Trauma Education Essentials
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Book reviews written by Dana Ross, MD, MSc, FRCPC. 

'Affect Regulation Theory: A Clinical Model' by Daniel Hill, PhD

“Affect is the conscious or nonconscious registration of the ebbs and flows of energy infusing the organism – an expression of the body read by the mind.” – Daniel Hill, 2015

In this book, Daniel Hill, Ph.D., a psychoanalyst, and educator, explains how we regulate our affect and why this is important clinically. He summarizes and then further develops Allen Schore’s work on Regulation Theory in which there are 2 types of affect, primary and secondary. Primary affect is “the nonverbal representation of the state of the body” while secondary affect is more of a cognitive-verbal experience and refers to the names that we give to emotions such as joy, anger, and shame. The focus in this book is on primary (body-based) affect.
When our primary affect, hereafter referred to as 'affect,' is regulated, we feel present, able to adapt to changing situations, and we experience a homeostatic internal state. When our affect is not regulated, we feel unsafe, less able to feel connected to others, our sense of agency is compromised, and we are dysregulated internally.
A few key points that can be found in Regulation Theory (Schore, 1994, 2003, 2012) and serve as a base for Hill's contributions in this book are as follows:

  1. Optimal functioning is grounded in our ability to regulate affect.

  2. Affect mediates our mental states.

  3. Deficits in our ability to regulate our affect state are related to developmental psychological disorders.

  4. Working to enhance one’s ability to tolerate and regulate affect is a primary therapeutic goal.

It’s important to understand the neurobiology behind Affect Regulation Theory. To do that, we need to know that the autonomic nervous system (ANS), composed of the sympathetic and parasympathetic systems, acts as the accelerator and brake for our vital organs, respectively. We need to know that there is also an associated neuroendocrine system, the hypothalamic-pituitary-adrenal (HPA) axis that also modulates the stress response via neurochemical reactions. And finally, that the limbic system, located centrally in the brain, integrates and assesses incoming information and in turn, regulates our arousal level via the ANS and HPA axis.
Hill also reminds us of the vertical organization of the brain. At the bottom are the subcortical structures that are the earliest to form in development, followed by the higher-up cortical structures. The limbic system, located in the middle of the brain, has both cortical (orbitofrontal cortex) and subcortical (amygdala, anterior cingulate, insula, hippocampus) structures. He also reminds us that the right brain is for automatic, unconscious processing of emotions (implicit processes, primary affect) and the left brain is for conscious processing of words (explicit processes, secondary affect).
I was unfamiliar with the role of the orbitofrontal cortex before reading this book, so I'll take a moment to explain its role in case you are also unfamiliar. The orbitofrontal cortex is located, not surprisingly, behind the eyes/orbital sockets, and is responsible for context-dependent integration of information. Information comes up from the body to the right subcortical limbic structures and is then sent to the right orbitofrontal cortex where the information is integrated with past experiences, current context about the environment, and information about other’s affective states. When things are working reasonably well, our orbitofrontal cortex is dominant and inhibits the amygdala and other subcortical limbic structures appropriately.
In case you were thinking that the left side of the brain is getting a bum deal here, let’s add it into the arousal pathway. Information coming up from the body goes to the right subcortical limbic system and then on to the right orbitofrontal cortex (all unconscious right-brain processes) and then, via the corpus callosum, to the left side of the brain for conscious processing, then apparently back over the right for the final processing. Got it? Up – right – right – left – right! Basically, our brain is working on processing information prior to us even becoming conscious of it.
Hill provides a helpful summary of the Strange Situation Procedure conducted by Mary Ainsworth in the 1960s. He connects the 4 different attachment patterns to varying states of affect arousal modulated via the pathways outlined above. Hill examines how secure attachment creates a flexible and resilient schema of self and others that allows for a wide range of affect tolerance. He then discusses how the 3 insecure attachment styles are associated with decreased affect tolerance.
There are 2 main avenues to regulate our affect, either through our relationships with others (dyadic regulation) or through ourselves (auto-regulation). An infant is initially dependent on caregivers for affect regulation so must rely on dyadic regulation for roughly the first year. It’s not until the infant starts to become mobile that it starts to develop the ability to self-regulate or 'auto-regulate.' When an infant is in a secure attachment relationship with their caregiver, it learns over time to engage in both relational-soothing and self-soothing.
During the first 10-18 months, the infant’s neural pathways that modulate hyperarousal are first formed, followed by the neural pathways that modulate hypoarousal. This is important to know because if all goes reasonably well in our attachment relationships, we then have a neurobiological system that can modulate itself appropriately. However, when things don’t go well, for example in insecurely attached infant-caretaker relationships, “infants experience chronic prolonged states of stress that generate neurotoxic conditions during the critical period in the development of their primary affect-regulating systems.” Depending on the type of insecure attachment that is present, an infant may be left with over- or underdeveloped hyper-or hypoarousal neural pathways.

Summary Chart of Affect Regulation and Attachment Styles.png

So why is this all important stuff to know when working with adult clients, including those who have experienced trauma? To answer this, Hill first flushes out his concept of an embodied mind or what he calls 'bodymind.' He writes that the ability to regulate one's affect is, "fundamental to the organization of bodymind and thus for adaptive functioning and subjective experience." Essentially, our ability to have a coherent, integrated sense of self, is dependent on our ability to regulate the state of our body.
Hill further explains that we tend to think of ourselves as a unitary self; however, we are actually composed of a variety of 'self-states.' He gives the example of how we can shift versions of ourselves in different contexts, in different relationships, and different states of affective arousal. Perhaps you are more confident and full of humour when you're with an old friend, and more passive and withdrawn in new social settings for example.
When our affect is regulated, we are operating from an integrated bodymind, and our self-states can shift fluidly and in a coherent fashion. On the flip side, when we are affectively dysregulated, we experience a disintegrated or dissociated bodymind with self-states that are partially or fully disconnected with each other, often involuntarily or automatically.
So, let’s really fire up our neural networks and try to tie this all together. Here’s what I gather and please email me with corrections if I’ve veered wildly off course. As infants, our affect regulating system develops sequentially over time and is thus vulnerable at various stages of development to the environment. The environment includes the attachment relationship between infants and their caretakers. The type of attachment formed, including secure, anxious, ambivalent, and disorganized attachment styles, has a profound impact on our developing primary affect-regulating systems. The result can be a balanced and flexible affect regulating system, or a dysregulated system, favouring either hypo- or hyperarousal, or a chaotic blend of both. In adulthood, chronically dysregulated affect, which we often see in our traumatized clients, can lead to a disintegrated or dissociated connection between self-states which contributes to an incoherent or unintegrated sense of self and others.
As therapists then, our task, according to Affect Regulation Theory, is to connect with our clients using right brain to right brain bottom-up approaches that focus on attunement to help to modulate the bodymind and increase our client's ability to tolerate and modulate affect. However, this is not to say we ignore the left brain, which can be engaged via top-down approaches through the use of verbal cognition, reflective processes such as observations, psychoeducation, and the mentalization of affect states. 
I am now going to end this summary as my left brain is fatigued and my bodymind is telling me (nonverbally of course) to rest. There is a lot that is covered in the book, for example around shame, and personality disorders, that I didn’t include here for the sake of brevity. Overall, I learned a great deal from this book that I think will deepen my clinical practice through increased awareness and appreciation of the importance of right-brain to right-brain, non-verbal attunement with my clients.

Thanks for reading!   - Dana

Dana RossComment