to be a central ingredient in secure attachments which facilitates healthy development-both neurologically and socially. In fact, the distinctions often drawn in words and perspectives between the biological, psychological and social domains begin to lose meaning and disappear with the recent findings from developmental and cognitive neuroscience.
Communication
Contingent responsivity appears to be at the heart of interpersonal communication which facilitates secure attachments. Researchers have found (Trevarthen) that by three months of age, infant-mother "protoconversation" depends on the mutually sensitive responses of the dyad, not merely on the upbeat emotional responsivity of the mother. In this study, infants and their mothers interacted via an on-line closed-circuit television monitoring system. When the infants were unknowingly replayed the happy responses from the mother recorded from the prior minute, they still became as profoundly distressed as infants do in the classic "flat face" experiments in which mothers in-person give no facial emotional response to their infant's bid for attunement.
From early in infancy, it appears that our ability to regulate emotional states depends upon the experience of feeling that a significant person in our life is simultaneously experiencing a similar state of mind. This observation has important implications for effective parenting, relationships and psychotherapy, expanding on the notion of empathy or mirroring by identifying mutually engaged psychophysiological states rather than just sympathetic communication.
An evolutionary benefit of this attunement of mental states includes the idea that caregivers' knowing what an infant feels will improve chances for survival by having his/her needs met. Researchers argue, however, that attachment is much more than a matter of security for survival. Becoming a part of a larger system, being joined by others, having a mental-state companion in life, is fundamental (neurologically, psychologically) to the healthy regulation of our mental states. This latter view, that it is not merely surviving--but emotionally thriving--which secure attachments provide, is both new and important in understanding the role of emotional relationships for mental health.
As the child grows, repeated experiences with caregivers begin to shape the models of attachment in the child's brain, proposed by Allan Schore, Ph.D., (Schore) to be part of the role of the orbitofrontal cortex. These representations of relationships are formed early on and are tenacious templates for future relationships. The psychotherapy setting can activate these sometimes latent models of attachment, revealing within the patient's behaviors and cognitive representations how these nonconscious processes may shape an individual's capacity for emotional connection to others, and to oneself.
Secure attachment appears to depend on the consistent emotional availability, sensitivity and effectiveness of the caregiver to meet the child's needs and attune to his or her state of mind (see Main). Consistency does not mean perfection-attunements are inevitably ruptured, and it is the effective repair or realignment of the child and parental (patient's and therapist's) mental states which provides for a sense of a secure base, facilitating development. Secure attachments are associated with a balance in the capacity for high levels of emotional intensity and the ability to have emotional regulation. Healthy affect regulation permits the acceptance of prohibitions to behavioral impulses when needed, facilitates a range of acceptable pleasurable and unpleasant emotions, and includes a mechanism for relatively rapid and effective recovery when emotional states move beyond the envelope of tolerability. Initially, affect regulation is dependent on the responses of the caregiver; as the child grows, regulation becomes an autonomous function, internalizing the attuned relationships as a representation of self-with-other and having it available for self-regulation.
Attachment Styles
Attachment research has demonstrated large categories of styles of attachment in which the relationship between child and caregiver can be generally classified into one of three or four groupings: secure, insecure-anxious, insecure-avoidant and disorganized. Studies have focused on infants, children, adolescents and their parents, noting a range of trends within classifications. For the purposes of this article, let me highlight selected findings relevant to emotions, memory and narrative.
In anxiously attached dyads, the parental intrusion of his or her state of mind onto that of the child's, coupled with emotional inconsistency, leads the child to have a model of uncertainty about the attunement of the parent and the parent's ability to provide comfort. Understandably, these anxious attachments are associated with a sense of permeable self-other boundaries and worries about how dependable others may be. As adults, the autobiographical narratives (Main) of the parents are filled with an intrusion of preoccupations with past events into the present.
In avoidantly attached relationships, parental rejection and insensitivity to the child's emotional state leads to a behavioral style of avoidance in the infant and of disconnection and overcontrol in the older child. Access to autobiographical memory, as well as the development of life narratives, appears to be limited. These findings suggest that the lack of experience of alignment of mental states may lead the child to not develop the capacity for self-reflection and self-knowledge: in a sense, the attachment history of disconnection becomes reflected in their own internal disconnection from themselves (Fonagy and others).
Fear inducing or fearful behavior on the part of the parent leads to disorganized attachments in which, unlike the two previous categories of organized approaches, there is a chaotic style of adaptation to parental behavior which has been inherently conflictual with the purposes of attachment: to provide a sense of security and contingent communication. Parents of these dyads appear to have a lack of resolution of trauma or grief-such that their past intrudes on the present and disorients and disorganizes them. In a similar fashion, the children of these dyads respond to separation and reunion with chaotic, often self-destructive acts and a tendency to dissociate or enter trance-like states. These children are at risk for disruptions in other cognitive functions, including attention, short-term memory and affect regulation. The capacity to have smooth shifts in states of mind is a developmental achievement unattained in this attachment setting, placing these children at risk for developing dissociative difficulties (Liotti).
The narrative process in the parents of disorganizedly attached children reveal unresolved trauma or grief as their discourse becomes disorganized when focusing on their unsettled past. Stories serve to both make sense of the world and regulate the self. Narrative coherency thus reflects the way in which these processes have been successful. Unresolved issues lead to both emotional turmoil and incoherency of narrative (Siegel).
Psychotherapy
Various studies of attachment and the development of emotions and memory in children reveal a fascinating set of findings. Briefly, in avoidantly attached dyads, language use by the mother appears independent of maternal facial expression of emotion when the child is 2 years of age. By 4 years, mothers of avoidantly attached children seem to be unable to tune in at the level of the child's development in attempting to jointly solve problems.["Double bind" theory is still valid!!] Ten year olds who were avoidantly attached as infants have a significant lack of autobiographical narrative capacity. Their parents have the unique characteristic of insisting that they do not recall their own childhood family experiences. These findings point to the interdependency of emotional connection and the development of autobiographical memory and narrative. They also suggest that certain attachment styles are associated with a disconnection between linguistic and nonlinguistic cognitive representations: feelings (sensations) and perceptions (images) may be difficult to access and then communicate to others (or the self) within linguistically based stories.
The development of memory is complex and highly social (Bartlett). Here is a necessarily telescopic overview: The early form of memory to develop first is called non-declarative or implicit and involves the direct encoding of experience into nonlinguistic representations: emotional, behavioral, somatic and perceptual. Retrieval of implicit memory does not involve an internal sense of recalling, but rather the direct activation of brain circuits responsible for the representational form in which the initial experience was encoded: [i.e., by hands-on body work, or inner body sensing] the amygdala and orbitofrontal cortex, the basal ganglia and motor strip, the somatosensory cortices and the perceptual centers, respectively. Implicit recall would, for example, result in a person feeling an emotion or having a behavioral impulse without knowing its original source or even feeling that something is being remembered.
By the second year of life, children begin to develop the later form of memory, called declarative or explicit, which includes both semantic (factual) and episodic memory (remembering oneself in an episode in time) (Squire). Encoding of explicit memory involves the medial temporal lobe, including the hippocampus, which does not fully develop its neuronal circuitry until around the third year of life, thus providing the developmental neurophysiological basis for infantile amnesia in which explicit recall is generally unavailable for the period before this age period. Interestingly, long-term storage of explicit memory eventually becomes independent of the hippocampus as it is consolidated in the associational cortex. Part of this consolidation process, requiring REM sleep and dreaming and taking weeks' to months' time, may be related to the narrativization of explicit memory. Narrative memory is a term referring to the way in which we may store and then recall experienced events in story form.
Narrative Memory
Children's explicit memory for events is greatly enhanced if the content of their memory is discussed with parents (Nelson). This memory talk lets the child know that their experience of events is of interest to the parent and also serves as a cognitive reinforcer of items stored in memory. This, combined with the attachment findings, suggests that the parent's attunement with the memory system and the emotional state of the child appears to enhance the development of the capacity to tell stories about their life. Coconstruction of narrative is a fundamental process, studied by anthropologists across all cultures, in which families join together in the telling of stories of daily life (Ochs and others). Many academicians have pointed to narrative as being crucial to a sense of self (Dennet, Stern and Kegan), thus raising the question of whether different attachment histories are associated with distinct internal sensations of self.
Narrative thought develops much earlier than the later, paradigmatic, logico-scientific form (Bruner). Narrative focuses on internal and external human experience--the emotions and activities of characters in the story. Narrative appears to rely on right hemispheric language: context dependent, emotional, sensory, perceptual representations sometimes referred to as "analogic" (Vitz). The logical communication of facts, which appears to be context independent, is the medium of left hemispheric language processing of digital or linguistic representations.
Narrative can be defined as the telling of a series of events and involves the perspective of the teller (first or third person, past or present), various characters' activities and mental states (emotions, attention, intentions) and the depiction of conflicts and their resolution. As a form of discourse, narrative takes into account the needs of the listener, supplying the necessary contextual information for the story to be understood and biasing the details of the story in order to maintain the interest of the listener. Three genres of narratives are present from early on: fictional, schematic (general descriptors of events) and autobiographical.
Narratives are felt to both help make sense of the world and provide themes which drive future action. The carrying out of these themes, called enactment, may shape a person's style of behaving with others. Autobiographical narrative thus historically documents events, deriving meaning in an attempt to make sense out of them, and guides plans for future action. As such, narratives are simultaneously shaped by mental models and states of mind internally; externally, as a form of discourse, they are influenced by listener expectation. Views of thought as an internalized form of dialogue point to the notion that attachment histories devoid of discussions of the child's internal state may lead to a paucity in autobiographical narrative capacity. Stories are driven forward by both explicit, consciously accessible memory, and by implicit memories in the form of emotion, behavioral response patterns, somatic sensations and perceptual recall. The telling of stories may thus be a primary way in which we can linguistically communicate to others--and to ourselves--the contents of our minds (Siegel, in press).
Narratives allow us to sequence the events of our lives using linguistic symbols--which can be shared with others--with our deeper, prelinguistic processes. The intrapsychic binding of these forms of mental processes within dispositional representations--including the somatic markers fundamental to emotion--thus creates a sense of a coherent self. For securely attached individuals, the coherency of attachment models is reflected in the fluidity and self-reflection of the adult's remembrances of childhood. In contrast, the narratives of insecurely attached individuals, either in their rigidity, lack of connection with the past, or intrusion of the past into the present in the form of preoccupations or disorientation, are tight, inflexible and at times conflictual templates of relationships in the past, and hence for the present and the future. Within their dispositional representations of personal relationships are segregations of the various layers of cognitive representations, flooding the anxiously attached individual with unpredictable emotional intensity (in the form of intrusive somatic markers) or isolating the avoidantly attached person's thoughts from the emotions which would give them personal meaning.
Healing Memory
Stories, in the form of myths, films, plays, novels, diary entries, dinner conversations or psychotherapy sessions, dominate our lives. Many forms of therapy--from play and drawing with children to the joint attention to autobiographical reflections with adults--involve the coconstruction of narrative around the memory talk between patient and therapist. This verbal communication takes place within the therapeutic setting based on the primary ingredients of a secure attachment: a safe environment with contingent communication, emotional connection and repair of inevitable disruptions in the therapeutic relationship. Through the sharing of states of mind, with joint attention to the verbal representations inherent in the therapeutic dialogue, the patient and therapist's orbitofrontal cortices are likely to become fully engaged.
Patients who may have had disrupted development in the orbitofrontal cortex, for any of a variety of reasons, may present with difficulties in affect regulation, in interpersonal communication, in finding emotional meaning and personal decision-making processes. For these patients, engaging in such an interactive therapeutic process may be a very specific, focused form of treatment. If neural plasticity beyond infancy allows (a debatable and fascinating question about the neurophysiological basis of therapeutic change), this development process, as with the growth of the infant's brain within the attachment relationship, permits the patient to first rely on the therapist for regulation of his or her emotional states and the exploration of meaning in life. As the mutual alignment of mental states in therapy progresses, the patient's orbitofrontal cortex may be able to form a mental model of the patient-therapist relationship which allows the emergence of autonomous and flexible affect regulation. Through contingent communication, the connection of the therapist's and patient's mental states, and the joint attention to the patient's life story, psychotherapy may be facilitating a profound neurological development which cognitive neuroscience is now just beginning to illuminate for us all.
Dr. Siegel is a psychotherapist in private practice and medical director of the Infant and Preschool Service at the University of California, Los Angeles (UCLA). He has served as a National Institute of Mental Health-UCLA research fellow, studying attachment, emotional regulation, memory and narrative.
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