The Divided Therapist

Hemispheric Difference and Contemporary Psychotherapy

Rod Tweedy, Rod Tweedy

• Publisher: Routledge
• Year: 2020
• ISBN:
  9781000192506
• Edition: 1
• Topic: Psychology
• Subtopic: Developmental Psychology
• Index: Psychology

This important new book explores the nature of the divided brain and its relevance for contemporary psychotherapy. Citing the latest neuroscientific research, it shows how the relationship between the two hemispheres of the brain is central to our mental health, and examines both the practical and theoretical implications for therapy.

Disconnections, dissociations, and imbalances between our two hemispheres underlie many of our most prevalent forms of mental distress and disturbance. These include issues of addiction, autism, schizophrenia, depression, anorexia, relational trauma, borderline and personality disorders, psychopathy, anxiety, derealisation and devitalisation, and alexithymia. A contemporary understanding of the nature of the divided brain is therefore of importance in engaging with and treating these disturbances.

Featuring contributions from some of the key authors in the field, The Divided Therapist suggests that hemispheric integration lies at the heart of the therapeutic process itself, and that a better understanding of the precise mechanisms that underlie and enable this integration will help to transform the practice of psychotherapy and psychoanalysis in the twenty-first century. The book will be essential reading for any therapeutic practitioner interested in how the architecture of the brain informs and effects their client's issues and challenges.

Chapter 1

The right brain is dominant in psychotherapy

Allan N. Schore

In 2009, the American Psychological Association invited me to offer a plenary address, “The Paradigm Shift: The Right Brain and the Relational Unconscious.” In fact, that was the first time an APA plenary address was given by a member in independent practice, and by a clinician who was also psychoanalytically informed. Citing 15 years of my interdisciplinary research, I argued that a paradigm shift was occurring not only within psychology but also across disciplines, and that psychology now needed to enter into a more intense dialogue with its neighboring biological and medical sciences. I emphasized the relevance of developmental and affective neuroscience (more so than cognitive neuroscience) for clinical and abnormal psychology. And so I reported that both clinicians and researchers were now shifting focus from left brain explicit conscious cognition to right brain implicit unconscious emotional and relational functions (Schore, 2009). Only a few years before, the APA explicitly articulated its new found emphasis on the relational foundations of psychotherapy. In 2006, the APA Presidential Task Force on Evidence-Based Practice boldly stated:

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

(p. 277)

This relational trend in psychotherapy had largely evolved from seminal contributions of psychodynamic clinicians, including Sullivan (1953), Kohut (1971), Mitchell (1988), and more recently, Bromberg (2011).

Over this same time, in parallel with psychological advances in psychotherapy, the paradigm shift to a relational “two-person psychology” had also progressed within neuroscience, especially in the discipline of interpersonal neurobiology. In this chapter, I briefly summarize my work in that field, utilizing the relational perspective of regulation theory (Schore, 1994, 2003a, 2003b, 2012) to model the development, psychopathogenesis, and treatment of the implicit subjective self. This interdisciplinary work integrates psychology and biology to more deeply understand precisely how relational experiences, for better or worse, impact the early development of psychic structure and the emergent subjective self, and how these structures are expressed at all later stages of the life span, especially in psychotherapeutic contexts. My studies continue to describe the fundamental role of the early developing right brain in relational processes. In the following, I present interpersonal neurobiological models of attachment in early development, in the therapeutic alliance, in mutual therapeutic enactments, and in the therapeutic change processes. This work highlights the fact that the current emphasis on nonconscious relational processes is shared by, cross-fertilizing, and indeed transforming both psychology and neuroscience, with important consequences for clinical psychological models of psychotherapeutic change.

A major purpose of regulation theory is to construct more complex theoretical models that can generate both heuristic experimental research and clinically relevant models of human social–emotional development. My studies in attachment neurobiology indicate that mother–infant relational communications operate rapidly, beneath levels of conscious awareness, while my research in developmental neuropsychoanalysis describes the early evolution of a “relational unconscious” and a right lateralized “social brain” that represents the biological substrate of the human unconscious. A large body of brain laterality studies now confirms the principle that “The left side is involved with conscious response and the right with the unconscious mind” (Mlot, 1998, p. 1006). Regulation theory thus strongly supports currently evolving psychodynamic models of psychotherapy, especially in the treatment of early forming attachment trauma. (Throughout, for the purposes of this chapter, the term “psychodynamic” can be equated with “psychoanalytic,” and “psychotherapist” with “analyst”.)

Interpersonal neurobiology of attachment: interactive regulation and the maturation of the right brain

A major contributor to the current relational trend derives from recent advances in attachment theory, now the most influential theory of early social–emotional development available to science. Following John Bowlby’s (1969) seminal contributions, over the past two decades I have utilized an interdisciplinary relational perspective to describe and integrate the developmental psychological and biological processes that underlie the formation of an attachment bond of emotional communication between the infant and primary caregiver (Schore, 1994, 2003a, 2003b, 2012). The organizing principle of this work dictates that “the self-organization of the developing brain occurs in the context of a relationship with another self, another brain” (Schore, 1996, p. 60). At the core of the model is the relational, interactive regulation of affects, which in turn impacts and shapes the maturation of the early developing right brain.

Modern attachment theory (J. Schore & A. Schore, 2008) is essentially a theory of the development of affect regulation, and thus emotional development. During attachment episodes of right-lateralized visual–facial, auditory–prosodic, and tactile–gestural nonverbal communications, the primary caregiver regulates the infant’s burgeoning positive and negative bodily based affective states. The theory posits that the hard wiring of the infant’s developing right brain, which is dominant for the emotional sense of self, is influenced by implicit (nonconscious), right brain-to-right brain affect communicating and regulating transactions with the mother. In this manner, the evolutionary mechanism of early attachment bonding is central to all later aspects of human development, especially adaptive right brain social–emotional functions essential for survival (Schore, 1994, 2003a, 2003b, 2012).

At the most fundamental level, the right brain attachment mechanism is expressed as interactive regulation of affective–autonomic arousal, and thereby the interpersonal regulation of biological synchronicity between and within organisms. During dyadic attachment transactions, the sensitive primary caregiver implicitly attends to, perceives (recognizes), appraises, and regulates nonverbal expressions of the infant’s more and more intense states of positive and negative affective arousal. Via these communications, the mother regulates the infant’s postnatally developing central and autonomic nervous systems. In this cocreated dialogue, the “good enough” mother and her infant coconstruct multiple cycles of both “affect synchrony” that up-regulates positive affect (e.g., joy–elation, interest–excitement) and “rupture and repair” that down-regulates negative affect (e.g., fear–terror, sadness–depression, shame). Internal representations of attachment experiences are imprinted in right-lateralized implicit–procedural memory as an internal working model that encodes nonconscious strategies of affect regulation.

Emotional states are initially regulated by others, but over the course of infancy it increasingly becomes self-regulated as a result of neurophysiological development and actual lived experience. These adaptive capacities are central to the emergence of self-regulation, the ability to flexibly regulate an expanding array of positive and negative affectively charged psychobiological states in different relational contexts, thereby allowing for the assimilation of various adaptive emotional–motivational states into a dynamic, coherent, and integrated self-system. Optimal attachment experiences that engender a secure attachment with the primary caregiver thus facilitate both types of self-regulation: interactive regulation of emotions accessed while subjectively engaged with other humans in interconnected contexts, and autoregulation of emotions activated while subjectively disengaged from other humans in autonomous contexts. Regulation theory defines emotional well-being as nonconscious yet efficient and resilient switching between these two modes (interconnectedness and autonomy), depending on the relational context. Internal working models of attachment encode both of these modes of coping strategies of affect regulation. Recall that Bowlby (1969) asserted that these internal representations of attachment operate at levels beneath conscious awareness.

As the securely attached infant enters toddlerhood, his or her interactively regulated right brain visual–facial, auditory–prosodic, and tactile–gestural attachment experiences become more holistically integrated, allowing for the emergence of a coherent implicit (unconscious) emotional and corporeal sense of self (Schore, 1994). Developmental neurobiological research supports the hypothesis that the attachment mechanism is embedded in infant–caregiver right brain-to-right brain affective transactions. Neuroscientific studies with adults now clearly indicate that right (and not left) lateralized prefrontal systems are responsible for the highest level regulation of affect and stress in the brain (see Schore, 2013; Schore, 2012 for references). They also document that in adulthood the right hemisphere continues to be dominant for affiliation, while the left supports power motivation (Kuhl & Kazen, 2008; Quirin et al., 2013b).

Furthermore, my work in developmental neuropsychoanalysis models the early development of the unconscious (vs. the later-forming conscious) mind. These studies echo a basic premise of classical developmental psychoanalysis, that the first relational contact is between the unconscious of the mother and the unconscious of the infant (Palombo, Bendicsen, & Koch, 2009; J. Schore, 2012a). Throughout the life span, implicit psychobiological regulation, operating at nonconscious levels, supports the survival functions of the right brain, the biological substrate of the human unconscious (Joseph, 1992; Schore, 1994, 2003b, 2012). Consonant with this proposal, the neuropsychologist Don Tucker has asserted, “The right hemisphere’s specialization for emotional communication through nonverbal channels seems to suggest a domain of the mind that is close to the motivationally charged psychoanalytic unconscious” (2007, p. 91). Indeed, a growing body of studies document that unconscious processing of emotional information is mainly subsumed by a right hemisphere subcortical route (Gainotti, 2012), that unconscious emotional memories are stored in the right hemisphere (Gainotti, 2006), and that this hemisphere is centrally involved in maintaining a coherent, continuous, and unified sense of self (Devinsky, 2000; McGilchrist, 2009). From infancy throughout all later stages of the life span, right-lateralized spontaneous, rapidly acting emotional processes are centrally involved in enabling the organism to cope with stresses and challenges, and thus in emotional resilience and well-being.

Right brain attachment communications within the therapeutic alliance

Regulation theory dictates that early social–emotional experiences may be either predominantly regulated or dysregulated, imprinting secure or insecure attachments. Developmental neuroscience now clearly demonstrates that all children are not “resilient” but “malleable,” for better or worse (Schore, 2012). In marked contrast to the earlier described optimal growth-facilitating attachment scenario, in a relational growth-inhibiting early environment of attachment trauma (abuse and/or neglect), the primary caregiver of an insecure disorganized–disoriented infant induces traumatic states of enduring negative affect in the child (Schore, 2001, 2003a). This caregiver is too frequently emotionally inaccessible and reacts to her infant’s expressions of stressful affects inconsistently and inappropriately (massive intrusiveness or massive disengagement), and therefore shows minimal or unpredictable participation in the relational 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. Because she provides little interactive repair, the infant’s intense negative affective states are long lasting.

A large body of research now highlights the central role of insecure attachments in the psychoneuropathogenesis of all psychiatric disorders (Schore, 1996, 2003a, 2012, 2013). Watt (2003) observes, “If children grow up with dominant experiences of separation, distress, fear, and rage, then they will go down a bad pathogenic developmental pathway, and it’s not just a bad psychological pathway but a bad neurological pathway” (p. 109). More specifically, during early critical periods, frequent dysregulated and unrepaired organized and disorganized–disoriented insecure attachment histories are “affectively burnt in” the infant’s early developing right brain. Not only traumatic experiences but also the defense against overwhelming trauma, dissociation, is stored in implicit–procedural memory. In this manner, attachment trauma (“relational trauma,” Schore, 2001) is imprinted into right cortical–subcortical systems, encoding disorganized–disoriented insecure internal working models that are nonconsciously accessed at later points of interpersonal emotional stress. These insecure working models are a central focus of affectively focused psychotherapy of early forming self-pathologies and personality disorders. There is now consensus that deficits in right brain relational processes and resulting affect dysregulation underlie all psychological and psychiatric disorders. All models of therapeutic intervention across a span of psychopathologies share a common goal of attempting to improve emotional self-regulatory processes. Neurobiologically informed relational infant, child, adolescent, and adult psychotherapy can thus potentially facilitate the intrinsic plasticity of the right brain.

Recall, Bowlby (1988), a psychoanalyst, asserted that the reassessment of nonconscious internal working models of attachment is a primary goal of any psychotherapy. These interactive representations of early attachment experiences encode strategies of affect regulation, and contain coping mechanisms for maintaining basic regulation and positive affect in the face of stressful environmental challenge. Acting at levels be...

Table of contents

• Cover
• Half Title
• Endorsements
• Title Page
• Copyright Page
• Table of Contents
• List of contributors
• Acknowledgements
• Introduction
• 1. The right brain is dominant in psychotherapy
• 2. Ways of attending: how our divided brain constructs the world
• 3. Social and emotional laterality
• 4. Distinct but linked: wellbeing and the multimodal mind
• 5. Systems-centred group psychotherapy: developing a group mind that supports right brain function and right–left–right hemispheric integration
• 6. Going beyond sucking stones: connection and emergent meaning in life and in therapy
• 7. A right-brain dissociative model for right-brain disorders: dissociation vs repression in borderline and other severe psychopathologies of early traumatic origin
• 8. Growing, living and being rightly
• 9. The therapeutic purpose of right-hemispheric language
• 10. The formation of two types of contexts by the brain hemispheres as a basis for a new approach to the mechanisms of psychotherapy
• Index