Gaensbauer 2009

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Theodore J. Gaensbauer / Leslie Jordan 57/4
PSYCHOANALYTIC PERSPECTIVES ON
EARLY TRAUMA: INTERVIEWS WITH
THIRTY ANALYSTS WHO TREATED AN
ADULT VICTIM OF A CIRCUMSCRIBED
TRAUMA IN EARLY CHILDHOOD
Information on the long-term effects of early trauma and how such

effects are manifested in treatment was obtained through interviews
with thirty analysts who had treated an adult patient with a circum-
scribed trauma in the first four years of life. Childhood traumas fell into
four categories: medical/accidental; separation/loss; witnessing a trau-
matic event; and physical/sexual abuse. Traumatic carryover was recorded
in terms of explicit memories, implicit memories (somatic reliving, trau-
matic dreams, affective memories, behavioral reenactments, and trans-
ference phenomena), and global carryover effects (generalized traumatic
affective states, defensive styles, patterns of object relating, and develop-
mental disruptions). Linkages between the early trauma and adult symp-
tomatology could be posited in almost every case, yet the clinical data
supporting such linkages was often fragmented and ambiguous. Elements
of patients’ traumas appeared to be dispersed along variable avenues of
expression and did not appear amenable to holistic, regressive rework-
ing in treatment. The data did not support linear models of traumatic
carryover or the idea that early traumatic experiences will be directly
accessible in the course of an analysis. Factors that we believe help
explain why traumatic aftereffects in our sample were so heterogeneous
and difficult to track over the long term are discussed.
A s an outgrowth of our shared interest in early trauma, some years

ago we decided to study the analyses of adults who had experienced
discrete traumatic events in the first years of life. We were interested
in learning about the long-term effects of early trauma and how such
Theodore J. Gaensbauer, Clinical Professor, University of Colorado Health

Sciences Center; faculty, Denver Institute for Psychoanalysis. Leslie Jordan, Associate
DOI: 10.1177/0003065109342589 947

Downloaded from apa.sagepub.com at RUTGERS UNIV on April 26, 2015
Theodore J. Gaensbauer / Leslie Jordan
emotionally powerful early experiences might manifest themselves,

either directly or indirectly, in the therapeutic setting. Would traumatic
memories or symptoms persist into adulthood? Would an early trauma
leave an identifiable imprint on the developmental trajectory? Would
representations of an early trauma be identifiable in the adult’s transfer-
ences, associative material, or character?
Studies of very young traumatized children have demonstrated
unequivocally that infants and toddlers have the prerequisite cognitive
and emotional capacities for trauma to have persisting effects. Infants
by the second half of the first year of life appear capable of demon-
strating most of the characteristic symptoms of posttraumatic stress
disorder (Scheeringa et al. 1995, 2001; Scheeringa and Gaensbauer
1999). Traumatized young children can also retain some form of inter-
nal representation of their trauma for months and even years, as dem-
onstrated through trauma-specific behavioral reenactments, affective
responses to traumatic triggers, sensory and somatic symptoms, expres-
sive play, and even verbal recall (Terr 1988, 2003; Gaensbauer 1995, 2002,
2004; Peterson and Rideout 1998; Peterson and Whalen 2001; Gislason
and Call 1982; Paley and Alpert 2003). What we do not know, given
the lack of systematic studies, is the long-term fate of these trauma-
derived symptoms and representations.
Historically, a conception that has had wide currency within the ana-
lytic literature is that significant trauma in childhood both interrupts
development and stamps it forever. The overwhelming of the ego induced
by trauma is thought to leave indelible memory imprints (conscious or
unconscious) that cause ongoing flashbacks, affective reexperiencing,
traumatically driven behavioral reenactments, trauma-determined fears,
and traumatic dreams (Freud 1920; Casement 1982, 2002; Herman 1992;
Terr 1987, 1991; van der Kolk, McFarlane, and Weisaeth 1996). The trauma
is seen as having an enduring organizational influence on the patient
throughout the life span, a conception we came to term a “full-fledged”
repetition. Describing cases of adults and children, Herman (1992)
observed that “long after the trauma is past, traumatized people relive
the event as though it were continually recurring in the present. . . . the
Clinical Professor, University of Colorado Health Sciences Center; faculty, Denver

Institute for Psychoanalysis.
The authors gratefully acknowledge the generosity and commitment of the thirty
analysts who shared their clinical experience and wisdom with them. Submitted for
publication May 11, 2009.
948
PSYCHOANALYTIC PERSPECTIVES ON EARLY TRAUMA
traumatic moment becomes encoded . . . and breaks spontaneously into

consciousness, both as flashbacks during waking states and as traumatic
nightmares during sleep” (p. 37). It is not clear whether, or with what
frequency, such direct forms of carryover might be observed in adult
patients who have been traumatized in the first years of life.
To date, assumptions about the enduring effects of a very early
trauma have depended on a small and disparate group of case reports of
adult analytic patients who manifested some form of symptomatic carry-
over (for a review of much of this literature, see Share 1994). Traumatic
aftereffects observed in adult analysands have included dreams and
visual imagery (Dowling 1982; Pulver 1987; Niederland 1965; Viederman
1995), bodily sensations (Isakower 1938; Lewin 1946; Easson 1973;
Leuzinger-Bohleber 2008), affective states (Casement 1982; Alpert
1994; Adler 1995), postural reenactments (Deutsch 1947; Anthi 1983;
Engel, Reichsman, and Viederman 1979), strong defensive reactions
(Rosen 1955; Segal 1972), and creative products (Terr 1987). Although
these case reports have provided evidence that symptoms associated
with an early trauma can persist into adulthood in linear fashion (what
we have termed a “red thread” effect) and can be accessible to ana-
lytic work, many uncertainties remain. The modalities through which
traumatic aftereffects were manifested in these reports varied greatly, as
did the degree to which the trauma was seen by the analyst to have influ-
enced the patient’s adult functioning and intrapsychic conflicts. In addi-
tion, the extent to which a reexperiencing in the transference relationship
was seen as central to a therapeutic working through of the trauma also
varied considerably. Finally, in several of the cases the linkage between
the patients’ symptoms and a specific early traumatic experience seemed
ambiguous and dependent on the analyst’s interpretation. In sum, such
notable heterogeneity among the individual case reports left us with con-
siderable uncertainty about how representative they were of patients who
have suffered early traumas (Pine 2001).
Questions about the carryover of early traumatic experiences are not
only of interest in themselves, but go to the heart of what Abrams and
Shengold (1978) identified as a core subject of debate within psycho-
analytic clinical theory, namely, “conflicting views about very early
psychic development and the possibility of its being explored in the
psychoanalytic situation” (p. 400). In his review of the many different
perspectives that analysts have taken on this issue over the years,
McLaughlin (1982) highlighted the many salient issues by contrasting
949
analysts who hold that “there is direct access to these early experiences
in the course of the analytic process” with, at the other end of the
spectrum, analysts who see “early experiences as contributing to the
matrix of interlocking development of object-relations and psychic
structure . . . but not directly accessible in the treatment situation”
(p. 229). We felt that the systematic examination of traumatic carryover
in a group of adult analytic patients who had experienced a well-defined
traumatic event in early childhood would offer a unique opportunity to
shed light on this long-standing debate.
METHOD
We sent a brief questionnaire to a large group of analysts accredited by the

American Psychoanalytic Association, asking if they had had patients who
had experienced a discrete trauma during the first four years of life and if
so whether, if confidentiality could be assured, they would be willing to
be interviewed about that patient. To be considered for the study, the
patient’s trauma had to meet the traditional DSM-IV exposure criterion
for the diagnosis of posttraumatic stress disorder, namely, an event involv-
ing actual and/or threatened physical harm to the patient or someone
close to the patient. Given the young child’s dependency on adults, we
included among traumatic events the abrupt loss of a caregiver for three
months or longer. From the responses, we identified thirty analysts who
had had such a patient in analysis or intensive psychotherapy and were
willing to participate in the study. With each analyst, we carried out a two-
hour semi-structured interview in which we explored the following topics:
the nature of the trauma and the patient’s age at the time it occurred; the
immediate impact of the trauma on the patient and the response of the
family; the nature of the patient’s memories of the trauma; the patient’s
developmental history; the problems that brought the patient to treatment;
how the analyst learned about the trauma; the analyst’s assessment of
carryover effects on the patient’s development and current functioning;
and how the trauma was handled in the treatment.1
1
Our initial questionnaire uncovered a very small number of patients with dis-
crete early childhood trauma treated by the psychoanalysts we surveyed. Fewer than
half the analysts reported having worked with such patients, and of these, the large
majority reported having only one or two cases. By contrast, our respondents
reported treating a significant number of patients who suffered “traumatic emotional
states” due to early trauma in a chronic form (i.e., repeating physical, sexual, or emo-
tional abuse). We observed that analysts’ memories about whether they had treated
950
Description of the Sample
Two-thirds of the patients on whom data were reported were women;

one-third were men. The mean age was 36 years, with a range from 21 to
63. Twenty patients had been in analysis (three to five sessions a week),
and the remaining ten had been in long-term psychodynamic psycho-
therapy (one to two sessions a week). The chief complaints that brought
these patients to treatment were typical of the problems one would expect
for analytic patients as a whole. These included difficulties with intimacy,
particularly sexual intimacy; marital and/or vocational problems; affect
dysregulation such as depression, anxiety, or emotional isolation; acting
out of sexual and/or aggressive impulses; substance abuse; and problems
with developmental progression, such as separating from the nuclear
family. Presenting problems were universally not of a specificity from
which one would automatically infer an early trauma. At the same time,
several patients, particularly those who had experienced quite severe
traumas, were very aware that their lives had been profoundly affected
and sensed that their trauma was something they needed to deal with.
The types of traumas patients had endured can be subsumed under
four general categories: (1) medical / surgical / accidental injury traumas
life-threatening or serious enough to require hospital treatment (n = 12
cases); (2) loss of a parent, either temporary (ranging between three
months to several years in duration) or permanent (n = 16); (3) the wit-
nessing of a traumatic event of an extremely frightening nature (n = 6);
(4) physical and/or sexual abuse (n = 7). The numbers add up to 41 (not
30, the number of patients) for two reasons. Five of the patients experi-
enced a trauma that involved more than one category, such as witnessing
the death of a family member, and six had suffered more than one
such patients were often quite evanescent, a phenomenon we related to both patients’
and analysts’ difficulties in retaining conscious access to this early period. There
were at least five instances in which an analyst indicated on initial contact that he or
she had had a patient with an early trauma but when we followed up (often after much
delay) could not recall which patient he or she might have been referring to. We also
had several instances in which analysts did not recall any patients with early trauma
in their initial response, but subsequently remembered that they indeed had had such
a patient. It appeared that issues of timing and subjective factors affecting memory
strongly influence whether such patients are remembered. For these reasons, among
others, we believe that the number of patients identified in our informal survey is
likely an underestimation of the total number of patients treated who had experienced
discrete early traumas. The sample to be described is thus made up of patients who
had suffered such a trauma and in whose treatment it played a role sufficiently sig-
nificant for it to be remembered by the analyst.
951
trauma before age four. The traumas varied in severity, ranging from
life-threatening with permanent consequences to relatively mild and
without long-term physical effects.
In every case except two, the traumas were known to the patient and
reported to the analyst either initially or relatively early in the course of
treatment, even though details were often reported over time, as the
patient’s comfort with the analyst increased. Patients were aware of the
events through having been informed of them by family members, through
being aware of the trauma’s consequences, and/or through their own
memories. Objective documentation of the traumas was almost universally
not available to the analyst, with the exception of a written summary of a
patient’s early life history prepared for the analyst by a parent of one patient
and medical records retained by another patient that documented early
abuse. In one of the two cases in which the patient was unaware of any
trauma, a medical trauma was reconstructed in the course of the therapy
and was confirmed by outside sources, even though the patient had no
conscious memory of the event. The other case was the only instance of
“recovered memory” in our sample. In this case, incestuous sexual abuse
could not be confirmed independently and was denied by the patient’s
parents. Interestingly, even though objective data was generally lacking,
over half the patients had either before or during treatment attempted on
their own to obtain further information that would validate and/or correct
memories and feelings they had retained about their early experience.
Although based on a much larger sample, our data share the prob-
lems of the typical case report, in that data were gathered from the ana-
lyst’s perspective. The amount of treatment documentation that analysts
had available, such as process notes or summaries, varied greatly. Much
of our data therefore depended on analysts’ memories of the cases and
their interpretation of the material, with the additional uncertainties that
these factors introduce. In addition, as we listened to the clinical material,
we found a number of cases in which varying degrees of uncertainty
arose in our minds about whether events could have occurred exactly in
the way the patient described them. The reasons for our uncertainty
reflect the whole spectrum of factors that can complicate therapists’ abil-
ity to assess the reliability of patients’ reports, such as the shadowy nature
of early memories, likely memory omissions and/or distortions, strong
emotional coloring, retrospective elaboration, possible secondary gain,
cognitive processing factors, and lack of outside information. Our find-
ings should be considered with these limitations in mind.
952
C A R R YO V E R E F F E C T S O F E A R LY T R A U M A
We examined the carryover effects of adult patients’ early traumas from three
perspectives: (1) explicit (conscious) memories of the trauma; (2) implicit
(unconscious) relivings/memories of the trauma; and (3) global patterns of
functioning influenced by the trauma.
Explicit Memories
Explicit memories were narrowly defined as conscious memories

for specific traumatic experiences. Since many of the patients were
aware of their traumas not only by direct knowledge but by hearsay, the
sources of their conscious memories were not always clear. Apart from
this issue, the quantity and quality of patients’ conscious memories
seemed most dependent on their age at the time of the trauma. For trau-
mas that occurred before two years of age a few images were reported,
but none that we could agree with confidence were memories of the
trauma. For events beginning around age two, a few patients reported
visual memories that were distinct, but isolated and fragmentary. By age
three and beyond, traumatic memories were more verbally accessible and
coherent and were reported in greater detail. Traumas involving the
infliction of strong physical sensations such as pain, or those that
involved dramatic, emotionally powerful discrete events such as wit-
nessing a death, were the most likely to be remembered, whereas traumas
that were less severe or less discrete, such as parental separations, tended
to be less well remembered. Overall, the kinds of explicit memories
reported in relation to the age at which the trauma occurred were consis-
tent with reports of children’s memories for early trauma (Terr 1988) and
adults’ recall of early childhood events (McNally 2003).
It is noteworthy that the explicit memories described for our sample,
rather than having the emotionally intense and intrusive quality usually
associated with traumatic reexperiencing, tended to be reported as
mental images unaccompanied by a remembered feeling. When strong
affects did accompany the mental images, they tended to reflect the
adult patient’s profound empathy and emotional resonance with the
childhood experience and its impact in later life, rather than an emotional
reliving of the original experience. For example, a patient who lost her
father at three and a half had only a vague memory of how she learned
of his death; she was unable to remember who told her, and had no
memory of crying at the time. In her analysis, however, she would cry
953
as she imagined the scene, as the impact of the loss of her father was
increasingly felt. Patients’ conscious memories of an affect or physical
sensation experienced at the time also tended to be reported without an
accompanying feeling in the present (e.g., “I remember I felt sad,” or
“I remember having the sensation of pain”)
Under one year (n = 8). No conscious memories were reported by
any of the eight patients who experienced a traumatic event in the first
year of life.
One to two years (n = 8). Five out of eight patients in this group had
no conscious memories of the trauma. Three patients reported conscious
memories, but of a nature that left considerable room for doubt as to
whether they were actual memories. One patient who at eighteen months
accidentally spilled hot wax on her leg had a conscious memory (not felt
but remembered) of the physical sensation of pain. This was accompanied
by a visual image of her surrounding environment and the people present
at the time. However, the patient wasn’t sure this was an actual memory
or the product of subsequent family descriptions of the event. Two patients
reported vague images of separation traumas. One woman who at age two
was abruptly given up by her mother to be raised by a relative had vague
images of a fight with her mother beforehand, plus a memory of later see-
ing a picture of her mother in the relative’s house; she remembered think-
ing, “Mother doesn’t love me anymore.” Another patient, who experienced
a three-month separation at nineteen months of age due to his mother’s
involvement in an auto accident, retained a visual image of seeing his
mother across a room during a visit to the rehabilitation center. As he
remembered it, it was almost immediately after returning home that his
mother left again for an out-of-town consultation. He had a memory of
standing by a tree as his mother left, experiencing a profound sense of
despair: “It felt like I was dying” (age twenty-three months).
Two to three years (n = 9). Three of the nine patients in this group had
no conscious memories to report, and one had very vague memories of the
traumatic event. Five cases, however, had clear and conscious memory
fragments of their traumas, including two patients traumatized very close
to their second birthday. One patient who suffered a burst appendix at age
two reported a series of very clear but isolated memories of his emergency
treatment, including going to the hospital, being strapped to a board and
poked with needles, and seeing his mother next to his bed. A patient who
at twenty-seven months saw a sibling killed by a gas stove explosion viv-
idly remembered sitting on a blue rug and seeing a flash of light as she
954
watched her sibling at the stove. Another patient remembered her throat
hurting, being tied to her bed, and wanting to be picked up and held during
her hospitalization for a tonsillectomy at age two years, seven months. A
fourth patient, who had a congenital deformity, had to wear a double leg
brace that from eighteen months to three years left her unable to move
about except by crawling. She had a memory of a time between two and
three when the brace broke and she was lying on the couch without it, ter-
rified to move lest her body “fall apart” without the apparatus. In the car on
the way to repair the brace, she remembered feeling terrified as she saw
“something” (she thought perhaps a screw from the brace) flying out of the
little “wing” window near her seat. On the day the brace was removed, she
had a memory of crawling up the stairs, feeling proud, to greet her happy,
tearful grandmother. A fifth patient reported sequential conscious mem-
ories for a terrible trauma that occurred around his third birthday. This
patient recalled being told to stay in his room by his mother, who then
went to the bathroom and shot herself. He remembered finding his mother’s
body, seeing blood and bone fragments, hearing sirens, and watching the
police and firemen arrive. He also remembered feelings of horror, guilt, and
anger at his mother. This patient also had memories of domestic violence
between his parents and of interactions with his mother such as sitting in
her lap before the suicide.
Three to four years (n = 11). Ten of the eleven patients in this
group reported conscious memories of their trauma. These memories,
though often still fragmentary, generally involved considerably more
detail than those from earlier on. One patient was nearly four when he
witnessed his older brother fall to his death from a Ferris wheel. He
remembered standing beside his mother and seeing his brother fall, had
vague images of chaotic movements immediately following, and retained
a subsequent specific image of the brother’s casket. Six of the seven
patients who experienced physical and/or sexual abuse before the age of
four recalled specific instances of their abuse. A patient who experienced a
medical procedure between the ages of three and four had fragmentary but
sequential memories of that procedure, and a patient whose father died
when she was three and a half had several isolated memories from around
that time.
Implicit Memories
Implicit memories were broadly defined to include a range of clinical

phenomena that appeared to be trauma-specific but where a conscious
955
link between the symptom and the trauma was absent. Since by definition
the link to the past was outside the patient’s conscious awareness, the
inference that a clinical phenomenon might be a manifestation of an
unconscious traumatic memory depended to a large degree on the inter-
pretive activity of the analyst. Not only did analysts differ significantly
among themselves in their readiness to infer such memories, but our own
impression of an inference’s validity was not always in accord with that
of the analyst we were interviewing. Our inclusion criteria leaned on the
side of conservatism.
For purposes of organization, we categorized implicit memory phe-
nomena under the following categories: (1) somatic memories; (2) intru-
sive thoughts and/or traumatic dreams (i.e., return of repressed or
dissociated memories); (3) posttraumatic fears and other affective mem-
ories; (4) behavioral memories (reenactments); and (5) transference phe-
nomena. With the exception of two cases where essential elements of a
traumatic event appeared to have been replayed in what we called full-
fledged reliving, the clinical manifestations of implicit memory in our
sample seemed to reflect isolated components of the trauma rather than
the trauma as a whole. As was the case with explicit memories, the older the
patient at the time of the trauma, the more coherent were the symptomatic
manifestations and the more readily could they be linked to the traumatic
experience.
Somatic memories. In four cases, somatic relivings were reported. The
somatic sensations were experienced rarely and inconsistently. Although they
were triggered in the context of emotional themes and/or environmental stimuli
linked associatively to the trauma, this was not predictably so.
The most dramatic case of a somatic memory was that of a patient
who during an analytic session reported a strange sensation of “fluid
leaking out of [her] eye.” This dramatic sensation in combination with
suggestive dream material prompted the analyst to ask if there had been
an early hospitalization. The patient had no awareness of a medical
problem in childhood but subsequently asked her mother, who con-
firmed that at eighteen months of age she had undergone surgery for a
periorbital and maxillary sinus abscess and that the hospital stay had
been a traumatic separation. In the course of her analysis, the “leaky eye”
sensation occurred only twice: on the eve of the first major separation in
the analysis and a second time during the termination phase. At numerous
other points in the analysis where separation issues arose, this symptom
did not appear.
956
The patient who had suffered a burst appendix at the age of two
experienced sensations of abdominal pain and bloating intermittently
during his analysis, seemingly triggered by feelings of anger or loss. His
medical crisis had occurred in the midst of a “terrible twos” battle with
his mother. A third patient, who had been exposed to repeated physical
and sexual abuse before the age of three and a half, described a physical
sensation in her breast and oppressive feelings of “being back in the
room” (where she was abused) on several occasions when her husband
attempted to suck on her nipple. In an analytic session she also experi-
enced a sensation in her throat as she described being forced to perform
oral sex. A fourth patient experienced waves of nausea as she described
a similar subjection to oral sex (although in her case such abuse persisted
beyond age four).
Intrusive memories and /or nightmares. Only one patient reported
flashbacks of the traumatic experience, and these were remembered from
childhood rather than experienced as an adult. This was the man who at age
three had found his mother dead after she had fatally shot herself in the
head. A year later he lost a tooth and had a fit of hysterical screaming when
he saw his bloody mouth in the mirror. His terror was so inconsolable that
he was taken to an emergency room for a sedative. As an adult he recalled
this incident without a recollection of a specific flashback, yet he “knew”
that the incident was connected to the trauma. This patient also described a
recurrent dream throughout childhood of being surrounded by stars that
came in and out of focus. The analyst was convinced that this dream
derived from the patient’s trauma, representing either the shattered remains
of his mother or a trauma-induced dissociative state with his vision going
in and out of focus. During his analysis, no flashback experiences or trau-
matic dreams were reported.
There were in our sample no reports of classic posttraumatic
dreams—dreams that replicate parts of the traumatic experience in close
to literal form. However, dreams suggestive of a link with early trauma
were reported in three cases. The patient whose appendix burst at age
two reported nightmares as an adult in which his stomach was bloated,
ants were eating his insides, or people were poking at his abdomen. The
patient who experienced periorbital surgery at eighteen months reported
vague dreams in which “white stuff ” and “long halls” appeared, as well as
a dream in which she was standing in a tub with water being poured over
her. These dreams were suggestive of a hospital setting and provided the
background context that prompted the analyst, when some months later
957
the patient reported the uncanny sensation of fluids leaking from her
eye, to ask about the possibility of an early hospitalization. In the third
case, based on a series of dreams of a symbolic nature, an early sexual
molestation was reconstructed and then remembered, with the uncertain-
ties that such “recovered memory” reconstructions can entail.
Posttraumatic fears and other affective memories. Seven patients in
our sample described fears and avoidance of trauma-related situations per-
sisting into adulthood. Among the eleven patients who experienced medi-
cal traumas in our sample, only four retained a fear of doctors. One woman
feared medical appointments throughout her adult life and also feared fall-
ing asleep at night, which she connected to a memory of terror on the
operating table that she would not wake up. Despite the obvious continuity,
we were hesitant to attribute persisting fears of doctors solely to these early
medical experiences, since each of these patients had had subsequent sur-
geries and/or significant interactions with doctors that affected them.
Persisting posttraumatic fear was seen in the woman who was two
years old when she witnessed the death of her sibling by fire. As an adult
she was hypervigilant, a person who kept herself safe through constant
anticipation of danger situations. She routinely checked for the location
of the exits whenever she was inside a vehicle or building. She had an
aversion to matches or any form of fire, to the point that she refused to
have a working fireplace in her home. The patient who experienced a
burst appendix at the age of two had been physically restrained in the
emergency room after an intense and prolonged struggle. He experienced
this as a frightening and violent assault, as confirmed by his mother. As
an adult he could not tolerate being physically held down in any form,
including being on the bottom during sexual intercourse.
One woman had a panic attack in a restaurant with green walls, which
occurred during a period in her analysis where she appeared to be associat-
ing affectively to her infantile trauma. She had spent the first six weeks of
her life in a hospital isolation room enduring painful medical treatments.
The analyst interpreted, based on his knowledge that many hospital rooms
were green during the era when this patient was an infant, that the panic
attack was an affective memory of overwhelming anxiety in the hospital.
To us this is an example of a “soft” link between an early trauma and an
adult symptom, since the symptom was both isolated and nonspecific, and
admitted of other explanations. Yet patient and analyst were convinced that
the interpretation, in the context of other work, was helpful in reducing the
fear of hospitals and doctors that had plagued her since infancy.
958
Behavioral memory / reenactment. In sixteen cases, there were enact-

ments within or outside the analysis that we felt could arguably be tied to
a patient’s early trauma. Depending on the specificity and scope of the links
to the trauma, we categorized these as full-fledged, partial, or generalized
enactment patterns. The differences we saw in these categories can best be
illustrated with case examples.
Two cases manifested what we categorized as possible full-fledged
enactments. One was the case of the woman whose mother abruptly left
her with a relative at the age of two. As an adult, she adopted a six-year-
old girl whom she carried around in her arms. Over time she and her
daughter had increasingly painful aggressive struggles, with the patient
alternating between feeling that her child was bad and that she was a bad
mother. After several years she chose to return the child to foster care,
after which the patient was hospitalized for depression. This experience
felt traumatic to her and was consciously and unconsciously linked in her
mind with memories of her own mother.
A second patient had been removed from her home at the age of one
year by social services. A neighbor had repeatedly found her crying in her
crib with no one at home, the mother having gone out with friends to do
drugs. In adulthood, when the patient was married with young children,
she began acting out a pattern of leaving at night to go to bars, where she
paired indiscriminately with men. She told her analyst that her longing
was not for sex but to kiss and be kissed by them. The analyst interpreted
this as an affective and body memory of her infantile hunger to be picked
up and nuzzled by whomever came through the door, combined with an
acting out of the mother’s abandonment behavior.
In both of these cases, the behaviors and reported affects appeared to us
to be sufficiently recognizable as repetitions of the major elements of the
original trauma as to be arguably categorized as full-fledged enactments. At
the same time, we felt that attributing these reenactment behaviors solely to
the patients’ early traumas was potentially problematic, in that both patients
experienced subsequent rejections and/or emotional neglect that powerfully
reinforced the original trauma-based affective constellation.
Five cases demonstrated what we call partial reenactment: behav-
ioral replays representing isolated aspects of the traumatic experience.
Of these, three were cases of sexual abuse, where sexual acting out
during adolescence or adulthood was common. Complicating the infer-
ence that the earliest sexual traumas were determinative was the fact
that in two of these cases the patient experienced abuse that persisted
959
beyond age four. However, supporting the powerful role of early experi-
ence was the fact that in the one case where there was incontrovertible
evidence that such experiences stopped before the age of three and a
half, sexual promiscuity and other forms of acting out were marked
during adolescence and young adulthood. Partial reenactments were
observed in this patient when as a young adult she established an ongo-
ing sexual relationship with an older woman. In this relationship she
allowed herself to be stimulated in ways that appeared to reenact
aspects of her past sexual abuse, but in a pleasurable context and with-
out the feelings of helplessness and fear associated with her original
experiences with men. Such stimulation of the patient had multiple
functions in that it was associated at times with fantasies of being a
baby and being held and touched in a caring way by a maternal figure.
For all of the sexually abused patients, their sexual acting out seemed
to reflect a generalized heightening of sexual drives and sexualized
modes of relating, rather than repetitive sexual behaviors that could be
specifically tied to the childhood experience.
A notable example of complex partial enactments was a woman who
was sexually molested for several years starting at age three by an older
cousin who had been taken in by her family. In adulthood, various aspects
of her traumatic experience were acted out separately with different
objects in her life. She played out the boundary violations with her hus-
band. She felt stunned and enraged when her husband would enter the
bathroom unbidden, and felt helpless to prevent it, just as she had with
her cousin. She also felt helpless to say no to certain sexual acts with him.
Meanwhile, in a another series of enactments, she seduced men who she
felt cared for her tenderly and then dropped them after several meetings.
This sequence replayed a different aspect of her experience with her
cousin, in that she initially felt loved as a result of her cousin’s attentions,
only to feel dropped later on when she realized he was using her. In dropping
her lovers, she was aware of seeking revenge on her cousin. With her
analyst, she played out another aspect of the trauma by alternately with-
holding and abruptly disclosing secrets about her sexual life (including
the history with her cousin), fearing that the analyst would reject her for
her misbehavior the way her mother had done.
We labeled a third category of enactments “possible generalized enact-
ments.” Nine patients were seen to fit this category, in which general behav-
ioral patterns as opposed to specific behaviors could be h ypothetically
960
linked to a patient’s trauma. An example of behavior in this category is the

man who at four witnessed his brother fall to his death from a Ferris wheel.
After that incident an inquest was held. Although the patient had “no feel-
ings” about these events and only a few fragmented memories of them, he
grew up to choose family law and child advocacy as a career. A patient who
experienced a life-threatening reaction to a bee sting at age two became a
doctor. The patient who experienced the early periorbital surgery and trau-
matic separation from her mother chose work at a preschool. In each of
these cases, as well as the six others, many factors in addition to the trauma
could be cited to explain the patient’s behavioral choices.
Transferences. When transferences that appeared to be connected to a
trauma did occur, they were generally partial, compartmentalized, and rela-
tively transient, rather than reflecting a full transference reliving. In many
cases the analyst was not the primary transference object. Rather, trauma-
derived affects were triggered most powerfully by outside figures such as
children, a spouse, or the original object, with the analyst being seen in a
defined and limited role. One woman as a very young child had been terror-
ized by a brother while her father, whom she idealized, was busy at work.
With her analyst she experienced feelings she had toward her idealized
father-protector; with her son she felt the rage and helplessness at the hands
of a brother out to hurt her; and with her husband she experienced the hurt
associated with the father’s absence. The patient who was molested by her
cousin starting at age three and who had demonstrated split and partial reen-
actments of the trauma as an adult also presented a split transference picture.
As noted, different aspects of the relationship with the cousin were trans-
ferred onto separate objects in her adult life. The transference toward the
analyst centered on only one element of her trauma, the lack of intervention
by her neglectful mother.
When the analyst was a transference object, he or she often repre-
sented not the central player or “perpetrator” of the trauma, but a figure
on the sidelines. From this vantage point, the transference perception of
the analyst was often of a person who would turn away from the patient’s
suffering because emotionally burdened by it. In a number of the medical
trauma cases, the analyst was cast not as a potential inflictor of harm but
rather in the role of the parent who witnessed the treatment and failed to
protect the child. In cases where the trauma was at the hands of an abusive
family member, the transference to the analyst was often not as the per-
petrator but as a family member who failed to prevent the abuse. The
transference interpretations in such cases centered on patients’ feelings of
961
abandonment and betrayal by the “nonperpetrator” parent. For example,

the patient whose mother committed suicide in his presence did not
manifest a mother transference toward the analyst, but did feel convinced
that the analyst, like the family who had “buried” the trauma along with
the body, could not tolerate hearing his emotions.
We believe that the patients who transferred feelings toward a parent
on the “sidelines” were essentially transferring a separation trauma.
Consistent with this conceptualization, it was our impression that the
most frequently transferred feelings within the group were those related
to issues of abandonment and loss of trust. Such feelings appeared to
resonate with the feelings of “betrayal” and “aloneness” that traumatized
young children universally experience, feelings stemming from the real-
ization that their parents have been unwilling or unable to protect them.
Tellingly, it was in cases where the main trauma was an actual separation
or abandonment that we most frequently heard about a transference to the
analyst as a central player in the trauma. In these cases a significant focus
of the work was on various permutations of the patient’s feelings of aban-
donment by the analyst, often associated with intense rage. For example,
one man had been sent away from home at sixteen months of age while
his mother underwent medical treatment. He had intense angry feelings
toward the analyst, expressing the urge to kill her and accusing her of
making him physically sick. At the same time, he deeply feared that the
analyst would be hurt or lost if he became attached to her. Another patient
with an early loss experienced almost uncontrollable rage during his
analyst’s absences and was so preoccupied with the personal comings
and goings of the analyst that it verged on stalking.
In over one-third of the cases, the most prominent transference
attitudes involved keeping the analyst within a “reality-based” role as
empathic and helpful and/or viewing the analyst as an idealized figure
posing no danger of retraumatization. In several cases the analyst
served primarily as a developmental object who provided the empathy
and understanding that had not been available in the patient’s early
childhood. Viewing the analyst as a consistently supportive presence
outside the traumatic situation (i.e., someone who was not going to be
hurt, lash out, or abandon them) not only did not preclude these patients
from exploring their difficult childhood experiences, but often seemed
helpful in facilitating the expression of affectively difficult material.
Obviously, such transferences served defensive purposes as well. In
some cases a defense transference was implacable to the point that it
962
appeared to prevent any reworking of the traumatic affect. An example is

a man who, having lost his father at age two, grew up relating to the
world through a character style that was calm and detached. As a child he
chose friends who were also missing a father so that he could avoid
awareness of his own lack. In treatment he perceived the analyst not as a
father figure he feared to lose, but as a distant and unshakable authority.
He and the analyst agreed that his stance was geared to preclude his re-
experiencing the conditions of the trauma. In this case and twelve others,
an analysis appeared to have taken place without the patient experiencing
any identifiable trauma-associated affects in the consulting room.
Global Carryover Effects
In contrast to the relative infrequency of specific posttraumatic

symptoms, a global carryover in some form was reported by almost all
the analysts we interviewed. Many pointed to affect states, defensive pat-
terns, self/object representations, or alterations in the developmental tra-
jectory that seemed to them derivative of the trauma. We were mindful,
however, that in moving from specific symptoms to general categories of
personality functioning, multiple forms of influence can come into play,
particularly since human emotions have qualitative continuity over the
life span and can be elicited by a wide variety of stimuli (Emde 1980).
Traumatic affective states as global carryovers. By far the most com-
mon form of carryover, described by fourteen of our analysts, was the
persistence of raw and overwhelming traumatic emotional states. Examples
would be bottomless feelings of loss and “terrible loneliness” in patients
who had experienced parental separation, or recurrent feelings of panic,
inner chaos, and rage in patients who had been physically traumatized. The
affects generated by the trauma were seen to have an organizing effect on the
patient’s psyche, shaping psychological themes, pathological beliefs, and
modes of self-regulation that persisted into adulthood. In cases of separation
trauma, it was common to hear of lifelong expectations of abandonment,
accompanied by struggles with rage and difficulties with self-definition,
creating intense internal conflict and deeply troubled personal relationships.
The patient whose mother committed suicide at age three had the conviction
that he was cursed: “If I get close to someone, they die.” In several cases of
medical trauma, the patient had persisting views of the world as a dangerous
place, associated with ongoing feelings of helplessness, vulnerability, and
fears of physical harm. For a few, a sense of victimhood had been generalized
into a part of their core identity.
963
Defensive/adaptive style as a possible global carryover. While there

was no question in our minds that the patients’ traumas would have mobi-
lized strong defensive mechanisms, the retrospective nature of our data and
the fact that defensive operations are by their nature relatively inconspicu-
ous made it difficult to clearly delineate defensive carryover from the early
trauma. While this meant that the role of the patients’ early traumas in shap-
ing defenses observed in adulthood was likely underappreciated both by us
and by our analysts, we felt that any generalization we made would be
highly speculative and not do justice to the multiplicity of variables and
complex interactions that likely influenced the patients’ coping mecha-
nisms over the course of their development. That said, at least a few
patients developed a reliance on extreme defenses that appeared to have
come about as a result of their trauma. At least three patients handled
affects with a marked dampening of emotional expression, yet could at
times be vulnerable to affective flooding. The very detached woman who
had lost her sibling at age two was unaware of emotions about this early
trauma. However, one day by happenstance she was exposed to a reminder
of her sibling in a way that was mundane but completely unanticipated. She
was suddenly caught in a wave of overwhelming anxiety, feeling as if she
had been “punched in the stomach.” Another early separation victim had
organized her relationships, including her relationship with the analyst, so
that she would always be the “leaver” rather than the “leavee.” Some
patients were described as using dissociation combined with splitting. In
one case extreme dissociation in the form of dissociative identity disorder
was triggered by a trauma in adulthood that appeared to release repressed
affects deriving from multiple traumas in the patient’s childhood.
Patterns of object relating as a global carryover. As noted in the
section on transference, a trauma is almost universally experienced by
a young child as a betrayal of the parent’s protective role. The reestab-
lishment of trust and the overall quality of the caretaking environment
in the aftermath of a trauma are crucial factors in a child’s long-term
outcome (Scheeringa and Zeanah 2001). In an ideal situation, parents will
recognize that the trauma has left an emotional template in the child’s
mind that subsequent events may trigger and will be able to respond with
empathic attunement and understanding to a child’s trauma-related dis-
tress. Such attuned responsiveness will help restore trust, facilitate affect
regulation, and promote psychological integration of the traumatic events,
likely ameliorating the long-term consequences. Less ideally, it is extremely
common for well-meaning parents to fail to recognize the persisting nature
964
of this template for the child because they believe the child is too young to
remember the trauma, and/or because they want to leave the trauma behind.
Even so, the empathic responding and developmental guidance of nurtur-
ing parents will likely have reassuring effects on the child’s emotions, even
in the absence of trauma-specific attunement and intervention.
Unfortunately, for all but two of the cases in our sample, parents’ dif-
ficulties in addressing their child’s traumatic symptoms extended beyond
simple lack of recognition. Even when parents were able to provide “good
enough” parenting under ordinary circumstances, they seemed unable to
provide adequate containment or soothing under the strain of heightened
regressive anxieties and rage in themselves or their child. As a result, ten
patients consciously traced their lifelong emotional withdrawal from par-
ents to their early trauma. In twenty-two of our thirty cases, parents’ denial
and avoidance led them to attempt to eradicate the trauma experience from
family memory, resulting in damaging relationship patterns. In four
extreme cases, a gruesome death could not be talked about.
An example of parental denial is the case of the patient who began
analysis with no conscious memory of her periorbital surgery at eighteen
months. When she asked her mother whether she had ever been in the hos-
pital, the mother confessed that she had intentionally never mentioned the
surgery to her, hoping that the painful ordeal would be erased from mem-
ory. At the time, extremely upset to hear her daughter screaming, she had
fled the hospital and did not return during the entire twelve days of her
daughter’s stay. The combined effect of the medical trauma and the moth-
er’s withdrawal appeared to have been pivotal: as an adult the patient was
single, affectively constricted, and disconnected from her family, personal-
ity characteristics dramatically different from those of her siblings.
In some cases, the parents went beyond denial to engage in destruc-
tive narcissistic or dissociative reactions. Other parents appeared to have
reacted to their child’s fear and anger with punitive or disapproving
responses, to the point where the child carried the label of “crybaby” or
“difficult child.” In other cases, patients described narcissistic parents
whose responses to the child appeared more oriented to the effect of the
trauma on themselves. In the case of the eighteen-month-old girl who
spilled hot melted wax on her leg, the parents had incorporated the incident
into family lore as a way of lamenting what a nuisance their daughter
was to raise. It was only in treatment that the patient was able to recognize
that the traumatic episode reflected a pattern of parental neglect and
externalization of responsibility that had pervaded her childhood.
965
In four cases, the parents seemed to have responded to their child’s

early difficulties with anxious overprotection. In one case, a general pat-
tern of parental overprotection appeared to have magnified a relatively
manageable surgical procedure into a terrifying experience. The patient
retained frightening images that carried over to adulthood and contrib-
uted to a sense of victimhood, disability, and sexual vulnerability.
Developmental alterations. Confidence in the inference that a trau-
matic symptom or emotional state has persisted into adulthood would be
enhanced to the degree that one could follow the “red thread” of that state
or symptom over the course of development. Unfortunately, in our inter-
views developmental data were almost uniformly scant. We asked our
interviewees such questions as, How long did PTSD symptoms endure?
Were there heightened fears about bodily integrity and castration anxiety
during the patient’s oedipal phase and beyond? Were there difficulties
with aggression or sexual acting out during latency, or persisting trau-
matic states that interfered with learning or socialization? Were separa-
tion issues ongoing? Unfortunately, in almost all the cases this kind of
information was either not remembered by the patient, was not discussed
in the patient’s family, and/or was not gathered systematically by the
analyst. In the absence of this kind of detailed developmental data, links
between the early traumatic experience and patients’ symptoms and
transference feelings tended to be based on contextual and affective cor-
respondence, with significant gaps in the developmental picture leaving
open the possibility of alternative explanations.
In the few cases where specific information was available, it generally
consisted of vignettes capturing an isolated moment in time, as opposed
to a linear developmental progression. At the same time, the vignettes that
were reported tended to support the assumption of an ongoing disrup-
tive influence of the traumatic experience on development, at least in the
months and years immediately following the trauma. These disruptive
effects were generally nonspecific in nature. In one case of the early loss
of a father, a number of vignettes during latency and adolescence were
identified that helped the patient recognize how much she had searched
for father figures throughout her life. At least five patients (two who
experienced medical traumas and three who experienced separations)
reported persisting anger and defiance toward their parents dating from
their traumas. The patient who lost her sibling at age two was later known
as an “incorrigible terror” in nursery school, though as an adult she
showed few problems with aggression. Several medical trauma patients
966
described themselves as shy and fearful from elementary school on. One
patient who experienced a parental death before his first birthday recalled
suicidal thoughts around age five, while another patient with an early loss
remembered a plan to run away from home around the same age.
M U LT I P L E PAT H O G E N I C I N F L U E N C E S
Despite the compelling nature of many of the carryover effects reported

by our analysts, we were equally struck by the fact that the histories of
the patients in our sample were characterized by multiple pathogenic
influences, influences that not only complicated the child’s processing
of the early trauma but, more important, appeared to have powerful
effects separate from the trauma. These influences included lack of emo-
tional support (around the trauma and in general), problematic parent-
child interactions, the occurrence of subsequent traumas, the presence of
emotional disturbances in the family, and the patients’ own biological
predisposition to emotional illness.
Maladaptive caregiver-child interactions were the rule rather than the
exception in our sample, often appearing to be a prominent contributor to
persistent symptoms and affective dysregulation in the child. These either
grew out of the trauma or, in many cases, existed independently of the
trauma. Although data on the patients’ experiences before the trauma were
almost universally absent, almost every one of the patients in the sample
reported significant parental and family problems, including parental
mental illness and/or substance abuse, emotional neglect, and significant
family discord that included parental divorce and problematic sibling
relationships. For example, at least fifteen of the patients reported a pat-
tern of interaction with their parents that we would categorize as neglect-
ful and/or emotionally absent, with an additional seven patients reporting
various degrees of emotional abuse. The dynamics that surrounded the
patients’ traumas often appeared to reflect a larger set of family themes,
complementary to the traumatic experience, that set the stage for emo-
tional vulnerability and/or reinforced the traumatic effects.
An additional complicating factor in our patients’ histories was the
fact that more than one traumatic event was the rule in our sample. As
noted earlier, five patients experienced a compound trauma, and six addi-
tional patients experienced at least two separate traumas during the first
four years of life. Even more striking, between the ages of four and nine-
teen, seventeen of the thirty patients reported experiencing at least one
967
additional trauma, with five reporting more than one. In sum, twenty of
the thirty patients in the sample had had more than one traumatic experi-
ence before the age of nineteen. The effect of repeated trauma was par-
ticularly evident in cases of early physical and sexual abuse in which a
discrete and identifiable incident of abuse occurred before the age of four,
but was followed by subsequent experiences of abuse. The patients’ early
traumas no doubt made them susceptible to greater distress and disorga-
nization in the face of a subsequent trauma, but exposure to multiple
traumas makes it difficult to tease out the specific effects of each.
Another major influence in a number of cases was a biological pro-
pensity toward pathogenic emotions. In eighteen cases a family history
of a diagnosable psychiatric disorder was either documented or could be
confidently inferred based on the patient’s description of family mem-
bers. Eleven patients reported substance abuse patterns in a family mem-
ber, and nine had themselves had substance abuse problems. Interpreting
whether intense emotional states (and/or maladaptive attempts to regu-
late such states, as through substance abuse) were the product of early
traumatic experiences that were being relived or were the result of other
causes, including strong genetic predispositions, was often extremely
difficult. For example, several patients who had experienced early paren-
tal separations also had strong family histories for depression. Persisting
feelings of “inner loss and inaccessible hunger” could be attributed not
only to an early childhood loss but also to depressive mood states to
which they were biologically vulnerable.
An oversimplified but prototypical example of how these various
factors might come together to produce enduring affective symptoms is
a patient who underwent several frightening corrective surgeries that
were only partially successful, the first one before the age of four. She
experienced significant difficulties with trust and self-assertion, as well
as persisting anxiety symptoms specific to doctors and her medical con-
dition, but experienced in a variety of other situations as well. There was
a strong family history for anxiety that included both parents. Beyond
this biological predisposition, the parents’ anxiety strongly influenced
their responses to the patient’s surgeries and more generally, resulting in
overprotection, an inability to address important issues with the patient,
and intolerance of the patient’s negative affects. The fact that the patient
was intimidated throughout childhood by a physically bullying older
sibling played an important role in her anxiety condition as well. She also
experienced a frightening attempted sexual assault in adolescence.
968
In summary, the emotional disturbances that the patients showed

appeared to resonate closely with the emotional functioning of their par-
ents and the family atmosphere in which they grew up, implicating both
biological and social-emotional factors in addition to traumatic ones. It
was our impression that rather than being the primary cause of the adult
patient’s symptoms, even when the trauma may have initiated or exacer-
bated a particular set of emotional and behavioral patterns, the persis-
tence of these patterns depended to a great extent on the existence of both
biological and environmental factors that reinforced and/or indepen-
dently promoted a similar set of affective structures.
DISCUSSION
At the outset of this paper, we pointed to the widely held conception

that trauma both interrupts development and creates an enduring stamp.
Our data suggest that this may be true, but that traumatic aftereffects
are far from predictable and far more subtle than traditional views of
traumatic carryover would suggest. Historically, expectations about the
effects of trauma have had strong linear elements. Freud’s regression/
fixation model, Anna Freud’s concept of developmental lines, and the
more clinically near concept of “following the red thread” all have strong
linear elements. They rest on the assumption that development follows
from a template set down by early history, with emotional expectations
from childhood carrying over into later experience and providing the
structures that mold adult character. Repetition compulsion has been a
cornerstone concept for understanding the impact of early trauma in the
regression/fixation model. The child’s development is thought to be
shaped by a trauma because it is imprinted on the child’s psyche and is
reenacted compulsively. Fixation on the overwhelming experience and
repetition of its literal details are thought to be a central mode of defense
and ultimately of mastery. Recurring conscious or unconscious memories
and holistic enactment of the trauma scenario are an expectable outcome
in this model. The model generates the expectation that an analyst should
be able to trace the red thread of posttraumatic repetition over the course
of development (Terr 1981).
Consistent with contemporary psychoanalytic theorists who have writ-
ten about nonlinear processes as they relate to the lack of predictability
in the carryover of childhood experiences into adult analyses (Stolorow
1997; Palumbo 1999; Coburn 2000), our data do not provide much support
969
for linear models as applied to early childhood trauma. The lack of valida-
tion of the regression/fixation model was particularly striking. In our
sample, aftereffects of an early childhood trauma were not absent, but dif-
fered in form and content from what might be expected if a PTSD picture
had been carried forward through development. Symptoms that many
authors have considered hallmark aftereffects of trauma—relivings in
flashbacks, nightmares, and behavioral repetition—were practically non-
existent (van der Kolk, McFarlane, and Weisaeth 1996; Terr 1991; Herman
1992). Although explicit memories of the early trauma were often present,
particularly from age three and up, they were generally not accompanied
by intense affect. Implicit forms of carryover, which were by far the most
frequently reported, carried with them all the ambiguities associated with
interpreting such phenomena and their origin in the clinical situation.
Correspondences between childhood and adult symptomatic structures
were often more suggestive than clear-cut. Symptoms or emotional cur-
rents having potential specific links to a trauma were likely to surface
fleetingly and then be dispersed or submerged in follow-up material in
ways that made conclusions about a definitive link difficult to verify.
Although some form of direct linkage between an adult symptom and
the early trauma could in many cases be reasonably posited, the clinical
phenomena supporting such linkages tended to be isolated, relatively rare,
fragmented, and inconsistent. It was as though varying aspects of the
patient’s traumas had been parceled out and dispersed randomly along
different avenues of expression. To the extent that the traumas were factors
in the etiology of the adult trouble, they seemed to be registered via allu-
sive ripple effects, “baked in the cake” as the adult personality was
formed. One would have a perceptible sense of the trauma contributing its
unique flavor, yet it would be difficult to specify exactly where that flavor
was coming from or what it had gotten mixed with.
An important qualifier of these conclusions is the fact that our data
are limited to traumas occurring in early childhood. The closer our
patients were to age four when their traumas occurred, the more detailed
and sequentially coherent were their memories and the more readily
interpretable were their implicit behaviors. Projecting those capacities
forward, it is reasonable to assume that the long-term impact of a trauma
might have a very different quality in older children and adolescents and
that their symptom picture might more closely approximate traditional
conceptions of traumatic carryover, including more direct forms of
continuity into adulthood. Keeping this caveat in mind, we believe that
970
the following factors can help explain why in our sample traumatic after-
effects were so heterogeneous and so difficult to track over the long term.
The Nature of the Traumatic Experience
PTSD diagnostic thinking is consistent with a linear model and pre-

dicts literal carryover of the trauma representation, yet inherent in the
definition of trauma is a contradiction of this model. Trauma is by defi-
nition an ego overwhelmed—that is, the ego’s representational capaci-
ties have failed to contain it, and the external auxiliary ego provided by
the parent has likewise failed. Thus it follows that the fallout from this
should be a fragmented picture, not an experience represented as a
coherent transference construct or internal schema. Saporta (2003) has
described how trauma may be registered in the form of perceptual and
somatic fragments that can remain unintegrated for years because pro-
cessing at the neuronal level has been disrupted. Fragmented represen-
tation is particularly likely with young children, whose capacities to
construct a coherent narrative about any experience, to say nothing of a
traumatic one, are very limited.
The Complexity of the Developmental Process
Even if seen for significant periods of time immediately following a

trauma, over the long term posttraumatic symptoms and behavioral re-
enactments will likely be superseded by other processes and submerged
into more general patterns of functioning. This is particularly true since
developmental processes themselves are not always linear or continuous,
but rather are characterized by periods of rapid change and reorganization
(Spitz 1959; Emde, Gaensbauer, and Harmon 1976; Shapiro 1976) at
both the neurological and psychological levels. At each major develop-
mental stage between early childhood and adulthood, traumatic memo-
ries and feelings will be seen from a new perspective, will take on new
meanings, and will be reintegrated within a whole new set of psychic
structures. Conceptions about the nonlinear nature of the developmental
process, strongly influenced by dynamic systems theory, have been
incorporated into contemporary psychoanalytic developmental thinking
by a number of analysts interested in early development (Beebe and
Lachmann 1994; Sander 2002; Tyson 2002).
Even in the short term, the degree of trauma-induced deflection
in a young child’s development can show great variation. Emotional
aftereffects may be limited to situations with very close stimulus links
971
to the trauma, or they may extend to influence a broad range of experi-

ences and situations. They can also exacerbate preexisting problems
and generate maladaptive patterns that take on a life of their own.
Alternatively, the reactivation of trauma representations can over time
lead to the detoxification of traumatic effects through desensitization,
cognitive reprocessing, new developmental perspectives, the blending
of traumatic memories with other memories, and caregiver responses.
To use Anna Freud’s concept, one can think of a trauma as introducing
a new developmental line, one with the potential for interacting with
other lines and for creating the kind of “developmental disharmonies”
that she thought underlie childhood psychopathology (Miller 1996).
Over time the various lines will become intertwined and synthetically
integrated, creating a process that is no longer linear. In Anna Freud’s
words, “It is the hallmark of the synthetic function that, while doing its
work, it does not distinguish between what is suitable and unsuitable,
helpful or harmful for the resulting picture. Thus every step on the
developmental line, besides being a compromise between conflicting
forces, also represents an amalgamate of beneficial with malignant
ingredients” (1979, p. 129).
This amalgamation into more general developmental processes can
happen even over a relatively short period, as demonstrated in a recent
follow-up study of traumatized children by Scheeringa et al. (2005).
They found that a year after the trauma more general disturbances in
affective regulation (e.g., increased distress on the one hand and
emotional numbing and avoidance on the other) tended to increase over
time, whereas trauma-specific reexperiencing symptoms significantly
decreased over the same period.
The Presence of Multiple Pathogenic Factors
As discussed earlier, multiple pathogenic influences were the rule in

our sample. There was not a single patient for whom the early trauma was
the sole disruptive influence in development. The persistence of patterns
seemingly initiated by the trauma appeared to depend on the existence of
both biological and environmental factors that reinforced and/or indepen-
dently promoted a similar set of affective and behavioral structures.
Cross-Modal Processing and “Supramodal” Representation of Experienced Events
Perhaps the least appreciated reason for the lack of linear effects is that
young children encode and process not only trauma but all experiences
972
through a variety of modalities, the different elements of which are

distributed to different parts of the brain (Stern 1985; Sander 2002). As a
result of neurologically mediated capacities for cross-modal processing,
young children are able to integrate the different elements of an experi-
enced event into a common, or “supramodal,” representation incorpo-
rating multiple modalities: cognitive, perceptual, sensory, motoric, and
affective (Meltzoff 1990, 2002). They use this supramodal schema as a
basis for expressing their understanding of their experiences through a
variety of channels: physiological, affective, multisensorial, behavioral,
verbal, and symbolic. Observations of trauma-driven play in children
suggest that even when a theme is recurrent, the play itself will not be
static or unchanging, nor will it necessarily be a veridical replication of
what the child experienced (Gaensbauer 1995). Behavioral reenactments
of a trauma in early childhood are characterized by the “creative” use of
cross-modal expressive pathways that capture central elements of the
experience, often from a variety of perspectives (first- vs. third-person,
victim vs. aggressor, etc.), while at the same time incorporating elements
derived from other experiences (Gaensbauer 2002, 2004). It is as if once
this overarching representation or schema has been established, the child
can “take it apart” and metabolize it in pieces. Because cross-modal pro-
cessing disperses the original trauma experience as well as reconfigures
it, it works against the holistic preservation of the original template.
CONCLUSION
We began with McLaughlin’s paradigmatic dichotomy (1982) between

analysts who hold that early experiences can be directly accessed in the
course of an analysis and those who believe that, while contributing
importantly to adult structure, they are not directly accessible in the treat-
ment setting. Our data support the position that for the most part early
experiences are not directly accessible.
Although there were cases in which a specific symptom seemed clearly
to have been derived from the early trauma, such symptoms were highly
delimited. In the vast majority of cases symptoms or affective states appear-
ing to have links to an early trauma were manifested implicitly, were quite
general in nature, and/or were susceptible to multiple influences. Although
there was no question that the patients’ traumas, especially the severe ones,
had had profound effects on their developmental trajectory, the inference
that a specific conflict in adulthood can be traced back to a specific
973
traumatic experience in early childhood was not supported by our data.

Rather, our findings suggest that in adulthood direct links to an early trauma
can be present, but they are likely to be rare, fragmented, and unpredictable.
Such links can be quite useful in creating a therapeutically valuable, though
not necessarily veridical, reconstruction of an early trauma and its likely
carryover effects, in the service of helping patients validate their emotional
experiences and develop a meaningful life narrative. The early trauma itself,
however, is not likely to lend itself to holistic, regressive reworking in treat-
ment, either in the transference or in the form of a full reliving.
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Theodore J. Gaensbauer
3400 East Bayaud Avenue, Suite 460
Denver, CO 80209
E-mail: [email protected]
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Theodore J. Gaensbauer / Leslie Jordan 57/4

Information on the long-term effects of early trauma and how such

A s an outgrowth of our shared interest in early trauma, some years

Theodore J. Gaensbauer, Clinical Professor, University of Colorado Health

DOI: 10.1177/0003065109342589 947

emotionally powerful early experiences might manifest themselves,

Clinical Professor, University of Colorado Health Sciences Center; faculty, Denver

traumatic moment becomes encoded . . . and breaks spontaneously into

We sent a brief questionnaire to a large group of analysts accredited by the

Description of the Sample

Two-thirds of the patients on whom data were reported were women;

Explicit memories were narrowly defined as conscious memories

Implicit memories were broadly defined to include a range of clinical

Behavioral memory / reenactment. In sixteen cases, there were enact-

linked to a patient’s trauma. An example of behavior in this category is the

abandonment and betrayal by the “nonperpetrator” parent. For example,

appeared to prevent any reworking of the traumatic affect. An example is

Global Carryover Effects

In contrast to the relative infrequency of specific posttraumatic

Defensive/adaptive style as a possible global carryover. While there

In four cases, the parents seemed to have responded to their child’s

Despite the compelling nature of many of the carryover effects reported

In summary, the emotional disturbances that the patients showed

At the outset of this paper, we pointed to the widely held conception

The Nature of the Traumatic Experience

PTSD diagnostic thinking is consistent with a linear model and pre-

The Complexity of the Developmental Process

Even if seen for significant periods of time immediately following a

to the trauma, or they may extend to influence a broad range of experi-

The Presence of Multiple Pathogenic Factors

As discussed earlier, multiple pathogenic influences were the rule in

Cross-Modal Processing and “Supramodal” Representation of Experienced Events

through a variety of modalities, the different elements of which are

We began with McLaughlin’s paradigmatic dichotomy (1982) between

traumatic experience in early childhood was not supported by our data.

Engel, G.L., Reichsman, F.K., & Viederman, M. (1979). Monica: A 25-year

Shapiro, T. (1976). Latency revisited: The age 7 plus or minus 1. Psycho-

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