847-869-1500 ext. 233

Papers by Yellowbrick Leadership

The Right Brain Implicit Self Lies at the Core of Psychoanalysis

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

To Be Published in Psychoanalytic Dialogues

For the last two decades my work has focused on the origin, psychopathogenesis, and psychotherapeutic treatment of the early forming subjective implicit self.  These neuropsychoanalytic studies of the evolution of psychic structure attempt to more deeply understand the essential psychological processes and biological mechanisms that underlie the psychobiological substrate of the human unconscious described by Freud.  Over this same time period the study of implicit unconscious phenomena has finally become a legitimate area of not only psychoanalytic but also scientific inquiry. In 2002 the neuroscientist Joseph LeDoux wrote in the journal Science, “That explicit and implicit aspects of the self exist is not a particularly novel idea. It is closely related to Freud’s partition of the mind into conscious, preconscious  (accessible but not currently accessed), and unconscious (inaccessible) levels” (p. 28).

Over the course of my writings I have provided a substantial amount of interdisciplinary evidence which supports the proposition that the early developing right brain generates the implicit self, the human unconscious (Schore, 1994, 1997, 2003a, 2005, 2007).  Current neuroscience authors are concluding, “The right hemisphere has been linked to implicit information processing, as opposed to the more explicit and more conscious processing tied to the left hemisphere” (Happaney. Zelazo, & Stuss, 2004, p. 7). And psychophysiological researchers are reporting, “We found that the left hemisphere more than the right can mediate conscious elaboration…This result is in line with previous research, that underlined a left-conscious/right-unconscious dichotomy” (Balconi & Lucchiari, 2008, p. 45).

In this presentation I want to demonstrate that current clinical and experimental studies of the unconscious, implicit domain can do more than support a clinical psychoanalytic model of treatment, but rather this interdisciplinary information can elucidate the mechanisms that lie at the core of psychoanalysis.  The body of my work strongly suggests the following organizing principles.  The concept of a single unitary “self” is as misleading as the idea of a single unitary “brain.”  Despite the designation of the verbal left hemisphere as “dominant” due to it’s capacities for explicitly processing language functions, it is the right hemisphere and it’s implicit homeostatic-survival and communication functions that is truly dominant in human existence (Schore, 2003a).  Over the life span the early-forming unconscious implicit self continues to develop, and it operates in qualitatively different ways from the later-forming conscious explicit self.  Recall Freud’s (1920) assertion that the unconscious is “a special realm, with its own desires and modes of expression and peculiar mental mechanisms not elsewhere operative.”  In essence, my work is an exploration of this “special realm.”

With the emergence of modern neuropsychoanalysis and its direct connections with contemporary neuroscience, the right brain’s dominance for an “emotional” and “corporeal” sense of self (Devinsky, 2000; Schore, 1994) is now common ground to both disciplines.   This integration clearly demonstrates that evolutionarily adaptive implicit bodily-based socioemotional functions represent the output of the unique developmental, anatomical, and psychobiological properties of the right brain.  Indeed the implicit functions and structures of the right brain represent the inner world described by psychoanalysis since its inception. From its origin in The Project for a Scientific Psychology, Freud’s explorations of the deeper levels of the human mind have exposed the illusion of a single state of surface consciousness, and revealed the essential contributions of a biological substratum of unconscious states that indelibly impact all levels of human existence. The temporal differences of right implicit and left explicit processing is described by Buklina (2005, p. 479):

The 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…the arrival of an individual signal initially in the right hemisphere and then in the left is more ‘physiological.’ (see Figure 1)

 

Right Brain

Figure 1. Implicit processing of right brain and subsequent connections
into left brain explicit system

A more profound and comprehensive understanding of the organizing principles of this rapid acting and therefore nonconscious right brain “physiological” implicit core system can provide not only essential and relevant clinical and experimental data, but also a theoretical lens which can illuminate and penetrate the fundamental problems addressed by psychoanalytic science.  Just as studies of the left brain, dominant for language and verbal processing, can never elucidate the unique nonverbal functions of the right, studies of the output of the explicit functions of the conscious mind in verbal transcripts or narratives can never reveal the implicit psychobiological dynamics of the unconscious mind (Schore, 1994, 2003a).  

This neuropsychoanalytic perspective echoes Freud’s fundamental assertion that the central questions of the human condition, which psychoanalysis directly addresses, can never be found in knowledge of how the conscious mind of the explicit self system works, but rather in a deeper understanding of the implicit psychobiological mechanisms of the unconscious mind.  Other fields of study are now appreciating the importance of this unconscious realm in all levels of human existence.  Thus not only psychoanalysis but a large number of disciplines in both the sciences and the arts are now experiencing a paradigm shift from explicit conscious cognition to implicit unconscious affect.  In a recent editorial of the journal Motivation and Emotion, Richard Ryan asserts, “After three decades of the dominance of cognitive approaches, motivational and emotional processes have roared back into the limelight” (2007, p. 1).  A large number of interdisciplinary studies are now converging upon the centrality of these implicit right brain motivational and emotional processes that are essential to adaptive functioning.

A more profound and comprehensive understanding of the organizing principles of this rapid acting and therefore nonconscious right brain “physiological” implicit core system can provide not only essential and relevant clinical and experimental data, but also a theoretical lens which can illuminate and penetrate the fundamental problems addressed by psychoanalytic science.  Just as studies of the left brain, dominant for language and verbal processing, can never elucidate the unique nonverbal functions of the right, studies of the output of the explicit functions of the conscious mind in verbal transcripts or narratives can never reveal the implicit psychobiological dynamics of the unconscious mind (Schore, 1994, 2003a).  

This neuropsychoanalytic perspective echoes Freud’s fundamental assertion that the central questions of the human condition, which psychoanalysis directly addresses, can never be found in knowledge of how the conscious mind of the explicit self system works, but rather in a deeper understanding of the implicit psychobiological mechanisms of the unconscious mind.  Other fields of study are now appreciating the importance of this unconscious realm in all levels of human existence.  Thus not only psychoanalysis but a large number of disciplines in both the sciences and the arts are now experiencing a paradigm shift from explicit conscious cognition to implicit unconscious affect.  In a recent editorial of the journal Motivation and Emotion, Richard Ryan asserts, “After three decades of the dominance of cognitive approaches, motivational and emotional processes have roared back into the limelight” (2007, p. 1).  A large number of interdisciplinary studies are now converging upon the centrality of these implicit right brain motivational and emotional processes that are essential to adaptive functioning.

Role of Implicit Learning in Contemporary Psychoanalysis

In this discussion I will describe a surface, verbal, conscious, analytic explicit self vs. a deeper nonverbal, nonconscious, holistic, emotional corporeal implicit self.  These two lateralized systems contain qualitatively different forms of cognition and therefore ways of “knowing,” as well as different memory systems and states of consciousness.  But I will argue that implicit (nonconscious) functions are much more than than just learning, memory, and attention, processes highlighted by cognitive psychology.  A psychological theory of cognition, even unconscious cognition, can not penetrate the fundamental questions of development, psychopathology, and the change process of psychotherapy.  In addition to implicit cognition (right brain unconscious processing of exteroceptive information from the outer world and interoceptive information from the inner world) the implicit concept also includes implicit affect, implicit communication, and implicit self-regulation.  The ongoing paradigm shift from the explicit cognitive to the implicit affective realm is driven by both new experimental data on emotional processes and updated clinical models for working with affective systems. Freud (1915) stressed that the work of psychotherapy is always concerned with affect states.  In my first book I expanded upon this therapeutic principle, asserting that affects are “the center of empathic communication,” and that “the regulation of conscious and unconscious feelings is placed in the center of the clinical stage” (Schore, 1994). Consonant with these ideas, the essential clinical role of implicit affect is underscored in current neuroscience research reporting unconscious processing of emotional stimuli is specifically associated with activation of the right and not left hemisphere (Morris, Ohman, & Dolan, 1998), and documenting a “right hemispheric dominance in processing of unconscious negative emotion” (Sato & Aoki, 2006) and a “cortical response to subjectively unconscious danger” (Carretie, 2005).  This work establishes the validity of the concept of unconscious (and also dissociated) affect, a common focus of the treatment of pathological defenses. In this same volume I offered a model of implicit communications within the therapeutic relationship, whereby transference-countertransference 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).  Neuroscience documents that although the left hemisphere mediates most linguistic behaviors, the right hemisphere is important for the broader aspects of communication.  This research also indicates 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).  Congruent with this model Dorpat (2001) describes the implicit process of “primary process communication” expressed in “both body movements (kinesics), posture, gesture, facial expression, voice inflection, and the sequence, rhythm, and pitch of the spoken words (p. 451).”  According to his formulation affective and object-relational information are transmitted predominantly by primary process communication, while secondary process communication has a highly complex and powerful logical syntax but lacks adequate semantics in the field of relationships.  In light of the fact that the left hemisphere is dominant for language but the right for emotional communication, I have proposed that the psychotherapy process is best described not as “the talking cure” but “the communicating” cure (Schore, 2005).  Chused (2007) now asserts, “I suspect our field has not yet fully appreciated the importance of this implicit communication (p. 879).”

Implicit Processes in Early Development

The concept of the unconscious, once uniquely studied by psychoanalysis, is crossing interdisciplinary boundaries.  Infant researchers now assert, “Preverbal communication…is the realm of non-consciously regulated intuitive behavior and implicit relational knowledge. Whether information is transferred or shared, which information gets across, and on which level it is ‘understood’, does not necessarily depend on the sender’s intention or conscious awareness” (Papousek, 2007, p. 258).  A large body of experimental data and clinical findings supports the developmental principle that rapid acting and thus implicit psychobiological attachment interactions are essential to the human infant’s development, specifically the maturation of the child’s capacity for self-regulation. These implicit affective interactions support and indeed are necessary for the experience-dependent development of the right hemisphere, the locus of the highest regulatory centers in the brain.  It is by this right brain evolutionary imprinting mechanism that early attachment experiences impact the individual at all later stages of development (Bradshaw & Schore, 2007).

In 1994 I proposed that the core of the attachment bond of emotional communication is not purely psychological, but essentially psychobiological.  During spontaneous right brain–to-right brain visual-facial, auditory-prosodic, and tactile-proprioceptive emotionally charged attachment communications, the sensitive, psychobiologically attuned caregiver regulates, at an implicit level, the infant’s states of arousal (Schore, 1994). These nonverbal interactions with the social environment are occurring during the brain growth spurt, which is maximally expressed in the early developing right hemisphere. Thus the period in which the human unconscious system initially self-organizes is a stage of right brain dominance.

Three years after I offered this model Chiron and her colleagues (1997) published a developmental neurobiological study entitled “The right brain hemisphere is dominant in human infants.”  In subsequent neuropsychological research on emotional lateralization in the second year of life Schuetze and Reid (2005) stated, “Although the infant brain was historically reported to be undifferentiated in terms of cerebral lateralisation until 2 years of age, evidence has accumulated indicating that lateralised functions are present much earlier in development” (p. 207). They further observe “lateralisation of negative emotional production to the right hemisphere in infants as young as 12 months of age,” and “a developmental enhancement of right hemisphere control of negative emotional expression that is evident by 24 months.”  Most recently Howard and Reggia (2007) conclude, “Earlier maturation of the right hemisphere is supported by both anatomical and imaging evidence” (p. 112).

This right lateralized system stores a vocabulary of nonverbal affective facial expressions, prosody, and gestures, right brain signals used in implicit attachment communications. The output of the right hemisphere, “the emotional brain” is a conscious affect.  The highest centers of this hemisphere, especially the orbitofrontal cortex, the locus of Bowlby’s attachment system, act as the brain’s most complex affect and stress regulatory system.  At the end of the first year right cortical-subcortcial circuits encode in implicit-procedural memory, an internal working model of strategies of affect regulation that nonconsciously guides the individual through interpersonal contexts.   A just-published near-infrared spectroscopy study of infant-mother attachment at 12 months concludes, “our results are in agreement with that of Schore (2000) who addressed the importance of the right hemisphere in the attachment system” (Minagawa-Kawai et al., 2008).

Implicit Processes in Psychopathogenesis

During early critical periods of brain development relational trauma-induced arousal dysregulation precludes the forementioned facial-visual, auditory-prosodic, and tactile-proprioceptive attachment communications and thereby alters the development of essential right brain functions.  In contrast to an optimal attachment scenario, in a relational growth-inhibiting early environment the primary caregiver induces traumatic states of enduring negative affect in the child. This caregiver is inaccessible and reacts to her infant's expressions of emotions and stress inappropriately and/or rejectingly, and therefore shows minimal or unpredictable participation in the various types of arousal regulating processes.  Instead of modulating she induces extreme levels of stressful stimulation and arousal, very high in abuse and/or very low in neglect.  And because she provides no interactive repair the infant’s intense negative affective states last for long periods of time.

There is now extensive evidence which indicates that stress is a critical factor that affects social interactions, especially the mother-child interaction (Suter, Huggenberger, & Schachinger, 2007). Overviewing the literature, these researchers report that during stressful life episodes mothers were less sensitive, more irritable, critical and punitive, and showed less warmth and flexibility in interactions with their children.  They conclude, “Overall, stress seems to be a factor that has the power to disrupt parenting practices seriously and results in a lower quality of the mother-child interaction” (p. 46).  In a review of parenting issues for mothers who manifest chronic stress dysregulation and diagnosed as borderline personality disorders, Newman and Stevenson (2005) conclude, “Clearly, this group of women are very fragile and experience high levels of inner turmoil. This distress, often a product of their own experiences of early abuse and attachment disruption in abusive relationships, can be re-enacted with their own infants” (p. 392). 

This re-enactment occurs in episodes of relational trauma (Schore, 2003b; in press). Interdisciplinary evidence indicates that the infant’s psychobiological reaction to severe interpersonal stressors is comprised of two separate response patterns, hyperarousal and dissociation.  During these episodes of the intergenerational transmission of attachment trauma the infant is matching the rhythmic structures of the mother’s dysregulated arousal states.  This synchronization is registered in the firing patterns of the stress-sensitive corticolimbic regions of the right brain, dominant for survival. Adamec, Blundell, and Burton (2003) report findings that “implicate neuroplasticity in right hemispheric limbic circuitry in mediating long-lasting changes in negative affect following brief but severe stress” (p. 1264). Gadea et al. (2005) conclude that an intense experience “might interfere with right hemisphere processing, with eventual damage if some critical point is reached” (p. 136).  Recall that right cortical areas and their connections with right subcortical structures are in a critical period of growth during the early stages of human development. 

The massive ongoing psychobiological stress associated with unregulated attachment trauma sets the stage for the characterological use of right brain pathological dissociation over all subsequent periods of human development. In this manner, “traumatic stress in childhood could lead to self-modulation of painful affect by directing attention away from internal emotional states” (Lane et al., 1997, p. 840).  In a transcranial magnetic stimulation study of adults Spitzer et al. (2004) report, “In dissociation-prone individuals, a trauma that is perceived and processed by the right hemisphere will lead to a ‘disruption in the usually integrated functions of consciousness’” (p. 168).  And in functional magnetic resonance imaging research Lanius et al. (2005) show predominantly right hemispheric activation in PTSD patients while they are dissociating.  They conclude that patients dissociate in order to escape from the overwhelming emotions associated with the traumatic memory, and that dissociation can be interpreted as representing a nonverbal response to the traumatic memory.

Dissociation thus reflects the inability of the right brain cortical-subcortical implicit self system to recognize and process external stimuli (exteroceptive information coming from the relational environment) and on a moment-to-moment basis integrate them with internal stimuli (interoceptive information from the body, somatic markers, the “felt experience”) (Schore, 2003b, 2008, in press).  A deficit in this integration represents a dysfunction in one of the primary operations of the right brain.  According to Schutz (2005),  

The right hemisphere operates a distributed network for rapid responding to danger and other urgent problems. It preferentially processes environmental challenge, stress and pain and manages self-protective responses such as avoidance and escape…Emotionality is thus the right brain’s ‘red phone,’ compelling the mind to handle urgent matters without delay. (p. 15)

In patients utilizing pathological dissociation at moments of stress the red phone line is dead. These data clearly suggest a paradigm shift in psychoanalytic models of psychopathogenesis, from oedipal repression to preoedipal dissociation, the “bottom-line defense.” At all developmental stages dissociation is associated with a re-activation of maternal preoedipal attachment dynamics.

Neuroscientists contend that the right hemisphere is centrally involved in “maintaining a coherent, continuous and unified sense of self” (Devinsky, 2000), and that “impaired self-awareness seems to be associated predominantly with right hemisphere dysfunction” (Andelman et al., 2004).  They also conclude “A nondominant frontal lobe process, one that connects the individual to emotionally salient experiences and memories underlying self-schemas, is the glue holding together a sense of self” (Miller et al., 2001, p. 821).  In patients who as infants experienced “dead spots” in their subjective experience and subsequently characterologically access pathological dissociation, this “glue” of the right brain emotional-corporeal implicit self too frequently fails in stressful moments of arousal dysregulation. Thus there is a deficit in implicitly generating and integrating what Stern (2004) calls “now moments,” the basic fabric of lived experience created in continuous small packages of interactions with others. These are the smallest molar unit of lived interactive experience exhibiting temporal and rhythmic patterning, and they operate at an implicit/procedural “core” level of consciousness.  Dissociation is commonly understood as “a basic part of the psychobiology of the human trauma response: a protective activation of altered states of consciousness in reaction to overwhelming psychological trauma” (Loewenstein, 1996, p. 312), but it is important to note that this restriction is not just of explicit but more importantly implicit consciousness.

The fragile unconscious system of such personalities is susceptible to mind-body metabolic collapse, and thereby a loss of energy-dependent synaptic connectivity within the right brain, expressed in a sudden implosion of the implicit self, a rupture of self-continuity, and a loss of an ability to experience a conscious affect. This collapse of the implicit self is signaled by the amplification of the affects of shame and disgust, and by the cognitions of hopelessness and helplessness. Because the right hemisphere mediates the communication and regulation of emotional states, the rupture of intersubjectivity is accompanied by an instant dissipation of safety and trust, a common occurrence in the treatment of the right brain deficits of severe personality disorders (Schore, 2007, in press).

Implicit Processes in Psychotherapy

A major tenet of my work dictates that the relevance of developmental attachment studies to the psychotherapeutic process lies in the commonality of implicit right brain-to right brain affect communicating and regulating mechanisms in the caregiver-infant and the therapist-patient relationship (the therapeutic alliance).  Not only psychoanalytic-based treatment models, but all forms of psychotherapy are now articulating the centrality of the therapeutic alliance, and are turning to attachment theory as the prime theoretical model (Schore, 2000).  In an overview of the extant literature on the therapeutic alliance Elvins suggests, “Attachment dynamics within caregiver child interactions have been robustly operationalized; and in addition to this measurement of interactional dyadic behavior, it also contains a well worked theory of the participants mental representations of the relationship.”  The attachment bond is specifically expressed in “aspects of patient, and therapist discourse in therapeutic sessions conceptually reflecting the attachment dynamic (significant affect laden disclosures from the patient, and the therapist’s response to these)” (Elvins, 2008, p. 14). 

I suggest that not left brain verbal explicit patient-therapist discourse but right brain implicit nonverbal affect-laden communication directly represents the attachment dynamic.  Just as the left brain communicates its states to other left brains via conscious linguistic behaviors so the right nonverbally communicates its unconscious states to other right brains that are tuned to receive these communications.  On this matter Stern (2005) suggests,

Without the nonverbal it would be hard to achieve the empathic, participatory, and resonating aspects of intersubjectivity. One would only be left with a kind of pared down, neutral ‘understanding’ of the other’s subjective experience. One reason that this distinction is drawn is that in many cases the analyst is consciously aware of the content or speech while processing the nonverbal aspects out of awareness. With an intersubjectivist perspective, a more conscious processing by the analyst of the nonverbal is necessary. (p. 80)

Studies show that 60% of human communication is nonverbal (Burgoon, 1985).  

Writing on therapeutic “nonverbal implicit communications” Chused (2007) asserts, “It is not that the information they contain cannot be verbalized, only that sometimes only a nonverbal approach can deliver the information in a way it can be used, particularly when there is no conscious awareness of the underlying concerns involved” (p. 879).  These ideas are echoed by Hutterer and Liss (2006), who state that nonverbal variables such as tone, tempo, rhythm, timbre, prosody and amplitude of speech, as well as body language signals may need to be re-examined as essential aspects of therapeutic technique. It is now well established that the right hemisphere is dominant for nonverbal (Benowitz et al., 1983) and emotional (Blonder, Bowers, & Heilman, 1991) communication.

Recent neuroscientific information about the emotion processing right brain is also directly applicable to models of the psychotherapy change process.  Uddin et al. (2006) conclude, “The emerging picture from the current literature seems to suggest a special role of the right hemisphere in self-related cognition, own body perception, self-awareness and autobiographical memories” (p. 65).  Decety and Chaminade (2003) describe right brain operations essential for adaptive interpersonal functioning, ones specifically activated in the therapeutic alliance:

Mental states that are in essence private to the self may be shared between individuals...self-awareness, empathy, identification with others, and more generally intersubjective processes, are largely dependent upon...right hemisphere resources, which are the first to develop. (p. 591)

This hemisphere is centrally involved in ‘implicit learning’ (Hugdahl, 1995), and “implicit relational knowledge” stored in the nonverbal domain is now proposed to be at the core of therapeutic change (Stern et al., 1998).

Knox (2003) states, “In essence, it is the concepts of implicit memory and the internal working model which provide the basis for a paradigm shift in relation to our understanding of the human psyche.”  Describing the right hemisphere as “the seat of implicit memory,” Mancia (2006) observes, “The discovery of the implicit memory has extended the concept of the unconscious and supports the hypothesis that this is where the emotional and affective - sometimes traumatic - presymbolic and preverbal experiences of the primary mother-infant relations are stored” (p. 83). Right brain autobiographical memory (Markowitsch et al., 2000) which stores insecure attachment histories is activated in the therapeutic alliance, especially under relational stress. Cortina and Liotti (2007) point out that “experience encoded and stored in the implicit system is still alive and carried forward as negative expectations in regard to the availability and responsiveness of others, although this knowledge is unavailable for conscious recall” (p. 207). These affective communications “occur at an implicit level of rapid cueing and response that occurs too rapidly for simultaneous verbal transaction and conscious reflection” (Lyons-Ruth, 2000, pp. 91-92).

More specifically, spontaneous nonverbal transference-countertransference interactions at preconscious-unconscious levels represent implicit right brain-to-right brain face-to-face nonverbal communications of fast acting, automatic, regulated and especially dysregulated bodily-based stressful emotional states between patient and therapist (Schore, 1994).  Transference is thus an activation of right brain autobiographical memory, as autobiographical negatively valenced, high intensity emotions are retrieved from specifically the right (and not left) medial temporal lobe (Buchanan, Tranel, & Adolphs, 2006).  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).  Current clinical models define transference as a selective bias in dealing with others that is based on previous early experiences and which shapes current expectancies, and as an expression of the patient’s implicit perceptions and implicit memories (Schore, 2003a).

Implicit Processes in Clinical Enactments

The quintessential clinical context for a right brain transferential-countertransferential implicit communication of a dysregulated emotional state is the heightened affective moment of a clinical enactment.  There is now agreement that enactments, "events occurring within the dyad that both parties experience as being the consequence of behavior in the other" (McLaughlin, 1991), are fundamentally mediated by nonverbal unconscious relational behaviors within the therapeutic alliance (Schore, 2003a).  These are transacted in visual-facial, auditory-prosodic, and tactile-proprioceptive emotionally-charged attachment communications, as well as in gestures and body language, rapidly expressed behaviors that play a critical role in the unconscious interpersonal communications embedded within the enactment.  Aron observes,

Gradually, patient and analyst mutually regulate each other’s behaviors, enactments, and states of consciousness such that each gets under the other’s skin, each reaches into the other’s guts, each is breathed in and absorbed by the other...Where the patient is not capable of using symbolic or metaphoric thought, the analyst may receive communications only nonverbally often in the form of bodily communications, a change in the climate, the air (mediated by the breath), a change in the feel of things (mediated by the skin).  [T]he analyst must be attuned to the nonverbal, the affective...to his or her bodily responses. (1998, p. 26)

This dyadic psychobiological mechanism allows for the detection of unconscious affects, and underlies the premise that “an enactment, by patient or analyst, could be evidence of something which has not yet been ‘felt’ by them” (Zanocco et al., 2006, p. 153).

In my book on the Repair of the Self I offered a chapter, “Clinical implications of a psychoneurobiological model of projective identification” (Schore, 2003a).  This entire chapter on moment-to-moment implicit communications within an enactment focuses on phenomena which take place in “a moment,” literally a split second.  In it I offer a slow motion analysis of the rapid dyadic psychobiological events that occur in a heightened affective moment of the therapeutic alliance.  This analysis discusses how a spontaneous enactment can either blindly repeat a pathological object relation through the therapist’s deflection of projected negative states and intensification of interactive dysregulation, or provide a novel relational experience via the therapist’s autoregulation of projected negative states and coparticipation in interactive repair. Although these are the most stressful moments of the treatment, in an optimal context the therapist can potentially act as an implicit regulator of the patient’s conscious and dissociated unconscious affective states.  This dyadic psychobiological corrective emotional experience can lead to the emergence of more complex psychic structure by increasing the connectivity of right brain limbic-autonomic circuits. 

Consonant with this conception of implicit communication (and citing my right brain neurobiological model) Ginot (2007) concludes, “Increasingly, enactments are understood as powerful manifestations of the intersubjective process and as inevitable expressions of complex, though largely unconscious self-states and relational patterns” (p. 317).  These unconscious affective interactions “bring to life and consequently alter implicit memories and attachment styles.” She further states that such intense manifestations of transference-countertransference entanglements “generate interpersonal as well as internal processes eventually capable of promoting integration and growth.”

In parallel work Zanocco (2006) characterizes the critical function of empathic physical sensations in the enactment and their central role in “the foundation of developing psychic structure of a human being.”  Enactments reflect “processes and dynamics originating in the primitive functioning of the mind, ” and they involve the analyst accomplishing a way of interacting with those patients who are not able to give representation to their instinctual impulses.  These early “primary” activities are expressed in “an unconscious mental activity which does not follow the rules of conscious activity. There is no verbal language involved. Instead, there is a production of images that do not seem to follow any order, and, even less, any system of logic” (p. 145).  Note the implications to implicit primary process cognition and right brain representations. 

According to Friedmann and Natterson (1999),

Enactments are interactions of analysand and analyst with communicative and resistive meanings that lead to valuable insight and can constitute corrective emotional experiences. Enactments that are recognized and defined become valuable dramatizing moments that have condensing, clarifying, and intensifying effects upon consciousness. (p. 220)

That said, it is important to repeat the fact that this relational mechanism is especially prominent during stressful ruptures of the therapeutic alliance.  Enactments occur at the edges of the regulatory boundaries of affect tolerance (Schore, in press), or what Lyons-Ruth describes as the “fault lines” of self-experience where “interactive negotiations have failed, goals remain aborted, negative affects are unresolved, and conflict is experienced” (2005, p. 21).  In light of the principle that an enactment can be a turning point in an analysis in which the relationship is characterized by a mode of resistance/counterresistance (Zanocco et al., 2006), these moments call for the most complex clinical skills of the therapist. 

This is due to the fact that such heightened affective moments induce the most stressful countertransference responses, including the clinician’s implicit coping strategies that are formed in his/her own attachment history.  These right brain systems regulate intense states of object relational-induced negative affect. Recall the “right hemispheric dominance in processing of unconscious negative emotion” (Sato & Aoki, 2006).   Davies (2004) documents, “It seems to me intrinsic to relational thinking that these ‘bad object relationships’ not only will but must be reenacted in the transference-countertransference experience, that indeed such reenacted aggression, rage, and envy are endemic to psychoanalytic change within the relational perspective” (p. 714).  Looking at the defensive aspect Bromberg (2005) reports, “Clinically, the phenomenon of dissociation as a defense against self-destabilization…has its greatest relevance during enactments, a mode of clinical engagement that requires an analyst’s closest attunement to the unacknowledged affective shifts in his own and the patient’s self-states” (p. 5)

On the other hand, Plakun (1999) observes that the therapist’s “refusal of the transference,” particularly the negative transference, is an early manifestation of an enactment.  The therapist’s “refusal” is expressed implicitly and spontaneously in nonverbal communications, not explicitly in the verbal narrative.  A relational perspective from dynamic system theory clearly applies to the synergistic effects of the therapist’s transient or enduring countertransferential “mindblindness” and the patient’s negatively biased transferential expectation in the co-creation of an enactment.

Making this work even more emotionally challenging, Renik (1993) offers the important observation that countertransference enactments cannot be recognized until one is already in them. Rather spontaneous activity is expressed by the clinician’s right brain, described by Lichtenberg, Lachmann, and Fosshage (1996) as a “disciplined spontaneous engagement.”  These authors observe that such events occur “at a critical juncture in analysis” and they are usually prompted by some breach or miscommunication that requires “a human response”.  Although there is a danger of “exchanges degenerating into mutually traumatizing disruptions” that “recreate pathogenic expectations”, the clinician’s communications signal a readiness to participate authentically in the immediacy of an enactment.  This is spontaneously expressed in the clinician’s facial expressions, gestures, and unexpected comments that result from an “unsuppressed emotional upsurge.” These communications seem more to pop out than to have been planned or edited, and they provide “intense moments that opened the way for examination of the role enactments into which the analyst had fallen unconsciously.”

These “communications” are therefore right brain primary process emotional and not left brain rational logical secondary process communications. Thus explicit, conscious, verbal voluntary responses are inadequate to prevent, facilitate, or metabolize implicit emotional enactments.  Bromberg (2005) refers to this in his assertion, “An interpretative stance…not only is thereby useless during an enactment, but also escalates the enactment and rigidifies the dissociation” (p. 8).  Andrade (2005) concludes,

As a primary factor in psychic change, interpretation is limited in effectiveness in pathologies arising from the verbal phase, related to explicit memories, with no effect in the pre-verbal phase where implicit memories are to be found.  Interpretation – the method used to the exclusion of all others for a century – is only partial; when used in isolation it does not meet the demands of modern broad-based-spectrum psychoanalysis. (p. 677)

But if not an explicit analytic insight–directed response, then what type of implicit cognition would the therapist use in order to guide him through stressful negative affective states, such as terror, rage, shame, disgust, etc?  What implicit right brain coping strategy could not only autoregulate the intense affect, but at the same time allow him to maintain “an attunement to the unacknowledged affective shifts in his own and the patient’s self-states”?

Implicit Processes and Clinical Intuition

In my introduction I proposed that the therapist’s moment-to-moment navigation through these heightened affective moments occurs by not explicit verbal secondary process cognition, but by implicit nonverbal primary process clinical intuition. From a social neuroscience perspective, intuition is now being defined as “the subjective experience associated with the use of knowledge gained through implicit learning” (Lieberman, 2000, p. 109).  The description of intuition as “direct knowing that seeps into conscious awareness without the conscious mediation of logic or rational process” (Boucouvalas, 1997, p. 7), clearly implies a right and not left brain function.  Bugental (1987) refers to the therapist‘s “intuitive sensing of what is happening in the patient back of his words and, often, back of his conscious awareness.” (p. 11).   In his last work Bowlby (1991) speculated, “Clearly the best therapy is done the by therapist who is naturally intuitive and also guided by the appropriate theory” (p. 16).

In a groundbreaking article Welling  (2005) notes that intuition is associated with preverbal character, affect, sense of relationship, spontaneity, immediacy, gestalt nature, and global view (all functions of the holistic right brain).  He further discusses that “There is no cognitive theory about intuition” (p. 20), and therefore “What is needed is a model that can describe the underlying formal process that produces intuition phenomena” (p. 23-24).  Developmental psychoanalysis and neuropsychoanalysis can make important contributions to our understanding of the sources and mechanism of not only maternal but clinical intuition.  With allusions to the right brain, Orlinsky and Howard (1986) contend that the "non-verbal, prerational stream of expression that binds the infant to its parent continues throughout life to be a primary medium of intuitively felt affective-relational communication between persons" (p. 343).  There are thus direct commonalities between the spontaneous responses of the maternal intuition of a psychobiologically attuned primary caregiver and the intuitive therapist’s sensitive countertransferential responsiveness to the patient’s unconscious nonverbal affective bodily-based  implicit communications.

In the neuroscience literature Volz and von Cramon (2006) conclude that intuition is related to the unconscious, and is “often reliably accurate.” It is derived from stored nonverbal representations, such as “images, feelings, physical sensations, metaphors” (note the similarity to primary process cognition).  Intuition is expressed in not language but “embodied” in a “gut feeling” or an in initial guess that subsequently biases our thought and inquiry. “The gist information is realized on the basis of the observer’s implicit knowledge rather than being consciously extracted on the basis of the observer’s explicit knowledge”  (p. 2084). 

With direct relevance to the concept of somatic countertransference, cognitive neuroscience models of intuition are now highlighting the adaptive capacity of “embodied cognition.”  Allman et al. (2005) assert, “We experience the intuitive process at a visceral level. Intuitive decision-making enables us to react quickly in situations that involve a high degree of uncertainty which commonly involve social interactions” (p. 370).  These researchers demonstrate that right prefrontal-insula and anterior cingulate relay a fast intuitive assessment of complex social situations in order to allow the rapid adjustment of behavior in quickly changing social situations.  This lateralization is also found in a neuroimaging study by Bolte and Goschke (2005), who suggest that association areas of the right hemisphere may play a special role in intuitive judgments. 

In parallel psychoanalytic work Marcus (1997) observes, “The analyst, by means of reverie and intuition, listens with the right brain to the analysand’s right brain” (p. 238).  Other clinicians hypothesize that the intuition of an experienced expert therapist lies fundamentally in a process of unconscious pattern matching (Rosenblatt and Thickstun, 1994), and that this pattern recognition follows a nonverbal path, as verbal activity interferes with achieving insight (Schooler & Melcher, 1995). Even more specifically Bohart (1999) contends that intuition involves the detection of “patterns and rhythms in interaction.”  But if not verbal stimuli, then which patterns are being intuitively tracked?

Recall, “transference is distinctive in that it depends on early patterns of emotional attachment with caregivers” (Pincus et al., 2007), and enactments are powerful expressions of “unconscious self-states and relational patterns” (Ginot, 2007).  Indeed, updated model of psychotherapy describe the primacy of “making conscious the organizing patterns of affect” (Mohaupt et al., 2006).  van Lancker and Cummings (1999) assert, “Simply stated, the left hemisphere specializes in analyzing sequences, while the right hemisphere gives evidence of superiority in processing patterns” (p. 95).  Thus I have suggested that the intuitive psychobiologically attuned therapist, on a moment-to-moment basis, implicitly tracks and resonates with the patterns of rhythmic crescendos / decrescendos of the patient’s regulated and dysregulated states of affective arousal.  Thus, intuition represents a complex right brain primary process, affectively charged embodied cognition that is adaptive for implicitly processing novelty, including object relational novelty, especially in moments of relational uncertainty.

Welling (2005) offers a phase model, in which the amount of information contained in the intuition increases from one phase to another, resulting in increased levels of complexity.  An early “detection phase” related to “functions of arousal and attention” culminates in a “metaphorical solution phase,” in which the intuition presents itself in the form of kinesthetic sensations, feelings, images, metaphors, and words. Here the solution, which has an emotional quality, is revealed, but in a veiled nonverbal form.  These descriptions reflect the activity of the right hemisphere, which is dominant for attention (Raz, 2004), kinesthesia (Naito et al., 2004), and the processing of novel metaphors (Mashal et al., 2007).

Phases of intuitive processing are thus generated in the therapists’s subcortical-cortical vertical axis of the right brain, from the right amygdala to the right orbitofrontal system (see Figure A-2 in Schore, 2003a).  The latter, the highest level of the right brain would act as an “inner compass that accompanies the decoding process of intuition” (Welling, 2005, p. 43).  The orbitofrontal system, the “senior executive of the emotional brain,” is specialized to act in contexts of “uncertainty or unpredictability” (Elliott, Dolan, & Frith, 2000).  It functions as a dynamic filter of emotional stimuli  (Rule, Shimamura, & Knight, 2002) and provides “a panoramic view of the entire external environment, as well as the internal environment associated with motivational factors” (Barbas, 2007, p. 239).  It also formulates a theory of mind, “a kind of affective-decision making” (Happeney et al., 2004, p. 4), and thereby is centrally involved in “intuitive decision-making” (Allman et al., 2005). 

I have suggested that the right orbitofrontal cortex and its subcortical and cortical connections represent what Freud described as the preconscious (Schore, 2003a).  Alluding to preconscious functions, Welling (2005) describes intuition as:

…a factory of pieces of thoughts, images, and vague feelings, where the raw materials seem to float around half formless, a world so often present, though we hardly ever visit it. However, some of these floating elements come to stand out, gain strength, or show up repeatedly. When exemplified, they may be easier to recognize and cross the border of consciousness. (p. 33)

Over the course of the treatment the clinician accesses this preconscious domain, as does the free associating patient. Rather than the therapist’s technical explicit skills the clinician’s intuitive implicit capacities may be responsible for the outcome of an affectively-charged enactment, and may dictate the depth of the therapeutic contact, exploration, and change processes. 

Implicit Process Central to Change: Affect Regulation

According to Ginot (2007), “This focus on enactments as communicators of affective building blocks also reflects a growing realization that explicit content, verbal interpretations, and the mere act of uncovering memories are insufficient venues for curative shifts” (p. 317).  This clearly implies that the resolution of enactments involves more than the standard Freudian idea of making the unconscious conscious. But if not these explicit factors, then what implicit therapeutic experience is essential to the change process, especially in developmentally impaired personalities who are not psychologically minded? At the base the implicit change mechanism must certainly include a dysregulating affective experience that is communicated to an empathic other. 

But in addition, the relational context must also afford an opportunity for interactive affect regulation, the core of the attachment process. 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)

It is the regulation of stressful and disorganizing high or low levels of affective-autonomic arousal that allows for the repair and re-organization of the right lateralized implicit self, the biological substrate of the human unconscious.

It is now clear that a deeper understanding of affective processes is closely tied to the problem of the regulation of these processes. Affect regulation, a central mechanism of both development and the change process of psychotherapy, is usually defined as set of conscious control processes by which we influence, consciously and voluntarily, the conscious emotions we have, and how we experience and express them.  In a groundbreaking article in the clinical psychology literature Greenberg (2007) describes a “self-control” form of emotion regulation involving higher levels of cognitive executive function that allows individuals “to change the way they feel by consciously changing the way they think.”  This explicit form of affect regulation is performed by the verbal left hemisphere, and unconscious bodily-based emotion is usually not addressed in this model. Notice this mechanism is at the core of insight, heavily emphasized in therapeutic models of not only classical psychoanalysis but also cognitive behavioral therapy.

In contrast to this conscious emotion regulation system, Greenberg describes a second, more fundamental implicit affect regulatory process performed by the right hemisphere. This system rapidly and automatically processes facial expression, vocal quality, and eye contact in a relational context.  Therapy attempts not control but the “acceptance or facilitation of particular emotions,” including “previously avoided emotion,” in order to allow the patient to tolerate and transform them into “adaptive emotions.’’  Citing my work he asserts, “it is the building of implicit or automatic emotion regulation capacities that is important for enduring change, especially for highly fragile personality-disordered clients” (2007, p. 416).

Even more than the patient’s late acting rational, analytical and verbal left mind, the growth-facilitating psychotherapeutic relationship needs to directly access the deeper psychobiological strata of the implicit regulatory structures of both the patient’s and the clinician’s right minds.  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). The clinical precept that unregulated overwhelming traumatic feelings can not be adaptively integrated into the patient’s emotional life is the expression of a dysfunction of “the right hemispheric specialization in regulating stress - and emotion-related processes” (Sullivan & Dufresne, 2006).  As described earlier this dissociative deficit specifically results from a lack of integration of the right lateralized limbic-autonomic circuits of the emotional brain (see Figure 1).

But recall Ginot’s assertion that enactments “generate interpersonal as well as internal processes eventually capable of promoting integration and growth.”  Indeed, long-term psychotherapy can positively alter the developmental trajectory of the right brain and facilitate the top-down and bottom-up integration of its cortical and subcortical systems (Schore, 2003a).  These enhanced right amygdala - ventral prefrontolimbic connections allow implicit therapeutic “now moments” of lived interactive experience to be integrated into autobiographical memory.  Autobiographical memory, an output of the right brain, is the highest memory system that consists of personal events with a clear relation to time, space, and context.  In this right brain state of autonoetic consciousness the experiencing self represents emotionally-toned memories, thereby allowing for “subjective time travel” (Kalbe et al., 2008).  The growth-facilitating expansion of interconnectivity within the unconscious system also promotes an increased complexity of defenses, right brain coping strategies for regulating stressful affects that are more flexible and adaptive than pathological dissociation.  This therapeutic mechanism supports the possible integration of what Bromberg (2006) calls “not-me” states into the implicit self.

Indeed, these developmental advances of the right lateralized vertical axis facilitate the further maturation of the right brain 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).  These neurobiological re-organizations of the right brain human unconscious underlie Alvarez’s (2005) assertion, “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” (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 potentially integrated into a more complex implicit sense of self. At the most essential level, the work of psychotherapy is not defined by what the therapist explicitly, objectively does for the patient, or says to the patient.  Rather the key mechanism is how to implicitly and subjectively be with the patient, especially during affectively stressful moments when the “going-on-being” of the patient’s implicit self is dis-integrating in real time.

 

References

Adamec, R.E., Blundell, J., & Burton, P. (2003), Phosphorylated cyclic AMP response element bonding protein expression induced in the periaqueductal gray by predator stress; its relationship to the stress experience, behavior, and limbic neural plasticity. Progress in Neuro-Pharmacology & Biological Psychiatry, 27: 1243-1267.

Allman, J.M., Watson, K.K., Tetreault, N.A., & Hakeem, A.Y. (2005), Intuition and autism: a possible role for Von Economo neurons. Trends in Cognitive Sciences, 9: 367-373.

Alvarez, A. (2006), Some questions concerning states of fragmentation: unintegration, under-integration, disintegration, and the nature of early integrations. Journal of Child Psychotherapy, 32: 158-180.

Andelman, F., Zuckerman-Feldhay, E., Hoffien, D., Fried, I., & Neufeld, M.Y. (2004), Lateralization of deficit in self-awareness of memory in patients with intractable epilepsy. Epilepsia, 45: 826-833.

Andrade, V.M. (2005), Affect and the therapeutic action in psychoanalysis. Internat. J. Psychoanal., 86: 677-697.

Aron, L. (1998), The clinical body and the reflexive mind.  In . L.Aron & F. Sommer Anderson (Eds.), Relational Perspectives on the Body, (pp. 3-37). Hillsdale, NJ: The Analytic Press.

Balconi, M., & Lucchiari, C. (2008), Consciousness and arousal effects on emotional face processing as revealed by brain oscillations. A gamma band analysis. International Journal of Psychophysiology, 67:41-46.

Barbas, H. (2007), Flow of information for emotions through temporal and orbitofrontal pathways. Journal of Anatomy, 211: 237-249.

Benowitz, L.I., Bear, D.M., Rosenthal, R., Mesulam, M-M., Zaidel, E., & Sperry, R.W. (1983), Hemispheric specialization in nonverbal communication Cortex: 19: 5-11.

Blonder, L.X., Bowers, D., & Heilman, K.M. (1991), The role of the right hemisphere in emotional communication. Brain, 114: 1115-1127.

Bohart, A.C. (1999), Intuition and creativity in psychotherapy. J. Constructivist Psychology, 12: 287-311.

Bolte, A., & Goschke, T. (2005), On the speed of intuition: Intuitive judgments of semantic coherence under different response deadlines. Memory & Cognition, 33: 1248-1255.

Boucouvalas, M. (1997), Intuition: The concept and the experience. In R.D. Floyd & P.S. Arvidson (Eds.), Intuition: The Inside Story (pp. 39-56). New York: Routledge.

Bowlby, J. (1991, autumn), The role of the psychotherapist’s personal resources in the therapeutic situation. In Tavistock Gazette.

Bradshaw, G.A., & Schore, A.N. (2007), How elephants are opening doors: developmental neuroethology, attachment and social context. Ethology, 113: 426-436.

Bromberg, P.M. (2006), Awakening the Dreamer: Clinical Journeys. Mahweh NJ: Analytic Press.

Buchanan, T.W., Tranel, D., & Adolphs, R. (2006). Memories for emotional autobiographical events following unilateral damage to medial temporal lobe. Brain, 129: 115-127.

Bugental, J.F. (1987), The Art of the Psychotherapist. New York : W.W. Norton.

Buklina, S.B. (2005), The corpus callosum, interhemispheric interactions, and the function of the right hemisphere of the brain. Neuroscience and Behavioral Physiology, 35: 473-480.

Burgoon, J.K. (1985), Nonverbal signals. In M.L. Knapp, & C.R. Miller (Eds.), Handbook of Interpersonal Communication (pp. 344-390). Beverly Hills CA: Sager Publications

Carretie, L., Hinojosa, J.A., Mercado, F., & Tapia, M. (2005), Cortical response to subjectively unconscious danger. NeuroImage, 24: 615-623.

Chiron, C., Jambaque, I., Nabbout, R., Lounes, R., Syrota, A., & Dulac, O. (1997), The right brain hemisphere is dominant in human infants. Brain, 120: 1057-1065.

Chused, J.F. (2007), Nonverbal communication in psychoanalysis: commentary on Harrison and Tronick. J. Amer. Psychoanal. Assn., 55: 875-882.

Cortina, M., & Liotti, G. (2007), New approaches to understanding unconscious processes: Implicit and explicit memory systems. Internat. Forum of Psychoanal., 16: 204-212.

Davies, J.M. (2004), Whose bad objects are we anyway? Repetition and our elusive love affair with evil. Psychoanal.  Dial., 14: 711-732.

Decety, J., & Chaminade, T. (2003), When the self represents the other: A new cognitive neuroscience view on psychological identification. Consciousness and Cognition, 12: 577-596.

Devinsky, O. (2000), Right cerebral hemispheric dominance for a sense of corporeal and emotional self. Epilepsy & Behavior, 1: 60-73.

Dorpat, T.L. (2001), Primary process communication. Psychoanal. Inq., 3, 448-463.

Elliott, R., Dolan, R.J. & Frith, C.D. (2000). Dissociable functions in the medial and lateral orbitofrontal cortex: evidence from human neuroimaging studies. Cerebral Cortex, 10: 308-317.

Elvins, R., & Green, J. (2008), The conceptualization and measurement of therapeutic alliance: An empirical review. Clinical Psychology Review.

Ezhov, S.N., & Krivoschekov, S.G. (2004), Features of psychomotor responses and interhemispheric relationahips at various stages of adaptation to a new time zone. Human Physiology, 30: 172-175.

Freud, S. (1915), The unconscious. Standard Edition, Vol. 14, 159-205. London, Hogarth Press, 1957.

------------ (1920), A general introduction to psycho-analysis. Standard Edition, 16.

Friedman, R.J., & Natterson, J.M. (1999), Enactmments: An intersubjective perspective. Psychoanal. Q., 68: 220-147.

Gadea, M., Gomez, C., Gonzalez-Bono, Espert, R., & Salvador, A. (2005), Increased cortisol and decreased right ear advantage (REA) in dichotic listening following a negative mood induction. Psychoneuroendocrinology, 30: 129-138.

Grabner, R.H., Fink, A., & Neubauer, A.C. (2007), Brain correlates of self-related originality of ideas: Evidence from event-related power and phase-locking changes in the EEG. Behavioral Neuroscience, 121: 224-230.

Greenberg, L.S. (2007), Emotion coming of age. Clinical Psychology Science and Practice, 2007, 14: 414-421.

Happaney, K., Zelazo, P.D., & Stuss, D.T. (2004), Development of orbitofrontal function: Current themes and future directions. Brain and Cognition, 55: 1-10.

Howard, M.F., & Reggia, J.A. (2007), A theory of the visual system biology underlying development of spatial frequency lateralization. Brain and Cognition, 64: 111-123.

Hugdahl, K. (1995). Classical conditioning and implicit learning: The right hemisphere hypothesis. In R.J. Davidson & K. Hugdahl (Eds.), Brain asymmetry  (pp. 235-267). Cambridge, MA: MIT Press.

Kalbe, E., Brand, M., Thiel, A., Kessler, J., & Markowitsch. (2008). Neuropsychological and neural correlates of autobiographical deficits in a mother who killed her children. Neurocase, 14: 15-28.

Knox, J.M. (2003), Archetype, Attachment, Analysis: The Emergence of Mind and Meaning. London: Routledge.

Lane, R.D., Ahern, G.L., Schwartz, G.E., & Kaszniak, A.W. (1997), Is alexithymia the emotional equivalent of blindsight? Biol. Psychiatry, 42: 834-844.

Lanius, R.A., Williamson, P.C., Bluhm, R.L., Densmore, M., Boksman, K., Neufeld, R.W.J., Gati, J.S., & Menon, R.S. (2005), Functional connectivity of dissociative responses in posttraumatic stress disorder: A functional magnetic resonance imaging investigation. Biological Psychiatry, 57: 873-884.

LeDoux, J. (2002), Synaptic Self: How Our Brains Become Who We Are. New York: Viking.

Lichtenberg, J.D., Lachmann, F.M., and Fosshage, J.L. (1996), The Clinical Exchange. Mahwah NJ: Analytic Press.

Lieberman, M.D. (2000), Intuition: a social neuroscience approach. Psychological Bulletin, 126: 109-137.

Loewenstein, R.J. (1996), Dissociative amnesia and dissociative fugue. In L.K. Michaelson, & W.J. Ray (Eds.), Handbook of Dissociation: Theoretical, Empirical, and Clinical Perspectives (pp. 307-336).New York, NY: Plenum.

Lyons-Ruth, K. (2005), The two-person unconscious: Intersubjective dialogue, enactive representation, and the emergence of new forms of relational organization. In L. Aron & A.

Harris (Eds.), Relational Psychoanalysis, Vol. II (pp. 2-45). Hillsdale, NJ: Analytic Press.

Mancia, M. (2006), Implicit memory and early unrepressed unconscious: Their role in the therapeutic process (How the neurosciences can contribute to psychoanalysis). Int. J. Psychoanal,, 87: 83-103.

Marcus D.M. (1997), On knowing what one knows. Psychoanal. Q., 66: 219-241.

Markowitsch, H.J., Reinkemeier, A., Kessler, J., Koyuncu, A., & Heiss, W. D. (2000), Right amygdalar and temperofrontal activation during autobiographical, but not fictitious memory retrieval. Behavioral Neurology, 12: 181-190.

Mashal, N., Faust, M., Hendler, T., & Jung-Beeman, M. (2007), An fMRI investigation of the neural correates underlying the processing of novel metaphoric expressions. Brain and Language, 100: 115-126.

McLaughlin, J. T. (1991),  Clinical and theoretical aspects of enactment. J. Amer. Psychoanal. Assn.,  39: 595-614.

Miller, B.L., Seeley, W.W., Mychack, P., Rosen, H.J., Mena, I., & Boone, K. (2001), Neuroanatomy of the self. Evidence from patients with frontotemporal dementia. Neurology, 57: 817-821.

Minagawa-Kawai, Y., Matsuoka, S., Dan, I., Naoi, N., Nakamura, K., & Kojima, S. (2008), Prefrontal activation associated with social attachment: facial-emotion recognition in mothers and infants. Cerebral Cortex.

Mohaupt, H., Holgersen, H., Binder, P-E, & Nielsen, G.H. (2006), Affect consciousness or mentalization? A comparison of two concepts with regard to affecr development and affect regulation. Scandinavian J. Psychology, 47: 237-244.

Morris, J.S., Ohman, A., & Dolan, R.J. (1998), Conscious and unconscious emotional learning in the human amygdala. Nature, 393: 467-470.

Naito, E., Roland, P.E., Grefkes, C., Choi, H.J., Eickhoff, S., Geyer, S., Zilles, K., & Ehrsson, H.H. (2005), Dominance of the right hemisphere and role of Area 2 in human kinesthesia. J. Neurophysiology, 93: 1020-1034.

Newman, L., & Stevenson, C. (2005), Parenting and borderline personality disorder. Clinical Child Psychology and Psychiatry, 10, 385-394.

Ogden, P., Pain, C., Minton, K., & Fisher, J. (2005), Including the body in mainstream psychotherapy for traumatized individuals. Psychologist-Psychoanalyst, XXV, No. 4: 19-24.

Orlinsky, D.E., & Howard, K.I. (1986), Process and outcome in psychotherapy. In S.L. Garfield & A.E. Bergin (Eds.), Handbook of Psychotherapy and Behavior Change (3rd Edn.). New York: Wiley.

Papousek, M. (2007), Communication in early infancy: An arena of intersubjective learning. Infant Behav. & Develop., 30: 258-266.

Pincus, D., Freeman, W., & Modell, A. (2007), A neurobiological model of perception. Considerations for transference. Psychoanal.  Psychol., 24: 623-640.

Plakun, E.M. (1999), Making the alliance and taking the transference in work with suicidal patients. J. Psychotherapy Practice and Research, 10: 269-276.

Podell, K., Iovell, M., & Goldberg, E. (2001), Lateralization of frontal lobe functions. In Salloway, S.P., Malloy, P.F., and Duffy, J.D. (Eds.), The Frontal Lobes and Neuropsychiatric Illness (pp. 83-89). American Psychiatric Publishing, London.

Raz, A. (2004), Anatomy of attentional networks. Anatomical Records, 281B: 21-36.

Renik, O. (1993), Countertransference enactment and the psychoanalytic process. In M.J. Horowitz, O.F. Kernberg, & E.M. Weinshel  (Eds.), Psychic Structure and Psychic Change: Essays in Honor of Robert S. Wallerstein (pp. 135-158). Madison CT: International Universities Press.

Rosenblatt, A.D., & Thickstun, J.T. (1994), Intuition and consciousness. Psychoanal. Q., 63: 696-714.

Rule, R.R., Shimamura, A.P., & Knight, R.T. (2002), Orbitofrontal cortex and dynamic filtering of emotional stimuli. Cognition, Affective, & Behavioral Neuroscience, 2: 264-270.

Ryan, R. (2007), Motivation and emotion: A new look and approach for two reemerging fields. Motivation and Emotion, 31: 1-3.

Sato, W., & Aoki, S. (2006), Right hemisphere dominance in processing unconscious emotion. Brain and Cognition, 62: 261-266.

Schooler, J., & Melcher, J. (1995), The ineffability of insight. In S.T. Smith, T.B. Ward, & R.A. Finke (Eds.), The Creative Cognition Approach (pp. 27-51). Cambridge, MA: MIT Press.

Schore, A.N. (1994), Affect Regulation and the Origin of the Self. Mahweh NJ: Erlbaum.

------------(1997), A century after Freud’s Project: Is a rapprochement between psychoanalysis and neurobiology at hand? J. Amer. Psychoanal. Assn., 45: 841-867.

------------(2000), Attachment and the regulation of the right brain. Attach. Hum. Develop., 2: 23-47.

------------(2001), The Seventh Annual John Bowlby Memorial Lecture, Minds in the making: attachment, the self-organizing brain, and developmentally-oriented psychoanalytic psychotherapy. Brit. J. Psychotherapy, 17: 299-328.

------------(2002). The right brain as the neurobiological substratum of Freud’s .dynamic unconscious. In D. Scharff (Ed.), The Psychoanalytic Century: Freud’s Legacy for the Future (pp. 61-88). New York: Other Press.

------------(2003a), Affect Regulation and the Repair of the Self. New York: W.W. Norton.

------------(2003b), Affect Dysregulation and Disorders of the Self. New York: W.W. Norton.

------------ (2005), A neuropsychoanalytic viewpoint. Commentary on paper by Steven H. Knoblauch. Psychoanal. Dial., 15: 829-854.

------------(2007), Review of Awakening the dreamer: clinical journeys by Philip M. Bromberg. Psychoanal. Dial., 17: 753-767.

------------(in press). Attachment trauma and the developing right brain: Origins of pathological dissociation. In P.F. Dell, & J.A. O’Neil (Eds.), Dissociation and the dissociative disorders: DSM-V and Beyond. New York: Routledge.

Schore, J.R., & Schore, A.N. (2008), Modern attachment theory: the central role of affect regulation in development and treatment. Clinical Social Work Journal, 36: 9-20.

Schuetze, P., & Reid, H.M. (2005), Emotional lateralization in the second year of life: Evidence from oral asymmetries. Laterality, 10: 207-217.

Schutz, L.E. (2005), Broad-perspective perceptual disorder of the right hemisphere. Neuropsychology Review, 15, 11- 27.

Spiegel, D., & Cardena, E. (1991), Disintegrated experience: the dissociative disorders revisited. Journal of Abnormal Psychology, 100: 366-378.

Spitzer, C., Wilert, C., Grabe, H-J., Rizos, T., & Freyberger, H.J. (2004), Dissociation, hemispheric asymmetry, and dysfunction of hemispheric interaction: a transcranial magnetic approach. J. Neuropsychiatry and Clinical Neurosciences, 16: 163-169.

Stern, D.N. (2004), The Present Moment in Psychotherapy and Everyday Life. New York: WW Norton.

------------(2005), Intersubjectivity. In E.S. Person, A.M. Cooper, & G.O. Gabbard (Eds.), Textbook of Psychoanalysis (pp. 77-92). Washington, DC: American Psychiatric Publishing.

------------(1998). Bruschweiler-Stern, N., Harrison, A.M., Lyons-Ruth, K., Morgan, A.C., Nahum, J.P., Sander, L., & Tronick, E.Z. The process of therapeutic change involving implicit knowledge: Some implications of developmental observations for adult psychotherapy. Infant Mental Health J., 19: 300-308.

Sullivan, R.M., & Dufresne, M.M. (2006), Mesocortical dopamine and HPA axis regulation: Role of laterality and early environment. Brain Research, 1076: 49-59.

Suter, S.E., Huggenberger, H.J., & Schachinger, H. (2007), Cold pressor stress reduces left cradling preference in nulliparous human females. Stress, 10: 45-51.

Uddin, L.Q., Molnar-Szakacs, I., Zaidel, E., & Iacoboni, M. (2006), rTMS to the right inferior parietal lobule disrupts self-other discrimination. Social Cognitive and Affective Neuroscience, 1: 65-71.

van Lancker, D., & Cummings, J.L. (1999), Expletives: neurolingusitic and neurobehavioral perspectives on swearing. Brain Research Reviews, 31: 83-104.

Volz, K.G., & von Cramon, D.Y. (2006), What neuroscience can tell about intuitive processes in the context of perceptual discovery. J. Cognitive Neurosci., 18: 2077-2087.

Welling, H. (2005), The intuitive process: the case of psychotherapy. J. Psychotherapy Integration, 15: 19-47.

Zanocco, G., De Marchi, A., & Pozzi, F. (2006), Sensory empathy and enactment. Int. J. Psychoanal., 87: 145-158.

At Yellowbrick, emerging adults find their way home.

If you or someone you know could benefit from the community-based treatment programs available at Yellowbrick, please contact Yellowbrick today at 847-869-1500.