...I am reprinting this book review by Jean Knox in hope that it will be of value to my readers who are healing from childhood trauma.
Review of The Impact of Early Life Trauma on Health and Disease written by Ruth Lanius, Eric Vermetten and Clare Pain. Published by Cambridge University Press, Cambridge, 2010; 315 pages.
Reading this book was a rather humbling experience in that I realized that there is so much more research on the impact of early life trauma than I knew, even though I was familiar with quite a number of seminal papers in the field. One of the remarkable aspects of the book is the range of research that it covers, from the epidemiology of childhood trauma and the history of professional attitudes to the problem, through diagnostic controversies, psychosocial issues, longitudinal studies on the immediate and long-term neurobiological, psychological and physical effects of early relational trauma, to the implications all these hold for clinical work with children and adults who have suffered early-life trauma. This huge body of research is discussed and summarized in three sections, each of which has short co-authored chapters, so that the expertise of key researchers and clinicians across the whole field of traumatology is represented. The editors of the book are three psychiatrists, Ruth Lanius and Claire Pain from Canada, and Eric Vermetten from the Netherlands, all neuroscience and trauma research specialists who also explore the implications of empirical research for clinical psychotherapy practice. The focus of almost all these papers is on the hugely damaging impact that neglect or abuse by primary caregivers has on the psychological and emotional development of the human infant, creating life-long consequences in terms of brain development, attachment and affect dysregulation, altered stress responses and a range of psychological symptoms, from the flashbacks and hyper-arousal of PTSD to altered perception, epileptic-type phenomena and dissociative states of varying degrees of severity, including borderline personality and dissociative identity disorder. This evidence from neurobiology powerfully supports the argument that it is real-life experience rather than innate unconscious phantasy that determines most of the problems our patients bring to the consulting room and so is highly relevant to our clinical practice. In Section I, the epidemiology and history of childhood trauma are first described, with several authors commenting on the reluctance of some professional groups to accept the link between childhood trauma and a range of physical and psychological symptoms they see in their patients. In the synopsis to this section, McFarlane suggests that: ‘Clinicians’ capacities for observation and description of patients’ predicaments are more determined by the models of psychopathology that clinicians adhere to than the history presented to them by the patient’ (p. 44). McFarlane suggests that psychoanalytic theory carries considerable responsibility for ‘the millions of patients whose stories were told but not believed, being dismissed as oedipal fantasies’ (p. 44). But medicine, psychology and psychiatry also failed to recognize the destructiveness of child- hood abuse, as part of a broader denial of the significance of trauma. Van der Kolk highlights the shocking example of one psychiatric textbook, published in the 1970s that actually extolled ‘the possible benefits to a child of incest’ (p. 58). This historical kind of denial is redressed in this section by a wide-ranging overview of the overwhelming evidence for the lifelong impact of early life trauma on a person’s mental and physical health, and Chapter 6 – by van der Kolk and d’Andrea – is one of the most powerful, making a strongly supported case for a new diagnosis of ‘developmental trauma disorder’ to be accepted. Section II explores in detail the neurobiological and neuroendocrine changes brought about by childhood trauma and the persistence of these effects into adult life, for example, in relation to dissociative states and temporal lobe epileptic-type symptoms. Several chapters emphasize the key role of early life trauma in causing permanent alteration to the hypothalamic–pituitary–adrenal axis, which leads to abnormal cortisol levels (the body’s response to stress) and damage to key parts of the brain such as the hippocampus (which deals with memory) and the corpus callosum (which integrates information in the left and right brain). In the synopsis to this section, Allan Schore spells out the impact of this research, for example, the trend towards research on trauma in the earliest stages of infant development and the increasing recognition of ‘relational attachment trauma in infancy as the major factor in altered development and psychopathogenesis’ (p. 144). He points out that this shift also recognizes that social and relational trauma, for example, in dysfunctional parent–infant relationships, causes serious and long-term damage to the infant’s brain development and that the focus of current research has shifted from studying ‘deficits in later-maturing conscious, verbal, explicit and voluntary behavior to impairments of early maturing, non-conscious, non-verbal, implicit and automatic adaptive social emotional functions’ (p. 144). Chapters 16 and 17 in this section were of particular interest to me, both of which have Ruth Lanius as one of the authors. Chapter 16 reviews the evidence that ‘shows that early childhood abuse has causative long-term effects on brain areas involved in memory and emotion’ and that PTSD represents ‘the behavioral manifestations of stress-induced changes in brain structure and function’ (p. 172). But it also spells out the ‘important public health implications of biological changes associated with childhood abuse’, such as the damage to the hippocampus, which impairs new learning and hence ‘could have detrimental effects on the ability of children to succeed academically’ (p. 172) Similarly stress-induced dysfunction of regions of the brain, such as the prefrontal cortex, which regulate social behavior, could contribute to a tendency to antisocial and violent behavior. Chapter 17 offers a powerful evidence-based argument for two types of dissociation, one of hyper-arousal, reflecting reduced activity in the medial prefrontal and anterior cingulate cortex, the brain areas that inhibit the limbic system (the emotional brain). So in this kind of dissociation there is a failure to down-regulate emotion in response to traumatic reminders, giving rise to ‘re-experiencing’ the flashbacks, nightmares and other symptoms of PTSD, arising from the over-activity of an unmodulated limbic system. The other form of dissociation is that of hypo-arousal, where there is high activation of the anterior cingulate and medial prefrontal cortex, with over-inhibition of the limbic system, giving rise to ‘subjective disengagement from the emotional content of the memory through depersonalization, derealization or other secondary dissociative responses’ (p. 182). The authors emphasize that secondary dissociation has been shown to have a profoundly negative impact on psycho- therapy outcome, possibly by preventing emotional engagement with trauma- related information. The implication is that any psychotherapy needs to provide targeted treatments to reduce dissociative symptoms, such as depersonalization, derealization and numbing, before attempting to explore the traumatic memories: ‘Failure to do so can lead to an increase in PTSD symptoms, including secondary dissociation, emotion dysregulation and an increase in the patient’s overall distress and functional impairment’ (p. 185). Section III examines the clinical effects in adults of early life trauma and their implications for treatment and this section may therefore appeal most directly to practicing psychotherapists. The first chapter in this section unequivocally states the theme that predominates throughout this book, that: ‘Abuse and/or neglect experienced in childhood is particularly toxic’ (p. 207), leading to major difficulties in identity, affect regulation and interpersonal relatedness. The very process of remembering the past, on which psychotherapy depends, is itself altered by trauma; and, in Chapter 20, the complex nature of these changes is discussed by Combs and de Prince, for example, the fact that: ‘PTSD is associated with both general deficits in explicit memory performance and heightened memory for trauma-related stimuli’ (p. 218). A range of treatment approaches to trauma are discussed, including Chapter 23 – the only chapter that includes British authors (Peter Fonagy and Anthony Bateman) and which describes a mentalization approach to treating attachment trauma. In spite of the diversity of the treatment approaches described in Section III, Judith Herman and col- leagues argue in their synopsis to this section that there are common themes to these differing treatments, which are interpersonal and affect focused and centre on developing a sense of safety, a capacity for affect regulation and acquiring an ability to have mutually rewarding and freely chosen relationships. They argue that: ‘Effective nuanced treatment of complex childhood-trauma- related pathology has the potential to help trauma survivors to have a dramatically different experience of life’ (p. 298). This remarkable book provides the overwhelming evidence base that under- pins the powerful and heartfelt plea of the Epilogue: The goal and moral imperative of the next decade must be to mitigate the effects of early life trauma through a major public health response that focuses on prevention and early intervention. If successfully accomplished, this will be a major public health advance of our time and alleviate the tremendous suffering and costs associated with the devastating effects of adverse childhood experience. (p. 302) In the face of the urgent imperative of this plea, the territorial squabbles of the psychotherapy profession, for example, in terms of session frequency and institutional allegiances, become an embarrassing diversion from the real public health crisis of the emotional, relational, psychological and physical havoc caused by early life trauma. As one of the final chapters in the book (Chapter 27) points out, psychodynamic psychotherapy is the most useful current treatment for patients with complex PTSD, but with the vital proviso that it must be modified to include a range of sensorimotor techniques that enable affect regulation, build self-awareness and facilitate mentalization. One of the most useful ways in which psychodynamic psychotherapy institutes in the UK could collaborate would be to pool resources to develop trauma treatment centers in this country that could offer the kind of modified psychodynamic psychotherapy that would be evidence-based, drawing on the wealth of research described in this book.
Society of Analytical Psychology
British Association of Psychotherapists Oxford © The authors British Journal of Psychotherapy © 2012 BAP and Blackwell Publishing Ltd, 9600 132 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA. DOI: 10.1111/j.1752-0118.2011.01266.x