Allan N. Schore, PhD

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Right Brain Affect Regulation: An Essential Mechanism Of Development, Trauma, Dissociation, And Psychotherapy

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

Right Brain Processes in Psychotherapy: Unconscious Affect, Transference, and Primary Process

At the beginning of this chapter I suggested that the regulation of not only conscious but also unconscious affects is an essential mechanism of the psychotherapeutic change process.  All forms of therapy currently view affect dysregulation as a fundamental condition of every psychiatric disorders (Taylor et al., 199), including personality disorders (Sarkar & Adshead, 2006), and therefore share a common goal of improving the effectiveness of emotional self-regulatory processes (Beauregard, 2001).  In terms of regulation theory defense mechanisms are forms of emotional regulation strategies for avoiding, minimizing, or converting affects that are too difficult to tolerate.  Treatment, especially of early forming severe psychopathologies, must attend to not only to conscious dysregulated affects but also to the early forming survival defense that protects patients from consciously experiencing overwhelming painful negative affects - dissociation.  It thus represents the major counterforce to the emotional-motivational aspects of the change process in psychotherapy (Schore, 2007).  This clinical principle is supported by research which shows that insecurely attached dissociative patients dissociate as a response to negative emotions arising in psychodynamic psychotherapy, leading to a less favorable treatment outcome (Spitzer et al., 2007).

In light of clinical studies of psychiatric patients reporting that severe early maternal dysfunction is associated with level of dissociation (Draijer & Langeland, 1999), and that physical abuse and parental dysfunction by the mother - not the father - is associated with somatoform dissociative experience (Roelofs et al., 2002), I suggest that pathological dissociation always represents (re-) activation of maternal preoedipal attachment dynamics.  In other words, in the therapeutic context later forming repression is associated with Oedipal dynamics and the left hemispheric inhibition of affects generated by the right brain, while early forming dissociation reflects preoedipal stages and a dysregulation of affects resulting from the dis-integration of the right brain, the biological substrate of the human unconscious.

Basic research on the human brain suggests that “While the left hemisphere mediates most linguistic behaviors, the right hemisphere is important for broader aspects of communication” (van Lancker & Cummings, 1999, p. 95).    Incorporating these data into regulation theory’s model of the psychotherapeutic process I have delineated the central role of implicit right brain-to-right brain nonverbal communications (facial expression, prosody, gesture) in transference-countertransference affective transactions.  Interdisciplinary data and updated clinical models lead me to conclude that the right hemisphere is dominant in treatment, and that psychotherapy is not the “talking cure” but the affect communicating and regulating cure (Schore, 2005a).

Studies in interpersonal neurobiology also reveal 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).  Note the reversal of this hemisphericity in Jung’s (1931) description of the therapeutic relationship:

In the treatment there is an encounter between two irrational factors, that is to say, between two persons who are not fixed and determinable quantities but who bring with them, besides their more or less clearly defined fields of consciousness, an indefinitely extended sphere of non-consciousness.

Jung is referring to transference-countertransference communications, which involve not secondary process rational “analytic” factors, but primary process irrational “non-analytical” functions. 

In “Psychology of the Transference” Jung (1946) conceptualized the unconscious-to-unconscious relationship between the therapist and patient by referring to alchemical images of the Rosarium philosophorum.  In Figure 3, the image of the King and Queen, note the joining of their left hands (controlled by their right hemispheres).  Jung writes,

The left…is the side of the heart, from which comes not only love but all the evil thoughts connected with it, the moral contradictions in human nature that are expressed most clearly in our affective life. The contact of left hands could therefore be taken as an indication of the affective nature of the relationship (my italics).


Figure 3. Rosarium philosophorum, Jung’s conception of the affective relationship of the transference

Figure 3. Rosarium philosophorum, Jung’s conception of the affective relationship of the transference

With direct relevance to transference-countertransference communications Howard & Reggia assert, “The right hemisphere develops a specialization for cognitive functions of a more ancient origin and the left for a specialization for functions of more modern origin” (2007, p. 121).  This characterization  echoes Freud’s  (1933) speculation that transference is an “original, archaic method of communication between individuals.” 

Freud (1925-1926/1961) proposed that transference “is a universal phenomenon of the human mind…and in fact dominates the whole of the each person’s relations to his human environment” (p. 42). Neuropsychoanalytic models of transference (Pincus, Freeman, & Modell, 2007) now contend that “no appreciation of transference can do without emotion” (p. 634), and that “transference is distinctive in that it depends on early patterns of emotional attachment with caregivers” (p. 636).  These authors suggest that Freud “was referring to an ongoing process by which we situate ourselves in our perceived present, an entirely unconscious process influenced by our developmental histories with ourselves and others, a mixing and transforming of the current context” (p. 630). In a neuropsychological description that echoes psychoanalytic conceptions of transference Shuren and Grafman observe,

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. (2002,  p. 918)

An essential tenet of Freud’s developmental model proscribed that the primary process system emerges in human infancy, before the secondary process system.  It is important to point out Freud’s also postulated that primary process cognition is frequently accompanied by affect.  Following this lead ego psychologists (Rapaport, 1951; Holt, 1967) also explored the primary process affective dimension. In more recent psychological studies, Russ (2000-2001) concludes, “primary-process is a subtype of affect in cognition that consists of content around which the child had experienced early intense feeling states…current primary-process expressions could reflect these early encodings of fused affect and cognition” (p. 31).  In line with current developmental and relational models I argue that right brain-to-right brain communications represent interactions of the patient’s unconscious primary process system and the therapist’s primary process system (Schore, 1994).  Congruent with the well established clinical relationship between early forming primary process and the development of object relations and the interpersonal world, I suggest that primary process cognition is the major communicative mechanism of the relational unconscious.

In a significant advance in our understanding of the dynamic processes of the relational unconscious, Dorpat (2001) describes the process of “primary process communication.”  Congruent with the current clinical emphasis on the central role of unconscious mechanisms in the therapy change process, he contends that it is critical for the therapist “to suspend attention to secondary process cognition while attending to the patient’s and the therapist’s own primary process derivatives” (p. 461).  In line with the different processing capacities of the right and left brains, he conceptualizes primary and secondary process as parallel and relatively independent systems for the reception, analysis, processing, storing, and communication of information, and that in different contexts one or the other may predominate.  In a striking similarity to attachment communications Dorpat states that “the primary process system is immediately and directly involved with perception…[it] analyzes, regulates, and communicates an individual’s relations with the environment,” (p. 449) and that this “nonverbal communication includes both body movements (kinesics), posture, gesture, facial expression, voice inflection, and the sequence, rhythm, and pitch of the spoken words (p. 451).”

Importantly, Dorpat notes that primary process “is a prereflective mode that does not immediately rise into awareness. We give meaning to all interactions without necessarily reflecting upon them or even clarifying them to ourselves” (p. 448).  A common misconception of current cognitive secondary process (insight) psychotherapy models is that meaning is only created through awareness and verbal mentation.  This prereflective mode, operating rapidly and beneath conscious awareness and equated with Fonagy et al.’s (2002) “mentalization” is the output of the right and not left hemisphere (Ohnishi et al., 2004). 

Indeed in direct relevance to the psychotherapy process, neuroscience authors contend that “The right hemisphere operates in a more free-associative, primary process manner, typically observed in states such as dreaming or reverie” (Grabner et al., 2007, p. 228).   Thus various disciplines are supporting earlier speculations of developmental psychologists of a direct link between the "puzzles of 'unconscious' and 'primary process' influences on later behavior" (Pipp & Harmon, 1987, p. 650).  Split brain neurobiological studies by Galin (1974) and Hoppe (1977) established that the right hemisphere generates primary process while the left secondary process cognition. Pioneering psychological studies of these two processing modes by Martindale and & Hasenfus (1978) specifically indicated that logical, analytical secondary process cognition accompanies medium levels of cortical arousal, while primary process accompanies either high or low levels of cortical arousal (see Figure 4).

Figure 4. Relationship between primary and secondary process and arousal

Figure 4. Relationship between primary and secondary process and arousal