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

Further Implications of Regulation Theory for Clinical Social Work: Models of Clinical Expertise

The unique biopsychosocial perspective of clinical social work highlights the critical importance of unconscious forces that drive all human emotion, cognition, and behavior within a sociocultural matrix. From its beginnings, attachment theory, grounded in psychoanalysis and ethology, has focused on how real experiences, especially in childhood, directly impact the unconscious system. This is, of course, a core principle of psychodynamically oriented clinical social work. This updated form of attachment theory, that is informed by neuroscience, elucidates the early experience-dependent development of the human unconscious system, which remains active over the course of the life span. In an excellent volume, Neurobiology for Clinical Social Work, Applegate and Shapiro ( 2005 ) apply attachment neurobiology specifically to social work practice.

We suggest that clinical expertise, especially with severely disturbed patients, relies more on nonconscious nonverbal right brain than conscious verbal left brain functions. Clinical efficacy is more than explicit left hemispheric technical skill in interpretation. Rather, increasing levels of clinical effectiveness with a broader spectrum of patients fundamentally involves more complex learning of a number of nonconscious functions of the therapist’s right brain that are expressed in the therapeutic alliance. All technique sits atop these right brain implicit skills, which deepen and expand with clinical experience: the ability to receive and express nonverbal affective communications; clinical sensitivity; use of subjectivity/ intersubjectivity; empathy; and affect regulation. Neuroscience now indicates that the implicit processes of intuition (Allman et al. 2005 ), creativity (Grabner et al. 2007 ), and indeed insight (Jung-Beeman et al. 2004 ), are all right, and not left, brain functions.

A Presidential Task Force on Evidence-Based Practice prepared by the American Psychological Association ( 2006) now suggests,

Central to clinical expertise is interpersonal skill, which is manifested in forming a therapeutic relationship, encoding and decoding verbal and nonverbal responses, creating realistic but positive expectations, and responding empathically to the patient’s explicit and implicit experiences and concerns (p. 277).

They further note that ‘‘Research suggests that sensitivity and flexibility in the administration of therapeutic interventions produces better outcomes than rigid application of…principles’’ (p. 278).

Sensitivity has, of course, been well-studied in the developmental attachment literature, where researchers observe that maternal sensitivity cultivates synchronous, reciprocal, and jointly satisfying mother–infant interactions, which, in turn, foster the development of a secure attachment relationship. In adult attachment studies Schachner et al. ( 2005 ) argue ‘‘nonverbal behavior and sensitivity to a relationship partner’s nonverbal behavior importantly influence the quality of interpersonal interactions and relationships, including attachment relationships.’’ We suggest that this attachment principle applies to the therapeutic relationship as well.

The dictionary definition of sensitivity is: ‘‘susceptible to the attitudes, feelings, or circumstances of others; registering very slight differences or changes of emotion (American Heritage Dictionary)’’. In previous writings Schore ( 2003b ) describes the operations of the therapist’s right brain by which ‘‘the sensitive clinician’s oscillating attentiveness is focused on barely perceptible cues that signal a change in state and on nonverbal behaviors and shifts in affects.’’ In discussing ‘‘the art of psychotherapy’’ Bugental ( 1987 ) stresses the importance of the sensitive clinician’s ability to ‘‘learn to experience finer and finer distinctions or nuances.’’ He states, ‘‘The primary instrument brought to the support of the client’s therapeutic efforts is the therapist’s trained, practiced, and disciplined sensitivity. In many ways, this sensitivity is akin to a musical instrument which must be carefully prepared, maintained, tuned, and protected’’ (p. 222). The clinician’s capacity for intersubjective communication depends upon her ‘‘being open to intuitive sensing of what is happening in the back of the patient’s words and, often, back of his conscious awareness’’ (p. 11).

This clinical sensitivity to even low levels of nonverbal attachment communications allows for the clinician’s involvement in a wider array of co-created affectively charged intersubjective fields. These collaborations of the client and therapist’s subjectivities allows for right brain communications and regulations of dysregulated affective states. The importance of this connection is stressed by Whitehead ( 2006 ):

[E]very time we make therapeutic contact with our patients we are engaging profound processes that tap into essential life forces in our selves and in those we work with…Emotions are deepened in intensity and sustained in time when they are intersubjectively shared. This occurs at moments of deep contact (p. 624).

An attachment-based clinical approach highlights the unconscious nonverbal affective more than the conscious verbal cognitive factors as the essential change process of psychotherapy. Thus, at the most fundamental level, the intersubjective work of psychotherapy is not defined by what the therapist does for the patient, or says to the patient (left brain focus). Rather, the key mechanism is how to be with the patient, especially during affectively stressful moments (right brain focus).

Bowlby stated that attachment behavior was based on the need for safety and a secure base. We have demonstrated that attachment is more than this; it is the essential matrix for creating a right brain self that can regulate its own internal states and external relationships. Attachment intersubjectivity allows psychic structure to be built and shaped into a unique human being. Our task as therapists is to understand and facilitate this developmental process with our clients. As clinical social workers we do this in the wider context of the culture and society. Regulation theory enhances and deepens the field’s bio-psycho-social-cultural perspective.