Allan N. Schore, PhD

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Modern Attachment Theory: The Central Role of Affect Regulation in Development and Treatment

Judith R. Schore &
Allan N. Schore, PhD
UCLA David Geffen School of Medicine

Transference–Countertransference as Implicit Right Brain/Mind/Body Transactions

Advances in neuroscience now clearly suggest that the capacity to receive and express communications within the implicit realm is optimized when the clinician is in a state of right brain receptivity. Marcus ( 1997 ) observes, ‘‘The analyst, by means of reverie and intuition, listens with the right brain directly to the analysand’s right brain (p. 238).’’ The neuroscience literature holds that ‘‘The left hemisphere is more involved in the foreground-analytic (conscious) processing of information, whereas the right hemisphere is more involved in the background-holistic (subconscious) processing of information’’ (Prodan et al. 2001 , p. 211).

Indeed, the right hemisphere uses an expansive attention mechanism that focuses on global features while the left uses a restricted mode that focuses on local detail (Derryberry and Tucker 1994 ). In contrast to the left hemisphere’s activation of ‘‘narrow semantic fields’’, the right hemisphere’s ‘‘coarse semantic coding is useful for noting and integrating distantly related semantic information’’ (Beeman 1998 ), a function which allows for the process of free association. Bucci ( 1993 ) has described free association as following the tracks of nonverbal schemata by loosening the hold of the verbal system on the associative process and giving the nonverbal mode the chance to drive the representational and expressive systems, that is by shifting dominance from a left to right hemispheric state.

These nonverbal affective and thereby mind/body communications are expressions of the right brain, which is centrally involved in the analysis of direct kinesthetic information received by the subject from his own body, an essential implicit process. This hemisphere, and not the linguistic, analytic left, contains the most comprehensive and integrated map of the body state available to the brain (Damasio 1994 ). The therapist’s right hemisphere allows her to know the patient ‘‘from the inside out’’ (Bromberg 1991 , p. 399). To do this the clinician must access her own bodily-based intuitive responses to the patient’s communications. In an elegant description Mathew’s ( 1998 ) evocatively portrays this omnipresent implicit process of bodily communications:

The body is clearly an instrument of physical processes, an instrument that can hear, see, touch and smell the world around us. This sensitive instrument also has the ability to tune in to the psyche: to listen to its subtle voice, hear its silent music and search into its darkness for meaning (p. 17).

Intersubjectivity is thus more than a match or communication of explicit cognitions. The intersubjective field co-constructed by two individuals includes not just two minds but two bodies (Schore 1994 , 2003a , b ). At the psychobiological core of the intersubjective field is the attachment bond of emotional communication and interactive regulation. Recall Pipp and Harmon’s ( 1987 ) assertion that the fundamental role of nonconscious attachment dynamics is interactive regulation. Implicit unconscious intersubjective communications are interactively communicated and regulated and dysregulated psychobiological somatic processes that mediate shared conscious and unconscious emotional states, not just mental contents. The essential biological purpose of intersubjective communications in all human interactions, including those embedded in the psychobiological core of the therapeutic alliance, is the regulation of right brain/ mind/body states. These ideas resonate with Shaw’s ( 2004 ) conclusion,

Psychotherapy is an inherently embodied process. If psychotherapy is an investigation into the inter-subjective space between client and therapist, then as a profession we need to take our bodily reactions much more seriously than we have so far because…the body is ‘‘the very basis of human subjectivity.’’ (p. 271)

There is now a growing consensus that despite the existence of a number of distinct theoretical perspectives in clinical work, the concepts of transference and countertransference represent a common ground. In a neuropsychological description that echoes psychoanalytic conceptions of transference Shuren and Grafman ( 2002 ) propose,

The right hemisphere holds representations of the emotional states associated with events experienced by the individual. When that individual encounters a familiar scenario, representations of past emotional experiences are retrieved by the right hemisphere and are incorporated into the reasoning process (p. 918).

Transference–countertransference transactions thus represent nonconscious nonverbal right brain–mind–body communications. Transference has been described as ‘‘an expression of the patient’s implicit perceptions and implicit memories’’ (Bornstein 1999 ). Facial indicators of transference are expressed in visual and auditory affective cues quickly appraised from therapist’s face. Countertransference is similarly currently defined in nonverbal implicit terms as the therapist’s ‘‘autonomic responses that are reactions on an unconscious level to nonverbal messages’’ (Jacobs 1994 ). In monitoring countertransferential responses the clinician’s right brain tracks at a preconscious level not only the arousal rhythms and flows of the patient’s affective states, but also her own interoceptive bodily-based affective responses to the patient’s implicit facial, gestural, and prosodic communications.

It is certainly true that the clinician’s left-brain conscious mind is an important contributor to the treatment process. But perhaps more than other treatment modalities, psychodynamic psychotherapeutic models have focused upon the critical functions of the therapist’s ‘‘unconscious right mind.’’ The right hemisphere plays a dominant role in the processing of self-relevant information (Molnar-Szakacs et al. 2005 ), affective theory of mind (Schore 2003b ), empathy (Schore 1994 ; Shamay-Tsoory et al. 2003 ), as well as in mentalizing (Ohnishi et al. 2004 ). A neuropsychoanalytic right brain perspective of the treatment process allows for a deeper understanding of the critical factors that operate at implicit levels of the therapeutic alliance, beneath the exchanges of language and explicit cognitions.

In this intersubjective dialogue, the psychobiologically attuned, intuitive clinician, from the first point of contact, is learning the nonverbal moment-to-moment rhythmic structures of the client’s internal states, and is relatively flexibly and fluidly modifying her own behavior to synchronize with that structure, thereby co-creating with the client a growth-facilitating context for the organization of the therapeutic alliance. The attachment between therapist and client is established over time, allowing for the expression of experiences that resonate with the original infant–mother intersubjective history of the first 2 years. If that was an insecure attachment to begin with, co-creating a new, secure interaction will take even longer.

Over the ensuing stages of the treatment, the sensitive empathic clinician’s monitoring of unconscious process rather than content calls for right brain attention to her matching the patient’s implicit affective-arousal states. The empathic therapist also resonates with the client’s simultaneous implicit expressions of engagement and disengagement within the co-constructed intersubjective field. This in turn allows the clinician to act as an interactive regulator of the patient’s psychobiological states. Such work implies a profound commitment by both participants in the therapeutic dyad and a deep emotional involvement on the part of the therapist (Tutte 2004 ). Ultimately, effective psychotherapeutic treatment of early evolving self-pathologies (severe personality disorders) facilitates changes in complexity of the right hemispheric unconscious system.