Working With Traumatic Memories To Heal Adults With Unresolved Childhood Trauma - Neuroscience, Attachment Theory and Pesso Boyden System Psychomotor Psychotherapy PDF

WORKING WITH TRAUMATIC
MEMORIES TO HEAL ADULTS WITH

UNRESOLVED CHILDHOOD TRAUMA
of related interest
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ISBN 978 1 84905 562 8
eISBN 978 1 78450 001 6
WORKING WITH
TRAUMATIC MEMORIES
TO HEAL ADULTS
WITH UNRESOLVED
CHILDHOOD TRAUMA
NEUROSCIENCE, ATTACHMENT THEORY
AND PESSO BOYDEN SYSTEM
PSYCHOMOTOR PSYCHOTHERAPY
Petra Winnette and Jonathan Baylin
Jessica Kingsley Publishers

London and Philadelphia
Photo of Albert Pesso and Diane Boyden-Pesso on page 257 courtesy of Petra Winnette.
First published in 2017
by Jessica Kingsley Publishers
73 Collier Street
London N1 9BE, UK
and
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Copyright © Petra Winnette and Jonathan Baylin 2017
Front cover image source: Petra Winnette.
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Library of Congress Cataloging in Publication Data
Names: Winnette, Petra, author. | Baylin, Jonathan F., author.
Title: Treating adults with unresolved childhood trauma : a mind-body and
brain-based approach / Petra Winnette and Jonathan Baylin.
Description: London ; Philadelphia : Jessica Kingsley Publishers, 2017. |
Includes bibliographical references and index.
Identifiers: LCCN 2016023366 | ISBN 9781849057240 (alk. paper)
Subjects: | MESH: Stress Disorders, Traumatic--therapy | Adult Survivors of
Child Adverse Events--psychology | Psychotherapy--methods
Classification: LCC RC552.P67 | NLM WM 172.5 | DDC 616.85/210651--dc23 LC
record available at
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British Library Cataloguing in Publication Data
A CIP catalogue record for this book is available from the British Library
ISBN 978 1 84905 724 0
eISBN 978 1 78450 182 2
I would like to dedicate this book to Albert Pesso,
my great teacher and supervisor. He had a life-changing
influence on me and the way I understand the meaning
of working with people and psychotherapy itself.
Petra Winette
I would like to dedicate this book to the main author,

Petra, and to the memory of the Pessos, who passed
away before I had the privilege of meeting them.
Jon Baylin
CONTENTS
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . 13
Introduction . . . . . . . . . . . . . . . . . . . . . . 15
Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Organisation of the book . . . . . . . . . . . . . . . . . . . . .15
Clarification of language . . . . . . . . . . . . . . . . . . . . . 19
Part I: Background 21
1. When Things Go Right
Developing Brain, Mind and Self in Good Care . . . . . . . . 23
Petra Winnette
How the brain develops . . . . . . . . . . . . . . . . . . . . . .23
Memory: The basis for learning
and understanding the world . . . . . . . . . . . . . . . . . . . 27
The role of memory . . . . . . . . . . . . . . . . . . . . . . . .28
The hierarchic development of memory . . . . . . . . . . . . . .28
Attachment . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Attunement and the child’s sense of self . . . . . . . . . . . . . 31
Feeling secure with my parent: A secure attachment style . . . . . 32
Adults and attachment . . . . . . . . . . . . . . . . . . . . . . .32
Secure attachment in childhood and a secure, autonomous
state of mind in adulthood . . . . . . . . . . . . . . . . . . . . 33
Adulthood and a safe model of autonomous life . . . . . . . . . .34
Window to Neurobiology of Good Care . . . . . . . . . . . . 36

Jon Baylin
Building brain bridges in stages:
Vertical, horizontal, lateral . . . . . . . . . . . . . . . . . . . . 36
Social buffering: The neurobiology
of parent–child bonding . . . . . . . . . . . . . . . . . . . . . .38
Behavioural epigenetics: The hot science
of experience-dependent development . . . . . . . . . . . . . . 39
The self-reflection system: Safe to be introspective . . . . . . . . 40
Social development as a whole . . . . . . . . . . . . . . . . . .42
2. When Things Go Wrong
Developing Brain, Mind and Self in Poor Care . . . . . . . . . 45
Petra Winnette
Early trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Healthy balance versus stress . . . . . . . . . . . . . . . . . . . 46
Insecure attachment style and state
of mind in respect to attachment . . . . . . . . . . . . . . . . . 49
Trauma and developmental trauma . . . . . . . . . . . . . . . . 52
Serial traumatic experiences in childhood:
Developmental trauma . . . . . . . . . . . . . . . . . . . . . . .53
The relationship between developmental
trauma and PTSD . . . . . . . . . . . . . . . . . . . . . . . . .54
Memory and trauma . . . . . . . . . . . . . . . . . . . . . . . .55
Adults with unresolved developmental trauma . . . . . . . . . . .56
Window to Neurobiology of Poor Care . . . . . . . . . . . . 58

Jon Baylin
The midbrain defence system . . . . . . . . . . . . . . . . . . . 58
Neuroception and social switching . . . . . . . . . . . . . . . .59
Suppression of social emotions
in favour of asocial feelings . . . . . . . . . . . . . . . . . . . .60
Dissociation: How opioids promote emotional numbing . . . . . 61
Suppression of reflective functioning . . . . . . . . . . . . . . .61
3. Children, Adults and Therapeutic Change
Who Are the Clients with Unresolved
Developmental Trauma? . . . . . . . . . . . . . . . . . . . . 63
Petra Winnette
Developmental trauma disorder . . . . . . . . . . . . . . . . . .63
Developmental trauma in adulthood . . . . . . . . . . . . . . . .65
Degree of unresolved developmental
trauma: Clients are on a spectrum . . . . . . . . . . . . . . . . .69
The core of developmental trauma: The sense of self . . . . . . . 70
Treating unresolved developmental trauma . . . . . . . . . . . . 71
Treating children . . . . . . . . . . . . . . . . . . . . . . . . .72
The healing power of a secure base . . . . . . . . . . . . . . . .73
PACE and PLACE . . . . . . . . . . . . . . . . . . . . . . . . .74
Therapeutic parenting . . . . . . . . . . . . . . . . . . . . . . .75
Treatment options for Clara as a child . . . . . . . . . . . . . . .75
Treatment options for Paul as a child . . . . . . . . . . . . . . . 76
The surprising, new experience of a safe haven . . . . . . . . . . 77
I need to be a baby again . . . . . . . . . . . . . . . . . . . . . 77
Core principles . . . . . . . . . . . . . . . . . . . . . . . . . . 80
Treating the developing mind . . . . . . . . . . . . . . . . . . .80
Treating adults . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Development through the life span:
The interplay of nature and nurture . . . . . . . . . . . . . . . .81
Nature and nurture in psychotherapy . . . . . . . . . . . . . . . 83
Pesso Boyden System Psychomotor therapy . . . . . . . . . . . .84
Window to Neurobiology of Therapeutic Change . . . . . . . 85

Jon Baylin
Neurobiology of trauma-focused treatment with adults . . . . . .85
Awakening the client’s brain, bottom up and top down . . . . . .86
Social buffering . . . . . . . . . . . . . . . . . . . . . . . . . .86
Procedural and structural safety . . . . . . . . . . . . . . . . . .87
Creating new relational experiences . . . . . . . . . . . . . . . 87
Safety to go inside: Activating the default mode network . . . . .88
Part II: Pesso Boyden System Psychomotor

as a Therapeutic System 91
4. Pesso Boyden System Psychomotor Therapy (PBSP)
An Innovative Psychotherapy . . . . . . . . . . . . . . . . . . 93
Petra Winnette
The authors and the evolution of PBSP . . . . . . . . . . . . . .94
PBSP theoretical background . . . . . . . . . . . . . . . . . . .96
Autonomy: An independent life . . . . . . . . . . . . . . . . . 110
The therapeutic content of PBSP . . . . . . . . . . . . . . . . 110
PBSP therapeutic process . . . . . . . . . . . . . . . . . . . . 115
Window to Neurobiology of Change in Pesso Boyden

System Psychomotor Therapy . . . . . . . . . . . . . . . . . 126
Jon Baylin
Neural integration . . . . . . . . . . . . . . . . . . . . . . . . 126
Experiencing the unknown: Being
loved, accepted, safe and good . . . . . . . . . . . . . . . . . 127
The neurobiology of the PBSP structure and therapy:
You can be present and safe, and explore . . . . . . . . . . . . 127
Reversing the wrong . . . . . . . . . . . . . . . . . . . . . . 130
The neuroscience of reversal learning: Antidoting . . . . . . . . 131
Creating new memories . . . . . . . . . . . . . . . . . . . . . 134
Neurological impact of PBSP . . . . . . . . . . . . . . . . . . 135
Part III: PBSP Clients’ Case Studies 137

5. Emma, a Woman and a Bowl of Cold Water . . . . . 139
Petra Winnette
Introducing Emma . . . . . . . . . . . . . . . . . . . . . . . . 139
Born nowhere, living nowhere . . . . . . . . . . . . . . . . . 141
Adopted . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
Introduction to a PBSP structure . . . . . . . . . . . . . . . . 143
The first structure: Emma and a bowl of cold water . . . . . . . 143
A later structure: Emma and no place . . . . . . . . . . . . . . 152
Emma, you are black! . . . . . . . . . . . . . . . . . . . . . . 155
Emma and a ‘bad sign’ . . . . . . . . . . . . . . . . . . . . . 160
Emma and the koan of two left slippers . . . . . . . . . . . . . 163
Emma and a light ring of connection . . . . . . . . . . . . . . 168
6. Anthony, a Young Man Who Jumped . . . . . . . . . 175
Petra Winnette
Introducing Anthony . . . . . . . . . . . . . . . . . . . . . . 175
Anthony’s first session . . . . . . . . . . . . . . . . . . . . . . 176
Anthony and his early relationships . . . . . . . . . . . . . . . 177
Anthony starts PBSP . . . . . . . . . . . . . . . . . . . . . . 179
A lesson on memory . . . . . . . . . . . . . . . . . . . . . . . 180
Anthony and an ideal Stella . . . . . . . . . . . . . . . . . . . 182
Anthony and the missing mother . . . . . . . . . . . . . . . . 188
Anthony and the Pole Star . . . . . . . . . . . . . . . . . . . . 195
Anthony and a child’s innocence . . . . . . . . . . . . . . . . 203
7. Rebecca, the Woman With the Ring . . . . . . . . . 211
Petra Winnette
Introducing Rebecca . . . . . . . . . . . . . . . . . . . . . . . 211
Rebecca and the Fat Fairy . . . . . . . . . . . . . . . . . . . 213
Rebecca and the phoenix . . . . . . . . . . . . . . . . . . . . 219
Rebecca and her adoptive daughter . . . . . . . . . . . . . . . 228
Rebecca, Garry, Anna and tantrums . . . . . . . . . . . . . . . 229
Rebecca can be angry . . . . . . . . . . . . . . . . . . . . . . 231
Rebecca and the ideal doctor –
A structure in a group setting . . . . . . . . . . . . . . . . . . 234
Dance, shape and counter shape . . . . . . . . . . . . . . . . . 235
The role of the group: Role playing . . . . . . . . . . . . . . . 235
Rebecca and the ideal doctor – Group opening . . . . . . . . . 237
A group exercise . . . . . . . . . . . . . . . . . . . . . . . . . 238
Ideal doctor structure . . . . . . . . . . . . . . . . . . . . . . 241
8. Silvester, The Man Who Changed Everything . . . . 245
My name is Silvester . . . . . . . . . . . . . . . . . . . . . . . 245
Being myself . . . . . . . . . . . . . . . . . . . . . . . . . . 245
Coming to PBSP by accident . . . . . . . . . . . . . . . . . . 246
My life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248
9. Epilogue . . . . . . . . . . . . . . . . . . . . . . . 249
Petra Winnette
Clara . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249
Paul . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 250
Emma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251
Anthony . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251
Rebecca . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252
Silvester . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 253
Daniel and Irene . . . . . . . . . . . . . . . . . . . . . . . . . 253
Part IV: Interview with Albert Pesso,

Co-Founder of PBSP 255
10. Interview with Albert Pesso . . . . . . . . . . . . . 257
Conducted by Petra Winnette on 3 September 2014 in Boston,
authorised by Albert Pesso in January 2016
Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 283
Petra Winnette
Critical points . . . . . . . . . . . . . . . . . . . . . . . . . . 283
Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 284
The future . . . . . . . . . . . . . . . . . . . . . . . . . . . . 286
References . . . . . . . . . . . . . . . . . . . . . . . . . . . 289
Subject Index . . . . . . . . . . . . . . . . . . . . . . . . . . 297
Author Index . . . . . . . . . . . . . . . . . . . . . . . . . . 303
ACKNOWLEDGEMENTS
I would like to express my gratitude to the teachers who inspired

me to focus on child development and how it relates to adult life.
This includes Albert Pesso and Diane Boyden-Pesso, Daniel Hughes,
Art Becker-Weidman, Allan Schore, Donald Kalsched, Jon Baylin and
many others whom I met at conferences and trainings over the years.
I am very thankful to two great colleagues and friends, Pirjo Tuovila
and Pat Walton, who have always shared with me a genuine interest
in children and people who seek help. I appreciate their generous
support.
It has been an exciting journey of exploration which continues.
Many thanks to Jon Baylin, who was courageous and open-minded
when engaging with me in this project; to my clients, children as well
as adults, who are so brave when they work on their painful history
and who have taught me so much, and to my sister Misha, who has
always supported me and never loses trust in my determination and
my work.
Finally, this book would not have been written without the
enthusiasm and support of my beloved husband, Miles. Our ongoing
discussions on therapy, science and human nature on mornings,
evenings and holidays are a beautiful part of our life. He has been my
first reader and insightful critic. His patience and help have been
invaluable.
Petra Winnette
Prague, Czech Republic
August 2016
I want to thank Petra for inviting me to work with her on this special
project. Her determination to make the work of the Pessos available
to a wider audience of mental health professionals was the driving
13
14 HEALING ADULTS WITH UNRESOLVED CHILDHOOD TRAUMA
force for this book. Thank you, Miles, Petra’s husband and companion
in life, for all of your help along the way and for being my tour
guide in beautiful Prague. I am grateful to my colleague and friend,
Dan Hughes, for the ongoing dialogue and shared curiosity about the
neurobiology of change in trauma-focused therapy. As always, I am
deeply thankful for the unending support of my wife, Sarah, who has
endured the many months of cluttered surfaces and weekend writing
that were part of this journey.
Jon Baylin
Wilmington, Delaware USA
August 2016
INTRODUCTION
Petra Winnette
Approach
This book first gives a brief overview of child development as a
background for understanding the consequences of developmental
trauma for children and adults. Next we describe how to help clients
with unresolved developmental trauma using the principles and
methods of Pesso Boyden System Psychomotor (PBSP) therapy, which is
uniquely suited for treatment of adults with a history of childhood trauma.
Organisation of the book

When we organised the book we wanted the reader to have a choice
in terms of how to approach the content. We used a framework of ten
chapters divided among four parts. The parts do not need to be read
in sequence.
Petra Winnette wrote Parts I–IV of the book and the Appendix.
Jon Baylin contributed by writing his ‘windows to neurobiology’
for each of the first four chapters of the book. He presents the latest in
neuroscience discoveries about brain structures and functions associated
with social development and the process of change in therapy.
Part I: Background
The developing brain, mind and self
In the first part of this book we focus on the effects of good care and
poor care on the developing child. Then we consider how different
experiences with caregivers in childhood impact functioning in adults.
The science of neurobiology shows there is a genetic base for
development. But this innate plan does not produce a good, meaningful
15
life and a resilient, stable personality on its own. The ‘nature’ of the
genetic template needs the ‘nurture’ of good caregiving to develop
to its full potential. The brain develops in a hierarchic way, stage by
stage. Healthy development can only happen when a child is in a safe,
interactive relationship with a parent or caregiver. A safe attachment,
interactive sensitive parenting, and fulfilment of developmental needs
are the essentials which support optimal development of the brain and
a positive sense of self.
A child who experiences traumatic events in the early stages of
development is at risk for adverse effects on the development of his
brain, other body systems, and his ability to connect and attach with
other people. These changes in structure and functioning in the brain
and in connecting with others program the individual for living in a
world which is unsafe. The severity and extent of the trauma is likely
to be reflected later in the individual’s functioning as an adult (Center
on the Developing Child at Harvard University 2016).
Developmental trauma is a form of trauma induced by caregivers
who consistently fail to meet a child’s developmental needs through
neglect and/or who engage in emotional, physical and/or sexual
abuse of their child. Trauma may result from various other events, of
course, but the focus here is on trauma within the fundamental care-
giving relationship in the early years of life. Developmental trauma
was originally referred to as ‘complex developmental trauma’.
We see many clients whose psychological problems are related to
trauma which occurred in childhood. Often the client has no idea how
the problems started or how they relate to his history.
In our clinical practice we see children and adults. Traumatised
children present difficult behaviour and emotional responses, which
puzzle their parents, teachers and mates. Adults with trauma in
childhood experience stress, fear and disorientation much of the time
when relating to other people. Bessel van der Kolk describes the core
difficulty in treating people with unresolved trauma. These clients
suffer from a painful, disorienting clash. In order to reduce stress
coming from their past, their brain either operates in a hyperactive,
aroused mode or it shuts down. That is, they are either reactive and
hyperactive or depressed, dissociated and numb. They are either alert
and anxious or blank, disconnected and self-absorbed. In those states
they cannot learn from new experiences, even though the experiences
might be helpful and healing. Their mental world is rigid. They go
Introduction 17
through repetitive cycles of experiences with the same trauma-related

content and emotion. In order to keep some level of control they often
become controlling and inflexible (van der Kolk 2014).
These clients suffer from being unable to safely connect with other
people, whether it is finding a partner or relating to their children.
They may have problems at work because it is difficult to cope with
authority figures. They feel useless, unworthy of love and confused
about relating to other people. They are often absorbed in endless
cycles of intrusive, traumatic thoughts. They do not feel they have
a good life. The client chapters provide many examples of clients’
difficulties relating to themselves and other people.
Jon Baylin in his window to the neurobiology of therapeutic
change emphasises that the need for social engagement is hard wired
and does not go away in the face of poor care. When it is safe to engage
in social connections, these capacities gradually become active again.
What is an effective treatment for clients who suffer from chronic
symptoms related to trauma from early childhood? What are the
principles of therapy which will help the client restore his good life?
Can we restore a good life in such cases? We summarise the main
principles of effective therapy as they apply to working with both
children and adults.
Part II: Pesso Boyden System Psychomotor

as a therapeutic system
The authors, evolution, content and process of PBSP
In Part II we introduce a therapeutic model called Pesso Boyden
System Psychomotor (PBSP) which focuses on developmental issues.
PBSP therapy evolved in an unusual way. It started with two talented
dancers, Albert Pesso and his wife, Diane Boyden-Pesso. At a certain
point in their artistic career they made discoveries, while teaching
expressive dance, which led them to the world of emotions and
helping people with the burden of unresolved childhood trauma. Their
therapeutic model is unorthodox and their interventions are unique.
We will describe PBSP using a method for comparing models of
therapy developed by James Prochaska and John Norcross (Prochaska
and Norcross 1999). We will explore the creative interventions used
in PBSP, and discuss its theory, content and process in the context of
developmental neurobiology.
Part III: PBSP clients’ case studies

Emma, Anthony, Rebecca, Silvester
In Part III we introduce four clients who have been involved in long-
term PBSP therapeutic work. With three clients we explore five to
six individual sessions, called structures, just as they happened. The
descriptions of the sessions are written so the reader feels almost as
if he were present in the therapy room. By reading these case studies
we hope the reader will have a better understanding of the impact of
unresolved developmental trauma on the lives of clients. We also hope
as the reader learns about the content and process of PBSP, he will get
a sense of the client’s experience during a structure. Each description
of a structure is followed by a section called ‘Therapist Thoughts’
in which the therapist shares her observations on the process and
outcome of the session.
Part IV: Interview with Albert

Pesso, co-founder of PBSP
Albert Pesso talks about PBSP and structures
I met Albert Pesso in 2003 when he was participating in a research
project on the effectiveness of PBSP. I was very impressed with his
work and immediately decided to study PBSP and get trained in
it. Since then I participated in many trainings and workshops with
Al, continuing my professional development while managing a busy
professional practice. In eleven years of regular training and supervision
with Al I witnessed his passion and eagerness to learn and create in the
field of therapy. Over the years he continued to make discoveries and
refine his approach to structures and his thinking about therapy. I am
grateful Al agreed to be interviewed (3 September 2014 in Boston)
and have his interview published in this book. He authorised the
written version of his interview in January 2016, a few months before
his death.
Appendix
In the Appendix we summarise critical points, research and future
directions for PBSP therapy.
Introduction 19
Clarification of language
Through the book we use ‘he’ to refer to persons whose sex isn’t
specified:
Both male and female pronouns are acceptable to use when the sex
isn’t specified. Therefore, it’s OK to write ‘he/she,’ ‘he or she’ or
declare one gender to use throughout an article. Many writers will
stick with their own biological genes – men tend to use the pronoun
‘he’ while women generally use ‘she.’ Both ways are perfectly fine.
The preference lies in the hands of the writer. (Matriccino 2010)
Part I
BACKGROUND
We open this book by providing a context for further discussion on

therapeutic change and Pesso Boyden System Psychomotor therapy.
We focus on normal development, the importance of attachment and
the role of memory in this process. Then we introduce how early
trauma interferes with development. With this background we can
understand the origin and nature of trauma-related difficulties later in
life and the goals and interventions of therapy to resolve them.
21
Chapter 1
WHEN THINGS GO RIGHT

Developing Brain, Mind
and Self in Good Care
Petra Winnette
How the brain develops

People want to know the best way to bring up children and how
childhood influences adulthood. Is it based on genes or does it depend
on parents? Neuroscience shows us how the brain develops and how
the genetic template gets activated and functioning through interaction
with the outside world.
The architecture of the brain is composed of highly integrated sets
of neural circuits (i.e., connections among brain cells) that are ‘wired’
under the continuous and mutual influences of both genetics and the
environment of experiences, relationships, and physical conditions in
which children live. Experiences ‘authorize’ genetic instructions to be
carried out and shape the formation of the circuits as they are being
constructed. This developmental progression depends on appropriate
sensory input and stable, responsive relationships to build healthy
brain architecture… If the responses are unreliable, inappropriate,
or simply absent, the developing architecture of the brain may be
disrupted, and later learning, behaviour, and health may be impaired.
(National Scientific Council on the Developing Child 2012, p.1)
A lot of attention is paid to the question of what it means to be a well-
functioning, happy and healthy adult. It includes having a meaningful
life, being good at work, enjoying relationships with others and being
a good parent. How do people get there? What qualities do they
23
need to develop to be able to live that way? John Bowlby, founder of

attachment theory, wrote:
During the past decade or two a number of clinicians have turned
their attention to the study of individuals who, it is reasonable to
believe, possess well-functioning and healthy personalities… First,
these well-adapted personalities show a smoothly working balance
of, on the one hand, initiative and self-reliance, and, on the other, a
capacity both to seek help and to make use of help when occasion
demands. Second, an examination of their development shows that
they have grown up in closely knit families with parents who, it seems,
never failed to provide them with support and encouragement…
Whilst autonomy is evidently encouraged in such families, it is not
forced. Each step follows the previous one in a series of easy stages.
Though home ties may be attenuated they are never broken. (Bowlby
2005, pp.128–129)
Stages
Early development in children is strongly influenced by the quality of
the bonds they form with caregivers.
The mind emerges from the activity of the brain, whose structure
and function are directly shaped by interpersonal experience.
(Siegel 1999, p.1)
If things go right, when a baby is born he is wanted, welcomed
and cared for. Someone is there, in the ideal situation a loving
mother and father. They are immediately engaged and stay that way
for a long, uninterrupted time. In the beginning the mother is usually
the one who does everything for us. But we also belong to a father
and we belong within our extended family and society. As time passes
a child learns to master different aspects of life and becomes more
independent. Early interactions with parents or primary caregivers
build the foundation for later developmental tasks (van der Kolk 2014).
There are stages or a sequence of when and how different parts
of the brain mature and connect. This development follows a genetic
programme. We can compare it with the growth of a tree. If the seed is
healthy and it gets all it needs, the tree will grow. First, the trunk and
root system develop. The health of the tree depends on the strength
When Things Go Right 25
of these structures and the suitability of the environment. The tree will
add another layer of bark every year. Then there will be strong, large
branches, tiny branches and leaves.
The brain also develops in a hierarchic manner. It starts from
bottom up, elaborating the original structures and adding new ones.
The first circuits to develop are simple and later become more complex
and intricately connected. Every part of development leads to new
competence which builds upon previous abilities. This organic process
starts at conception and continues into adulthood.
Emotional well-being and social competence provide a strong
foundation for emerging cognitive abilities, and together they
are the bricks and mortar that comprise the foundation of human
development. (Center on the Developing Child at Harvard University
2009, p.5)
Senses and social connecting

Sensory pathways, such as hearing, vision and touch, are the neural
pathways that develop first. The sense of touch, for example, is well
developed at birth. Science writer Lydia Denworth in an article for
Scientific American Mind magazine points out the essential role of touch
at the beginning of life as a base for developing social connections
(Denworth 2015).
Affective touch is a potential way in to understanding the development
of the normal social brain… It is giving the brain knowledge of me
and you, and the emotional quality of gentle nurturing touch is a very
important feeling that underpins a lot of social interaction. (McGlone,
Wessberg and Olausson 2014, p.32)
When a mother touches her new-born with love and tenderness, it
gives the brain sensory and emotional information. There is me and
you; you are not alone; we are connected. Touch may be soothing,
calming and pleasurable. Neuroscientists discovered that even a
very young baby discriminates different types of touch. They sense
a tactile difference between a blanket and skin. They distinguish
the emotionally rich, loving touch of mother from touching fabric.
There are special nerve fibres which recognise this difference and they
serve in the development of attachment between a new-born and his
mother (McGlone et al. 2014). By being held and touched the infant
feels the closeness of the other person and safety. Other senses, such
as smell, hearing and vision, also serve to connect the infant with
his mother. These early connections further the development of other
brain circuits which will contribute to bonding as well. The growth of
sensory pathways is followed by development of language and other
higher cognitive functions. The competencies which come to life later
stand on the shoulders of the earlier ones (Center on the Developing
Child at Harvard University 2009). As we will see, if the first stages are
impaired, later functioning will be adversely affected.
Mother Rat: Licking and touching

promotes resilience and strength
Michael Meaney, researcher at McGill University, studied rat mothers
and compared rat pups who were well cared for with ones who were
not. He especially focused on the licking and cleaning of pups, which
provides lots of sensory experiences. He divided healthy rat pups into
three groups. The first group got a lot of care from the mother rat.
Researchers found that pups who had a lot of licking and cleaning
in the first twelve hours of life developed very well. They could
better modulate their level of cortisol, one of the stress hormones, for
example. They were calmer and better able to explore and learn about
their environment. They developed lifelong, optimal functioning. Pups
from the second group had fewer touches in their first twelve hours.
As a result they had a less developed system for regulating the level of
cortisol and they suffered consequences from this for the rest of their
lives. They performed in a restless, hyperactive way, displayed anxiety
and had a high readiness to become stressed. They were afraid to
overcome obstacles and explore. The third group was separated from
the mother altogether. These pups ended up being numb, unresponsive
or in extreme stress (Meaney 2010).
Meaney’s experiment with rat mothers and pups showed that rats
which were not touched and licked did not develop the resilience,
balance and strength necessary to cope with life. This suggests that early
lack of care prevented realisation of the genetic program for optimal
development. Describing human development Allan Schore, from the
clinical faculty of the Department of Psychiatry and Biobehavioral
Sciences, UCLA, concludes that interaction between the young child

and his parents (caregivers) shapes the expression of genes. This
occurs because the interaction induces production of hormones which
directly impact gene transcription which, in turn, directs development
of neuronal connections and circuits (Schore 1997). Thus, stages of
development are determined by genes but the expression of genes and
the resulting rate and extent of development are significantly affected
by environmental factors including social interaction. To sum it up
briefly, development depends on interaction with the outside world
(Center on the Developing Child at Harvard University 2009). For
a more detailed picture of neurobiology and the early stages of brain
development, see Jon Baylin’s window to the neurobiology of good
care at the end of this chapter.
Memory: The basis for learning

and understanding the world
Lovijs Perquine, Dutch psychiatrist and psychotherapist, describes
memory as a huge database of information. In humans the
estimated memory capacity is 100 trillion bits of information. Stacked,
they would make up a tower some 100 kilometres in height. We use
this information to make sense of current situations.
First we had to learn to remember what is edible. A 16 month old
child will put a piece of mud pie in its mouth. A two-year old will
not. Monkeys that eat a large number of different tree-fruits have
a large visual memory capacity and a correspondingly large brain
area… A person walks through a dark alley at night and feels goose
pimples and a sensation of tension between his shoulder blades.
The echo of his own footsteps is unconsciously associated with a
mugging that happened ten years ago. Sensorimotor and kinesthetic
stimuli and experiences, like auditory and visual stimuli, are stored
in memory. Every time we detect a physical sensation, it connects
with previous physical sensations and experiences gained in the past.
(Perquin 2004, p.126)
Without long-term memory the interpretation of current sensory
information would be impossible (Perquin 2004).
The role of memory

Memory shapes our present experience and expectations for what will
happen in the future:
The purpose of memory is to predict the future. (James McGaugh,
University of California, in Kaku 2015, p.113)
Our understanding of ourselves and the world is unthinkable without
long-term memory. People may assume that memory is a database of
events as they actually happened, a mirror of reality. But memory is
a neurobiological system which does not simply record an event like a
camera or tape recorder. Rather it encodes how the individual person
experienced the event. Milner, Squire and Kandel conclude that the
structure of the brain is unique to each individual because it was shaped
by the individual experiences. The individual history is encoded in
the brain and its structure (Milner, Squire and Kandel 1998). People
have different experiences and encode experiences differently too. For
example, several children in a family may remember the same event in
the family very differently. This is because each has their own unique
lenses and filters which impact how an event is recorded and later
recalled.
Memory is a complex system which activates neural patterns
and forms connections between them and thereby encodes our
experience of the world, including our experience of ourselves. As
we experience an event, memory is built to keep this experience, if it is
somehow deemed significant, and reopen the recording when it might
be useful or triggered by an associated event. Memory thus serves as a
tool which stores experiences and uses them when responding to the
outside or the inner world (Siegel 1999).
Human beings learn on many different levels and continue to
learn throughout life. As with other parts of the brain, memory and its
different systems and functions develop in a hierarchic manner. There
are many different levels of memory. Each has its own unique role in
the encoding and use of information.
The hierarchic development of memory

Implicit memory
Implicit memory is one of the brain systems which develop before
birth. New-borns perceive the world. They have the capacity to
remember their experience with behaviours, sensations and emotions

and learn from their experience (Bauer 1996; Fivush and Hudson
1990). Learning is only possible when there is a memory system which
keeps the information for later use. Infants can perceive sounds, smells,
internal physical sensations and touch and react to them. Memory
which records this information is called ‘implicit’. It is available at
early stages of development and does not require conscious processing
when it is encoded or retrieved. Implicit memory stores the most
fundamental experiences of life: emotional states, behaviour patterns
and images. It serves in the development of our sense of self. We can
feel who we are without recognition of the experiences which formed
that image of ourselves. Another role of implicit memory is summing
up experiences and transforming them into generalised mental models
(Siegel 1999). Mental models are the bricks of implicit memory.
When something happens on a social and emotional level, implicit
memory rapidly, without consideration, retrieves the encoded model
and through the lenses of that model assesses the situation here and
now (Squire, Knowlton and Musen 1993).
Explicit memory
Explicit memory develops later. It is episodic (autobiographic) and
factual. It encodes ‘who, what, when, where and how’. Explicit memory
is what we use when we deliberately try to remember something.
Explicit memory needs a more developed brain and collaboration
between centres such as the hippocampus and the orbitofrontal cortex.
The encoding process needs focus and conscious attention directed
to the object or situation. Then the information will be stored in
different types of memory: working memory, long-term memory and
permanent explicit memory. The process of encoding information on
these different levels is not completely known yet.
Implicit and explicit memory co-create our reality

It is a common experience that when something has a high emotional
importance to us we remember it better. If a child was bitten by an
angry dog at the age of three, it is highly likely he will remember it,
although his memory functions are still immature. His memory system
may remember few details of the actual events, the episode itself, but
the child may be afraid of dogs for the rest of his life. Why is that?
There are many factors involved, but a significant one is the production
of hormones. When an event triggers stress, stress hormones create
high arousal.
This physiological arousal may last several minutes and during this
time our mind has a tendency to go back to it, talk about it and make
sense of it (Bower and Sivers 1998). The physiological response to
events and situations creates a strong link between sensory inputs and
the emotional reaction of the body. The emotional, stressful reaction
to an event, such as being bitten by an angry dog, puts together two
important parts of this particular memory record: the situation and its
meaning. The little boy will probably be afraid of dogs. His memory
system will use the whole recording. The meaning of it is: never again.
The fear is now in service of avoiding being bitten by a dog again,
although the child may not connect his later fear of dogs with any
specific incident. A child consciously recalls very few specific events
and situations from that age. The reason for this is that he primarily
forms unconscious connections between sensations and emotion. This
type of unconscious learning is also common in adults, even though
they have developed explicit memory with the capacity for narrative
description and making a conscious connection between events and
feelings.
In a highly charged positive situation the system works in a similar
way. A child will remember and talk over and over again about his
big birthday party with his parents and family. He got presents and
everyone was singing to him. His important people made him feel
special and attached. In this case the chemistry of a positive experience
is linked with the event. Often children like to repeat the same rituals
when celebrating their birthdays because of their association with
good feelings. The meaning of this recording is: yes! I want this again.
The happy emotions are in service of repeating positively experienced
situations again. Albert Pesso explains that we see the present through
the lenses of memory. Everyone carries a gigantic library of encoded
past experiences. This information is available to our brain and shapes
the decisions we make, sometimes consciously and often outside our
awareness (Winnette 2011).
Attachment
Principle of attachment: Survival
John Bowlby was interested in ethology and it gave him supporting
evidence for his observations. A young animal as well as a young
child experiences separation from its mother as threatening because
it endangers his survival. When we are very young it is a necessity
to have our own closely bonded, dedicated caregiver in order to be
safe, have our needs met and have our brain regulated so we can explore
and learn. At different developmental stages the child gradually shows
different forms of attachment behaviour: protests when mother leaves
the room, clinging when he is afraid, following mother when he is
able to, enjoying interacting with her and feeling happy and reassured
when she comes back after separation (Karen 1994).
Attunement and the child’s sense of self

Donald Winnicott, British paediatrician and psychoanalyst, focused
on the child’s inner experience and emphasised another special level
of the mother’s care: sensitivity and attunement. He noticed that a
baby needs more than well-balanced, healthy caregiving provided by
a skilled person. A baby has got a receptive, sensitive mind, which
primarily operates on an emotional level. He senses the emotional
state of his mother and this has a powerful effect on him.
In Winnicott’s view, an inborn programme in infants included a
need for love and special relating between mother and baby. According
to him, this intimate bond influences the child’s sense of himself. Being
seen and touched with love ‘transcripts’ into an inner feeling of ‘I
am good and lovable’ (Karen 1994). There is a continuous chain of
interactions between mother and baby. Children reach out to get their
needs met and they respond to the other who provides for them and
interacts with them. This process influences their genes and shapes
their developing brain. Attachment is a bond between mother and child
which keeps the child feeling safe. Sensitive and attuned caring creates
an inner feeling of self-worth, dignity and self-confidence. Like John
Bowlby and Donald Winnicott, many contemporary psychiatrists and
psychologists subscribe to the idea that our sense of ourselves and who
we are is created in our minute-to-minute communication and interaction
with our parents and caregivers early in life (van der Kolk 2014).
Feeling secure with my parent:

A secure attachment style
The Strange Situation experiment
Mary Ainsworth, a professor of psychology at the University of
Virginia, was a researcher and close co-worker of John Bowlby. Her
main interest was studying behaviour and interaction between mothers
and babies in relation to their attachment. Her idea was that the
attachment system is activated when the child experiences some level
of stress, especially when the child is separated from his mother. Based
on this idea she developed a creative method for assessing the type of
attachment pattern in children from age one to three. The diagnostic
tool she developed is called the ‘Strange Situation’. In her research she
realised that children can be classified according to their attachment
style. Attachment style develops in relationship with parents and their
style of parenting. Sensitive parents who are available to their child and
respond to their needs in a perceptive, responsive and collaborative
manner most often have securely attached children (Siegel 1999).
Secure attachment style

Securely attached children have integrated their parents’ care and it
has become part of their internal model of being. They feel safe and
explore the world. If they need help or support, if they feel insecure,
they seek safety and support with their parents. In neurological
language this means whenever their level of stress goes up, they seek
their parents to get regulated, calm down and re-establish balance and
safety. Once this happens they go out into the world again and explore
and learn.
Adults and attachment

Mary Main, an American scientist devoted to attachment research, in
collaboration with Ruth Goldwyn and her students, Carol George and
Nancy Kaplan, developed a tool which gives insight into this process.
To get a picture of adults’ ‘state of mind with respect to attachment’ they
developed a semi-structured interview: the Adult Attachment Interview
(AAI) (George, Kaplan and Main 1985). It is constructed to gather two
types of information. The questions focus on the client’s childhood
experiences with caregivers, mainly his parents. At the same time, the
interviewer looks at how the client talks about these topics (Karen
1994). The AAI gives the interviewer important information about
how the client managed stressful situations when he was a child. The
interviewer also looks at the emotional quality of his speech now and
carefully observes his manner of responding. The assumption is that
the client’s emotional reactions to his history influence the way he
speaks about it now. Emotional responses are often reflected in the
quantity of speech and the relevance of the client’s continued remarks
to the original topic of his early childhood experience.
As criteria for assessing the quality of a client’s speech, Main and
her colleagues decided to use Grice’s four maxims of an adequate
response: quality, quantity, relevance to the topic and way of speaking
(Grice 1975). Main and her colleagues assumed some people will talk
about the topics in a coherent and adequate way, while others will
give less cohesive and more disorganised responses. Coherent or less
coherent speech about childhood attachment topics may reflect how
people experienced their attachment figures in early years. The authors
conclude that one’s original attachment style is present in their state
of mind (Karen 1994; Vrtbovska 2010). It is apparent in our thinking
and emotional responses when we recall our history and when we
respond to present events in our life.
Secure attachment in childhood and a secure,

autonomous state of mind in adulthood
The ‘Strange Situation’ in a laboratory environment shows the
attachment style and pattern of a child. When a psychologically
healthy child is assessed in the Strange Situation he behaves in
predictable ways. He is connected to his mother and soon feels safe
enough to explore the room and toys. When his mother leaves the
room, the infant does not like it and misses her. Sometimes the child
cries for a while. He will let a stranger comfort him, but he prefers
his mother. He shows distress but it is not overwhelming for him.
When mother is back, he is happy and often initiates physical contact.
Then after a re-connecting period he goes back to his interests and
continues exploration and playing in the room. Safety is re-established
and then life continues in the same balanced way.
If this child were interviewed as an adult, his answers in the Adult

Attachment Interview would be coherent and he would respond in
a collaborative manner. He would appreciate close relationships and
attachment in his life. He would be objective about his past. If there
were stressful periods in the past, the trauma would be resolved. So the
person can talk about it without re-living the stress again.
We can hypothesise that such an adult would manage his life in a
manner consistent with the attachment style revealed in the interview.
He has close relationships and feels safe relating to people. He is
independent and mature but at the same time he can rely on others
when needed and be available to them. If he goes through difficult
times he goes through natural grieving and gets back to normal. He is
hopeful about the future.
Adulthood and a safe model of autonomous life

We have talked about brain development and basic systems which
influence how the personality is shaped by interactions with others. The
hierarchic development of the brain is influenced by the physical and
interpersonal environment. Memory is the foundation for learning and
present responding and attachment is necessary for survival and
optimal development. The memory of early attachment experiences
co-shapes one’s sense of self and one’s approach to the world.
John Bowlby believed that strong and well-seated memories of
attachment strongly influence adults’ social and emotional life:
Evidence is accumulating that human beings of all ages are happiest
and able to deploy their talents to best advantage when they are
confident that, standing behind them, there are one or more trusted
persons who will come to their aid should difficulties arise. (Bowlby
1979, p.103)
Bowlby used the expression ‘secure base’ to refer to the phenomenon
of ‘having a trusted person behind’. He believed that as the child
grows up a secure base is remembered, integrated and becomes an
organic part of his personality. This base allows the adult to have close
relationships and trust and depend on his attachment figures. At the
same time, he has the ability to be happily alone. The internalised
secure base includes a felt sense of being loved, feeling worthy of being
loved and having confidence in being able to love. It creates a flexible
internal model of living among people and a feeling of being happy

in one’s existence as a unique, creative human being (Karen 1994).
Alan Sroufe, professor at the University of Minnesota, and
his colleagues studied a large group of children with the aim of
exploring how the environment and upbringing interact with inborn
temperament. One of their findings relates to resilience. This refers
to the capacity to overcome difficulties and find balance after the
hardships which inevitably happen in life. The research showed that
the most resilient children were those who had a safe, reliable caregiver
in the first two years of life. Thus, a safe model of autonomy seems to
be established at the beginning of life (Sroufe 2005).
We will end this brief summary of development in good care with
Bowlby’s citation of Grinker’s findings in a study of sixty-five college
students.
The large majority of students seemed straightforward youths, honest
and accurate in their self-evaluation, with a capacity for close and deep
human relationships…to members of their families, peers, teachers…
The typical picture [of their home experience] presented was of a
happy peaceful home in which the parents shared responsibilities and
interests, and were regarded by the children as loving and giving.
(Bowlby 2005, p.130)
In Chapter 4 we outline the PBSP theory of healthy development and
show how it relates to the neurobiology and the therapeutic process.
Below, Jon Baylin in his window to the neurobiology of good care
gives a detailed picture of the neurobiology of development of a
healthy brain in good care.
Window to Neurobiology of Good Care
Jon Baylin
Building brain bridges in stages:

Vertical, horizontal, lateral
The brain develops key connections in stages, basically from the
bottom up, right side to left side, back to front. Neuroscientists
refer to this as vertical integration, horizontal integration and lateral
integration (Cozolino 2016). Within the first eighteen months of life,
the child’s brain is forming core vertical connections between lower,
more ancient brain regions and higher, evolutionarily newer brain
regions. This construction project occurs predominantly in the right
hemisphere during this sensitive period for building the social brain
(National Scientific Council on the Developing Child 2009). The
right side of the brain is more highly connected to the body than
the left and specialises in nonverbal, emotion-driven processes, as well
as rapid self-defensive, survival-based processes. This also makes the
right hemisphere the repository of implicit, emotion-driven memories
of positive and negative experiences with caregivers.
This right brain construction project is partly ‘hard wired’, driven
by genes that orchestrate the development of basic connections
between different regions of the brain. But, importantly, this
construction project is also ‘experience dependent’, meaning that early
experiences with caregivers affect the way the child’s brain develops
(Meaney 2013). In this early period of development, the brain is
especially sensitive to the sensory experiences the young child has
with parents in the process of being ‘tended’ to. Because the child is
completely dependent on parental care to survive the first year of life,
the child’s brain is exquisitely responsive to the quality of care being
offered. Not only is the child’s brain responsive in the moment to
sensory experiences engendered by interacting with a caregiver; the
developing brain also records these experiences as implicit, emotion-
based, relational memories to be used as a guide for how to relate to
people in the role of attachment figures later in life (Siegel 2012).
Indeed, neuroscientists have shown that the young brain develops
36
differently in the context of good care than in the context of poor care,
care that is lacking in responsiveness to the child’s needs for comfort,
protection and companionship (Tottenham 2014).
Vertical integration: The fronto-limbic circuit

The key vertical connections being formed in the first year of a child’s
life are connections between the so-called limbic system, deep parts
of the child’s brain that generate emotion and regulate basic approach
and avoidance behaviours, and regions of the prefrontal cortex (PFC).
This vertical integration involves the construction of a ‘fronto-limbic’
circuitry in the right hemisphere that functions as the core social brain
system early in life. Memories of how a child is treated by caregivers
are stored in this fronto-limbic ‘highway’ and these memories comprise
the internal working model of self and self–other relationships that
guides future behaviour (Schore 2002b). These right brain memories
constitute the original version of a self, a self that is implicitly,
nonverbally valued according to the way it felt to be in the presence
of caregivers (Lanius, Paulsen and Corrigan 2014; Panksepp 2003).
Horizontal integration: Right and left

In typical development, in the context of ‘good enough’ care, there is
a shift in brain functioning from right to left-hemisphere dominance
after the initial stage of right brain development. This leftward shift
supports the emergence of language, the ability to put right brain
nonverbal experiences into words and to create explicit narratives
about one’s life experiences that can be shared with others (Siegel
2012). When children receive good care, this right to left shift
gives the child new powers of information processing and meaning
making, enabling the child to think and reflect using language as a
way of deepening self-understanding, and understanding the minds
of other people. During this stage of horizontal integration, the child
gains a new level of social functioning that facilitates deeper, more
intersubjective relationships with others. Neuroscientists have found
that activation of the higher regions of the left prefrontal cortex is
associated with positive affect and approach behaviour while activation
of the same regions on the right side support avoidant behaviour
(Davidson 2004). It appears from this research that well-cared-for
children develop the ability to regulate avoidant tendencies with their
right-hemisphere fronto-limbic system so that they can use their left

fronto-limbic system for engaging in social interaction. It is very telling
that people with unresolved trauma from childhood exhibit greater
right frontal activity than left, a pattern that tends to be reversed when
trauma-focused treatment leads to successful resolution and recovery
from post-traumatic stress disorder (PTSD) (van der Kolk 2014).
Lateral integration: When the back

and front regions stay connected
The third broad stage of brain connectivity is the strengthening of
connections between the back or posterior regions of the brain and the
frontal regions. These connections reach a ‘mature’ level of connectivity
during a period spanning roughly late adolescence (around seventeen
years old) into the early twenties (Siegel 2012). The underlying
process that creates this increased connectivity is the myelination
(insulation) of the long-distance pathways that connect brain cells
in the posterior parietal region to brain cells in the dorsolateral or
topmost region of the prefrontal cortex. When this myelination
reaches a critical level, messages back and forth between the back
and front of the brain can be transmitted at least 100 times faster and
more efficiently than previously. This level of transmission enables a
person to process thoughts or action plans longer and more deeply
before going into action. Importantly, this new level of connectivity
confers more ‘veto’ power on the prefrontal cortex, more capacity to
decide not to do something or say something that could be destructive
or risky. In this way, lateral integration gives people greater ability to
manage relationships and refrain from actions that could damage their
connections with other people. This increased frontal power is a key
part of the enhanced executive abilities that adults display in contrast
to children. When these enhanced frontal powers get shut down, as
they do when people dissociate or ‘flip their lids’ in anger or fear,
executive abilities are starkly diminished and more primitive regions
of the brain take control of feelings, thoughts and actions.
Social buffering: The neurobiology

of parent–child bonding
In neuroscience terms, the caregiver responds to the infant’s distress in
ways that ‘buffer’ the infant’s distress system, shifting the infant’s
brain and body from a state of dysregulation to a state of regulation,

relieving the infant’s distress and, in the process, providing a pleasurable
experience of being comforted. This is called ‘social buffering’ and can
actually be observed in real-time brain imaging that shows the presence
of the mother essentially turning off the child’s stress response system,
switching the child’s brain from ‘stressed out’ to calm and regulated,
at least for the moment (Tottenham et al. 2012). This soothing power
of the nurturing caregiver fosters the child’s healthy dependency on
the parent, a trust-building process that operates on an unconscious
level in the child’s brain, channelling brain development in support
of a secure attachment strategy before the child has the brain power
to ‘know’ what is happening. In this sense, a child learns to trust or
mistrust a caregiver within the first year of life before the child is really
mindful of being a partner in the trust-building process. The nurturing
caregiver becomes a secure base for the child before the child even
knows he needs one, laying the groundwork for the child to feel
highly valued, constructing the neurobiological basis for an enduring
positive self-image. The social buffering effect of good parenting
works primarily by triggering the release of oxytocin into the brain
regions that regulate defensive responses under threat, especially the
amygdala, and functionally disarming the defence system and enabling
the social engagement system to ‘turn on’ (Tottenham et al. 2012).
Behavioural epigenetics: The hot science

of experience-dependent development
Experiences with caregivers that are positive, experiences of being
responded to in highly nurturing, comforting and pleasurable ways,
affect the developing brain very differently than experiences with
caregivers that are distressing, painful and frightening. Positive
experiences actually trigger a different pattern of gene activity in the
child’s brain than negative experiences. This is called ‘epigenetics’ or
behavioural epigenetics, a hot new area of social neuroscience (Weaver
et al. 2004). The basic story of epigenetic effects of early experience
is that good care promotes the expression of many genes in regions
of the brain that support social engagement while suppressing the
expression of genes that contribute to the construction of the self-
defence system. In short, early experiences with caregivers ‘program’
gene expression to adapt brain development to the nature of care being
provided. This is nature’s way of helping the young child build a brain
suited to living in the kind of world first presented to the child by the
kinds of messages – facial expressions, tones of voice, touch – sent
by caregivers. Within the first eighteen months, good care fosters the
epigenetic development of strong connections between the lower and
upper regions of the child’s brain that form the fronto-limbic system,
that vertical integration process. Why is this a big deal? Because the
stronger these fronto-limbic connections, the better a child becomes
at self-regulation – emotion regulation, impulse control, and so on –
and the better the child is at staying present and engaged with others
without shifting into deeply defensive states that shut down the social
engagement process.
The self-reflection system:

Safe to be introspective
Good care also promotes the healthy development of the brain system
that we use when we are being reflective, when we look inside instead
of outside. Recently brain scientists have learned that when our minds
are not occupied with a task or with being vigilant about what is
happening in our environment, we switch to a brain network that
we use to think about ourselves, our relationships, our personal and
interpersonal experiences. This is called the default mode network
or DMN (Raichle and Snyder 2007). The DMN supports reflective
functioning, the ability to step back from immediate reactions to an
experience and to think about this and other relational experiences with
feelings, an ‘affective/reflective’ process that we can use to construct
a deeper understanding of ourselves, others and our relationships
(Fonagy et al. 2002).
We have to feel safe in our current environment in order to switch
from outer focus to inner focus, to turn on and sustain our default
mode network to engage in self-reflection. Constructing the brain
circuitry that supports reflective functioning begins during late infancy
in response to good care, care that makes it safe for the child to
be introspective, to daydream, to think about an emotional experience,
and then to share this inner world, this subjective process with a trusted
other, intersubjectively (Trevarthen 2013). Creating a robust DMN is
one of the great benefits of receiving good care early in life, laying the
foundation for being able to access this inner space, to be reflective
rather than just reactive, and ultimately, to increase one’s self-awareness,

understanding of self, and ability to understand others. Good care gives
the child positive experiences that engender a sense of being valued,
liked, cherished, creating memories that are safe and even pleasurable
to recall rather than memories that don’t feel safe to recall, that need to
be avoided, like all traumatic memories. Good memories of experiences
with caregivers promote the development of a healthy DMN and
the emergent ability to reflect on one’s experience, not just to have
these experiences. The process of reflecting on experiences is essential
for growth, for changing one’s mind based on new experiences, for
adapting flexibly to changing circumstances in life. This makes the
DMN and reflective function key to both good parenting and to
successful therapy, especially for adults. Looking ahead to the therapy
process, we will see the importance of helping adult clients access their
reflective system, their DMN, in therapy in order to facilitate a process
of changing one’s mind in response to new experiences that counter
old experiences. We will see that the DMN is a work space essential to
turn on and keep on in therapy as the client brings up the old, creates
the new, and processes the competition between the two until the new
learning gains in power and can ‘win’ the competition for our valuation
of self and for how we relate to ourselves.
The middle prefrontal cortex (MPFC):

Zone of self-reflection
The middle prefrontal cortex or MPFC appears from many studies to
be the headquarters of the default mode network (Raichle and Snyder
2007). The MPFC is a much expanded region of the human brain
in contrast to other mammals and it seems to have a rather uniquely
human function of serving as a work space for self-related thought,
informed by feelings. The MPFC is a convergence zone where affective
processes coming up from below, including from the amygdala and the
rest of the limbic system, converge with information from all the senses
and from constant monitoring of one’s environment. While the brain
region above the MPFC in the dorsal PFC is more devoted to being
a work space for matters involving the external world and cognitive
tasks, the MPFC appears to be the brain region we use when we reflect
on our own and other people’s feelings, our inner worlds, and try
to deepen our understanding of ourselves and important others in
our lives. The MPFC seems to function as the working memory for
personal reflection.
Just as we need to use a working memory system for doing maths,
to hold all of the information and steps in mind until we get the answer,
we have to use a working memory system for relational thinking in
order to reprocess old beliefs and change our beliefs in light of new
experiences. The MPFC, as the main convergence zone for the DMN,
appears to be the relational working memory system that supports this
process (see Figure 1.1).
Figure 1.1 The default mode network
Social development as a whole

Taken as a whole, social developmental neuroscience research shows
that early social experiences channel the development of the brain in
five core systems that together comprise the social brain.
These five systems are:
• The social engagement system that supports attachment and
‘sociality’ (Porges 2011).
• The self-defence system that rapidly appraises sensory
experiences for safety and threat (Liddel et al. 2005).
• The social emotion system that supports the emotions of

separation distress and the development of empathy and
remorse, emotions that help to ensure the maintenance of
strong affiliative bonds (Eisenberger and Lieberman 2004;
Panksepp 2003).
• The stress response system or HPA axis which produces stress
hormones like cortisol to help mobilise the brain and body to
meet all kinds of challenges (Lupien et al. 2009; McEwen and
Morrison 2013).
• The social switching or state regulation system that orchestrates
shifts between social engagement and self-defence (Mayes et al.
2009; Porges 2011).
The early programming of these developing systems by good care
and poor care largely determines the makeup of the child’s social
brain as the child emerges from the preverbal period of development.
Children in nurturing environments emerge from this sensitive period
for attachment-based brain development with a bias towards social
engagement over self-defence; an ability to feel the social pain of
separation distress and safely seek and receive comfort; and a stress
response system that works efficiently to help the child meet challenges
and then ‘turn off’ (see Figure 1.2).
Social engagement Self-defence

approach
NA and enjoy
fight
BLA CE
flight
freeze
amygdala
PAG
NA = nucleus accumbens
PAG = periaqueductal grey
BLA = basolateral
CE = central amygdala
amygdala
Figure 1.2 Social engagement versus social defence

Chapter 2
WHEN THINGS GO WRONG

Developing Brain, Mind
and Self in Poor Care
Petra Winnette
Early trauma
This kid is strange: Daniel
In my therapeutic practice I often work with young children. It’s a
time in life when their brain is developing fast and they are expected
to be full of energy and enthusiasm to learn, be playful and loving.
However, when I start seeing a family and a child, it often looks
different. For instance, let’s look at Daniel. He was in the hospital
for the first two years of his life where he was successfully treated for
leukaemia. One of our sessions at the beginning of treatment started
like this. Eight-year-old Daniel sits on a chair as far as possible from his
parents. He has a strange gaze. Mother leans towards him and gently
touches his shoulder. Daniel sits still and does not respond. ‘Do you
like when your mother strokes you?’ I ask him. There is no response.
‘Why do you think she does that?’ ‘She likes me,’ Daniel responds, but
his answer sounds flat and he is dwelling somewhere in another world.
Then he turns to his father: ‘Will you buy me a chocolate bar?’ This is
how he connects with his parents. He asks for things. ‘Later,’ his father
says and Daniel goes back to his still and frozen mode. Mother offers
to let him sit on her lap. He actually sits on her knees, but he is stiff,
distant. ‘How does it feel?’ I am curious about his feelings. ‘I don’t
know. It’s strange. I feel somehow hot. I want to sit somewhere else.’
He is with us, he listens, but his spirit is not here.
Later in my office his parents tell me that he is ‘behind a glass wall’
all the time. Recently his father asked him not to swing on a chair.
45
Daniel jumped up and started shouting, ‘I hate you! I will kill you! All
of you!’ He ran away and locked himself in a closet.
Traumatised children are not able to explain themselves very well. I
did not need to ask Daniel if he was happy or unhappy. It was obvious
from his behaviour. His parents see it. His teachers see it. He is lost in
the middle of it: dissociated, unable to reflect on himself and insecure
with his parents. Neither loving parents nor anyone else at that time
could help him to get ‘unlocked’. Everyone wished for him to be an
ordinary, happy kid, a naughty boy with a smile on his face, to have
friends and lots of fun. The parents asked me, ‘What happened?’
The ‘tree metaphor’ illustrates it. In the beginning it has only a tiny
root system and slender trunk. The root system and trunk will support
the tree all of its life. If that is not strong and healthy, the whole tree
will have problems. If something vital is missing or something injures
the little tree at this stage the tree may not survive. Under less severe
conditions, the little tree will survive, but it will develop in a strange
way, different from the optimal way its genes had planned. Its original
genetic potential might be for a tree that stands five metres high, has
large branches and wonderful green leaves, and grows apples. But a
little tree with a hard beginning may have stunted growth, its trunk
bowed, and it may not bear fruit.
Healthy balance versus stress

The world around us is not ideal and we are faced with situations
which are dangerous or hurtful, or we may experience a deficit
of something we need. An extreme situation can endanger our
survival. In less serious circumstances we may experience a high
level of discomfort and strong, unpleasant feelings. Stress activates
systems which help us to adapt and manage the threat. There are
hormones which are produced as a part of responding to stress. Two
which play an important role are adrenaline and cortisol. Both of these
hormones in normal situations help the body to cope with short-
term, manageable stress. Adrenaline is produced when there is acute
stress. It is essential for survival as it mobilises energy and gets the
body ready for action. Cortisol helps the body to cope with generally
adverse situations (National Scientific Council on the Developing
Child 2005/2014).
When Things Go Wrong 47
The power of cortisol

Cortisol is important in orchestrating the body’s response to stress.
Cortisol provides energy by increasing blood glucose levels, and
this fuels our metabolic functioning, resulting in increased levels of
arousal and alertness, coupled with increases in body temperature
and blood pressure that are linked to inhibition in functions such
as reproduction, appetite and immune response… When the stress-
triggering incident is ephemeral, the long-term consequences to the
individual of this inhibition in reproduction, appetite, and immunity
are negligible. (Guilfoyle and Sims 2010, p.33)
Australian scientists studied groups of children, age three to six, who
were placed in different day-care centres. They measured the level of
cortisol in the children’s saliva while the children were in the centres.
The study showed that children attending centres with good-quality
care demonstrated a decline in cortisol level during the day. Children
placed in low-quality services demonstrated chronically elevated levels
of cortisol. The quality of care was measured using the Australian
national quality assurance system (National Childcare Accreditation
Council 2001).
Atypical cortisol activation has an impact on systems of the
developing brain. It suppresses growth hormones. It is associated
with both hypoactive and hyperactive functioning of the amygdala.
These changes have been linked to psychiatric conditions including
personality disorder, anxiety disorder, conduct disorder, melancholic
depression, eating disorders and substance abuse. People with atypical
cortisol levels are also likely to have immune problems. In addition,
the research found that abnormal cortisol activation results in a smaller
hippocampus and affects other areas of the brain, resulting in problems
with memory and learning (Smider et al. 2002).
The study showed that when children are placed with good
caregivers their neurobiological systems are balanced. When children
are placed in poor care situations, without a parent or other available,
safe caregiver, they experience repetitive, prolonged stress which
adversely affects their physiology and neurobiological development.
Positive, tolerable and toxic stress

A significant body of research indicates that chronic stress in early
childhood can be toxic to the developing brain as it continuously
activates systems for adapting to life-threatening situations. When
these systems are activated for prolonged periods of time, there
are significant changes in how the brain develops and functions
throughout the life span. The extent of changes in brain functioning
depends on the intensity, duration and meaning associated with
a stressful experience.
Positive stress
Short-term, moderate stress can be considered ‘positive’, as it is a
normal part of life and it provokes processes for managing minor
problems. For example, mother talks on the phone and the child needs
to wait for some time to get her attention back. Although the child
might be stressed, it only takes a short time before the caregiver helps
the child to calm down and relax again.
Tolerable stress
Under more severe circumstances the stress can be called ‘tolerable’.
It occurs in cases such as loss or a particularly frightening incident.
For example, the death of a beloved grandmother causes distress to
the whole family. In these situations, the intensity of the stress is more
severe, but it does not continue indefinitely. The event has an impact,
but the child’s distress is modulated by caregivers and he gradually
recovers from the shock.
Toxic stress
‘Toxic’ stress leads to strong, continuous activation of the body and
brain stress management systems. Toxic stress occurs under conditions
which are prolonged and extreme, for example, when a child does
not have a safe parent and chronically experiences being alone and
helpless (National Scientific Council on the Developing Child 2009).
In this case the child is not helped to regulate his affect and return to
a calm, safe base. Later in the book you will read about clients who
experienced toxic stress due to long stays in institutions for children or
in hospitals or who were severely neglected by their parents.
Parents co-regulate stress

The presence of a good parent makes the important difference.
A child’s brain needs a parent or safe caregiver in order to maintain a
regulated state of mind. Although life brings difficulties and losses,
they can be handled and overcome by a child who has the support of
caregivers. When the caregiver is the source of overwhelming stress
or the caregiver is unavailable to the child, the child suffers toxic
stress and is at risk for its negative effects on his developing brain.
Insecure attachment style and state

of mind in respect to attachment
Unsafe with parents
As we discussed in Chapter 1, Mary Ainsworth described a secure
attachment style based on her research with the ‘Strange Situation’.
Securely attached children showed the capacity to explore the world
and use the mother as a secure base. When a child doesn’t develop
a safe relationship with caregivers, the child is likely to show one
of two insecure attachment styles identified by Ainsworth: avoidant or
ambivalent. Ainsworth concluded that the child’s attachment style is
shaped by the parents’ characteristic ways of relating to the child.
Avoidant style
Avoidant children show independence and a low level of bonding with
their mothers. They focus on their interests and they do not engage
much. Ainsworth concluded that such a style is related to mothers or
parents who are emotionally disengaged and initiate few affectionate
and playful interactions. Their children do not expect much from these
parents and avoid close connecting with them.
Ambivalent style
Ambivalent children often show anxious, resistant behaviour. They
cling and hold on to the parent. Yet when the ambivalent child feels
stressed, he does not allow the parent to soothe him. The child does
not trust the parent. As a result, when a stressful situation is over, the
child is not calmed by interaction with the parent and stays in an
activated, restless state. Ainsworth concluded that such an attachment
style develops from interactions with parents who are so inconsistent

that the child learns not to rely on them to meet his needs. The child
is not sure if the parent is or is not available, which makes him feel
insecure most of the time.
Both these attachment styles are considered ‘organised’. Although
there are gaps in consistency and reliability in the caregiving, the
parents are predictable in their own way. The child gradually develops
strategies for how to get the best he can from his parents. His style
of getting needs met matches how his parents typically respond
to him. In the long run he creates his own model for relationships
which anticipates a world in which people will respond to him the
same way his parents did. For instance, children with an avoidant
type of attachment often become very independent. They develop
strategies to get needs satisfied with limited relating or collaborating
with others. They may use other children or bully them, for example.
Ambivalent children usually depend too much on their parents and
they feel anxious around them. They may try to please other children,
so they can be accepted and liked. This way they can become targets
for bullying (Main and Solomon 1990).
Disorganised-disoriented style
In 1990, Mary Main and her colleagues identified a group of children
who showed more disturbed behaviour. These children appeared to be
physically and emotionally stuck. In the ‘Strange Situation’ they could
neither approach the mother nor leave her proximity. It looked like they
were faced with an unsolvable dilemma. They often started rocking
on their hands and knees. Some would indicate they wanted to be
hugged, then show a huge resistance to it. Some would dissociate and
stand in a frozen posture. When Main studied the parenting situation
of these children, she realised that the parents or caregivers were the
source of the child’s distress and terror (Main and Solomon 1990).
Insecure attachment in adulthood

The model that children internalise for getting needs met with their
parents (or caregivers) is the blueprint for their approach to close
relationships as adults. The Adult Attachment Interview is useful
for evaluating an adult’s orientation to attachment. As we discussed
in Chapter 1, securely attached children usually develop a secure,
autonomous state of mind later in life. Mary Main and her colleagues
identified three categories of insecure attachment in adults.
Avoidant attachment style – Dismissive state

of mind in respect to attachment
A person who shows an avoidant attachment style in childhood may
be more likely to develop a dismissive state of mind in respect to
attachment as an adult. In this case the person’s responses in the Adult
Attachment Interview will tend to be inconsistent and generalised.
Thus, his description of a childhood event may be emotionally flat
with few details. He may frequently describe relationships as ‘normal’
without elaborating on his feelings and thoughts about his experiences,
for example. Sometimes there is a discrepancy between the emotional
response (or lack of emotional response) and the significance of the
situation. ‘My father was not often at home. It was OK, I did not
need him.’ If these answers are assessed using Grice’s criteria (see the
section ‘Adults and attachment’ in Chapter 1) for an adequate answer,
they do not meet the criteria for quantity and quality. They are too
brief and emotionally flat.
Ambivalent attachment style – Preoccupied

state of mind in respect to attachment
Adults whose childhood relationships with close caregivers were
ambivalent are often preoccupied with relational connections in
adulthood. They often display strong emotions, such as anger or
sadness during the interview. They frequently jump from talking
about the past to talking about the present and add irrelevant details.
They fail to meet Grice’s criteria in the areas of relevance to the topic
and quantity.
Disorganised (disoriented) style – Unresolved

(disorganised) state of mind in respect to attachment
People with severely adverse childhood experiences may develop a
disorganised-disoriented attachment style as children. Their speech in
the Adult Attachment Interview is often disorganised and features lapses
and discrepancies in reasoning. They may make incorrect attributions
to events in their life. For example, they may be convinced they caused
the death of a parent or sibling when this is clearly not true. They
may have long silences when answering and make emotionally
charged, illogical statements. Often their answers do not meet any of
Grice’s criteria for an adequate response. Attachment styles develop
throughout childhood and adolescence, building on what has been
learned before. They are affected by current experiences but often
prove firmly encoded so that elements of the pattern established early
in life are apparent throughout one’s life (Grice 1975; Main 2000;
Siegel 1999).
Trauma and developmental trauma

Trauma has traditionally been described as follows:
An emotional response to a terrible event like an accident, rape or
natural disaster. Immediately after the event, shock and denial are
typical. Longer term reactions include unpredictable emotions,
flashbacks, strained relationships and even physical symptoms like
headaches or nausea. While these feelings are normal, some people
have difficulty moving on with their lives. (American Psychological
Association 2016)
When we are healthy and happy, our general understanding is that
life is good. And then something unexpected happens and breaks our
world into pieces. Our life was safe and had positive meaning. All of
a sudden that feeling is gone. It seems nothing will ever be the same.
Danger waits around every corner. Disaster can happen at any time.
We want to hide somewhere and make sure ‘it’ will never happen
again. Something wrong and hurtful has violated our sense of safety
and our sense of who we are. In many cases, when a child or an adult
can turn to a safe person and share his pain and despair, slowly, after
a period of grieving and processing, the psyche returns to normal.
This is how we cope with losses such as the death of a loved one or
the destruction of our home during a fire. Some people have difficulty
recovering from a traumatic experience and suffer from conditions
such as post-traumatic stress disorder.
Serial traumatic experiences in

childhood: Developmental trauma
We like when something feels right. For instance, a mother is expecting
a baby. Fortunately, she and her unborn baby are healthy. Mother,
father and the whole family prepare everything for the baby. Their
love, attention and effort goes to their little child and they are excited
about becoming parents. But this lovely scenario does not always
happen. Suppose father is an alcoholic and abuses the mother. When
the baby is born, mother gets depressed. She sees her child as another
burden. Neither parent is responsive to what the child needs or takes
good care of the child. The child is often alone, often hungry. The
child experiences severe neglect and violence at home. He sees his
mother depressed and unhappy. Over and over again. All these events
take place when the child is completely dependent on his parents and
his brain and body are rapidly going through major developmental
phases. The very people who should protect him and provide a
loving, safe, supportive relationship are creating stress, pain, fear and
isolation instead.
Bessel van der Kolk, and his colleagues from the National Child
Traumatic Stress Network Complex Trauma Task Force, describe a
form of trauma associated with chronic maltreatment of a child. They
call it ‘complex developmental trauma’. ‘Typically, complex trauma
exposure refers to the simultaneous or sequential occurrences of child
maltreatment, including emotional abuse, and witnessing domestic
violence, that are chronic and begin in early childhood’ (Cook,
Blaustein et al. 2003, p.5).
Complex developmental trauma is a likely outcome when a child
repeatedly experiences fear or terror which is unpredictable and out
of his control. He cannot reach a safe and reliable parent to help him.
In the absence of a parent to protect, nurture and support him, a child
must rely on his own underdeveloped resources to survive. Children
who experience serial traumatic events in early childhood are at risk
for difficulties in one or more areas of development: attachment,
biology, affect regulation, cognitive functioning and self-concept
(Cook, Blaustein et al. 2003).
The relationship between

developmental trauma and PTSD
The syndrome called ‘shell-shock’ was first described during World
War I. As soldiers returned from the battlefield, Dr W. H. R. Rivers,
the dedicated neurologist and social anthropologist, sought to help
those soldiers who arrived with the typical symptoms of flashbacks,
altered states of mind and being detached and withdrawn. Soldiers
started having these symptoms after they experienced events such as
the terror of one-to-one combat, being in unsolvable life-threatening
situations or witnessing the death of their friends and fellow soldiers.
Dr Rivers’ efforts to treat these patients is described in ‘The Repression
of War Experience’ (Rivers 1918) and in Pat Barker’s novel Regeneration
(Barker 1991).
War veterans and survivors of rape, homicide or natural disasters
have since been the subject of extensive research. Helping people
overcome the effects of trauma and identifying principles which could
lead to prevention of trauma-related disorders have been a central
theme for many psychologists and psychiatrists. Researchers wondered
if the key to prevention may be found by discovering why some people
cope with trauma better than others.
Veterans and PTSD

Moises Velasquez-Manoff (2015) describes recent findings on PTSD
and its relation to the immune system. He also looked at whether
we can predict the likelihood that a person will develop PTSD after
exposure to extreme trauma, such as war.
Experiencing terror rapidly changes bodily functioning. There
is hyperactivity of the amygdala, accelerated heart rate, changes in
adrenaline level and cortisol distribution and the blood stream is directed
to the muscles in preparation for fight or flight, that is, the responses
to terrifying situations. Researchers found that patients who suffer from
PTSD have disturbed cycles of hormone distribution and altered gene
expression involved in the fight–flight response. The findings showed
that people who develop PTSD have systems that continue to respond
as if a threat were still present long after the trauma. Researchers wanted
to find out (1) if clients with PTSD had a predisposition to develop the
disorder and (2) if the trauma changed their brain and body functioning
so it was not possible for the body to return to normal after the danger
was past. In the Marine Resilience Study (Velasquez-Manoff 2015)

cohort researchers found that soldiers who reported they had a difficult
childhood were three times more likely to develop PTSD than those
who reported a good childhood and little distress in their upbringing.
Children in orphanages, who were deprived of one-to-one
sensitive care, have amygdalas which respond to even minor stimuli.
Chronic stress in childhood reduces the volume and functioning
of the prefrontal cortex, which is responsible for self-control, self-
awareness and executive functions. When these areas of the brain
function well they modulate reactions to stressful situations. Amit
Etkin, neuropsychiatrist at Stanford University, hypothesises they do
not work properly if there is a history of early maltreatment. They
do not effectively manage the body’s response to stress. This is
believed to contribute to the persistence of obsessive thoughts and
other symptoms of PTSD (Velasquez-Manoff 2015).
According to neuroscientists, trauma in early developmental stages
alters development and functioning of many brain areas and affects the
connections between them. Then later in life if we experience extreme
stress, the stress response is more intense, there are more symptomatic
effects and it is difficult to recover from them (Crittenden 1998; Kagan
2003). When the same level of stress occurs to a healthy brain and
nervous system which developed under safe and healthy conditions
there is a greater capacity to modulate the stress response and return
to pre-trauma levels of functioning. Later in this chapter we discuss
clients who arrive with acute problems related to a recent traumatic
event. In the course of therapy we uncover developmental trauma
which seems to have a significant impact on how the client copes with
the recent trauma.
Memory and trauma

Intrusive memories
Daniel Siegel, professor of clinical psychiatry at the UCLA School of
Medicine and Executive Director of the Mindsight Institute, explains
that the degree of stress associated with a traumatic experience will
have a direct impact on memory. Situations with a low level of stress
are not identified as significant. Therefore, the information probably
does not make a deep and lasting impression. If there is a higher level
of distress and arousal related to an event, it is encoded in memory
as ‘important for further usage’. We maintain a high level of arousal

processing the event over and over again and the experience is vividly
remembered. This process may serve to prevent us from experiencing
such an event ever again (Bower and Sivers 1998).
Dissociation
Terrifying and life-threatening situations may cause changes in parts
of the complex system of memory functioning so that we experience
dissociative states and other phenomena associated with trauma. For
example, explicit memory may be blocked and not encoded during
a traumatic event due to increased activity of the amygdala which
reduces input from the hippocampus (Siegel 1995).
On the other hand, implicit memory may be intact and encode
strong emotional reactions associated with the event without
an explicit record of the factual context. As a result, people may
later experience disturbing emotions and bodily sensations and have
difficulty identifying any specific event connected with them. People
may also dissociate when remembering an event and not be able to
recall explicit memories that they do have.
The way trauma is encoded in memory is a key to understanding
how trauma can have lasting, damaging effects on people. This concept
applies to both acute and developmental trauma as they seem to be
closely related.
Adults with unresolved developmental trauma

An insecure model of autonomous life
Alan Sroufe’s longitudinal study of risk and adaptation assessed
a large number of children from before birth until they were thirty
years old. He and his colleagues looked at levels of arousal in the
children and their ability to regulate affect and maintain control over
their mental balance in upsetting situations. Children with unreliable,
unsupportive parents typically showed an excessive need for attention
and a high level of frustration even when faced with minor challenges.
They hardly ever reached a calm, comfortable state of mind. Constant
arousal was associated with chronic anxiety and inability to explore
and try new things. This all contributed to strange and unpleasant
behaviours. Parents, teachers and peers tended to reject them.
It seems reasonable to predict that people who are dysregulated and

anxious as children are more likely to have psychological difficulties
as adults (Sroufe 2005). Early experiences of being unsafe, failing to
accomplish tasks and meeting with frequent disapproval establish a
way of thinking, feeling and functioning in the world. This will be
our internal model of who we are and how we will live when we
leave our family and attempt to live independently in the world.
Clients with a disorganised-disoriented attachment style are at the
greatest risk of developing severe psychological issues or psychiatric
conditions. Absence of a secure base throughout early childhood or
continued terror caused by parents or caregivers damages biological
and neurobiological systems, such as memory. This damage is apparent
in problems in everyday functioning which depends on these systems.
The lack of a secure base would seem to leave one struggling with
a profound and painful loneliness…haunted by a fear of loneliness,
some form of separation anxiety, occasioned by panic attacks or
depressions, and a hungry search for a sense of internal goodness.
(Karen 1994, p.383)
One of the most serious consequences is a disorganised sense of self
based on feeling wrong, inadequate, bad and unlovable and having
an overwhelming feeling of shame about who one is. In the next
chapter and later in the book you will meet clients with unresolved
developmental trauma. We will discuss the principles of therapy which
can be effective with them. The most promising and interesting aspect
of such therapy is how it reaches memories of trauma and changes
their impact on present functioning.
In his window to the neurobiology of poor care below, Jon Baylin
describes the brain chemistry and functioning which result from poor
care and developmental trauma.
Window to Neurobiology of Poor Care
Jon Baylin
The midbrain defence system

Poor care during the first year of life promotes the development of
the child’s self-defence system while suppressing the development
of the social engagement system. Over time, poor care epigenetically
programs the child’s developing defence system to create a bias towards
self-defence over social engagement, a bias that gets structurally
embedded in the child’s brain by sensitising the pathways between
the amygdala, the self-defence responses of fight, flight and freeze,
and the stress response system, lowering the threshold for triggering
defensive/stress reactions while making it relatively harder to activate
the social engagement system (Meaney 2013; Moriceau et al. 2009).
In particular, poor care stimulates the development of an interactive set
of deep brain regions called the midbrain defence system (Corrigan
2014; Lanius, Bluhm and Frewen 2011). Parental neglect and abuse
target this defence system at the expense of the circuitry that would
typically support the development of the social engagement system.
The midbrain defence system connects the processes of (1) orienting
to a stimulus; (2) appraisal of the threat value of this stimulus; and
(3) defensive reactions.
By strengthening the connections among these three brain
processes, poor care epigenetically fosters the development of a
highly sensitive ‘alarm system’ in the young child’s brain. Importantly,
this system not only enables the child to respond defensively to a
caregiver; it also stores memories of the experiences of being
defensive, memories that, in essence, form the young child’s core sense
of self-in-relationship. The alarm system is functional very early in
life and is capable of forming conditioned emotional responses to
threatening social stimuli, including angry facial expressions, harsh
tones of voice and painful touch. This brain circuit then stores this
learning in the form of unconscious, implicit, preverbal memories that
can be triggered at any age in life (Siegel 2012). When this happens,
these old fear-driven memories are experienced as coming ‘out of
58
the blue’ without explicit connection to the present context in which

they emerge. The kind of ‘remembering’ that stems from the midbrain
defence system creates the subjective experience of re-living traumatic
experiences with a vividness or intensity that matches that of the
original experiences, a kind of memory that is out of time and place,
that is not contextualised. This is the nature of flashbacks that are part
of PTSD (see Figure 2.1).
SC = Superior colliculus
PAG = Periaqueductal grey
A = Amygdala
Early SC: orienting

childhood ECT
trauma (ECT): PAG: freeze
angry faces
loud voices A
threat
painful touch appraisal
Preverbal traumatic experiences

get stored in the midbrain defence system
that processes these multi-sensory experiences
at the time they happen
Figure 2.1 The subcortical midbrain self-defence system
Neuroception and social switching

Neuroscientist Stephen Porges (2011) coined the term ‘neuroception’
to describe the ultra-fast appraisal process conducted by the midbrain
defence system to determine as rapidly as possible the ‘valence’
of sensory input. Is this ‘thing’ being sensed safe to approach or
dangerous to approach, something pleasurable or something painful?
It’s the job of the right amygdala to make a rough appraisal of the
emotional relevance of all sensory information within less than one
tenth of a second, much faster than the brain processing time required
to give rise to a conscious perception of something being sensed (about
250 to 300 milliseconds) (Vuilleumier 2005). The key brain region
in this rapid, unconscious appraisal system is the right-hemisphere
amygdala, in connection with those brain regions that control the
orienting response and brain regions that activate approach and
avoidant behaviours. When the sensory experiences of good care pass

through the child’s midbrain threat detection system, the amygdala
suppresses defensive reactions while triggering the social engagement
system, enabling the child to feel safe approaching the caregiver for
comfort and companionship. When the sensory experiences of poor
care pass through this initial social filtering process, the amygdala
triggers the brainstem defence circuit, leading to avoidant behaviour
that lays the foundation for a habitual stance of mistrust and
hypervigilance in the presence of caregivers.
So in addition to being a threat appraisal system, the midbrain
defence system functions as an unconscious, ‘bottom up’ social
switching station in the brain, capable of rapidly and automatically
orchestrating changes in internal states, reflexive alternations between
approach and avoidance, social engagement or social defence,
depending upon the moment-to-moment assessment of the level of
threat or safety in the immediate, ‘proximal’ environment. This is also
the neural substrate for the formation of an embodied, ‘valenced’ sense
of self, for experiencing the self in an unreflected, ‘mindless’ way as
being of high value or low value or no value, all of which makes
the midbrain defence system the ‘epicentre’ of developmental trauma
(Fisher 2014).
Suppression of social emotions in

favour of asocial feelings
Children forced to adapt to poor care have to suppress positive
social feelings, including the joy of connecting with others and
empathy, feeling the pain of others, because these feelings would
motivate the child to get closer to the caregiver when being close
is not safe (Panksepp 2003). Pleasurable and painful social emotions
move the child and parent towards each other to create the ‘call and
response’ dyadic dance of secure attachment. The poorly nurtured child
has to learn to suppress these ‘vitality affects’ (Stern 2000) in order to
keep a safe enough emotional distance from an untrustworthy, hurtful
attachment figure. In the process of suppressing these primary social
emotions, the child is also suppressing the development of secondary
social emotions, including empathy and remorse, that would normally
emerge in the context of a trustworthy, nurturing relationship. Instead
of developing these primary and secondary ‘pro-social’ emotions,
the child has to develop an asocial state of mind and body towards
attachment figures by blunting attachment-related feelings.
Dissociation: How opioids promote

emotional numbing
In dissociation, when feeling and caring hurt too much to bear due to
the overwhelming experiences of frighteningly poor care, this ‘caring
system’ can shut down, primarily by releasing opioids throughout the
brain regions that make up this circuit (Lanius 2014). Massive release
of opioids triggered by overwhelming pain and distress in infancy has
the effect of shutting down the brain regions that would normally be
active to support the development of self-awareness, the ability to ‘feel
and deal’ (Fosha 2000), and the capacity to sustain caring feelings about
oneself and others. When infants have to use this dissociative strategy,
they begin to shut down the developmental process of connecting the
lower, subcortical regions of the limbic system to higher regions
(the anterior cingulate cortex and lower prefrontal cortex) that would
typically become the ‘executive system’ for the social/emotional brain.
Shutting down this developmental pathway in infancy is a major part
of the neurobiology of developmental trauma, a defensive process
that prolongs the use of the more primitive bottom-up state switching
process that is required for basic survival in a harsh world (Belsky
2013; Lanius et al. 2011).
This emotional suppression early in life sets the stage for habitual
use of emotional disengagement as a defence when interacting with
potential social partners later in life. Use of this chronic self-protective
pattern buffers the person from acute social pain but prevents the
development of trusting relationships, promoting a vicious cycle that
perpetuates failed attempts at ‘partnering’ and parenting. In this way,
poor care sets the stage for the child to develop chronic mistrust
of caregivers and, later, potential partners, creating a chronically
hypervigilant state of mind and body in the presence of other people
who try to come close.
Suppression of reflective functioning

In the context of developmental trauma, the default mode network
(DMN) that eventually supports self-reflection is likely to be
underdeveloped due to the demands that are placed on the developing

brain to pay attention to the outer world. When the young brain has to
be dedicated to self-defence, it is vital to develop chronic hypervigilance
in order to keep eyes, ears and all senses focused outward to detect the
earliest signs of impending rejection or abuse in other people’s faces,
voices, movements, touch. Also, when early experiences with caregivers
are painful, the memories of these experiences are not emotionally safe
to reflect upon using the DMN, making the process of ‘looking inside’
alarming rather than safe and productive.
As a result, it is much harder for the survivor of early childhood
trauma to go inside to revisit and reprocess relational experiences in
order to reassess them in light of new experiences and reappraise old,
unexamined beliefs about self and relationships. The inside world that
is the business of the DMN is not an emotionally safe place to dwell
and when the DMN is triggered, it is usually in the form of a flashback
or a disturbing memory that shocks the brain into shutting the self-
reflection process down and activating the reflexive self-defence
system. When clients bring this lack of inner and outer safety into
the therapeutic setting, they need help on both fronts: help to feel
safe enough to be in this external setting with the therapist and safe
enough to go inside themselves to work on their issues.
Chapter 3
CHILDREN, ADULTS AND

THERAPEUTIC CHANGE
Who Are the Clients with Unresolved
Developmental Trauma?
Petra Winnette
Developmental trauma disorder

As we discussed in Chapters 1 and 2, when children or adolescents
experience prolonged adverse situations in an attachment relationship
with their parents or caregivers, their brain and body suffer from
chronic stress. This has been referred to as ‘developmental trauma
disorder’ (DTD) and it is associated with specific consequences and
symptoms including impaired development. Although developmental
trauma disorder has not been recognised yet by the Diagnostic and
Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) (American
Psychological Association 2013), it provides a systematic framework
for clinicians and scientists to conduct further study and research. In
this book we focus on clients who meet criteria for DTD. It means
that they were exposed to prolonged, adverse and disruptive events in
caregiving in childhood and they exhibit symptoms related to this
history in areas, such as dysregulation of affect, physiology, attention,
behaviour, relationships and self-concept. They may also suffer from
PTSD symptoms. The proposed criteria for DTD also include areas
of functioning where the client may show significant distress or
dysfunction: school, family, peer group, legal, health and work (van der
Kolk 2005).
We follow two adult clients who experienced prolonged childhood
trauma, which influenced their development, and who did not get
63
treatment until they were adults. We explore the factors which lead to
different degrees of severity of developmental trauma.
Human beings are social creatures. Our survival and well-being
depends on other people. This starts at birth and continues until the
end of our life. Understanding people, relationships and collaborative
connections are the most important ingredients for a meaningful life
(van der Kolk 2014).
In my clinical practice I see many children and adults. Sometimes
they have been diagnosed, medicated and treated for a specific disorder.
Biological parents, foster parents or adoptive parents bring their child
and describe what they think is wrong. John is easily triggered and
then aggressive at home and at school. He will not do his homework.
He is passive and lazy. He does not have any friends. When he plays
with peers he is controlling and wants everybody to follow him. If
they reject him, he cries and shouts that he will kill them all. Adult
clients often talk about feeling anxious, feeling different from others
and having difficulty relating to people. Some feel strange, or even
awful. They often dissociate or develop strategies to hide how they
feel from others. Some wear the mask of an outgoing, funny person.
But behind that they are hiding the terrible creature that they think
they are. Some resign themselves to failure. ‘That’s me – worthless,
rubbish.’ They think and live accordingly.
To some extent they always experience pain and fear when they
relate to others. They want to be normal. They want to have a partner,
to be loved and enjoy friends and having children. They try over and
over again but it does not work out.
Severe cases of relational and attachment trauma produce
unmanageable chronic stress which impairs both physical and mental
functioning (Hughes and Baylin 2012).
Some of our clients started their life with complex trauma
experiences and this continued throughout their childhood. Some
clients seem to have had a good enough childhood, but there were
one or two severe deficits in caregiving which produced specific,
repeated experiences of trauma. This resulted in specific symptoms
and problems.
Alan Sroufe concludes that who we are and become as a person is
the result of our capacities, tendencies and behaviour over time. We are
not able to list all the elements and how the composition is created.
But we know that development in interaction with others is one of the
fundamental elements in forming who we are (Sroufe 2005).
Children, Adults and Therapeutic Change 65
Developmental trauma in adulthood

Children who experience severe complex developmental trauma and
show a disorganised and disoriented attachment style are at high risk
for psychological disturbances in adulthood. These clients suffer from
an incoherent picture of themselves. They have a damaged sense of
unity and continuity in life and do not feel safe relating to anyone.
They live in ongoing emotional instability. Their social interactions
are reactive and disruptive. They cannot regulate their level of stress
(Lyons-Ruth and Jacobovitz 1999). This applies to children and adults.
THE STORY OF CLARA

When I met Clara she was a likeable, talented young woman who
should have been starting a beautiful life as a young adult. But
when I did the Adult Attachment Interview with her, her speech was
disoriented, she felt ashamed and she often dissociated. It was hard
for her to complete the task and stay with me in the room.
Clara and her ‘five mothers’

Clara was placed in a children’s home right after her birth. Her
biological mother, we will call her the ‘first mother’, left Clara in a large
residential institution for children. There was nothing like ‘Mum and
Dad’ there at all. Clara lived in the institution for the first five years of
her life. She was fed, supported, protected and had limits set for her.
But all this was done by many different nurses and educators. She
was not special to anyone and no one was special for her. She had
very limited interaction with caregivers as there were many children
in her group. She was always just one part of a group.
Adoption of a lost child

At age five Clara was adopted. We will call her adoptive mother the
‘second mother’. Her new mother was single and an unhappy person.
They lived together in a house a few miles away from a village. Clara
did not know what it meant to be connected and have someone to
rely on. Her way of interacting was strange. Her adoptive mother
did not know what to do and she had her own deep problems. She
started treating Clara like a difficult animal. She locked her up and
beat her. She was very controlling and would not let Clara go out
or play with friends. She repeated to Clara over and over again how
awful and incompetent Clara was. Clara’s mind and heart stayed
hungry, desperate and confused.
Mother number three

When Clara was seventeen, she ‘fell in love’ with a female teacher
at school. Neither of them understood what was going on. The
teacher felt lonely and Clara desperately needed someone. Clara’s
relationship with the teacher was dependent and needy. When
she was eighteen, she moved to her teacher’s house. Before long the
situation became surprisingly similar to her life at her adoptive home.
The teacher started being very controlling and aggressive towards
Clara. She often told Clara she was incompetent and impossible.
She even approached a court in order to have Clara declared legally
incompetent. She thought she could keep Clara to herself and under
control this way.
Fourth and fifth…

Clara left the teacher and found a professional organisation which
supports young people with extremely difficult childhoods. There
she met Rachel. Rachel immediately became her ‘fourth mother’.
Fortunately, this ‘mother’ was a gifted social worker who did not
repeat the old pattern with Clara. The organisation helped Clara
learn how to live an independent and stable life. After successful
completion of the programme she was able to rent her own
apartment and find a job. But her deeply rooted desire for a mother,
love and a safe relationship did not disappear. Clara found a job as
a personal assistant to a severely disabled woman. It was not long
before Clara’s client became her ‘fifth mother’. Again the same type
of destructive relationship surfaced with a controlling mother figure
and a helpless, ‘stupid’ and incompetent young woman.
Clara cannot stand herself

When I started working with Clara she was twenty-three. She was
keeping in touch with all four of her ‘mother figures’, and she was in
a deep, life-threatening despair. At the age of twenty-three, she had
been through her first suicide attempt. Her way of being an adult
involved despair, isolation, anxiety and absence of hope. Her life
had no meaning to her. Her independent life on her own felt unsafe
and she experienced fear and despair every day. She could not
stand people around her and when she was alone she got severely
depressed. Drugs and suicide seemed to be doors to a place where
she could feel better. Clara wanted to be somewhere else than in
her own skin, in her own mind. Her childhood experiences created a
strong network of memories of feeling bad and helpless. For her the
ultimate meaning of those well-stored experiences was that she was
a terrible and hopeless creature.
THE STORY OF PAUL

Another client of mine, Paul, had a different life story. He was loved and
cared about. But still something wrong had a lasting and destructive
impact on his life. When I did the Adult Attachment Interview with
Paul, it took a long time to complete it. He was collaborative and
tried hard to focus on the task. His picture of his childhood was ‘nice’.
Although he was very calm during the interview, he was also talkative.
He would tell long stories with many details but unrelated to the
original topic. He constantly commented on himself. His relationship
with his mother was ambivalent. There was love, anger and guilt, all
mixed. Therefore, it was hard for him to give adequate answers. His
mind was flooded with ambivalent emotions about his childhood
and it made his stories overly long, detailed and full of contradictory
emotions. His picture of his interaction with his parents was that all
the problems happened because he was a difficult child. His parents
had a hard life with him. They were good, he was bad.
You are born to make us happy

Paul was the last of four children. His parents were lawyers, busy
and successful people. His three older brothers were already
attending school when he was born. His parents were not planning
to have another baby; they seriously thought about abortion. Paul
remembers very well what his parents told him: ‘We decided to have
you so you would make us happy when we are old.’ Paul inherited
a kind and rather phlegmatic nature. However, his parents had less
energy and time than the young and clever boy needed. His bright
developing mind wanted to explore the world and he was on an
ongoing adventure. He was always taught that he was supposed
to be good but he was not. He told me an interesting story which
illustrates this.
Bad boy on a sled

Paul was about three years old when he spent some time with his
mother in a small town in the mountains. One afternoon his mother
dressed him to go together to slide on a sled in the fresh white snow.
Little Paul could not wait. How great! He was lively and noisy. His
mother took him outside and put him on the sled. But she had to
go inside again. She might have told him, ‘Paul, just wait here, do
not go anywhere.’ He does not remember it. He remembers he went
down the street on the sled and it was great. The street was long and
he was quietly moving forward. Fantastic! There was a crossroad at
the end of the street. Paul was too small to realise the danger before
his sled missed a car coming from the right. Then the sled stopped.
The next thing Paul recalls was his mother trying to teach him by
shouting and hitting him. Quite a big lecture. He remembers it well
even now when he is fifty-one. He also remembers feeling a huge
shame. ‘I was supposed to be nice and make my parents happy, but
I was so naughty. I made them angry and frustrated all the time.’ As he
speaks he is fully convinced his understanding is logical and he caused
a lot of trouble for his loving, kind parents. His childhood continued this
way and his parents told him many other stories about how much
trouble he was – difficult Paul, the bad and naughty boy. His parents
used physical punishment as well as repeatedly criticising him.
Paul was not allowed to be a normal lively developing child.
Whenever he tried to be, they told him, ‘We are not happy with you,
because you are being naughty.’
His parents’ view of him coloured their interactions with him and
caused him a special kind of ongoing stress. He was stressed because
he was not good enough for his beloved parents. He adapted to it
and resigned himself to the stress: ‘I am bad and I cause other people
trouble. I should be happy that they let me live and be around
them.’ He became depressed, gave up vitality and courage and
kept surviving.
Paul’s partners
Paul is a gifted, bright person. He is a doctor, a neurologist. He has
many friends, plays in a band and plays softball. He is bringing up
a son. However, he has had strange problems with his partners. He
recalls that all his partnerships evolved in a similar way. He tried
hard to be nice. He was a very tolerant and supportive partner. His
partners enjoyed that, but for some reason they later started being
critical of him. When they expressed dissatisfaction with the way he
was, he felt guilty and thought they were right. He felt that he should
make them happy.
I do not deserve any better…

Paul decided to see me when his current girlfriend physically attacked
his young son from his first marriage which had ended in divorce. It
was hard for Paul to understand what was wrong. His girlfriend had
been aggressive towards Paul before. But that was familiar. He bore
it with his typical humble attitude: ‘I am a bad boy. I cause people
trouble. I just have to keep going. Such is life.’ Now he was in a big
conflict. He loved his son and would never let anybody hurt him.
He wanted to protect his son, but could not see what was wrong
with his girlfriend. He was making excuses for her and still seriously
considering moving in together and marrying her. His inner compass
based on his memories was showing him his old way, ‘Accept that
you are a naughty, bad partner. It is hard to be around you. You are
born to please people. You deserve to have people being angry
and mistreating you.’ He was now an independent adult with many
resources and competencies. But the model he learnt in childhood
still strongly influenced his thoughts, feelings and behaviour in close
relationships. Paul was not conscious of this model. His memory
contained the meaning of things and himself. It carried it on.
Degree of unresolved developmental

trauma: Clients are on a spectrum
The proposed criteria for developmental trauma disorder define
exposure to stressful and traumatic experiences as one of the
important factors in DTD (van der Kolk 2005). There will be
differences in severity depending on factors related to the exposure to
traumatic events. As we saw in Chapters 1 and 2 the brain develops
in a hierarchic way. When trauma happens in the early stages of
development it has an impact on areas of the brain related to the
emotional state of mind and affect regulation. A study which focused
on factors related to development of borderline personality disorder
(BPD) showed a significant relationship between a diagnosis of BPD
and severe early trauma. It suggested that the earlier the trauma occurs,
the more significant the impact may be. In the majority of cases for
patients with BPD, the abuse happened before they were seven years
old (Herman, Perry and van der Kolk 1989).
The extent of the trauma also plays an important role. A prolonged
traumatic experience, especially when there is no support for recovery,
will have a toxic influence on brain architecture. If the trauma is caused
within the caregiving relationship or there is no caregiver, it may be
the most damaging form of traumatic experience (National Scientific
Council on the Developing Child 2005/2014).
The degree of severity of consequences, therefore, depends on
factors such as the age when it happened, how long it lasted, how
often it happened, what happened and with whom. In Clara’s case
we see that her trauma started soon after birth, lasting for all of her
childhood and adolescence, and happening in caregiving relationships.
The neglect and abuse were severe. That beginning of life influenced
everything which happened later in her life. Not being helped in her
childhood, Clara suffered consequences from her history, not knowing

what was wrong and blaming herself, until she sought help at age
twenty-three. Paul had less pervasive and severe traumatic relational
experiences in childhood. He developed impairment in the areas
of sense of self and building safe close relationships. Both clients
experienced trauma in caregiving relationships in early childhood.
But differences in their histories had an impact on the severity of their
developmental trauma disorder.
The core of developmental

trauma: The sense of self
Allan Schore explains that early trauma has an impact on right-
hemisphere development. The right hemisphere and right orbitofrontal
cortex are central areas associated with many psychological problems.
They are responsible for empathy, processing emotional experiences,
trust, an affective theory of mind, and evaluation of social signals.
The right hemisphere develops rapidly and is dominant in early stages
of development. A child processes emotional and social information
which he can see in his mother’s facial expression, her eyes and her
behaviour. His right hemisphere is connected with his mother’s right
hemisphere; it creates emotional and social attunement between
the child and his mother. This connection with the mother directly
influences how the child experiences himself and his sense of being
(Schore 2001). The right hemisphere ‘reads’ social signals which are
then processed and linked with our experience of ourselves. In this
way the right hemisphere is the area for our ‘implicit I’ (sense of self ),
which is interlinked with emotional meanings, nonverbal and social
communication, attachment, intersubjectivity, empathy and self-image.
This is why the right hemisphere is a dominant area in therapeutic
care and treatment. In the therapy with adult clients, it is the right
orbitofrontal cortex which is active (Schore 2002a).
With both Clara and Paul, we can see how developmental trauma
impaired their sense of self. If the development of the sense of self
is impaired by long-term trauma in a caregiving relationship, the
client’s experience of himself is accompanied by emotions such as
shame, anxiety, anger, disgust, helplessness, hopelessness and despair.
The memory of feeling that with the mother or caregiver is encoded.
Now it is who I am.
I am not a human!
I don’t want you to see me
I’m such an ugly monster
I have to hide in a deep dark cave
There is no light, I am alone
I don’t have to trust anybody again
Therefore, deeper understanding of brain development and
development of the sense of self should influence the art and science
of psychotherapy (Vrtbovska 2007).
Treating unresolved developmental trauma

The case studies illustrate factors related to trauma for two developing
children. Clara went through complex traumatic experiences which
lasted all of her childhood. Paul’s trauma experience was centred
on the message that his worth depended on meeting other people’s
expectations.
When the trauma involves developmental factors, treatment
should address them. Helping Clara build her self-confidence will not
be successful if therapy does not reach the depth of her shaken sense
of self. If Paul wants to solve his partnership difficulties and find a
good partner for himself and a good mother for his son, he will need
to reach his childhood feelings of being born only to please others.
How to do that?
Bessel van der Kolk emphasises that through the science of
neurobiology we understand better that trauma, and early trauma
especially, has a huge impact on our overall physical and mental reality.
It influences the very core of us, who we are. It reorganises thinking,
perception and the way we remember. Trauma can damage the way
we think and our ability to talk about basic life experiences. Treating
developmental trauma, therefore, cannot focus solely on talking about
the events in the past. The trauma which happened early in the
attachment relationship creates a map, an internal model, which is part
of the emotional right brain structure. The imprint of trauma became
part of the developing personality and its complex functioning in the
world. Therefore it cannot be reversed just by knowing about it and
understanding what happened (van der Kolk 2014). Intervention must
reach areas of the brain in the right hemisphere which process and
store emotional, implicit and social memories.
Allan Schore summarises new directions in psychotherapeutic

thinking based on neuroscience:
We’re moving to more complex, dynamic systems and holistic models
of the organism adapting to the environment and the changes that
it makes as it adapts to stress, etc. It is now time to put together
not just a piece of the mind here and a piece of the body there.
When you focus in on an affect as opposed to cognition you can’t
help but then turn it to the body because you can’t talk about affect
purely in terms of a cognitive state. You’re also talking about changes
in heart rate, respiration, muscle tension, etc. Affective neuroscience
is now moving us more into the body and people like myself and
Damasio, etc. are now becoming confident that the mind-body gap,
the Cartesian problem, can be bridged. By putting together these
psycho-biological models of infancy and adulthood these will lead to
more powerful models incidentally in the treatment of psychosomatic
disorders. (Schore 2001)
Treating children
Principles of Dyadic Developmental Psychotherapy
Daniel Hughes, the founder of Dyadic Developmental Psychotherapy
(DDP), explains how he started thinking differently about children
with early and developmental trauma. At the time the term and
understanding were not yet developed, but the young clients existed.
He was trained as a family therapist and a play therapist. There
were some children who were doing well, and some who seemed
to get limited benefit from his interventions. When he studied and
applied Bowlby’s attachment theory he realised why some children
do not improve. He started seeing his young clients through the
lens of the long-lasting childhood trauma which these children had
experienced. The next step was to create a therapeutic model which
would help developmentally traumatised children get back ‘on the
rails’ of a healthy developmental path. Hughes therefore named the
therapy according to its treatment goals. ‘Dyadic’ means that from the
beginning the goal is for mother and child to develop attachment and
a relationship in a safe dyad. ‘Developmental’ refers to the fact that the
therapy addresses developmental issues (Hughes 2006a).
His book Building the Bonds of Attachment tells the story of Katie,
a girl who suffered from abuse and inconsistent care by her parents.
Katie is placed in foster families, but none of them can cope with her
emotions and behaviour. Katie is a psychologically damaged child
in a hopeless situation before her enthusiastic social worker finds a
therapist and a foster mother who are willing to give Katie another
chance. Their work consciously reaches the deep roots of Katie’s
despair: her ongoing stress and anxiety, lack of safety, fear of being
hurt and abandoned again, lack of trust in adults and others in general
and her blocked ability to enjoy herself and have fun (Hughes 2006b).
The healing power of a secure base

Dyadic Developmental Psychotherapy was created to help traumatised
children and repair what had gone wrong in their past. The main
agents of the repair are the safe people who take care of the child
now. They learn to understand his difficulties and how to help him
recover from trauma and enjoy his life as a child. These are biological
parents, adoptive parents, foster parents, relatives or other caregivers.
The model emphasises that the relationship between parents and their
child is essential to the child’s development (Hughes and Baylin 2012).
Hughes defines five core principles and tasks which the therapist uses
in DDP:
Attachment: The role of the therapist is similar to the role of a mother.
He provides the child with a safe base so the child can explore. It is
emphasised that the therapist accepts and supports the child who is in
trouble and his concern is to promote the child’s welfare. The therapist
is responsive, attentive and empathic. He encourages the child to
explore his thoughts, feelings and actions in the present and in the
past (Bowlby 1988b).
Safety: The first task for the therapist is to establish ‘safety’ and
maintain it through the phases of joining, engaging, developing an
alliance and relationship building. The therapist’s intention is that the
child experiences a sense of safety. The therapist develops a sense of
safety first in his relationship with the parents. Then the therapist and
the parents together provide safety for the child.
Intersubjectivity: When people share their inner world with someone
else, a rich flow of information can be exchanged. It involves how
they experience each other, the subject of interest and how they feel
about it. That richness can be described by the term ‘intersubjectivity’.
Intersubjectivity means there is matching affect, joint attention and

congruent intention. Intersubjectivity plays an important role in day-
to-day communication, collaboration and sharing life with someone
else. It is a core principle in therapy. It means that the therapist and
client are attuned, share matching affects related to their experience
and attend to the same object, that is, a story, a person, a memory, and
so on. Congruent intention means they have a clear contract about
their goals and steps in the therapy. If any of the three intersubjective
elements is missing, it will influence the process and relationship
between the therapist and client (Hughes 2011).
Co-regulation of affect: Allan Schore explains the impact of intersubjective
communication. According to him, it regulates mind and body states
based in the right brain (Schore 2005). This is essential for building
a feeling of safety and collaborative exploration. When affect is
regulated within the relationship, the client is able to receive new
healing experiences.
Co-creation of new meaning: The child can integrate new positive
meanings through intersubjective experiences. The therapist facilitates
such experiences between himself and the parents and then between
himself, the parents and the child. From this process the parents learn
to facilitate intersubjective experiences between themselves and their
child. The child experiences himself and discovers who he is through
sharing his parents’ mind and heart and their attitude towards him.
The sharing includes hope, joy, contentment, affection (Hughes 2011).
We present an example of such intervention later in this chapter.
PACE and PLACE

DDP uses core therapeutic stances throughout the process. They apply
to both therapist and parents. They are summarised by the acronyms
PACE and PLACE.
PACE refers to the attitude of the therapist. It means that he creates
a healing space which is Playful, Accepting, Curious and Empathic.
PLACE refers to the attitude of the parents. They create a healing
space for their child which is Playful, Loving, Accepting, Curious
and Empathic.
Conflicts and misunderstanding are part of every healthy
relationship. PACE outlines the manner in which the therapist and
parents will explore issues, conflicts and events. This method is

designed so that topics are discussed in an interactive mode, where
caregivers are actively creating safety and connection with the child.
Whenever there is a break in the relationship, PACE helps create a safe
and explorative communication to repair the break. (Becker-Weidman
2012; Hughes and Baylin 2012)
Therapeutic parenting
Our discussion of DDP highlights the importance of parenting and
caregiving in treating children with developmental issues. The family
or caregivers should be involved in repairing trauma. As we explored
earlier in this book, a child’s developmental needs are fulfilled in
an attachment-based relationship. The quality of this relationship
plays a crucial role in the development of a child, especially in his
social and emotional well-being. Therapists using DDP use the term
‘therapeutic parenting’. It captures the principle that when a child
is traumatised in relationships with his parents or caregivers early
in life, it is a caregiving relationship which will repair the damage.
Even when trauma happens outside the family, a child needs support
and assistance from an adult he can trust and depend on (Hughes and
Baylin 2012).
Treatment options for Clara as a child

Clara was an unwanted, abandoned child and then she was traumatised
for five years by the absence of an attachment relationship and other
conditions in a childcare institution. We can hypothesise that if Clara
had been placed with loving and sensitive adoptive parents at this
point, she might have had a chance to heal her early trauma. A therapist
could assist her adoptive parents so they would be therapeutic and
perform the following fundamental tasks for the treatment process:
• help Clara to feel safe and regulate her stress
• help Clara relate to her parents and safely depend on them
• help Clara rediscover joy and fun in relationship with her parents
• help Clara learn how to resolve problems
• help Clara develop a positive sense of self

• help Clara to have friends and develop close relationships
• help Clara explore and realise her talents and gifts
• help Clara to safely learn about her past and integrate it as a
non-threatening part of her life
• help Clara prepare so that she will become a healthy, resilient
adult and realise a productive and positive independent life.
Treatment options for Paul as a child

Paul’s parents made him think he was a problem and a burden, that he
needed to be a certain type of child and he was not. They used lectures
and physical punishment in a way that left Paul feeling he was bad and
didn’t deserve to be happy or treated well by others.
Paul internalised a very negative view of himself. It left him feeling
powerless to take care of himself in relationships or feel good about
himself and his life.
If Paul’s parents decided to see a therapist, they would probably
present Paul as a naughty boy they could not control. The therapist
would help the parents to see the situation differently and facilitate
repair of the relationship. The therapist would assist the parents so
they were prepared to perform the following tasks:
• help Paul feel safe and understood
• help Paul establish a safe relationship with them in which Paul
would feel loved and accepted the way he is
• help Paul learn to accept limits without feeling shamed, hurt
or disoriented
• help Paul to no longer see himself as a burden for other people
• help Paul feel positive about himself and set limits for other
people
• help Paul become a healthy, resilient adult and realise a
productive and positive life.
In most cases treating children requires good parents and family or
dedicated, trained caregivers. If there are gaps in a parents’ ability,
family or individual therapy can address them and restore the family
system so it can provide therapeutic care for a child who needs it.
Involving the parents in therapeutic parenting decreases the chance
that a child with a history of trauma will feel inadequate, deficient and
wrong (Hughes and Baylin 2012).
The surprising, new experience of a safe haven

In developmental therapy the therapist builds an alliance with parents
and helps them explore their own attachment and relational history and
issues. Parents need to understand attachment and the developmental
nature of their child’s problems. Then they learn the principles of
therapeutic parenting. This is vitally important to the therapy process
and outcome. Healing does not happen solely through talking in the
therapist’s office. Therapeutic interventions also involve a great deal
of ‘experiencing’. They provide authentic interactions between the
parents and the child in the office with the therapist. Then the parents
continue the process with the child at home. Allan Schore emphasises
the importance of right-hemisphere implicit experiences in healing.
He writes that affective psychotherapy supports development of the
sense of self. A healthy sense of self is a key element in regulating
affect and stress, in creativity and humanity (Schore 2000).
I need to be a baby again

When I work with children who spent the beginning of their life in
residential care units, their parents or caregivers often report that the
child has a tendency to act much younger than his age. It is confusing
to the parents. One day the child fights about homework and the next
day he wants to crawl under a blanket and act like a new-born baby.
In cases like this I use a technique to activate elements characteristic
of early developmental stages: touch, sound, the behaviour of parents,
right-hemisphere emotional experiences and stress regulation. It
includes an attachment experience and a meaningful end. In these
cases, the intervention focuses on a preverbal stage. It is designed to
imprint the experience so that it is linked with similar experiences
which took place at an early stage of development. The record of
such an experience is encoded in many levels of implicit memory
(Joseph 1995).
THE STORY OF IRENE AND ONE SESSION

WITH HER AND HER PARENTS
Irene’s early childhood
I first met Irene when she was five. She had been severely neglected
by her mother for her first two years of life, then placed in an
institution. Her mother later returned and took Irene home. When
social workers got a call from a neighbour, they went to the home and
found Irene dehydrated, hungry and cold. The girl was immediately
placed in a hospital and later moved to an institution. At this point
a couple decided to adopt Irene. They were prepared for difficulties
they might face as adoptive parents and they were willing to help
Irene as much as they could. They did not want Irene to be placed in
a psychiatric hospital for disturbed children and heavily medicated.
We worked together to prevent this.
This session took place when Irene was six. Her behaviour and
mental states were severely disorganised. I remember her as a tiny
girl who said ‘no’ to everything. When she was asked to make a
picture in a sand tray she took all the toys and buried them in the
sand. She suffered from severe enuresis and encopresis (i.e. difficulty
controlling urination and defecation).
We started work with DDP. I explained the effects of
developmental trauma and disorganised attachment to the adoptive
parents. They understood that therapy has to involve experiences
which help Irene learn to regulate her emotions and develop a
safe attachment with her parents. We planned and conducted the
following session with Irene.
Let’s play baby

When the adoptive father and mother, Irene and I arrive in the play
room, Irene runs about as usual, screaming and hiding under the
chairs. I know at home she often hides in a corner, sucks her thumb
and cries helplessly. Her parents do not know what to do about it as
she does not let them hold or comfort her. Today I ask the parents to
sit on the sofa as I start talking to the rushing Irene.
‘I’ve heard sometimes you like playing a baby. Am I right?’
‘Hmmmm, yes, I do,’ she nods and continues singing and hopping.
But she comes closer to me. ‘Oh! In that case I have a great idea!’ I
exclaim. This catches her attention. ‘You know what? Today we can
play with your mum and dad like you are a tiny, little baby and they
take care of you. Ha? What do you think?’ ‘Yes!’ She is interested. I let
her have a great deal of control. ‘OK. Where should they sit? Should
they hold you?’ Irene is puzzled and unsure. I keep going, ‘Or I can
bring this beanbag here and we can turn it into a baby cradle.’ ‘Yes, I
want a cradle.’ She gets ready to arrange the beanbag. ‘Great. But you
know when there is a little baby, it’s the mother and the father who
prepare everything. So you just watch them doing it.’ ‘Yes,’ she smiles,
imagining it. Irene watches her parents with great curiosity as I give
them instructions about the cradle. I let Irene give them instructions
too. She is restless and moving.
‘Where should they sit?’ I ask. She points to the couch. ‘Here on the
sofa.’ They slowly sit down and Irene gets into the beanbag. She lays
down and keeps moving and talking. ‘You know what? Now you are a
new-born baby and they don’t talk and they don’t move. They just lay
and rest.’ I am aware that her restlessness is a sign of stress and poor
self-regulation. So far she has hardly ever been able to calm down, here
or at home. I am curious how she will respond to what I said. I wait to
see what happens. Irene heard me and stops moving and talking at
once. She puts her thumb in her mouth. She does that because she
really wants (and needs) to be a baby again. Her face changes and
looks softer, much younger. It surprises me. I ask her mother to put a
blanket over Irene.
Then I start speaking softly: ‘Now you can feel like a tiny, new-
born baby and your mum and dad are with you.’ Irene looks at me and
at them with a calm, intent look. ‘Do you want them to be closer?’ She
nods in a dignified, serious way. I help her parents to sit near her head
where they put their arms around each other’s shoulder and around
the cradle. ‘Smile and look at her like she is your new-born baby,’ I
whisper and help them with the facial expression. They understand
and feel the importance of this moment. Irene is very calm and looks
into their eyes. She just nods when I ask her something. ‘Do you
want them to touch you?’ Nod. Her mother puts her palm on Irene’s
stomach. Then I ask them to say, ‘If you were born with us, we would
be with you and you would be safe and happy like this.’
It is very moving for all of us. Irene is deeply involved in her new
experience. We do not say anything more. At last I say, ‘Now you are
six again. Our play is over.’ Irene jumps from her beanbag and starts
talking again like nothing had happened. But a lot happened that
day. It was the first time she calmed down in her parents’ arms and
since that session she can do that at home too. It was the beginning of
her ability to be physically close and safe with her parents. Maybe for
the first time she experienced herself as calm, safe, loved and good.
I often use ‘playing baby’ as part of DDP with children. Other

techniques in DDP have the same goal of creating a healing, felt
experience between parent and child which can be repeated at home
on their own. It depends on a child’s age and level of trauma, but
the therapeutic change is always aimed at building a safe attachment

relationship with the parents or caregivers. This serves as a base for the
development of a healthy resilient personality.
Core principles
It takes a long, slow process for traumatised children like Irene to
recover. It involves a wide range of experiences for the child, facilitated
in the office in close collaboration with the therapist and at home by
the parents or caregivers. It is broadly agreed that essential areas to be
addressed for effective treatment of early trauma include the following:
• establishing safety
• establishing self-regulation
• processing self-reflective information
• understanding and processing traumatic past experiences
• developing connectedness and engagement in relationships
• integration of positive affective experiences
• developing a positive sense of self.
The categories correspond to the seven domains of impairment of
complex developmental trauma (Cook, Henderson and Jentoft 2003).
Treating the developing mind

Treating children means treating the developing mind. A developing
mind is very receptive and dependent on influences from the
environment. This openness, immaturity and dependency makes
young children very vulnerable to the impact of negative parenting
and caregiving. It also makes them open and receptive to positive
parenting and new healing experiences in therapy.
The necessary condition for a treatment based on therapeutic
parenting is the ability and commitment of the parents or caregivers.
‘Parents are the keystone of good treatment outcomes,’ as Becker-
Weidman 2012 states (p.8). Parents need to be prepared, educated
and properly engaged in dyadic therapy. In some cases, a parent’s
own attachment issues are not resolved or there are other reasons why
they are unable to be sensitive, patient and responsive to a child’s

needs. In such cases, without changes in the parent, it is difficult to be
effective with this method. In most cases the damaging effects of early
trauma can be repaired or reduced later in the life of a child by healing
experiences with responsive, safe parents or caregivers.
As one would expect, the process is different when treating an
adult who suffers from difficulties related to developmental trauma.
Treating adults
James Prochaska and John Norcross in their book Systems of
Psychotherapy (1999) offer a definition of the psychotherapeutic
modality. Psychotherapy is the focused and intended application of
methods and interpersonal approaches which is based on recognised
psychological principles. It is applied with the aim of helping people
to change their behaviour, thinking, emotions and/or personal
characteristics in a way which both the therapist and the client agree
to be beneficial for the client (Norcross 1990).
We believe treatment of developmental trauma should consider
the neurology of early development, attachment theory and the impact
of early trauma on implicit social and emotional memories.
Development through the life span:

The interplay of nature and nurture
A core dimension of psychopathology is a pervasive pattern of
defensiveness in interpersonal relationships, poor impulse control
and poor emotional regulation. Emotional vulnerability is defined
as heightened sensitivity to emotional relational stimuli, abnormally
strong affective reactions and a slow process of recovery. These
symptoms are caused by stress experienced in the early stages of brain
development (Siegel 1999).
American mental health experts are seeing an epidemic of PTSD
among returning soldiers. Between 10 and 20 percent develop
symptoms of the disorder, which include agitation, irritability,
disturbing and intrusive imagery, and difficulty sleeping… Studies
show that experiencing trauma early in life seems to increase the
chance of suffering from PTSD later – perhaps because these early
traumas alter the expression of genes involved in how the body

responds to stress, threats, injury and infection. (Velasquez-Manoff
2015, p.58)
Other studies agree that stress changes the expression of genes in the
human body. When abused children were tested, they showed specific
modifications in seventy-three genes. They came from different ends
of the social spectrum, but abuse had the same effect on them. Large
changes in the human body can be caused by external toxins and
chemicals. The impact of social trauma also transforms the genetic
template (Szyf, McGowan and Meaney 2008).
Research suggests that people who have an adverse childhood are
more likely to develop post-traumatic disorders after experiencing
trauma, perhaps due to changes in brain functioning and genes. They
may seek help later in life because they have acute problems related
to a recent traumatic experience or due to continuing problems in
relationships. Later in therapy they may realise that stress, unresolved
pain and frustration were there in childhood and they are being
triggered now by recent events.
We learnt in Chapters 1 and 2 that the Adult Attachment
Interview typically reflects the attachment style that the adult showed
in childhood. Clara’s interview suggests that she had a severely
disorganised-disoriented attachment style in her childhood. Paul
showed an insecure-ambivalent attachment style as a child.
Earlier in this chapter we speculated about what could have been
done for Clara and Paul to treat their developmental trauma while
they were still children. However, the nature of their problems was
not recognised and they did not have parents or caregivers who could
help them get on the right track. In adulthood they experienced the
consequences. They continued to struggle with making a positive,
productive life for themselves. A central problem for each of them
was building close, safe, dependable attachment relationships. Instead
of building healthy relationships they unknowingly repeated patterns
from childhood.
Both Clara and Paul felt that their life was beyond their control.
They were deeply unhappy and had no idea of what to do about
it. They each suffered and that is why they decided to seek help.
Nature and nurture in psychotherapy

Bessel van der Kolk suggests that recovery from trauma means to
regain mastery of mind and body, including one’s sense of self. How
does it feel to have mastery over oneself ? A person has feelings and
thoughts without being overwhelmed, dysregulated and shamed by
them. He is able to regulate his affects and be calm and focused. He
can be present and enjoy life here and now. He can establish safe,
meaningful relationships. And he does not have to dissociate or hide
away from painful memories about his past (van der Kolk 2014).
Nurturing development of a healthy

and positive sense of self
The mind is an entity which is endlessly evolving from a flow of energy
and information within the brain and interactions with other brains.
The mind is constantly co-shaped by the physiology of interactions
and experiences with environment. The mind develops as a part of
brain development. It is co-created by relational experiences which
shape its genetically programmed nature (Siegel 1999).
The desired result of a combination of healthy genes (nature) and
good care (nurture) is healthy development through the life span. The
individual has a good life, with the capacity to work and be a good
parent. The child and later the adult can enjoy life and be resilient
when faced with difficulties and problems. Effective psychotherapy for
adults with unresolved developmental trauma must therefore involve
developmental issues. When contact with others causes pain and fear,
when one feels wrong and helpless and it seems to be unchangeable,
life is hard. The central issue, the most unbearable consequence of
developmental trauma, is the never-ending feeling and sense of oneself
as bad.
From that point of view, effective therapy can be seen as a means
to provide the client with experiences which nurture development of
his sense of self, the core of his mind.
There is an advantage in working with adult clients. Their brain
has matured, connections have developed between different areas, and
the prefrontal cortex. When the child needs help, it is the parents who
seek the help and bring him to the therapist’s office. We discussed the
importance of parents in DDP. An adult can recognise his difficulties
seek treatment, recognise what works for him and co-ordinate his life
towards healing.
Jon Baylin discusses more details of the adult brain in therapeutic
change in his window to the neurobiology of therapeutic change below.
Pesso Boyden System Psychomotor therapy

The rapidly developing field of neuroscience brings to light new and
fascinating discoveries about the brain and the relationship between
body and mind. At the same time, therapists learn about the individual
stories, personal struggles, challenges and traumas of the past and
present in the lives of their clients. It is hoped that one day knowledge
from these two areas may be integrated into a new, highly effective
approach to understanding and treating disorders of mind and body.
In the following chapters we introduce an inspiring, though less
well-known, therapeutic approach. We hope to enrich the knowledge
and understanding of therapeutic possibilities. We specifically look
at how this method can be applied in the treatment of clients with
unresolved developmental trauma. We explore Pesso Boyden System
Psychomotor as a therapeutic system in the context of the neuroscience
of early development and trauma discussed in Chapters 1–3.
First, Jon Baylin explains what might be the effect of the PBSP
approach and intervention on brain function.
Window to Neurobiology
of Therapeutic Change
Jon Baylin
Neurobiology of trauma-focused
treatment with adults
The need for social engagement is hard wired, ‘genetic’, to use Al
Pesso’s term. This need does not go away in the face of poor care.
Rather it goes underground, perhaps awaiting a relationship and
therapeutic processes that can make it safe enough to remove the
blockage and bring forth the inherent drive to connect, letting this
long under-expressed need for engagement see the light of day
(Cozolino 2016). First, however, the chronic fear of engagement and
the strategies that go along with living defensively have to be put on
hold to allow for safe enough revisiting of the old core self to produce
substantive change.
The negative core self that lies at the heart of developmental
trauma has to be addressed in therapy and re-programmed, literally
restructured, epigenetically, by enriched experiences that can compete
with and eventually replace the devalued self embedded in the
brain during childhood (Lanius et al. 2014). The negative core self
has to be accessed, making it available for change, by engaging it
simultaneously with higher brain regions that come online later in
development and are not mature until the early twenties, a process
which is now thought to continue into the third decade and beyond.
This maturational sequence of brain development is what makes adult
therapy different in some important ways from child therapy. The
adult has greater access to higher prefrontal regions that can both
inhibit the subcortical midbrain defence system from above and serve
as a mental workplace for the reprocessing of childhood memories.
With the new science of good care and poor care as a framework,
we can see that therapy with adults who experienced poor care early
in life has to ‘go deep’, reaching the circuitry of the brain that stored
the original social experiences in the form of implicit, emotion-driven
85
memories that generate the felt sense of self. It is not sufficient to

work with the higher regions of the adult brain alone to convey new
information through psychoeducation or to produce new, more positive
cognitions because these processes will not reach deeply enough into
the brain to alter the structure and functioning of the mostly subcortical
circuitry that holds the under-processed early childhood memories.
Treatment has to be experiential and emotional as well as cognitive,
bottom up as well as top down, embodied as well as minded. This
requires the activation of adult brain systems that are not yet mature in
the brains of children and adolescents. Awakening the fully adult brain
to utilise both bottom up and top down functions is an important part
of treatment (Ogden, Minton and Pain 2006).
Awakening the client’s brain,

bottom up and top down
In brain terms, trauma-focused treatment needs to ‘awaken the prefrontal
cortex’ in adult clients (Ogden et al. 2006), helping the client to move
up the brain from the subcortical regions of the midbrain defence
system to the higher regions of the brain that were not yet functional
at the time of the traumatic experiences, regions that can quickly shut
down again, in the present, if traumatic memories are triggered as
flashbacks, creating a ‘mindless’ dissociative state of remembering
without self-awareness. Therapy requires helping the client shift from
lower and faster brain processing to higher and slower processing.
As long as the client is in the throes of chronic defensiveness, no real
change is possible. Therapy has to jiggle the client’s brain out of this
defensive state into a more open and engaged state in which the client
is helped to sustain the process of revisiting the past, creating new
experiences in the present, comparing and contrasting the differences,
reflecting upon these differences, and using this news of a difference
to reappraise old beliefs and build a new narrative about self, others
and relationships.
Social buffering
Treatment has to enable the client to feel safe enough to access under-
processed early memories that need reprocessing and ‘updating’
while, at the same time, helping the client to activate the higher
brain regions that were unavailable at the time these early memories
were stored in the brain. To create this level of safety, the therapist
has to provide the kind of ‘social buffering’ of the client’s defence
system that we reviewed earlier, the relational process that is essential
for creating the subjective experience of safety in the presence of
another person. In essence,the therapist has to be a source of safety
messages throughout the therapeutic process, requiring the therapist
to constantly monitor the level of safety the client is experiencing,
mostly from paying attention to the client’s nonverbal communication.
The therapist has to be aware of the signs of emerging dissociation
and disengagement in the client and have ways to keep the client
present, to help the client ‘come back’ and stay aware and mindful of
what is happening.
Procedural and structural safety

Another way in which treatment provides a sense of safety for the client
is in the structure of the treatment process. Having a roadmap of how
to proceed with trauma-focused treatment is essential and the therapist
needs to share this roadmap with the client to help instil a sense of
confidence that the processes used in treatment are understandable
and essential to helping the client make the shift from core mistrust to
trust. This procedural and structural safety needs to be combined with
the core relational safety noted above, the social buffering process,
to provide the multiple levels of safety that clients with histories of
developmental trauma require.
Creating new relational experiences

Then, with basic safety established (and re-established, as needed),
treatment needs to provide new relational experiences that counter the
old negative ones, creating the novelty that is essential for triggering
what neuroscientists call ‘reversal learning’, ‘disparity processing’,
‘memory reconsolidation’ and ‘reappraisal’ (Baylin and Hughes 2016).
Therapy has to provide the client with opportunities for unexpectedly
positive relational experiences to trigger therapeutic competition
between new and old relational memories. These new experiences
prime the client’s under-utilised potential for wonderment, curiosity
and reflection, processes long suppressed by the need to maintain a
hypervigilant state of mind and body. Now the client can contrast
old and new experiences to see the differences, and then reassess their
core beliefs in the light of this new learning. Ultimately, the client can
use the new experiences as the basis for creating a new belief system.
These processes involve moving upwards in the brain, from the deep
brain regions where preverbal experiences were first embedded, to
the lower regions of the prefrontal cortex and then to the middle
prefrontal cortex, the MPFC, where self-reflection and reappraisal can
be used to literally ‘change one’s mind’ about self and the possibilities
for new ways of being-in-relationships.
Providing new relational experiences in the therapy process serves
to activate these stepwise brain processes that support deep change. This
change process begins in the lower PFC region called the orbital cortex
and in the midbrain structure called the cingulate, regions that support
the processes of reversal learning and conflict resolution when dealing
with competition between old and new experiential learning (Whalen
and Phelps 2009). These new experiences then need to be embedded
in the client’s brain using that default mode network and especially
the MPFC, the brain system that enables self-reflection and gives rise
to self-awareness and the capacity to think about oneself in relation to
others, to ‘mind’ the process of social engagement.
Safety to go inside: Activating

the default mode network
In therapy with adults who have histories of childhood trauma and
insecure adult attachments, it is essential to help clients experience
the therapeutic setting as safe enough to allow themselves to access the
default mode network, that brain system devoted to self-reflection and
relational thinking (Fonagy et al. 2002). Activating this system
and keeping it activated is essential for reprocessing old memories,
reflecting on new relational experiences created in the therapeutic
work, and developing a new, healthier, more positive narrative about
self and relationships. The client has to bring up personally relevant
material and then be given the support or scaffolding by the therapist
to stay in this mental work space and in their bodies in order to
connect old thinking to new experiences and then to reflect enough
to begin to make new meaning, to update old self-referential beliefs.
This involves getting the MPFC up and running and keeping

it ‘on’ so that the client can do the integrative and reflective work
that is necessary to re-evaluate and ‘revalue’ the self in light of adult
capacities for making sense and in light of new experiences gained
in the therapeutic setting. In an important way, this is uniquely adult
work that requires an adult brain because in children, the default mode
network is still under development and it is very hard for most children
to engage this system fully and keep it on for self-directed, mindful,
reflective work.
Part II
PESSO BOYDEN SYSTEM

PSYCHOMOTOR AS A
THERAPEUTIC SYSTEM
91
Chapter 4
PESSO BOYDEN SYSTEM

PSYCHOMOTOR
THERAPY (PBSP)
An Innovative Psychotherapy
Petra Winnette
In their book Systems of Psychotherapy: A Transtheoretical Analysis, James

Prochaska and John Norcross (1999) present a model for comparing
methods of psychotherapy. We will use this model to look at the
elements of PBSP and place PBSP in the wider context of other
therapeutic methods. For practical purposes we apply an adapted
version of the scheme used by the authors. Drawing on Prochaska and
Norcross, we describe our therapeutic model in terms of its:
• authors, biography and development of the system
• theoretical background
• therapeutic content
• therapeutic process
• critical points.
(based on Prochaska and Norcross 1999)
(Critical points, research and future directions for PBSP are discussed
in the Appendix.)
93
The authors and the evolution of PBSP

Beginnings
Albert Pesso and Diane Boyden-Pesso were both born in 1929. Their
childhoods were quite different. Pesso was the youngest child of nine
in a Jewish family, which came to the United States from the former
Yugoslavia. He fell in love with working on the body. First he did body
building and later was inspired by the Greek ideal of a physically and
mentally developed personality. He discovered dance at the age of
seventeen. He dedicated his early career to the world of theatre and
art. Pesso studied dance with several famous dancers including Martha
Graham. Later he received a scholarship to Bennington College.
There he met his dance partner, lifelong partner and co-worker in the
exploration and development of PBSP, Diane Boyden.
Diane was the oldest girl in a middle-class Protestant family.
Both her parents were oriented towards art. Her father wanted to be
an artist. Her mother was a concert pianist and little Diane loved to
improvise dance performances to her mother’s playing. At the age of five
she decided to be a dancer. She studied ballet in Boston with Harriet
Hoctor and occasionally with Russian ballet stars. At age fourteen she
started the Boyden School of Dance. She got a scholarship to attend
Bennington College. There she met her future husband, kindred dance
spirit and congenial soul in developing PBSP – Albert Pesso.
The Pessos married and established their life in New York. They
both developed careers as professional dancers. However, after their
first daughter, Tana, was born they decided to have a larger family
and their careers had to change. They left active professional dance,
moved to Massachusetts and started a school of dance. These were
not easy years for them. But their fate was waiting for them and it
was hidden somewhere they did not expect. In the course of teaching
dance, the Pessos began to experiment with expressing feelings and
communicating them to others through movement. In the process
of training they explored the impact of different types of movement
on the dancers and those watching them. This led to the formulation
of three basic types of movement: reflexive, voluntary and emotional
(Howe 1991; Pesso and Boyden-Pesso 2012b).
Pesso Boyden System Psychomotor Therapy (PBSP) 95
Three modalities of movement

Reflexive movement is described as movement which the body does
without a person’s conscious involvement. For instance, the body
adjusts in order to ensure balance. Voluntary movement is defined as
movement led by a person’s conscious, co-ordinated will. For instance,
the person reaches to pick up an object. Emotional movement,
according to the Pessos, relates to one’s inner state and expresses needs
and affects. For instance, a person spontaneously puts his hands on his
face when feeling overwhelming shame.
The Pessos continued to experiment and teach students exercises
which more and more included their interesting discoveries. Some of
these exercises are still used in PBSP therapy trainings (Howe 1991;
Pesso 2004; Pesso, Boyden-Pesso and Vrtbovska 2009).
From dance to psychotherapy

The first ‘structure’ happened during a body-based improvisation
on emotionally charged topics. Diane was doing an exercise and
remembered her grandfather’s funeral. She felt angry and expressed
it in movement. Albert reacted to this and asked another student to
stand there and receive her anger. He intended that Diane would feel
her anger had an effect. She moved and directed her anger towards
the person. At this point she realised she was angry at her father. Later
when she reflected on that astonishing experience, she realised she
was angry her father did not behave differently at the funeral. She was
angry as a child and felt angry when she remembered the funeral
again as an adult. After the exercise, she felt unsatisfied and still angry.
The Pessos wanted to change the outcome of the exercise. They
decided to have two figures respond to Diane. One figure represented
her real father so she could express her anger towards him. The other
figure was an ideal father figure! This figure did for her what she
needed and wanted her father to do when she was a child at her
grandfather’s funeral. Diane’s feelings changed dramatically. The
second exercise was wonderfully satisfying. She felt calm and content
afterwards. This was an enlightening discovery and it was to become
a core principle in the therapeutic method, PBSP (Howe 1991; Pesso
et al. 2009).
Therapy
In the sixties the Pessos became fully absorbed in developing their
model of therapy. In 1964 Albert Pesso was invited to use psychomotor
techniques with patients at McLean Hospital, a psychiatric clinic in
Boston. He later used psychomotor techniques in many other clinics and
institutions. Their therapeutic model became known as Psychomotor
Psychotherapy. In 1969 after the first new practitioners had been
trained by the Pessos, it was a natural step to establish an institute
devoted to teaching and presenting Psychomotor Psychotherapy.
Since its inception the therapeutic system has continued to evolve
and be refined. Later it was officially named Pesso Boyden System
Psychomotor (PBSP).
Eighties until now

For 50 years Albert Pesso was developing PBSP, teaching, training,
speaking at conferences and introducing PBSP to new audiences
around the world. Diane Boyden-Pesso was his collaborative
partner in PBSP until she retired. Albert Pesso trained hundreds of
students in PBSP and influenced practitioners around the world. PBSP
is now used as a therapeutic model in the United States, Holland,
Belgium, Norway, Switzerland, Germany, Israel, Denmark, the
Czech Republic, the UK, and Portugal. The Pessos were co-founders
of PBSP, a registered trademark. Albert Pesso had been president of
the Psychomotor Institute, Inc. since 1971. In 2012 he received a
Lifetime Achievement Award from the United States Association
for Body Psychotherapy (Pesso and Boyden-Pesso 2012b). Diane
Boyden-Pesso died on 4 March 2016 in Boston and Albert Pesso died
soon after on 19 May 2016 in Boston.
PBSP theoretical background

The evolution of PBSP theory
Psychotherapeutic systems typically include a model for understanding
human behaviour, pathology and the mechanisms of change induced by
the system. This model may include a theory of personality development
(Norcross 1985). Without a comprehensive theoretical framework,
the therapist will randomly gather bits and pieces of information
from sessions with a client (Prochaska and Norcross 1999). Theory
provides a frame of reference, organises and prioritises information

and guides the therapist’s thinking and exploration with the client.
In the course of working for decades and seeing thousands of adult
clients, the Pessos formulated the core theoretical principles of PBSP.
David E. Cooper from Northern Michigan University wrote in 1996
that through extensive practice the Pessos derived a coherent method
based on ‘practical wisdom’ (Cooper 1996). Pesso often commented on
the creative and evolving nature of his method: ‘PBSP is an ongoing,
working laboratory. After I have used a technique or a therapeutic
intervention a hundred times and it then shows surfacing principles, it
is incorporated into the theory’ (Pesso et al. 2009, p.16).
Theory of personality
Expecting happiness
Albert Pesso always said in his trainings and workshops, ‘We are
born to be able to be happy in an imperfect world, that is endlessly
unfolding, and we are the local agents of that cosmological unfolding’
(see Chapter 10). Happiness and the desire to establish balance in life
are the basic tenets of PBSP. It means that human beings are essentially
built to enjoy living. It is genetically pre-programmed. This idea
resonates with the idea of John Bowlby that babies are born with a
genetically based expectation that they will live satisfying, meaningful
lives, connected to others.
In PBSP happiness is a quality of life experienced by a harmoniously
developed personality. It is a coherent state of mind and body which
includes satisfaction, connectedness with others and a meaningful life
as a whole.
Unhappiness is defined as a state of mind and body which involves
frustration, isolation and lack of meaning in life. As we discussed
in Chapters 1–3, current scientific findings support the theory of
a genetic program which needs to be nurtured in the right way for
optimal development.
Stress caused by traumatic experiences of neglect and abuse
damages brain architecture and the whole mind–body system. We have
mentioned research in epigenetics which shows that stress may actually
change gene expression. Studies on trauma and development show
that severe trauma, which happens on an interpersonal relational level,
can negatively influence genes which affect social and psychological
resilience (Krystal 1988). ‘Healthy development can be derailed by

excessive or prolonged activation of stress response systems in the
body and the brain’ (National Scientific Council on the Developing
Child 2005/2014, p.1).
Five basic developmental needs

During therapy clients told the Pessos over and over again what
they had missed and longed for ever since childhood. The clients
wanted good, loving parents, who would be dedicated to them.
Their parents would interact with them in a sensitive way that felt
right and give them what they needed when they were young,
vulnerable and developing. Based on these descriptions, the Pessos
proposed five basic developmental needs. These needs could only be
fulfilled in interaction with ‘the other’. When a parent is available and
responsive, parent and child can attune to each other and together
experience pleasure and relief from stress. Through arousal and stress
modulation from interaction and pleasurable soothing, they connect
and further develop their relationship (Howe et al. 1999). If a child
is severely neglected, it might lead to his death or severe impairment
of his development. Significant and repeated deficits in satisfaction of
basic developmental needs is likely to have a dramatic impact on the
child’s functioning which continues into his adult years. Such deficits
prevent the child, and later the adult, from realising his potential and
becoming his true self. We give specific examples of the effects of
trauma and deficits in the chapters about clients.
The five basic developmental needs defined in PBSP are:
• place
• nurture
• support
• protection
• limits.
We can look at this list of developmental needs as metaphors for what
good parents provide for a child. In other words, a child needs to
experience through parental care a literal and emotional sense of the
five aspects above. We will describe these in more detail below.
Place
‘Need for place’ is a metaphor for a sense of belonging and a sense of
having a right to exist and be loved and accepted without condition.
Without ‘place’ there is no possibility of living in the body and in
the world. In an ideal situation parents provide their child with a
wonderful place in their lives, hearts and minds. A child’s sense of self
develops from his caregivers’ inner picture of him and interaction with
him. When a parent or caregiver sees the child as lovable, important,
competent and interesting, the child feels these feelings inside himself.
It makes a big difference in a child’s life if he develops a sense of
belonging somewhere with someone and ‘being a good person’
(Vrtbovska 2010). The first years of life have a profound impact on
the development of the sense of self. A child develops and internalises
his sense of identity over time (Bowlby 1988a).
According to PBSP, people who grew up with deficits in satisfaction
of their need for place suffer specific consequences. When they come
to the therapy, they report that they feel like strangers. They feel they
do not fit anywhere, like they ‘come from Mars’, and do not belong
here. They might be wanderers, who travel from place to place and
never settle down and develop roots. They keep looking for someone,
something or somewhere to fulfil their need for place.
Nurture
‘Nurture’ means caring for a child’s needs which sustain health and life
such as nursing, feeding, grooming, washing and touch. An infant is
unable to feed himself and satisfy other needs. He must have a caring,
loving person to provide for him. It is important that needs are met in
a soothing, affectionate way as physical and emotional needs are met
in the same interaction. In later years nurturing includes more verbal
and symbolic expressions such as giving strokes, valuing, appreciating
or admiring in addition to joyful togetherness and sharing fun. It
also includes intellectual ‘food’ such as reading stories and explaining
the world. Clients who have deficits in getting their childhood need
for nurture met often feel ‘bottomless’ or empty. They try to fill the
emptiness with material objects and shallow relationships, but they are
never satisfied for long.
Support
In the early years, parents’ arms and laps provide literal support for
the child so he can physically balance. They also emotionally support
him with smiles and encouragement. When the child explores the
world, undergoes his fast development and is stressed by difficulties
and disappointments, parents give reassurance. Support meets a need
for assistance with activities and development. It is the parent’s task
to be available and help the child regulate stress, feel safe and cope
with challenges. They are ‘behind him’ when he needs their strength
and guidance. Through years of physical, emotional and intellectual
support, healthy parents help their child feel that difficulties and
obstacles can be challenged and overcome. This way the child’s internal
programme will include a sense of mastery and self-confidence.
Lack of support during development negatively influences a child’s
sense of being capable and efficient. Clients might report that they feel
inadequate and doubt their abilities. They feel incompetent, not good
enough, and have difficulty undertaking challenges. Such clients often
talk about feeling tired and having no one to lean on.
Protection
Protection means keeping a child safe from harm. A baby is vulnerable
and defenceless. His safety and survival is completely in the hands
of others. Parents defend a child’s vulnerability, providing a shield
between him and possible harm such as bad people, a dangerous dog,
sharp objects, and so forth. In later years this includes teaching a child
how to behave safely. It includes acting on the child’s behalf when he
is at risk of having his rights violated or being hurt emotionally. When
the child is anxious or afraid, it is the parents’ job to restore his sense of
safety. According to PBSP, when there was a deficit in protection during
early developmental stages, the adult client often suffers from anxiety
and fear and feels unsafe in everyday situations. He may be unable to
protect or take care of himself in relationships and in the world.
Limits
The Pessos state that providing limits means helping a child safely
deal with his inner energies, impulses and affects (Pesso et al. 2009).
It is the parents’ role to set flexible, firm and clear limits. This needs
to be done in a loving and accepting way. Again, emotional needs are

met in the context of meeting other needs, including setting limits.
Parents set physical limits to keep a child from harming himself,
others or valuable objects. Later, limits are also expressed verbally.
Gradually the child learns about limits in society as defined by laws,
rules and customs. If parents set limits with love and acceptance, the
child develops a comfortable sense of limitations and boundaries.
The child learns to be comfortable with authority and recognises
the rights of others. If limits are not set in a clear, fair, loving and
consistent way, the child develops a distorted idea of himself. He
may not respect the rights of others, have difficulty controlling his
own affect and behaviour, mistrust authority, and feel entitled to do
whatever he wants. According to PBSP, the client will develop a sense
of omnipotence and difficulty regulating aggression and sexuality.
When parents set clear and adequate limits in accepting and loving
ways, the child’s brain develops ways to regulate arousal related to
disappointment and frustration. Young children do not have the
capacity to understand, name and regulate what is happening inside
of them. If the caregivers are consistent, give clear responses to the
child’s behaviours, and are engaging, it creates the capacity for affect
regulation (Beeghly and Cicchetti 1996).
The four developmental tasks in PBSP:

Integration of polarities and development of
consciousness, the pilot and uniqueness
The Pessos defined four developmental tasks which need to be
completed in order to have a fully developed personality. If any of these
tasks are unrealised or compromised through poor upbringing, the
individual will have difficulty achieving satisfactory functioning
in the world. Children need the help of their parents to complete
these tasks.
Integration of polarities
PBSP theory states that it is important for development to be aware of
given polarities and to integrate them into a cohesive, balanced state
of mind. Examples of this are the separate functions of the left and
right hemispheres in the brain or differences in male and female genders.
Through good parenting the child can develop a good balance.

According to the Pessos, a client who did not complete this part of
development may have specific difficulties in this area, for instance, in
balancing female and male qualities in his personality, or he may feel
confused by conflicts between his emotions and his logical, practical
ways of thinking.
Development of consciousness
The phenomena of consciousness is widely discussed and science
does not have enough material to describe it yet. There are different
approaches to it.
Consciousness is the process of creating a model of the world
using multiple feedback loops in various parameters. (Kaku
2015, p.43)
Consciousness in PBSP theory includes two elements: being aware
of something and being aware of a meaning associated with it. A
child’s consciousness develops in close connection with his parents.
The child’s grasp of reality depends on how his parents see it and how
they present it to him. They name things and give meaning to them,
including the child himself. They name the child’s feelings and states
of mind, and form his understanding of people and the world. In
this way the existence and meaning of himself, others, the world and
the universe is established. We need to internalise a positive, coherent
sense of self and an internal map which is realistic and adaptive for
living in our environment.
Development of the pilot

‘The pilot’ is a term used in PBSP to describe the fundamental mental
function of co-ordination of emotional, sensory, motor and cognitive
processes. In neurobiological terms, ‘the pilot’, as the Pessos describe
it, refers to functions performed in the prefrontal cortex. These
functions include the ability to plan and understand ideas and make
logical connections between them. The pilot is engaged throughout
the PBSP therapy session. John Baylin presents a detailed description
of this area of brain functioning in the window to the neurobiology of
change in PBSP therapy at the end of this chapter.
Development of uniqueness
PBSP theory assumes that our genes ‘push us’ to become who we really
are. In other words, under ideal conditions we realise our potential, an
optimal expression of our genetic endowment. Each of us has unique
gifts. We need to learn what they are, how to value them and to enjoy
using them. We are also ‘inspired’ to use our unique way of being to
contribute to the development and well-being of others.
The five developmental needs and four developmental tasks
in PBSP overlap in many ways with Bowlby’s concept of a secure
base. He understood a secure base to be a place where a child can
always return and be sure he will be welcomed, accepted, nourished
emotionally and physically, protected when frightened and reassured
when stressed. Parents create a secure base by being available and
assisting or acting whenever the child needs them (Bowlby 1988a).
Good care in PBSP

The ongoing process of interaction
In PBSP theory the Pessos use a diagram to describe the process of
fulfilling developmental needs.
1. Energy 2. Action 3. Interaction 4. Satisfaction (Meaning)
Energy refers to having a need. Action is behaviour to express the
need. Interaction between parent and child leads to satisfaction of the
need. The whole process creates meaning and influences the child’s
sense of self. The process is remembered on many levels and the
memory is used to anticipate the outcome of future interactions (Pesso
et al. 2009). We will later see how this scheme is used in PBSP therapy.
Spitz created a similar diagram in order to explain the arousal–
relaxation cycle in early care-providing interactions. His diagram is
in the form of a circle, which shows how the meaning of good care
becomes stronger with the repetition of good experiences. In his
version, need creates displeasure. When a need is satisfied, the process
builds safety, trust and secure attachment (Spitz 1965). Young children
express their needs and emotions in behaviour. In good caregiving, the
adult is attuned to the child and learns to recognise his needs and states
of mind. Through fulfilment of basic needs in a secure-attachment
relationship, the child develops a collaborative manner of relating to
his parents or caregivers. He does not need to be in control. He can
trust and depend on his caregivers. This attachment helps him regulate
his behaviour throughout childhood (Crittenden and DiLalla 1988).
Shape and counter shape: Parents do the right thing

PBSP theory includes the concept of an ‘ideal counter shape’. ‘Shape’
refers to a need and ‘counter shape’ refers to interaction or objects
which satisfy the need. An ‘ideal’ counter shape provides the ‘optimum
or ideal fulfilment’ of a need. The ideal response which will fulfil a
need is, according to PBSP, pre-programmed in genes. The genetic
program is flexible enough to balance out small and short-term
discrepancies in the way a child is taken care of, but genes ‘look’ for
a response which matches the need the best way and feels right. The
‘fittingness’ is felt inside as something right and unquestionable. The
brain develops fast during the first months after birth. There are only
a few developed areas at first. The brainstem and midbrain are there to
sustain bodily functions and alertness. The infant needs the caregiver to
co-modulate arousal. At this stage only the right hemisphere is active.
The right-hemisphere processes feeling and sensing. As the child
becomes a toddler there is a shift to more left-hemisphere processes
including language, reasoning and planning. With good caregiving
the child gradually develops harmonious, concerted functioning of
the rapidly developing nervous system and brain centres (De Bellis et
al. 2002; Kagan 2003).
Developmental needs must be fulfilled at the right time

According to PBSP, there are responses which satisfy needs in a way
which is optimal for development. As a child develops, his needs
change and the way they need to be satisfied changes too. So responses
must be sensitive to a child’s developmental stage. Every stage requires
shifts in the parents’ approach. If parents treat a two-year-old as if he
were five years old, they may try very hard to do everything right, but
they will not meet the child’s needs adequately.
Neuroscience explains the importance of sensitive caregiving, which
provides the child with optimal interactions according to his age and
stage of development. Cognitive development follows development of
the sense of self, relationship with the other, cause-and-effect schemes
and a sense of managing oneself. If these early phases of development
go right, then later during school age, academic competence becomes

dominant. A safe and regulated child can use his cognitive capacity
and concentrate on exploring, learning and academic tasks (Cook,
Blaustein, et al. 2003).
Developmental needs must be fulfilled in the right way

In PBSP fulfilling needs in the ‘right way’ means ‘as close to ideal as
possible’. If there is good caregiving, short-term stress is recognised and
modulated, the problem is solved and the relationship is interactively
repaired. This way the child develops resilience and biological
flexibility is supported (Champagne and Meaney 2001; Gunnar and
Donzella 2002; Schore 2001).
If a child is abandoned by his biological parents and placed in a
residential unit, there will be a large discrepancy between the care
a loving mother could provide versus what nurses can provide on their
shifts. When the emotional and relational needs of infants and young
children are not adequately fulfilled in the residential care system,
their development will be impaired.
Developmental needs must be fulfilled

in the right kinship relationship
‘It’s hard to be a child, when you don’t have parents,’ says Daniel
Hughes (2012). I have worked with many children who do not live
with their birth parents because they were abandoned, abused and/or
neglected. They all experienced severe trauma from this relationship.
However, the majority of them dream about their biological family.
When I ask them about their biggest wish, I often hear the same
answer: ‘I wish my birth dad and mum would live together and I was
with them.’ We see this phenomenon often in adopted children. Most
of them suffer if they are not able to explore, fill in the information
gaps and have a coherent narrative about their early life. This does
not mean that biological parents are somehow better parents than
adoptive or foster parents, only that many children and adults need to
resolve issues related to a history of loss and abandonment.
We will see later in Chapters 5–7 how some adult clients in
PBSP therapy deal with their history of being abandoned by their
biological parents.
Parents as a secure haven

Mary Ainsworth coined a phrase to refer to a ‘secure base’ for infants:
‘mother as a secure haven’. When an infant shows discomfort, the
mother is available to provide relief. Later when the child is exploring
the world, the mother’s role is extended to a providing a secure base
(Ainsworth, Blehar and Waters 1978). The child returns to her as
needed to re-establish safety, then continues exploration. There seems
to be a biological instinct that draws the child to his attachment
figures whenever he needs them. These relational experiences are
encoded and form an ‘internal working model’ of social interaction
and forming connections throughout life.
Most scientists agree that a good childhood includes good care,
safe attachment and healthy development. The end result is an adult
with a resilient, stable personality, who experiences life as satisfying
and contributes to society (see Chapter 1). We can see that PBSP
theory is congruent with current research and ideas on good parenting
or good care. In PBSP good care means that parents provide care
which is shaped by the age of the child and the situation. It needs to
fit for the child at the given moment. Under the conditions of attuned
and fitting interactions between child and parent, the brain develops
in an optimal way, expressing a child’s unique genetic inheritance
(Cairns 2002).
Hughes and Baylin describe parenting in light of attachment
theory. This model lists five domains of good parenting which are
consistent with the PBSP conception of development. The domains
are (1) parental ability to feel safe and stay open while interacting
with child, (2) experiencing parenting as pleasurable and satisfying,
(3) ability to attune and empathise with the child, (4) ability to make
sense of mutual experiences, and (5) ability to regulate and co-regulate
mental states (Hughes and Baylin 2012).
PBSP defines three motivators: Work, love, justice

The Pessos define three basic motivators for human behaviour:
• Work: ensures survival of the self.
• Love: ensures survival of the other.
• Justice: ensures rightness, order and meaning in the world.
(based on Pesso 2013, p.69)
According to the Pessos, there are three inborn programs which people
follow, although usually we are not aware of it. The first two were
described by Freud and seem to be generally accepted. The Pessos
assume if maturational needs have been fulfilled, the person will
become a happy and productive adult (work) and he will feel a drive to
be useful and contribute to the well-being of others and society (love).
The third endeavour, realising justice, needs further explanation.
Completion and justice in PBSP

A central principle in PBSP is that people want and expect things
to be complete, whole and just. People expect cycles of completion
and when completion is achieved we feel pleasure. When it is not
achieved, we feel displeasure, frustration and anger. If the completion
is postponed indefinitely, we feel depression, despair, and hopelessness
combined with an inclination to seek alternative areas of pleasurable
existence (Pesso 2013).
Most people naturally empathise and sympathise with others.
Experiencing injustice creates, according to the Pessos, intense
emotional reactions. For instance, experiencing or hearing stories of
racism creates reactions which include feelings of frustration, rage, guilt,
shame and the thought that life makes no sense. Experiencing justice, for
instance experiencing or hearing stories of complete and functioning
social networks where people’s needs are met, creates reactions which
include feelings of contentment, hope, pleasure, a sense of rightness,
and the thought that life makes sense. PBSP theory explains that when
a child experiences gaps in family networks or problems in society, it
clashes with his innate sense of justice. Then he unconsciously tries to
‘do’ something for others in real life or in his imagination.
Somehow our brains are cued to be alert to the mental states of others
as we struggle to play a productive role in developing a moral code
in a social group. Somehow it would seem the universally recognised
mechanisms of self-survival have been co-opted and are used to work
in more social settings. Evolution is saving the group, not just the
person, because it would seem that saving the group saves the person.
(Gazzaniga 2005, p.172)
Memory in PBSP
Daniel Siegel wrote, ‘Memory is more than we consciously recall
about events from the past. A broader definition is that memory is
the way past events affect future function. Memory is thus the way the
brain is affected by experience and then subsequently alters its future
responses’ (Siegel 1999, p.24).
As we discussed in Chapters 1 and 2, implicit memory develops
early and encodes emotional states in relation to experiences and
relationships. Explicit memory develops later and encodes episodic
and factual information (i.e. who, what, when, where and how).
Memory encodes both emotional and factual experiences as the person
processes them. These memories are a library of information about
oneself and how to live in the world. They are retrieved, combined
and used to process and comprehend new sensory information and to
simulate the possible future (Kaku 2015).
PBSP describes memories of deficits,

trauma and holes in roles
Pesso describes three categories of memories associated with poor care
and unfulfilled needs. The categories are called memories of deficits,
memories of trauma and memories of holes in roles. These memories
of adverse or damaging experiences, if not healed, will shape the
mental state and behaviour of a person throughout his life. Pesso also
states that these memories determine how the client will perceive the
present and what he is primed to experience in the future.
MEMORY OF DEFICITS
In PBSP memory of deficits means a ‘bank of records’ of unfulfilled
maturational needs. A deficit means one or more basic developmental
needs were not satisfied in the right way, at the right time or in the
right kinship relationship. Severe neglect typically involves repeated
deficits in meeting many of a child’s basic needs.
Deprivation of responsive caregiving caused by maltreatment,
neglect or absence of a significant caregiver can result in lifelong
increased levels of stress and reactivity. Trauma interferes with brain
development, for example, the integration of left and right hemispheres.
Traumatic stress results in changes in neuro-hormonal functioning of
the brain and body (Crittenden 1998; Kagan 2003). Children with an
early trauma history are confused about who they are and what the
meaning is of the world around them. It should be noted here that
severe deficits in caregiving (i.e. neglect) can be described as a form of
trauma and abuse.
MEMORY OF TRAUMA
Memory of trauma is a record of verbal, physical or sexual abuse.
These memories have an impact on the person’s ability to regulate
affect, aggression and sexuality. They disorient the meaning of the self
and one’s sense of safety in the world. The Pessos emphasise that it is
the memory of unresolved trauma which is damaging. Van der Kolk
reflects on new technologies which show the impact of trauma on
the brain:
Since the early 1990s brain-imaging tools have started to show us
what actually happens inside the brains of traumatised people. This
has proven essential to understanding the damage inflicted by trauma
and guided us to formulate entirely new avenues of repair. (van der
Kolk 2014, p.21)
When a parent or caregiver is not available to help a child cope with
overwhelming stress, the psyche may protect itself by applying a
mechanism called dissociation. Dissociation is automatic and helps
to deal with unbearable trauma. It is a failure to integrate experience
or information in an expectable fashion (Putnam 1997). In the case of
developmental trauma, it can be a state of mind which the child or adult
re-creates whenever they feel stressed. It reduces one’s ability to learn
or connect with other people. Later in the book we see the client,
Emma, experience dissociation in her first PBSP session.
MEMORY OF HOLES IN ROLES

PBSP describes another type of ‘bad’ memories, the memory of holes
in roles. When a child experiences gaps, injustice or unhappiness in
his family network, it triggers his compassion and he has impulses to
repair the situation. Children who hear about relatives in concentration
camps experience a hole in role when they imagine their relatives in
trouble. James Wilson, political scientist from Harvard and later UCLA,
argues that there are universal moral and justice-related instincts which
are not learnt. The highest instincts reflect those actions commonly
understood in most societies as wrong: murder and incest, abandoning

children, breaking promises and lying (Wilson 1993). Brain imaging
research shows how when we consider moral issues the emotional
parts of the brain are active automatically, which may predict the
moral and justice-related response (Gazzaniga 2005).
PBSP theory suggests that memories of filling holes in roles have
a significant impact on people. When a child unconsciously takes the
role of ‘healer’ or provider, this view of himself and the world will
persist and affect his relationships and sense of self later in life. He feels
‘omnipotent’, as if he is the ‘only one’ who can ‘save the world’ (Pesso
2013; Pesso et al. 2009) Often he cannot receive help or support or
depend on others in a healthy way.
Autonomy: An independent life

Autonomy is a desired stage of development. It only develops in a
healthy way when a child has been through a stage of benign and
satisfying dependency with good parental figures (Bowlby 1969).
PBSP believes healthy autonomy develops gradually. It is important
that the basic developmental needs are satisfied so the whole complex
personality can grow and mature at the right time in close, loving
relationships with parents and a wider network of extended family
and society. In this way one has a chance to become who one really
is: a unique personality, happy in life, work and parenting. How does
a person succeed in having his own independent life? It will depend
on his genetic inheritance and a long chain of experiences gained in
childhood and early life. Is the person going to be safe and productive
in an autonomous life? Or will he relive traumatic patterns from
childhood and have difficulty functioning as an independent adult
in work and relationships? The equation of nature + nurture is now
going to be lived (Pesso 1994, 2004, 2005; Pesso and Boyden-Pesso
2012d; Pesso et al. 2009; Winnette 2015).
The therapeutic content of PBSP

Norcross and Prochaska define the content of therapy as ‘what’ needs
to be changed. The process of therapy refers to how the change
is facilitated.
The therapeutic content of PBSP: To

change the impact of memories of
deficits, trauma and holes in roles
Most people experience times of happiness and times of difficulties or
crisis. But there are people who are unhappy and in crisis most of the
time. Why is that? Pesso sees happiness as the result of a successfully
handled maturational process. According to PBSP, unhappiness
comes from memories of frustration of basic needs during our
developing years:
That is why when life fails to provide that innately-anticipated
outcome we are deeply disappointed and feel cheated out of a
fundamental right. Do we then give up that longing for satisfaction
of those deepest desires and hopes? Not very easily. Though we may
have endured a lifetime of being unhappy, we are under a never-
ending pressure from a remembered (although unrecognised) needy
child-self to complete and satisfy our maturational needs. Because it
is the necessary foundation for the experience of happiness. (Pesso
2013, p.63)
A new memory: Integration of experiences with

good care and satisfaction of developmental needs
PBSP therapy focuses on changing the impact of traumatic memories.
In PBSP we recall memories associated with deficits, trauma and
holes in roles. Then, in this context, we have experiences which reverse
those traumatic events so that we create memories of what it is like to
have our developmental needs met. The content of PBSP therapy is
an experience of good care, satisfaction of developmental needs, and
a safe attachment relationship created in the session and integrated in
the client’s psyche.
The circle of need fulfilment

We mentioned before that the Pessos use a diagram to show how
needs are fulfilled through interaction.
1. Energy 2. Action 3. Interaction 4. Satisfaction (Meaning)
We can imagine this process as a circle of interaction, as shown in

Figure 4.1 (adapted from Erikson 1950; Fahlberg 1991; Pesso 2011a;
Spitz 1965).
Figure 4.1 Circle of interactions
These circles of developmental social interaction and need fulfilment

are embedded as memories. The client’s brain uses them as patterns
or internal models for future emotional appraisal and behaviour. If
a child’s needs are met in a sensitive, caring way, the memory of
satisfaction will be positive and build up trust, secure attachment,
safety and a positive sense of self (Spitz 1965). If there are problems
in caregiving, such as neglect, disruptive behaviour, rejection or
shaming interaction, the child will experience stress, isolation, feeling
worthless and a negative sense of self (Fahlberg 1991). In the case of
developmental trauma, the client’s memory contains strongly wired
connections for circles of interaction which ended in shame, fear and
isolation. It also creates a negative sense of self. When the client faces
similar situations in the future, thoughts and feelings from the past are
retrieved from memory and affect how he responds. He may react very
strongly to a minor situation and be puzzled by the intensity of his
response, for example.
The circle of need fulfilment in PBSP therapy

When a client with developmental trauma issues comes to therapy,
he brings with him the memory of unfulfilled needs, and adverse
experiences when trying to get his needs met. He often describes
his frustration and helplessness in relation to his needs and his failed
attempts to satisfy them. The content of PBSP therapy can be expressed
using the model of the circle of need fulfilment.
1. A client expresses frustration and pain related to his current life.
2. The therapist helps him see how his frustration and unsatisfied
needs today relate to his childhood. The client recalls concrete
situations and re-experiences the old emotions.
3. The client is encouraged to reverse the memory of the old,
negative circle by imagining getting his needs met in childhood
in an ideal, positive interaction with an ideal caregiver or parent.
4. This way the client, using his imagination, experiences a new
circle, a circle of good care. He experiences satisfaction in
connection with a safe caregiver or parent. He integrates the
meaning of the whole process including feeling safe, worthy,
connected, and good about himself.
The process and its meaning are encoded in the memory as a new
experience.
The experience with the positive scenario repairs the encoded
meaning of the old, negative circle and bad scenario. The client’s
internal model and expectations shift in a positive direction.
New memory
In Chapter 3 we explored one of Paul’s traumatic memories. When I
worked with Paul in one of his structures, we revisited his old, painful
memory of sliding on a sled and getting into trouble with his mother.
He was convinced that the story illustrates what a difficult and bad boy
he was. He gave me that story as an evidence for his bad and shameful
sense of himself.
In the structure he was asked to imagine what the situation would
be like if he had a new, ‘ideal’ mother with him at age two. He was
encouraged to imagine what she would do that would exactly fit what
he needed to experience at that time. He imagined experiencing the

following scenario.
PAUL AND HIS IDEAL MOTHER

Paul imagines sledding with his ideal mother when he is three years
old. The ideal mother would take him outside. She would understand
he is a very young boy, who will not just sit and wait for her without
taking action. She would go with him. They would sit on the sled
together and go down the street. Yippee! What fun! His ideal mother
would have gone with him! Paul feels how much joy he would have
had. He would have jumped in the snow. He would have used all his
energy and his mother would have loved it. He wants to experience
limits too. They would have walked hand in hand. If there was a car,
his ideal mother would hold him in her arms. She would tell him, ‘We
must be careful around cars, you know. Keep close to me and I will
protect you.’ He understands he cannot jump and slide when a car is
coming. He can regulate his impulsiveness because he is connected
with his ideal mother. He feels connected and good inside.
The results of ‘new memories’

Paul experienced a new positive circle of interaction. When Paul was
experiencing this imaginary scene between himself and his ideal
mother in the structure, he was smiling. He enjoyed this possibility.
It is so different from the original, the real one. Paul now has two
different recordings of the same situation. One is the real one from
his childhood. Now it is matched with a new, opposite memory which
has interesting effects. In his imagined situation he received positive
interaction and good care from a sensitive ideal mother. He felt good
and happily connected to her. He felt good about himself. He was a
good boy. It feels right to him. It is how life should have been. In this
way his early unmet needs can be met and his longing for love and a
place in his parent’s heart can be fulfilled (van der Kolk 2014).
A structure provides clients with simulated experiences of growing

up in an attuned, affectionate, ideal family, where they are protected,
supported, loved. Client and therapist create this scene together so
that it fits with the client’s deepest wishes and unique personality. A
reversal is designed to be a convincing alternative to the old traumatic
events. The client remembers the process and the relief gained in the
session. His life continues in not quite the same way. Something has
changed. He has experienced and remembers how it feels to have a
better childhood and attuned parental care. It is assumed that change

occurs when the new ‘memory record’ is used by his psyche to assess
present events. The client experiences himself and the world more in
line with how he would have experienced it if he had been raised with
good care as a child (Pesso 2011a, 2011b; Pesso and Boyden-Pesso
2012a, 2012c, 2012d).
PBSP therapeutic process

Experiencing good care in the past
When the client re-lives the old trauma as real and actual, here
and now, the healing has to involve reaching its roots in the past and
provide healing in terms of the past (Freud 1914).
The question is widely discussed as to whether the internal
working model established in childhood can change and if so, how
this can be accomplished. Science explains that the brain changes
every time a new experience is encoded. This way mental models
change throughout the life span. At the same time, how we experience
and record a new event is shaped by our memory of prior events
(Goldberg 2000). A central issue for most models of psychotherapy is
how to create new, positive experiences which have a lasting impact.
Many adults who come to therapy were mistreated in childhood.
In their families they felt unwanted, unsafe and unworthy of love.
They internalised a sense of themselves as ‘bad’. They may be
outwardly successful with a career and other accomplishments, but
inside they are struggling. Often they are treated for symptoms such
as anxiety, depression, sleep disorders, eating disorders, relationship
problems. A treatment method may not consider the role of childhood
experiences in current symptoms or may not address these issues
effectively. Thus, the original imprint of parents who looked at them
with hatred or did not see them at all never fades. Such clients hide in
dark caves. They still think they are rubbish or wish they had never
been born. Often these clients show limited benefit from traditional
therapies based on talking (Herman et al. 1989).
As we discussed in Chapters 1–3, the brain develops in stages over
time. When trauma happens, how severe it is, with whom it happens,
how often and for how long are all factors which determine which
structures and functions in the brain will be affected and how severely.
This difference in trauma history and later functioning is illustrated
in our comparison of the clients, Clara and Paul. Early trauma in a

caregiving relationship often results in a disorganised-disoriented
attachment style. If this is not treated in childhood, it appears likely
that such an adult will have difficulties in relationships as his approach
will mirror his early, trauma-related style of relating to people.
If trauma occurs in the first thirty months of life, it is encoded as
feelings and sensations without an explicit context (who, what, when,
where, why and how). Staying mainly on a verbal, intellectual level
in therapy is unlikely to have much impact on memories stored in this
way. The Pessos discovered interventions which combine talking with
bodily and emotional experiences. In a PBSP session the client is in
a feeling state of mind and experiences imaginary scenes which are
dramatised and felt. The ultimate goal is to have the client taste what it
would have been like to have had a benign and happy past with good
and safe parents (Scarf 2004).
The structure is a miniature of the

whole therapeutic process
Every PBSP session deals with one or more of the client’s issues. It
addresses traumatic experiences from childhood and completes their
repair. The therapeutic process is congruent with factors shared by
most therapeutic systems as summarised by Prochaska and Norcross.
We will explain the process in PBSP using the following factors:
• positive expectations
• therapeutic relationship
• attention
• exploration of the inner world
• enhancing consciousness
• realisation of the therapeutic content
• corrective experience and therapeutic change
• integration.
(adapted from Prochaska and Norcross 1999)
Each of the elements above is realised in every structure. This does not
mean treatment is necessarily complete in one session. One session
may complete a particular issue for a client, but in many cases healing
requires a series of structures.
The process of a structure

Positive expectations
CONTRACT
Pesso recommends doing an introductory session at the start of
therapy. The therapist can assess the nature of the client’s problems
and explain the theoretical background and principles of PBSP. This
way there is a clear contract about how therapy will proceed. If PBSP
is done in a group setting, the contract includes every group member.
In addition, they are instructed about role playing and what to do
when observing another client doing a structure. The client is given
responsibility for a ‘good end’ to a structure and the therapist is
responsible for facilitating this outcome.
This aspect of the contract is believed to enhance the client’s
consciousness and motivate the client to take an active role in seeking
a better way of being. A client may bring a specific issue or topic that
he wants to address. This is not required, however, as issues often arise
spontaneously and take their own direction as the structure unfolds.
Therapeutic relationship
POSSIBILITY SPHERE
The role of the therapist in PBSP distinguishes this approach from
traditional relational therapies. The therapist establishes a positive,
collaborative relationship with the client. But the relationship between
client and therapist alone is not considered sufficient for change to
occur. Change takes place as a result of an imagined, ideal interaction
in the past. The therapist establishes a safe, open environment called
the ‘possibility sphere’, where the client can be himself and try new
possibilities. The possibility sphere includes the present, here and now,
as well as the past that the client wants to explore. The therapist’s
role is to serve as a facilitator, scene organiser, teacher and coach.
The therapist uses his insight, intuition and theoretical knowledge in
service of the client.
THE RITUAL CHARACTER OF A STRUCTURE

The therapist leads the structure with dignity, respect and understanding
of the meaning of the client’s inner processes. He treats the client
with genuine respect for life and truth. Rituals in most cultures create
emotional learning through the experience of a new, special way of
being and connection with our true selves. When Native Americans
gather in a circle for prayer, it is related to the deep meaning of
the circle. ‘There is no need to hold hands because we know it is
enough to stand in the circle, already joined together, inextricably
bound, through the earth which lies beneath our feet, the earth who
is, after all, the true mother of each of us’ (Kidwell, Noley and Tinker
2001, p.50).
Attention
MICRO-TRACKING: WITNESS FIGURE AND VOICE FIGURE
Micro-tracking is a PBSP term for a technique which helps the client
be aware of his emotions as they arise in the context of his thoughts
and memories. The therapist uses an imagined figure in the air, called
‘the witness’, to name the client’s emotions as he experiences them
in the room. The therapist speaks for the witness figure and names
the client’s feelings in the context of his story. For example: ‘A witness
would say, “I see how sad you are when you think of your mother, who
died.”’ He also uses an imagined figure called ‘the voice’. The voice
figure is used when the client makes a statement about how he finds the
world to be, for example, ‘You can’t trust anyone.’ The therapist speaks
for the imaginary ‘voice figure’ and repeats the client’s statement out
loud to the client in the form of a command, ‘That’s a voice; it says,
“You can’t trust anyone.”’ This serves to make the client aware of the
messages which, usually unconsciously, direct his thoughts, feelings
and behaviour. Micro-tracking creates an intense, intersubjective
experience between client and therapist. The client feels seen, heard
and accepted in a way that is uncommon in everyday life. The client
feels valued just the way he is and this facilitates safety to open up
his memories.
Exploration of the inner world

REMEMBERING AND PLACEHOLDERS
The client speaks and the therapist uses micro-tracking to identify
his thoughts and feelings. When the client mentions a person, place
or topic and there seems to be significant emotion associated with it,
the therapist asks the client to choose an object to represent all the
qualities of that person, place or topic. When the client selects an
object from a basket containing seashells, stones, pieces of fabric or
wood, and such like, the object is ‘enrolled’ to represent the person and
is placed on a table or on the floor. The objects are called placeholders.
Often many placeholders are used in a session. This way persons
and significant topics that are on the client’s mind are represented
in physical space and both client and therapist can see them, refer to
them and make connections between them during the session. Place
holders externalise and map the client’s view of the world.
CONTACT FIGURE
Clients with developmental trauma may experience strong affect and
dissociative states in therapy when traumatic memories are triggered
by thinking and talking about people in the clients’ past. This often
happens when they put a placeholder on the table or on the floor.
When a client is overwhelmed by emotion, PBSP uses two techniques
to help him regulate his affect. The therapist continues micro-tracking,
so the client’s state of mind is named and accepted, and the therapist
offers an imaginary ‘contact figure’. In a group setting the client is
given the option to choose a group member to role play a contact
figure. Otherwise, he may use an object, such as a blanket, or have an
imaginary figure in the air take this role. The choice is up to him. The
client places the contact figure in collaboration with the therapist.
The client can have physical contact with the contact figure and ask
it to say certain words to him, for instance, ‘With me you can feel all
your feelings. I will be with you when you feel so much.’ This way the
client regulates his affect through interaction and he is never left alone
when he is in distress. The contact and regulation happens exactly
according to his needs as he asks for certain things and the therapist
suggests possibilities which are likely to be beneficial.
Enhancing consciousness
PRINCIPLES AND LINKAGES
Sometimes the client links qualities of his parents or other childhood
figures with people in his current life. When the therapist realises the
client is projecting or linking present people with people from his
past, he will say, ‘That is a principle of [for example] your ideal father
which you unknowingly placed on your boss.’ The therapist suggests
that the client use a piece of paper to represent this principle. The
paper (principle) is then placed on the placeholder for the person who
is the object of the projection. This technique is shown in the chapters
in Part II.
TEACHING
When the client explores his inner processes and meanings, the
therapist can offer insight, make connections or teach using theory.
Realisation of the therapeutic content

REVERSALS WITH IDEAL FIGURES
Memories of emotion are saved in implicit memory in the right
hemisphere. These memories are triggered when current events are
seen as associated with past events in some way. The emotional
memories are used to process the new situation and co-create its
meaning (Vrtbovska 2007).
Thus, to make sense of new events we use memories of what we
have already experienced. The client may begin by talking about a
current distressing situation, then recall situations in the past which
appear similar and generate a similar emotional response. If the client
is re-living and reinforcing old, painful memories, the therapist will
suggest that the client do a reversal of the negative experience. The
therapist outlines an ideal figure who will give the client what they
need now to feel safe and handle their feelings. Then the therapist will
assist the client to imagine an ideal figure who does what the client
needed as a child so the original negative event would never happen
or so the client as a child would be assisted to handle the event when
it did happen. It is important that the client uses his imagination to
experience what it might have felt like to have this very opposite and
positive outcome when he was a child. It is hypothesised that this
process may establish connections with the early emotional memories,

which are so strong and distressing, and reduce their intensity and their
effect on current functioning. The content of the reversal depends on
the needs and wishes of the client and the judgement of the therapist as
to what is beneficial. A reversal always involves ideal interaction with
an ideal figure or figures. Typically, the client experiences great relief
from their distress after a reversal. Then the therapist continues micro-
tracking, using placeholders and facilitating reversals for persons or
events that caused the client pain, distress or trauma in childhood. The
case studies in Part III offer many examples of reversals.
USING THE ‘PILOT’

The client is in a ‘childhood state of mind’ as he remembers events
and re-experiences emotions associated with his history. The therapist
follows the client, explores insights and assists the client in recognising
what he needed in the past. He helps the client decide what his ideal
figures should say or do for him as a child in the past to reverse the
injury or loss he had experienced. Here the client makes connections
in a childhood state of mind, at an emotional level. At the same time,
the client relates and talks to the therapist on an adult level. When he
processes the experience with insight and conscious understanding
it is called ‘using his pilot’. Jon Baylin discusses the ‘pilot function’
in PBSP therapy in his fourth window on neurobiology later in
this chapter.
INTERACTING WITH IDEAL PARENTS

The client chooses the form his ideal figures will take. In a group
setting he can choose one or more group members to role play ideal
figures. In a one-to-one setting the client can imagine ideal figures or
choose objects in the room to represent them. The client is supported in
positioning his ideal figures in order to organise a scene which can best
meet his needs. The therapist makes sure the process helps the client
experience a new, positive possibility of a good care. It is important
that the client does not unknowingly re-create a traumatising scene.
The therapist never takes the role of an ideal figure. The therapist stays
in the role of coach and assistant. However, the therapist does ‘speak’
as the voice of the ideal figure when role players are not used. For
example, a client felt anxious with his real mother. Now in a structure
the therapist says the words the client needs to hear from his ideal
mother. ‘If I was with you, when you were a child, you would have
felt safe with me.’ He uses the client’s own words, when possible, to
increase the fit with the client’s wishes for the ideal interaction.
Corrective experience and therapeutic change

A NEW, IMAGINARY EXPERIENCE OF AN IDEAL CHILDHOOD
The client accepts new ideal figures (most often ideal parents) who
would have treated him according to his needs and had a safe, loving
relationship with him. The client explores the new possibility in his
mind. He imagines it is happening in his childhood. He often has a
strong emotional reaction to this and shares his experience with the
therapist. The therapist can offer insights and make connections based
on the client’s shared thoughts and feelings related to his childhood
memories. He focuses on the client’s insights and does not impose his
own ideas or interpretations.
GOOD END
In his mind the client develops a new, positive experience which provides
satisfaction of his childhood needs in a healthy, safe attachment with
ideal parents. The client experiences this new possibility as if he were
a child when it takes place and remembers how it would have felt for
him to have it as a child. This way (in PBSP terminology) the client
experiences the place, nurture, support, protection and limits (the
five basic developmental needs we discussed earlier in this chapter)
in interaction with his ideal parents: in the right way, at the right
time and in the right kinship relationship. This experience reflects the
innate genetic plan for optimal development.
RELIEVE-GRIEF
Often, towards the end of a structure, the client experiences relief and
grief at the same time, and it surprises him. In PBSP this phenomenon
is called ‘relief-grief ’. It involves feeling the contrast between sadness
about how things were and relief after experiencing an antidote to the
trauma. The therapist explains that the grief is about how it was in the
past. The client looks back and has an emotional reaction, compassion
for himself and other people in his history. But the experience is
not traumatic and overwhelming. It is reflected on from the newly
discovered safe place. Relief is felt when the need for understanding
and connection is finally met.
The process involves implicit and explicit emotional biographic
memory. The therapist supports this process and uses micro-tracking
with the witness and voice figures as needed.
Integration
NEW MEMORY
The client integrates the new possibility, saving it in memory. The
therapist is aware of the process and checks with the client about what
is going on in his mind. He can affirm the process as it is completed.
When the client shows signs of being ready to finish the session,
the therapist asks if the client is ready to finish the structure. When the
client agrees, the therapist de-roles the objects and role players and
ends the session.
Dealing with resistance or inability to receive

Filling holes in roles: Making and watching ‘movies’
Resistance can occur at any stage in a structure. In most cases it
happens as follows. The client describes trauma or deficits related to his
parents or other important people in his history. The therapist suggests
reversals with an ideal possibility as a healing step. The resistance
occurs when the client does not accept the solution or expresses the
idea that ‘nothing can ever help me’. Sometimes this has the stronger
character of a defensive quality directed towards the therapist. In such
cases the therapist does not confront the client by pointing out his
resistance. The therapist checks to see if he was going too fast or the
client is lost or confused by the process. In the possibility sphere,
the therapist encourages exploration of difficulties and accepts them as
a part of the process.
In many cases what is seen as resistance is the result of roles a client
took as a child. For example, when a child’s parents are struggling in
some way, a child may unconsciously take the role of parenting his
parents. He may develop a sense of the world which tells him, ‘It
is safer and less threatening if I am in control of others. I will not
let anybody take care of me.’ In the structure he is faced with the
possibility of being vulnerable and depending on good care from an
ideal figure. It seems too much and too far from where he feels safe.
Clients with more severe developmental trauma may become

controlling as children (see Chapter3). Such a defence gets in the
way of receiving from benign attachment figures in childhood and in
structures in adulthood. Even though the ideal figures in the structure
are imaginary, the disorganised ability to seek safety and support with
others reappears. To address this issue, the therapist asks the client who
he worried about or took care of when he was a child. The therapist
teaches the theory of ‘holes in roles’. The client talks about people he
cared about or had to take care of and expands on their stories. They
are often tragic and hopeless stories in which the client sees himself as
the only one who tried to or could help those people. Some clients in
childhood were invested in rescuing nations or groups of people, for
example, targets of genocide.
Intervention: Creation of ‘movies’

The therapist suggests using objects to create ‘movies’ where the people
the client worried about or took care of receive ideal parents, or other
ideal figures, who would have helped them. Movies are created on the
floor in a separate place from the placeholders. Small objects are used
to represent the significant person and his ideal figures. Sometimes
many different movies are created when needed by the client. In the
movies the client’s important people get their needs met by their own
ideal figures. The client experiences relief as he watches these movies.
The client feels compassion for his important people who are now
receiving help in the movies. He feels free of the role of the ‘only
healer’ when he sees his significant people getting their needs met
by someone else. Often the client unknowingly stayed in this role for
years and it prevented him from recognising and being able to satisfy
his own needs.
The therapist ensures that the client just watches the movie and
does not imagine that somehow he is still providing care and help
to his important people. The therapist explains to the client how this
phenomenon works and offers theory and insight. After the movie,
in most cases, the client is no longer emotionally caught in the old
history of filling gaps in his family or social networks. Now the
client can receive a healing experience from imaginary interactions
with ideal parents or other figures (Pesso 2013; Pesso et al. 2009;
Winnette 2015).
The effect of the experience of good care and rightness

In his book, The Body Keeps the Score, Bessel van der Kolk, who studied
with Albert Pesso, presents his view of what makes PBSP effective. The
structure gives the client the possibility of experiencing being seen,
loved and related to, and feeling safe and relaxed in an attachment
relationship with significant adults and parents. When people need to
change the consequences of long-term, repetitive and painful memories
of hurt, injustice and fear in relationships with caregiving figures, they
need visceral, antidoting experiences in order to heal. The new, felt
experience with imagined, ideal caring can counteract the trauma and
the sense of a ‘bad’ self. This will, of course, never erase what happened
in real life in the past. But those intensive, antidoting therapeutic
experiences gained in PBSP structures are offering something new to
the clients: having an experience and memory of being with people
who would love them, protect them, support them and be a safe haven
for them. For most of them it is something they never believed was
possible for them (van der Kolk 2014).
Jon Baylin’s window on neurobiology for this chapter, below, outlines
the neurobiology of change in PBSP therapy.
Window to Neurobiology of
Change in Pesso Boyden System
Psychomotor Therapy
Jon Baylin
Neural integration
PBSP likely promotes neural integration by facilitating the three basic
levels of connectivity necessary for effective reprocessing of traumatic
memories: vertical integration, horizontal integration and lateral
integration. PBSP engages both bottom up and top down brain systems,
right and left interaction, and back to front interaction to promote
recovery from developmental trauma. The PBSP structure and the
processes that accompany it provide the relational, contextual and
inner safety the client needs to create new, positive, emotionally
powerful experiences that compete with the negative childhood states
of mind and body and eventually help to replace the old core self with
a new, more positive, newly re-embodied self-image.
This begins with primarily right brain (Schore 2002b) work
that links the subcortical self-defence system with the prefrontal
regions, including the regions that support self-awareness and self-
reflection. The process then expands to include horizontal integration,
with co-activation of right brain and left brain processes necessary
for constructing more integrated narratives and putting embodied
experiences into words. Later integration occurs when the client is
able to activate the default mode network (DMN), that introspective
system, to go inside safely to reflect upon new experiences, compare
them with old, and construct a new, more positive, more coherent
narrative about self and others.
126
Experiencing the unknown: Being

loved, accepted, safe and good
I feel alive and hopeful
PBSP helps to reawaken the suppressed social emotions, unblocking
the joys and pains of living in connection rather than living through
mistrust and emotional disengagement. The processes used in PBSP
target the early suppression of these social feelings and help the client
begin to experience the natural urge to expand into his social space
and be seen, heard, and responded to with empathy and pleasure. It
is a therapy model that helps the client reclaim a natural birth right:
to live large, safe to feel all emotions, to have a vibrant, energised,
moving self that is safe to connect with other vibrant, moving selves.
Through bringing up memories of the devalued self and creating new
experiences of feeling valued, loved, nurtured, of being a source of
delight and wonderment, PBSP promotes ‘double safety’, the safety to
go inside and the safety to be with others, safety to take up space in
the world, being seen, heard and touched without having to ‘go away’
or shrink oneself.
PBSP can best be understood in brain terms by referring to
the recent neuroscientific work on the DMN (see my window on
neurobiology in Chapter 1, ‘When Things Go Right’) and the effects
of traumatisation on this system. All of the processes used in PBSP
can be seen to have the function, neurodynamically, of activating and
sustaining the activity of the DMN system. The PBSP ‘structure’
creates a safe enough space for the client to go inside using the DMN
system as a work space for reprocessing old experiences and feelings
and self-referential beliefs in order to update, reappraise and ultimately
revalue the self.
The neurobiology of the PBSP

structure and therapy: You can be
present and safe, and explore
Possibility sphere
The structure of a PBSP session helps to provide the outer safety
the client needs to go inside into the default mode network to
do the necessary work of therapy. The structure provides a context
of trustworthiness in the presence of the therapist while reducing
ambiguity and uncertainty about what is going on in the therapy

process. The relationship between the therapist and the client is
metaphorically called a ‘possibility sphere’ where the client feels safe
and can operate on different time levels and experience all of his
emotions in both the child state of mind and adult state of mind.
Safely orienting the client to the process helps to calm the client’s
defence system from the outside so the client has a chance to use
his own brain, especially the MPFC (middle prefrontal cortex, see
Chapter 1, ‘When Things Go Right’), to quiet the defence system from
the inside, in a top down way using inhibitory input from the MPFC
to the midbrain defence system. The safe presence of the therapist
as a trustworthy guide helps to provide the ‘social buffering’ effects
of having a safe partner available while doing something hard and
potentially painful (Coan, Schaefer and Davidson 2006).
Importance of pilot
The MPFC, the working memory of the DMN, is the pilot, to use
the language of PBSP. This is the convergence zone for childhood
memories, present experiences, new information, for making new
movies that integrate new and old. The MPFC is a rich convergence
zone that can work with images and scenarios and movie-like
productions that can embed new experiences, new feelings, new
information into old memories while those memories are ‘up and
running’. The retrieval of memories is posterior, in the posterior
cingulate cortex and inferior parietal cortex (Vogt and Sikes 2009).
Then these memories are shunted forward, reaching the MPFC
work space when the client is staying present and minding what is
happening. The PBSP therapist is careful not to distract the client and
pull him out of this work space, but instead does everything she can
to help the client stay inside without dissociating or getting stuck in
negative states, using the DMN to reprocess safely the old, troubling,
negative memories that would normally keep triggering the midbrain
defence system and overwhelming the client or triggering dissociation.
When the MPFC is active, it inhibits the stress response and
defence system by inhibiting the activity of the amygdala, the brain
region that can trigger these systems so readily when there is no ‘top
down’ modulation. Specifically, the MPFC can send excitatory input to
inhibitory neurons in the amygdala called GABA cells. (GABA is the main
inhibitory chemical in the brain that can suppress firing of brain cells by
sending inhibitory messages to these cells). GABA cells in the amygdala
can shut off the output to the stress system and to the periaqueductal
grey (PAG), the region in the upper brainstem that orchestrates the fight,
flight, freeze reactions when triggered by the amygdala. This effectively
turns off stress and defensive reactions in favour of social engagement
(Davis and Whalen 2001; Vrticka et al. 2008). When the MPFC triggers
this top down inhibitory process on amygdala outputs, the client has
the subjective experience of a letting go, of a weight falling away, of a
release of chronic distress (Lanius et al. 2011). This relief comes from the
deactivation of the midbrain defence system that has been chronically
active in the client over many years.
Micro-tracking: You are seen, heard, felt, and it is safe

Micro-tracking of nonverbal as well as verbal signals informs the
therapist when it’s necessary to address the client’s PFC, the ‘pilot’.
Micro-tracking includes witnessing and using the voice figure
(engendering safe experiences of being seen, heard and felt).
In PBSP, the therapist uses both his MPFC and his external
attention system to monitor both the client’s inner processing and
the outward signs that indicate the client’s shifts in states, informing the
therapist through this micro-tracking of the shifting internal states
of the client. The goal of this tracking by the therapist is to help the
client stay present, keeping the processing of old and new experiences
productive rather than regressing to a more primitive brain state and
getting stuck in rumination or dissociation.
Placeholders: Let us see what is happening inside

The use of ‘placeholders’ helps to keep the process representational,
‘once removed’ from the kind of direct sensory experiences that can
trigger dissociative reactions or overwhelmingly distressful feelings.
In brain terms, this helps the client to maintain access to prefrontal
functions necessary for ensuring sufficient affect regulation to avoid
shutting down effective processing of trauma-related memories.
Having the client choose and manipulate objects to represent real
people helps the client stay emotionally safe enough while keeping
these figures from real life ‘in mind’.
Reversing the wrong

Ideal parents: How it feels to be a source of delight
The use of ideal figures which provide the ideally fitting care and
interactions in the present while also accessing a childhood state of
mind is the core of the PBSP therapy. This process generates what
neuroscientists call ‘reversal learning’, the process of changing behaviour
in the face of new experiences that counter old ones. The reversals in
PBSP provide novel experiences that counter the negative experiences
the client had with original parental figures. These new experiences are
created by having the client imagine encounters with ideal caregivers
or having the client interact with role takers carefully coached by the
therapist to provide the ‘just right’ experiences needed to counter the
negative experiences with real caregivers. The goal of these processes
is to give the client novel experiences of being valued, nurtured,
of literally having an opportunity to look into loving eyes and see
oneself reflected back with joy, with delight. These experiences can
surprise the client’s brain, violating chronic expectations of being
rejected, criticised or ignored. These new experiences then need to be
contrasted with the old experiences, a neural process of competition
in which the old and the new literally activate different brain patterns
that compete for dominance. In support of this conflict resolution
process, the MPFC, the zone of self-reflection in the default mode
network, appears from research (Siegel 2012) to be the brain region
that can compare and contrast old memories and bodily reactions
from childhood with the new affectively positive experiences. The
MPFC works in conjunction with the anterior cingulate cortex (ACC)
to keep conflicting thoughts and feelings from shutting each other
down, giving time and space for the integrative process to work. The
ACC becomes more active as the degree of ‘competition’ between two
mental processes increases, helping to sustain the process of conflict
resolution (Vogt 2009).
Movies: You can watch your people being happy

In addition to providing novel experiences with ideal caregivers, the
PBSP structure includes a process of having the client envision
the original caregivers having healing experiences, so-called ‘movies’
about the significant others receiving ideal care. This process which
the client co-creates and watches in the therapy room is designed to

release the client from unconscious roles of healer and caretaker taken
on unknowingly as a child.
The neuroscience of reversal

learning: Antidoting
Reversals and movies teach the brain a new
possibility of safe relating and hope
In brain terms, reversal learning takes place when our expectations of
reward or punishment, pleasure or pain, are ‘violated’ by unexpectedly
positive or negative results of our habitual ways of behaving. Reversal
learning involves the detection of changing contingencies of reward
and punishment in our environment (Schoenbaum, Saddoris and
Stalnaker 2007). In the case of interpersonal relationships, reversal
learning occurs when we expect a kind or unkind reaction from another
person and get the opposite. Neurobiologically, reversal learning
depends heavily on the lowest region of the prefrontal cortex, the
orbitofrontal cortex or OFC, and its connections with the amygdala.
Together, the OFC and amygdala help to determine when violations
of expectations warrant a change of ‘mind’ about the relationship
between certain things or objects in the environment and the value
of these stimuli. Reversal learning is fundamental to the process of
changing our behaviour and our minds in response to changing
conditions in our environment. Reversal learning is triggered by
novelty, by unexpected results from engaging in habitual behaviour.
In the context of social learning and developmental trauma, the
chronically defensive client automatically expects negative reactions
from other people, especially if the client actually approaches
the other person with an intent to engage. Unexpected, surprising
results from doing things habitually trigger what neuroscientists call
‘error signals’ in the brain. One of the key types of error signal is
triggered by unexpectedly positive experiences when we are expecting
a negative, even painful experience. These positive error signals are
called positive prediction errors or PPEs. PPEs are known to activate
the dopamine system, the neurochemical system that supports new
learning about ‘rewarding’ experiences (Steinberg et al. 2013). A goal
of psychotherapy that relies on the creation of new experiences would
depend on triggering these positive prediction errors and getting the

client’s dopamine system involved in learning about changes, reversals
in the contingencies of approach and avoidant behaviours.
The reversals in PBSP would very likely ‘work’ by triggering
positive prediction errors and the surprisingly positive experience
of being seen by kind eyes, spoken to by kind voices, getting the
opposite from these imagined interactions or role-based scenarios to
what the core self-memory system or internal working model predicts.
The conflict that emerges following unpredicted positive experiences
between the old habitual expectations and the new experiences turns
on the ACC, a brain region that helps to support conflict processing and
decision making when old ways are conflicting with new information.
When the person is intentionally working on resolving this conflict,
the ACC helps to support this conflict resolution process. Helping the
client to keep the ACC activated during this process is essential to
preventing regression to the old ‘prepotent’ habits of mind. The ACC
is also a gateway or link to the MPFC, helping this work space for
self-referential thinking to stay activated, as well.
Imagine that you had ideal parents

when you were a child
In PBSP, the therapist induces reversal learning by having the client
imagine experiences with ideal caregivers that are the opposite of what
they actually experienced in childhood. Al Pesso refers to ‘genetically’
determined expectations regarding what we need from relationships
in order to feel whole, complete. In his terms, certain experiences can
provide a ‘fit’ that completes a need that we may have been seeking
to fulfil for a long time. Reversal learning may fulfil this genetic
expectation when the new experience with an ideal parent is the
missing piece, the completing response to a long-held, unmet need for
comfort, acceptance, love from the kind of person, a parental figure,
whom nature ‘intends’ as a provider of such nurturing care: ‘If we were
with you back then, you would feel that safe, loved and happy.’
Ideal figures that invite the client to look into loving eyes and
hear loving voices are a particularly evocative part of PBSP. Looking
into kind eyes and hearing kind voices are known to trigger the
limbic system and the release of oxytocin and perhaps opioids and
dopamine, the brain chemicals that help to calm the defence system
and enable the person to feel safer and more trusting in the presence
of others. Oxytocin is also now known to be activated by listening to
dramatic stories (Zak 2012) and, probably, by making little movies in
the mind when these movies depict scenes of validation, acceptance,
loving relationships. Activating the oxytocin system in clients in these
ways is most likely one of the ways that PBSP works to help clients
achieve greater internal safety and a heightened sense of well-being.
Relief-grief: It is sad how it was, but I am safe now

The reversal experiences in PBSP can trigger strong emotions, often
a mixture of joy and sadness, a release of blocked attachment-based
emotions that would have fuelled the separation distress, call-and-
response, comfort system in a healthy, ‘species typical’, genetically
expected dyadic relationship. The recovery of the ability to feel these
social emotions is key to recovering from developmental trauma and
having a ‘second chance’ at engaging safely in the dyadic emotional
dance of separation and reunion, attunement, misattunement and repair,
the healthy cycle of secure attachments (Baylin and Hughes 2016). This
is a scenario in which opioid levels drop during separations, causing a
felt need for the comfort of the other and spurring on actions that can
culminate in joyful reunion.
All of these processes help to buffer the influence of the
midbrain defence and stress systems so that higher processing can
occur. In this sense, the PBSP therapist helps the client to activate
fronto-limbic pathways that can convey top down messages to the
subcortical limbic regions that have the effect of quieting the chronic
hyper-arousal that has been present since early childhood. When a
memory that activates the chronic defence system is being processed in
the MPFC, the MPFC starts to inhibit the defence system, leading to
very powerful shifts in subjective, affective experience of the client in
the moment. This fronto-limbic top down process is the source of rapid
brain state shifts in which the old memory is ‘defanged’, detoxified.
Creating new memories

Memory of right in the past changes
the present and the future
‘Reconsolidation’ is the term neuroscientists use to refer to the
process of embedding new information into old memory networks
and then restoring these memories as permanently changed memories
that have the opposite affective charge from the original negatively
charged memory (Nader, Schafe and LeDoux 2000). This is thought
to occur when the client brings the old memory into the brain’s work
space, the MPFC, and then brings the new information based on new
experiences into this work space. In doing so the client embeds the
new learning about himself, neurally, linking it synaptically to the old
memory network. This process inhibits the amygdala-driven outputs
to the stress/defence networks. In this way, the integration of the new
with the old creates a new memory while at the same time taking the
shock effect out of the memory before restoring the new memory.
In all probability, it is this process of reconsolidation that is being
facilitated in PBSP when the therapist helps the client bring up old
memories, keep these online, and combine the old memory system
with new affectively positive experiences drawn from reversals and
experiences with ideal care-providing figures. The process is carefully
conducted by the therapist (see Figure 4.2).
Top down
PBSP MPFC PMC
OFC
A
Bottom up
MPFC = middle prefrontal cortex
PMC = posterormedial cortex
AI = anterior insular cortex
A = amygdala
OFC = orbitofrontal cortex
Figure 4.2 PBSP calms the defence system, promotes

reversal learning, activates the default mode network
Neurological impact of PBSP

In short, PBSP appears to be a process of gradual, safe, gentle
expansion of the self to make it safe to ‘be’, to be more fully present
in the world, in relationships, with less fear of rejection, abandonment
and criticism. PBSP honours the fact that deep change requires
visceral, embodied new experiences of feeling cared about and being
safe, with having a vibrant self, an energised self, and with being more
fully alive and present. Creating new experiences to counter the old
experiences of not feeling safe being fully present is at the heart of
PBSP. The process of creating new experiences of feeling safe to
counter old experiences of feeling unsafe is a central aspect of PBSP.
The process of creating new experiences of feeling safe to counter old
experiences of feeling unsafe is a central aspect of PBSP. The PBSP
structure enables the client’s brain to metabolise new experiences and
to allow the new to compete effectively with the old. The integration
of deeply seated ‘memories of ideal caregiving’ newly acquired in
PBSP therapy results in new solid ways of experiencing the self,
enabling the person to take a new path of living with oneself and
others, recovering the capacity to grow and change and to realise one’s
human potential.
Part III
PBSP CLIENTS’
CASE STUDIES
Chapters 5–8 present four case studies, giving detailed descriptions of

structures with clients in PBSP therapy. They illustrate the elements
of the therapy process. Emma, Anthony, Rebecca and Silvester went
through developmental trauma. Their stories show the horror of being
a child without safe, reliable parents. We can see what a challenge it
is for a client to approach developmental trauma and work on it in
therapy. The Epilogue at the end of Part III summarises the clients’
progress and hopes for the future.
137
Chapter 5
EMMA, A WOMAN AND A

BOWL OF COLD WATER
Petra Winnette
Introducing Emma
Emma is a beautiful, interesting-looking woman. Her skin is dark. Her
hair is curly and long. Her outfit has got an African flavour and she
moves with unusual grace. She tells me about her master’s degree in
fine arts. She is a visual artist and worked for a famous gallery in town.
She has got two almost grown up children, twin brothers. There are so
many admirable things about her.
When Emma first talked to me, she spoke about her achievements
with pride, but she felt deeply lost and had run out of motivation to
live her life. ‘What a discrepancy,’ I think, ‘Emma can list many great
qualities she has, but she has no hope in her life.’ I ask, ‘What brought
you here?’ I want to learn more about her thoughts. ‘I am so tired of the
endless effort to control my life,’ she says with a desperate look in her
dark eyes. ‘I have been stressed out all my life. Everything is so difficult
and nothing works. Sometimes my feelings get so intense I can hardly
concentrate on anything. I am unable to be a good parent. I can’t do
work I would like to. I had a husband, but it didn’t work out.’ Emma is
trying to explain why she decided to see me. She has been in therapy
before, but so far nothing has changed.
‘I am trying to make sense of what is going on with me, but it
seems impossible. My parents and siblings think I am strange. My
former husband and his mother find me lazy and difficult. All these
people keep trying to advise me how to live. They don’t understand
me at all!’ Emma is desperate and she is vividly in a very isolated place.
All of a sudden she gets quiet. Then she says, ‘I feel very hot around
my face. I have tension in my arms. And I have no thoughts now.’
139
‘It seems there are many very confusing things in your life,’ I
respond to Emma’s long and painful explanation of herself. ‘Today
we will talk and create a contract about our work. Scientists tell us
that a lot of problems we experience in adult life have got roots in
our childhood. It will be useful if we can look at your life from the
very beginning,’ I suggest. ‘Then we’ll go through the theory and
principles of PBSP therapy so everything is clear to you.’
Emma agrees. ‘It makes sense to me. You know I was adopted as
a young kid. My parents adopted me when I was fourteen months
old.’ ‘Where did you spend the first fourteen months of your life?’
I ask. ‘In a baby home. Maybe my problems have to do with that.’
Emma says this with a shy, angry expression on her face. She has
heard of attachment theory, knows about my work in this field and
wants to learn more about it. There is desperation in the way she
tries to understand herself. Emma is a lifelong researcher into her
own fate and life. She has been haunted all of her life by strong,
uncomfortable feelings and confused explanations for those feelings.
Sigmund Freud talked about such an endless struggle. Things which
we do not understand keep coming back to our mind over and over
again, like ghosts. They will not disappear until the secrets behind
them are discovered and resolved and their mysterious power broken.
Emma feels exhausted and has no hope for the future. It has
been like this for decades. It seems like a thousand years, forever, to
her. There is almost no space for anything else. Work, relationships,
explorations, her own free decisions, fun…all these elements of
goodness collapse in her life. Now there is light at the end of the
tunnel. She hopes I will have ideas and solutions which will resolve
her unending inner conflict.
I know one thing for sure. I could talk with Emma for hours,
giving her all kinds of ideas about what happened to her, why she
feels the way she does and how it all fits together. But she would not
get any better. She would only have more material for her endless
self-analysis. I don’t discuss this but simply tell her if we are going to
work together, we will work with her memories of childhood. Emma
and I agree on this step. Let’s find out what happened with a beautiful
woman named Emma.
Emma, a woman and a bowl of cold water 141
Born nowhere, living nowhere

Emma knows nothing about her origins and very little about the
beginning of her life. The stories she was told differed and nothing
was certain. Why didn’t her parents want her? Why has she got dark
skin although she was born in Europe? Where did her parents come
from? There are few answers and many important questions. Emma
has lived for many years with a big, grey, empty room in her mind.
She was told her birth mother left her in a maternity hospital. She
wonders if her mother was a student of languages and if her father was
a diplomat. She knows her father was black and her mother was white.
Maybe her mother was afraid of keeping a black baby. None of her
conjectures may be true. Her uncertainty about her origins became
one of her ‘ghosts’. ‘Who are my parents? What did I inherit from
them? Am I as good as them or as bad as them? How does all this
make me different from others?’ she asks herself.
We know what happened after she was born. As an abandoned
new-born, Emma was placed in a residential facility for babies and
young children. These used to be called ‘baby homes’. At the time,
they held thirty or forty children from new-borns to three-year-olds.
Basically, a ‘baby home’ looked and worked like a hospital for young
children. There were three wards: one for infants, one for toddlers and
one for children with developmental issues or disabilities. One nurse
took care of ten or twelve children at a time and there were at least
three nurses per shift. White coats, and regular regimes for feeding,
changing nappies, bathing and sleeping were the routine. There was
no time for cuddling, laughing, eye contact or close attunement with
a baby. No other being would have looked in Emma’s eyes, smiled at
her or comforted her when she was sad, scared or confused. There was
no loving mother or primary caregiver either.
Little Emma stayed in her bed on her own. There were many
people around her, but she did not belong to anyone. This is all we
know. Fourteen months in a universe of emptiness. Emma talks about
this part of her history with uncertainty in her voice. Was it bad? She
does not know. She does not remember anything. According to her,
she can recall almost nothing about the first five or six years of her life.
Adopted
Emma’s adoptive parents had problems conceiving a child. Adoption
was a solution for that. Emma’s adoptive mother shared her feelings
and thoughts about those times with Emma. She did not really want
to have children. Her relationship with her husband was shaky and
she was nervous about being a mother. However, she and her husband
decided to adopt a baby from an orphanage and become parents. They
knew nothing about adoption or what kind of problems they were
going to face. Most of all, they knew nothing about how hard it was
for a little girl, age fourteen months, who arrived one day at their home.
She looked different than they expected. She was developmentally
delayed due to early trauma related to her hospitalisation in a ‘baby
home’. She did not walk, speak or smile. Severe neglect causes extreme
stress and is destructive to a child’s development on many levels. ‘The
significant absence of basic, serve and return interaction can produce
serious physiological disruptions that lead to lifelong problems in
learning, behaviour, and health’ (National Scientific Council on the
Developing Child 2012, p.4). She had never had a mother or a close
relationship in her life. And now her new mother and father did not
know how to relate to her.
Emma’s new mother got pregnant and Emma’s sister was born not
long after Emma arrived. But her adoptive parents were not getting
along. When Emma was seven, they divorced and she and her sister
went to live with their father. Emma had some happy times in early
childhood which she remembers as almost ideal. When she visited
her grandparents in the countryside, her grandmother was kind to her
and easygoing. Emma loved nature and a nearby river. These are
her happiest memories. When her grandmother died, it was a big loss.
Emma connects this loss to her lifelong sense that ‘It’s always like
that. When I establish a close relationship with someone, after a short
period of time, it ends abruptly and for good.’
After getting married, Emma got pregnant and her husband was
unfaithful. Emma did not know what to do. Her feelings at the time
were familiar to her. If they could speak, they would say, ‘Life is like
this. Good things end. You are ugly and strange. You aren’t worth
anything better. If you try to live a good life, it doesn’t matter, death
and disaster always come.’ Later the marriage ended. Emma developed
ways to cope with her experiences. She survived, but life feels like a
bag of stones.
Introduction to a PBSP structure

Here we are. Emma arrives at my office. She and I have decided to
work together so she can feel better and have a better life. Emma
is ready for her first session in Pesso Boyden System Psychomotor
therapy. I know she has been through therapy before, but she says so
far nothing has changed her inner feeling of inadequacy. Day by day,
her life is an ongoing struggle.
At the beginning of therapy with a new client I usually do
an introductory session. The client learns about PBSP theory and
interventions and experiences the therapy process. PBSP is different
from other approaches and it is not beneficial for a new client to
start therapy without a basic understanding of the method. The
relationship between therapist and client in PBSP is based on clarity
and shared responsibility for the therapeutic process. The client
understands he is responsible for a good outcome to each session and
that the therapist will facilitate this. The contract creates a solid base
of safety for the client and a reliable relationship with the therapist.
The therapeutic alliance develops throughout the sessions. Therapist
and client are closely connected as they focus on the client’s unfolding
issues and create healing interventions together. At the same time, the
relationship with the therapist is not considered the essential element
in the healing process. It is more important that the therapist help the
client have a new experience with ‘ideal figures’. That is, the client
has a symbolic experience of what it would have been like to have
ideal interactions and relationships when he needed them as a child.
It is important for the client to be aware of this. I promised Emma we
would look at the principles of PBSP together.
The first structure: Emma and

a bowl of cold water
Emma sits on the sofa; she looks lost. I start the session with the
explanation that today we will do a typical PBSP structure but with
quite a lot of teaching. It will flow naturally and at the same time, she
will learn how it works. I tell her, ‘PBSP is a highly structured method
which uses specific interventions. I will explain everything to you as
the session organically develops.’ I am clear and open with Emma.
Now we can start the session.
‘How are you feeling now? What is happening in your mind?’
‘I feel hot and anxious,’ she says. ‘I do not know why. I was
looking forward to coming here and now all I feel is this tension and
hot cheeks and forehead.’ Emma is quiet, she has no thoughts. She
would like to express herself eloquently. She would like to discuss so
many things, but all of a sudden she is out of words. ‘Why is that?’
she wonders. It all started when I simply asked her to tell me what
was happening with her in my office at that moment. ‘PBSP uses this
step, this question, very often.’ I start with a bit of teaching. ‘Often
we are aware of issues or problems that we find kind of “burning”.
And we can explain them. But sometimes we confabulate stories and
make up reasons why we are feeling badly, when the real root of the
difficulty is hidden and unknown to us. The issue is unclear. Other
times a client dissociates and “feels nothing and thinks nothing”. It
often happens when a client experiences strong affect.’ I gently help
Emma understand what she is going through at the moment.
When I asked Emma, ‘What is happening?’ she had a reaction
that she often has and does not understand. She had no thoughts, few
feelings and no meaning or context for her experience. She simply had
strong physical sensations of tension and a hot body and face. Later
we realised these physical sensations and her difficulty with thought
processes are a response to overwhelming stress.
‘What would you like to do with it, if possible? What does your
body want to do?’ I ask, bearing in mind that I create a safe space for the
client in my office and in my mind. Albert Pesso calls this the ‘possibility
sphere’. It means openness, curiosity, acceptance and empathy for all the
client’s sides and needs as they appear during a session.
‘Cold water,’ Emma responds. She is obviously very certain about
the answer.
‘Let’s have a real bowl of cold water here and now in this room,’
I suggest. Emma goes to the kitchen and brings a large bowl of cold
water. She looks around, not quite knowing what she is supposed to
do with it. I encourage her: ‘Put it wherever feels right for you.’ Emma
looks around the room again. She does not seem disoriented at all
now. She finds a suitable place on the floor and carefully places the
bowl there. She sits near it and looks at the surface of the clear, cold
water. I can see how much she is attracted to the water in the bowl.
The bowl is already doing something very important for her. So far
Emma has not said much, but she is fully involved in her activity with
the bowl of cold water.
‘What is happening?’ I check with Emma. ‘It is refreshing and I

feel calmer,’ she says as she touches the water and sprinkles her face
with it. She smiles gently. In this therapy we accommodate the client’s
needs. Emma is now feeling comforted by the water in the bowl.
In PBSP the client is invited to actively collaborate in creating his
new experiences. Emma is safely taking in joy and pleasure. She feels
calmer playing with the water.
In a structure we help the client not only to be active, but
interactive. So how can we create an experience in this situation, so
the client not only feels satisfied by herself, but she has a satisfying
interaction? Fortunately, in the possibility sphere we can have objects
speak and provide comfort. Without further explanation, I simply
say, ‘So if the bowl of water could speak, it would say, “You can feel
refreshed with me.”’ Emma doesn’t seem at all surprised by the ‘talking
bowl’. I continue, ‘The bowl of cold water would say to you, “You can
come to me any time and get refreshed and feel calm with me.”’
‘It sounds like the voice of a mother,’ Emma realises, thinking aloud.
‘Oh yes. Mothers do play such a role in a young child’s life.
Young children are very curious and explore, but sometimes they get
overwhelmed by their interaction with the world. The good mother is
there for them and they can easily find her calming, supportive and safe
presence. If a child gets tired from active exploration, mother offers a
refreshing place to rest. You didn’t have such a mother when you were
a very young girl. So you might have been missing this experience
in your life.’ I speak with the aim of giving Emma a context for her
ongoing experience.
‘No, I did not have it. As far as I remember I took care of my
mother.’ Emma shakes her head with sadness in her eyes.
I tell Emma, ‘Let’s reverse this. Now imagine there was an ideal
mother in your life when you were young. She has no part of your
adoptive mother.’ I gesture in the air to outline the possibility of an
ideal mother. Emma felt so stressed before and received comfort and
gentleness from the water. Her fascination with the experience shows
there is a ‘principle’ of comfort in the water for her. I try to help her
imagine having similar feelings with a special comforting person in
her childhood. ‘Remember feeling stressed in your childhood. Now
imagine having an ideal mother, who is available to you and you feel
refreshed and relaxed again in her presence. You would have had a
feeling similar to the one you have now when you play with the water.
It’s pleasurable, isn’t it?’ Emma continues putting her hands into the
water and smiles. ‘Yes, it feels calming and comforting.’
‘So your ideal mother says, “If I was your ideal mother back then
when you were a child, you could have come to me and felt calm and
comforted with me.”’ I suggest how it would have been for Emma
to experience with her ideal mother in the past the feelings she is
enjoying here and now in the therapy room with the bowl of water.
Emma looks at me with a question in her eyes. ‘It sounds nice,
but it’s hard for me to imagine any kind of ideal mother. When you
say “a mother”, I can only see my adoptive mother and sister.’ Emma
mentions real people she remembers from childhood. We will have
them symbolically present in the room in the form of placeholders.
‘Let’s have objects represent the people who come to your mind.
It’s one of the steps in this work. Whatever comes to your mind –
people, places or topics – will be represented here in the room.’ I offer
Emma a basketful of small objects: stones, pieces of wood, corks, sea
shells, and such like. In this step of PBSP we ask clients to pick an
object to represent any person they have on their mind and mention in
the structure. Clients usually find an object which in some way reflects
qualities of the person they are thinking about.
‘Who are you thinking of now?’ I am teaching Emma about PBSP
again. ‘My adoptive mother.’ She puts her head down a little bit.
‘OK’, I say. ‘There’s a basketful of different small objects. Choose one
to represent your adoptive mother.’ I take small steps while leading
the structure. I am aware at the beginning it is not always easy for the
client to grasp all the steps in Pesso therapy. I like a slow, clear process
in which the client and I are congruent and focused on the same thing.
This helps the client feel safe and in control. It supports a healthy
collaborative relationship between client and therapist.
Now we will focus on Emma’s adoptive mother. Emma takes
her time as she really wants to choose the best-fitting symbolic
object. Finally, she picks up a green stone. ‘Now put it here in front
of you. The green stone is a placeholder for your adoptive mother.
It represents all her qualities and what she means to you. It covers
past as well as present experiences and thoughts you have about her.’
Emma looks at the stone which is now a symbolic representation of
her adoptive mother. She seems puzzled. ‘What is happening to you
when you think of your adoptive mother?’ I ask. ‘She didn’t like
being a mother!’ Emma exclaims, her voice full of emotion. ‘She was
so unhappy having me as her child.’ If we had a witness in the room,

the witness would see how burdened and upset Emma is when she
thinks of her adoptive mother and her adoptive mother’s attitude
towards her. Her cheeks get red. Her eyes seem to turn inside and
watch really painful scenes. Her voice sounds suppressed and weak.
Emma’s relationship with her adoptive mother is surfacing right now
on her face and in the tonality of her voice. These are important
moments in any therapy. In PBSP we want clients to be conscious of
their inner shifts and waves of emotion as well as their thoughts. The
Pessos developed the technique of having an imaginary figure, called
‘the witness’, present in the therapy room. Now is the time to explain
this intervention to Emma.
She knows the session is organised so she can learn about typical
procedures in PBSP therapy. I gently tell her about the witness figure
we will use. ‘You are experiencing a lot of puzzling feelings when
you look at the placeholder for your adoptive mother. In PBSP we
use an imaginary figure which we can picture as being here with us
in the room. It is somewhere in the air.’ I use my left hand to sketch
the outline of a figure in the air. ‘It’s a “witness figure” who can see
all your emotions, but he is not judging or analysing them. He fully
accepts them and puts a name on them. If he is not right, you can
always correct him by saying, for example, “I am not sad, actually I
feel angry.” Does this make sense to you?’ Emma nods.
There are many theories, steps and interventions to be introduced
in Pesso therapy. But we are just beginning and I do not want Emma to
be too busy with the method. I hope she will get a real felt experience
today, not just a list of new terms and explanations. I simply say, ‘From
now on we’ll use the witness figure in our sessions.’ Emma is fine.
She is clear about this intervention and continues speaking about her
adoptive mother again.
‘I always felt like I was a big burden to her. Like everything was
wrong with me. Whenever I was around her, I felt like I should do
something about it. I should be different, somehow better, but I did
not know how. Or I just tried to hide and be invisible.’ Emma is
getting back to her place in the middle of nowhere. ‘If a witness was
here, a witness would say, “I see how confused and desperate you
feel when you remember how you experienced your adoptive mother
when you were a child.”’ I use the imagined witness figure to help
Emma be aware of her mental state. ‘Yes,’ Emma agrees immediately.
This indicates the witness’s observation fits and accurately names her
feelings. She feels heard, seen and understood now.
I add an interpretation to it: ‘It seems as a child you tried to
do what your adoptive mother needed. Sometimes you tried hard
to be “a good girl” for her. Other times, as you said, she didn’t want to
be your mother at all. She wanted you “not to exist”, so you tried
to disappear. At the same time, I see the little girl Emma trying very
hard to be connected with her mother, but receiving rejection and
weird, negative messages from her. How confusing it must have been
for a child, especially one who had already experienced rejection by
her birth mother.’
According to PBSP theory, a child unconsciously tries to make
his parents and other significant people happy, to establish justice
and order based on an innate sense of what is right. When a child
experiences some kind of ‘gap’ where someone is missing or people
are unhappy, he will try to do something about it. Pesso calls this
automatic, unconscious response ‘filling holes in roles’. The child
‘fills holes in roles’ by putting himself in the role of helper or healer.
Sometimes this phenomenon creates extraordinary things. I think
of Emma. What would have helped Emma’s adoptive mother so she
was not burdened by Emma as a child? ‘No Emma’ is the answer.
Somewhere in Emma’s consciousness her mother’s wish created an
inner response. Emma saw herself as a burden for other people and so
she did not allow herself to fully exist. I can imagine the pain Emma
must have felt as a child.
‘Yes.’ Emma exhales with an expression of deep helplessness.
‘As a child I did not know how to make her happy. I was trying
hard to be nice and useful but I never succeeded. I felt strange and
unwanted. So I tried to disappear.’ I could make Emma feel better by
expressing empathy for her and giving her insight into her problems.
If I took that direction, she might feel some immediate relief. But
later the old thoughts and feelings would return. Clients’ childhood
experiences and ideas about themselves are deeply imprinted in their
psyches. They create a fundamental ‘truth’ which surfaces over and
over again.
Albert Pesso developed an interesting and playful intervention
which helps clients resolve the unrecognised, powerful consequences
of filling holes in roles in childhood. This is what I am going to do
with Emma now.
‘In such a case, we should look at your adoptive mother’s life first.
Pick an object which will represent her here in the room, but this
time it’s not a placeholder. It will represent her as a young woman.’
Emma is curious about this unusual suggestion. She selects a small
piece of wood and I place it on the floor. I summarise what we have
done: ‘So this is your mother when she was a young lady and did
not want to have children.’ ‘Why do you think she did not want to
have children?’ is my next question. Emma thinks and then says, ‘I
think she couldn’t do what she really wanted when she had kids.
She couldn’t realise her dreams and enjoy her talents when she was
young and then she had children. She was frustrated by it.’ Emma is
certain about her mother’s issues. I take the opportunity to tell Emma
more about this phenomenon.
‘Children hear their parents talk about themselves. If a mother
often speaks about how much she lost and suffered because she had
children, her children hear it as an ultimate truth. An implicit message
is like a seed planted in their souls. They carry that meaning with
them. The child feels unwanted and experiences himself as a burden or
an obstacle to the parent. As a child, and later as an adult, the person
typically does not know where this inner conviction comes from, but
he feels it is a reality, an indisputable truth.’
‘Oh, yes! It makes sense.’ Emma is surprised and ready to learn
about this topic. To her it is such a familiar description of herself:
being a burden, an unwanted creature!
‘So let’s create another scene here which will be just the opposite
of the scenes you remember with your adoptive mother. Albert Pesso
calls this step “making a movie”. Here is how we do it.’ Emma is keen
to continue this process. ‘We have here a piece of wood and it has
the role of your adoptive mother as a young lady. Now we can give
her ideal parents who would have helped her develop all her talents
and gifts. She would have felt happy and satisfied as a youngster and
as an adult.’ I ask Emma to choose two other objects and I put them
beside the piece of wood representing her adoptive mother. It looks
good. Together we watch a scene in a movie where Emma’s mother
has got an imagined ideal life. I make a little theatre where the ideal
parents talk to their daughter (i.e. Emma’s adoptive mother as a young
woman). ‘So they say to her, “If we had been your ideal parents when
you were a child, we would have made sure you had time, space and
our support, so you could develop your talents and a satisfying life.”’
In the movie I created a scene where Emma’s mother experiences a

different childhood and adolescence than she had in real life. Emma
looks at it with a smile and satisfaction. It is amazing how it affects her.
‘Yes,’ she says, ‘my mother wouldn’t have had children. Maybe at
all. She would’ve been an intellectual lady. It’s nice seeing her in this
little movie. I couldn’t help her with that. I was actually an obstacle in
her way!’ Emma is impressed by her own recognition.
‘Yes, so it seems’: I confirm her insight. ‘But now you can see how
her life would have been different if she had ideal parents and she
could have the life she wanted.’ Emma looks at the movie and back to
the placeholder for her adoptive mother. ‘It’s strange. When I look at
my mother in the movie, I don’t experience the tension I felt before.’
Emma says this with astonishment, but with a relaxed expression
on her face. I witness what is happening with Emma emotionally. ‘A
witness would say, “I see how relieved you feel looking at the movie
with your mother being happy and satisfied. And how surprised you
feel that your tension has disappeared.”’ ‘Yes,’ Emma agrees with the
witness. ‘But I would not be born if that was the case.’ (Here Emma
metaphorically refers to the fact that, without her adoptive mother,
she would not have the only mother-figure she has ever known.) She
looks around, scanning the room.
‘Do you remember we have the outline of your own ideal mother
here in the room?’ I remind Emma of our original idea of an ideal
mother for her with the positive qualities of the bowl of cold water.
Emma remembers it well. She feels free now to allow herself to
enjoy such an idea. ‘Oh, my ideal mother would be available to me,
she would be happy having me.’ Emma knows for sure what kind
of mother she needed and wanted as a child. She is sitting on the
floor, leaning against the sofa. She looks calm. One of her hands plays
with the water. I take the next step: creating an interaction between
Emma and her imagined ideal mother. I speak in Emma’s own words.
Her ideal mother states exactly what Emma needed: ‘If I had been
your ideal mother when you were a little girl, I would have always
been available to you and you would have felt how happy I was
having you.’
‘And my ideal mother wouldn’t have wanted anything from me
when I was a young child! She would have supported me!’ Emma adds
something very important to her. She is enjoying the cold water again.
She can feel calm and refreshed by the water, but the water does not
need anything from her. Playing with the water has a quality which
is now associated with the experience of interaction with her ideal
mother. The ideal mother repeats what Emma just said: ‘If I had
been your ideal mother back then, I would have supported you and
I wouldn’t have wanted things from you when you were a little girl.
You would have felt refreshed and calm with me.’
Emma sits for a long while, quietly indulged in this very new
unknown way of being for her. She can re-experience herself as a
child, of course, but now she is experiencing a completely different
interaction with a newly developed, imaginary ideal mother. She
takes in what it would have felt like to have a different caretaker.
How different her life would have been with such a beginning. What
a difference having this experience makes to her now. Her face looks
much younger as her brain processes and saves this experience in
implicit memory where emotion and meaning are encoded. Albert
Pesso calls this ‘creating a new memory’. Clients of Pesso therapy
typically end a session with a positive new experience. Although the
memories of the old events remain, their meaning and impact are
changed by information from the new memory.
Emma is doing it now. Finally, she looks into my eyes with deep
understanding. She does know what has just happened. She knows
and I know too. Something fundamental has changed. This change
will stay with her and influence her way of being to become a more
relaxed and calm one.
Her look tells me she is ready to finish the session. ‘If you are
ready, we can de-role all the objects here.’ I speak softly so nothing
disturbs the fine completion of the structure. One by one I take the
objects into my hand, saying, ‘This is no longer a placeholder for your
adoptive mother, it’s just a stone. This is no longer a movie about your
mother’s ideal childhood and life as a young woman…’ Last of all,
we de-role the witness and Emma’s ideal mother. And Emma’s first
structure is over.
Therapist thoughts
It is still astonishing to me how quickly a client in PBSP therapy
touches on deeply hidden issues. Emma felt stressed and lost at the
beginning of her first session. She was not able to say anything about
it as she dissociated when exposed to close attention from another
human being; her therapist in this case. But her body, her right
hemisphere, knew what she needed: comfort, rest and acceptance. She
got it at first in the form of cold water. Gradually, she could imagine
feeling comforted and calmed as a child with an ideal mother. She feels
the impact of the session now, but the real impact will appear later. It
all happened in one introductory session.
A later structure: Emma and no place

This structure happened after Emma and I had been working together
for two months. This is her third structure.
She tells me about progress she has made. ‘It’s a different way of
existence, you know.’ Emma cannot find the right words. ‘It is new
to me. It feels like I have a new solid base.’ Emma uses a metaphor to
express her new experience of existence. I enjoy getting such feedback.
‘How do you feel here and now?’ I start our session today. ‘Well,
I keep thinking of my apartment.’ Emma has got a lost and helpless
look. ‘People should have a stable, safe home.’ In her voice there is
also a flavour of being irritated and frustrated about it.
‘That’s a voice of truth, it says, “People should have a stable and
safe home.” And if a witness was here, a witness would say, “I see how
frustrated and helpless you feel thinking of your apartment.”’
‘Oh, that’s right.’ Emma sighs. ‘My apartment is unfinished,
uncomfortable, not permanent. Actually, I live in the house of my ex-
mother-in-law.’ She says this with a sense of failure in her voice.
‘In PBSP we use the witness figure, as you know, and a voice
figure.’ ‘Voice figure?’ Emma is unsure. Although we have used it
before, I teach more about this element of PBSP therapy now. ‘Clients
often make statements about how they find the world to be. The
statement may sound like a demand, for example, “People should have
a safe and stable home.” Sometimes it has the character of a universal
truth, for instance, “Life is hard.” When a client makes a statement like
this, the voice figure repeats it back to him out loud. In this way the
client hears from outside the words which otherwise unconsciously
guide his thinking and reactions to himself and the world. Does this
make sense to you?’
‘Yes, it is OK.’ Now Emma has no problem with it. We can
continue. ‘Let’s have a placeholder for your apartment and one for
your ex-mother-in-law here.’ Emma finds a blue wooden cube and
puts it on the table. It represents the apartment. A small stone is the
placeholder for her ex-mother-in-law. ‘What comes to mind when you

think of your apartment?’ ‘It’s not my home. My ex-mother-in-law
doesn’t want me there. It’s not home at all. And I can’t do anything
about it.’ ‘That’s a voice, it says, “You can’t do anything about it!” And
a witness would say, “I see how immobilised you feel when you think
that you have no home.”’
It is time to ‘reverse’ this part of Emma’s ‘reality’. Her feelings
have got a deep-rooted source and there is no point letting her re-
experience helplessness in relation to this issue. She tells me she has
been trying to establish a home for many years, but she always ends
up doing nothing. It has become an endless problem with no solution.
‘Well, let’s outline an ideal home.’ In the air I sketch a simple reversal
of the home she has now and I let it speak. ‘The ideal home would say,
“If I was your ideal home, you would feel wanted and safe with me.”
How does that sound?’
‘Hmmm. I don’t know.’ Emma resists my attempt.
‘She’s right,’ I think. ‘She’s tried to create a good, safe home many
times and it always collapses. So what’s the point of trying to imagine
it again here in this room?’ She is not ready to accept this possibility
which is so far from what she has experienced.
‘You know, Emma, maybe we can start with something far less
specific. What would you think of an “ideal space”?’
‘We can try it.’ Emma is still uncertain, but she looks interested.
‘Let’s find an ideal space in this room. You can put a blanket on the
floor or you can find the most comfortable spot or corner somewhere
in the room.’
Emma likes having such freedom and time. She walks around
the room with enthusiasm. PBSP therapy makes use of the choices
of the client. It is based on the belief that a client feels satisfaction
when he does what accommodates his needs. The therapist, therefore,
encourages the client to find things which fit, which are right for him,
in order to create a healing interaction which will be meaningful and
satisfying. This is happening right now.
‘It will be a symbolic ideal space for you,’ I remind her.
She decides to spread an orange blanket on the floor near the open
window. She looks at it from a short distance away. She seems tempted
to try it, but she is not sure. She is silent.
‘Well, when you feel like it, you may try to go inside that space
and taste it.’ I continue by gently suggesting the next step. Emma
has never been in a safe space. Her biological mother did not want
her. The residential facility for babies did not make her feel wanted.
Both provided only a temporary place. Her adoptive family did not
know how to accept her. She was different. Her parents divorced and
she moved to her father’s house. She got married as a young woman,
then divorced. Her husband did not want her. What a long list of
experiences of having ‘no place’ in her life. I can feel her despair. As a
therapist I can help her create an antidote for her despair and lack of
place in life. Together we will take slow steps now to get there.
All of a sudden Emma takes a step and she is there inside her
‘ideal space’. She is sitting in the middle of the orange blanket and she
looks comfortable. Then she lies down and stretches her arms and legs.
It works.
‘I can relax here,’ she says with genuine surprise. I have the space
speak in order to give Emma an interactive experience. ‘If I was your
ideal place, you could lie down, relax and be comfortable with me.’
Emma does not say much. She is experiencing a new feeling of safety
and comfort in her own space.
‘This is what you did not have at the beginning.’ I clarify its
meaning for her. ‘We could extend this ideal place to the womb of
your ideal mother. How does that sound?’ I am unsure. This may be
taking too big a step. If Emma says ‘No,’ it is perfectly all right. We
will look for something more believable for her at this moment.
‘Yes. I would like that.’ Emma is ready to have an ideal mother
and experience being safely inside her. Her ideal mother wants her and
provides a safe, caring place for her.
‘If I was your ideal mother before you were born, I would love
you and I would be very happy being pregnant with you. Your ideal
father and I would be expecting you with love. You would have a
permanent and caring place in the world with us.’
This is a novelty for Emma. It is so different from the real beginning
of her life. Emma just nods. She doesn’t speak. She lies on the blanket,
relaxed physically as well as mentally. She takes a long time integrating
this unusual experience.
‘If I was your ideal mother, you would feel this quiet, peaceful
and safe with me from the very beginning. You would have your
permanent, safe home with me and your ideal father.’
Emma wants to tell me something. ‘You know I was born to
nowhere, to a vacuum!’
‘Yes. But now you can experience the difference. Your ideal mother
says, “With me you would be safe inside me and after being born you
would have a warm, safe home in my arms and my heart. You would
feel welcome in the world, not strange.”’ Emma takes time to stay with
this new idea. She can imagine being an infant again and still think
logically about the process here in the room.
Then she says, ‘I think I’ve got it. I’m sad I didn’t feel safe and
grounded like this when I was a child. It would have been such a
difference.’ Emma has tears in her eyes. ‘Why do I feel sad?’
‘You are experiencing grief after feeling relief. But it’s a different
sadness than the one you felt before. Before the feeling was very sad
and hopeless. It looked like nothing else was possible. But now you
feel both relief when you see how it feels to get what you needed with
an ideal mother and sadness when you remember how your life really
was. Therefore, we call it “relief-grief ”. It will go away.’
When Emma is ready, we de-role the placeholders, the witness and
the voice figures. Last of all, we de-role the ideal mother. But Emma
will remember this new experience of being a wanted, cherished and
beloved child forever.
Therapist thoughts
Emma has been working with strong determination and bravery. Today
she opened a very painful and shaming issue: ‘I have no place in the
world.’ The voice of her inner truth kept telling her this and it became
part of her working model of how life is. Now she’s experienced
a new beginning of life, the beginning she should have had, with a
loving, caring mother, where she feels safe and accepted from the very
beginning. She has a place in the womb and in the welcoming eyes
and arms of her ideal parents. It makes me think about the process
of Pesso therapy. How is it that when a client can vividly imagine
a different first year of life, or even a different prenatal time, it can
change how they value and think about themselves?
Emma, you are black!

Emma continues to come once a month for ninety-minute individual
sessions and once a month for a PBSP therapeutic group. She often
has strong emotional reactions to events in her daily life. She spends a
lot of time absorbed in this and trying to make sense of it. She keeps
trying to construct a story she can live with which explains her life,
her feelings and herself too.
Today Emma arrives with a tired expression on her face. She suffers
from feeling she is a burden for other people. She is talking about
her state of mind today, but she is aware this has been a conviction
of hers for a long time. Somewhere deep in her consciousness she feels
she is a nuisance to everyone. This is an ‘ultimate truth’ for her.
‘I am so weird, a burden to everybody.’ Emma is very tense and
gives me a hopeless look, like someone who is drowning.
‘A witness would say, “I see how lost you feel when you imagine
you are a burden.”’
‘Hmmm,’ Emma hangs her head.
‘That’s the “voice of truth”; it says, “You are a burden.”’
The human mind needs to be oriented to its own inner processes.
There is a neurological network in the brain which is responsible for
creating stories and explanations for our mental states (Gazzaniga
2005). The process is activated in early childhood when the parents
or caregivers explain to a child what is happening with him. They give
names to the child’s mental states. Gradually the child understands
his feelings and even more importantly, he communicates about them
with other people. However, when a parent or caregiver often uses
strong negative words to describe a child or shows disapproval of or
ignores certain parts of a child, these negative names and responses
give the child a false understanding. The child learns he is wrong or
bad, or that some part of him is unacceptable. Often these negative
responses become demanding inner voices which shape the child’s
way of seeing the world. When a parent or caregiver speaks negatively
about the world or other people, it has the same effect. For instance,
if a parent is prejudiced about skin colour or race, a child may often
hear comments such as ‘Black people are lazy.’ Usually the child
unconsciously accepts his parent’s attitude and it shapes his thinking.
It is human nature to make judgements about the world and ourselves.
In this case, Emma’s ‘voice of truth’ says, ‘You are a burden!’
‘Yes. I always feel like that.’ Emma agrees with the voice figure.
‘About fifteen years ago it turned into a long-term depression. I was
not able to take care of my children and husband. Sometimes it feels
so unbearable. I wake up with it and I go to bed with it. I am so
exhausted.’ Emma puts her head down. She looks like she is carrying
‘the burden of herself ’ on her own shoulders right now.
I respond to it using the witness figure: ‘If a witness was here, the
witness would say, “I see how down and helpless you feel thinking
you are a burden and when you remember you could not take care
of your children and husband.”’ Emma nods. This is usually a sign that
the observation about her state of mind and emotions is accurate. Emma
is aware of what is happening with her here and now as she explores
her very uncomfortable experiences with herself. She continues, ‘My
adoptive parents used to tell me with disgust, ‘You are black! Nigger!’
Here we are. Emma’s history is opening quickly. Emma’s deep
sense of being inadequate has got very old roots. She has lived with it
for decades. In fact, she knows no other way of thinking about herself.
We put placeholders for her adoptive parents on the table. They are
two small pillows, one green and one brown. I immediately suggest a
‘reversal’ for this traumatising memory of her adoptive parents. ‘What
would be an ideal possibility?’ I let Emma picture an ideal possibility
in her own mind.
‘Parents who would see differences, such as a different colour of
skin, as a positive thing, not a dirty thing,’ Emma wishes.
‘Let’s have somewhere here in the air the possibility of ideal
parents who would say, “If we were your ideal parents, when you were
a child, we would have appreciated differences. Your skin colour would
be a positive feature, not a burden, to us.”’
Emma listens, but she is still caught in her old painful memories.
The PBSP therapist does not let clients reinforce traumatic memories
by rehearsing them over and over again. Instead he intervenes to break
this cycle by creating a healing antidote. So I keep going by sketching
another ideal possibility for Emma. ‘Your ideal parents would also say,
“If we were your ideal parents, we would have the same colour skin
as you. You would feel like a natural part of our family. We would be
proud of our origin.”’
Emma does not like this ideal possibility very much. She is lost in
her own contradictory thoughts.
Suddenly Emma states, ‘It all starts with my biological father. He
was black. But I know nothing about him. I have no idea why he left
me behind.’ Emma has got a desperate, longing expression in her eyes.
‘A witness would say, “I see how sad and yearning you feel thinking
of your biological father.”’ I name the emotions Emma shows when
she thinks of her unknown biological father.
Emma replies, ‘Yes, I do. I think about him often. I feel so

fragmented.’
‘It seems you have been busy with him. What did you think about
him when you were a child?’ I am aware Emma must have been trying
to solve this puzzle about her father already as a child. He was black.
She knows about that. He did not take care of her. What happened?
Why did it happen?
‘Oh, yes. I always wished I knew more about him. I was told so
many different stories. As a child I was imagining where he was, who
he was. Maybe he had some problem so he could not take care of me.’
Emma remembers the concerns she had when she was young. They
have not faded since then. No wonder Emma feels fragmented. In
her mind she has been trying to glue all these pieces of her history
together. This may also be the reason for Emma’s difficulty imagining
the possibility of ideal parents. I understand that children try to take
care of people who are close to them and other significant people.
They may take care of people in their mind, imagining ways they
could help or solve problems for them. Sometimes they may even try to
parent their parents. According to PBSP theory, when we are very
busy taking care of something or someone else, our brain is not able
to receive care and support.
When Emma confirms that she is concerned about her father, I
continue, ‘Well, we know nothing about him except he was black.
At the same time, I see how much you thought and cared about him.
We might create a movie for him.’ Emma agrees. She takes a stone
and I put it on the table as a placeholder for her father. I frame the
scene. ‘It represents your biological father as a young man when he is
finding his ideal partner and having children.’ I ask Emma how she
imagines his ideal life when he is ready to have a partner and children.
‘He would have a partner from the same country and she would have
the same skin colour.’ Emma is imagining what she would wish for her
biological father as a young man.
‘Yes! So here we have his ideal wife and ideal children.’ We put
two more stones near the one which represents her father.
I continue, ‘They speak to him: “If we were your ideal family, we
would share a culture, country and colour of skin.”’ Emma listens to
this carefully as she looks at the stones.
‘It is surprisingly relieving,’ she says after a while. ‘When I imagine
this, I don’t feel like I need to do something for him. It sounds right
for him. If he had such an ideal family, he wouldn’t have to solve the
problem of having an illegitimate child in Europe. Me. It must have
been a burden for him.’
Emma experiences peace. The burden falls from her shoulders. She
is seeing her father happy and not stressed about her as his unwanted
child. She is a little surprised by it.
I clarify a bit in order to give Emma a frame of reference for her
new experience. It also outlines the next step. ‘You know, it seems there
is a genetically based “need for place” in us. Parents and extended
family belong to a certain culture. A child should experience that their
parents feel safe and proud of belonging to their ethnic group, nation
and country. In that case, the child develops a safe attachment to the
wider world. They feel happy to be part of it.’
Now, after taking away the burden she imagined her father
carried, Emma can go back to her own childhood. What would be
the ideal origin for her? Something she could experience as a safe nest
where she can grow and thrive without feeling like a burden? Yes,
now she has got a clear picture and she is painting her ideal childhood
with ease. Now she feels free to experience something very different
and positive.
‘My ideal parents would be Creoles!’ Emma says and gives me a
big smile. ‘They are as dark as I am, but they are very happy about it! I
can be there with them as a little girl. They are proud of me, their little
daughter. There is a village and I visit with my relatives and friends
often. We all look the same. We are proud of our origin. I feel so free.’
She speaks freely and there are stars in her eyes. They are stars of hope.
No sign of burden at all.
‘A witness would say, “I see how vital and liberated you feel
imagining such a possibility.”’ I use a witness figure to highlight
Emma’s emotions in the context of her experience with ideal parents
and family in her past. Emma nods with a big, relaxed exhalation and
content smile.
I speak for her ideal parents. ‘If we were your ideal parents, we
would be Creoles and we would have the same dark colour of skin
as you do. With us you would have the feeling of safe belonging and
freedom growing up.’
I remind her, ‘Imagine you would have experienced this as a little
girl. Experience this as if you were a child again.’ Emma smiles, being
fully absorbed in her new memorable experience.
‘Oh yes. It is a state of mind, belonging. I am not a burden to

them. We belong to each other. They love me the way I am.’ Emma
integrates her ‘new memory’. It is a completely different world from
the one she grew up in. This one fits with her childhood needs and it
feels right. Emma can relax and have peace. When she indicates she
has completed her structure, we de-role all the objects she used for
placeholders and de-role the witness and voice figures in the air. At the
end we de-role the image of her ideal parents and family.
Therapist thoughts
In PBSP theory ‘place’ is one of the basic developmental needs. ‘Place’
plays a very important role in this structure. When Emma says, ‘I feel
so fragmented’ it reflects her broken roots and having no licence to
belong somewhere and be accepted as she is in the world. It is hard to
have a sense of roots, identity and belonging when your life starts with
such confusion and it does not get resolved. But I am thinking that the
deficit of ‘place’ which constantly disturbs Emma’s inner peace also
involves the ‘vacuum’ spots in her history that she could not resolve.
Knowing nothing about her birth parents, she just makes guesses
about them. The human mind does not like ‘unknowns’ when it comes
to our closely related people. Because Emma never had a warm, loving
place and safe attachment in her adoptive family, she kept looking for
it and imagining her biological parents could have given it to her if
they had a chance. Today Emma experienced something astonishing
and unexpected. She was asked to give her biological father an ideal
family. And she realised she always wanted to see her biological father
happy. A PBSP structure allows such an extraordinary thing. When
Emma saw her biological father, whom she has never met, happy in
the movie, she was freed from a very painful puzzle. No, it is not her
job to make him happy; the appropriate people take care of it. What
a new and liberating thought. And when she lets this burden go she
is able to imagine and integrate the idea of her own ideal family:
something she always wanted and never had.
Emma and a ‘bad sign’

Emma has often touched on her feelings of insecurity during our
sessions. We have reversed her bad memories in many structures. She
has started feeling better. She arrives for sessions and starts differently
than ever before, feeling content and eager to do more work. Her
relationships with members of her adoptive family have improved. She
has become a happy mother, proud of her children and taking good
care of them. About one year after the structure about ‘being black’,
she has to deal with another level of the same problem.
‘I am good. I’m sure about it and I don’t want to analyse it,’ she
says, sitting comfortably on the sofa in my office. Then her expression
changes. There is a dark shadow on her face.
‘Today I went shopping. People were looking at me with
smiles. They seemed to be positive, but I didn’t quite trust it. It was
pleasing looking at them, but at the same time, I could see a darkness
behind that.’
‘A witness would say, “I see how depressed and haunted you feel
remembering how you experienced people in the shop today.”’ I
respond to her story by micro-tracking her emotions.
‘Yes, haunted. It’s like being marked with a bad sign which
everyone can see.’
‘That is the voice of the “bad I”. It says, “You are marked with a
bad sign and everyone can see it.”’
An old memory of Emma’s opens right away. She tells me a story
she often heard from her adoptive mother when she was a child. ‘My
mother used to take me for walks. I must have been young. I suppose
I was in a pram. People would see a black baby with a white woman.
They shouted at my mother, “You are a whore!” They thought she had
conceived me with a black man and she wasn’t married to him.’
‘Let’s have placeholders for your adoptive mother and for those
people.’ Once the placeholders are on the table I quickly reverse that
memory. ‘Let’s have an ideal crowd in the air. The ideal people would
see your mother with you and say to your mother, “What a lovely baby
you have. She is so sweet.”’
‘Oh, they all would celebrate me.’ Emma expands the image. ‘It
wouldn’t matter what I was like: what kind of talents or gifts I had,
what I inherited. Because they would accept me and appreciate me
the way I am.’ Emma is very sure about how it should have been. She
strongly wishes she was genuinely accepted. I put her ideal picture
into words spoken by her ideal parents. ‘So they say, “If we were
your ideal parents when you were a child, you would feel proud of
yourself and you could be yourself. We would have recognised you

and appreciated you the way you were. And the whole community and
society would have too.”’
Emma says, ‘There would be no stereotypes. I could play and be
myself all the time.’ She is back in time imagining herself as a little girl
and a young woman surrounded by her parents, relatives and society,
who would not see her as strange, different or having a ‘bad sign’. She
is quieted and she experiences that peace for a long time.
‘What’s happening?’ I ask about her inner process.
‘You know, I’m good at swimming. And so are my children. We
love water and we swim like fish! I like that about us!’
‘A witness would say, “I see how proud you feel remembering that
you and your children are good swimmers.”’
‘Yes! It’s in us. It’s biological and it makes us similar. We have this
special feature in common.’ Emma enjoys exploring this interesting
detail which came to her mind. I provide a bit of teaching and add
a layer of meaning to her ideal parents: ‘You see, that means being
biologically connected. It is a genetic connection. Imagine you had
felt such a biological connection with your ideal parents. They would
say to you, “If we were your ideal parents when you were a child, you
would have felt you were ours, that you came from our bodies.”’
Emma finds this a very powerful, fascinating idea and experience.
It is very new to her. She always felt as if she ‘came from nowhere’.
Now she imagines sharing a biological, physical connection to her
ideal parents. It is an ideal possibility she can now experience in her
mind and body.
The structure came to a good end. It helped Emma experience
herself as a beautiful human being connected to her family and society.
How safe and natural it felt. The experience brought another level of
peace to her. She remembers now on both explicit and implicit levels
of memory what it means to be part of a family. She can belong now.
She knows how right it feels to belong to your closely related people.
What a simple thing and yet what a discovery for Emma.
Therapist thoughts
Emma is making progress. At the beginning of our work she felt
exhausted and out of place all the time. Now she feels secure and
happy most of the time. I like to call it a ‘growing land of happiness’.
But her brain remembers the beginning of her life. It stores the
sensory, emotional and cognitive records of the confusion and chaotic
experiences she went through. Sometimes ordinary situations still
trigger these memories and reactions related to her history. Then she
re-experiences the confusing, painful thoughts and feelings she had as
a child. Slowly she is addressing different facets of her childhood
trauma and letting go of the distress they cause her. It is a long road
but not endless.
Her work in PBSP is complicated by the fact that she deals with two
sets of parents: biological ones, who abandoned her, and adoptive ones,
who often mistreated her. I have worked with many adopted children
and adults. It seems to be a universal issue that they often feel different,
strange. Some of them cannot forget for a single day about their being
adopted. They keep trying to resolve their questions and distress, but
relief does not come. What does adoption and its circumstances do
to the brain? What happens to the brain in a structure like Emma
did today? The complete reversal of that situation is a surprise for
her and for her brain too. We are not negating adoption at all. It was
helpful for her to experience what it would be like to be brought up by
biological parents and belong to them to address the meanings she had
generated about having unknown parents and their possible rejection
of her. I know this topic will be back. It has got many facets and today
we touched only one of them.
Emma and the koan of two left slippers

The term ‘koan’ is well known among Buddhists. It refers to an
unsolvable paradox which is used by Zen Buddhist practitioners to
break dependence on logic and reasoning. One of the most famous
ones is about ‘the sound of one hand clapping’. Solving a ‘koan’ may
lead to enlightenment.
Some more months and structures went by. On a December
morning Emma arrived feeling merry and full of joy. She had recently
been to a family gathering and felt connected to all the members of
her adoptive family. She is speaking with her adoptive mother again
after years of silence. Emma can be in touch with her family and not
feel overloaded by unresolved memories from childhood. Everything
seems to be going well. She tells me she saw a little girl in the hallway
outside my office. She felt just as innocent as that lovely, cheerful child.
‘You know that is a happy, good childhood: innocent laughter,

jumping and singing, lots of energy.’ Emma summarises all the qualities
of a good childhood and the way she says this has got the flavour of
a deeply felt wish.
‘If a witness was here, a witness would say, “I see how much longing
you feel when you think about the attributes of a good childhood.”’
‘Well, yes, but I am kind of angry too.’ Emma responds to my
witnessing. ‘When I was trying to find slippers in the hallway, I only
found two left ones! It irritated me. It’s not natural! They don’t fit! It
doesn’t feel right to my feet!’
I respond, ‘That’s a voice which says, “It’s not natural.” And a
witness would say, “I see how angry you are thinking of two left, non-
fitting slippers.”’
‘Yes!’
‘Let’s have a placeholder for those two left slippers.’ Emma puts
two small pillows on the table to represent all the qualities of those two
slippers. I continue speaking with a thought in mind. ‘It looks like
these left slippers remind you of something, something which is not
fitting. Something which should be right, but it’s not.’
‘Exactly!’ Emma exclaimed. ‘That’s how I often feel. Like
everybody’s telling me, “You don’t fit.”’ All of a sudden, Emma is full
of doubt. She can feel the difference between the innocent child and
the strange, non-fitting person that she thinks she is.
‘It seems there’s a principle of “non-fittingness” on those slippers.
Take a small piece of paper and put it here on the placeholders for
the slippers.’ Emma does this. ‘And they remind you of you being so
unfitting.’
‘Yes.’
‘Yes. Just like that. Now we can see it clearly. The principle of
“unnatural and unfitting” is on the slippers and on you. You feel like
you are “not fitting” too. Let’s have another piece of paper and put it
on you. The piece of paper represents this same principle which you
see in yourself.’
I simply tell her, ‘Al Pesso developed this intervention in order to
work with projections and linkages our mind unconsciously creates.’
Then I ask Emma, ‘Who are the people you mentioned before?
Who might be telling you you don’t fit? Do you have somebody
in mind?’
‘My former husband and his mother. They always let me know I was
strange. And then my adoptive family. They are so full of themselves
they have no space for me. None of these people ever listened to me.’
We put placeholders on the table for each of these individuals.
Emma comments on it with a sad and angry expression: ‘They all find
me strange, non-fitting.’
‘A witness would say, “I see how frustrated you feel when you
think of all the people who don’t listen to you and find you strange.”’
‘Oh, yes.’
‘What would be a reversal for this group of people?’
‘I would like to have a group of ideal people who would be very
different.’ Emma knows what she wants. ‘First, they would listen to
me, then they would have a real picture of me.’
‘Let’s have such a group of ideal people here. They say, “If we were
your ideal people, we would first listen to you and then we would have
a real picture of you.”’
‘Yes. I would like them to understand what it means to be adopted.’
Emma is trying hard to clarify what she has on her mind. It is
obviously so important to her.
‘A witness would say, “I see how eager you are to explain yourself
and be understood.”’
‘Why do I find it a problem? When does the problem of adoption
appear? After the child is separated from her mother? In the baby
home facility? In the adoptive family?’
I decide to give Emma some simple facts about these issues.
Sometimes it is helpful for the client to hear about scientific findings
or psychological theories. It is often used in Pesso therapy to normalise
the client’s experience and help them understand their difficulties.
‘Well, it seems to be an issue for most adopted people. Many
adopted people say the fact of being adopted is always on their mind.
Let’s think about it. A child experiences separation from his birth
mother. This experience is saved in implicit memory as a rejection
and loss. Trauma. Then the child is placed in a residential facility or
a short-term foster family. Typically, a few months later, he’s moved
to an adoptive family. A young child is not biologically built to cope
with these events on their own. But many adoptive families don’t
know how to help a child with this fundamental issue. Like your
adoptive family, your parents were not trained to be supportive and
understanding. As you can see, it is a cascade of unfortunate events.
Later, when biographical memory becomes active, the child hears

stories about his origins. If adoptive parents and professionals don’t
know how to help the child with this issue, the child relies on his own
fantasies and creates his own stories to cope with it. Often the child
is left with questions and distressing feelings. Most of these people
will say, “If I had a choice, I wouldn’t want to be adopted! I wish I
had a good mother and father and lived with them.”’ Emma has been
attending with genuine interest.
‘It sounds so good, that it might be a “biological fact”. Something
we are born with. You know, my parents never talked to me about
it! I thought myself that it must have been something terrible when
they didn’t speak about it.’ Emma is holding her knees. She looks and
sounds very small. Her voice is weak and quiet.
‘A witness would say, “I see how ashamed you feel when you think
about your parents and how you thought about yourself when you
were a child.”’
Emma nods with deep sadness.
‘Usually we would have ideal birth parents here for you, so your
life would start the right way from the beginning. But today I think
we should have ideal adoptive parents, who would have helped you to
be a happy, healthy adopted child and adult.’
‘I think so,’ Emma agrees. ‘I would like to have someone with me
all the way through from the very beginning to the present time.’
‘Who would that be?’
Emma says with a shy hope, ‘A fairy called Adopee.’
I sketch an ideal fairy called Adopee in the air and have her talk to
Emma. ‘If I was your ideal fairy, Adopee, I would have been with you
from the very beginning to the present time. I would talk to you and
explain everything to you about your adoption.’
Emma says with relief, ‘It sounds good and normal.’
‘A witness would say, “I see how relieved you feel when you think
of such a possibility.”’
I continue, ‘There is a principle of ideal adoptive parents on that
fairy. It would be the job of your ideal adoptive parents to be with you
and explain all these issues to you with love and acceptance.’ Emma
nods. We put ideal adoptive parents in the room. They are represented
by two big pillows behind Emma’s back. She decided to put them
there so she can lean on them and rest with them.
I continue, ‘If we were your ideal adoptive parents, we would

be with you from the beginning. We would understand you and we
would know what being adopted means to you. You could rely on us.’
Emma adds, ‘And we would know that it’s a good thing! It is
a good thing!’ Emma says this with a light of new recognition in
her eyes.
I respond to her, ‘A witness would say, “I see how inspired you feel
by your discovery about adoption being good.”’
Emma keeps going with the same enthusiasm, ‘Nobody wants
to be adopted, but it is good! I got it!’ She feels deep relief in her
entire body.
I continue, ‘Imagine you had such an experience with your ideal
adoptive parents from the very beginning of your life. They would
say, “If we were your ideal adoptive parents you would have felt this
inspired, light and content with us from the beginning to the present
time and forever.”’
Emma smiles. ‘We would talk about adoption freely any time. We
would know what it’s about. Nobody wants to have an arm in plaster,
but it’s good plaster exists!’
I remind her about the two left slippers. I gently say, ‘It might be a
good time to move the principles. When you put on two left slippers,
you knew about it. It did not feel right. You felt irritated by it as it
reminded you of that feeling of “non-fittingness”. So that principle
belongs to your childhood. Now we can move the principle from the
slippers and put it where it belongs.’ We move the piece of paper and
put it on the placeholders for Emma’s adoptive parents and for the
residential facility for babies. That is where her feeling of not fitting
started. We also take the same principle from her body and place it on
the placeholders for her real adoptive parents and the ‘baby home’ too.
Emma suddenly feels free and full of life. She says, ‘I can see the
three of us: me and my ideal adoptive mum and dad. We are singing
a song together:
Nobody wants to be adopted
Nobody wants to be adopted
But it’s good, but it’s good.
She is very happy.
‘You know people don’t understand this and that’s OK. It’s
important that my ideal adoptive parents would understand though
and that they would help me understand it. It is like a resolved “koan.”’
‘If we were your ideal adoptive parents, we would understand
you and you would feel safe and secure with us. There would be no
irresolvable issues.’ Emma is glowing. It was a very important structure.
It gives her a new perspective on her life.
Therapist thoughts
Emma suffers from emotional difficulties which we often see when
working with adopted clients. We can imagine their confusion as
a house which has shaky foundations. There is a building but it is
built on sand. Adopted clients often speak about feeling good about
themselves but feeling strange, different and inadequate beneath that.
This discrepancy is difficult to live with. PBSP therapy aims for
an ‘ideal experience’ in terms of an evolutionary, genetic program.
According to Albert Pesso, our genes carry information as to how
developmental needs should be met so we develop to our full potential.
Therapeutic intervention should provide an experience for the client
which will reverse the effects of childhood trauma.
This means that in a PBSP structure an adopted client experiences
being born and growing up with ideal, loving biological parents: the
way it should have been in the first place, what our genes programme
us to anticipate. However, Emma was dealing with another type of
issue today. She was adopted and a part of her difficulties was that her
adoptive parents made her feel ashamed of it. So we did a structure
which gave Emma a chance to experience ideal adoptive parents, who
would have made her feel good, proud of herself and OK with being
adopted. This had been one of the irresolvable ‘koans’ in her life. The
structure liberated Emma from some of the sense of strangeness and
shame about being adopted.
Emma and a light ring of connection

The next structure happens after I have been seeing Emma for three
years. Emma arrives with a new haircut and a big confident smile on
her face. She looks girlish and full of light. She chats about her new
life and what she wants to do. She plans to take dance lessons as she
has always wanted to do. She celebrated her birthday with friends and
family members.
‘I am content and happy. My life is in order and I experience
peace. It is so nice!’
What a difference. I think, ‘This is the real Emma. The dark
shadows have disappeared as if they had never been there.’
Emma speaks proudly about her children. ‘My son, Richard, has a
partner, Julia, and they’ve started their independent life.’
‘Let’s have placeholders for Richard and Julia.’
Emma carefully chooses two small woollen pillows and tenderly
puts them on the table.
‘What comes to your mind when you think of them?’ I ask.
‘They are so wonderful to me. They care about me. They are part
of my life and support me. My son, Andrew, and his girlfriend, Jane,
are very nice too.’ Placeholders for Andrew and Jane are placed on
the table too. Emma shines with pride and happiness as she looks
at the placeholders. Then she says, ‘They now support me, you know.
They invite me for meals, they care about me. It’s very reassuring.’
‘So there is a principle of support on them. Let’s put a piece
of paper on each placeholder for your children, which means they
provide you with support.’ Emma does this.
‘Yes, I feel safer when they support me.’ She leans towards the sofa.
It is visible how much the thought of the support her children provide
makes her feel relaxed.
‘A witness would say, “I see how relaxed and carefree you feel
thinking of your children supporting you.”’
‘Yes.’ Emma agrees with a deep exhalation and a mellow expression
on her face.
‘I also saw my schoolmates from high school. We all went to
climb a mountain.’ Emma puts placeholders for schoolmates and the
mountain on the table. She is absorbed in her story.
‘I was slow and at the end of the hike, two friends had to support
me. It was hard to breathe and I could not catch up with the group.’ She
says this with a gentle smile and her eyes are tender. It is interesting
that her expression is so calm as she remembers hard climbing and
being tired and slow. But she is actually talking about something else;
the helping hands and hearts of her mates.
‘A witness would say, “I see how comfortable and reassured you
feel when you remember your friends helping you.”’
Emma nods and continues, ‘They were both men. One of them
was a doctor. I felt so safe with them and they did not leave me when
I was not able to keep up.’
‘Let’s have placeholders for both of them, the friend and the
doctor friend.’ Emma places two stones on the table.
‘There is a principle of support on them too.’ We put pieces of
paper on the placeholders, which makes the meaning of her memory
visible. Her main feeling about her memory is pleasure in being taken
care of and supported when she was weak. I immediately think of her
as a young child who needed supportive parents. I don’t mention this
now as I trust the process and this surfacing topic will either fade or
she will follow it further by herself. We will see.
‘We had a great party with my family; my adoptive parents, my
siblings and their children.’
‘Placeholders for your family members.’ We put placeholders on
the table. It is pretty full now, but it covers what is going on in Emma’s
mind thus far. Emma continues.
‘But my sister, Martha, was angry, even aggressive.’ All of a sudden
Emma looks like a lost, young child.
‘A witness would say, “I see how confused and lost you feel
thinking of the behaviour of your sister, Martha.”’
‘Yes. No. I feel mad and rather sad. It is sad she was so bad to me.’
Her voice is sad and there is a flavour of disappointment.
‘A witness would say, “I see how sad and disappointed you feel
remembering your sister.”’
‘That’s right. Yes. But on the other hand, members of my family
didn’t let her shout at me. They took care of her and helped her calm
down. When we were children I was on my own. There was nobody
there. Nobody even knew she was treating me with such aggression.’
‘A witness would say, “I see how reassured part of you feels when
you remember family members supported you, and how helpless part
of you feels when you think of how alone you were as a child dealing
with your aggressive sister.”’
‘Exactly.’ Emma looks at me with gratitude. The witness captured
her state of mind very well. It is a great thing to be understood and
have clarity about what she is feeling.
‘As you remember these scenes of your childhood now, let’s reverse
them. Let’s have the outline of your ideal parents here, who say, “If we
were your ideal parents when you were a child, we would protect you
and support you. You would not be alone with trouble.”’
Emma nods, but she is still busy with her sister, Martha.
‘She was so needy. I was supposed to be there for her and then she
was fighting with me. My parents did not have time for her.’
Emma has difficulty receiving and letting herself experience the
possibility of being supported and connected when she thinks of her
sister and childhood. It seems impossible because her childhood was
so different, just the opposite. And it became her ‘truth’. She was in
charge and no one else would deal with her difficult sister. At the
same time, she tried to get support wherever she could find it. Such a
conflict creates confusion and ambivalence. One emotion seems good:
she feels like a hero because she took care of her sister. Another set
of emotions is negative. She feels overlooked, worthless, helpless and
desperate for support. The intervention which follows helps straighten
out this emotional tangle.
We will be ‘making movies’. The therapist uses small objects to
enact a scene so the clients see people, whom they tried to take care
of, getting their needs met by ideal figures.
‘Let’s make a movie for your sister when she was young. Pick an
object and give it to me. It will represent your sister as a baby.’
Emma picks up a small blue pillow and hands it to me. I put it on
the floor saying, ‘This represents your sister, Martha, as a tiny baby.
What kind of parents did she need?’
‘Oh. Her ideal parents would love her. They wouldn’t have divorced.
They would support her and set loving limits.’ Emma is bursting with
ideas. As always, it astonishes me how clients who parent or take care
of someone – siblings, parents, grandparents and so on – are so clear
about what those others needed. This applies even to clients without
prior experience in PBSP and who had poor parenting themselves.
‘Pick two objects and give them to me.’ She chooses two pink
stones. I put them close to the blue pillow representing her sister as a
little girl. I enact a scene using Emma’s exact words. ‘The ideal parents
say this to baby Martha: “If we were your ideal parents, we wouldn’t
have divorced. We would’ve loved you and we would’ve set loving
limits for you.”’
Emma watches the movie and her energy flow changes. I can see
her breathing change and her shoulders relax. She is somehow more
grounded now.
‘It’s great. Before she was like a high, dangerous flame. Now
she would be a clear, warm fire, good for people. It’s so satisfying to
see that.’
‘Yes. And it wouldn’t be up to you to take care of her.’ I make a

little theatre play by animating the stones. I lift the two pink stones in
the air like little puppets. ‘Now Martha’s ideal parents talk to you.’ I
show the stones to Emma and say, ‘“It’s our job to take care of Martha.
Not yours.”’ Then I put the stones back in the movie with the pillow
representing her sister as a little girl. ‘And they go back in the movie.’
It is a humorous intervention. Albert Pesso used some of his dance
and theatre talent when developing it. It works very well. In this way
Emma is reassured. She hears with her own ears and sees with her
own eyes that, yes…Martha’s ideal parents take care of Martha. It is
not Emma’s job. Now she can relax and leave it. Watching the movie
frees her from the strange consequences that result from her role in
childhood. Her confused emotions and preoccupation with another’s
need no longer overwhelm her. She is not needed in the movie because
there is no hole there. She is no longer caretaker for her difficult sister.
She is free of that role. Emma experiences this. She digests this new
possibility and sits quietly for a while thinking.
‘But then I have no sister in my childhood. That’s sad. I don’t like it.’
‘A witness would say, “I see how dissatisfied you are when you
think that this way you wouldn’t have a sister when you were a child.”’
‘Hmmm.’
‘As you know, in our possibility sphere here in this room, we
created the outline of ideal parents for you.’ I remind her about them
by pointing to the air. ‘You can have an ideal sibling too.’
‘Yeah. I want them. And could I have an ideal younger brother
too? One year old?’
I paint in the air her ideal parents and her ideal brother. She wants
her parents placed behind her back with her little brother next to her
on the sofa. Emma takes in this new experience easily and quickly.
When clients leave their lifelong role of caretaker, provider, and so on
which they learned as children, they feel relieved and are more open to
having their own needs met. Emma expresses this by telling me how
she feels now. It is her healthy, happy childhood state of mind with
ideal parents and an ideal sibling.
‘We belong together. They love us and they enjoy us. When we
have a problem, we deal with it and they help us solve it. I have full
support from them. I am never alone with them. We love each other.
And it’s no effort. It is so simple and natural!’
‘Yes. A witness would say, “I see how content and easy you feel
experiencing such a possibility for childhood.”’ I let her talk and
I name her experience. This way she registers it on emotional and

logical levels, connecting them with language.
‘I feel bonded with them. It is like a “light ring of connection”.
Something bonds us together. Nothing can break it.’
‘So your ideal parents say, “If we were your ideal parents when you
were a child, you would feel safe, supported, loved. With us you would
feel bonded and connected like there was a ‘light ring of connection’
among us. Nothing could break it.”’
Emma looks very happy. She has got the expression of a young girl.
‘I feel strong too. I feel very confident inside. My life is all in front
of me and I want to contribute to it.’
‘If we were your ideal family, you would have felt self-confident. You
would feel your life is all in front of you and you can contribute to it.’
Emma integrates this for a long time. I let her relax and stay with
her new experience. When she is ready to finish, we take the principles
of support from the placeholders for her friends and children and
place them on her ideal parents. This way she can see that her need
and satisfaction related to being supported belongs to her childhood.
She missed it so much there and today she experienced it with her
ideal family. She has to get it in the as-if past. The unmet need from
childhood will continue when the client only experiences support on
an adult level. We both know it was a deep, important structure.
Therapist thoughts
Emma has made significant progress. She sometimes seems like a
different person. But she is not someone else at all. Rather her sense of
herself has changed. Some clients say their entire life changes and they
find it hard to remember what their life was like before. Yes, I think,
Emma had a terrible start and an extremely difficult childhood. She
was carrying consequences in her mind and heart and it seemed her
fate was sealed. But Emma used her will, bravery and effort to change.
Her ‘pilot’ was always present and she was in charge of her steps all
the way. And now she is in a different place. She is stronger and more
ready to live. It will be a life of challenges, work and relationships.
Nobody’s life is easy and it is not the aim of therapy to create an
easy life. Emma does not expect that. She feels confident, strong and
enthusiastic to live her life the way it should be.
Chapter 6
ANTHONY, A YOUNG
MAN WHO JUMPED
Petra Winnette
Introducing Anthony
Anthony did not call me himself. He would never think of it. When
he was twenty, things got unbearable for him, so he jumped in front
of a subway train. Not many people survive such a decision. Anthony
did. He spent six months in a coma. Doctors did not know how well
his brain was going to work if he ever came back to consciousness.
I heard about Anthony from a colleague of mine. She is a
social worker at an organisation which runs a half-way house. The
organisation provides services for young people with very difficult
family backgrounds. They have nowhere to live, no job skills, and
they are not mature enough to start life on their own. The organisation
is called the Little House. I have been collaborating with colleagues
from the Little House for many years. From time to time they call and
ask me to see one of their clients. These are very special young people.
Most of them have been through a very tough childhood. From the
very beginning they have no experience with even a tiny bit of ‘good
enough’ parenting. A typical history involves a neglectful or abusive
mother, many different step-fathers, trauma, institutional care, jail and/
or psychiatric clinics. When they turn eighteen, they are supposed to
be grown up, autonomous and capable of an independent, pro-social
life. Instead, they end up on the street, lonely, lost and confused.
Clients of the Little House get another chance to mature. They
learn basic work skills and have a place to live while finding a job.
Most important, they have professional adults there who offer honest,
healthy relationships and an environment which fosters their ability
175
to relate to other people, because most of the time this is their

biggest issue.
So one day a social worker, Hannah, told me about Anthony.
Hannah is his caseworker and she really cares about him. Anthony has
lived at the Little House for more than a year and he has made
significant progress on many levels. He can now keep a job and he
does not have tantrums any more. He is on medication which balances
his affective dysregulation. Anthony and Hannah have developed
a nice relationship and trust. However, Hannah and her supervisor
know Anthony is progressing and stagnating at the same time. His
general confusion about people and himself is massive and it does not
seem to be changing. Anthony is an intelligent, capable, good-looking
young gentleman. He has got his own original view of the world. But
Anthony and his emotional life go around in a ‘vicious circle’.
He is constantly absorbed in analysis of who he is now and who
he was before his suicide attempt. Deep depression and hopelessness
do not leave him. His self-esteem is so low and his shame so high
that Anthony often refuses to leave the Little House. His relationships
with peers and partners end in failure. He wishes to find a partner, a
true love, whom he can trust, love and be with all the time. As you
will see, he creates severely dependent relationships instead. When
Anthony falls in love, he loves with an innocent, young child’s heart.
But he also wants attention and connection twenty-four hours a day.
His friends and partners see him as an attractive man, but often they
later use him and leave him. And Anthony’s circle of hope and despair
is repeated. Meeting Anthony meant meeting an attractive young man
as well as a suicidally depressed client with a dark future.
Anthony’s first session

With a great deal of hesitation, Anthony decided to see me. He wanted
to have his caseworker, Hannah, with him. I let clients from the Little
House choose if they prefer to see me on their own or bring their
caseworker with them. Hannah was excited about his willingness to
see me, but sceptical about his participation in PBSP therapy. Of course
he agreed to it, but he has never been in therapy before and such an
idea conflicts with his usual way of dealing with things. Typically,
he agrees to start an activity, then declines to continue. So definitely
Anthony, a young man who jumped 177
there was not a lot of determination on his side. We tried anyway.

Really, was there anything to lose?
So late one day Anthony and Hannah are sitting in my office. I
always think it is a good start when, after lot of hesitation, a client
finally arrives and is sitting in front of me. Here he is. He has made
the first step. A huge step given his mind-set. I know how hard it is
for him. Most often I open the first session with a longish interview
which involves talking about the client’s expectations and making
our contract. We also review his history and early relationships. An
inventory based on the clinical application of the Adult Attachment
Interview (George et al. 1985) naturally opens the door to the client’s
history and the thoughts and feelings connected with his early
memories. This is not a typical step in PBSP, but it is helpful and it
gives the work a certain frame. First of all, I can assess the client’s
state of mind and his connection with reality. Second, it brings up
the topic of childhood and how it relates to the present. Clients like
Anthony have never heard that a difficult childhood has an impact
on people later in life. He is aware his life is not going happily and
successfully, but he never links his problems with his childhood. When
you ask a client like Anthony why they want to see you, they may
simply say they do not want to see you and leave. They are sitting in
front of you in your office, but their mind and heart are trying to hide
a thousand miles under the sea.
Anthony and his early relationships

Anthony was born to an eighteen-year-old girl who lived with her
parents. His father did not know about him. When we talked about
Anthony’s relationship with his mother, he was aware of its nature
and could speak about it with clarity. He was slow and it took a long
time for him to express himself. Sometimes it looked as if he had
got lost somewhere in his mind and would never come back. But he
did come back. Let’s see how he felt as a child and how he sees his
mother and his relationship with her as a child and now as an adult.
He remembered the relationship as neglectful and fearful. She often
wronged him. Anthony has got a lot of memories of his mother telling
him he should not exist and he made her life miserable. Anthony
tried to be a good boy, but she did not care about him anyway. When
he wanted something, he knew she would say ‘no’, so he was afraid
of asking. When he was upset as a kid, he would never go to her.

What he recalls well is an omnipotent feeling about his own abilities
and independence. He could only rely on himself. He was a very
independent kid and he was proud of it.
When his mother married Martin, Anthony was six years old. For
a short time, Martin was a nice, reliable person in his life. He liked
Martin and would go to him if he needed something. But before long
his mother divorced Martin and Martin disappeared from his life.
Anthony remembers feeling unwanted. He knew it as a child. He
envied friends who had parents who liked them and had relationships
with them. He is aware of being rejected by his mother. When I asked
why he thinks she treated him like that he was sure about it. ‘Because
I destroyed her life. Because she was selfish and only liked herself.’ He
continued, ‘She only did what she wanted. I’m like that too. I should
be sad about it, but I’m not. She cared just about herself and I’m the
same. Selfish. We have not seen each other for about seven years. I
only have bad memories. There is absolutely nothing between us.’ He
paused. ‘Actually, she liked theatre and she used to take me to theatres.
That was good.’
Later in his life Anthony met his biological father. According to
him, his father was a very intelligent, educated man. He let Anthony
live with him for a short time, then rejected him. Anthony does not
want to give me any details. It is a recent experience and it is too
painful to recall it. Anthony is quiet. It is hard for him. Somewhere
deep inside he is in touch with the rejection by his father and he hates
himself.
At the end of the first session I gently explain that the work we
are going to do together will be about what is happening in his life
and mind now, and it will be going back to his past and childhood,
because some of the problems he is experiencing have their roots
there. I will tell him more about our work next time. ‘Do you want
to come back? Shall I bring my diary and shall we find a date for our
next appointment?’ I always ask my clients this. ‘You can think about it
and call me later, if you need more time. It is entirely up to you.’ I am
opening a wide door to his uncertainty and giving him space for his
possible hesitance. Anthony is hesitant. He is quiet again. He does not
know anything about therapy and now he is facing it. It will be about
him and his life, memories, thoughts and feelings. Ehhhhh.
However, Anthony says, ‘Yes.’ He seems to be coming back for
another session.
Therapist thoughts
The above cluster of information is about all I had before we started
working together. Anthony’s reluctance about therapy is typical for
youngsters from the Little House. Ordinarily people like Anthony
never appear in a therapist’s office. They are not motivated in the
way psychotherapy requires. They do not have money to pay for
it. They often do not have a place to live and people to support
them. They experience such massive shame talking about themselves,
it causes them pain and unbearable struggle. Their understanding of
their life, the causes and consequences in their life, is basically none.
The result of all this is they do not get help. Thanks to the Little
House and Hannah, Anthony got support to overcome these obstacles.
However, now it is he, himself, who is going to do it. I admire all my
young clients from the Little House. They find the courage to see me.
And despite their inner struggle and despair, they decide to come back.
Anthony starts PBSP

Anthony arrived late for his appointment. Hannah was nervous,
thinking the whole thing might be in vain. I was thinking what I
usually think. ‘It is a real struggle for him, he is not coming for fun
and a piece of cake. All I need is him sitting in front of me. When that
happens, everything is open again.’ And he is here. I remind him about
our collaborative agreement which says when he is late his session will
be shorter. We signed a contract last time so our field is clear.
Then Anthony says he is not sure he should be seeing me. ‘Of
course you are not sure. It is perfectly OK. Do you want to leave
and think about it some more?’ I respond to him genuinely, open to
anything he has on his mind. I understand very well that a client needs
to be invested and it needs to come from his own inner wish and need.
In Anthony’s case, getting to this point will be a slow and delicate
process and I enjoy giving him every option and no pressure. He feels
that and says, ‘I think I want to be here and work with you.’
‘Great. And be sure any time you might change your mind, you
still can leave.’ I give him control over his presence and willingness to
do our work together.
I continue the session. ‘Today I am going to explain how we will
be working and then, if you agree, we will do a short introductory
session together. Is that OK?’ ‘Yes.’ Anthony looks curious. His
intelligent mind likes to discuss things and he feels relief that I am
going to explain things and teach him about himself. What I like about
sessions like this is that I am not the ‘clever one’ leading a ‘confused,
ill patient’. In PBSP we call it working with the client’s ‘pilot’. Today
we establish a nice co-working contract between my pilot and his. It
will be like that through all our sessions.
A lesson on memory
‘Well. We are going to work with your memory, most of all. So I will
explain a little about how memory works.’ I draw a picture on a flip
chart. ‘Here is a person in the here and now. Let’s think, he is twenty-
five years old, a young man. This is Tommy.’ I draw his head in the
picture and I draw his brain. The picture looks like a cartoon. ‘There is
his past. It’s located in his brain in memory. There is what is coming,
what he sees in front of him, his future. Now look how it works.
Let’s imagine when he was a child he had a traumatic, bad experience.
When the young man was a little boy, his father let him walk by
himself and he was bitten by a dog.’ I paint a dramatic picture of the
scene: the stress and pain of a little boy who is bitten and injured by a
dog while he is exploring the world after his father leaves him alone
for few minutes.
Anthony is interested and involved. I turn our attention to what
happens with Tommy when he is twenty-five. ‘As you can see in
the picture,’ I explain, ‘the event, as Tommy remembers it, is stored
in memory. There are some facts, loads of emotion and finally, the
implicit meaning attached to it.’ One does not have to be too scientific.
I explain it simply and I am animated. I want this to be understood. ‘We
can imagine what Tommy remembers. His brain remembers the event
on many levels. It remembers the actual physical injury. The memory of
fear, pain and stress is also strongly recorded. It’s so because Tommy’s
brain is programmed to avoid situations like this in the future.’ I draw
details of this in our picture. Red flags and arrows on Tommy’s brain
show the power of the bad experience in childhood to activate means
to avoid such a situation in his future life.
‘What do you think will happen when Tommy sees a dog some
time later?’
‘He’ll be afraid of it.’ Anthony actively responds using common
sense and my lecture.
‘Of course! That’s how it works. He will be very afraid of dogs. He

may also be afraid of walking alone or doing anything alone. Because
his memory recorded that he was alone when it happened. This is
how “memory” protects him from having such trauma happen again.’
I make sure Anthony registers this little demonstration so I can use it
later as a reference when we talk about his memories of the past. He
seems to like it. His intelligent mind enjoys new information and the
fact that this is not about him. It is safe. Our alliance is slowly growing
as we enjoy looking at how the brain and memory work together.
‘Well, now I have a question for you.’ I am going to proceed to
how PBSP works with memory. ‘Let’s go back to the day of Tommy’s
childhood experience. He was young, less than three years old. Ideally
what would happen so his memory of that day would be different?’ I
am very curious what Anthony will come up with.
‘Hmmm, the dog wouldn’t be there. I don’t know.’ Anthony is
unsure.
‘I have a suggestion and you see how you like it, right?’ I try
to keep Anthony involved because I might be teaching too much
today. Anthony agrees, genuinely interested. ‘OK. Let’s imagine this.
Tommy’s father walks with him. When the angry dog appears, he
lifts Tommy up and chases the dog away. Now we see a different
picture. Father is holding little Tommy and the beast is gone. What
do you think?’
Anthony agrees without hesitation and relief is visible on his face.
‘Oh yes, that would be good.’ Silence for some time. ‘I never had
anybody with me when I was a child.’ Right away Anthony’s brain
connects his childhood experience with this story. Hearing stories
often makes us feel as if they are happening to us. It switches on
empathy and feelings for the people or animals in the story. It also
switches on our own stories which are emotionally related to what we
are hearing.
‘Oh, I don’t know very much about your childhood yet, but
your mother was not paying attention to you. You did not have a
father when you were as young as Tommy.’ I confirm his reflection
and his ‘pilot’. We are building our intersubjective understanding
and communicating what is on our minds. It is very nice as it is
slow and naturally developing. ‘Well, you can easily see what would
have been right for little Tommy.’
Anthony, like many people when they hear stories about wrong
and bad, naturally knows what would be right and good, and what a
child needs. This is a basic principle of PBSP.
At this moment Anthony looks puzzled and unsure. I feel I am
overloading him with these details and my speech is getting too
theoretical. So it’s time to move towards practice. I give Anthony a
few principles for our next steps. ‘This is how we work using the
PBSP method. We start with how you feel and what is on your mind
right here and now in this office. You are not expected to present a
problem or a theme. Just speak about what is going on in your mind.
Of course, if you are dealing with a problem, it is on your mind, and
you can speak about it as freely as you want.’ Our introduction took
about thirty minutes. Now we have about thirty minutes to taste how
it works.
Anthony and an ideal Stella

I start by asking gently with a neutral interest, ‘What is on your mind?’
‘I am hysterical. Hysteria…’ He says it with an expression of disgust.
Right away Anthony authentically opens his mind. Obviously he
has been thinking of it for some time and maybe my lecture was not
as interesting to him as his own ‘hysterical mind’. Our lesson was
important as it created a frame of reference. But it will be the work
which will help Anthony step by step to leave his self-hatred and
preoccupation with himself.
‘We use a symbolic figure here called a witness figure.’ I give the
simplest introduction to PBSP methodology. ‘It is a very understanding
figure who can see all your emotions and name them in relation to
what you are thinking of.’ I continue lightly without emphasis. ‘So
if a witness was here, a witness would say, “I see how much disgust
you feel when you think of yourself being hysterical.”’ ‘Yes.’ Anthony
looks into my eyes. He is pleasantly surprised. It is exactly how he
feels. He is seen and heard! He understood the concept of the witness
figure with no problem. ‘I’m hysterical. I’m upset all the time. Everyone
knows that about me. I cannot cry. Catherine, a friend of mine, knows
all that about me.’ ‘Let’s have a placeholder here for Catherine. It
means you pick an object from this basket and put it here on the
table.’ Anthony follows my instructions with no difficulty. I add that
whenever he speaks about a person, place or thing, we will have a
placeholder for it in the therapy room so we can both see what is on

his mind. The object represents all the qualities of the person or thing.
The placeholder Anthony picks for Catherine is a small wooden star
painted gold. Catherine is somehow significant. The object shows that
he puts her somewhere high. She has got ‘star-like’ qualities for him.
More information will come.
‘What comes to mind when you think of Catherine?’ ‘She is so
intelligent, special. You know, before my “injury” I was somebody.’
Anthony refers to his suicide attempt with the resulting brain injury,
other injuries and long hospital stay as his ‘injury’. ‘People found me
important and admired me.’ Anthony’s emotions shift. Now he looks
proud and full of himself on the one hand, and sad and frustrated on
the other. ‘That’s a voice,’ I say. ‘It says, “You were somebody before the
injury.”’ Anthony nods. I explain about another symbolic figure we use
in PBSP. It is called the ‘voice figure’. It repeats back to the client
statements which the client makes about himself and the world. As
he is experiencing a lot of emotion also, I continue, ‘And a witness
would say, “I see how proud and sure of yourself you feel when you
remember how people admired you before your injury and how sad
and frustrated you feel when you remember your injury ended that.”’
‘Yes.’ Anthony nods. The witness figure is accurate. The comment is
so fitting that Anthony’s feelings and thoughts just flow. ‘There were
many people who liked me and thought I was great.’
‘Let’s have placeholders for those people,’ I say.
Anthony picks objects and puts them on the table. We enrol them
as placeholders for the people he thinks of now: Catherine, Garry,
Richard and Stella. ‘Stella was like my twin! She was an extraordinary
person! A unique and special friend of mine!’ Anthony exclaims. I
briefly comment, ‘It sounds like a kindred spirit.’ I continue, ‘A witness
would say, “I see how much admiration and love you feel when you
think of Stella.”’
‘She was an exceptional person in my life. Now she is in London.
Catherine knows and hates that I’m so hysterical.’ There is despair on
his face again.
‘A witness would say, “I see how devastated you feel thinking
of Stella, who is in London, and Catherine, who hates that you
are hysterical.”’ Anthony nods again. He is falling into his deep
hopelessness. This often happens when a client is listened to and
understood, but nothing brings the possibility of solution or hope to

his despair.
So I open a new option for Anthony. I suggest a reversal of
his current frustrating relationships with Stella and Catherine. ‘You
know, Anthony, you feel so desperate and hopeless right now about
Stella and Catherine. It is overloading you. We always do something
about this in PBSP therapy. I will now outline a new idea.’ I paint
an imaginary figure in the air with my finger. ‘It is the possibility of an
ideal friend. This ideal person has nothing to do with the real Stella
and Catherine. This ideal friend would say to you, “If I was your ideal
friend, I would stay close to you. You could talk to me and I wouldn’t
be critical about your being hysterical.”’ It’s a reversal of the real girls
he spoke about. An ideal friend would be available, unlike Stella. She
would not be critical and rejecting like Catherine. I know it is an
unusual and surprising step for those unfamiliar with the techniques
of PBSP. In the beginning it is so strange an idea to some clients that
they get confused. This happens with Anthony. He does not know
what I meant. ‘For me,’ he says, ‘it is Stella. She was just so perfect,
we had such a special relationship. A witness would say, “I see how
much longing and loss you feel when you think of Stella.”’ Anthony
responds with, ‘Ehhhhhh.’
‘Stella has got qualities of an ideal friend. Let’s have a piece of
paper and put it here on the placeholder for Stella.’ Looking puzzled,
Anthony follows my instructions. I am relaxed. This is an introductory
session. We are doing a structure and at the same time, I’m introducing
the steps and interventions we use in PBSP. It takes time and everything
doesn’t have to happen today.
As he puts a piece of paper on the placeholder for Stella, I clarify
this for his pilot: ‘There is a placeholder for Stella. She is a real person
who used to be in your life. You still think of her a lot. There are
many memories of her, your relationship and events you experienced
together. It all has got meaning for you. All this is represented in
this room by this placeholder. There is also a principle on Stella,
which is the principle of an ideal, kindred spirit, a very close person
you are longing for.’ ‘Yes, that’s who she is!’ Anthony emphasises
her importance and the special qualities of Stella. ‘Yes,’ I reply. ‘And
we are not going to change that. That is why we have a placeholder
for Stella right here. But I am outlining in the air an “extraordinary
possibility” which we can have here in the room. It is the possibility
of an ideal friend. Someone who would know who you really are and
stay with you, even if you have qualities like being hysterical.’ I take
it slowly as I’m aware it is very hard, almost impossible, for a person
with a traumatic childhood and life to imagine something so good for
himself – someone who unconditionally accepts him as he is, likes him
and does not leave him.
Anthony’s genetic expectation of a good, fulfilling, responsive
relationship is covered with pain and disappointment. His emotional
memory is full of longing and hope for someone who will be there for
him. Remember Anthony’s childhood and his mother. As a baby and
a little boy, he loved and admired her. She was his goodness. But she
was never there for him and no one else was either. He was longing
for her all of his childhood. His memory is filled with frustration and
disappointment associated with his longing to connect with caregivers.
These memories are triggered when he tries to connect with people as
an adult. How hard it is now to imagine a reversal.
‘Anthony, what would such a person be like? I mean ideal for you?’
I let him explore this possibility.
‘I never thought about it.’
‘You can try now. You have all the time you need. In our “possibility
sphere” here in the room you can explore all the possibilities that
come to your mind.’ I gently introduce another fundamental element
of PBSP therapy. This is the ‘possibility sphere’ where the client, in
co-operation with the therapist, can experience possibilities and an
open space for exploration and being himself. It also involves the
possibility of moving through time, remembering things from the past
and experiencing an ideal in the past.
‘Would it be a man or a woman? We can have two friends too.’
I help Anthony by giving him more concrete direction and opening
options.
‘Oh yes. I would like to have an ideal partner, a man, and an ideal
friend, a woman.’ Here he goes! His mind is searching for hope and the
possibility of good and right. He begins to create a new experience in
his emotional and relational mind. He knows what he needs and what
he longs for. In PBSP we work right here in this beautiful moment
of opening. The client connects with himself and is given a chance to
express his needs in their pure and innocent form when we ask, ‘What
would be the “ideal”?’
I place his imagined ideal friends in the air and speak for them. ‘If I
was your ideal male partner, I would recognise you and I would know
you and accept you.’
‘If I was your ideal female friend, I would be a real friend, I would
recognise you and accept you.’
Anthony listens to what they are saying and then he says, ‘For
me it was Stella. But when I was in the hospital after that injury,
she visited me and told me about something bad I had done. I have
not told anybody about it. Hannah doesn’t know.’ He looks at his
caseworker in the room. He is fully involved and his mind brings out
all the different connections and related emotions. He looks lost in
terms of his relationship with Hannah.
‘A witness would say, “I see how uncertain and ashamed you feel
when you consider that Hannah doesn’t know this bad story about
you.”’ Anthony nods.
‘Remember our contract. You can always ask Hannah to leave
the room and not be present. Is it OK with you, Hannah?’ She
answers, ‘Yes.’
Anthony is again given a choice and his pilot co-ordinates all
the information. Here is his decision. ‘I will tell the story,’ Anthony
continues. He has decided to reveal something he is very ashamed of.
‘Stella and I had a friend, Mary, a long time ago.’ We put a placeholder
for Mary on the table. He looks at it. ‘It was before my injury. I was
using drugs. I needed money. I went to her apartment and stole some
valuable things there. I didn’t know Stella knew about it, but in the
hospital she told me she knew. I think I lost her as a friend. It was
the end!’
‘A witness would say, “I see how heartbroken you feel when you
think of the broken relationship with Stella after she learnt about
you stealing from Mary.”’
I suggest another ideal possibility, expanding on the outline of
an ideal friend in the air. ‘An ideal friend is talking now: “If I was
your ideal friend back then, I would understand that at the time you
were young, you were using drugs, and you had made a serious
mistake. But I would know who you really are and I would stay with
you as your true friend.”’ Anthony listens and all of a sudden he has
got tears in his eyes.
‘It would be good,’ he says. Relief is visible on his face and his
whole body relaxes.
‘If I was your ideal true friend back then, I would have understood
you and I would not have left you because you made a mistake.’ I
repeat the ideal friend’s speech so Anthony can hear it. His face looks
different now; it looks very childlike. Anthony takes in the new,
previously unknown possibility for a long, quiet time. At the end of
our structure he looks at me and his eyes are different. There is sadness
and a spark of hope.
This is quite different from any interaction he has ever had. He
imagines an ideal friend in his past and through this he experiences
acceptance and understanding in a good relationship. The experience has
got a different meaning than most of his childhood experiences: ‘You
are worthy. You make mistakes but you can still have a safe relationship.
You are important to someone and the relationship endures.’ It is a
good end.
When he is ready, we de-role all the objects on the table and at the
very end, we de-role the ideal friends in the air. This is important as
it gives the client’s pilot the message that the therapy process and the
possibility sphere is closing and the client is now back to his real life.
However, the inner impact of the experience stays and it will influence
his state of mind as a ‘new memory’. I close the session softly: ‘This is
the end for today.’ Then I ask Anthony my traditional questions: ‘Shall
I bring my diary? Shall we find a date for your next appointment?’
‘Hmmmmmm. I don’t know. I’m not sure I want to be in therapy.’
Anthony is back in his old familiar shoes.
‘Of course. That’s perfectly fine. You know if you don’t come
back, it’s all right. If you think about it and want to come back, just
call me. Yes?’ I leave the door wide open again.
‘I think I want to come back. Let’s set the next appointment.’
Anthony smiles shyly. I bring my appointment book and together we
find a date for our next session.
Therapist thoughts
Today I remembered the words of Milton Erikson. He wrote:
Too often it is not the strengths of the person that are vital in
the therapeutic situation. Rather, the dominant forces that control the
entire situation may derive from weaknesses, illogical behaviour,
unreasonableness, and obviously false and misleading attitudes of
various sorts. Therapists wishing to help their patients should never
scorn, condemn, or reject any part of a patient’s conduct simply

because it is obstructive, unreasonable, or even irrational. (Erickson
1980, pp.212–213)
We can see a piece of Anthony’s inner world: preoccupation with
broken relationships, and blame and shame on himself. He remembers
the ‘great times’ before his injury as an ‘island of good things’ that
he lost. The latter sounds like dreaming of a ‘golden age’. But this
idea conflicts with his lifelong reality. He was abandoned, neglected,
rejected and blamed as a child and youngster. When he allows himself
to imagine an ideal friend, who would stay with him and accept him
as he is, it changes everything.
It is very surprising and new to Anthony, almost incomprehensible.
But his emotional brain vividly creates a new memory which antidotes
the old negative ones. Most important, he feels differently in interaction
with the ideal figure and the meaning of himself changes as a result.
Does it matter that the ideal friend in his past is only imagined? It
seems not to. He remembered himself as he was about eight years
ago and in his mind he lived a different experience at that age. What
matters is the inner emotional experience of good and rightness and
the meaning which comes from it.
This was the first drop of a new possibility. So far he is very unsure
about his participation. I don’t know if he is coming back. Hannah is
still sceptical. She asked me, ‘What do you think?’
‘I think he did great.’ There is a deep desire in him, despite all
his negative emotional memories. He is genuinely longing for a safe,
loving relationship. That is a very good sign.
His early attachment with his mother was insecure, ambivalent,
rather disorganised. Today we did not touch his early childhood. We
started with his history when he was seventeen. He was trying to
have an ideal maternal relationship with his friend, Stella. We did an
antidote for his damaged attachment at that age and he is carrying it
with him now. We’ll see how we proceed next time. It has to be at
his pace.
Anthony and the missing mother

Anthony arrives on time for his second session. Hannah is with him.
He decided to continue doing therapy with her present. We smoothly
start our second structure.
I ask the usual question, ‘What is on your mind?’ ‘Nothing, because

I have those problems with my memory and “cognition”.’ Anthony
often talks about his ‘cognition’. His injury has certain consequences,
but it has become so frequent a topic with Anthony that it creates what
I call a ‘comfortable trap’. What I mean by this is complaining about
his injury and loss of abilities is a ‘trap’ as it serves as an unbeatable
excuse for passivity and hopelessness. It confirms his view that there
is no answer anywhere.
I take a rather unorthodox step now. He talks about his memory as
if it were an external entity, an object that is not part of him. In order to
make this mental process visible I suggest, ‘Let’s have a placeholder for
your memory here.’ Anthony picks up a small stone from the basket
and puts it on the table.
‘I used to have a great memory before my injury,’ he comments.
His affect is rather complex. He feels better when he tells me about
his great memory in the past. I capture it in two steps, first a voice
figure and then the witness. ‘That’s a voice. It says, “You used to have
a great memory before your injury.”’ ‘A witness would say, “I see how
important it is for you to tell me you used to have a great memory.”’ I
am relaxed and quiet as I use micro-tracking techniques so Anthony
can connect with himself. The imaginary witness figure names the
client’s emotions in the context of the client’s story and the voice
figure repeats out loud the client’s statements about himself and the
world. I have no agenda of issues to talk about or fix. I am curious and
interested in where Anthony will go, but I have no wish or plan for it.
I remember Albert Pesso once saying in training, ‘I don’t know where
the structure and the client will go, but I know how it’s going to end.’
I am present for my client and ready to assist him to find a good end
and satisfaction of his childhood needs.
Anthony continues, ‘Well, I am actually thinking of a friend of
mine, her name is Catherine.’
‘Let’s have a placeholder for Catherine. What comes to your mind
when you think of Catherine?’
‘Oh, she is so intelligent, so much like me and she has got a good
character too.’
‘A witness would say, “I see how much admiration you have for
Catherine.”’
‘Yes. And I also think of Hannah.’ He turns to his social worker
who is in the room with us.
‘Let’s have a placeholder for Hannah too.’ Anthony chooses

another stone and places it on the table. In PBSP, whenever the client
names a person, we always put out a placeholder for the person. So
even when Hannah is here with us a placeholder is used for her. The
idea is: there is a reason for the client having this person on his mind
in this context. Therefore, the image of the person which comes
to the client’s mind is externalised in the form of a placeholder even
if the person is in the room. This approach applies to the therapist as
well. So there could be a placeholder for me, Petra (the therapist) too,
if Anthony speaks about me.
This is one of the techniques in PBSP which frees the client from
dynamics and interaction with the here-and-now reality of others in
the therapy room. He can reflect on his thoughts and feelings, whatever
comes to him from inside, and safely keep the focus there.
Hannah knows about this principle and process in PBSP therapy.
She is here, present and quiet. She does not interrupt or bring up her
own agenda. She has been instructed about her role. ‘What comes to
your mind when you think of Hannah?’
‘She helps me. She supports me and we are close. We enjoy reading
the same books.’
‘It looks like there is a principle of a supportive person and kindred
spirit on Hannah.’
‘She is like that! She is like my sister or adoptive mother.’ Anthony
speaks with a vivid investment.
‘A witness would say, “I see how important it is for you that
Hannah feels like your sister or adoptive mother.”’ Anthony nods as he
considers this idea.
‘Well, we have principles of an ideal sister and an ideal mother on
Hannah. Let’s use small pieces of paper to represent those principles.’
As we are organising this visualisation of Anthony’s mental
processes on the table, I want to make sure he is clear about what we
are doing. It is only his second structure and I am aware he is just
getting used to it. But I do want him to be involved and to understand
the steps and details so the process is clear and structured. Now I am
going to show him how he projects his need for a mother and sister
onto Hannah.
‘What I mean by these principles of ideal sister and mother on
Hannah is that you see her as “like a sister or an adoptive mother”.
It means she has got qualities and you have the kind of relationship
which makes you feel that way about her. So as you speak about it we
make it visible here on the table. Does it make sense?’ Anthony nods.
I try to be as clear as possible. ‘It looks like it’s a principle of a sister
or a mother, a close kindred-spirit-like person, that you wish to have
in your life.’
‘Ehhh. Stella was a kindred spirit person.’ Tony puts his head
down and his voice is full of resignation and sadness.
‘Let’s have a placeholder for Stella. A witness would say, “I see
how hopeless and resigned you feel when you think of Stella.”’
‘But Stella is in London now.’
You may notice Anthony is repeating the beginning of his last
structure. He seems not to notice this. I let him continue. We’ll see what
happens. I just comment on the topic. ‘May I tell you how it looks?’
‘Yeah.’
‘It seems like you have been longing for a close, real relationship
with a person similar to you, but even if such a person exists, she or he
always disappears.’ Anthony nods with a depressed look on his face.
He is silent, absorbed by the frustrating relationship with Stella. He
adores and likes her so much, but she is not here any more. She is not
available.
‘It was me who destroyed it, eh,’ Anthony continues. He tells me
his story again about stealing things from his and Stella’s friend, Mary.
Word for word. The same story. The same despair with no solution to
it. However, there is a difference. This time he speaks more about Mary.
‘You know, she told everybody that story. It destroyed many of my
friendships.’
‘A witness would say, “I see how betrayed you feel when you
remember what Mary did.”’
At this moment, being aware that Anthony is unknowingly
repeating his story, I can see this time he emphasises a different aspect
of it. Last time we worked on his issues about Stella leaving him
because he stole something from Mary. This time he is focusing on
how Mary dealt with the situation. She used the story against him
and he lost a lot of friends because of it. This inspired me to take a
different step.
‘Let’s take an unusual step here,’ I say. ‘Let’s have here in the air
a reversal for Mary, the outline of an ideal person who, if you stole
things from her apartment, would react differently than Mary.’ With
my finger I paint an ideal figure in the air. ‘What would an ideal friend
do in such a situation?’
Anthony responds firmly, ‘She would have talked to me directly
and she would have told me to bring her stuff back.’ After a long
silence he says with sadness, ‘I would have given it back to her, all of
it.’ Anthony looks regretful.
‘A witness would say, “I see how much regret you feel when you
remember how you stole things from Mary and could not repair it.”’
‘Yes. I wish I had not done it or that I could have done something
about it.’
Anthony realises what he needed: a chance to repair the mistake
he made. He was seventeen or more when it happened, but basically he
acted like a little kid. He needed someone there who would have
understood and helped him put things back in order. Of course, in
real life, a friend who had been robbed like that would be unlikely to
do this. Anthony’s need is an old one from childhood. A parent would
help a child learn to respect other people and their property. But here
we start with an ideal friend.
I continue, ‘So an ideal friend would say, “If I was your ideal friend
and you had stolen things from me, I would talk to you directly, right
away and you could bring things back and repair the situation and our
relationship.”’
‘Yes. It would have been nice.’ Anthony is content with it.
‘It looks like there are relationships you would like to have in your
life, but it seems you lose them by making mistakes, then you blame
yourself for it and regret it. It seems there is nothing you can do about
it. Am I right?’
‘Yes, you are.’ Anthony is now connected to this experience. It
makes him feel very hopeless.
‘Well, let me give you a little bit of theory, is that OK?’
Anthony nods. He looks at me with curiosity and helplessness.
‘Children explore the world and they know very little about how
things work. So they try everything out, often for the first time. They
make mistakes and stretch boundaries all the time. When they have
good parents, a good mother and father, the parents stay with them
and support them. They are interested in their children and help
them learn what is right and what is not. Even when the parents set
limits, they always have a secure relationship with their child which
does not break. A small child wants to be similar or the same as his
parents too.’
Anthony: ‘Yes.’
‘You did not have that. So look here [I point at the placeholders],
you have been looking for such a safe haven with your friends.’ I
review the principles on his friends and Hannah: love, acceptance,
togetherness, kindred spirits, support, an unbreakable connection. I
tell Anthony about the connection between these relationships and
him not having parents when he needed them. But a friend cannot
take the role of a parent. ‘Let’s have here in the air an outline of ideal
parents. Imagine they had been with you when you were a small child.’
‘But I had that,’ Anthony responds. ‘It was my Aunt Tonya. She
was like that.’ Anthony heard my words about good parents and his
memory immediately brought up a picture of his aunt.
‘Pick a placeholder for your Aunt Tonya.’ Anthony does this and
continues. ‘She took care of me. She took me to her home when my
mother abandoned me. She was a good cook. I like her.’ This is what
comes to his mind when he puts a placeholder for Aunt Tonya on
the table.
‘A witness would say, “I see how reassured you feel when you
remember your Aunt Tonya.”’
I point out to Anthony how it is related. ‘Oh yes, look, there are
many qualities of an ideal mother here on Tonya. You see we put
these principles on her. We use pieces of paper for principles. It does
not change her. She has got these qualities, but we can also see these
are the qualities one expects from a good mother.’ Now I point to the
‘principles of ideal mother’ on Hannah, Catherine, Stella and Aunt
Tonya. ‘You know these are the qualities of a good mother, whom you
needed and should have had as a child.’
‘Yes, that’s true.’ Anthony is deeply involved in our work. He
integrates what he is seeing now.
‘So now remember we have the possibility of an ideal mother here
in the air. She has no qualities of your real mother. She has all the
qualities you like about Hannah, Catherine, Stella and Aunt Tonya.’
When I summarise what Anthony needed from his mother when
he was a child, it captures everything we have been talking about
today. His sense of what he needed comes from himself and his deep
wishes. In PBSP we present this as words coming from the imaginary
ideal mother. I speak slowly, clearly and with dignity. ‘This is what
your ideal mother would say: “If I was your ideal mother when you
were a child, I would have known you and understood you. I would
have loved cooking for you and I would never have given you up.
I would have been in your life from the beginning until now and
for all of your life. If you made a mistake, I would have helped you
repair it.”’
Just like the last time, Anthony all of a sudden sits quietly. His
face is relaxed. He looks younger, about ten years old. He listened to
the words of his ‘ideal mother’ and they fit. It is true. This is what he
missed and what he has been longing for all his life. He is here and
connected to me and at the same time, he is aware of his childhood
state. Everything would have been different if he had had such a mother
and he can sense it. He is experiencing it and it takes a long time.
When he is ready, together we move the principles to his ideal
mother. We remove the bits of paper, the principles, that we put on the
objects which represent Catherine, Stella, Hannah and Aunt Tonya. We
now place them on Anthony’s shoulders. Symbolically, ideal parents
stand behind the client. So principles can be placed on his shoulders.
It can be done in other ways, but today this is a good option. He
imagines having an ideal mother with all these qualities when he was
a small boy. In this way he symbolically experiences a completely new
and surprising idea of mothering. He did not have that in the past,
but now he experiences it in the structure. Also, he can now relate
to current people in his life without projecting or linking them with
these unfulfilled needs from childhood.
Then, when he indicates he is ready to finish, we de-role all the
placeholders, the voice figure, the witness figure, the ideal friend and
finally, the ideal mother and the principles. The structure is over. He
looks at me with trust and connection. ‘I don’t want to admit I missed
my mother’s love.’ He smiles and it is a sad, shy smile, but very honest
and it is not hopeless this time. ‘But I did. And I still do miss it.’ He
feels guilty about it. Because his structure is now finished, I just add
one sentence: ‘The need for a good mother and father is in our genes.
That’s why it is so important to everyone. Sometimes people deny it,
because they were hurt and had to survive without them. But they
miss them too.’ Anthony smiles. It is reassuring.
He continues, ‘You know, I’m not sure I want to go to therapy
sessions. One of my friends told me it was a mistake.’
‘Of course. It’s entirely up to you. You can think about it. Now you
know how it works, so you can make your own decision. Let’s not set
up the next session. You call me if you feel you want to come back.’
I welcome his hesitation again. It is very nice seeing him have such
intense and unusual experiences for him. ‘I’m stupid,’ he says. ‘Let’s set
the next session. I want to come back.’
Therapist thoughts
It is uncommon for a client to repeat the beginning of his structure
the way Anthony did today. Nonetheless, focusing on another facet
of the story and his emotional experience brought us to a different
outcome. We can see a child who was unwanted, neglected, and did not
have good supervision and loving limits. Although he really wanted
a safe and enduring relationship, it never happened. He was blamed
and there was no repair of the relationship. It left him very confused.
This type of relationship keeps coming back to him with his friends.
At age twenty-five, he has not been able to change it. When he has a
conflict with others, feelings of guilt, worthlessness and helplessness
come from his childhood. They are massive and destructive. In the
structure today we hit this key topic. It involves many different aspects
and details he deals with from day to day. The end, the good end, was
when Anthony got to his childhood state and experienced himself
in a radically different situation. Now he has got the memory of an
experience in a childhood state with an ideal mother, who is with him,
loves him and meets his developmental needs.
This is a cognitive and emotional process which changes his
emotional and relational experience of life and his sense of hope for
the future. The new memory of being with an ideal mother changes
how he perceives himself and others and thereby changes how he will
interact in the world. I am full of optimism, but I know it may take a
long time and many new experiences, that is, memories, before his felt
sense of himself will finally be secure and permanently changed. We
will see what happens.
Anthony and the Pole Star

I spoke to Hannah and the Little House manager. They have known
Anthony for more than a year. They have both noticed a recent, gentle
change in the way he is. He is more content, more confident and more
sure of himself. He also acts differently, as you will see.
It is a good news. Unresolved developmental trauma and attachment
disorders leave people with persistent, negative feelings about
themselves. It is often a lifelong sentence. The meaning of themselves

is ‘I am wrong, inadequate and bad.’ Period. Such an inner state creates
ongoing shame and attempts to reduce the shame and feeling bad.
Most of the time it is a battle that takes a huge portion of the person’s
capacity. For a long time, Anthony has been preoccupied with cycles of
‘being terrible and trying to hide it’ and ‘reassuring himself and others
it’s not so bad’. The other side of the coin is an omnipotent super ‘I’,
who does not have to be afraid of other people because he looks down
on them. Now we are at the beginning of something new, something
healthy and natural. He is calmer, less preoccupied and feels happier
inside. I am glad to hear that. Maybe a seed we planted is starting to
grow. When we work together I can feel his hesitation and he reminds
me of a shy and scared animal. Treating such deeply distrustful people
was compared many years ago by Adrian Stephen with trying to
make friends with a shy or frightened pony. It needs prolonged, quiet
and friendly patience (Stephen 1934). Bowlby reminds us that ‘Only
when the therapist is aware of the constant rebuffs the patient is likely
to have been subjected to as a child whenever he sought comfort or
help, and his terror of being subjected to something similar from his
therapist, can he see the situation between them as his patient is seeing
it’ (Bowlby 1988b, p.144).
Today Anthony arrived for his fourth structure, on time and on
his own. He did not need to be accompanied by Hannah. She arrived
later and was pleasantly surprised to find he was here and ready to
work. ‘I am moving from the Little House,’ he says to start his PBSP
session. ‘I have finished my programme there. I rented a room. I’ll be
living with a room mate and friend, Jack.’
‘Place holders for the Little House, the new room and Jack.’
‘I was so distracted by all the moving, now I’m aware of what I
am going to miss. There were always people around me at the Little
House. Like Rose. She cared about me.’
‘Place holders for the people at the Little House and Rose. There
is also a principle of “having someone around you” there, a principle
of “the presence of the other”.’ I summarise in the language of PBSP
what Anthony’s thoughts and feelings are right now. We put a piece
of paper (to represent the principle) on the placeholders for the Little
House and the people there.
‘I won’t be allowed to smoke there and drink beer. Oh, I’m so lost.
My thoughts are jumping from here to there.’
Anthony is obviously having a problem with concentration today.

It is a sign of being anxious. Since birth he has always been unsettled
and moved around. There were short periods of safety, then breaks,
gaps and falling into despair and loneliness. This is where my mind
is going and I feel a lot of empathy and understanding. I will let the
theme develop and use micro-tracking so he will get more connected
with what is happening with him. Then we can look at how it all
started and find an antidote for such despair.
Anthony continues, this time in a self-critical, discouraged tone
of voice which suggests he is a ‘lost case’. ‘Therapy is impossible with
people who have an attention disorder.’
I respond using the voice figure: ‘That’s a voice of truth, a statement
about how you find the world to be; it says, “Therapy is impossible
with people with attention problems.”’ Then I use the witness figure.
‘“I see how bitterly sure you feel, lost and frustrated, thinking therapy
is impossible with people with attention problems.”’ Anthony nods.
In such cases the client feels seen and heard, but the feeling of
frustration, because there is no solution to it, becomes strong. It
could go on like this forever. There is a technique in PBSP to give
the client an ideal figure so he has somebody with him when he feels
overwhelmed here and now in the therapy room as he thinks of an
unbearable issue. The ideal figure is usually supportive, providing
comfort and a presence when the client feels so lost and desperate.
‘Anthony,’ I say to him gently, ‘now you feel lost and alone with
your distracted mind and attention problems. That’s not good. In this
therapy we don’t leave people alone in such despair. Let’s have here
in the room an imagined ideal figure who tells you, “With me you can
be distracted and discouraged. Your thoughts can jump from here to
there. I will stay with you when you feel like that. It’s OK. You will
not be alone.”’
Anthony is not registering his ideal support figure in the therapy
room. There is a lot going on in his mind and not much space to
receive something from outside. However, I believe he has heard my
words. He might not take it in altogether, but his ears have heard it and
of course, his brain has ‘heard it’ on some level too. It is important to
take the right steps so the information is there when the client finally
has got enough space and peace in his heart and mind to process it.
‘I saw my psychiatrist recently,’ he continues. ‘I told him I started

therapy and he just said, “Hmmm. Good luck!” I think he really doesn’t
believe in therapy at all.’
‘Place holder for your psychiatrist.’
‘I don’t remember all these placeholders, you know.’
I keep going with PBSP: ‘Well, let’s have a placeholder for your
doctor here. That’s the way we work. It’s good to have the things and
people who come to your mind represented here on the table. We both
can see them and your pilot and my pilot can review what we have
been talking about. It’s helpful.’
‘It doesn’t help me,’ Anthony says with a very discouraged look
on his face. I can see how confused about and disgusted with himself
he is now that even his doctor has implied he is not suitable for
therapy. His old suspicious attitude is supported by the authority of
a psychiatrist. His trust in the real Anthony, his soul and his healthy
(although unfulfilled) childhood needs, as well as his deep hope that
things can be better, are all severely shaken. And again it is something
about him that is wrong. No hope for such ‘junk’. He cannot solve
his inner conflict. He feels a desire to develop, live and be happy.
At the same time, he is convinced he is wrong, damaged, impossible
and it will be like this for the rest of his life. Now this side has been
reinforced by his doctor.
I remind him of the ideal figure in the room. The figure talks to
him softly: ‘With me you can be discouraged, sad, lost, distracted. I am
here and I will stay here with you.’ The ideal figure is not trying to
talk him out of his despair. It is not putting down his psychiatrist. The
ideal figure lets him know he is with him, completely accepting and
understanding him and he will stay with him when he feels this way.
But Anthony is not accepting it. He is not disputing it either. I think,
as always in such cases, the client has heard it. His ears and brain have
heard the information. He is upset now, but there are networks in his
brain which are aware even now. They receive the emotional message
for Anthony, ‘You are all right. At this moment you feel discouraged,
but you are good and I am with you. I see you.’ It is good enough for
now. I am not pushing him anywhere.
‘I like my doctor. He is himself. He isn’t pretending anything.’
‘What’s his name?’
‘Doc March.’
‘A witness would say, “I see how positive and admiring you feel
when you think of Doctor March.”’
Anthony continues without a reaction: ‘Well, I’m not angry
at myself, you know. I have those problems with my memory and
cognition.’ Again he mentions impaired cognitive functioning from
his injury.
‘That’s a voice, “Don’t be angry at yourself. You have a problem
with your memory and cognition because of your injury.”’
The structure seems to be getting lost. I feel I am trying too hard
and that is never a good thing to do. But I feel open and easy about
Anthony as well and I trust in the possibility of a good direction and
that light at the end of the tunnel exists. So I decide to step back and be
silent. The ideal figure who said to Anthony, ‘It’s OK to be distracted
and lost’ is here in the air with him. I do not know if he registers it or
not. But the figure is here. We will see what happens next.
After a few minutes of silence, Anthony says, ‘It’s good this way.
This way deeper things surface.’
‘Yes, you’re right, they do.’ I am glad he is present and his mind is
working and processing what we are doing. I am learning something
about the way Anthony operates. On the surface he has oppositional,
negating thoughts and responses. He is a kind of ‘devil’s advocate’.
But the ‘real him’ is open, listening and looking for good things. His
healthy brain networks are present and ‘looking forward to some
solutions’.
I continue teaching: ‘And once the deep things appear and we can
see their nature better, here in PBSP, we always do something with
them. We create a new ideal possibility; the way it should be or should
have been.’
Anthony looks at me with interest. Something tells me to say one
more thing. ‘You know I have no agenda for you here. I won’t push
you to do something, think something or change something. And I
don’t see you as a patient who is sick or ill. Not at all.’
Anthony smiles. His smile is innocent and happy. ‘I’m glad,’ he
says, genuinely, pleasantly surprised. ‘My thoughts are still much
disorganised. Just now, I thought of…’
‘It looks like you feel somehow fragmented and split in many
pieces. Like you don’t have a centre you can always find in you.’ I try
to put a name on his state of mind and help his pilot to grasp it.
‘Yes. Exactly.’ Anthony agrees. ‘I can’t do anything about it.’

I use the voice figure: ‘That’s a voice, it says, “You cannot
do anything about it!” So as a reversal for that let’s have an ideal
something which would always give you orientation. Something like
an ideal Pole Star, anchor or centre point. This would have been with
you from the beginning of your life.’
‘Yes. It would’ve been good.’ Anthony is all of a sudden quieted,
calm. The notion of the possibility of being centred is already powerful.
This works for him. The ideal thing is rather impersonal, but it has got
the exact quality, the principle, which has been missing in his inner
world for his entire life. It is emotional as well as cognitive. I will try
to help him have an interactive experience which young babies and
children need to have with their parents, especially at the beginning
with their mothers. When children feel lost or confused and there
is too much happening in their developing minds, they go to their
mothers who comfort them, giving them the feeling of a centre and
safety. The mother’s centred mind is a centre for her child’s mind. In
this very interactive and collaborative way a sense of centre develops
in the child’s mind and heart.
In PBSP we would typically introduce an ideal mother now
who would have done this for Anthony when he was a baby. But at
this moment Anthony is probably not ready for such a fundamental
experience, so totally foreign to him. He never experienced it with
his real mother or anyone else. He has no memory record of such
an interaction. He severely suffers from not having it and on a
developmental level there is a powerful longing for it. But I am afraid if
I suggest the possibility of an ideal mother, he will get distracted again.
It might be an elephant pill, good but too big to swallow. So today we
will work with something symbolic which has those qualities. Slowly
and smoothly, I continue by checking with him. ‘What should it be,
such an ideal person or thing, which you would always feel centred
and “at home” with?’
‘A unicorn.’ Anthony responds immediately with a smile as if he
has had this on his mind for a while.
Interestingly, he chooses a spiritual, symbolic creature. It is a
sign he really wants to believe in it. Real people in his childhood and
life have betrayed him most of the time. But they did not destroy his
hope and the healthy nature of his being. A unicorn holds qualities of
magic. It is a positive creature whom he can trust.
‘Oh yes,’ I respond to his suggestion. ‘So imagine a unicorn which

would have been with you all your life from the very beginning.
He would say, “If I were your ideal unicorn, you would have felt
centred with me. You would have felt at home with me. Your thoughts
could be distracted, but you would still feel safe with me.”’
I speak with dignity and it creates a ritual atmosphere. Anthony
is discovering a completely new world now. For the first time he feels
safe and centred and he can feel that in an interaction. It is a serious
and important moment and he will only integrate it if it is true for
him. In rituals symbolic action becomes the truth. In the same way,
a PBSP structure helps the client experience a new truth. The one
he lost when he was mistreated as an innocent child. The good truth
about the world and himself.
‘I have chosen the wrong creature, you know. A unicorn is not
capable of everything.’ Anthony tells me what is happening inside
him now.
‘OK. Let’s de-role the unicorn. This could be just an “ideal being”.’
I follow his pace and energy. Anthony is genuinely involved and his
original image does not quite fit. I suggest a ‘being’ so the client can
create his own image of such a figure without much struggle. An ideal
being, a good soul, has got indefinite qualities, but still suggests the
possibility of a human being and soul. We’ll see. Anthony can always
disagree and suggest something himself.
‘That is nice,’ Anthony says with relief on his face. He accepts
the ideal being as a possibility. ‘I will be doing better next time.’ An
apologetic smile comes from Anthony.
‘A voice: “You will be doing better next time.” If a witness was
here, a witness would say, “I see how sorry you feel towards Petra,
thinking you aren’t doing well now and how you wish that next time
you will do better.”’
I use micro-tracking and the figures so Anthony feels seen and
heard and he can connect with himself. I repeat what the ideal being is
doing and how they relate to each other: ‘If I was your ideal being
when you were a child and ever since, you would always have a
centre with me. I would be your Pole Star. You could always see me
and come to me. You would be safe with me even if your thoughts
were confused and your attention distracted. I would stay with you.
You could connect with me whenever you needed to.’ I use Anthony’s
own words for the ideal being.
Anthony is silent, calm, centred, content. He experiences being

connected and safely dependent on an ideal being. It is moving to see
him in such a peaceful place. It is rare.
After a long pause I suggest, ‘Tell me when you’re ready. Together
we will de-role the objects and end the structure.’ Anthony stays in his
emotional contemplation several more minutes. I remind him he had a
very fragmented childhood and had no ‘Pole Star’, no mother and father
with him. It is not just his injury which makes his mind disoriented.
‘That ideal being would be something like your ideal mother.’ I outline
such a possibility so Anthony can hear it. So his ears and brain and soul
can hear it. After a while we de-role the placeholders. He remembers all
of them to Hannah’s and my surprise. I have to admit to him I do not
remember all of them. When I ask him if he wants another session, he
says, ‘Of course. I want to see you again. Soon.’
Therapist thoughts
Therapists in training and later in practice have to work on their own
personal issues. It is a compulsory and very important part of training
and working as a therapist. If you decide to become a PBSP therapist,
you will have at least three years in training and you will do structures
as a client. My teacher and trainer was Albert Pesso. I remember one
of my structures with him. I needed a reassuring experience of light
and hope. Al followed my way of thinking and my emotions. In
my structure I was very sure about what I needed but it was hard to
express and to get it symbolically present and interacting with me in
the therapy room. Al’s house and training centre at the time was on the
shore of Webster Lake at Strolling Woods in New Hampshire. There
were large French windows in the training room facing the surface of
the lake.
I was looking around not knowing what to do for a while. After
some struggle I got it. I took a piece of glittering glass and put it on the
window frame. The afternoon light shone through the glass. It created
an amazing spot of light and purity. That was it. ‘This represents the
light and hope I needed as a child,’ I said to Al. He let me interact
with light and hope as much as I needed. Much later we agreed there
was a principle on the glass of a person in my childhood with whom
I could feel there was always light and hope in life.
I remember that structure very well. It was very important to me. A

colleague of mine told me a few years later, ‘I was astonished by that.
Most people get hugs from ideal parents and you insisted on that piece
of glass full of light.’ ‘Yes,’ I said, ‘Al let me do that and helped me to
create exactly what I needed.’
I remembered that experience after Anthony left my office. We all
need something to go to when the world does not make sense. It is great
if it is a wise, honest, hopeful mother and father when we are young.
Anthony and a child’s innocence

Anthony has done four sessions so far. A few days ago he sent me an
e-mail. ‘Petra, please give me another chance with my therapy. Thank
you. Anthony.’ That is what it said. Perhaps he was struggling again
with his ambivalence about being in therapy and wanted reassurance
that I believed in the process and in him. I responded by e-mail, ‘Hi
Anthony. You are in therapy. Your next appointment is on 26 October
at two. I look forward to seeing you. Petra.’
Anthony arrived on time, on his own, in a good mood. He was
suffering from the flu, which made his nose red and runny and his
complexion pale. He felt miserable. But he looked happy, confident
and relaxed. Quite a different person from the one I saw six months
ago. His caseworker, Hannah, is here too. The three of us are sitting
comfortably in the therapy room drinking hot tea with honey. I tease
Anthony about his flu, saying if he is at least 150 centimetres from
us, we will not catch it. We all laugh and I can see and feel how
our relationship has developed and become comfortable. It brings a
thought to mind and I say it right away. ‘Anthony, I was thinking,
maybe you can reconsider Hannah’s presence in your sessions now.
What do you think?’ Anthony smiles and looks at Hannah with a
slightly guilty look.
‘Well, there are things I would like to tell you that I don’t want to
tell Hannah.’ He looks uncertain.
‘Yes. I was thinking you and Hannah have issues you work on –
social benefits, where you will live, etc. and it might be distracting to
have her here in the room.’ I leave Anthony time to think about it. I
reassure him about our original contract: ‘You have a choice. It’s your
decision, but somehow it came to my mind to ask you about it. Maybe
think about it and tell me next time.’ I want Anthony to experience

having a choice and the solidness of our contract.
‘Oh, then I know now. I would like to do therapy just with you
and social issues just with Hannah!’ His smile shows he has completed
the decision-making process and he is content with it. I agree to the
new arrangement. ‘OK, that’s fine with me.’
‘Are you sure you don’t mind?’ Anthony turns to Hannah. ‘I’m
perfectly OK. I’m glad it’s worked so well. So, see you next week.’
Hannah leaves the room in a relaxed, friendly way. I think this
interaction shows how differently Anthony deals with making choices
and negotiations. I believe it is not just our relationship which allows
him to do this with such ease. He feels more secure and confident
when he expresses his needs and thoughts outside therapy too. It is
nice to see who Anthony really is. And I am to see more of this in the
following structure.
Anthony continues talking after Hannah leaves. She is still on
his mind. ‘Hannah has been so good to me. I call her my substitute
mother.’
I suggest a step, a sort of double step. ‘Let’s have a placeholder
for Hannah and, as you mention it, let’s have the principle of an ideal
mother on her placeholder too.’ Anthony follows and he is inspired
with more thoughts and feelings related to Hannah and his missing
mother too. He is not fully aware of all this yet.
‘Yes, she is like my mother. She has done so much for me and the
Little House has too. Without them I would be a homeless person
now.’ Anthony says this with a complex emotion visible on his face
and colouring the tone of his voice.
‘A witness would say, “I see how thankful, grateful and humble
you feel remembering what Hannah and the Little House facility did
for you.”’
A noticeable nod on his side and his connected look into my eyes
confirms it really fits. When the therapist, using the witness figure,
‘hits the bull’s eye’ and precisely names the affect of a client, when
the client feels the rightness of it, it creates a deeply felt connection
between them. This just happened between Anthony and me.
I add a bit of theory about what is happening. ‘The principle,
this little piece of paper, is actually the principle of an ideal mother.
The good mother you should have had from the very beginning
to the present time. Hannah is doing some of her job.’ Anthony has
no problem accepting this clarification. It seems some of the pain

related to his extreme neglect and missing his mother has faded. He
is able to think and talk about it with clear understanding and no
attempt to avoid the issue.
‘At the same time, I’m glad I have moved out of the Little House
and become independent. I wouldn’t like to be addicted to it, like
some clients there seem to be.’ Anthony now looks mature and like he
is enjoying his freedom and grown-up state. I witness it and he agrees.
‘Well, I think often about “the old fellow Anthony” before my
injury. How different he was from who I am now. He was very bright,
intelligent, but also proud. He was a bastard then. He had a lot of
friends who admired him. He liked that and abused it. Now I have
much more experience of life and I have changed, but my intelligence
is all damaged.’ He has a hopeless, ‘poor thing’ look.
‘A witness would say, “I see how discouraged and hopeless you
feel, thinking of your intellectual abilities now.”’
‘Yes.’ A bitter smile appears about the witness’s correct naming
of his emotions. I find it extraordinary how he speaks about himself.
He talks about himself before his suicide attempt in the third person,
whereas he uses ‘I’ statements when he talks about himself now. He
seems to be split into two parts which know little about each other.
One is the lost ‘genius’, but a ‘bastard’, whom he calls ‘old Anthony’.
He looks back in time at him and compares him with the way he is
now. Now he is wiser but stupid, dysfunctional, lost, nobody. The
obvious weirdness of his perspective on himself inspires me to take
an unorthodox step. Being faithful to the principle of clarity I tell
Anthony about it.
‘It’ll be an unusual step, but as you speak it sounds like you are
talking about someone else when you think of “old Anthony”. So
let’s have a placeholder for “old Anthony”.’ Anthony picks up a little
golden sun and smiles. It represents very well his ‘lost glory’. I am not
sure where things will go from here, but Anthony solves the problem
without any difficulty. He keeps talking.
‘There were three main things I did wrong back then,’ he says,
judging himself with conviction.
‘That’s a voice of judgement, it says, “You did three main wrong
things back then.”’
‘Yes. One: I left high school. Two: I stole at work. Three: I jumped
under the train.’ He is clear.
I start with the one he mentions first. It looks like it is charged

with some urgency. ‘Tell me more about it. How old were you when
you left high school?’
‘I was thirteen. I didn’t study much. I had to leave because
my mother abandoned me. I had to move to my aunt’s and live in
another town.’
‘You know, Anthony, it sounds like you were very young and you
couldn’t do anything about it. Your mother failed you and you were
placed with your aunt, miles away. It was not your fault, really.’
Anthony looks at me with surprise. It had never occurred to
him that as a child he did not have stability, support or boundaries
provided by his parents that would have allowed him to develop. It
never occurred to him the problem was not his fault. Telling him this
is not going to change much. It is important to give the client relevant
insight and information, but it needs to be sealed by his own felt
experience. So right away I paint the outline of ideal parents in the air.
I reverse the original deficit. The ideal parents say, ‘If we were your
ideal parents when you were thirteen and studying at high school, we
would have supported you. We wouldn’t have failed you. We wouldn’t
have left. With us you could concentrate on your studies and you
wouldn’t have to move anywhere.’
‘But I was lazy too. I didn’t study much, although before the injury
I was clever.’
‘If we were your ideal parents, we would know you were a bright
kid. We would have helped you develop discipline and we would have
established good limits when you needed them.’
Anthony nods, but the dialogue with his ideal parents reminds
him of how it really was. He reacts and responds genuinely, ‘But I’m
glad I have all my experiences, although my childhood was rough.
Because it made me the way I am now. I want to keep them. They are
part of me.’
I use the voice figure. ‘That’s a voice. It says, “Your rough childhood
experiences made you the way you are. Keep them.”’
‘Yes.’ Anthony feels heard and understood.
‘Well, let me tell you something. That’s right, our childhood
experiences become memories. Memories do co-create the way we see
things, how we feel about them and the meanings we give to them. It
feels like part of us. Given that, if a young child experiences too many
bad things and a lot of stress, fear and shame, it gets encoded in his
psyche and the child suffers from it from then on. In other words, a
child’s experience shapes him. Keeping the memories as they were first
encoded means keeping pain and confusion. Pain and confusion is
part of such a child (and later such an adult), but it is not the real him.’
Anthony listens carefully. He is learning something new. Then he
remembers a ten-year-old boy he saw in the hallway when he arrived
at my office today.
‘He was fun. Did he have a bad childhood too?’
‘He did indeed. He is great, but he still needs some help.’ I don’t
share any more information about the boy. Still, it makes a connection
for Anthony. When they met he quickly engaged with the boy and
became very playful. The boy was also very interested in Anthony.
He felt his gentle friendliness. ‘I like children. I always did.’ We put
placeholders for the boy and children on the table.
‘A witness would say, “I see how mellow and happy you feel when
you remember you like children.”’
‘I have been feeling strange around adult people recently,’ Anthony
says with a sad and slightly depressed expression. ‘I feel like they
think I’m crippled.’
‘A witness would say, “I see how down and hopeless you feel
when you imagine that people think you’re crippled.”’ We have a
placeholder for ‘people who think he is a cripple’. As it is generalised,
he uses one stone for all these people. This way he can talk about
the generalised feeling he gets from them – the feeling he is wrong,
inadequate and impossible. Now it is clear why he used a different
grammatical form to describe himself before the injury. ‘He’ was the
great Anthony before the suicide attempt, but now that is gone. The
new Anthony is crippled, wrong and awful. I don’t say this. Instead I
suggest a reversal. ‘Could we have an imagined ideal person here with
whom you could feel free and good?’ I am curious if he can come up
with such a possibility. His memory brings the picture of a real girl.
‘Little Kathleen. She was my aunt’s daughter. I often took care of
her. She was about five years old. I really liked her.’ Anthony shows
his tender look again as he thinks of Kathleen. I ‘witness’ this and
we put a placeholder for her on the table. It inspires me. The contrast
between the ‘bad, inadequate Anthony’ when he thinks of people in
general, and the tender, innocent Anthony when he thinks of children
is striking. ‘May I say something about this, Anthony?’ I make sure my
insight will be welcomed.
‘Yes, of course.’
‘I think your little cousin Kathleen was a happy, innocent child,
full of trust, and she liked you. You felt that. You didn’t have to try to
figure her out. You didn’t have to guess what she was thinking. You
enjoyed her and yourself, the way you really are. And it looks like who
you really are is a good guy. Tender, innocent Anthony.’
‘I think deep in my heart and soul I am a good guy.’ Anthony is
now relaxed. His face looks very young, about eight or ten years old.
He is in touch with himself. And he is just one, not split.
‘You were just confused when you were a young boy. Adult people
made you feel bad and strange. It was confusing and you took that
in. Then they left you, both of them, your mother and your father
too. It left you feeling bad as if you’d caused it. It happens to children
this way.’ Anthony listens and handles it very well. I outline his ideal
parents in the air.
‘Your ideal parents would say, “If we were your ideal parents when
you were a child, we would have known you and understood who you
were. We would have protected your innocence. You could be yourself
with us and we wouldn’t leave you.”’
Anthony integrates this new, and at the same time so familiar,
feeling. It is safe to be himself – kind and innocent. He does not
negate this any more. He knows it’s real. He is connected to himself
and experiences it inside. If he had had good parents, he would have
this experience most of the time from the beginning to the present.
I complete his structure with one more thought: ‘In a structure we
don’t erase old experiences. You aren’t asked to forget them and lose
that part of yourself. Those memories are yours and being aware of
them and understanding them, you can use them for something good.
But in the structure, in the possibility sphere, you experience yourself
being treated the way you should have been treated. You can have such
an experience in the “childhood state of mind”. Then it creates a new
memory. Your brain will use it in the future. It fits the genetic plan for
you and all the children in the world.’
Anthony understands. He is quiet, but fully engaged in integrating
it. ‘I feel grounded, centred, calm and dignified,’ he comments.
‘Yes. And you are one unified person who understands himself too.
You have always been.’
Anthony gives me a wise smile.
‘So let’s de-role the placeholder for “old Anthony”.’ We do that. I

repeat the fact that now and forever he is one unified, centred person.
I add a few more words from his ideal parents: ‘If we were your ideal
parents, when you were a little boy, you would have felt this way from
the very beginning. We would support you so you could finish high
school and study whatever you wanted to. With us you wouldn’t have
been confused. You would learn about things, good and bad, slowly in
a safe relationship with us. You wouldn’t think you were a “bastard”.
We would know, and you would know, you are a good person.’ This
is a ‘good end’.
Therapist thoughts
This structure involved quite a lot of insight and teaching. I find that
insight and education are especially important for clients with early
trauma and attachment disorders in the process of internalising models
of healthy attachment and self-worth. I often see that such early stress
poisons the very self of a child and it can stay that way into adulthood.
I call it the ‘bad I syndrome.’ It develops in the early years when
parents’ or caregivers’ attitudes towards the child are dominant and
indisputable for the child and he naturally absorbs these attitudes. At
that age a child is so dependent on caregivers that he integrates as
his own everything they say, think and feel. When the message is
predominantly negative, it is a hard thing to deal with as a child and
later on as an adult. When the sense of self is ‘I am bad,’ the client
owns it and cannot imagine anything else. When the client experiences
himself as a child with ideal good parents, who see him, like him and
teach him, all of a sudden he feels his own inborn goodness.
He finds a golden treasure in himself.
Chapter 7
REBECCA, THE WOMAN

WITH THE RING
Petra Winnette
Introducing Rebecca
Rebecca asked me to work with her after participating in my training
for adoptive parents.
She and her husband recently adopted a sweet two-year-old girl
named Anna. Rebecca is a beautiful, intelligent, young woman who
teaches art and is very successful in her career. But Rebecca is not
happy. Yesterday she got really mad at her husband, Garry. Garry and
Rebecca were celebrating Rebecca’s birthday. Garry knew Rebecca
loves rings and decided to surprise her. He really wanted her to be
happy. He looked for a very special diamond ring and when he found
one he thought she would like, he happily bought it. They had a
nice evening together with candles, dinner, flowers and the present.
Rebecca opened the little silver box and found a ring. She tried it on.
Oh no! It was too big! Rebecca got mad in a millisecond. Really angry!
‘How could Garry be so senseless? What a stupid mistake!’ Rebecca
says. She thought Garry must know where she keeps her rings. ‘Why
couldn’t he have been clever and simply taken one of them with him
and bought the same size?’
Sitting in my office, Rebecca gets upset as she remembers this
recent story. She speaks quickly and loudly. Her face is red. She looks
angry and frustrated. Her husband made her this angry. It is obvious it
is not the first time. In fact it happens all the time. More stories follow.
All of a sudden she gets quiet and sad. ‘I hate myself for these feelings,’
she says. ‘I so often get very upset. It’s because I always know how
things should be. You know, so it would be right. But I can’t control
211
everything all the time! Like my birthday present. Why didn’t he ask
me which size?!’
‘Maybe he wanted to surprise you. He hoped it would make
you really happy and feel special if it was a surprise. He would be
with you when you saw the ring for the first time.’ I try retelling the
original story. However, I can see no suggestion like this will work.
Rebecca’s frustration has got the nature of real despair and disaster.
As she already mentioned, she tries to control things so they work
perfectly. But she cannot be everywhere and do everything. It sounds
like she is furious at her husband for buying a ring the wrong size. But
as a matter of fact, she is furious with herself. She failed to control the
world. A world out of control is a terrible place to live and Rebecca
has lived there for a long time.
‘I know he wanted me to be happy! But why didn’t he try harder
then? He just didn’t think enough! He was lazy. He is so selfish.’
Rebecca is angry again. Then she breaks into tears. ‘I have been like
this all my life. I’m very tired of it. I don’t know what to do.’ I see how
strange and miserable her life must be. There is such conflict between
her emotions on the one hand and her reasonable mind on the other.
As she speaks I can see the vicious circle. Rebecca wants life to be
predictable, controllable and perfect. When she is in charge, it seems
to her she can manage it. If, in her mind, she manages it, it reduces
intense anxiety. But no one else can do the job. Her husband, friends,
colleagues, as a matter of fact other human beings in general, will
fail. People are incompetent. They make silly mistakes and overlook
details. Rebecca cannot leave anything without her supervision. But
even when she tries to be the ‘watch dog’, things often go wrong
anyway. She is exhausted. She hates herself too because she is not able
to run her life to perfection and she can see how ridiculous this effort
is. There is no escape.
Rebecca has been in therapy before. It was a therapy which focused
on the client’s attitude and point of view towards events in their life and
how they name them. By renaming events a client re-frames them and
can better cope with them. Rebecca learned something about herself
in the therapy and she can use the ‘renaming and re-framing’ technique
when she needs to. She says it really helped her. She had a chance to
see that naming things differently, to a certain extent, changes the
way she feels about them. However, she recognises her emotions are
very strong and often negative and destructive despite this. She finds
Rebecca, the woman with the ring 213
herself very frustrated when she tries to rename and change her angry
or depressed feelings and she is not able to do it. She thinks she should
be able to use that effective technique, but when she is overwhelmed
by disorienting, strong affect she fails. A vicious circle of trying to
control and losing control is in action again. She wants to escape from
this cycle. She wants to feel better and be a good mother for her
adoptive daughter and a good wife for her husband.
Rebecca and the Fat Fairy

We will see Rebecca now after she has done about one year of PBSP,
about twelve structures. At this stage Rebecca regularly arrives in
a depressed, hopeless state of mind. She could be described as a
determined client, who desperately wants to change, who works as
hard as possible, and yet feels hopeless about changing. Her need
to control everything and depend only on herself prevents her from
being on the receiving end and getting her needs met. This structure
shows the steps that can be taken in PBSP even when a client is not
yet ready to receive.
Rebecca starts talking as she sits on the sofa: ‘I often feel so
depressed and hopeless.’
‘What triggers it? Which people, situations, places?’ I encourage
her to give me specific contexts. Sometimes a client can get so
absorbed in themselves they only report on their mental states and
their interpretation of these states. In PBSP we ask them to talk
about the people and events associated with their emotions, if possible.
In this way the client becomes aware of how his affects are linked to
interactions with the world and people around him.
‘Ehhh. Many of my friends are pregnant now and they have their
own biological babies.’ Tears in Rebecca’s eyes show the depth of her
pain. ‘And I can’t conceive because of my health issues which I’ve had
since birth.’
‘A witness would say, “I see how down and heartbroken you feel
thinking of your health issues and inability to conceive.”’
‘Yes. But I’m not so frustrated about my problems with my heart.
That is surprising to me.’ Rebecca reports a positive change in how
she thinks and feels.
‘A witness would say, “I see how surprised you feel when you
realise how much less it bothers you to think about your problems
with your heart.”’
I am glad. This is a sign of a progress. Her depression may keep her

from seeing progress and enjoying positive changes, but still Rebecca
reports a surprising change. Her distress, related to the early trauma
and continued complications of a serious medical condition, is less
intrusive. This is an important difference.
In my experience, PBSP induces change from ‘inside out’. Clients
have an experience which creates emotional learning. It changes how
they perceive themselves and the world. They feel differently and
approach the world differently. It may surprise them. Often they are
not able to explain how it happened exactly, but it feels like this is how
the world should be. I can see this starting to happen with Rebecca.
For now, let’s go back to her structure.
‘Let’s have placeholders for your pregnant friends and those who
have biological babies.’
Rebecca puts objects on the table.
‘And let’s have objects to represent the consequences of your
health issues. Which ones come to mind?’
Rebecca puts objects on the table and names them, ‘This is a
placeholder for my skin problems. This is a placeholder for my hairy
legs. It is caused by medication. For the fact that I can’t conceive.’
‘What’s on your mind when you think of them?’
‘I hate myself for the way I feel about it.’
‘That’s a voice, it says, “Hate yourself for the way you feel about
your health issues.”’ The voice figure repeats her statement back to her
as a command. This way she can hear it and consider it. It reduces
the power of the message and the feelings associated with it. There is
also the implication that she can chose whether to follow a command
or not.
‘I feel defective. My self-esteem is so low.’
‘A witness would say, “I see how lost and defeated you feel, when
you think about feeling defective.”’
Rebecca nods with tears in her eyes and looks lost. She is facing
an overwhelming sense of hopelessness.
‘Let’s have a supportive figure here, who will be with you when
you have all those overloading feelings. It will be a reassuring figure,
who gives you permission to have all your feelings and supports you
when you have them.’ I outline an ideal figure just by describing it
for now. Then I speak for the figure without waiting for Rebecca’s
response to my suggestion. ‘If I was an ideal support figure, I would
stay with you so you could have all your feelings and I would help
you handle them.’
‘It’s better.’ She smiles and looks relieved.
After a while Rebecca responds, ‘Hmmmm. But I don’t believe it.
Why is that? I can believe something good for a short time, then it
collapses and it doesn’t work again.’
‘Is it OK if I tell you what I think?’ I gently give her the power to
decide how to proceed. This is the time to give her a bit of theory and
a frame of reference for the process she is going through, but I do not
want to do this if she is not open to it.
‘Yes, tell me, please.’
‘When you were a child your life was full of pain and horrible
experiences. You stayed in the hospital, went home for a short time
and then went back to the hospital. From time to time, things looked
better, but then you had to go back and undergo another painful
procedure.’ I can summarise this information because we have been
through that part of her life in our previous sessions. ‘You were so
young you couldn’t make sense of it. You didn’t understand what was
going on with you. But you remember that circle on an emotional
level. Whenever something ‘smells’ good, your brain will let you have
it and enjoy it for a while and then a wave of negation arrives and you
anticipate trouble again. It follows the pattern which was happening in
your childhood. There was no constant, safe person in your life. There
was no safe place you could always go to, feel secure and connected
and know it would last.’
Rebecca breaks into tears as I speak. ‘Yes. That’s exactly how it
was. Nobody was ever there and helped me. I was three years old. I
remember being alone with doctors and nurses restraining me. They
were causing me pain and discomfort. I wanted to fight with them, but
there was no chance.’ She keeps talking to me through tears. Such an
injustice! I put a reversal in the air knowing she is not ready to receive
an antidote to that massive trauma. Not yet.
‘Let’s have the possibility of ideal doctors and nurses here. They
say, “If we were your ideal doctors and nurses back then, we would
have been kind to you when you needed us as a child. We would’ve
made sure your parents were with you all the time and you wouldn’t
feel hopeless and tortured.”’
‘Yes.’ Rebecca nods, she is calmer and continues talking. ‘And then
my parents came to visit me on Sunday afternoon. They were being
cheerful and optimistic. They told me encouraging words, smiled at

me and told me to be brave. They didn’t want to hear about my despair
and pain! They wanted me to be OK! So I tried to be a brave and good
girl. I often felt sorry for them that I was so defective, a sick kid.’
Here we are. What a complex issue we see here. Since birth
Rebecca was repeatedly hospitalised and suffered many painful
treatments. Most of the time she was alone and professionals did not
treat her as sensitively as a young child needs. She had loving parents,
but they did not know what she needed or how to support her. They
thought encouraging her and expecting her to be brave and cheerful
would be good for her. But what happened? Rebecca grew up in
hospitals, dealing with a great deal of uncertainty, loneliness, physical
discomfort and pain. She did not have a safe relationship. When her
parents were there, they were not emotionally available to her. To put
it simply, she lived alone with overwhelming stress. She had no chance
to share her feelings with someone close to her. There was no one to
comfort her. No one to let her know that they understood how she
was suffering and that they would stay with her no matter what. It is
now clear why Rebecca’s approach to life has got features of no hope,
the effort to be self-sufficient and in control all the time, being self-
critical and a huge frustration and disappointment with other people.
As I hear Rebecca talk about it I think of a reversal for her memory
of her parents failing to support her. I suggest the possibility of ideal
parents: ‘If we were your ideal parents, when you were a child, we
would be with you when you were distressed and you could share all
your pain, sadness and anger with us. We would understand it and we
would always stay with you.’
Rebecca listens and nods as she hears what she needed back then.
Then she asks with a childlike, innocent smile, ‘Could I have an ideal
animal there with me? Instead of ideal parents? I can’t imagine them.’
With a sceptical tone of voice, she adds, ‘I know it’s not real. They
wouldn’t allow animals in a hospital.’
‘You know, Rebecca, it seems you can believe in an ideal animal
who would stay with you so you wouldn’t be alone in distress. In the
possibility sphere we work on a symbolic level. It’s not like the “real”
world. Here you can have the things you can imagine. The animal
you’re thinking of has the qualities of an ideal parent.’
Before we outline an ideal animal in the therapy room, Rebecca
responds to my clarification with another image which comes to mind:
‘When I was a child, I often read a book called Rosa, the Fat Ghost. In
that book there was an old, fat fairy or maybe it was a ghost. She was
a very kind, fat, old lady who lived as a ghost in the attic. She helped a
little girl who lived in the house and had problems. Nobody else could
see her. Just that child could. I always wanted somebody like that.’
Here we go. Rebecca dreamed of having a safe person. She was
longing for such a relationship so much as a child, she invented one in
her mind based on the book.
‘Let’s have a placeholder for the character from the book.’ We
do that.
‘Oh yes. And now let’s have an ideal Fat Fairy here for you in the
air. And she says, ‘If I was your ideal Fat Fairy when you were a child,
I would be kind to you. I would help you and nobody could see me,
just you.’ I capture all the qualities Rebecca emphasised.
‘Oh yes. That’s important. Because if the ideal Fat Fairy was there
with me in the hospital and they saw her, they would chase her out.’
Rebecca re-experiences her history although she is imagining an ideal
Fat Fairy. The new experience of a safe figure gets mixed up with the
old memories. When something good happened, it was always swept
away by doctors, nurses and parents. They all did the best they could,
but still Rebecca was alone in enormous despair. I am aware we are
going at a slow pace but we are making progress today. The fact that
Rebecca can believe in an ‘ideal fairy’, who would be with her so she
would not be alone, is great.
‘Yes, if I was an ideal Fat Fairy with you in the hospital when you
were a child, no one could see me and no one could chase me out.’
‘Yes.’ Rebecca nods with satisfaction. This creature is powerful;
nobody can chase her out. She stays with Rebecca and Rebecca can
imagine trusting her. Rebecca experiences herself in a ‘childhood
state of mind’, being three years old and having a Fat Fairy with
her. She tells me about it: ‘I can imagine that. She’s sitting on my
bed. She goes home with me when they release me from the hospital.
She knows what it’s like there and she understands me. I can have my
own feelings. I don’t have to be cheerful and brave with her all the
time the way I had to be with my parents.’
‘If a witness was here, a witness would say, “I see how comfortable
and safe you feel having the ideal Fat Fairy with you all the time.”’
Rebecca integrates this new emotional experience for a long time.
‘I wish she was helping all the other children in the hospital too.’
Rebecca remembers her mates from the hospital and her compassionate
side comes out.
‘This is just your ideal Fat Fairy, you know. She would have been
in your life all the time. She’s got the qualities of an ideal mother. So
let’s create a “movie” where each of those children you are thinking of
(maybe every child suffering in the world) has an ideal fairy. Everyone
has got his own.’ We created a movie for all the children and each
one had a protective figure in the form of an ideal fairy.
‘Oh good. Then my own ideal Fat Fairy could be with me all
the time.’
‘Exactly. That’s what she says: “If I was your ideal Fat Fairy, I
would be yours and yours only. I would always be with you, all the
time. I would never disappear.”’
Rebecca experienced a very good end to her structure. Then slowly
we de-roled the placeholders, the movie and the ideal Fat Fairy. But
this new experience stays with her.
Therapist thoughts
‘It’s a very good sign she can have an interactive and visceral experience
with a protective figure when she remembers her experience in the
hospital,’ I think after Rebecca has left. The ideal fairy has qualities of
a good mother. This way she accepts the possibility of a good mother.
For a long time, she had difficulty believing that anything good would
last. She spent most of her first four years in the hospital. She was
prematurely born, survived in an incubator and then was diagnosed
with a severe developmental disorder in her heart. She had long stays
in the hospital. In therapy we have been dealing with the consequences
of this history. Her symptoms show signs of a disorganised-disoriented
style of attachment. She has symptoms associated with post-traumatic
stress disorder and developmental trauma. She experiences these
consequences and tries to make sense of her experience and talk about
it, but that does little to change anything. Bessel van der Kolk explains
this when responding to a question by David Bullard in an interview
about developmental trauma.
David Bullard: ‘Could you say something about why talk therapy
alone doesn’t work when treating trauma?’
Bessel van der Kolk: ‘From my vantage point as a researcher we
know that the impact of trauma is upon the survival or animal part of
the brain. That means that our automatic danger signals are disturbed,
and we become hyper- or hypo-active; aroused or numbed out. We
become like frightened animals. We cannot reason ourselves out of
being frightened or upset. Of course, talking can be very helpful
in acknowledging the reality about what’s happened and how it’s
affected you, but talking about it doesn’t put it behind you because it
doesn’t go deep enough into the survival brain.’ (Bullard 2014)
Despite severe trauma in early years of life, Rebecca is progressing.
In this structure she made a good step forward. She has the powerful
emotional experience of a having a safe figure with her when she was
three and suffering. Does it matter the safe figure was an invisible Fat
Fairy from a vivid childhood memory? Does it matter Rebecca only
imagined having an interaction with the fairy in the past which reversed
her history? Well, in PBSP therapy we see it is these very elements,
in fact, which make the experience meaningful and convincing for
the client.
Rebecca and the phoenix

Rebecca has been seeing me for PBSP therapy for some time. She is very
collaborative and approaches therapy with her typical, intensive focus
and determination. She wants to change. She wants to feel better. But
she wants results now and she gets discouraged and depressed when it
does not happen right away. She still relives ways of thinking, feeling
and coping she developed as a child living with severe trauma. She
developed them in order to handle pain and isolation. Paradoxically,
these strategies are the very ones which make her life stressful, painful
and isolated now. We have been slowly discovering the depth of
her suffering and connecting ongoing issues to their source in early
trauma and unfulfilled developmental needs. However, in PBSP we do
not leave the client here. The therapist helps the client experience an
interaction with imaginary, ideal figures which can relieve the client’s
distress and change their way of thinking, feeling and coping with life.
Rebecca arrived on time and ready to work. She always does. She
allows me to film her sessions and use them for scientific purposes.
Rebecca is a very collaborative and hard-working person. But still her
world is hardly ever the way she wants it to be.
She feels good today. She reports having more energy and feeling
less anxious.
‘What is happening in your mind?’ I ask the familiar question.

‘I have a topic today. It’s my husband, Garry.’
Her husband is a frequent topic in Rebecca’s sessions as is her
adoptive daughter. It is not difficult to figure out why. These two
people are Rebecca’s closest relationships. With them she experiences
the consequences of her traumatic childhood in the most intense way.
‘Let’s have a placeholder for Garry here on the table.’ I remind her
about this step. Rebecca has learned the PBSP process and techniques
now and enjoys the clarity of it. She finds a dull-looking piece of
wood to represent all the aspects of her husband and puts it on the
coffee table in front of us.
‘He leaves everything to me. I mean household chores, taking care
of Anna… I am so angry at him. He is so uninvolved!’ She emphasises
his passivity and speaks with anger and frustration in her voice.
‘A witness would say, “I see how frustrated and on edge you feel,
when you think of your husband being so uninvolved.”’
‘Yeah. But also I feel bad about it. I think maybe it’s just me who
sees everything so dark and so wrong.’
Rebecca looks disoriented and her emotions are in conflict. As a
matter of fact, they are sweeping her from one side to another. She is
torn between two contrary, strong emotions and two interpretations
of what is happening. Either Garry is terrible or she is. A voice figure
makes her aware of her own internal statements (meanings). A witness
figure helps her recognise the different affective states related to herself
and other people in her life.
I say, ‘That’s a voice, it says, “You see everything so dark and
wrong.” And a witness would say, “I see how angry part of you is when
you think of Garry being uninvolved. And how frustrated and lost part
of you feels when you think it’s you who’s wrong.”’
Rebecca looks at me with gratitude. It feels good to her that
someone can clearly see and describe what is happening inside her.
It calms her down. She continues by giving some background about
Garry.
‘It was like that in my husband’s family too. He was an only child
and he didn’t have to do anything at home. If he did, his parents
would help him and didn’t let him try and complete tasks by himself.’
‘Let’s have placeholders for Garry’s parents.’
Rebecca puts two little stones on the table. ‘Now he’s sick. He’s got
the flu. He behaves like a little child. He’s in bed and complains. Poor
little thing! I’m getting used to the fact that it’s like that with him.’
‘That’s a voice: “Get used to the fact it’s like that with him.”’
The voice repeats Rebecca’s statement as if it was a command. Albert
Pesso says statements of our internal voice function like hypnotic
suggestions. They work automatically and direct our responses to the
world. Hearing the voice come from outside makes its message clear
and the client sees it as something separate from himself, something
he can look at critically. It takes some of the power out of it.
‘A witness would say, “I see how pissed-off part of you feels
when you think of Garry being like a small child and how resigned
part of you feels when you think about getting used to Garry being
that way.”’
‘I sometimes think I produce all the problems. What shall I do?’
I am tempted to provide Rebecca with insight and information.
As we know, she is a hard-working client and student. She really
appreciates being instructed. She reads self-help books and enjoys
discussing them with me. But there is a problem. When Rebecca
comes back for our next session, she feels depressed, anxious, lost. My
lovely lecture and our fine dialogue have faded and there is not much
left. She needs another dose of reassurance, teaching and connection
with someone she can be open with and who does not judge her.
Sometimes this approach is useful. But it is clear to me it is her affective
dysregulation and the meanings she puts on her experiences which are
the source of her confusion. That confusion is the result of living with
chronic, high levels of stress which she had to deal with as a child on
her own. Unless we address this history, the circle will go on and on.
She will continue to re-experience intense negative affect and despair,
feel compelled to try to control everything, struggle in relationships
and be self-critical.
I briefly comment that couples function based on an invisible
balance between their distinct personalities and ways of approaching
the world. One might be a ‘receiver’, passive and less productive, and
the other, an active organiser, a manager and engine of activity. One
might be in a more parental role – controlling and achieving, while
the other is in a more childlike state – dependent and avoiding
responsibilities. These roles fit the models they developed as children.
It may work to some extent and it feels familiar to them. But in

the long run it may become an obstacle for each of them and their
relationship too. They cannot develop healthy autonomy and become
who they really are. They may feel uncomfortable and discontent. I
think to myself, ‘Enough! Enough lecturing here!’ Rebecca is such
a good student it often elicits a teacher’s response from me. But it is
not in her best interest. I move towards clean and clear PBSP work. I
trust it is needed here far more than my ability to teach and talk with
Rebecca about all her issues.
‘You know, you and Garry could try couple’s therapy. It’s up to you.
But I understand you’ve been struggling with anxiety, guilt, shame and
anger which you experience, not just with your husband, but with your
daughter, other people and alone. That suggests you’re on the right
path when you work on these issues in individual therapy. What do
you think?’ I summarise our discussion so Rebecca can proceed and we
are congruent on our path. And we can be back to our PBSP contract.
‘Yes. I’m really keen to do that. It’s been helpful. I think I would
just like to see results soon. I’m impatient.’
‘That’s a voice, it says, “See results soon.”’
‘Yes.’ Rebecca smiles at me. Her smile suggests she is not taking
herself so seriously. It indicates she is now on better terms with herself
and genuinely prepared to work.
I take a special PBSP step here. Rebecca’s angry reaction to
thoughts about her husband brings the possibility of an ‘ideal husband’
to the scene.
‘Let’s have the outline of an ideal husband for you here in the air.
He will be a “reversed version” of your husband with no part of your
real husband.’ My finger paints a figure in the air. Rebecca’s pilot now
distinguishes between her husband, the placeholder for her husband
on the table and the imagined ideal husband in the air.
‘Where would you like to place him?’
‘Here.’ She points to an empty space next to her on the sofa. She
is interested in what is going to happen.
‘So he says, “If I were your ideal husband, I would be fully involved
and you wouldn’t feel everything is left on you.”’
Rebecca nods and adds, ‘He would cooperate with me. He would
talk about things with me and together we would agree on what to do.
I would feel sure of myself and safe with him.’
I repeat what she says about her ideal husband: ‘So he says, “If I
were your ideal husband, I would cooperate with you. We would talk
about things and agree what to do. And you would feel safe and sure of
yourself with me.”’ This technique gives the client the special possibility
of experiencing an interaction with an ideal antidoting figure. There is
a difference between simply imagining something versus hearing your
own words and ideas expressed by a voice speaking for an ideal figure.
PBSP therapy emphasises interaction and in this way the ideal figure
provides connection and responses in an interaction which mirrors the
client’s deepest hopes and needs.
Rebecca is vividly relieved and she radiates optimism and energy. I
need to make sure she is not imagining the real Garry being improved
to an ‘ideal’ Garry. That would not be therapeutic. On the contrary,
it would be playing with pleasant, but ineffective, ‘wishful thinking’.
Because she knows Garry is not ideal, she will never accept an
imagined ideal version of him.
I gently remind her, ‘Make sure you’re imagining an ideal husband
and not Garry.’
‘Oh no! My ideal husband is someone else than Garry. Completely
different!’ Rebecca is amused. She likes being free and open to
this new possibility. She feels satisfied with it. But this is just the
beginning. The ideal husband represents and shows Rebecca the
qualities she longs for and misses in Garry. It is understandable. If
this was the whole problem, they could solve it in couple’s therapy.
The therapist would help Rebecca express her wishes directly and
the couple could learn together about effective communication and
collaboration. However, what Rebecca experiences in relation to her
husband is affective dysregulation related to the closest person in
her life. She experiences severe disorientation and disorganisation in
their relationship. Rebecca lives much of her life re-experiencing early
trauma because everyday events trigger the emotional states, thinking
and responses she learned in childhood. The reaction makes no sense
to her now, out of its original context, and yet she is unable to respond
in any other way. ‘Trauma is not the story of what happened long ago,
the long-term trauma is that you are robbed of feeling fully alive and
in charge of yourself ’ (Bullard 2014).
The session has to reach the source of such a state of mind, the
early trauma-related memories which control her perspective and
responses in the present. Garry entered the picture much later. Often
the client starts talking about childhood naturally. But today Rebecca is
still dwelling on the possibility of an ideal partner. Maybe I should just
be quiet and wait. I choose to continue by talking to Rebecca’s pilot.
‘Your emotional charge indicates some of the problems have deep
roots. Do you think that in your past, when you were a child, there
was a time when you “did everything” or “took care of other people”?
Does it remind you of something you know from your history?’
‘You mean that I felt terrible myself and it was a relief to focus on
somebody else and provide support or help?’
‘Yes. I was thinking when you were a child you might have been
providing more than receiving. I could be wrong too.’ I am not
interpreting Rebecca. I am opening the door to her early years, but
she can refuse it too.
‘Oh yes, of course I did! I took care of children in the hospital.
When I was fifteen, I had to undergo another surgery. Some doctor
decided that. He didn’t consult with me. He didn’t consult with my
parents. You know they didn’t talk to me.’
‘Let’s have a placeholder for your parents and the doctor.’
Rebecca quickly puts placeholders on the table and continues
talking, absorbed in her memories. She sounds like she is reporting
something she has talked about many times. There is not much affect,
although the story is obviously a horrific one. This looks like mild
dissociation. She keeps going: ‘It was completely out of my control.
They treated me like an object. That surgery was unnecessary and he
just decided to do it!’ Now Rebecca is full of anger.
‘A witness would say, “I see how furious you are remembering that
doctor and how you had no control when he decided to do surgery
which was unnecessary.”’
‘Yes!’ She nods in emphatic agreement. ‘It was so terrible.’
I bring the beginning of a new experience. ‘Let’s have here ideal
parents and an ideal doctor. They say, “If we had been with you back
then, we would have consulted with you and involved you in making
decisions.”’
She does not look convinced. Rebecca is not sure this could ever
happen. The strong record of trauma in her memory dominates her
reality and thinking. I leave the outline of her ideal parents and ideal
doctor in the air. But Rebecca has got something urgent on her mind.
‘I remember there was a young girl there about four years old. I took
care of her, hoping she wouldn’t have to suffer like I did.’
‘Let’s have a placeholder for the little girl you took care of in the
hospital.’ Rebecca carefully picks up a little wooden star and with
delicate care, gently puts the placeholder on the table. She shows so
much patience. In her mind she is saving this other little girl from
suffering.
‘I liked taking care of her. I felt less hurt, tortured and senseless
that way.’ One can see relief on Rebecca’s face as she speaks about it.
‘A witness would say, “I see how tender you feel when you
remember that little girl. And the relief you feel when you remember
taking care of her.”’ Rebecca nods. I decide to talk to Rebecca’s pilot.
‘What you were doing in the hospital was providing care and presence
for that little girl. She could not get it from her parents because they
were not there.’
‘I think so. I was helping and nobody else was there. Just me.’
‘Well, there was a big gap there. She did not have parents and good
doctors there. You didn’t have parents and good doctors there either.
You empathised with that girl and you automatically filled the gap you
saw. In a way you became her “ideal mother”. Can you see that?’
I explain to Rebecca the phenomenon which Albert Pesso calls
‘holes in roles’. ‘By doing that, in your psyche you were no longer a
child who needed reliable parents, good care and adults you can safely
depend on. You became a “parent figure”, a provider of care. It reduced
your feeling helpless and trapped. In that role you could be competent
and in charge.’
Rebecca is hanging on my words. ‘Yes! It’s exactly what it felt like.
I always did that. And still I often think of all the children I met in the
hospitals where I was placed.’
‘Of course you do. Most of us are social and emotionally connected
beings. If we see a gap in a social network, if we see suffering around
us, in our minds we try to fix it. Sometimes we can even do something
about it. But this way, as a child, we step into someone else’s role.
You took the role of that girl’s parents. So now, let’s create a “movie”
where that little girl will get ideal care from ideal caregivers – ideal
parents and ideal doctors too.’ She lets me organise it. ‘Pick an object
for the little girl you remember and give it to me.’ I put this object on
the floor. ‘This is that little girl. Now pick up two objects which will
represent her ideal parents and give those to me.’ She does this and
I arrange a scene there. The ideal parents talk to the little girl and I
speak for them: ‘If we were your ideal parents and you had to be in
hospital, we would be there with you all the time and take care of you.
You would never be alone and helpless.’
Rebecca watches the scene which I enact with small stones on the
floor. In her mind she sees the girl she took care of long ago and now
she sees her in this new scene. She smiles. ‘It would have been so much
better. And I want her to get an ideal doctor too.’
She picks up an object to represent an ideal doctor for the girl.
I place it in the scene on the floor. Now our movie is complete. The
doctor says to the girl, ‘If I was your ideal doctor back then, I would
be kind and competent and I would talk to you.’
Rebecca relaxes, leans towards the armchair and exhales deeply. A
great relief. ‘I don’t have to do that job any more, right?’ She checks
with me to see if her surprising reaction to the ideal scene is correct.
‘No, you don’t. Listen to what they say to you.’ I play a little
theatre with the objects. ‘Now the ideal parents of that girl and the
ideal doctor talk to you.’ I pick up the stones, show them to her and
say, ‘It’s our job to be good parents and comfort our daughter in the
hospital. Not yours. It’s my job to be a good doctor. Not yours.’ And I
put them back in the movie with the little girl, represented by a stone,
and establish a nice, cosy setting around her.
‘Oh, that’s such a great picture. I like it that way.’ Rebecca is
relieved. For the first time since the situation happened she is free
from being the one who has to save the child and she sees the child
getting her needs met.
‘And what about me? Now I have nothing to do there. I am on my
own, sick, in the hospital.’ After leaving such a big job, clients typically
feel empty and lost. Now Rebecca remembers her own trauma again.
‘Well, we have the outline of ideal parents and doctors in the air
for you.’ I remind her of the step we took twenty minutes ago. At that
time she was not able to take it in.
‘And an ideal nurse too?’ Rebecca is receiving the new experience
now. She has got ideal parents to take care of her and ideal doctors.
Right away she completes it with an ideal nurse. Hurrah. I am glad
Rebecca has moved to this stage.
‘Well, of course. I enrol an ideal nurse too. Here you have ideal
parents with you, an ideal doctor and an ideal nurse. What would they
do when you were in the hospital at age fifteen?’
Rebecca is sure about that. ‘My ideal parents would never let the
doctors take over. They would’ve talked to me and let me be part of any
decision. They wouldn’t have thrown me there so helpless.’ Rebecca
has got tears in her eyes. It is sadness and hope at the same time.
‘A witness would say, “I see how moved you feel experiencing the
difference between how it was and how it feels now.”’
‘Yes.’ Rebecca gives me a grateful look. She can have this new,
unusual experience. It is so much better than how it really was. She
bathes in it for a while.
‘Imagine it happening when you were fifteen years old’; I remind
her pilot about the time frame. Rebecca and I talk in real time, here
and now, but she is experiencing the ‘good end’ of her structure in her
‘childhood state of mind’ at age fifteen.
‘I feel like a phoenix,’ Rebecca says after some time in silence with
tears of relief on her cheeks. It is a beautiful metaphor. It does not need
explanation. But I put her emotional experience into words: ‘It’s your
awakening life, vitality and hope for the future. It’s the real you.’
At the end of the structure, before we de-role all the placeholders
and ideal figures, I have her ideal parents speak to her again: ‘If we
were your ideal parents when you were a child, you would have felt
this vital, this hopeful and this alive from the beginning until now and
forever.’ After the structure Rebecca tells me, ‘I like this work. I also
feel very tired. I can see that I have a big job to do.’
‘You’re right. It is work. For the client who is genuinely involved it
can be a demanding experience. But slowly, step by step, as your sense
of self changes, it will ease the process. If you want to, stay here for
ten or fifteen minutes and relax. Do you want a cup of tea or coffee?
It’s good to relax and let your brain integrate the new recording which
is now linked with the early traumatic memories. It’s no surprise you
are tired. You’ve been touching on hurt places in your memory and
creating completely new memories.’
‘But the new ones are so much better.’ Rebecca is reassured,
knowing her feelings after the structure are OK. She has a cup of
tea and rests for ten minutes on the sofa. Then, feeling good, she
leaves and goes out into the world.
Therapist thoughts
Rebecca made significant progress. Her issues have a powerful effect
on her life. Her childhood memories are alive and constantly colour
her psyche. Today she arrived feeling very frustrated with her husband,
but it is part of a general frustration and fatigue from trying to control
and fix everything around her.
We can see how this relates to her childhood reality. Incompetent
adults didn’t do their job and she had to cope with that. She helped
the little girl in the hospital and relieved her own suffering. Her brain
remembers that strategy of taking charge and repeats it over and over
again. The strategy may be effective when she takes care of others,
but it leaves her in an empty and isolated place where she can’t rely
on anyone or feel comfortable and safe with them. She has to repeat
the strategy over and over because the state of mind she had as a
child – feeling helpless and tortured – is still not healed and is easily
triggered.
She had done a similar session recently in which she could only
accept an ideal figure who was not a human being. In this structure
she agreed to have ideal parents, an ideal doctor and an ideal nurse.
What she needed as a child was a safe connection with people. It is a
new step in her work.
Rebecca and her adoptive daughter

I mentioned before that Rebecca and her husband adopted a two-year-
old girl named Anna. Sometimes we have consultations about Anna
and parenting issues as well as a PBSP therapy session. From time
to time I see both Rebecca and Garry and we discuss their daughter
and the specific difficulties of children who have had a troubled early
childhood. We have a contract to use DDP with the family and PBSP
with the mother.
Anna was born to a young mother who gave her up in the
maternity hospital. She was placed in a ‘baby home’ for four months,
then placed in a foster family. When legal procedures were completed,
Anna was adopted by Rebecca and Garry. Both parents were
inexperienced with little knowledge about how to parent a child who
had a disruptive beginning of life. They realised their limitations soon
after Anna arrived.
It is very interesting to work in parallel on Rebecca’s personal and

parenting issues. It makes me think how well these themes complement
each other. Let me now share another session of Rebecca’s. This one
combined consultation about her daughter and a PBSP structure
which grew naturally from the discussion of parenting issues.
Rebecca, Garry, Anna and tantrums

Rebecca arrives for our PBSP session and tells me at the beginning,
if I do not mind, she needs to consult about Anna. Anna is almost
four now and she has been showing some consequences of her early
history.
‘OK. It’s fine with me.’ I am curious what she has to say.
‘Well, Garry and I don’t know how to handle Anna’s tantrums.
They happen often, maybe once or twice a day. We don’t know why.
We don’t know how to prevent them. And we don’t know what to do
when she acts so crazy.’ Rebecca summarises her concerns and looks
at me with a question in her eyes. I know her eagerness to fix things
and control the world around her. I understand how difficult it must be
for her not to be able to keep Anna calm and happy and ‘fix’ her when
she is upset. Rebecca suffers from strong waves of emotion herself and
now she is supposed to comfort and regulate her daughter’s strong
emotions. ‘No wonder it seems impossible,’ I am thinking.
‘Please tell me more about it.’ I usually ask clients to come up with
examples of problem situations which happened recently so we can
focus on something tangible.
‘Oh, it happens mostly when Anna is tired. It often is in the
evening when Garry comes home from work. Anna gets triggered by
minor things. She gets irritated when the wind blows almost.’
I know what she is talking about. Children with early trauma,
who had deficits in attachment and no safe relationships at the very
beginning, like Anna, suffer from affective dysregulation. Their
responses to frustration are rapid, easily triggered and enormously
strong. They hit the ceiling in a millisecond and it seems as if they will
never calm down. It is also possible the parents unknowingly elicit this
behaviour in some way. But before I intervene I still want Rebecca to
give me a recent example of such a situation and behaviour.
‘It was just yesterday. It was typical. Garry was feeding Anna with
a teaspoon. It was going OK, but he missed once. The teaspoon hit
the chair and the food fell on the floor. That was enough. Anna started
crying. She was hitting her father and me too.’ Rebecca is upset.
‘We didn’t know what to do. But I got so angry with her! I had
to hold myself so I wouldn’t hit her back. I just wanted her to stop! I
wanted her to stop now!’
And then Rebecca reflected on herself with a familiar self-critical
tone. ‘I know it’s my fault. I know how she feels. I think she’s like me
when I was angry as child. I can really identify with her.’
‘What happens when you feel like that towards her?’
‘Then I feel furious towards Garry. He caused it. He should have
been more careful!’
‘It must be confusing. Do you want me to speak about it now?’
‘Oh yes, please.’
‘Well, given your own history, you may be able to empathise and
feel the intensity of your daughter’s stress in your body and mind. She
is dysregulated because in early childhood she did not have interaction
in safe relationships which would help her form neural circuits which
modulate stress and speed up recovery from it. You did not have this
either. So you react to her stress with extreme stress of your own. And
then there is nobody there who can help Anna calm down. Anna feels
bad, helpless and out of control. She hits you because she hates herself
and hates you because you made her feel that way. She can’t think
about it. That’s why her tantrum is so strong and lasts so long. And
if you want her to stop it, she can’t do that, so she feels even worse.’
‘Oh yes. I know. You’ve taught me that before and I read books
about it. But when it happens, I lose it.’
‘It is understandable, you know. When we get stressed, our
limbic system takes over and our logical, educated brain switches
off. It happens to all of us.’ I help normalise Rebecca’s view of her
daughter’s distress. ‘As you can be so empathic when Anna is upset, it
can serve you as a good resource for knowing what to do. Let me ask
you a question.’ I am going to show Rebecca that deep in herself she
actually knows what to do. I will use a perspective from PBSP here.
Rebecca looks interested. ‘OK. Can you tell me what you think Anna
needs at such a moment?’
Rebecca looks at the situation from a different point of view now.
Before she was frustrated not knowing how to stop bad Anna who is
crying. Now she is using a mother’s sensitivity and wisdom to identify
what her upset girl might need, what she is communicating in her
tantrum.
‘She needs someone who will be with her and give her time to
calm down,’ Rebecca says.
‘Yes! An ideal parent would give her time to calm down and stay
with her. It’s like in a structure. You can use your PBSP experience
when you help your daughter.’ I link Rebecca’s therapy with her
parenting. ‘What do you think she experiences when she has got
someone like that with her?’
‘She can be angry and still sure the ideal person can handle it. She
feels safe.’
‘And not bad.’ I add one more detail. ‘If you as a mother use that
awareness, then your mother’s brain will slowly regulate Anna’s affects.’
Rebecca is smiling. Things make sense to her now and she feels
better equipped. She continues by focusing on herself.
Rebecca can be angry

‘You know, I’ve been feeling much better recently. I can really notice
the benefit from our PBSP work. I don’t know how to describe it.
It feels inside of me like I have a choice about how to experience
situations now. It’s like something in me knows the “good” now and I
can choose it or I can choose the old “bad”.’
‘Could you give me an example?’
‘Yesterday I was putting Anna to bed. Garry was watching TV
as usual, comfortably relaxed on the sofa, resting from work. When
Anna was asleep, I walked into the living room and saw him. One part
of me got angry. “Look at him again! He is so lazy, so uninvolved!”
It used to be my only reaction to this situation. But this time I could
recognise something new and surprising. Another part of me was
seeing something different. “Oh look. He is so relaxed and cosy. He is
watching something stupid, but it would be great to join him, hug him
and have a relaxed evening together.”’
‘A witness would say, “I see how impressed you are when you
realise you have different reactions to situations and now you have a
positive choice about what to do.”’
‘And what did you actually do?’ I am curious and pleased at the
same time. What Rebecca is describing about herself sounds like a
miracle. There is a new, relaxed and happy network in her brain.

Hurrah! Step by step she can become her real self and she does not
have to relive her childhood for ever.
‘Well actually, somehow, I decided to be angry. My old way is safe.
I know how to be angry and detached much better than how to be
safe and close. My mother used to do the same thing. She would get
angry at my father and pull me aside; complaining, being angry and
discontent.’
‘Let’s have placeholders for your mother and father on the table.’
Rebecca puts two small stones on the table. I do reversals right away.
‘So we place the possibility of your ideal parents in the air. No part of
your real parents. Your ideal mother says, “If I were your ideal mother
when you were a child, I would be content and I would enjoy relaxed
time with your ideal father. I wouldn’t pull you aside and complain
about him.”’
‘Oh yes. That’s great. I remember my last structure. I had my ideal
parents being good partners, close, collaborative. It really helped me.’
Rebecca enjoys the memory of her last structure (it is not included in
this book). It is easy for her to continue. She says, ‘I imagine them
holding hands. If there’s a problem, they sit together and talk. If they
were my ideal parents, we would’ve had a calm and peaceful home.’
She looks peaceful and much younger.
‘A witness would say, “I see how content and happy you feel as you
experience your ideal parents when you were a child.”’
‘Yes, it’s bliss.’ Rebecca is smiling as she takes in the new
experience. ‘They are OK together and I can just be a child. I can just
float there carefree. It’s so peaceful.’ Rebecca’s tonality and expression
changes. It is tense now. ‘Oh, all of a sudden, I’m thinking of Anna
and Garry again.’
‘Let’s have a placeholder for Anna and Garry here.’ She puts two
objects on the table.
‘What’s on your mind when you think of them?’
‘That I only know how to be angry.’
‘That’s a voice, it says, “You only know how to be angry!”’
‘Yes. I feel like he tries to avoid me when I’m angry. Then I avoid
him and go to my dark cave where I can be angry by myself.’
‘That’s a voice, it says, “Avoid Garry. Go to your dark cave and
be angry there on your own!”’ A witness would say, “I see how
tormented you feel when you remember Garry avoids you and then
you avoid him.”’
‘No, not really, I feel angry.’
‘…how angry you feel…’
‘That was my reliable strategy from childhood. That’s what I always
did. I couldn’t be angry with my parents. It would have destroyed
them. So I hid inside of me and stayed there feeling awful.’
‘Remember we have your ideal parents here in the room. They’re
holding hands. They love each other and you can just be a child
with them.’
I bring Rebecca back to the memory of her ideal childhood which
she experienced today and in our last session too. It is important to
antidote her old childhood state of mind and emotional strategies
with the possibility of having ideal parents. Rebecca gets oriented
immediately. ‘With them I could be angry and naughty. They would’ve
known how to handle me! They’d do what I can do with Anna! They
would stay with me until I calmed down. We would have a secret sign.
When we use it we would know we’re friends again and things are
good again.’ Rebecca speaks with certainty. It sounds like inside she
knows the truth.
It is astonishing to me how beautifully the pieces fit together in
Rebecca’s structure – marital, parenting and individual concerns. She
is realising it inside. What is most important, she has linked together
all the emotion and meaning which come with the experience. It is
new to her, but it feels so right. That is the way it should have been.
‘And they would actually be happy I can be so angry. They would
know it’s good too. And then life would be good again.’
‘If we were your ideal parents, we would have been happy you
could be so angry. We would have known it’s a good thing. And then
life would be good again.’
I add one more piece: ‘And you wouldn’t have to detach and hide
in your dark cave when you had strong emotions. You could share
them with us. It would be completely safe. And then life would be
good again.’
‘Could you say it again?’ Rebecca takes in this new possibility
eagerly.
I am moved too and repeat my words with dignity and a ritual
atmosphere. ‘And you wouldn’t have to detach and hide in your dark
cave when you had strong emotions. You could share them with us. It
would be completely safe. And then life would be good again.’
We slowly finish the structure. I think it was a ‘good end’ and a
good beginning.
Therapist thoughts
Rebecca’s issues are complex. The process of PBSP therapy reveals how
early trauma affected Rebecca as a child and how the consequences
of that trauma are re-played in her functioning as an adult. When she
really feels furious, she suppresses it. She has no licence to be angry
and deal with it openly. Remember the structures which revealed that
when she was angry and furious as a child, she could not show it. Her
parents only allowed her to be a brave and cheerful kid.
We can see how this history is re-played in her feeling helpless
and angry when her daughter has a tantrum. She didn’t know how to
help when the girl was angry and she felt the girl shouldn’t be angry.
In the structure above she has ideal parents, a good strong couple,
whom she can be angry with and they know how to help her learn to
regulate her affect. It is believable to her that she could have a good
childhood and she benefits from this. The change is manifest in her
life. Her ability to relax and see the world from a positive point of
view has been surfacing slowly, but it is evident. It is coming from her
inner world. Maybe one day she will hug her husband on the sofa and
enjoy feeling close and safe with him and her daughter. She will know,
although they are imperfect and she is imperfect, it is safe to love them
and safe to be loved too.
Later Rebecca reported that she handles Anna’s tantrums without
feeling so bad and frustrated. Now she can accept when her child cries
and gets angry. With calm and balanced emotions, she can help Anna
regulate her affects. The structure apparently reduced the distress she
feels in everyday situations in her role as a mother and she is better
able to respond to her child’s needs.
Rebecca and the ideal doctor –

A structure in a group setting
Before we follow Rebecca on her journey, let me speak about how
PBSP therapy works in a group setting. Albert Pesso liked to say PBSP
is a one-to-one therapy which can be done in a group or an individual

setting. This sounds confusing. If it is a ‘one-to-one’ therapy, why use
it in a group?
Dance, shape and counter shape

PBSP was originally created and practised only in a group setting.
As we know the Pessos were dancers. Their natural gift for dance
and performance on stage influenced their thinking when it came
to organising the therapeutic setting and environment. We learned
about the birth of PBSP therapy when the Pessos realised when a
dancer expresses emotion he needs a response to the emotion. In
their own way they touched on one of the most important principles
of human development and social connection in general. Children
as well as adults need to be responded to and to connect through
shared emotion and experience. That way they get a sense of being
seen, heard and understood. Most importantly, they feel valid and
worthy. I think in this way people actually get the sense that they
exist. Fulfilment of needs in interaction with another trustworthy and
close person became a core principle of PBSP therapy. The Pessos
adapted their knowledge and experience with dancers to the way they
organised therapy sessions and so they thought group members were
needed to respond to the client during a structure. Albert Pesso later
discovered that if he used language in a deliberate and careful way,
many clients benefited from imagining an interaction. They did not
necessarily need a group setting where others could role play ideal
figures for them.
The role of the group: Role playing

A PBSP group usually consists of six to twelve group members and
one therapist. Participants take turns so each member of the group can
do a structure with the therapist.
We already know how a structure works. So what is different in a
group? The difference is participants are present in the room as an
audience and they can be asked to role play ideal figures for the client.
Role playing in PBSP is different from role playing in other therapeutic
systems, such as drama therapy, psychodrama, body therapy. The role-
playing participant never acts on his own. He must follow precise
instructions from the therapist and the client who work together to
create an ideal interaction with this ideal figure. The therapist oversees
the process and ensures the interaction is therapeutic. Group members
who are not role playing do not speak and only observe the session.
Example
Client: ‘I would like to have an ideal mother here.’
Therapist: ‘Yes. Do you want to imagine your ideal mother in your
mind? Do you want to use an object? Or you can ask a group
member to role play your ideal mother.’
[The client considers the options and looks around the room.]
Client: ‘I would like to choose a group member. Paula, please, could
you role play my ideal mother?’
Paula: ‘Yes.’
Therapist: ‘Paula, please say, “I enrol as your ideal mother and no part
of your real mother.”’
Paula speaks to the client: ‘I enrol as your ideal mother with no part of
your real mother.’
Therapist [to Paula]: ‘Now you can stand up, but stay where you are. Do
not move or do anything yet.’
Therapist [to the client]: ‘Where should she be?’
Client: ‘Well, here, behind me. I would like her to put her hand on my
left shoulder.’
[Paula in the role of ideal mother slowly walks forward, stands behind
the client and puts her hand on his left shoulder. The client smiles
and nods.]
Therapist: ‘Is that OK?’
Client: ‘Yes. I like this. I feel like she is supporting me. I never felt this
way with my real mother.’
The role-playing participant becomes a ‘projection screen’ for the
client’s imagined ideal figure. Because the client is in complete charge
of how the role player behaves, the client can form an ‘ideal’ version of
such a person and how he would act. He can choose a group member
to role play his ideal mother, ideal father, ideal sibling, and so forth. As
we have seen in individual structures, the client imagines ‘ideal’ figures
who interact with him in an ‘ideal’ way, that is, in the way he needs
now and he needed in the past.
There are differences between imagining an ideal person in his
mind and having a real person role play this figure. The appearance,
voice quality, physical presence, gaze, touch and numerous other factors
from another person who is role playing can make the structure an
even more powerful experience for some clients. There is an authentic
living being for the client to interact with. There are clients who
benefit from group sessions and having role players is very important
to them. Some clients prefer individual sessions without the group or
they choose to imagine ideal figures in the group setting. Some clients
find both modalities beneficial. Let’s look at a structure Rebecca did
in a group setting.
Rebecca and the ideal doctor – Group opening

Rebecca decided to join a group after she had done about fifteen
individual structures with me. She was feeling stronger and more
secure and she wanted to meet other PBSP clients. I invited her to a
one-day PBSP workshop. A workshop typically takes six hours with
three hours in the morning, a lunch break and three hours in the
afternoon. This gives a small group time and space to work together.
Usually the group does an exercise and three or four participants each
do a structure.
The group arrives and there are eight people in the room. They
look comfortable sitting in their armchairs. Rebecca is new and so
are two other participants. Some clients come to all the groups, some
come rarely. Today there is a mixture of long-time group regulars and
newcomers.
First, we do a brief introduction. Everyone says a few words about
themselves and talks about how they feel today, what is on their mind.
Here we go. It’s Rebecca’s turn now.
‘I have doubts about this. I’m not sure I want to be here.’ Rebecca’s
voice is full of anxiety. She looks lost and angry.
‘What’s happening?’ I ask in order to give Rebecca space to express

her mixed feelings and confusion.
‘Well, I wanted to come here and I’m happy that I came, but
listening to other people I feel like they’re all going to observe me.
They seem to be like “doctors” who like to study and analyse patients.’
Rebecca’s memory of being observed by strange doctors is present
in her thoughts and feelings here. This is the way she felt as a child in
the hospital. The group setting triggered these emotions and thoughts.
If Rebecca were a regular member of the group, such a reaction could
be the immediate start of a structure for her. But I am aware she is
in group for the first time and for her safety I choose not to start
a structure yet. I am aware she is reacting to the immediate loss of
control she experiences in the group. In childhood she was left alone
and helpless in the middle of ‘helping’ people. Is it not similar to the
situation today?
First of all, I speak softly to her and give her choices. ‘You know,
you can make your own decision. Maybe you really wanted to join the
group, but now, when you are actually here, it feels difficult. Please
make your own choice according to your feelings. Take your time. It
will be perfectly all right whatever you choose.’ Silence.
‘Ehhh. I want to stay.’ Rebecca speaks with a shy smile and looks
at me with more courage.
She could make the decision after she was reassured she is not
sentenced to sit here and be observed. When she knows she can leave,
she can stay. I do not know if she will be present as a group member
only or if she wants do a structure today. But now we have a contract
for her participation in the group and I trust it.
Other group members introduce themselves. They each have very
different emotions and things to say. After everyone speaks we are
ready to work together. People seem to have found their place in the
room and in the group.
A group exercise
A stimulating way to start a group is to do an exercise. The Pessos
developed a number of PBSP exercises which help clients experience
different elements and details of the therapy process. Exercises are
body-based, that is, they make clients more sensitive to what they
experience in their body and to their state of mind. They also illustrate
aspects of the theory.
Today I decide to do an exercise which I developed as a slight
modification of a traditional PBSP exercise. The original exercise gave
clients a chance to create their own ideal figure to provide for them
satisfaction of their basic developmental needs. My version involves
environment and place.
I introduce the exercise to the group in this simple way. ‘This
exercise has got four steps. After I give you instructions, you will do
all four steps by yourself. After you finish the exercise, go back to
your chair and then the whole group will reflect on the process. Are
you ready?’
‘Yes.’ The group is quite curious and definitely ready to start.
‘So here are the instructions:
‘First step. Look around the room and think what would be an ideal
place for you in this room. Somewhere you would like to sit or lay
down and be comfortable. Think about it and make a decision where
and how it will be.
‘Second step. Make a plan for how you will get to that place and
how you will use that place.
‘Third step. Go and execute your plan. Find the ideal place for you
in this room. Adjust it, if needed, and enjoy it the best way you can for
a while. Evaluate how it works and how you feel.
‘Fourth step: When you’re done, go back to your chair and sit down.
Reflect on the whole process and how you feel. Ready?’
The exercise starts.
Group members quietly follow the instructions and step by step
complete the process. After about twenty-five minutes everyone is back
in their seat and ready to speak about the experience. It is amazing to
me how differently people approach such simple instructions and how
different their reflections are on what happened with them. This time
is no exception. One member found a place on the carpet where the
sun was shining. The client loved it. He enjoyed the fact he could lay
on the warm floor, close his eyes and relax while being touched by the
sun’s warmth. Another client picked a book, sat back against the wall
and read very contentedly. Another had to adjust to the fact someone
else was in the place he wanted and there was not room for two people
there. He was disappointed and this triggered the thought that this
always happens to him – someone else has what he wants and there is
nothing left for him.
Now it is Rebecca’s turn to reflect on the exercise. ‘I couldn’t
find any place I liked; an ideal place. So I resigned myself and sat
somewhere in a corner feeling disappointed and angry. It seemed that
other people were in my way.’
As Rebecca speaks I hear sadness, anger and resignation in
her voice. She has the same constellation of feelings over and over
in her life. We can see that the client’s experience in the exercise gives
us a sample of how they typically think, feel and behave in response
to the world. Rebecca is not happy and looks uncomfortable. The
exercise confirms for her that her way of being is a sad and painful
one. In PBSP we do not leave a client in despair or distress. We give
him an antidote to relieve his immediate distress and prevent him from
reinforcing negative patterns from his history. The client’s distress is
understood to be a consequence of deficits in having his needs met
in childhood. When seeking to meet those needs now, the client re-
experiences the old, familiar pattern of failure and despair.
Rebecca tried to find an ideal place and now she feels like a failure.
I am going to suggest some steps to her which will reverse the old
pattern of failure and help her meet her needs and feel completion and
satisfaction here in the group.
‘OK. You didn’t find an ideal place in the exercise. Maybe I can
assist you now and you can complete the exercise to your satisfaction.
What do you think?’
‘Hmmm. As a matter of fact, I liked the place I found. But I
needed a blanket and there were no blankets available. Someone was
using them.’
‘I see. You can have blankets now.’
Rebecca is inspired and starts where she had finished her exercise
before. She is quiet and focused and she obviously knows what she is
doing. First, she finds a place by the wall. On one side there is a sofa
and on the other, there is a wall. She sits there and covers her body
with a warm, orange blanket. She does not look very comfortable. She
stands up again, brings a solid wooden chair and puts it opposite the
sofa, so now three sides of her little place are protected.
Then she covers this with a large heavy blanket which covers
the entrance too. She creates a tiny house or cave this way. Then she
climbs inside, wraps herself in the orange blanket and sits there in
complete silence. I cannot see her face. I understand this well. She
only feels safe when she is protected on all four sides and no one can
see her. She has spontaneously created her ideal place. Indeed.
‘What is your ideal place doing for you?’ I ask softly. Rebecca starts
crying. I can only hear a desperate, childlike weeping. She is not doing
an exercise any more. Her old history has opened. This sometimes
happens during group exercises. For some clients it is a door to their
deep emotions, and it is usually an interesting and genuine place to
start a structure. I decide now is a good time to do a structure.
Ideal doctor structure

Rebecca whispers, ‘Here nobody can see me. I can be on my own, only
with myself.’
‘So your ideal place speaks to you.’ I make her experience an
interactive one. ‘It says, “With me you can be on your own. Nobody
can see you. You can be with yourself.”’
It is hard to tell if her crying has got the flavour of relief or despair.
I cannot see her face and the sound is unclear. But Rebecca gives me
a clue. ‘But I’m alone.’
Oh yes. Rebecca responds to the anxiety she experiences around
people and creates an ideal place which provides protection and makes
her invisible. But when she successfully inhabits the perfect protection
for herself, she is unhappy, isolated and alone.
‘Could I have an angel here with me?’
‘An ideal angel, ideal company, so you are safe and not alone?’ I
add the idea of feeling safe and connected with another being. ‘We
can put an ideal angel in the air.’
‘Oh. It so much reminds me of my childhood.’
I take it slowly and let her connect with herself. Her inner
experience is overwhelming. If she is to get regulation and comfort in
an interactive way, it needs to be a gentle process. Now I wait for cues
from Rebecca.
‘I don’t really want an angel. I need an ideal doctor here!’
How interesting. As a child she had no human being with her
when she suffered. Her child’s mind needed someone so desperately
it created an angel, a protective ideal angel. This figure used to come
to mind at the beginning of her PBSP therapy and it came today too.
But such an angel has a big weakness. When she imagined an angel
as a child it did not help. She still experienced pain and despair. So
an imaginary angel did not change anything then and it is unlikely to
change anything today. Her recovering mind knows this and she goes
for a different solution.
‘Could I have an ideal doctor there in the hospital when I was four
years old?’
‘Of course,’ I agree, and I feel happy for her. She touches her
old trauma and she quickly looks for a reversal of that remembered
situation.
‘As we’re in group today, you have a wider choice. You can imagine
an ideal doctor in your mind, you can use an object to represent the
doctor or you can ask a group member to role play an ideal doctor
when you were a child.’ I summarise her options and I let her make a
decision at her own pace.
Rebecca does not hesitate and she speaks to a group member.
‘John, could you role play my ideal doctor?’ John agrees and I assist
him to take the role appropriately.
‘Where would you like to place him?’
You may have noticed that the situation is unusual. Rebecca is sitting
hidden in her cave and cannot be seen. You may also have noticed we
are not using the witness figure or placeholders in the structure. Her
structure developed from the exercise and it is organically evolving, so
I am happy to be a bit unorthodox. The main PBSP principles are in
place and I will make sure they are applied throughout the session. I
am curious how Rebecca is going to deal with a person in the role of
an ideal figure.
‘He should stand here in front of me.’ John stands facing the front
of Rebecca’s cave. She likes this and spontaneously describes how
she would have liked him to behave. ‘He would have been gentle
and he would have respected me.’ I can hear, as she takes in this new
possibility, her emotions have changed. Her voice is full of hope now.
I have John repeat her words back to her in a way that is healing
for the original trauma. John says, ‘If I were your ideal doctor, when
you were four years old, I would have been gentle and I would have
respected you.’ As John says this sentence, Rebecca listens carefully
to his calm, reassuring voice. She wants to hear a few more sentences.
She is fully involved emotionally and I can hear in her voice how
much she is absorbing this new experience. Her ideal doctor is being
role played by a real human being. A man. It gives Rebecca a vivid
sensory experience and she can imagine very well the possibility of
such a doctor in her childhood.
‘He would’ve talked to me. I wouldn’t have been an object for him
that he would observe and torture.’
I tell John the words he is to say and he repeats them to Rebecca.
‘If I were your ideal doctor, I would’ve talked to you. You wouldn’t
have been an object for me to observe and I would never torture you.’
John is doing and saying exactly what she needed then, when she was
a helpless, hurting child, all alone.
‘He wouldn’t have let me be hurt. He wouldn’t have done anything
which was unnecessary and painful to me.’
‘If I were your ideal doctor…’ As John speaks to her, she gets
reassured and calmer. Her little cave is not so necessary any more. She
moves forward a little and I can see her now. Her structure continues,
it is long and deep, with repeated healing interactions with her
ideal figure.
Toward the end I add a detail. ‘I am thinking of something. Is it
OK if I say it?’
‘Yes.’
‘It seems your ideal doctor has got some qualities of an ideal
father too.’ I put him in the air as a possibility. ‘Your ideal father would
have protected you and he would not have let you be hurt. He
would have talked to you and talked to your doctor too.’
Rebecca quietly accepts the possibility of an ideal father. It is just
an idea now. It is where her future work may go. Now at the end of her
structure in the group she has got a new, strong memory.
‘I’m ready to finish,’ she says after a long time of integration. ‘I
am tired too!’
‘John, please say, “I’m no longer in the role of your ideal doctor,
I’m John.”’ John de-roles and goes back to his seat. I continue closing
the structure: ‘I de-role the chair, sofa, wall and blankets as parts of an
ideal safe place. And I de-role the ideal father in the air.’
Rebecca is instructed to relax and take it easy for the rest of the
workshop.
‘Would you like to leave? You might be tired now. It would
be perfectly OK. Or you can relax in my office.’
Rebecca smiles, ‘No, I want be here in the group. I might just be
quiet for a while.’
Therapist thoughts
Rebecca needs to take slow, sensitive steps. She was hospitalised for
most of the first four years of her life. Instead of her parents, who
were present in a very limited way, she interacted with doctors. They
saved her life, but she felt as if she were being tortured by them. She
wanted to hide and called out for angels to help her. But none of these
strategies rescued her. In PBSP therapy she learned how in the present
she is in many ways re-enacting the traumatic internal experience she
had as a child. When she did this structure in the group, she was
ready to accept the idea of an ideal doctor and the possibility of
ideal parents. A few months later she was able to realise her deep need
for parents who would have protected, supported and understood her.
This was an important step. She needs a big dose of ideal parents
to get a sense of what it would have been like for her to be happy
and carefree as a child. Then from this perspective, in contrast to her
previous one, she would see the world as a place where she belongs
and her needs can be satisfied. And so she can live as she was meant
to live, as her real self. This is the hope that therapy and the future
hold for her.
Chapter 8
SILVESTER, THE MAN WHO

CHANGED EVERYTHING1
My name is Silvester
I am fifty-five. I left home at age sixteen. I got on a motorcycle and
headed for California where I knew no one. For three days my parents
had no idea where I was. I was almost a thousand miles from home
when the police arrested me for being a runaway. My father came and
brought me back. At home no one in the family spoke to me about
my disappearance. No one asked why I left, where I was going or
even what happened on the trip. No one said they worried about me,
that they loved me and didn’t want me to leave or even that they
were angry. Everyone acted like nothing happened. It was a deafening
silence. But I wasn’t surprised. This kind of isolation was typical in
our family.
Being myself
I had little emotional support or nurturing in my childhood. If I had
worries or fears, I had to handle them myself. My father was distant.
He told us little about himself and rarely showed affection towards me.
I was distressed, anxious and often in trouble. When I did something
wrong my father hit me with a belt on my bare legs, which was
frightening and humiliating, although I got no serious physical injury
from it. He did this from my early childhood until I was fourteen. He
rarely did this to my siblings. I was the bad child, the scapegoat of the
family. I was afraid of my father until the day he died.
My mother is narcissistic, a confusing mixture of over-intrusive and
1 This story was written by a client about his experience with structures and PBSP
therapy.
245
then distant, but always focused on herself. She has several stories she
likes to tell about me. The moral is always the same – what a difficult
kid I was. For example, when I was small, probably age three or four,
she wanted a break from children so she locked me in a bedroom on
the second floor. I guess she could ignore me calling and wanting to
be let out but couldn’t ignore when a neighbour called and told her
someone was throwing clothes out the window onto the roof of our
garage. When she tells these stories she shows no awareness of what it
was like for a child being subjected to her parenting methods.
I felt anxious around other people and whenever I tried something
new. So school was a big challenge. I started seeing therapists in high
school and continued during my adult years. I was angry, confused
and isolated. By the time I was fifty, I was more comfortable relating
to people, thanks mainly to group therapy. But I had a job I didn’t like
and an emotionally distant marriage. In my marriage we developed
a way of treating each other that repeated my old family pattern of
isolation and disapproval. It was a pattern we continued for decades.
I was preoccupied with family-of-origin issues and always somewhat
depressed. I took Prozac and saw a psychiatrist who helped me cope
with life. I thought I was doing nothing worthwhile (except that I
loved having children). I was isolated from close connections with
people and still afraid of doing anything new. I spent my two- or
three-week summer vacations staying with my mother in her summer
home and worrying about her abuse of alcohol and prescription
drugs, which she denied was a problem. Like many traumatised
children, much of my life revolved around trying to please and take
care of my parents. I couldn’t get free of them and I was resigned to
this way of living.
Coming to PBSP by accident

I met Al Pesso for the first time in a small town in New Hampshire.
As an observer of Al and PBSP for the first time, I was very impressed.
He was working with people in a way I had never seen before. And I
was very experienced with therapy. It was playful and creative. I was
amazed at how much information came out in one structure. People
were working on intense issues but they were getting relief from their
distress. It was comforting and inspiring to see.
I was so impressed with Al and PBSP I started going to workshops
and trainings a couple of times a year – doing about six structures a
Silvester, the man who changed everything 247
year. I continued this for four or five years. In a structure I was very
concentrated on what was happening. I felt I was reaching deeper
levels of myself, like I experience sometimes in dreams. I found that
what I had told myself about situations was very different from what
the structure revealed I was really feeling. I felt the material was coming
from me and the therapist was arranging it so I could keep going, feel
safe and valued, and have a specific type of experience. I covered a lot
of issues in each session and saw how they were connected, especially
how I was re-living as an adult patterns and feelings from childhood.
I saw what happened in the past and how it affected me now. I got
validation of needs that weren’t met and an experience of what it
might have felt like to have those needs met as a child. After a session
life looked much brighter.
In one structure I reported feeling fearful of people when I walked
in the streets of Boston where the workshop was being held. I said I
saw people as dangerous: crazy, bad, angry, criminal, not to be trusted.
We put out a placeholder for people. I had learned to be afraid of
people and I also identified with outcasts – people no one wanted to
associate with. I remembered that very early my parents and siblings
blamed me for how I acted. They said there were no problems in the
family but me. I felt like an outcast and ‘unlovable’. I felt out of control
and that no one cared or could understand me. Al told me within that
structure that when children are difficult there are reasons for it.
As the structure progressed Al and I had two group members role
play ideal parents who would have loved all the different sides of me
and taught me how to handle anger, confusion – whatever I felt as
a child. I especially liked holding their hands. I felt physical touch,
connection and support. Two group members were carefully directed
in the role of ideal parents who say and do the opposite of what
my real parents did. The experience in that structure made new and
astonishing sense to me. I felt valued. I belonged with the ideal parents
and they could handle whatever I felt or did. I felt the contrast between
how much I had missed feeling safe and missed feeling caring touch
compared to how good it felt to experience what it might have been
like having those needs met as a child. It was a moving experience
and completely the opposite of what I experienced in childhood. I
had loving connection instead of distance, silence and blaming. The
world and people were safe. My needs were seen and met in a caring
way. The experience was something I had missed and longed for
without knowing it. It was really striking to me that it was possible
to experience relationships like this with other people. I had an

experience of what I had been deprived of in childhood – a normal,
loving relationship with parents.
My life
The most surprising discovery, however, was how my distress and
preoccupation with family issues decreased in the days and months
after a session. I began to take on challenges that seemed unthinkable
to me before. I was not consciously trying to make changes or
analysing myself, but I was living differently, more in line with things
that suited me. Maybe the change took place on an emotional, rather
than cognitive, level. I gradually came to feel I was a person worth
loving, that I had something worthwhile to do in life and that the
world was a place where I could be myself and belong. I felt it was safe
to let the ‘real’ me out of hiding. I found the courage to try new things.
I got divorced, married another partner and found a job I like. Now I
found myself believing it was safe to love and trust I could be loved.
My wife loves me and I love her. I can feel that and enjoy it. It is a
great way of being that opened up for us. We can talk about problems
and solve them, rather than be distant from each other.
Gradually I stopped being focused on my mother and family of
origin. I lost the feeling of constantly wanting something I could
never get – being understood and feeling really loved by my parents
and siblings. I don’t obsess over it any more. The memories are still
there but do not have the emotional intensity they once had. I can
focus my energy on living now. I enjoy seeing my mother, but I take
care of myself and limit how long I visit. I am OK now with the
limitations of our relationship and the memory of our past which was
so painful to me. I stopped looking for something in a place where it
will never be found. I stay in contact with my siblings and enjoy not
having silence and distance between us. However, there too I have to
accept that we may never be as close as I would like.
I work with a PBSP therapist and do a structure sometimes when I
see myself worrying or engaging in repetitive behaviour that does not
get anywhere. I feel I can face challenges and find a way to live that
fits for me. I like the process of learning how it is to be the real me.
I am really not so terrible and ‘unlovable’ as I had believed myself to
be in childhood. I am grateful to Al and Diane and Petra for helping
me find the way to a good and happy life after years of unhappiness.
Chapter 9
EPILOGUE
Petra Winnette
The case studies and structures in this book happened as described. They

are written with the aim of keeping the clients’ stories as authentic as
possible. They are based on video tapes of the sessions or on detailed
case notes. I believe capturing a client’s work as it is done, step by
step, and keeping a record of the therapist’s immediate thoughts
and responses to the client provides a wealth of exceptionally useful
material. Names, ages, locations and other details were changed to
protect the clients’ identities. In this chapter we report on the clients’
recent progress.
Clara
When Clara started to work with me she lived in a sheltered living
centre. She suffered from severe anxiety. She was not able to be alone
and she experienced terrible fears when she was around people. She
could not stay at home and could not stand being outside. She tended
to join the homeless community as she felt more adequate and safer
there than around school mates, friends, or adults in general. Clara
worked with me for four years in PBSP therapy and at the time
this book was submitted for publication she had done thirty-three
structures.
There have been breaks in her therapy. Now she sees me about
once a month. She had a hard time trusting the new experience of
being accepted and valued. But slowly, in her way, she made good
steps towards this goal. She can take in good things about herself more
easily now. She became more aware of her good qualities. She knows
she can be a good friend and she does not have to be subservient to
anyone who might misuse her good heart. But she is still learning how
249
to protect her boundaries to avoid repeating the old pattern of being

mistreated in relationships. She is open about her homosexuality and
is looking for a real partner for life.
She is bright. She enjoys being around educated and interesting
people. She discovered she takes good photographs and that
other people appreciate them. She recently started taking photography
and French lessons. She seeks help when she needs it. She is a unique
young woman with hope for the future.
Paul
Paul started working with me when he was in a personal crisis and
in deep resignation about his life and happiness. He tried to find
help because of his young son. For himself, he was convinced life
was terrible and could not get any better. He had altogether given up
on the idea of being satisfied with his life. Paul worked with me for
two years and three months and did fourteen PBSP structures. He has
finished with regular therapy sessions now and is doing very well.
When he first arrived it was not easy for him to believe he was a
good person. He was also unconsciously taking care of his parents.
He was told he was ‘born to make them happy’ and he did not want
to give up this role. He told himself relationships with women were
unnecessary. Unconsciously he did not want to repeat the painful
experiences of his previous relationships. He had felt for a long time
that life made no sense and he just had to live through it.
In therapy we revisited many of his childhood memories and he
had a chance to re-experience them in an ‘ideal’ version. When Paul’s
healthy sense of himself started to surface, he liked that. He became a
relaxed man. He ended the relationship with his aggressive girlfriend.
Now he is in a new, healthy relationship. He was careful to find a
partner who can love his son. He enjoys his job and still has time to
play music in a band. His still loves his parents, but does not depend
on their ‘picture’ of him. He has his own truth based on possibilities
discovered in therapy. He knows who he is and he likes himself. We
e-mailed recently. ‘We are doing fine,’ he wrote, ‘I have not called you
for some time. It is because I am so busy.’ His letter was optimistic and
happy. I know if he needed therapy or a single session, he would be
back. However, therapy isn’t needed now.
Epilogue 251
Emma
When Emma started working with me she felt she was at the edge of
an abyss. Her relationships seemed all to be broken. She felt she was
failing as a mother. She was not able to find any satisfaction in the
world. She was obsessed with thinking about herself and her own
thoughts. She was very tired of life in such despair with no hope for
her future and no hope for change.
Emma worked with me for five years and did forty-four structures.
She sees me now once every six or eight weeks. She is living her life
in a very different way. Feeling content and having a positive attitude
towards her close people and herself has become part of her. She is
open to the world and enjoys relationships. She connected with her
biological mother and learnt from her about her biological father.
The story of the beginning of Emma’s life is tragic. Her mother got
pregnant as a result of a rape. But Emma could handle hearing it and
she accepts it. She will meet her biological half-sister soon. Her sons
are interested in their half-aunt too.
Emma can understand her entire life and be happy with it. She has
found a safe shore. Her confusion and preoccupation with self-analysis
and dissociation slowly disappeared. Her progress in therapy was
gradual and she went through periods of despair and hopelessness,
but she never gave up. Each time she saw me she built a new stepping
stone. At this time, as I finish this book, Emma is optimistic and ready
to make more changes in her life. Finding her own apartment and a
new job she likes are her immediate goals. Recently she did a structure
which focused on finding a partner. Emma touched on her experience
of living alone with her adoptive father. The situation created an
emotionally and sexually charged confusion. After working on this
issue she feels freer and more open to having a partner in her life.
Anthony
When Anthony started work with me he was living in a half-way
house. He often regressed and wanted to live a dependent life. He
suffered from strong emotional tantrums when he felt abandoned or
disapproved of by his mates. This made his life difficult. His self-esteem
was very low and he was obsessed with mourning over his lost mental
capacity. His social worker liked him but had doubts about his future.
Up to the time this book was submitted for publication, Anthony

had worked with me for fourteen months and done thirteen structures.
I see him about once a month now. In this book we followed his
first attempt at therapy and the next few sessions. He has made good
progress. His situation is difficult. For the first time in his life he has
to make a living, live independently and pay his debts. His biological
mother does not want to see him. His father lost interest in him long
ago. He has no other relatives around. He is on his own at the age of
twenty-five without ever having had support or nurturing from his
family. Hannah is still his caseworker and supports him when he needs
advice or guidance.
Anthony is making it. He is not a depressed, hopeless, lost child
any more. He is not involved in drugs or stealing. He has not been
in a psychiatric clinic. He is not thinking of suicide. He wants to live.
He is holding his life together, although it is not easy. In our most
recent session, he was no longer describing himself as if he had two
personalities – the omnipotent Anthony before the injury and the
crippled Anthony now. This disappeared altogether along with his
obsession about his cognitive abilities. He reduced his medication to a
minimum with the approval of his psychiatrist. He applied for a new
interesting job and is taking steps to finish high school.
Rebecca
Rebecca started work with me after trying other therapeutic methods
and feeling nothing changed. She was frustrated with her marriage and
unsure about her parenting. She blamed herself much of the time
and tried to control everything. She was locked into thinking she was
the only one who could run things and that she was a failure when this
didn’t work. Torn by these thoughts, she was exhausted and depressed.
Rebecca has worked with me for two years and ten months and done
twenty-two structures. I still see her for PBSP sessions and we consult
on her parenting attitudes and skills. Thanks to PBSP therapy she
feels more open and relaxed reflecting on her parenting attitudes and
approaches. Her need to control has diminished. The post-traumatic
consequences of spending her early childhood in hospitals on
her own still influence her psyche. Given the length and degree of her
developmental trauma, it is not surprising that overcoming its effects
is a gradual process. Recently she decided to see a psychiatrist. After
Epilogue 253
being medicated for depression she feels better and very motivated for
further therapeutic work. We continue working on her personal issues
in PBSP and in her most recent session she was very responsive to
experiencing new memories. ‘That was so wonderful,’ she said after a
long deep session and interacting with ‘ideal parents’.
Silvester
Silvester started his PBSP therapy with Albert Pesso after he spent
decades with other therapists in traditional therapies. He was depressed
and discouraged with the way he lived, but he did not know how life
could be different. His marriage was torturing him. He did not enjoy
his job and he was over-involved with his mother and siblings. He was
stuck. Silvester was in PBSP therapy for six years. He did twenty-four
structures with Albert Pesso and forty-one structures with me.
A few years ago Silvester finished his therapy and only sees me
from time to time now. His life and state of mind have improved
dramatically. He found a new wife and they are happy together. He
found work that suits him and he enjoys it. He continues learning and
trying new things. His relationship with his family of origin is healthy.
He handles it with love and a sense of humour. He says, ‘I don’t know
exactly how it happened. It’s hard for me to remember how I was,
how I felt and how I was thinking five years ago. But I am living now
in a way that fits for me. I didn’t think it was possible before. I like
myself and I enjoy life. It is still new to me.’ I am very thankful he is
willing to share his story and let me publish it in this book.
Daniel and Irene

They are now fifteen years old. Both live with their adoptive parents
and have safe and loving relationship with them. Irene and Daniel do
well at school, both show great empathy and ability to understand
other people and social situation. They have matured in a nice
and healthy pace.
Part IV
INTERVIEW WITH
ALBERT PESSO,
CO-FOUNDER OF PBSP
255
Chapter 10
INTERVIEW WITH
ALBERT PESSO
Conducted by Petra Winnette on
3 September 2014 in Boston, authorised
by Albert Pesso in January 2016
Albert Pesso and Diane Boyden-Pesso
Petra Winnette: Hello Al. Thank you for giving me this interview. We
are going to talk about the history of PBSP. I also would like to
learn more about how the structure developed as a therapeutic
method, the ingredients in the structure process and if we can, talk
a little about some of your case studies. Well, the history of PBSP,
I assume, starts with you and your childhood. Would you mind
telling me a little bit about your childhood?
257
Al Pesso: I never thought of PBSP coming out of my childhood but

it may have had an influence. Where it certainly has an influence
is that I was always very body-oriented. As far back as I can
remember I did a lot of body building. Even as a little boy. I
wasn’t simply thinking of strength. I know very shortly as I got
to be a teenager, I had a sense of the Greek ideal – strong body,
strong mind.
Petra Winnette: The Greeks called such an ideally developed human
being Kalokagathia. [‘Kalokagathia’ is a derived noun used by
classical Greek authors to describe an ideal of personal conduct.]
Al Pesso: That was there. I was a very good student. I went to a top
science school but I also wanted to build my body. But I didn’t
like big fancy thick muscles. I always thought of it as Greek
statuary and people said I looked kind of like that [laughs]. So I
very naturally moved into dance. So it was odd. I went into dance
not because I wanted to show off, but because when I first heard
about modern dance and Martha Graham, they had a ritual, classic
quality. She used to do dances about Greek drama. So it wasn’t
the kind of dancing where you were an exhibitionist, showing
off all kinds of skills, but you were making rituals and expressing
things, like from ancient Greek drama, to say something about
life. So I had this body feeling, scientific feeling and philosophical
feeling as well as an artistic feeling. You are asking me about my
history, I suppose there it was.
Petra Winnette: It’s interesting, that Greek idea of a developed
personality, physically as well as psychologically. I understand you
were a dancer and met your wife. How did it happen that you two
together thought about dancing?
Al Pesso: We met at Bennington College which was a women’s college
where women could get a degree in dance. But since it was a
college for females they had no men. I was one of the fortunate
two men that were given a scholarship. And that’s how we met.
We just fell in love. I can’t put it any other way. We just found each
other and kind of got connected. That was sixty-three years ago.
There was some part of our hearts and minds that were joined and
are still joined.
Interview with Albert Pesso 259
Petra Winnette: Made for each other.

Al Pesso: Yeah.
Petra Winnette: If I can jump a little bit ahead. You and Diane were
dancing together. Then you started teaching dance. At a
certain point how did you make that transition from dance to
psychotherapy? When and how did it happen?
Al Pesso: I had become an associate professor and the director of the
Dance Division at Emerson College which was a theatre school.
We had left New York City which was where the artistic new age
stuff was coming. And we wanted to make sure that our dancers
really knew their instrument. It wasn’t just a matter of exercises.
We thought they should know ‘you are the instrument and you
should know your instrument’. We looked at ‘How does movement
come out of the human being?’ and ‘How does movement of
other people affect the inner emotional part?’ We were looking
at how to make them better dancers by learning how to control
their movement, and better choreographers by knowing the impact
of movement on the audience. And of course that is part of PBSP.
We did something that seemed so natural at that time. That was at
the absolute base. We knew that people move with all three motor
systems simultaneously and we said let’s take that apart. That is the
root, PBSP came out of examining the interplay of three motor
systems: (1) body righting reflex, (2) voluntary motor system and
(3) emotional motor system.
Petra Winnette: When and how did you realise you knew something
very important about the human psyche and that it might be
useful to help people?
Al Pesso: When we had them move in the emotional category without
the modifying influence of the other two and people let all their
emotions come out without control. Everything that was in there,
that they never expressed, that was locked up in the body and
modified and kept hidden, it burst out. We and they saw so many
things that they had never let out before. We ‘discovered’ catharsis.
But we saw catharsis is no complete answer or solution. That is an
ancient medical thing where you want to get the bad things out.
They had a momentary relief but there was dissatisfaction because
emotions are an interactive process.
Petra Winnette: So this was still when you were teaching dance? Or
when you were trying to do therapy?
Al Pesso: I never thought we would do therapy. That thought never
entered my mind.
Petra Winnette: How did you end up being a therapist?
Al Pesso: The therapy just arrived because when these emotions came
out – there was an emotion and no answer. We thought ‘Emotions
are interactive. Let’s give an answer to each emotion.’ We began to
see there is a shape that needs a counter-shape. That’s fundamental
psychologically and neurologically, that when there is an answer
there is a reward system [activated] in the brain. We began to see
what fit, we began to see innate expectations of satisfaction. So we
began to get a semblance of what was in the genetic push that was
locked up in them because it never had an answer. And then we
began to make answers and their lives began to change.
Petra Winnette: They were dance students and through this work they
were getting better as human beings.
Al Pesso: They were better performers but their lives changed. We
began to diverge. We didn’t say let’s do a therapy. The therapy
just arrived.
Petra Winnette: That is very interesting but still at a certain point you
and Diane must have realised you are in a different field. It must
have happened somehow.
Al Pesso: It certainly did. We became aware and then we began to
have groups for people and not only dancers. But there is a very
interesting moment here. Diane was teaching some of these basic
things in the Sunday school at the Unitarian Church which was
a very progressive one. There were two among those children
who went back to their parents and showed them what they had
experienced. The parents said, ‘What is this?’ It happened to be
that their father was a psychoanalyst and the chief of psychiatric
research at the Veterans Administration Hospital in Boston. We
arranged a visit and he said, ‘What are you people doing? I want to
know what you are doing.’ He attended one of our groups and he
was fascinated. He said, ‘You are opening up a whole new world.’
And we already knew we were doing therapy because we had

groups by then. He took me under his wing.
Petra Winnette: Tell me when this was?
Al Pesso: That was two years after the work got established in 1961.
We met him in 1963. Already there were articles in the Boston
Globe about the work we were doing. He then came upon it. He
was fascinated and open-minded enough, because analysts at that
time didn’t have any sense of using the body. His father was a gym
teacher so he had that kind of combination. He appointed me,
so I went from an Associate Professor in Dance to a Consultant
in Psychiatric Research at the Boston Veterans Administration
Hospital. For five years I had the absolute privilege of working
with him and a renowned behaviour therapist. I began to know
more about psychoanalytic theory, which I had known and read
about before, and behaviour therapy. And the work got more and
more refined. At that time we were living on a street where many
executives lived and the director of Mass. General Hospital was one
of them. He said, ‘This is fascinating.’ He invited Eric Lindemann
to come in and see our work. He was a very famous psychoanalyst
working with trauma and bereavement.
Petra Winnette: Do you remember clients that you worked with at these
very early stages?
Al Pesso: You are talking about fifty-three years ago. I guess I could. I’ve
worked with thousands of people. They kept saying their lives had
changed. I had a phone conversation two days ago with a colleague
who was talking about a very good friend of his whom he had sent
to me. I won’t mention any names. He was an executive coach. He
was in psychotherapy. He was a psychiatrist. He was in a despair
and depression. Life was plunging. He said to my colleague, ‘I
can’t believe what happened. It absolutely changed my life.’
Petra Winnette: It’s a recent client?
Al Pesso: This was way back. Now he is a world traveller doing
elements of PBSP with his executive thing. It was so striking. He
said, ‘I’ve been in therapy for years and in three minutes he hit
things that nobody had ever hit. It absolutely changed my life.’ I
hear that over and over again. People’s concept of their lives and
the way they approach their lives just unalterably changes. I don’t
know how I learned how to do that so well.
Petra Winnette: I would like to go through a structure as you do it now.
Why do you start with opening the possibility sphere? Why is it
important for the client?
Al Pesso: Because present consciousness is a tapestry woven of threads
of memory. Every moment of the present is absolutely loaded with
the past. I present an atmosphere and a quality of relationship.
I don’t tell them, ‘I am going to make a possibility sphere.’ I don’t
do anything like that, but it’s something in the way I relate in the
here and now. In my mind I’m beginning to see them as if they
are in a kind of globe that moves through time and space. Because
when I say ‘possibility sphere’, I’m going to make it possible that
what should have happened in childhood will be experienced in
their brain on the childhood level. So that possibility sphere is
moving through time and space.
Petra Winnette: You said there is something you are doing here and now
in the room in order to allow the client to have that possibility.
Can you describe it?
Al Pesso: I start with no expectation. I don’t say, ‘What do you want
to work on?’ Then I’m going to be entering. So I start on a
philosophical base, not on a medical base. A medical base says
something is wrong, they are sick and they need to be healed.
That’s fine. I sometimes don’t want to call this a therapy. It’s a
philosophical process where we are dealing with the meaning
of life and people want to become wholly themselves. That’s
interesting. When I say ‘wholly’ I mean that in both senses. I mean
it both in a quasi-spiritual sense and to become whole. Because
part of becoming whole is to make a contribution to life. That’s
the philosophical part.
Petra Winnette: That’s your philosophical understanding of the
possibility sphere. It opens your brain and it allows the client to
have that space.
Al Pesso: I open my brain in the sense that I remain unsure and have a
place of emptiness around them out of which parts of themselves
that never appeared can appear. I deal with ambiguity rather than
an agenda. And then stuff rises up out of that. That was there
from the beginning. I didn’t name it until further on. But from the
beginning I felt ‘Let’s make a space where parts of the self that
have never emerged [that are part of becoming whole and holy],
that have been constrained, can emerge.’ So I don’t think they are
ill. They are not fully formed yet. Then the client doesn’t feel they
are being told they are sick and then respond, ‘Heal me, doctor, as
I have no power.’ I don’t see people as powerless. I think the brain
in every individual is phenomenal and they don’t have access to
it or their history has dampened it down. So in the possibility
sphere we let something emerge without saying to them, ‘Here
is what you have to do – do this exercise, take this pill.’ I just see
what comes up and what part of history got in the way of that
emerging part of the self.
Petra Winnette: And so that is the background of the whole structure
from beginning to end.
Al Pesso: Exactly. It is basic. If people who are trained don’t have this
sense, they may know the techniques but nothing special is going
to happen. Because the client is not going to feel trusted or seen.
They are going to surrender to an authority who is going to tell
them. The average person goes into therapy thinking that they have
to surrender. I very quickly try to make a new contract with them.
Petra Winnette: In your therapeutic method how do you think about
contracting with a client?
Al Pesso: First, I let them know theoretically what this process is all
about – that there are different forms of memory and there are basic
needs. That here we are not going to let things out, we are going
to make a new memory because we see the world through the lens
of history [memory].
Petra Winnette: Let’s say I am a new client. I don’t know much about it
yet. How would you phrase it so I would know what is your part,
my part, what the boundaries are?
Al Pesso: I teach that because otherwise, if I stay without teaching,
without making a contract, they are going to be helpless and
wondering what in the world is happening. And I want them to
know. That’s why I’m dealing with their prefrontal cortex which
is overseeing them and I’m with that part. I don’t think I’m
with the ‘sick’ part. So I teach that part what theoretically and
philosophically this is all about. And that we are going to make a
‘new memory’ to change what the old memory did in making us
see the world in a very unhappy frame and form. The second part
is that it is their responsibility to make a new memory with a good
end. My responsibility is to be a resource in support of that.
Petra Winnette: This is very different. Does it ever happen that the client
does not understand it, maybe the ones who have been in different
therapeutic schools?
Al Pesso: Then we may end up not working together. That’s relatively
rare. But I would not do the work until they understood it. Because
if they don’t understand it they are going to start an ancient process
of being helpless and incompetent, which is the history of their
past. And they have to obey the authority and I don’t want to get
into that kind of setting with people.
Petra Winnette: So engagement of the client means the client understands
the process and understands he will be taking responsibility too.
Al Pesso: Absolutely. I am wanting that more advanced part of the brain
to be in charge of the whole thing. So this is not a regressive process.
We may deal with childhood needs, but we have the present adult
looking and controlling that. And not being the child but feeling
some of those emotional expectations.
Petra Winnette: And that would happen if they tried to follow you, that
would be kind of a child.
Al Pesso: As soon as I see that I stop and bring it back to the other
balance, because I want to make sure they are always in charge.
Otherwise they may be in a regressive state and the healing
doesn’t occur; it doesn’t get fixed in the brain. Let me tell you
a funny story. When we first started doing this and some of the
other professionals heard we were doing psychotherapy, one very
angrily on the street said, ‘I hear you are doing psychotherapy now.
What are you going to do next – brain surgery?’ By God, what we
do is ‘brain surgery’! It takes a very delicate, very precise process in
language and motion and touch. We take what is happening in the
present and place it in that part of the brain with the old memory.
That is the important part.
Petra Winnette: What led to developing micro-tracking? Why did you
develop micro-tracking, the witness figure and the voice figure?
Why was it so important?
Al Pesso: Because when we started from bottom up we would say, ‘What
are you feeling in your body?’ When we started the whole process
[with dancers] in the reflexive-relaxed stance, we would say, ‘What
is hidden in the body, let it come out.’ It came out and they didn’t
know what in the world to do with it. And it didn’t fix in any part
of the brain. They did all kinds of stuff. So we decided to start
from the top down and look at what’s in present consciousness and
then see what part of history is influencing present consciousness.
That way, what we do, their present consciousness is in control of
it. People would say, ‘I don’t know why. I don’t know where it
came from. I don’t know anything about it.’ We’d see these huge
emotional outbursts but they would come back the next week and
say, ‘I don’t know what to do with that.’
Petra Winnette: To help the client be more aware of what is happening,
you developed the micro-tracking method which involves the
voice figure and the witness.
Al Pesso: Well, particularly the witness. When we do micro-tracking we
do a very interesting thing, where the witness figure, for instance,
is a kind of template of what a mother does for a child. The child is
having an emotional state and the mother says, ‘Are you hungry?
Are you cold?’ And the child learns ‘Oh, maybe that is why I am
crying.’ The mother is now connecting left-hemisphere, rational,
I-thoughts to right-hemisphere affective states. And that is what
we are doing using the witness figure. We are doing a kind of
mindfulness process. We are having this [imagined witness] figure
see and report about the affect on the face, because whatever is on
the face is closer to consciousness than what is in the body as a
symptom. So we are micro-tracking facial expression and verbal
prosody which are all related to the right hemisphere.
Petra Winnette: Tell me why you just don’t do it as a therapist, why do
you need a witness figure?
Al Pesso: Because when I do it I want their prefrontal lobe to look at

themselves without including me. When I have a witness figure
identify feelings [‘If a witness were here, a witness would say…’]
versus when I do it as myself [‘I see how…’], then they are going
to have this other figure who is seeing them and they can be
busy with themselves without including me. I prefer not to have
them in a regressive state where they have to include me. It works
better minus the therapist’s personality. My personality is there to
make and support the possibility sphere, but I want to have them
looking at themselves without including the relationship with me.
Petra Winnette: So that figure can have them looking at themselves
without thinking about ‘what Al thinks’.
Al Pesso: That’s right. It’s a subtle, small thing but such a powerful
difference in the inner state of the client. The reason this question
comes up is because so much of therapy is happening in the
relationship. I don’t want the therapy to happen in a relationship.
It’s going to happen in the hypothetical past with the figure that
should have been there at that time.
Petra Winnette: What’s the role of the voice figure? How did you
develop the voice figure?
Al Pesso: When people speak with affect in a context, then I have the
witness figure. But when they talk about values or strategies or
warnings that are statements of how they have found the world to
be, that comes from their own mind. They say, ‘Nothing good will
ever happen to me.’ People respond to their thoughts as if they
were hypnotic suggestions.
Petra Winnette: It looks like the witness figure and the voice figure are
dealing with very different parts of the brain.
Al Pesso: When they hear those words [from the voice figure], the
history of making those thoughts pops up.
Petra Winnette: Why does it happen?
Al Pesso: Because when people speak words they remember the
influence of those words and they remember the people connected
with those words.
Petra Winnette: The memory brings up the source of it, the beginning
of it.
Al Pesso: The situation. That’s accurate. We started as a whole body
thing, but we are seeing the power of language. Language lets us
move through time and space, whereas our senses and our motor
system can only see and react to what is in the present. So when
people hear words and recall the history behind those words, they
are then moving through time and space. If they mention the name
of someone, they see that someone and their body reacts.
Petra Winnette: What is the reasoning and thinking behind using
placeholders?
Al Pesso: The reasoning behind that is to make a difference between
feeling over again what had happened with that person in the past.
The client says, ‘My mother was always hitting me,’ and if we say
‘Let’s have somebody role play your mother,’ then they would be
back in childhood with that mother. They would be losing their
pilot, the overseer of their present consciousness, a little. When
they say ‘mother’ a part of their brain is going to light up. And so
I ask them instead to put all known or remembered parts of the
mother there. Not as if the mother were there at that moment, but
a ‘placeholder’ – a data base of every part of their memory of their
mother. So then one can look at one’s brain rather than look at
one’s mother and react. Of course some people are going to get a
charge. But when they do that then there is not going to be any
big load. Then they can look at what is happening in their own
mind when they think of the mother.
Petra Winnette: How did that develop? Why did you change it?
Al Pesso: Because before we thought we had to get the bad feelings out
and discharge. Now we know that when people feel all the old
negative history it reinforces memory. I honestly can’t remember
the shift but it was a very clear shift. Now I wouldn’t think of
having somebody role play because they are going to be back
in the old situation and I don’t want them in the old situation.
Nowadays we are going to do ‘movies about everything about the
person’ rather than any one single event.
Petra Winnette: So somehow you just did it, you realised it worked and
since then it works.
Al Pesso: I don’t think that I invent. I’m just a vessel or channel. It
springs up from the back of my mind. I see that it works and I
continue using it.
Petra Winnette: So it’s very intuitive. Do you notice what happens to a
client when they put out a placeholder?
Al Pesso: They get a little calmer. I used to think we had to work with
high emotional stimulus. I’d rather work with them looking at it
and seeing what had happened, then make immediate reversals
set up in the past with an ideal figure. So, as soon as they say,
‘My mother…’ Boom [placeholder]. ‘My husband did…’ Boom
[placeholder], so they can start scanning their brain. It is a whole
other way. It’s so much faster.
Petra Winnette: It makes them calmer. Sometimes the person says, ‘I
don’t want this placeholder here.’
Al Pesso: Then you have to teach a little bit. I go along and say ‘Let’s
put it a little out of the way.’ When we reverse the old history, they
get a sense of clarity and calmness. When they scan all this stuff
then towards the end of the session they begin to see the linkages
between all of it.
Petra Winnette: A kind of little lay-out of their brain and thinking and
important figures.
Al Pesso: They are more in charge then.
Petra Winnette: …and it changes through the structure. The original
lay-out looks different and it feels different.
Al Pesso: Exactly.
Petra Winnette: Nowadays whenever there is a big charge or distress
coming up from what the client is talking about you right away
offer an antidote.
Al Pesso: It’s a little bit different when there is a big charge and they are
stressed. If their body is stressed, I’m still looking at the motoric
side of it, some people can’t handle it. There is no counter shape,
their body is like exploding. Then I bring in, not an antidote to

history, first I bring in a containing figure to help them handle
that level of distress. That figure might evolve [into another ideal
figure]. But usually when they experience distress I immediately
go to the reversal. They will say, ‘Oh, it is so awful.’ So I say, ‘Let’s
invent an ideal mother who had she been there…’ and I’ll just
reverse the distressing experience.
Petra Winnette: Although you may not know enough history yet,
because the client has just started talking, still you do the reversals.
Al Pesso: Yes. Over and over people say, ‘In other therapies I would
have talked for weeks about this.’ And here we go ‘boom’ and
change it.
Petra Winnette: What are the reactions of clients to these quick reversals?
Al Pesso: I’d say for the vast majority it is fine. Some people think they
have to get it out. And they do it over and over again [tell the
same stories] to get it out. But some people can’t handle reversals
because they have resistance.
Petra Winnette: There are clients who really talk a lot. They let micro-
tracking, placeholders, the reversals go by and they keep going.
They kind of don’t care what you are doing. They are on their
own trip. How do you deal with that?
Al Pesso: Those would be people who are accustomed to traditional
therapy where they think they have to talk, talk, talk. Some people
want to do that and they think they are going to empty. But they
are going to find it isn’t working. They have a whole roster of
people they have done it with and it doesn’t work. There is an
element of resistance in that.
Petra Winnette: Are there certain types of people who have psychological
conditions where it may be difficult for them to follow the process?
Al Pesso: Then I try to work as best I can with where they are and slowly
teach and not do anything that is overwhelming. Otherwise, if I
say, ‘No, just follow me,’ they are going to quit being in their own
pilot place and they are going to surrender. So I try to do some
teaching all along the way and modulate what I’m doing so that
it fits them. That means I have to be flexible and develop new

processes with each person.
Petra Winnette: It’s about the contract too. If people insist on a certain
therapy and you are not doing it, it’s important to know that.
Al Pesso: I remember when Primal Scream was the big thing and people
said they wanted to do that. I would say, ‘We just don’t do that.
You ought to do Primal Scream [with a therapist who specialises
in that method].’ What you are talking about is really interesting
because the therapist has got to be flexible, to adapt.
Petra Winnette: Talk more about flexibility in PBSP.
Al Pesso: First of all I think people have really got to know the theory.
Then when you know the theory and techniques you should know
that everybody is not the same and find parts of yourself that can
adapt to work with this person so you don’t get to be exclusive.
But some clients don’t want to make that contract. They have an
old history and they just want to repeat the same old stuff.
Petra Winnette: For some therapists it might be difficult to be flexible
while keeping the method.
Al Pesso: What that says is: if anybody is going to learn this technique
and do the technique, they should do their own personal work
so they can be broad enough, flexible enough and kind enough to
not just impose and be the big leader – ‘My way or the highway’
kind of thing.
Petra Winnette: The next question is about making a new memory. I
read that the brain organises events and remembers them as stories.
People remember bad stuff that happened in the form of stories.
Al Pesso: I don’t know if they remember stories but they will tell you
a story about it.
Petra Winnette: The experience of a structure creates a new story for the
client. What would you think about that?
Al Pesso: I would say a new ‘history’ because if it is just a story it doesn’t
go in the past. Hopefully to make it an experience. Because you
have to use the right words as they are going to make images in
their brain and when you have images in your brain, your body
is going to react. So it isn’t just a story that is just now verbal.

I am very careful that the words I’m saying can make a feeling
state and then get that feeling state in their sense of themselves
as a child. You have an old history that pops up when they look
at the placeholder. We make a reversal and they have the ideal
figure, maybe someone is role playing it and they are holding the
client, and they say, ‘If I had been your ideal father [for example]
I wouldn’t have allowed the neighbour to come near you and you
would have been safe. You would have been able to be vulnerable
and safe.’ And the person says, ‘Oh, what a relief.’ Then I say, ‘You
are feeling the relief in your body at this moment. Now get in
touch with your mind/body [in your brain] at age twelve when that
happened to you and feel it in that state in your brain.’ And they
say, ‘Oh God. The whole world would be different.’ That means
that people don’t just hear the story. You have got to give them the
option of feeling the experience of that event in a definite portion
of their brain. And that makes an enormous difference. Because I
see what they are feeling when they first feel it and when I tell
them to put it back in time, it hits another level of sensation.
Petra Winnette: How that works is one of the secrets of the PBSP
method. We might not know yet. When and how did you realise
this? What made you first tell the client, ‘Now you feel relief,
imagine it in the past’?
Al Pesso: Because if it isn’t in the past, it is just in the present and the
past is going to just keep repeating. I want it to be experienced
and then placed beside the old memory.
Petra Winnette: How did you know it would work?
Al Pesso: I didn’t know. All I know is it seemed to be absolutely
necessary.
Petra Winnette: It is an essential component but why it works we don’t
know.
Al Pesso: I saw the difference between one way and the other way. I saw
the power. At first I assumed when they listened to the voice of the
ideal mother, they were in the child body state. But I discovered
that they weren’t all always back there. So I make a point of having
them [go back]. Otherwise it doesn’t land in the right spot and it
has no lasting value.
Petra Winnette: It sounds like the brain has the whole history available
and it can be repairable by taking the [new] feelings and experience
back in your imagination, back in memory.
Al Pesso: We can awaken the child state and then place the new memory
in that child state. It has a much longer-lasting effect.
Petra Winnette: That is where the trauma happened.
Al Pesso: It doesn’t erase the old memory but it reduces the emotional
impact of it. We talk about genetic needs. They have to be met at
the right age with the right kinship relationship. So if it happens
now in the room it is not satisfying the genetic need. It should
have happened in the past. Because when we say the ideal parent,
the gene says, ‘Ah! That’s what I expected!’
Petra Winnette: It should have happened back then.
Al Pesso: Then the reward system clicks. I just knew that. And I could
see the difference between one way and the other. And that it had
to happen in the as-if past which is located in the brain. Otherwise,
everything is in the relationship and it all depends on the quality
of the relationship.
Petra Winnette: It all depends on if you can influence the past and it
seems that in the psyche you can.
Al Pesso: They have found you can erase memory with rats and put a
new memory in. We are having the prefrontal cortex [the ‘pilot’]
not erase [memories], but plant [new ones] in the right place. And
that comes from the words the therapist uses and here we have to
look at how precise the therapist’s language has to be.
Petra Winnette: So people really can do that transition from doing it
here and now to putting it ‘in the past’.
Al Pesso: Sometimes the conditioning happened in a prenatal state and
I have to have them imagine a foetal age and only then does it
make a difference. This happened quite recently. When people hear
stories, their brain reacts and wants to heal the story. Now I have
found that when people are in the foetal stage and the mother is
in a period of distress somehow that gets communicated in detail.

The child then picks up so much history without consciously
knowing it. You can’t do that reversal unless they are back in
the foetal stage. You have to have an ideal mother who was in a
totally different state and they are going to have to be in the foetal
condition to receive it. Because if you do it at age one it doesn’t
go far enough back.
Petra Winnette: The difficulty with this one is that they don’t know
what happened.
Al Pesso: But you can ask them, ‘What was your mother’s state?’ ‘Well,
my father had gone away and the war was going on and they had to
hide down in the…’ And as we know all that gets communicated.
Petra Winnette: Could you talk a little more about the core of the PBSP
structure, that is, the experience of a new interaction with ideal
figures? What was the thinking behind ideal figures, how did
it develop?
Al Pesso: That was very, very early. We somehow knew there were
basic needs that were inherent, soon we thought it was genetic, by
following what people felt and how they modulated what would
make the optimum feeling [in a structure]. We figured that was
genetic knowledge that they would move things until they fit.
Slowly, slowly, by seeing actually what people wanted, we began
to get the sense of what basic needs were. Because when we first
started [laughs] all we knew was babies had to be nursed. By God,
everybody had a nursing mother. We thought that was the whole
therapy. Then we saw – Oh, there is this. Oh, there is that. Little by
little, just by seeing what emerged from people when you touched
their core stuff and their longing, it was very specific. That’s how
we got place, nurture, support, protection, limits [a description
of basic needs]. Then we began to get a sense… We talk about
the ‘good enough’ mother. Of course that’s reality, but our genes
are waiting for the perfect response. They say you get a reward
with ‘good enough’ mothering, but we looked for what made the
optimum connection. So we were watching. We never said, ‘We
now have it. We fixed it.’ We are in an endlessly unfolding process
of learning in the laboratory of working with people. It’s exciting,
it just keeps changing. Not changing, it becomes. That’s what I
have in my basic sentence when I say what life all about is. ‘We
are made to be able to be happy in an imperfect world that is
endlessly unfolding and we human beings are the local agents
of that cosmological unfolding.’ So we are getting genetic stuff
and we are also talking about the evolution of the whole cosmos.
There is a spiritual element here.
Petra Winnette: Sometimes the client hesitates to receive a new experience
with ideal parents. We might call it resistance or sometimes it is a
kind of hesitance. How do you deal with that?
Al Pesso: I’m learning to make a distinction between those two words.
With hesitation you have to take slower, smaller steps. But
resistance often has a quality of aggression in it.
Petra Winnette: Do they do it to avoid giving up defences that protect
them from pain associated with a traumatic history?
Al Pesso: I disagree with that theory. I think it isn’t broad enough.
When people have had poor histories and can’t take in, I don’t see
it as just suppression. Those people may have heard stories very
early in their life about injustice and empty spaces in their family
network and then they make movies [in their mind to fill these
‘holes in roles’].
Petra Winnette: Let’s look at the people who don’t receive because they
filled holes in roles.
Al Pesso: In filling holes in roles they get loosening of aggression and
sexuality.
Petra Winnette: Why?
Al Pesso: Because they are ‘the only’. Whenever we are ‘the only’ then
there is no one to give limits on aggression and sexuality.
Petra Winnette: Why should they be aggressive if they were trying to
help someone when they were kids?
Al Pesso: I don’t know. The way I explain it is when we are the ‘Messiah’
we are the one and only. When we are the one and only there is
no other, so there is no counter shape for limiting of aggression
and sexuality. It may not be correct but that is how I understand it.
Petra Winnette: How do you deal with holes in roles, that is, when
people realise they took care of someone and are still invested in it
[and so they unable to receive nurturing themselves]?
Al Pesso: It is not that they realise it. The steps that I do when people
can’t receive… Sometimes, years ago, they would stay with not
being able to have an ideal mother or ideal father and have an
ideal dog, etc. They couldn’t ever get to what the ideal expectation
was. That means they can’t receive. They can’t take in what they
needed. That is what I mean by resistance; they can’t take in.
Before I thought they were being aggressive. Now I know they
can’t help being in that position. They are just stuck there. So
I say to them, ‘Who did you have compassion for and empathy
for?’ And the very figures that may have injured them, they may
have compassion for. ‘When my mother was a little girl, her father
died. And it was such a terrible thing for her.’ There is where I’m
believing a child’s brain makes an unconscious movie where they
fill those empty spaces and they become the healer.
Petra Winnette: What do you mean by an ‘unconscious movie’?
Al Pesso: There is a part of the brain that ‘makes movies’ when we dream.
There is a part of our brain that will make a movie that we see and
that we are in. I think that children have an absolutely powerful
innate sense of justice. They want to punish the bad ones and take
care of the good ones. They immediately want to correct the bad
thing. I think a part of the brain makes a correction and I call it a
‘movie’. The brain makes a correction that the person doesn’t see,
but the body reacts to having been a provider of healing.
Petra Winnette: In other words, the kid sees injustice or hears a story
about it. Then because of the sense of justice and because the brain
is not fully developed at that developmental stage, they react to it
very strongly [and take the role of the healer].
Al Pesso: They are not conscious of being the healer at all but the brain
has done it. When I think about genes now – I think of survival of
the self, survival of the species, making things complete and doing
justice. It is a genetic process that they need to make something
complete. They hear stories that something is incomplete,
something is missing. They are not able to modulate their feelings

and that means something breaks loose and what I think breaks
loose is not only the healer, the one and only, but there is no longer
the modulation of those energies [sexuality and aggression].
Petra Winnette: Why do you think they become ‘the only’? What is
wrong with it? It is a kind of childish, underdeveloped thinking.
Al Pesso: I think the brain reacts, I am not saying they feel like ‘the
only’ at all. What we do is make a counter-movie. This is why
I believe it is functioning. We use stones [or other objects],
‘placeholders’, and say, for example, ‘This is your mother as a little
girl and we are going to make a movie’ and an object will be her
[the mother’s] ideal father in the movie. The therapist will [act as
the voice of the placeholder and] say, ‘If I were your ideal father, I
wouldn’t die when you were four and I would be your father
for your whole life.’ When the client sees that movie, they get a
profound shift of affect. Their body may have been loaded with
anxiety, panic attacks or somatic symptoms, whatever, which just
melt away. That makes me think their body has been loaded with
those energies and they have been suppressed because they can’t
be safely expressed. When the client sees that counter-movie their
body absolutely shifts. They breathe differently. They say, ‘I feel
as if some load came off my shoulders.’ Their gaze shifts so their
perception of the present changes and they say, ‘If my mother had
had a good father, she would have been able to be a good mother
to me.’ Then I say, ‘How about we give you an ideal mother?’
When I said it before [they resisted] and now they say, ‘What a
good idea.’ Suddenly they are receptive after this funny little thing
done with stones.
Petra Winnette: Sometimes the client says [after the movie], ‘Now that
mother would be a great mother to me. Let me have that mother.’
Al Pesso: No. But we say, ‘Let’s have an ideal mother who didn’t have
a father die in the first place.’ So we try not to have the real
mother improved, but start with an ideal mother, no part of the
real mother.
Petra Winnette: So it brings us back to the mystery that things which
happen in childhood sit there and influence the person until they
get resolved. You are right about the big relief when they realise
‘Oh, things would have been different.’
Al Pesso: The movies make a phenomenal speed-up of receptivity to new
memories. If there is resistance to new memories, I will say, ‘Who
did you feel compassion for?’ Some people will say, ‘My mother,
my father,’ and then I say, ‘Let’s look further back.’ Some people
will go back to the Holocaust, the Crucifixion, the rainforests…all
different kinds of things. When they hear things are wrong, some
part of them wants to heal it. Then something disruptive happens
in their receptivity. You see that in saints. They are busy taking care
of the world and they live a miserable, martyred life.
Petra Winnette: They don’t think it is miserable.
Al Pesso: But they don’t receive. Some are very unhappy. They think
in the afterlife they are going to get it. I think I’m touching
something that is really happening in the brain. When we make
these movies we think we are ‘the only’ and it takes away memories
of counter-shapes that modulate those primordial energies. When
you make the counter-movie, the modulator comes back on and
they get quieter.
Petra Winnette: It is very painful for the kid to see injustice. The kid is
trying to deal with it. As an adult they are still very invested and
still doing it somehow. Still thinking, ‘Somehow I can do it.’
Al Pesso: The movie is different from what they think consciously. I am
making a big distinction between the two.
Petra Winnette: Let’s talk more about principles.
Al Pesso: What I began to see is that people were linking two different
figures without knowing it. When they speak of one figure, the
association in the brain is awakening patterns from the other
figure. You might call it projection, but I think it is more linkage.
I’m calling that brain linkage a ‘principle’.
Petra Winnette: How do you deal with it? Do you use placeholders?
Al Pesso: We start out with micro-tracking. The client says, ‘I was
at work today and my boss drives me crazy and makes me so
despairing I could pull my hair out.’ I say, ‘Let’s put a placeholder
for your boss.’ Then they talk about it. Then they talk about their
father. They say, ‘My father is so like my boss. My father used to

drive me nuts. My boss is doing the same thing.’ So I say, ‘There
must be a principle from your father. Let’s get a small piece of
paper, we will call it the principle of your father, and put it on
your boss.’
Petra Winnette: So it is a visualisation of that process and the client
realises it is just the same and they are able to see it.
Al Pesso: I tell them, ‘When you see your boss, your father’s history with
you is firing and you are reacting to your boss as if he were your
father.’ Then we look at the history with the father and we heal it
with an ideal father. Then they look at the placeholder and say, ‘I
feel calmer when I think about my boss now. He’s just my boss.’
Then we make a ritual and I say, ‘Let’s take the principle off your
boss and put it on your father.’ That means we are de-linking the
parts of the brain. That’s what we are doing with the principles.
Petra Winnette: It’s very neat that you can see it. You don’t just say to
clients, ‘You are projecting your father onto your boss.’
Al Pesso: I wouldn’t do it that way. The timing of that is very important.
That you can’t just simply get insight. You have to then make a new
memory with the ideal father so they don’t project all that again
and re-experience it with the boss. The new things of movies,
principles and placeholders speed up the process without all the
emotional arousal. And they change very important organisation
in the brain.
Petra Winnette: It seems a lot is happening in one structure.
Al Pesso: That is what people say – that in one structure they got weeks
and months of therapy. People are talking about the speed with
which this stuff works.
Petra Winnette: What is the most important and powerful ingredient of
the method which you developed? What is the core of it?
Al Pesso: It allows the person to know that life is not fixed. Because
some people think, ‘This is my destiny and I’m stuck with it.’
But with this work we get a different sense of the flexibility and
creativity that is inherent in our foundation. And they have a whole
other way of living and looking at the world. And get a sense of
investment in their life and in doing something in the future. I

think that is the most important thing. Have people really look at
meaning. We are back to being the philosopher.
Petra Winnette: That’s nice. We started with philosophy and now we
are back to it.
Al Pesso: How they are understanding life and meaning. People say over
and over again when they have done the work, ‘It just changed
my life. I have a whole other way of looking at the world.’ And
that life has some meaning and it’s not going to be happening
in the afterlife. They are going to have meaning in this life. Because
the afterlife is the hope to get what you missed in life.
Petra Winnette: That’s a different life philosophy.
Petra Winnette: What do you leave out now in PBSP in developing
the model, something you believed in that you realised is not
so useful?
Al Pesso: Negative accommodation.
Petra Winnette: Tell me more about it – why you thought it was useful
and why you leave it out now.
Al Pesso: Because we thought we had to ‘let things out’. When we
did that I think it somewhat reinforced an omnipotent aggression.
And it also reinforced the old history. I don’t ever do any more
negative accommodation but I certainly do containing figures and
limiting figures. What I did leave out before [in the story of PBSP]
is Diane’s boldness in moving from dance into psychotherapy. She
comes from a whole history of leaders and she has something in
her spirit of trusting her sense of rightness. She was bold enough
to do it and put in the face of other professionals that we are
standing here. I was a little more cautious than that. Even though
there is another part of me that is bold, but finds this harder. I
come up with all these new ideas, or I am a channel for it, but at
the very beginning we needed her strength of mind to say, ‘Let’s
step out in the world and do it. Do it openly.’ I just admire that so
much in her.
Petra Winnette: PBSP used to be a group type of therapy. You needed
people in a group. And now individual sessions are considered to
be just as effective as a group. How did that happen and what do

you think about it?
Al Pesso: I’m not sure. It just evolved, that is all I can tell you. That as
we did this we found short-cuts, I suppose, to doing things; but I
still think it’s important to have, when necessary, a sensory input. It
works very, very well for people who have a good sensory memory
and history, or you can use objects to touch. I think working from
dance we thought there had to be movement and others. Then
we found if you use the right movement and language you can
do without having all the others. But you have to have an artistic
sense of language and pick the right words and gestures and put
it in the right place.
Petra Winnette: So clients might need two different types of therapists.
One who is better with the group and another who is better with
individual sessions?
Al Pesso: I think there are still very important things that can happen
in a group. For some people it is necessary to really feel lifted, to
really feel limited. Other people can do it without all that.
Petra Winnette: So it depends on the client.
Al Pesso: It may have been just a matter of age. As I am getting older
I am trying to look at less energetic things. Who knows? My age
may be having a part in it.
Petra Winnette: It is very important for the therapist to understand that
the effectiveness is not based [just] in group or just in individual
[sessions].
Al Pesso: It depends on how clearly the work is done. And that calls for
language and recognition of what is going on in the body.
Petra Winnette: Last question. What would you like for therapists who
practise PBSP to keep in mind? What is your message to them?
What is your wish for the next generation of PBSP therapists?
Al Pesso: That they keep learning. Look at the difference between two
different kinds of brands. Coca-Cola never changing and Apple
endlessly changing. I like to think of this work that it is not fixed,
that it will keep on growing. It will have its essential roots, but
it will get further and further into the complexity. So I would

like them not to hold back. But first, before they are going to
get creative, get the essential foundation and then just keep on
learning. I hope that people who are the trainers beyond my
lifetime are going to keep the foundation and then still let it grow.
Petra Winnette: Congratulations. Thank you.
APPENDIX
Petra Winnette
Critical points
At this point I would like discuss difficulties which may affect the
wider use of PBSP. As mentioned before, Albert Pesso and Diane
Boyden-Pesso were originally artists and their therapeutic approach
evolved over decades of clinical work. It is a creative and unusual
way to establish a therapeutic modality. They use their own unique
terminology and theoretical framework to describe developmental
needs and the other aspects of their discoveries. Their theory broadly
corresponds with attachment theory, some concepts in psychoanalytical
thinking and current views on the neuro-psychology of brain
and mind functioning. However, for the professional community
trained in traditional modalities of psychology and psychiatry the
unconventional language and approach used in PBSP may prove an
obstacle to understanding and wider acceptance.
Second, and most important, well-designed research studies have
not been conducted to provide evidence of the effectiveness of PBSP
therapy, despite promising case-based evidence from practitioners
using this method in the United States and Europe.
The third critical point is that once one gets used to the novelty
of the approach, it may seem that PBSP is a predictable and
uncomplicated method, which is rather easily employed. However,
appearances are deceiving. A PBSP therapist must master a precise set
of steps and interventions which require a solid understanding of the
theory and principles on which they are based. Use of this method,
as with other therapies, requires a deep of understanding of people,
flexibility, the ability to accommodate to a client’s needs, intuition
and an appreciation of the complexities of clinical work developed
283
through years of working with clients and clinical supervision. It

requires discipline to use this method – to let go of having an agenda
for the client, to accept the uncertainty and ambiguity in not knowing
how a session will unfold and trust in the method and the process, and
not to mix elements from other treatment modalities which change
the focus of the session. For some therapists it is hard to stay with
pure PBSP and not combine it with other therapeutic approaches. But
the effectiveness of PBSP therapy lies in the ability of the therapist
to run a structure in a compassionate, flexible manner and adhere to
the essential principles of the method. Some techniques form PBSP
can be effectively used within other therapeutic modalities (e.g. family
therapy, marital therapy). However, such an application needs to be
distinguished from PBSP therapy itself.
Research
The examples of research on PBSP given below show two directions
which have interested researchers. One is the overall effectiveness of
the method. The second is looking at specific interventions and aspects
of the theory as they are used in clinical practice.
The effect of PBSP therapy on emotional brain

activation as measured by fMRI in patients
with post-traumatic stress disorder
Research using functional magnetic resonance imaging (fMRI) was
organised at Charles University in Prague. The study involved nine
clients, aged eighteen to sixty-five. There were two goals: to identify
brain regions activated (or deactivated) by emotional stimulation
related to psychological trauma and to measure the effect of PBSP
therapy sessions on the activity of these brain regions in traumatised
people. Each client was scanned with fMRI. Clients were exposed to
pictures which triggered memories of childhood trauma and then they
were exposed to pictures with neutral meaning, such as a landscape.
After the initial scanning each client participated in two individual
PBSP sessions run by Albert Pesso. After the therapeutic intervention,
all clients were scanned again using fMRI. The results showed
that trauma-related photographs activated brain areas involved in
processing strong affect. The research also showed that exposure to
Appendix 285
trauma-related photographs increased activation of brain areas which

may contribute to processing intrusive thoughts and images: the
cingulate cortex (used in focusing attention) and the inferior frontal
anterior lobe (used in decision making). This pattern was found in clients
with obsessive compulsive disorder and clients with intrusive thoughts
associated with post-traumatic stress disorder. Neutral pictures did not
activate these neurological patterns. FMRI scans showed significant
changes in affect-related brain activity when measured before and
after PBSP treatment sessions. After PBSP intervention fMRI scans
showed that the pre-treatment pattern had diminished. Areas activated
when clients were shown neutral photos did not differ across pre- and
post-treatment conditions. The research suggests that PBSP sessions
reduced activity in areas of the brain associated with repetitive,
intrusive thoughts and increased activity in brain areas which play a
role in mastering overwhelming emotions (Horáček et al. 2005).
Changes in clients’ self-concept associated

with Pesso Boyden System Psychotherapy
A research project done by a graduate student in psychology at Jan
Masaryk University in Brno focused on changes in self-concept as
reported by clients who had had long-term treatment in PBSP therapy
and as evaluated by the client’s therapist. The study showed that
childhood traumatic experiences negatively influenced clients’ sense
of self. New experiences gained in PBSP helped the clients build a
positive self-concept. The new experience consisted of experiencing
a reversed version of traumatic childhood events. The research also
showed that PBSP therapeutic work reduced symptoms of depression
and anxiety related to the clients’ sense of themselves (Slaninová 2015).
The effectiveness of scenic-symbolic

interventions used in PBSP for inducing
a corrective emotional experience
Abstract of a research conducted by a graduate student
at Charles University in Prague (in progress)
In traditional approaches the corrective emotional experience is
produced only in an interpersonal setting, either in the client–therapist
relationship or among members of a therapeutic group. The vital

contribution of PBSP to the current discussion of psychotherapy is
shifting the corrective emotional experience from an interpersonal to
a symbolic reality. For this purpose, PBSP developed a unique system
of symbolic inclusion of the physical space of the therapy room into
the therapeutic process, as well as a very special use of symbolic objects
and role playing. This research tests the hypothesis that the Scenic-
Symbolic Interventions used in PBSP therapy are effective in creating
a corrective emotional experience. The results are expected by the end
of 2016 (Siřínek 2016).
Development and factor analysis of Levang

Inventory of Family Experiences (LIFE):
A new way to operationalise and validate
Pesso Boyden System Psychomotor
This project included development of a new assessment tool looking
at childhood developmental history (LIFE) based on concepts from
PBSP theory. Forty-five subjects from a clinical population and
130 from the general population were tested. The LIFE represents the
first empirical evidence to support the existence of two measurable
types of basic needs: literal and symbolic. From a clinical perspective,
distinguishing literal from symbolic needs provides greater precision
in determining the focus of therapy and applying interventions. The
study also showed that the higher a client’s score on the factor ‘holes
in roles’, the less likely they were to have had basic needs met. This fits
PBSP theory which states that awakening one’s caretaking responses
too early is associated with one’s own needs not being met adequately
(Levang et al. 2016).
The future
Training
There are PBSP institutes and organisations throughout the US and
Europe. There are three- and four-year training programmes which use
an official curriculum and which are taught by certified trainers and
supervisors (www.PBSP.com). After completing a training programme
trainees must submit a tape of their work for approval before they can
become eligible to be certified as PBSP therapists. The tape is evaluated
Appendix 287
by two independent senior trainers. One of these was always Albert

Pesso himself until his death in 2016. The PBSP Institute established
these rules and guidelines in order to maintain high-quality therapeutic
work done by certified therapists.
Applications of PBSP
Although PBSP as a therapeutic system is structured, it also allows for
creative applications.
The Natama Institute for Family Development in Prague has
integrated PBSP theory into training for future adoptive and foster
parents. PBSP is also used here as a therapeutic adjunct for parents
who attend family therapy treatment and realise they need to work
on their own issues from childhood in order to become more
competent parents. PBSP is a therapy for adults, but there are elements
which can be applied when working with children. Michael Bachq,
a German psychologist and PBSP therapist and trainer, developed a
special approach based on PBSP which helps children in difficult
and traumatic family situations. His modality is called ‘Feeling Seen’
(Bachq n.d.). The process of a structure has some similarities to the
Adult Attachment Interview and specific techniques could be adapted
for use in assessment.
Research
Research is needed on the effectiveness of PBSP in treating
developmental trauma and on its usefulness with different types
of clients. Also, it would be valuable to study the effectiveness of
specific interventions such as reversals (having clients imagine
positive interactions with ideal figures), and making movies and how
these interventions affect memory for traumatic events. Research using
fMRI could map the brain activities involved in trauma and measure
changes in brain functioning following treatment with PBSP. This
may shed light on how memory works and how it can be effectively
influenced for the benefit of traumatised clients.
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SUBJECT INDEX
adolescence, brain development 38 belief systems 88

adoption The Body Keeps the Score (van der Kolk) 125
impact on the developing brain 163 borderline personality disorder (BPD) 69–70
not feeling understood 163–168 boundaries and limits 100–101
adrenaline 46 Boyden-Pesso, Diane, biography of 94–96
Adult Attachment Interview (AAI) 32–33, 177 brain connectivity 37–38
adult trauma new pathways 130–133
PTSD studies 54–55 reawakening of 85–86, 87–88
treatment with Dyadic Developmental brain development 23–27
Psychotherapy 81–84 key stages 36–38
affect regulation 74, 229–230, 234 defence systems 58–60
ambivalent attachment style 49–50 integration of connectivity 37–38
in adulthood 51 reawakening of 85–88
amygdala 42, 43, 55, 59–60 shutting down pathways 61
and cortisol 47 Building the Bonds of Attachment
inhibition of 128–129 (Hughes) 72–73
anger feelings 232–234
anterior cingulate cortex (ACC) 61, 130, 132 case studies see client case histories
anxiety 211–213 change through PBSP
arousal responses 46–48 from inside out 214
role of memory 29–30, 55–57 neurobiology of 126–135
see also flight or fight responses research on PBSP approaches 285–286
attachment 31 see also integration in PBSP sessions
in childhood 31, 32 child development
in adulthood 32–35 attachment behaviours 31
secure 32, 33–34 nurture need 99, 273–274
styles of 32, 49–52 sense of self 31
as therapeutic task 73 child therapy sessions, use of Dyadic
therapy through playing baby 77–80 Developmental Psychotherapy 72–81
attention disorder 197 childhood development history
attention (PBSP) 118 assessment tools 286
attunement 31 childhood memories
autonomy in PBSP 110 neurobiology of retrieval 128–129
avoidant attachment style 49 recall in adulthood 55–57,
in adulthood 51 206–207, 265–278
avoidant behaviours, brain activity see also memory; client case histories
37–38, 59–60 childhood trauma 52–55
memories in adulthood 55–57
bad I syndrome 209 neurobiology of 38, 48–49, 58–62
behavioural epigenetics 39–40 reimagining and therapeutic
change 122–123
297
childhood trauma cont. developmental trauma disorder (DTD) 63–64

serial experiences 53 case histories 65–67, 67–69, 69–72
see also developmental trauma; developmental in adulthood 65
trauma disorder (DTD) sense of self 70–71
chronic maltreatment 53 spectrum of unresolved traumas 69–70
circle of interaction model (PBSP) 111–113 treatments 71–72
client case histories disorganised–disorientated attachment 50
Anthony (young man with suicidal in adulthood 51–52, 57, 218–219
depression) 175–209, 251–252 disparity processing 87–88
Clara (institutional and adoptive care) dissociation 56, 61, 144
65–67, 70, 71, 75–76, 249–250 DMN see default mode network (DMN)
Emma (abandoned as a baby and severely domestic violence 53
neglected) 139–173, 251 DTD see developmental trauma disorder
Irene (severe neglect and Dyadic Developmental Psychotherapy 72–84
institutionalisation) 78–79, 253 core principles and tasks 73–75, 80
Paul (destructive relationship patterns) goal setting and case histories 75–80
67–69, 70, 71, 76–77, 114, 250 healing modalities 73–74
Rebecca (perfectionism and control nature vs nurture interplay 81–84
needs) 211–244, 252–253 PACE and PLACE 74–75
Sylvester (the child scapegoat) role of therapeutic parenting 75
245–248, 253 treating adults 81–84
completeness and justice (PBSP) 107 treating children 72–81
complex developmental trauma 53
concentration difficulties 197–199 emotional movement 95
congruent intention 74 emotional vulnerability 81–82
consciousness (PBSP) 102 energy/action/interaction/satisfaction
enhancement 120 process (PBSP) 103–104
contact figures 119 epigenetics 39–40
contracts for sessions (PBSP) 117, error signals 131–132
203–204, 263–264 executive brain functions 38, 61
corrective emotional experiences, explicit memory 29
research 285–286 role in arousal 29–30
cortisol 43, 46, 47
false understandings 156–160
default mode network (DMN) 40–42, 61–62 fear responses 54–55
reactivation 88–89, 126–129 role of memory 29–30
defensive states filling gaps (memory) see holes in roles (Pesso)
inhibition of 128–129, 133–134 flashbacks 58–59
neurobiology of 39, 40, 42–43, flight or fight responses 42–43,
58–60, 133–134 46, 48, 54–55, 58–59
and resistance to therapy 123–124 foetal stage 272–273
see also avoidant behaviours fronto-limbic circuit 37
developmental needs 98–101, 103
fulfilment criteria 104–105 GABA cells 128–129
timing of 104–105 gene expression, and early interactions
developmental trauma 52–55, 63–64 26–27, 39–40, 82
case stories 65–72 genetic needs 272–274
neurobiology of 85–89 good care in early life, neurobiology of 36–43
problems with ‘talking about’ 218–219 good parents see ‘ideal parents’ (PBSP)
and PTSD 54–55 grief responses 133, 155
and serial experiences 53 group PBSP sessions 235–244
therapeutic change through reimaginary introductions 237–238
experiences 122–123 session exercises 238–241
unresolved 56–57, 69–72
use of dissociative strategies 61 happiness, expectations of 97–98
holes in roles (Pesso) 148–149, 225, 274–275
Subject Index 299
hope 127 and trauma 55–56, 58–59

hypervigilance 62, 218–219 triggers and flashbacks 58–59
memory in PBSP 108–115
ideal figures (PBSP) 120–121, 130 creating new 134, 149–151, 267–278
explaining to clients 185–187 deficits, trauma and ‘holes’ 108–110,
interacting with 121–122, 148–149, 225, 274–275
132–133, 150–151 sessions on 180–182
therapeutic value of 188, 193–195 memory reconsolidation 87–88
use of animals 216–217 mental models 29
use in case studies 145–146, 150– micro-tracking (PBSP) 118, 129
151, 184–187, 216–219 development of concept 265
use of objects 143–152, 202–203 midbrain defence systems 58–60, 133–134
and wishful thinking 223 middle prefrontal cortex (MPFC) 41–42, 88
ideal parents (PBSP) new pathways 130
concept development of 272 as ‘the pilot’ (PBSP) 128–129
resistance to 274 the mind 83
reversing the wrong 130, 132–133 mother-infant relations
working with clients 150–162, 170–173, attachment styles 31, 32, 33–35
193–194, 206–209, 216–218, basic needs of 273–274
224–228, 231–234, 244, 247–248 and developmental trauma 70–71
implicit memory 28–29 neurobiology of 38–39
role in arousal 29–30 sensory pathways 25–26
triggers for 58–59 mothers, creating ‘ideal’ figures 145–146,
inferior parietal cortex 128 150–151, 192–195
insecure attachment style, in adulthood 50–52 motivators in PBSP 106–107
integration in PBSP sessions 134–135 movement, modalities of 95
with clients 154–155, 160–161, 173, movie-making in PBSP 124,
194, 201, 208–209, 217–218 130–131, 275–277
integration of polarities (PBSP) 101–102 neurobiology of 131–132
interaction process (PBSP) 103–104 use in case studies 149–151, 171–173
circle of interaction model (PBSP) 111–113
intersubjectivity, as therapeutic task 73–74 Natama Institute for Family
Development (Prague) 287
Kalokagathia 258 nature vs. nurture and psychotherapy 81–84
koan (unsolvable paradox) 163–168 neglect
and developmental trauma 53
language, power of 266–267 neurobiology of 58–62
learning neural integration 126
role of memory 28–30 neurobiology of
unconscious 29–30 brain development 23–27
see also reversal learning good care 36–43
left brain functions 36, 37–38, 104 poor care 58–62
limbic system 37 therapeutic change 85–89
limits and boundary needs 100–101 therapeutic change with PBSP 126–135
Lindemann, Eric 261–262 neuroception 59–60
Little House 175–176 new memories
corrective reimagining 122–123,
meaning 149–151, 267–278
co-creation of 74 integration of experiences 111–115, 123
see also integration in PBSP sessions and relational experiences 87–88
memory 27–30 nurture needs 99, 273–274
brain connectivity 37–38 see also mother-infant relations
filling in the gaps 109–110, 148–149
hierarchic development 28–30 objects as ‘ideal figures’ 143–152, 202–203
levels of 28–30 obsessive thoughts 55
role of 28 opioids 61
orbitofrontal cortex (OFC) 131–132 with Rebecca 211–244, 252–253

orphanages 55 with Sylvester 245–248, 253
oxytocin 39, 132–133 Pesso, Albert
biography of 94–96, 257–261
PACE 74–75 childhood 258
parent-child bonding getting involved with therapy 259–261
attachment styles 49–52 meeting Diane 258–259
neurobiology of 38–39 physiological arousal see arousal responses
and state of mind 49 ‘the pilot’ (PBSP) 102, 121
see also mother-infant relations importance of 128–129
parenting and prefrontal cortex 272
core domains of (Hughes and Baylin) 106 use with clients 180–181,
see also ‘ideal figures’ (PBSP); 184–187, 223–227
‘ideal parents’ (PBSP) PLACE 74–75
parents and child psychotherapy ‘place’ needs 99, 160
outcomes 80–81 in case studies 152–160
in PBSP 106 ‘placeholders’ (PBSP) 119, 129
see also ‘ideal figures’ (PBSP); de-roleing of 194
‘ideal parents’ (PBSP) development of 267–268
personal reflection see self-reflection introducing to clients 182–183
personality, theory of 97–98 not remembering 197–198
Pesso Boyden System Psychomotor use in case studies 146–147, 189–191
(PBSP) model 17, 84, 93–125 ‘playing baby’ 77–80
critical points 283–284 positive expectations 117
development and history 257–281 positive prediction errors (PPEs) 131–132
evolution and theoretical positive responses
background 96–110 brain activity 37–38
five developmental needs 98–101 role of memory 30
four developmental tasks 101–103 the ‘possibility sphere’ 117, 127–128,
future directions 286–287 144–145, 185–187
good care principles 103–105 development of 262–263
model of need fulfilment 111–113 post traumatic stress disorder (PTSD)
motivators for 106–107, 179 and developmental trauma 54–55, 81–82
neurobiology of 126–135 research on PBSP methods 284–285
new applications 287 posterior cingulate cortex 128
reconsolidation of new memories 134 prefrontal cortex 37
research on 284–286 mid zone (MPFC) 41–42
resistance to treatment 123–124 therapeutic awakening of 86, 87–88,
role of autonomy 110 131–132, 263–264
role of parents 106 as ‘the pilot’ 272
therapeutic content 110–115 veto powers of 38
therapeutic process 115–125 prenatal states 272–273
training in 202, 286–287 ‘principle’ (Pesso) 277–278
Pesso Boyden System Psychomotor protection needs 100
(PBSP) sessions psychiatric conditions, and disorganised-
contracts for 117, 203–204, 263–264 disorientated attachments 57
first encounters 139–140, 143, 176–179 PTSD see post traumatic stress disorder (PTSD)
first steps 143–152, 180–188
flexibility of 269–272 reappraisal therapy 87–88
introducing PBSP methodologies reconsolidation 134
143–152, 179–183, 215 reflective functioning see self-reflection
outlining structures of 143, 179–180, 182 reflexive movement 95
resistance to interventions 123– relational experiences, neurobiology of 87–88
124, 179, 269–270 relief-grief 133, 155
with Anthony 175–206, 251–252 reluctance to engage with therapy
with Emma 139–173, 251 123–124, 179
Subject Index 301
research into PBSP methods 284–286, 287 stress management

resilience 35 inhibiting defensive mechanisms 128–129
resistance to interventions 123–124, 179, 269 memory and attachment pathways 34–35
reversal learning 87–88, 268–269, 271–273 stress responses 48
neurobiology of 131–133 and attachment 32–35
reward systems 131–132, 272 and gene expression 82
right brain functions 36, 37–38, 70, 104 healthy vs. unhealthy responses 46–49
rituals 118 HPA axis 43
role playing 235–244, 267 inhibition of systems 128–129
see also ‘placeholders’ (PBSP) parental co-regulation 49
role of memory 29–30
sadness 133 social buffering mechanisms 38–39
safe havens 77 structure of PBSP sessions 143, 179–180, 182
see also secure base subcortical midbrain defence systems
‘safety’ as core DDP principle 73, 87 58–60, 128–129
activating the DMN 88–89 support needs 100
secure base 34–35, 103 survival mechanisms 31
healing powers of 73–75 Systems of Psychotherapy (Prochaska
and parent roles 106 and Norcross) 81, 93
use in case sessions 153–155, 239–243
self (sense of ) 31, 37, 60 therapeutic parenting 75–80
and developmental trauma 70–71 see also Dyadic Developmental Psychotherapy
neurobiology of therapeutic therapeutic relationship (PBSP) 117–120
interventions 85–89 timing of interventions 104–105
nurturing and development of 83–84 touch 25–27
research into PBSP therapies 285 toxic stress 48
splitting of 205–209 training for PBSP counselling 202
see also self-reflection trauma 52, 218–219
self-defence system 42–43 encoding and memory 55–56,
self-reflection 58–60, 218–219
neurobiology of 40–42 see also adult trauma; childhood trauma;
reawakening of 88–89 post traumatic stress disorder (PTSD)
suppression of 61–62 treatments for unresolved DTD 71–72
sense of self see self (sense of ) with adults 81–84
sensory pathways 25–26, 59–60 with children 72–81
separation anxiety 43, 57 Dyadic Developmental
sessions with clients see Pesso Boyden System Psychotherapy 72–84
Psychomotor (PBSP) sessions opportunities for new relational
shame feelings 176, 188 experiences 87–88
‘shape’ and ‘counter shape’ (PBSP) 10 see also Pesso Boyden System
shell shock 54–55 Psychomotor (PBSP) model
silences in sessions 199 trust, neurobiology of 39
social buffering 38–39, 86–87
social development unconscious learning 29–30
key neurological systems 42–43 uniqueness (PBSP) 103
suppression of emotions 60–61 unresolved states of mind 51–52
see also social engagement; social interaction
social engagement 42–43, 59–60, 85–86 voice figure in PBSP 118, 123, 129
neurobiology of 85–89 development of 265–266
social interaction explaining to clients 183
and gene expression 26–27 use with clients 152–156, 183, 189, 194,
neurobiology of 37–39 197, 200, 207–208, 214, 220
social switching 43, 59–60
splitting (sense of self ) 205–209 war experiences 54–55
Strange Situation experiment the witness figure in PBSP 118–119, 129
(Ainsworth) 32, 49–52 explaining to client 182
with client case studies 147–172, 182–208
AUTHOR INDEX
Ainsworth, M. S. 32, DiLalla, D. L. 103–104 Kidwell, C. S. 118

49–50, 106 Donzella, B. 105 Knowlton, B. 29
American Psychological Krystal, H. 97–98
Association 52, 63 Eisenberger, N. I. 43
Erickson, M. H. 187–188 Lanius, R. A. 58, 61, 129
Bachq, M. 287 Erikson, E. H. 112 Lanius, U. F. 37, 61, 85
Barker, P. 54 LeDoux, J. E. 134
Bauer, P.J. 28–29 Fahlberg, V. I. 112 Levang, C. 286
Baylin, J. 6, 73, 75, 77, Fisher, S. 60 Liddel, B. J. 42
87, 102, 106, 133 Fivush, R. 29 Lieberman, M. D. 43
Becker-Weidman, A. 75, 80 Fonagy, P. 40, 88 Lupien, S. J. 43
Beeghly, M. 101 Fosha, D. 61 Lyons-Ruth, K. 65
Belsky, J. 61 Freud, S. 107, 115
Blaustein, M. 53, 105 Frewen, P. A. 58, 61, 129 McEwen, B. 43
Blehar, M. C. 106 McGlone, F. 25–26
Bluhm, R. L. 58, 61, 129 Gazzaniga, M. S. 107, McGowan, P. 82
Bower, G. H. 30, 56 110, 156 Main, M. 32–33, 50–52, 177
Bowlby, J. 24, 31, 34–35, 73, George, C. 32, 177 Matriccino, D. 19
97, 99, 103, 110, 196 Goldberg, S. 115 Mayes, L. 43
Boyden-Pesso, D. 94–97, 100, Grice, H. P. 33, 51–52 Meaney, M. J. 26, 36,
103, 110, 115, 124 Guilfoyle, A. 47 58, 82, 105
Bullard, D. 223 Gunnar, M. R. 105 Milner, B. 28
Minton, K. 86
Cairns, K. 106 Henderson, M. 80 Moriceau, S. 58
Center on the Developing Herman, J. L. 69, 115 Morrison, J. 43
Child at Harvard Horáček, J. 285 Musen, G. 29
University 16, 25–27 Howe, D. 98
Champagne, F. 105 Howe, L. 94–95 Nader, K. 134
Cicchetti, D. 101 Hudson, J. A. 29 National Childcare
Coan, J. A. 128 Hughes, D. A. 64, 72–75, Accreditation
Cook, A. 53, 80, 105 77, 87, 105–106, 133 Council 47
Cooper, D. E. 97 National Scientific Council
Corrigan, F. M. 37, 58, 85 Jacobovitz, D. 65 on the Developing
Cozolino, L. 36, 85 Jentoft, K. 80 Child 23, 36, 46,
Crittenden, P. 55, Joseph, R. 77 48, 69, 98, 142
103–104, 108 Noley, H. 118
Kagan, J. 55, 104, 108 Norcross, J. C. 17, 81, 93,
Davidson, R. J. 37, 128 Kaku, M. 28, 102, 108 96–97, 110–111, 116
Davis, M. 129 Kandel, E. R. 28
De Bellis, M. D. 104 Kaplan, N. 32, 177 Ogden, P. 86
Denworth, L. 25 Karen, R. 31, 33–35, 57 Olausson, H. 25–26
303
Pain, C. 86 Schore, A. N. 26–27, 37, 70, Trevarthen, C. 40

Panksepp, J. 37, 43, 60 72, 74, 77, 105, 126
Paulsen, S. L. 37, 85 Siegel, D. J. 24, 28–29, 32, van der Kolk, B. A. 16–17,
Perquin, L. 27 36–38, 52, 55–56, 24, 31, 38, 53, 63–64,
Perry, J. C. 69 58, 81, 83, 108, 130 69, 71, 83, 109, 114,
Pesso, A. 94–97, 100, 103, Sikes, R. W. 128 125, 218–219
106–107, 110–112, Sims, M. 47 Velasquez-Manoff, M.
115, 124, 132, 144, Siřínek, J. 286 54–55, 81–82
148, 168, 225 Sivers, H. 30, 56 Vogt, B. A. 128, 130
Phelps, E. 88 Slaninová, G. 285 Vrtbovska, P. 33, 71, 95,
Porges, S. 42–43, 59–60 Smider, M. A. 47 97, 99, 100, 103,
Prochaska, J. O. 17, 81, 93, Snyder, A. Z. 40–41 110, 120, 124
96–97, 110–111, 116 Solomon, J. 50–52 Vrticka, P. 129
Putnam, F. W. 109 Spitz, R. A. 103, 112 Vuilleumier, P. 59
Squire, L. R. 28–29
Raichle, M. E. 40–41 Sroufe, L. A. 35, 56–57, 64 Waters, E. 106
Rivers, W. H. R. 54 Stalnaker, T. A. 131 Weaver, I. C. G. 39
Steinberg, E. E. 131 Wessberg, J. 25–26
Saddoris, M. P. 131 Stephen, A. 196 Whalen, P. 88, 129
Scarf, M. 116 Stern, D. 60 Wilson, J. Q. 110
Schaefer, H. S. 128 Szyf, M. 82 Winnette, P. 30, 110,
Schafe, G. E. 134 124, 257–281
Schoenbaum, G. 131 Tinker, G. E. 118
Tottenham, N. 36–37, 39 Zak, P. J. 133

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WORKING WITH TRAUMATIC

MEMORIES TO HEAL ADULTS WITH

Theory and Practice of Focusing-Oriented Psychotherapy

Emerging Practice in Focusing-Oriented Psychotherapy

Neuroscience for Counsellors

Counselling Skills for Working with Trauma

Counselling Skills for Working with Shame

Petra Winnette and Jonathan Baylin

Jessica Kingsley Publishers

I would like to dedicate this book to the main author,

Window to Neurobiology of Good Care . . . . . . . . . . . . 36

Window to Neurobiology of Poor Care . . . . . . . . . . . . 58

Window to Neurobiology of Therapeutic Change . . . . . . . 85

Part II: Pesso Boyden System Psychomotor

Window to Neurobiology of Change in Pesso Boyden

Part III: PBSP Clients’ Case Studies 137

Part IV: Interview with Albert Pesso,

I would like to express my gratitude to the teachers who inspired

Organisation of the book

through repetitive cycles of experiences with the same trauma-related

Part II: Pesso Boyden System Psychomotor

Part III: PBSP clients’ case studies

Part IV: Interview with Albert

We open this book by providing a context for further discussion on

WHEN THINGS GO RIGHT

How the brain develops

need to develop to be able to live that way? John Bowlby, founder of

Senses and social connecting

Mother Rat: Licking and touching

Sciences, UCLA, concludes that interaction between the young child

Memory: The basis for learning

The role of memory

The hierarchic development of memory

remember their experience with behaviours, sensations and emotions

Implicit and explicit memory co-create our reality

Attunement and the child’s sense of self

Feeling secure with my parent:

Secure attachment style

Adults and attachment

Secure attachment in childhood and a secure,

If this child were interviewed as an adult, his answers in the Adult

Adulthood and a safe model of autonomous life

internal model of living among people and a feeling of being happy

Building brain bridges in stages:

Vertical integration: The fronto-limbic circuit

Horizontal integration: Right and left

right-hemisphere fronto-limbic system so that they can use their left

Lateral integration: When the back

Social buffering: The neurobiology

brain and body from a state of dysregulation to a state of regulation,

Behavioural epigenetics: The hot science

The self-reflection system:

rather than just reactive, and ultimately, to increase one’s self-awareness,

The middle prefrontal cortex (MPFC):

Figure 1.1 The default mode network

Social development as a whole

• The social emotion system that supports the emotions of

Social engagement Self-defence

Figure 1.2 Social engagement versus social defence

WHEN THINGS GO WRONG

Healthy balance versus stress

The power of cortisol

Positive, tolerable and toxic stress