Inside Out: A Transactional Analysis
Model of Trauma
Jo Stuthridge
Abstract
This article presents a transactional analysis model of trauma located within a relational paradigm. It proposes that the Adult
ego state enables us to form a narrative self
or coherent sense of identity. Trauma interferes with this integrative capacity, creating
excluded ego states and a disorganized self.
The child's experience of abusive caregivers
is internalized in a series of toxic Parenti
Child ego states. This inner world shapes the
child's view ofthe world outside, leading to
patterns of transferential enactment that reinforce a traumatic script. Therapy is concerned with developing the Adult capacity to
create a coherent narrative that allows the
client to move from enacting to reflecting.
This article is based on years of clinical experience with adult survivors of childhood physical and sexual abuse. Its title was partly inspired by my sons' preference for wearing their
trousers "low-rider," revealing a gaudy slice of
satin boxer. It occurred to me that this fashion
for wearing underwear on the outside is very like
working with adult survivors of child abuse,
where intrapsychic "garments" are worn on the
outside in the guise oftransferential enactments.
I offer the following example as an illustration. Annie was sexually abused by her father
from the age of 5 until 15 years, when she ran
away from home. Later she married Bill and together they had four children. She never allowed Bill any physical contact with their children, describing a feeling of disgust when he
went near them. She did allow the children to
stay with her parents, and when her teenage
daughters disclosed that they had been sexually
abused by their grandfather, Annie reacted with
angry disbelief.
Annie was 49 when I met her; she brought
her baby granddaughter to sessions rather than
leave her with Bill. During therapy, Annie began to realize that despite all her efforts to
avoid the past (by using alcohol, silence, and
denial), she had been reenacting the story of
her own abuse over 30 years. She used the marriage to project an abusive Parent ego state and
failed to protect her children as her mother had
failed to protect her. The pain ofher own abuse
remained safely outside awareness in an excluded Child ego state.
Annie's tragic story illustrates an incoherent
self-narrative. This is evident in the telling of
her story and also in the way her life is lived.
This article argues that when trauma impairs
the Adult capacity to create narrative, the unintegrated experience is reenacted in the person's
present life.
Stories like Annie's have been explained in
very different ways over the past 100 years.
Freud (1905/1953) argued that unconscious
fantasies, not child abuse, were the real cause
of hysteria. During the 1970s, with research
into posttraumatic stress disorder (PTSD) (see
van der Kolk, 2000, p. 244) and the development of feminism, the pendulum of opinion
swung toward actual trauma as the cause of
pathology (Masson, 1984). This historical development can be seen as a dialectic between
the importance of inside (fantasy and intrapsychic conflict) and outside (actual abuse and
parental failure). The question being asked here
is this: Does pathology arise from real life
monsters or from monsters of the mind?
This article considers that question by using
transactional analysis to bridge the divide between psychoanalysis and empirical psychology. I begin with a reinterpretation of the ego
state model. I then offer a brief exploration of
the impact of trauma on development and suggest a transactional analysis formulation of
trauma. Finally, case material is provided to illustrate a relational approach to therapy using
the model described.
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INSIDEOUT: A TRANSACTIONAL ANALYSIS MODEL OF TRAUMA
A Story of Self: Development of I, Me, and Self
This section offers a theory or story about the
emergence ofselfwithin a relational paradigm;
it revisits ego state theory in light of infant research and neurobiology.
Is it appropriate to begin writing about incest
with comments about my sons' underwear?
How did this happen? Me watching I. William
James (1892, p. 176) made this distinction between a complex reflecting self-a "me"-and
the simple experiencing "I." I propose that the
selfin James's sense ofa transient experiencing
"I" is best conceived of in transactional analysis terms as a multiplicity of discontinuous
ChildlParent ego state configurations that produce shifts in consciousness in response to context. A sense of"me" as coherent and continuous over time develops with the Adult ego state
capacity to link ego states through story, thus
creating a "narrative self." This concept of self
encompasses the paradoxical experience of
changing with time or context while knowing I
am the same person. It also allows for the possibility of an "I" that is not part of me.
Citing infant research, several authors (Beebe
& Lachman, 1988; Lichtenberg, 1983; Stern,
1985) suggest that an emergent sense of self
develops out of repetitive reciprocal interactions between infant and caregiver. Beebe and
Lachman (1988, p. 306) used empirical evidence of the infant's capacity to recognize, remember, and expect these recurring interactions to suggest that the infant forms symbolic
representations of self and other. This process
of internalization involves representations of
both infant and caregiver, a dyadic system that
cannot be described on the basis of either partner alone (Beebe & Lachman, 1988, p. 305;
Fonagy, Target, & Gergely, 2000, p. 104).
In transactional analysis terms, we might say
that repeated transactions between the child
and his or her caregivers are aggregated and
internalized to form the basis of developing
Child, Parent, and Adult ego states. As Berne
(1961) put it, the mind contains "relics of the
infant who once actually existed, in a struggle
with the relics of the parents who once actually
existed" (p. 55). He emphasized that ego states
are phenomenological entities, not abstract representations (p. 4).
The internal structure of the self, then, arises
from a matrix of relationships. I use the phrase
"Parent/Child ego state dyad" to stress that a
whole relationship is internalized, not just an
introject: for example, an anxious Child ego state
in response to a critical Parent ego state. Little
(2005) refers to a similar concept as "ego state
relational units" (p. 136).
We might assume that the mind contains multiple ego state dyads that reflect the child's experience ofthe caregiving environment. Fonagy
(2001, p. 165) and Schore (1994, p. 498) refer
to multiple sets of self-other representations in
securely attached children. Relational psychoanalysts (Bromberg, 2001, p. 181; Mitchell,
1988) describe multiple relational configurations within the mind. Bromberg (2001, p. 244)
suggests it is only with maturity that we attain
an adaptive illusion of self that overrides the
awareness of discontinuity.
This ordinary phenomenological experience
of being many selves is summed up succinctly
by Virginia Woolf (1928/1993): "A biography
is considered complete ifit merely accounts for
six or seven selves, whereas a person may well
have as many thousand" (p. 224).
Selfas Story: The Adult Ego State. One starts
to wonder, how do we experience any sense of
identity, a single "me" in the midst ofthis shifting milieu?
Berne (1961) referred to the integrative function of the Adult ego state but acknowledged
that "the mechanism ofthis integration remains
to be elucidated" (p. 213). I suggest that selfnarrative is the key mechanism for integrating
disparate Parent and Child ego states into a unified sense of self or "me." The capacity to tell
stories about the self involves a reflective process.
Fonagy, Gergely, Jurist, and Target (2002)
argue that the development of such a reflective
capacity is dependent on attunement in early
relationships. When the caregiver accurately
represents experience for the child, this pattern
of relatedness is internalized, and the child develops an ability to integrate experience into
narrative. The child learns to name his or her
internal states and those ofothers. Fonagy et a1.
(2000, pp. 108-9) cite empirical evidence to
demonstrate a high correlation between secure
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10 STUTHRIDGE
attachment, reflective abilities, and narrative
coherence.
In transactional analysis terms, accurate attunement facilitates the Adult capacity for reflective function and self-narrative. This concept of neopsychic function as a process of integration, reflective function, and narrative is
consistent with recent theoretical developments
in transactional analysis (Allen, 2003; Erskine,
2003; Tudor, 2003). Allen (2003) uses the term
"psychological mindedness" to refer to "peopIe's ability to think about their psychodynamics and to put their experiences into narrative
script context" (p. 132).
The mind is experienced, then, as an unruly
crowd ofChild-Parent ego states with their own
unique modes of relating and affective tones
that are given meaning and shape by a narrator
-the Adult ego state.
The Narrative Self. Accumulated evidence
from neuroscience supports the idea that the
self does not start as an integrated whole but
rather is nonunitary in origin (LeDoux, 2002).
LeDoux (p. 192) and Damasio (2000, p. 189)
both argue that narrative provides the essential
glue that binds various neural networks to create a unified sense of self. The brain uses stories to create a single "me" out of fragmented
experience. Neurological research suggests that
memory plays a major role in this process (Damasio, 2000).
In transactional analysis language, script theory aptly describes the crucial role ofstory in the
development of self-identity. A life script is a
story that arises out of interactions between a
child and the world. It can either be life enhancing or self-limiting (Allen & Allen, 1997;
Cornell, 1988; Loria, 1995). Using a structural
ego state model, neurological findings about
memory can be used to deepen our understanding of an integrating Adult ego state, the emergence ofscript, and the development ofa narrative self (see Table 1).
Our earliest stories are wordless and arise
from nonverbal transactions between infant and
caregiver; they rely on sound, touch, and movement internalized as PriCo ego state dyads. This
experience is integrated into subsymbolic narrative by an early Adult ego state (An) that relies on implicit memory systems. The term
"subsymbolic" refers to affective and somatic
patterns of organization (Cornell, 2003, p. 45).
Implicit memory remains outside of awareness. These memories are stored in emotions,
sensations, and behaviors, with no sense of
conscious recollection (LeDoux, 2002). Stories
stored in implicit memory systems might be
associated with Berne's (1961, p. 118) concept
of protocol, which comprises the early relational patterns that form the basis of script.
Allen (2003) suggests that experience stored in
implicit memory creates "nonconscious organizing principles" (p. 131) that underlie later
script decisions. Implicit storytelling is not replaced but continues to exist alongside later
explicit story forms (Damasio, 2000).
For example, when an infant's earliest interactions are experiences of being adored and
held snugly with a full belly, this set of sensations forms a subsymbolic narrative. These
wordless stories form an emotional background
-setting the mood, tone, and broad themesthat defmes the world as safe or dangerous.
Simple symbolic stories about the selfemerge
with the development of explicit memory at 18
months (Schore, 1994, p. 483). Explicit memory involves conscious recall, language, and
symbolic processes. These stories define the
basic plot, the ending, and the goodies and baddies. This is the magical and concrete thinking
of Beme's (1961) Little Professor or AI neopsychic process. Al process tends to overgeneralize experience, thus forming injunctions
Table 1
The Narrative Self
Ao
Subsymbolic. affective.
sensorimotor stories of self. Present
at birth (Cozolino, 2002, p. 178).
Implicit memory systems.
A,
Simple symbolic. verbal stories of
self. Present from 18 months
(Schore, 1994, p. 487). Explicit
episodic memory.
A2
Complex symbolic stories of self and
reflective capacity. Present from 4-5
years (Fonagy, 2002, p. 245).
Autobiographical memory.
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and core script beliefs. Explicit episodic memory captures highly charged emotional scenes
typical of the memories accessed using redecision therapy. These scenes provide evidence
used to justify and reinforce early themes.
Complex self-narratives (A2) are possible by
4-5 years with the development of autobiographical memory (Nelson, 1992) and reflective abilities (Fonagy, 2002, pp. 245-248).
Autobiographical memory makes it possible to
organize remote events into a verbal narrative,
including aspects of both fact and fiction, implicit and explicit memory (Damasio, 2000).
Siegel (1999) referred to the "narrativization of
episodic memory" (p. 61) as a child learns to
string together episodes to create more complex coherent stories. These are the changing
stories I tell about myself, and they involve a
conscious narrator.
Autobiographical memory allows us to form
a narrative self, a "me" who persists over time
(Damasio,2000,p. 217). Coherentautobiographical narratives connect the past, present, and future, thus allowing a person to make sense of
life (Siegel, 2003, p. 52). These narratives are
fluid and flexible; they allow the integration of
conflicting experiences into a coherent whole.
This capacity is a developmental achievement
associated with secure attachment (Fonagy et
al.,2002; Siegel, 1999).Autobiographicalmemory can be modified by new experiences (Damasio, 2000, p. 173), and this has important
implications for therapy. It means I can change
the story I write about myself.
The Adult ego state acts as a narrator, weaving stories that bind various senses of "I"
(Parent/Child ego state dyads) into a coherent
"me": a narrated identity. Selfis located within
a story rather than an ego state-more like a
process than a structure. The narrative self, like
a good biography, contains diverse ego states,
or many selves, linked by story. The ego state
model described here might be diagrammed as
shown in Figure 1.
Stories and Trauma
What happens when trauma interferes with
the development ofthe self? This section briefly explores the evidence from neurobiology, attachment studies, and clinical research.
PO' Pl , P2-Parent
ego states encoded in implicit,
explicit, and autobiographical
memory
Ao, Al , A2-Adult
ego states encoded in implicit,
explicit, and autobiographical
memory
Co, C1, C2 -Child
ego states encoded inimplicit,
explicit, and autobiographical
memory
Figure 1
Second-Order Structural Model: An
Alternative Configuration of Ego States
I propose that trauma impairs the Adult ego
state's capacity to form self-narrative, which
results in dissociated ego states. This is not a
new idea. Pierre Janet in 1889 (as cited in van
der Kolk, 2000, p. 238) suggested that trauma
causes a failure of narrative memory. He described how the experience of trauma is fragmented into emotional and sensory elements
that are split off from ordinary consciousness
or dissociated. Contemporary neuroscience has
begun to elucidate the underlying mechanisms
for this breakdown.
Neurobiology and Childhood Trauma. The
absence of a secure attachment figure is one of
the most critical factors contributing to chronic
effects of child abuse (Schore, 2003; StreeckFischer & van der Kolk, 2000). Infants are dependent on an attuned caregiver in order to develop a capacity to regulate emotional states
(Schore, 1994). Traumatic attachments result in
an inability to regulate arousal and chaotic biochemical alterations that can damage the infant's brain (Schore, 2003; van der Kolk et al,
1996).
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Several studies indicate limbic system abnormalities and reductions in the size of the left
hippocampus in adult survivors of child sexual
abuse (Teicher, 2002, p. 71). What does this
mean? Van der Kolle(2000) argues that disruption to the limbic system-in particular, to the
hippocampus-results in a failure to integrate
traumatic experience into narrative. The hippocampus is responsible for the contextualization
of experience in time and place. Impairment to
hippocampus functioning leads to the persistence ofdissociated memory fragments, smells,
images, and sensations that are not located in
time and space.
To return to the example of Annie, she did
not come to therapy with a neat story. She presented, instead, with a series of symptoms that
made her feel crazy: disgusting smells that would
not wash away; nights lying awake in frozen
terror hearing footsteps in the hallway, and
vivid images ofher father standing by her bed.
She slept with the light and TV on. The events
of her childhood were not integrated into selfnarrative; instead, the trauma intruded in the
present in the form of sensory intrusions or
flashbacks.
Damasio's (2000, p. 235) work with brain injuries confirms that damage to the hippocampus will halt the growth of autobiographical
memory. Memory research also suggests that
under extreme stress, explicit memory can fail
while implicit memory is enhanced (LeDoux,
2002, p. 29; van der Kolk & Fisler, 1995). Siegel (2003) and Cozolino (2002) both argue that
trauma impairs neural integration in the developing brain, resulting in a failure to integrate
implicit memories of trauma into autobiographical narrative.
In transactional analysis terms, these biological changes interfere with the Adult ego state's
capacity for integration through narrative. Feeling states, events, and relational patterns of
trauma can all be recorded in implicit memory.
In other words, whole ego state systems may be
dissociated, not just the sensory elements of
trauma.
For example, Annie's proud memories of
walking to church hand in hand with her father
sit alongside vivid sensory memories of the
sexual abuse. There is no integration of these
experiences; the abusive father/abused child
and the good respectable father with the good
child remain side by side. These incompatible
ego state dyads seem to alternate in Annie's
consciousness.
Attachment and Trauma. Child attachment
researchers describe a similar process using different language and concepts. Numerous studies (Carlson, Cicchetti, Barnett, & Braunwald,
1989; Lyons-Ruth & Jacobvitz, 1999) verify a
high correlation between child abuse and disorganized attachment patterns. The child struggles to integrate contradictory experiences of
the caregiver as protective and hostile, leading
to contradictory clinging and fight and flight
behaviors.
Longitudinal studies show that disorganized
attachment in children predicts dissociative
symptoms in adults (Carlson, 1998). Fosha
(2003, p. 250) explains this link by suggesting
that painful feelings and events are dissociated
in order to maintain the attachment to the abusive caregiver. This Faustian compromise creates autobiographical narratives that lack emotional coherence.
Clinical Evidence and Dissociation. Adult
survivors of intrafamilial child abuse present
with symptoms that meet a vast range of DSM
IV disorders (American Psychiatric Association, 1994). However, clinical evidence from
three key areas of research-sexual abuse
(Briere & Runtze, 1988; Herman, 1992), PTSD
(McFarlane & Yehuda, 2000; van der Kolk &
Fisler, 1995), and dissociative disorders (Putnam, 1989}-all confirm a connection between
childhood abuse and the process of dissociation. The evidence suggests that dissociation is
a critical mediator between child abuse and a
variety ofpsychiatric symptoms, including substance abuse, self-harm, suicide (Kisiel &
Lyons, 2001), somatization, borderline personality disorder (BPD), and PTSD (StreeckFischer & van der Kolk, 2000). Dissociation
can be understood as a disruption in the integration ofmemory, consciousness, and identity
(American Psychiatric Association, 1994, p.
477).
Braun (1989) described a continuum of dissociation from normal that includes "highway
hypnosis" to PTSD and finally to dissociative
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identity disorder (DID). The degree of dissociation in an adult survivor depends on the
availability ofan adequate caregiver, age ofonset, severity of trauma, and closeness of the
relationship to the abuser. With patients with
DID, 95-98% of them have been victims of
severe child abuse (p. 308).
The evidence accumulating from empirical
studies, like a braided river, seems to take different pathways to a similar destination. Neurology, attachment studies, and clinical research all point to the same conclusion: Trauma
interrupts the capacity to form self-narrative,
thus creating a division of experiences or dissociation. In transactional analysis terms, we
might call this exclusion.
Self without Story: A Transactional
Analysis Model of Trauma
This section proposes a model oftrauma that
integrates a relational theory of self with empirical evidence about the impact of trauma on
development.
The Disorganized Self. Trauma impairs the
Adult ego state's capacity to organize experience through narrative, which results in a fundamentally disorganized self, one without an
effective story to bind disparate Parent-Child
ego states into a cohesive identity. The disorganized self includes many different "I"s and
no coherent "me."
Inside Out.
1. Outside gets inside. The experience ofchild
abuse is internalized structurally as a kaleidoscope oftoxic Parent/Child ego states stored in
implicit memory systems (PoIC o)' These relational prototypes represent the child's diverse
emotional experience ofabusive and neglectful
Parent introjects alongside abused and abandoned Child ego states.
2. The capacityfor self-narrative is impaired.
In the absence ofsecure attachment, trauma impairs the Adult capacity for complex selfnarrative (A2) . The abuse survivor relies on
earlier forms of neopsychic functioning (Ao or
At), thus forming restrictive stories or traumatic script. Incoherent self-narrative gives rise to
excluded ego states.
3. The inner world shapes the view outside.
The adult survivor continues to see the world
through the kaleidoscopic lens created by his or
her unique ego state patterning. This ego state
matrix determines affect regulation and relational patterns. Neutral cues are experienced as
signs of danger, while other people are perceived as untrustworthy or abusive. The internal world is turned inside out through projections of excluded Parent and Child ego states.
The unintegrated experience oftrauma is reenacted through these repetitive patterns oftransference, thus reinforcing the traumatic script.
At this point we have an answer to the question posed at the beginning. The monsters were
outside but they get inside via the internalization of early relationships in Parent/Child ego
states. The intrapsychic structure then shapes
the view of self, others, and the world outside
so that the adult survivor of abuse continues to
see monsters long after they are gone.
The real tragedy for most survivors of childhood trauma is the struggle they have in forming satisfactory loving relationships as adults.
Traumatic Script.
Subsymbolic narrative, A o.. Physiological
symptoms ofPTSD give voice to three cornerstones of the traumatic script using Ao sensorimotor language. These symptoms tell a story
without using words,
1. "Never forget" is the message expressed
through intrusive symptoms: flashbacks,
somatic symptoms, nightmares, and panic
attacks, all relating to implicit memories
of trauma,
2. "Never go this way again" is suggested
by avoidant symptoms: forgetting, emotional numbing, denial, dissociation, and
drug and alcohol abuse.
3. "Be prepared" is the clarion call of hypervigilantsymptoms:agitation,anxietystates,
and exaggerated startle reactions (Dalenberg, 2003).
Simple symbolic narrative, A J• AI process
gives rise to simple, overgeneralized, concrete,
or magical stories. A traumatic script is formed
based on beliefs about the self as bad, mad,
unworthy, or unlovable, while other people are
depicted as malevolent, untrustworthy, or uncaring. Bad things are attributed to a bad self.
The child without narrative has no buffer against
external events.
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For example, Nancy first knew she was bad
at age four when her mother suddenly abandoned the family, pinning a note to Nancy's
back as she left. Nancy did not feel bad-she
was bad. When her uncle, a priest, sexually
abused her when she was five then threatened
to shoot her father if she told, she knew this had
happened because she was a very bad child.
When her stepmother locked her in a dark cellar, Nancy knew she was as black and bad inside as the cellar was outside. Years later, the
black returned, perceived as a sticky black substance inside her body. Sometimes the black
would ooze out and stick to her hands. She often scrubbed them until they bled. Nancy was
careful not to tell her husband about the black
for fear he would see her badness. She told him
nothing of her past. He left one day after 20
years of marriage saying she did not trust him.
Nancy knew he left because she was bad.
Exclusion. Exclusion is defined here as a
process of "dis-integration" due to a failure of
the Adult ego state to integrate experience into
narrative. Parent/Child ego state dyads become
excluded from Adult awareness and each other,
alternating in mutually exclusive patterns.
Excluded Parent/Child ego states may include painful feelings related to trauma, unmet
relational needs, and conflicted experience of
a caregiver as loving and abusive. Exclusion
results in a discontinuity ofself-experience but
also preserves more adaptive ego states that alIowa child to cope.
Erskine (1993) suggests that trauma leads to
"ego fragmentation and dissociation" (p. 38);
however, the process he describes is very different from what I am suggesting here. He assumes that the selfbegins as a whole entity and
fragmentation occurs with lack of contact. I am
proposing that self begins as a multiplicity of
ego states and integration through self-narrative
is a developmental achievement.
Sharon's story illustrates this model. During
her first few sessions, Sharon would sit, wringing her hands, with her head lowered and her
body shaking. Long silences, tears, and stammering attempts at speech dominated the hour.
Her whole presence powerfully evoked the
sense of a small, frightened child squirming
with shame. It was difficult to reconcile this
image with the charming, friendly, quite humorous Sharon who turned up to subsequent
sessions. At other times, she would walk out of
sessions in fits of rage, quit her job, overdose,
cut herself, and binge eat. These diverse presentations reflected a series of alternating ego
states with no coherent self-narrative.
Sharon had been sexually abused by her father from her earliest memories until she was 16.
Her father disguised this exploitation with apparent adoration and involvement in her activities. Her mother never asked questions. The
secret of incest remained safely hidden behind
the family's quiet middle-class lifestyle. Sharon
either pretended that things were fine or she got
sick. She had no words to explain her distress.
This childhood reality was reenacted during
her adult life. For long periods Sharon pretended, hiding the incest secret from her own
awareness. She looked after her children and
worked in a supermarket. Alternately, she became sick with depression, self-disgust, suicidal thoughts, and flashbacks of sexual abuse.
Sharon had frequent hospital admissions over
20 years, diagnosed with bulimia, BPD, and
PTSD. As she became aware of this process,
she began to describe herself as a Jekyll and
Hyde: "I have to be either one thing or the other."
During our work together over 6 years, these
distinct ego state systems achieved some level
of integration. Sharon managed to attend both
work and therapy and learned to live in the
present, creating a narrative of self that included her past.
Stories without Words: When Actions
Speaker Louder . . .
The unfolding ofthe script is the substance
of the psychoanalytic process. The transference consists not merely of a set of interrelated reactions, a transference neurosis, but ofa dynamically progressive transference drama, usually containing all the
elements and subdivisions of a Greek tragedy. (Berne, 1961, p. 174)
The abuse survivor arrives in therapy with a
chaotic display of symptoms-the outer manifestations of a disorganized state of mind. Intrapsychic relationships between ego states are externalized through shifting constellations of
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transference/countertransference enactments.
The term "enactment" refers to nonverbal actions and interactions in the therapy setting
(Aron, 1996, p. 198). Abusive Parent introjects, terrified Child ego states, and fantasized
fairy godmothers are all brought to life in the
therapeutic arena. As these characters interact
with the therapist, exchanging roles in various
combinations, the traumatic script unfolds in
the therapy room.
Berne's ego state model provides a theory of
self that sits squarely within a relational tradition as described by Mitchell and Aron (1999).
The self is constituted through the internalization of interpersonal experience, with relationalneeds (recognition) replacing drive theory
as the key to motivation. Berne's methodology,
however, is closer to a traditional objectivist
approach than to a relational style of therapy.
He encouraged the therapist to act as a Martian
observer (Berne, 1966, p. 84) who detects the
client's discounts, games, and script from an
objective stance. Using a classical orredecision
transactional analysis approach, the therapist
confronts an enactment as a game, thus refusing
the transference; the therapist remains safely on
Mars, outside the relationship.
Trends within transactional analysis over the
past 10-15 years have begun to address this incongruity between theory and method. Berne's
method is a one-person approach, focused on
the client as object with decontamination or insight as the road to cure. Cornell and Hargaden
(2005) trace the development of a two-person
relational transactional analysis approach that
focuses on the therapeutic relationship as a
vehicle for change. Moiso (1985); Novellino
(1990); Erskine, Moursund, and Trautmann
(1999); and Hargaden and Sills (2002) have
been key contributors to this development of
transactional analysis theory and practice.
A relational approach is essential to therapy
with survivors of child abuse. The experience
of trauma is often stored in implicit memories
and excluded ego states, beyond words. This
story can only be learned through attention to
relational dynamics in the present, not by dredging for explicit memories of traumatic events.
Using a relational approach, transferential
enactments provide a crucial voice for implicit
relational patterns and excluded ego states.
With this approach, the therapist becomes
both participant and narrator in the drama. Relational therapies recognize the inevitability of
participation and the need to observe the impact of the therapist's participation on the process (Aron, 1996, p. 194). Through immersion
in the client's emotional world, implicit relational patterns formed in the abusive context
inevitably emerge in the therapy relationship.
When therapist and client manage to repair
these disruptions, excluded experience such as
shame, rage, or terror can be integrated into an
expanded self-narrative. As this process of attunement, rupture, and repair is repeated many
times over, a new relational prototype develops
within the client. Interpretations oftransference
facilitate this transition from implicit memory
to explicit story, thus ending the repetitive enactments of the traumatic script.
The model of trauma outlined here provides
a theory of mind and a method that is consistent with principles of contemporary relational
psychoanalysis (Aron, 1996; Mitchell, 1988).
These theories emphasize the importance ofrelationships, both internal and external, real and
imagined (Aron, 1996, p. 18). Here a dyadic
structure ofmind (Parent/Child dyads) emphasizes internal relationships between ego states
derived from relational configurations. This
inner world influences external relationships in
the present, and therapy requires participation
in cocreated patterns of transference to bring
about change. Transactional analysis provides
a bridge between intrapsychic and interpersonal
realms, including both fantasized and real relationships.
Three Transference Patterns. Clinicians who
work with trauma from a psychodynamic perspective often describe predictable patterns of
transference based on variations on themes of
helplessness, hostility, and rescue (Davies &
Frawley, 1994; Gabbard, 1994, pp. 309-311).
In my experience, three major transference patterns can be delineated (see Figure 2). Each involves a Child/Parent ego state dyad.
1. The good child in relation to an idealized
parent, a Victim-Rescuer theme
2. The abused child in relation to the abuser, a Victim-Persecutor theme
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JO STUTHRIDGE
Uninvolved
Parent
Fairy
Godmother
Abuser
Internal
dialogue
l4--'t--
Empty Child
Abused Child
Figure 2
The Disorganized Self: Three Transference Patterns
3. The empty child in relation to the uninvolved parent, a Victim-Bystander (Clarkson, 1987) theme
With intrafamilial abuse, there is almost always
an uninvolved parent who failed to protect the
child. Neglect plus abuse forms a particularly
toxic matrix of Parent/Child dyads.
While the themes and characters are familiar,
each ego state system is a manifestation of actual relationships that have been internalized.
The emphasis is on phenomenology: finding
names and addresses for ego states involved in
transferential transactions.
A Parent/Child ego state dyad may be experienced as an intrapsychic impasse, as an active
Parent or Child ego state, or interpersonally
when one aspect of the dyad is projected. Client and therapist can find themselves experiencing both aspects ofan internalized ego state
dyad. The concept of transference used here
draws on Erskine's (1991) defmition-"externalized expressions of internal ego conflicts"
(p. 66)-and assumes that both Child and Parent ego states can be projected. The transferential relationship is viewed as a mutual construction (Hargaden & Sills, 2002, p. 63).
In the following sections, case vignettes illustrate a relational approach to therapy with adult
survivors of child abuse.
1. The good child and the fairy godmother.
This transference pattern (see Figure 3) is a
Cinderella story and often marks the beginning
of therapy. Stories of a child being raped or
beaten easily tug on the heartstrings, thus invoking the Rescuer ever present in many therapists with the desire to alleviate suffering by
magic. From the client's perspective, feeling
believed and understood for the first time can
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a
a • internal dialogue b - projected ego state c - social transaction d· transference transaction
Figure 3
The Good Child/Fairy Godmother (after Moiso, 1985, p. 197)
provide a powerful elixir that conjures up
unheard-of promises and the fantasized fairy
godmother. This dynamic can be formulated as
an expression of Co longings for unrnet needs
(Hargaden & Sills, 2002) or an attempt to find
a symbiotic fusion through projection of the
fantasized Parent figure (P 1+) (Haykin, 1980;
Moiso, 1985). I believe there is no reason to
differentiate this fantasized introject from other
introjects (P2 ) ; both are real subjective experiences formed from a mix offantasy and reality.
For example, Sharon had a constant fantasy
as a child that her kindly neighbor, an older
woman, would one day take her home. In therapy, an idealizing transference emerged very
quickly in which I was viewed as the best
therapist she had ever seen, an all-loving, perfect mother who could magically remove her
pain. She used glimpses of me with my family
in public as proof of her perception.
Over time, an entitled Child ego state emerged.
IfSharon truly was as innocent as I maintained,
then surely she deserved a few phone calls?
During suicidal crises, pleas for extra sessions
and phone calls escalated; somehow I was not
doing enough.
Working through a fairy godmother transference usually involves giving up hopes ofrescue, acknowledging that the abuse did happen,
and mourning for a lost childhood. Instead of
waiting for the therapist to wave a magic wand,
the client leams to tolerate the pain of never
having felt cared for.
2. The abused child and the abuser. Fairbairn (1952/1992) first noted in his work with
abused children that the abusive parent is
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10 STUTHRIDGE
frequently internalized and split off or dissociated from consciousness. This sadistic Parent
ego state is evident in harsh internal dialogue
and persistent self-blame. It often seems intent
on a campaign oframpant self-sabotage, manifested in self-destructive behavior like Sharon's
starving, purging, cutting, and overdoses.
This abused child/abuser ego state dyad appeared in therapy with Sharon during long stuck
periods when she would tell variations on the
same story over and over (e.g., "People are cruel
to me"). She felt distressed and helpless (abused
Child), while everyone around her, including
me, was seen as being hurtful (projected abuser).
Occasionally there would be a rapid switch
in ego states. During a period of crisis, Sharon
began asking me to hold her hand during sessions or to sit next to her on the couch. I gently
refused the physical contact, suggesting we talk
about her need for touch instead. Shortly afterward, I received a call from her psychiatrist;
Sharon had complained that she felt abused by
me.
Sharon had recreated her family of origin in
this drama. The psychiatrist requested meetings
and explanations, while I felt trapped and guilty.
Sharon seemed to enjoy exercising some power
over me. My supervisor made an insightful
comment: "She's fucked you." This summed up
the nature of the intrusion I felt-projective
identification with an abused Child ego state.
Over several months, Sharon and I managed to
unravel the tangle. She understood that her feelings ofguilt in coming to see me were much like
the feelings she had about her relationship with
her father. She felt guilty about being in therapy for several years and kept the relationship
secret from her family. When she disclosed
abusive memories, she felt abused by me as she
was by him (projection of the abusive Parent).
She acknowledged the complaint was an expression of anger and eventually recognized
her own behavior as being like her father's (active Parent), an alien, excluded part of herself.
The enactment was repeated again some
months later. On this occasion, Sharon had just
been diagnosed with arthritis, a disease from
which her father also suffered. She felt as
though he was in her body again and experienced the arthritis as a violation ofher physical
integrity, like sexual abuse. She began cutting
herself; memories and sensations of sexual
abuse flooded her awareness. She phoned me at
home feeling desperate. I calmed her somewhat
and then suggested we talk further in the session. Angry at my response, she immediately
phoned my colleague and then her insurance
case manager, complaining about my lack of
availability. The case manager phoned me, accusing me ofignoring Sharon's distress-guilty
again. I received this call a day after my motherin-law died. I entertained a brieffantasy about
calling Sharon to cancel the next session because of the funeral. A retaliatory fantasy"See how guilty you feel now." At this point I
realized the extent of the guilt Sharon had felt
as a child and the way it was being tossed between us in the transference and countertransference. This time it was only a week before
she recognized the pattern.
Sharon began to accept the depth of her anger and to understand her guilt. With this Adult
awareness, previously excluded feelings were
integrated into an expanded autobiographical
narrative.
Using game theory and blanket labels of
"Kick Me" or "Now I've Got You, You Son of
a Bitch" to explain these events would miss the
subtle detail of the relational dynamics being
repeated in the transference.The sudden switches
in Sharon's ego states resulted from disjointed
self-narrative and unintegrated ego states, both
characteristic ofBPD.
In my work with Sharon, I found myself navigating an uneasy path between actual recapitulations of past trauma and creating a stage on
which these silent dramas, which have been excluded from awareness, can be enacted, symbolized, and integrated into conscious narrative. My supervisor reminded me ofthe importance of keeping the doors to the "theater" shut
(boundaries) while the "play" is in progress to
prevent fantasy from spilling out into the real
world.
3. The empty child and the uninvolved parent. In therapy, Nancy was silent for long periods, staring out the window. When I asked a
question she seemed not to hear or asked me to
repeat it. Her mind seemed utterly disconnected, like a computer that freezes. She was
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on medication and had had many courses of
electroconvulsive therapy (ECT). Long before
this treatment she had perfected the art of dissociation during countless incidents of sexual
abuse as a child by numerous offenders, including brothers, cousins, and uncles. At these
times, Nancy would leave her body and view
the abusive scene from a third-person perspective. For long periods I felt as though I had
completely lost contact with her. She came and
went from sessions with little change, apparently unreachable. During sessions I often
glanced at the clock, feeling irrelevant.
In one session, Nancy and I had the following exchange:
Nancy stared blankly.
Jo: Where are you now?
Nancy: I'm back in the cellar. (She goes on
to describe the wee square of linoleum she
sits on, the cold and dark.)
Jo: What are you thinking about?
Nancy: That someone might find me ...
Jo: Your mum?
Nancy: No. She didn't want me .... She's
dead (said in a deadpan voice).
It slowly dawned on me during this session
that I was experiencing myself as Nancy's "dead
mother." She had no investment of hope in me
at all. Nancy's mother had left when Nancy was
four, leaving her vulnerable to years of sexual
and physical abuse. These feelings ofdeadness
or emptiness can be harder to cope with than
the drama of the abuser-victim dyad. Gabbard
(1992) suggested that the tenacity with which
the incest survivor clings to the paternal transference may be an attempt to avoid this deadening void.
This transferential dyad often appears as a
perception that the therapist is uncaring or unavailable-projection ofthe uninvolved Parent.
A switch can occur ifthe therapist is inspired to
"go the extra mile" to prove caring, thus provoking the entitled Child. Attempts to love the
client more than the uncaring mother did might
also lead to a sexual transgression of boundaries wherein the therapist becomes the abuser,
thus repeating the incest. A significant percentage of clients involved in sexual relationships
with therapists have been incest victims as
children (Gabbard, 1992).
Creating New Stories: Cure
I believe the goal of therapy is to strengthen
the Adult ego state's capacity to create coherent self-narrative. Within a relational therapy,
intrapsychic dynamics are externalized through
transferential enactments. As client and therapist resolve these impasses in the relationship,
excluded Parent-Child ego state dyads can be
integrated into an expanded self-narrative. Attunement in the therapeutic relationship is used
to develop the Adult capacity for reflective
function and self-narrative.
Adult attachment research shows that coherent narrative in a parent is the most robust indicator of secure attachment in infants (Hesse,
1999). These findings suggest that integration
within the mind fosters interpersonal connections. In transactional analysis terms, this means
that coherent self-narrative can prevent the intergenerational transmission of script.
To return to the story of Annie, one day she
arrived at the session with a broad smile and
without her baby granddaughter. We both knew
this meant she had left the baby with her husband Bill, trusting him for the first time-ever.
As she said, "It just feels so different. It's only
now talking to you that I realize how different
I am. It's such a warm good feeling to see Bill
holding the baby." We both share "the warm
good feeling" in a moment of eye contact-so
different from the furtive glances and shame
that has permeated our sessions in the past.
Coherent narrative integrates disparate ego
states into a continuous sense ofself. The client
is free to roam in previously excluded parts of
the mind. The stream of consciousness becomes deeper and wider rather than being forced
down the narrow channels carved by the traumatic script. The client develops a broader,
more flexible story of self that makes sense of
the past and creates a new future. A client
summed this up for me during a final session.
When I asked her what had changed, Jamie
said, "It's like having a walk-in wardrobe in
your mind."
Conclusion
This article proposes that self-narrative is a
key function of the integrating Adult ego state.
Trauma and neglect in early relationships impair
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10 STUTHRIDGE
this capacity and result in a disorganized selfstructure. The goal oftherapy, using a relational approach, is to develop the client's ability to
create a coherent self-narrative.
This transactional analysis model of trauma
places the consequences of childhood abuse in
a psychodynamic relational framework, highlighting the complex interplay between fantasy
and reality, inside and out.
Trauma therapies that focus on outside, recall ofevents, and abreaction are insufficient to
bring about lasting change. It is essential to address internal ego state relationships to facilitate a reorganization of mind or cure (Berne,
1961, p. 246). As Bromberg (2001) writes,
We do not treat patients . . . to cure them
of something that was done to them in the
past; rather we are trying to cure them of
what they still do to themselves and to others in order to cope with what was done to
them in the past. (p. 237)
Jo Stuthridge, MSc., is a Teaching and Supervising Transactional Analyst (psychotherapy)
and member ofthe New Zealand Association of
Psychotherapists. She is codirector ofthe Physis Institute and maintains a private psychotherapy practice in Dunedin, New Zealand.
She can be reached at PO Box 1205, Dunedin,
New Zealand; e-mail: [email protected]
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