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: Interactive Affect Regulation as a Central Mechanism of the Change Process

Various authors have described the subtle psychological activities of the sensitive clinician who scaffolds the co-creation of an intersubjective field with the patient. Bromberg observes,

When [a therapist] gives up his attempts to ‘understand’ his patient and allows himself to know his patient through the ongoing intersubjective field they are sharing at that moment, an act of recognition (not understanding) takes place in which words and thoughts come to symbolize experience instead of substitute for it. (p. 2006, 11)

The dyadic nature of this deep affective exploration of the self was noted by Jung’s (1946) suggestion that the clinician must go to the limit of his subjective possibilities, otherwise the patient will be unable to follow suit. According to Lichtenberg (2001), staying with the patient’s immediate communication longer and more intensely usually gains more understanding than is achieved either by a defense focus or a genetic focus on what isn’t said.  And Whitehead describes the affect amplifying effects encountered in the deep strata of the unconscious:

Every 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.  (2005, p. 624, my italics)

As previously discussed, a central tenet of regulation theory dictates that the interpersonal resonance within an intersubjective field triggers an amplification of state. The resultant co-created increased arousal (metabolic energy) allows for hypoaroused dissociated unconscious affects to be intensified. This bottom-up interactive regulation enables affect beneath conscious awareness to be intensified and sensed in both. Thus the “potential beginning” of an unconscious affect (Freud, 1915) is intersubjectively energized into emergence.

As in all attachment dynamics, a dyadic amplification of arousal-affect intensity generated in a resonant transference–countertransference context facilitates the intensification of the felt sense in both therapist and patient.  This same interpersonal psychobiological mechanism sustains the affect in time, that is, the affect is “held” within the intersubjective field long enough for it to reach conscious awareness in both members of a psychobiologically attuned therapeutic dyad.  It should be noted that this affect charging-amplifying process includes an intensification of both negative and/or positive affect in an intersubjective field.

But more than empathic affect attunement and deep contact is necessary for further therapeutic progression: at the psychobiological core of the intersubjective field is the attachment bond of emotional communication and affect regulation. The clinician’s psychobiological interactive regulation / repair of dysregulated especially unconscious (dissociated) bodily-based affective states is an essential therapeutic mechanism.  Recall Bucci’s  (2002) proscription that the threatening dissociated affect must be sufficiently regulated. Sands notes that

[D]issociative defenses serve to regulate relatedness to others…The dissociative patient is attempting to stay enough in a relationship with the human environment to survive the present while, at the same time, keeping the needs for more intimate relatedness sequestered but alive.  (1994, p. 149)

Due to early learning experiences of severe attachment failures, the patient accesses pathological dissociation in order to anticipate potential dysregulation of affect by anticipating trauma before it arrives.  In characterological dissociation an autoregulatory strategy of involuntary disengagement is initiated and maintained to prevent potentially dysregulating intersubjective contact with others. But as the patient continues through the change process, she becomes more able to forgo autoregulation for interactive regulation when under interpersonal stress. In this work, “it is not the past we seek but the logic of the patient’s own state regulating strategies” (in Schwaber, 1990, p. 238).

Ogden and her colleagues conclude,

Interactive psychobiological regulation (Schore, 1994) provides the relational context under which the client can safely contact, describe and eventually regulate inner experience…Rather than insight alone, it is the patient’s experience of empowering action in the context of safety provided by a background of the empathic clinician’s psychobiologically attuned interactive affect regulation that helps effect…change. (2005, p. 22)

This interactive affect regulation occurs at the edge of the regulatory boundaries of both high and low arousal intersubjective fields.

In this work Bromberg warns, “An interpretative stance…not only is thereby useless during an enactment, but also escalates the enactment and rigidifies the dissociation” (2006, p. 8).  A therapeutic focus on regulating not only conscious but unconscious (dissociated) affect highlights the conclusion that implicit nonverbal affective more than the explicit verbal cognitive (insight) factors lie at the core of the change process in the treatment of more severely disturbed patients. 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).

Note the similarity of working at the right brain regulatory boundaries in the heightened affective moment of enactments to Lichtenberg’s  “disciplined spontaneous engagements” that occur within “an ambience of safety:”

Spontaneous refers to the [therapist’s] often unexpected comments, gestures, facial expressions, and actions that occur as a result of an unsuppressed emotional upsurge. These communications seem more to pop out than to have been planned or edited. The [therapist] may be as surprised as the patient.  By engagement, we refer to communications and disclosures that are more enactments than thought-out responses. (2001, p. 445)

Tronick’s “moments of meeting,” a novel form of engagement of the therapeutic dyad, also occur at the regulatory boundaries: “The [therapist] must respond with something that is experienced as specific to the relationship with the patient and that is expressive of her own experience and personhood, and carries her signature...It is dealing with ‘what is happening here and now between us.’ The strongest emphasis is on the now because of the affective immediacy…It requires spontaneous responses and …need never be verbally explicated, but can be, after the fact.” (2007, p. 436).

According to Greenberg & Pavio (1997) reliving the traumatic experience in therapy within the safety and security of an empathic, supportive therapist provides the person with a new experience.  This new experience is specifically the clinician’s interactive regulation of the patient’s dysregulated right brain hyperaroused and hypoaroused affective states.  In support of this model current experimental researchers report “as suggested in clinical practice, it is necessary to ‘revisit’ an emotionally distressing memory before it can be controlled, ” and demonstrate that prefrontal areas that inhibit emotional memories and suppress emotional reactivity are lateralized predominantly to the right hemisphere (Depue, Curran, & Banich, 2007, p. 218).

In addition to scaffolding the co-generation a wider variety of more intense and enduring affects in the intersubjective field, the clinician also facilitates “the processing to be safer and safer so that the person’s tolerance for potential flooding of affect goes up” (Bromberg, 2006, p. 79).  Resultingly,

The patient’s threshold for ‘triggering’ increase, allowing her increasingly to hold on to the ongoing relational experience (the full complexity of the here and now with the therapist) as it is happening, with less and less need to dissociate; as the processing of the here and now becomes more and more immediate, it becomes more and more experientially connectable to her past. (p.69)

Effective work at the regulatory boundaries of right brain low and high arousal states ultimately broadens the windows of affect tolerance (see Figure 10). 

LeDoux offers an elegant description of this advance of emotional development:

Because emotion systems coordinate learning, the broader the range of emotions that [an individual] experiences the broader will be the emotional range of the self that develops…And because more brain systems are typically active during emotional than during nonemotional states, and the intensity of arousal is greater, the opportunity for coordinated learning across brain systems is greater during emotional states.  By coordinating parallel plasticity throughout the brain, emotional states promote the development and unification of the self (2002, p. 322). 

Growth-facilitating experiences of at the regulatory boundaries thus promote the “affective building blocks of enactments” (Ginot, 2007). The patient’s increased ability to consciously experience and communicate a wider range of positive and negative affects is due to a developmental advance in the capacity to regulate affect. This further maturation of adaptive self-regulation is in turn reflected in the appearance of more complex emotions that result from the simultaneous blending of different affects, and in an expansion in the “affect array.”

Figure 10. Psychotherapy expands windows of affect tolerance

Figure 10. Psychotherapy expands windows of affect tolerance

Effective psychotherapy of attachment pathologies and severe personality disorders must focus on unconscious affect and the survival defense of pathological dissociation, “a structured separation of mental processes (e.g., thoughts, emotions, conation, memory, and identity) that are ordinarily integrated” (Spiegel & Cardeña, 1991, p. 367). Overwhelming traumatic feelings that are not regulated can not be adaptively integrated into the patient’s emotional life.  This dissociative deficit specifically results from a lack of integration of the right hemisphere, the emotional brain.  But long-term therapy can positively alter the developmental trajectory of the deep right brain and facilitate the integration between cortical and subcortical right brain systems. This enhanced interconnectivity allows for an increased complexity of defenses of the emotional right brain, coping strategies for regulating stressful affect that are more flexible and adaptive than pathological dissociation.  This in turn enhances the further maturation of the right hemisphere core of the self and its central involvement in  “patterns of affect regulation that integrate a sense of self across state transitions, thereby allowing for a continuity of inner experience” (Schore, 1994, p. 33). 

The increased resilience of unconscious strategies of stress regulation that results from an optimal psychotherapeutic experience represents an experience-dependent maturation of “the right hemispheric specialization in regulating stress - and emotion-related processes” (Sullivan & Dufresne, 2006).  Efficient functions of the right brain implicit self are essential for the reception, expression, and communication of socioaffective information, the unconscious regulation of physiological, endocrinological, neuroendocrine, cardiovascular, and immune functions, subjectivity / intersubjectivity, trust, affective theory of mind, and empathy.  Hartikainen et al. summarize the critical role of nonconscious emotion processing for human survival:

In unpredictable environments, emotions provide rapid modulation of behavior. From an evolutionary perspective, emotions provide a modulatory control system that facilitates survival and reproduction. Reflex-like reactions to emotional events can occur before attention is paid to them…Neuropsychological evidence supports a right hemispheric bias for emotional and attentional processing in humans. (2007, p. 1929).

At the outset of this chapter I asserted that the emerging paradigm shift is highlighting the primacy of affect in human development, psychopathogenesis, and treatment. A large body of research in the neuroscience literature suggests a special role of the right hemisphere in empathy, identification with others, intersubjective processes (Decety & Chaminade, 2003), autobiographical memories, own body perception, self-awareness, self-related cognition (Uddin et al., 2006), as well as self-images that are not consciously perceived (Theoret et al., 2004), all essential components of the therapeutic process. 

A fundamental theme of this work is that bodily-based right brain affect, including specifically unconscious affect needs to be addressed in updated psychotherapeutic interventions. Studies confirm that unconscious processing of emotional stimuli is specifically associated with activation of the right and not left hemisphere: “The left side is involved with conscious response and the right with the unconscious mind” (Mlot, 1998, p. 1006).   Due to it’s unique neuroanatomical and neurobiological properties (see Figure 5),

[T]he more ‘diffuse’ organization of the right hemisphere has the effect that it responds to any stimulus, even speech stimuli, more quickly and, thus earlier. The left hemisphere is activated after this and performs the slower semantic analysis and synthesis…the arrival of an individual signal initially in the right hemisphere and then in the left is more ‘physiological.’ (Buklina, 2005, p. 479)

Even more than the patient’s late-acting rational, analytical and verbal left mind, the growth-facilitating psychotherapeutic relationship needs to directly access the regulatory boundaries and deeper psychobiological strata of both the patient’s and the clinician’s right minds. Alvarez asserts, “Schore points out that at the more severe levels of psychopathology, it is not a question of making the unconscious conscious: rather it is a question of restructuring the unconscious itself” (2006, p. 171).

Earlier I suggested that the right hemisphere is dominant in the change process of psychotherapy.  Neuroscience authors now conclude that although the left hemisphere is specialized for coping with predictable representations and strategies, the right predominates for coping with and assimilating novel situations (Podell et al., 2001) and ensures the formation of a new program of interaction with a new environment (Ezhov & Krivoschchekov, 2004).  Indeed,

The right brain possesses special capabilities for processing novel stimuli…Right-brain problem solving generates a matrix of alternative solutions, as contrasted with the left brain’s single solution of best fit. This answer matrix remains active while alternative solutions are explored, a method suitable for the open-ended possibilities inherent in a novel situation. (Schutz, 2005, p. 13)

The functions of the emotional right brain are essential to the self-exploration process of psychotherapy, especially of unconscious affects that can be integrated into a more complex implicit sense of self. Both optimal development and effective psychotherapy promote more than cognitive changes of the conscious mind, but an expansion of the right brain implicit self, the biological substrate of the human unconscious.