This is an article by Allan Schore. I'm liking this author because it is very integrative and synthetic. This kinds of perspetives are extremely necessary, because, as some of you know, there are hundreds or perhaps thousands articles published each day. and it has been like this for various years, deling with new neuroscience findings. So, synthetic/integrative approaches, help to make sense of all the information, even though some of the findings cannot be considered perhaps as part of each integrative perspective, or brain structures dealt with in each integrative model (and many key processes involve series of systems/structures in parallel). This article is from 2001 I think. It deals with the role of the right brain in attachment, and the role of the orbitofrontal cortex in emotional regulation. He also makes some general associations between these types of structures and psychoanalitic concepts. And thus he goes into describing the process of attachment as the sychronization of the two right brain hemispheres within the dyadic relationship between child and mother. Or, from a psychoanalitic point of view, a synchronization or communication between the two unconscious.
MINDS IN THE MAKING: ATTACHMENT, THE SELF-ORGANIZING BRAIN, AND DEVELOPMENTALLY-ORIENTED PSYCHOANALYTIC PSYCHOTHERAPY
Allan N. S chore
It is an honor to be invited to present the Seventh Annual John Bowlby Memorial Lecture. Indeed, this is a double privilege in that it follows another last year, in which I was asked to write the Foreword to the re-issue ofBowlby's ground-breaking volume, Attachment (Bowlby 1969). In that work I surveyed, from a perspective at the close of what has been called 'the decade of the brain', his far-sighted proposals about the biological and neurological nature of attachment. Indeed, in a number of contributions I am describing how a spectrum of psychological and biological disciplines have adopted his ideas as the dominant model of human development available to science.
Each of these fields of scientific inquiry, when documenting the origins of the theory, points to Bowlby's integration of ethology (the study of behavioral biology) and psychoanalysis. In a contemporary description of the volume, Ainsworth wrote, 'In effect what Bowlby has attempted is to update psychoanalytic theory in the light of recent advances in biology' (Ainsworth 1969, p. 998). I suggest that in the three decades since the publication of Attachment, although the connections between attachment theory and science have deepened, those between itself and psycho¬analysis, especially clinical psychoanalysis, have not. This situation is currently improving, however, due to the contributions of developmental psychoanalytic and psychological attachment research that demonstrate the clinical relevance of the concepts of mental representations of internal working models and reflective functions. Experimental and clinical attachment researchers are now describing, in detail, these two fundamental characteristics of 'minds in the making', the theme of this meeting.
It has sometimes been forgotten that attachment theory is a direct outgrowth of Freud's developmental perspective, not just a repudiation of some of his early speculations. Indeed, in the very first paragraph of Attachment Bowlby (1969) begins his ground-breaking work with specific reference to Freud's fundamental goal of understanding early development. In his opening passage, he contrasts Freud's methodology for generating developmental hypotheses - analyzing the dreams and symptoms of adult neurotic patients and the behavior of primitive peoples - to his own, and so he states, 'although in his search for explanation [Freud] was in each case led to events of early childhood, he himself only rarely drew for his basic data on direct observation of children' (p. 3). Expanding this latter theme is the focus of the book, yet in the final chapter he returns to a summary of developmental psychoanalytic concepts with a chapter, 'The child's tie to his mother: a review of the psychoanalytic literature'.
In this lecture I want to present some recent interdisciplinary advances that are forging tighter links between the common goals of classical psychoanalysis and attachment theory. It may appear surprising that the new developments that are re-coupling Freud and Bowlby come from neuroscience. Yet this information bears upon a shared interest of the two most important contributors to a theory of the development of the early mind, specifically, an interest in internal psychic structure, and how it is influenced by early relational interactions.
At the very outset of his first chapter Bowlby (1969) quotes Freud's (1915a) final paragraph of 'Repression': 'We must select first one and then another point of view, and follow it up through the material as long as the application of it seems to yield results'. In ongoing writings I am presenting, from a psychoneurobiological point of view, a specification of the structural systems of the developing unconscious in terms of recent brain research. This work on 'the origin of the self (a phrase I deliberately used to evoke an echo of Darwin's phylogenetic speculations on 'the origin of species') attempts to document the ontogenetic evolution of the neurobiology of subjectivity and intersubjectivity, which I equate with specifically the experience-dependent self-organization of the early developing right hemisphere. In a 1997 article in the Journal of the American Psychoanalytic Association and another in 1999 in Neuro-Psychoanalysis, I suggested that the structural development of the right hemisphere mediates the functional development of the unconscious mind. And this year, in Attachment and Human Development, I offer further evidence to demonstrate that the right hemisphere is the repository of Bowlby's unconscious internal working models of the attachment relationship (Henry 1993; Schore 1994, 2000b; Siegel 1999).
Taking this even further, in the following, I want to suggest that an integration of current findings in the neurobiological and developmental sciences can offer a deeper understanding of the origins and dynamic mechanisms of the system that represents the core of psychoanalysis, the system unconscious. Psychoanalysis has been called the scientific study of the unconscious mind (Brenner 1980), clearly implying both that the unconscious is its definitional realm of study, and that this realm is accessible to scientific analysis. This has been so from its very inception. Although Freud was well aware of Darwin's ground-breaking biological concepts, the major science that influenced his thinking was neurology (Schore 1997a). Despite the fact that he failed to produce 'a psychology which shall be a natural science' in the 'Project for a Scientific Psychology' (1895), Freud transplanted its germinal hypotheses concerning the regulatory structures and dynamics of the system unconscious in chapter seven of his masterwork. The Interpretation of Dreams (Freud 1900).
As you remember, Freud predicted that there would some day be a rapprochement between psychoanalysis and neurobiology. A number of current rapidly expanding trends indicate that this convergence with the other sciences is now under way. Indeed, in this last year we have seen the appearance of a new journal, Neuro-Psychoanalysis, with a dual editorial board composed of both psychoanalysis and neuroscientists. The first issue centers on Freud's theory of affect, and in that journal I (Schore 1999a) present evidence from both domains of science, the study of the mind and the study of the brain, to argue that the early developing right brain or, as the neuroscientist Robert Ornstein (1997) calls it, 'the right mind', is the neurobiological substrate of Freud's system unconscious. Freud, of course, deduced that the unconscious system appears very early in life, well before verbal conscious functions. A body of research now indicates that the right hemisphere is dominant in human infancy and, indeed, for the first three years of life (Chiron et al. 1997).
Freud (1920) described the unconscious as 'a special realm, with its own desires and modes of expression and peculiar mental mechanisms not elsewhere operative'. Due to its central role in unconscious functions and primary process activities, psychoanalysis has been intrigued with the unique operations of the early developing right brain for the last quarter of a century. In the 1970s Galin (1974), Hoppe (1977), Stone (1977), and McLaughlin (1978), stimulated by the split brain studies of the time, began to link up psychoanalysis and neurobiology by positing that the right hemisphere is dominant for unconscious and the left for conscious processes.
The relevance of hemispheric specialization to psychoanalysis continued in the work of Miller (1991), Levin (1991) and, particularly, Watt (1990). Watt suggested that the right hemisphere contains an affective-configurational representational system, one that encodes self-and-object images, while the left utilizes a lexical-semantic mode. In fact, current neurobiological studies are revealing greater right than left hemispheric involvement in the unconscious processing of affect-evoking stimuli (Wexler et al. 1992). Most intriguingly, a neuroimaging study of Morris, Ohman and Dolan (1998) demonstrates that unconscious processing of emotional stimuli is specifically associated with activation of the right and not left hemisphere, and the reporter in the journal Science described this finding as indicating that 'the left side is involved with conscious response and the right with the unconscious mind' (Miot 1998,p. 1006).
In an updated description of the unconscious, Winson (1990, p. 96) concludes:
Rather than being a cauldron of untamed passions and destructive wishes, I propose that the unconscious is a cohesive, continually active, mental structure that takes note of life's experiences and reacts according to its scheme of interpretation.
Notice his use of the term structure. Although psychoanalysis has used this term to describe internal cognitive processes, such as representations and defenses, and content, such as conflicts and fantasies, I suggest that structure refers to those specific brain systems, particularly right brain systems, that underlie these various mental functions. In other words the internal psychic systems involved in processing information at levels beneath awareness, described by Freud in his topographic (1900) and structural (1923) models, can now be identified by neuroscience.
A common ground of psychoanalysis, neurobiology and psychology is an emphasis on the centrality of early development. In 1913 Freud proclaimed: 'from the very first, psychoanalysis was directed towards tracing developmental processes. It... was led... to construct a genetic psychology' (Freud 1913b, pp. 182-183). Continuing this tradition, I would argue that the most significant psychoanalytic contributor to our understanding of developmental processes was, indeed, John Bowlby (Schore 2000a, 2000b). As mentioned earlier, in Attachment he applied then current biology to a psychoanalytic understanding of infant-mother bonding, and in so doing offered his 'Project', an attempt to produce a natural science of developmental psychology. This volume focused upon one of the major questions of science, specifically, how and why do certain early ontogenetic events have such an inordinate effect on everything that follows? Bowlby's scientifically-informed curiosity about this question envisioned the center stage of human infancy, on which is played the first chapter of the human drama, to be a context in which a mother and her infant experience connections and disconnections of their vital emotional communications.
Because these communications are occurring in the period of the brain growth spurt that continues through the second year of life (Dobbing & Sands 1973), attachment transactions mediate 'the social construction of the human brain' (Eisenberg 1995), specifically the social emotional brain that supports the unique operations of 'the right mind'. Attachment is thus inextricably linked to developmental neuroscience. Stem has recently written, 'Today it seems incredible that, until Bowlby, no one placed attachment at the center of human development' (Stern 2000, p. xiii). I suggest that the great advances in our knowledge of early development have been the engine which has transformed contemporary psychoanalysis which, according to Cooper, is 'anchored in its scientific base in developmental psychology and in the biology of attachment and affects' (Cooper 1987, p. 83).
In 1920 Freud proclaimed that 'the unconscious is the infantile mental life'. This fundamental tenet is directly relevant to the topic of today's Bowlby Memorial Conference, Minds in the Making, and suggests that what particularly interests us here are unconscious minds in the making. We now know that an infant functions in a fundamentally unconscious way, and unconscious processes in an older child or adult can be traced back to the primitive functioning of the infant. Knowledge of how the maturation of the right brain, 'the right mind', is directly influenced by the attachment relationship offers us a chance to understand more deeply not just the contents of the unconscious, but its origin, structure and dynamics.
In Affect Regulation and the Origin of the Self (Schore 1994) I described a number of psychoneurobiological mechanisms by which attachment experiences specifically impact the experience-dependent maturation of the right hemisphere. In a continuation of this work, in a just published article (Schore 2000b), I offer an overview of Bowlby' s classic volume and argue that attachment theory is fundamentally a regulatory theory. In the following talk I want to offer some ideas about the psychobiological regulatory events that mediate the attachment process, and the psychoneurobiological regulatory mechanisms by which 'the right mind' organizes in infancy.
In the latter part of this lecture I will suggest that regulation theory describes the mechanisms by which the patient forms an attachment, that is, a working or therapeutic alliance with the therapist. This construct - created to define the subtle, interactive dynamic relationship between patient and therapist - is the most important conceptualization of the common elements of the different therapy modalities (Horvath & Greenberg 1994; Safran & Muran, 2000). In a just published volume, Bradley (2000) points out that all psychotherapies, psychodynamic, cognitive-behavioral, experiential and interactional, show a similarity in promoting affect regulation.
In other words, this information about attachment, regulation and the emotion-processing right brain is describing the 'nonspecific factors' that are common to all forms of clinical treatment, factors particularly accessed in developmentally-oriented psychoanalytic psychotherapy (Schore 2000e). The major contribution of attachment theory to clinical models is thus its elucidation of the nonconscious dyadic affecttransacting mechanisms that mediate a positive therapeutic working alliance between the patient and the empathic therapist. Complementing this, the neurobiological aspects of attachment theory allow for a deeper understanding of how an affect-focused developmentally oriented treatment can alter internal structure within the patient's brain/mind/body systems. (Throughout the following, the term 'psychoanalyse is equated with "psychoanalytically-oriented psychotherapist'.)
The Neurobiology of a Secure Attachment
The essential task of the first year of human life is the creation of a secure attachment bond between the infant and primary caregiver. Indeed, as soon as the child is born, it uses its maturing sensory capacities, especially smell, taste and touch, to interact with the social environment. But at 2 months a developmental milestone occurs in the infant brain, specifically, the onset of a critical period in the maturation of the occipital cortex (Yamada et al. 2000). This allows for a dramatic progression of its social and emotional capacities. In particular, the mother's emotionally expressive face is, by far, the most potent visual stimulus in the infant's environment, and the child's intense interest in her face, especially in her eyes, leads him to track it in space, and to engage in periods of intense mutual gaze. The infant's gaze, in turn, reliably evokes the mother's gaze, thereby acting as a potent interpersonal channel for the transmission of 'reciprocal mutual influences'. It has been observed that the pupil of the eye acts as a nonverbal communication device (Hess 1975) and that large pupils in the infant release caregiver behavior (see Figure 1, p. 304). According to Feldman, Greenbaum, and Yirmiya:
Face-to-face interactions, emerging at approximately 2 months of age, are highly arousing, affect-laden, short interpersonal events that expose infants to high levels of cognitive and social information. To regulate the high positive arousal, mothers and infants... synchronize the intensity of their affective behavior within lags of split seconds. (Feldman et al. 1999, p. 223, my italics).
In this process of 'affect synchrony' the intuitive (Papousek & Papousek 1995) mother initially attunes to and resonates with the infant's resting state but, as this state is dynamically activated (or deactivated or hyperactivated), she fine-tunes and corrects the intensity and duration of her affective stimulation in order to maintain the child's positive affect state. As a result of this moment by moment state of matching both partners increase together their degree of engagement. The fact that the coordination of responses is so rapid suggests the existence of a bond of unconscious communication.
In this interpersonal context of 'contingent responsivity' the more the mother tunes her activity level to the infant during periods of social engagement, the more she allows him to recover quietly in periods of disengagement, and the more she contingently responds to his signals for reengagement, the more synchronized their interaction (see Figure 2, p. 304). Lester, Hoffman and Brazelton (1985, p. 24) state that 'synchrony develops as a consequence of each partner's learning the rhythmic Structure of the other and modifying his or her behavior to fit that structure'. The primary caregiver thus facilitates the infant's information processing by adjusting the mode, amount, variability and timing of stimulation to its actual temperamental-physiological abilities. These mutually attuned synchronized interactions are fundamental to the ongoing affective development of the infant.
Reciprocal facial signalling thus represents an open channel of social communication, and this interactive matrix promotes the outward expression of internal affects in infants. In order to enter into this communication, the mother must be psychobiologically attuned not so much to the child's overt behavior as to the reflections of his internal state. In light of the fact that misattunements are a common developmental phenomenon, she must also modulate nonoptimal high levels of stimulation which would trigger hyperarousal, or low levels which engender hypoarousal in the infant.
Most importantly, the arousal-regulating primary caregiver must participate in interactive repair to regulate interactively induced stress states in the infant. If attachment is interactive synchrony, stress is defined as an asynchrony in an interactional sequence, and, following this, a period of re-established synchrony allows for stress recovery. In this reattunement pattern of 'disruption and repair' the 'good-enough' caregiver, who induces a stress response in her infant through a misattunement, self-corrects and, in a timely fashion, reinvokes her psycho¬biologically attuned regulation of the infant's negative affect state that she has triggered. The key to this is the caregiver's capacity to monitor and regulate her own affect, especially negative affect.
These regulatory processes are precursors of psychological attachment and its associated emotions. An essential attachment function is 'to promote the synchrony or regulation of biological and behavioral systems on an organismic level' (Reite & Capitanio 1985, p. 235). Indeed, psychobiological attunement, interactive resonance,and the mutual synchronization and entrainment of physiological rhythms are fundamental processes that mediate attachment bond formation, and attachment can be defined as the interactive regulation of biological synchronicity between organisms (Schore 1994, 2000a, 2000b,2000f, 200 la, 200Ib).
To put this another way, in forming an attachment bond of somatically expressed emotional communications, the mother is synchronizing and resonating with the rhythms of the infant's dynamic internal states and then regulating the arousal level of these negative and positive states. Attachment is thus the dyadic (interactive) regulation of emotion (Sroufe 1996). The baby becomes attached to the psycho-biologically attuned regulating primary caregiver who not only minimizes negative affect but also maximizes opportunities for positive affect. Attachment is not just the re-establishment of security after a dysregulating experience and a stressful negative state, it is also the interactive amplification of positive affects, as in play states. Regulated interactions with a familiar, predictable primary caregiver create not only a sense of safety, but also a positively charged curiosity that fuels the burgeoning self's exploration of novel socioemotional and physical environments.
Furthermore, attachment is more than overt behavior, it is internal, 'being built into the nervous system, in the course and as a result of the infant's experience of his transactions with the mother' (Ainsworth 1967, p. 429). Next question - in this 'transfer of affect between mother and infant', what do we know of 'the processes whereby the primary object relations become internalized and transformed into psychic structure?' The work of Trevarthen on maternal-infant protoconversations bears directly on this problem (see Figure 3, p. 305). He notes that 'the intrinsic regulators of human brain growth in a child are specifically adapted to be coupled, by emotional communication, to the regulators of adult brains' (Trevarthen 1990, p. 357). In these transactions, the resonance of the dyad ultimately permits the intercoordination of positive affective brain states. His work underscores the fundamental principle that the baby's brain is not only affected by these transactions, its growth requires brain-brain interaction and occurs in the context of an intimate positive affective relationship. These findings support Emde's assertion that 'It is the emotional availability of the caregiver in intimacy which seems to be the most central growth-promoting feature of the early rearing experience' (Emde 1988, p. 32).
There is now consensus that interactions with the environment during sensitive periods are necessary for the brain as a whole to mature. But we know that different regions of the brain mature at different times. Can we tell what specific parts of the growing brain are affected by these emotion transacting events? It has been observed that:
The emotional experience of the infant develops through the sounds, images, and pictures that . constitute much of an infant's early learning experience, and are disproportionately stored or processed in the right hemisphere during the formative stages of brain ontogeny. (Semrud-Clikeman & Hynd 1990, p. 198)
A body of evidence shows that the right hemisphere matures before the left, a finding in line with Freud's assertion that primary process ontogenetically precedes secondary process functions.
The learning mechanism of attachment, imprinting, is defined as synchrony between sequential infant maternal stimuli and behavior (Petrovich & Gewirtz 1985). I suggest that, in these affectively synchronized, psychobiologically attuned face-to-face interactions, the infant's right hemisphere, which is dominant for the infant's recognition of the maternal face, and for the perception of arousal-inducing maternal facial affective expressions, visual emotional information and the prosody of the mother's voice, is focusing her attention on and is therefore regulated by the output of the mother's right hemisphere, which is dominant for nonverbal communication, the processing and expression of facially and prosodically expressed emotional information, and for the maternal capacity to comfort the infant. In support of this, Ryan and his colleagues, using EEG and neuroimaging data, now report that 'the positive emotional exchange resulting from autonomy-supportive parenting involves participation of right hemispheric cortical and subcortical systems that participate in global, tonic emotional modulation' (Ryan et al. 1997, p. 719).
There are now clear experimental and theoretical indications that this emotional exchange also affects the development of the infant's consciousness (another primary factor to the theme here of 'minds in the making'). Tronick and his colleagues are now describing how microregulatory social-emotional processes of communication generate intersubjective states of consciousness in the infant-mother dyad. In such there is 'a mutual mapping of (some of) the elements of each interactant's state of consciousness into each of their brains' (Tronick & Weinberg 1997, p. 75). Tronick et al. (1998) argue that the infant's self-organizing system, when coupled with the mother's, allows for a brain organization which can be expanded into more coherent and complex states of consciousness. I suggest that Tronick is describing an expansion of what the neuroscientist Edelman (1989) calls primary consciousness, which relates visceral and emotional information pertaining to the biological self, to stored information processing pertaining to outside reality. Edelman lateralizes primary consciousness to the right brain.
Thus, regulation theory suggests that attachment is, in essence, the right brain regulation of biological synchronicity between organisms. Feldman et al. (1999) have recently published a study entitled, 'Mother-infant affect synchrony as an antecedent of the emergence of self-control'. At the same time Caravan, Ross and Stein (1999) reported, in a functional magnetic resonance imaging (fMRI) study, 'Right hemispheric dominance of inhibitory control'. These data bear upon Bowlby's (1969) assertion, 30 years ago, that attachment behavior is organized and regulated by means of a 'control system' within the central nervous system.
Maturation of an Orbitofrontal Regulatory System
Bowlby hypothesized that the maturation of the attachment control system is open to influence by the particular environment in which development occurs. Current neurobiological studies show that the mature orbitofrontal cortex acts in 'the highest level of control of behavior, especially in relation to emotion' (Price et al. 1996, p. 523) and plays 'a particularly prominent role in the emotional modulation of experience' (Mesulam 1998, p. 1035). The orbitofrontal regions are not functional at birth. Over the course of the first year limbic circuitries emerge in a sequential progression, from amygdala to anterior cingulate to insula and finally to orbitofrontal (Schore 1997b, 2000c, 200 la). And so, as a result of attachment experiences, this system enters a critical period of maturation in the last quarter of the first year, the same time that working models of attachment are first measured.
The orbital prefrontal cortex is positioned as a convergence zone where the cortex and subcortex meet. It is the only cortical structure with direct connections to the hypothalamus, the amygdala, and the reticular formation in the brain stem that regulates arousal (see Figure 4, p. 305), and through these connections it can modulate instinctual behavior and internal drives. But because it contains neurons that process face and voice information, this 'key prefrontal region for encoding information' (Frey & Petrides 2000) is also capable of appraising changes in the external environment, especially the social, object-related environment. Due to its unique connections, at the orbitofrontal level cortically processed information concerning the external environment (such as visual and auditory stimuli emanating from the emotional face of the object) is integrated with subcortically processed information regarding the internal visceral environment (such as concurrent changes in the emotional or bodily self state). In this manner, the (right) orbitofrontal cortex and its connections function in the 'integration of adaptive bodily responses with ongoing emotional and attentional states of the organism (Critchley et al. 2000b, p. 3033).
The orbitofrontal system is now described as 'a nodal cortical region that is important in assembling and monitoring relevant past and current experiences, including their affective and social values' (Cavada et al. 2000, p. 238). In a recent entire issue of the journal Cerebral Cortex on 'The mysterious orbitofrontal cortex', the editors conclude that:
the orbitofrontal cortex is involved in critical human functions, such as social adjustment and the control of mood, drive and responsibility, traits that are crucial in defining the 'personality' of an individual. (Cavada & Schultz 2000, p. 205)
This frontolimbic cortex is situated at the hierarchical apex of an 'anterior limbic prefrontal network' interconnecting the orbital and medial prefrontal cortex with the temporal pole, cingulate, and amygdala. This cortical-subcortical limbic network is involved in 'affective responses to events and in the mnemonic processing and storage of these responses' (Carmichael & Price 1995, p. 639). The limbic system is now thought to be centrally implicated in the implicit processing of facial expressions without conscious awareness (Critchley et al. 2000a), in the capacity 'to adapt to a rapidly changing environment', and in 'the organization of new learning' (Mesulam 1998, p. 1028). Current findings thus support Bowlby's (1969) and Anders and Zeanah's (1984) speculation that the limbic system is the site of developmental changes associated with the rise of attachment behaviors. Indeed, it is now held that 'the integrity of the orbitofrontal cortex', the highest level of the limbic system, 'is necessary for acquiring very specific forms of knowledge for regulating interpersonal and social behavior' (Dolan 1999, p. 928).
The orbitofrontal system, the 'senior executive' of the social-emotional brain, is especially expanded in the right cortex (Falk et al. 1990), and in its role as an executive of limbic arousal it comes to act in the capacity of an executive control function for the entire right brain (see Figure 5, p. 306). This hemisphere, which is dominant for unconscious processes, performs, on a moment to moment basis, a 'valence tagging' function in which perceptions receive a positive or negative affective charge in accord, as Freud speculated, with a calibration of degrees of pleasure-unpleasure. Very recent studies show that the right hemisphere is faster than the left in performing valence-dependent, automatic, pre-attentive appraisals of emotional facial expressions (Pizzagalli et al. 1999). It also contains a 'nonverbal
affect lexicon', a vocabulary for nonverbal affective signals such as facial expressions, gestures and vocal tone or prosody (Bowers et al. 1993; Snow 2000), a finding directly relevant to Bowlby's (1969, p. 120) speculation that, in intimate settings, human feelings are detected through 'facial expressions, posture, tone of voice, physiological changes, tempo of movement, and incipient action'.
The right hemisphere is more so than the left, deeply connected into not only the limbic system but also both the sympathetic and parasympathetic branches of the autonomic nervous system (ANS), that are responsible for the somatic expressions of all emotional states. For this reason the right hemisphere is dominant for a sense of corporeal and emotional self (Devinsky 2000; Schore 1994), and the representation of visceral and somatic states and the processing of 'self-related material' (Keenan et al. 1999) are under primary control of the 'non-dominant' hemisphere. The ANS has been called the 'physiological bottom of the mind' (Jackson 1931).
The connections of the highest centers of the limbic system into the hypothalamus, the head ganglion of the ANS and anatomical locus of drive centers, supports Freud's idea about the central role of drive in the system unconscious. The fact that the right hemisphere contains 'the most comprehensive and integrated map of the body state available to the brain' (Damasio 1994, p. 66) indicates that Freud's (1915b) definition of 'drive' as 'the psychical representative of the stimuli originating from the organism and reaching the mind' may be more properly characterized as reaching the 'right mind' (Ornstein 1997). It may also elucidate Freud's remark to Groddeck: 'the unconscious is the proper mediator between the somatic and the mental, perhaps the long-sought "missing link"' (Groddeck 1977, p. 38).
For the rest of the lifespan the right brain plays a superior role in the regulation of fundamental physiological and endocrinological functions whose primary control centers are located in subcortical regions of the brain. Since the hypothalamo-pituitary-adrenocortical axis and the sympathetic-adrenomedullary axis are both under the main control of the right cerebral cortex, this hemisphere contains 'a unique response system preparing the organism to deal efficiently with external challenges', and so its adaptive functions mediate the human stress response (Wittling 1997, p. 55). It therefore is centrally involved in the vital functions that support survival and enable the organism to cope actively and passively with stress (Sullivan & Gratton 1999; Schore, 2001a). In support of Bowlby's speculation that the infant's 'capacity to cope with stress' is correlated with certain maternal behaviors (Bowlby 1969, p. 344), the attachment relationship directly shapes the maturation of the infant's right brain stress-coping systems that act at levels beneath awareness.
The right hemisphere contributes to the development of reciprocal interactions within the mother-infant regulatory system and mediates the capacity for biological synchronicity, the regulatory mechanism of attachment. Due to its role in regulating the biological synchronicity between organisms, the activity of this hemisphere is instrumental to the empathic perception of the emotional states of other human beings (Schore 1994, 1996, 1997c, 1998a, 1998b, 1998c, 1998d, in press a). According to Adolphs et al., 'recognizing emotions from visually presented facial expressions requires right somatosensory cortices', and in this manner 'we recognize another individual's emotional state by internally generating somatosensory representations that stimulate how the individual would feel when displaying a certain facial expression' (Adolphs et al. 2000, p. 2683). The interactive regulation of right brain attachment biology is thus the substrate of empathy.
The right brain stores an internal working model of the attachment relationship which encodes strategies of affect regulation that maintain basic regulation and positive affect even in the face of environmental challenge (Schore 1994). Since the right hemisphere is centrally involved in unconscious processes and in 'implicit learning' (Hugdahl 1995), this unconscious model is stored in right cerebral implicit-procedural memory. Neuropsychological studies now also reveal that the right hemisphere, 'the right mind', and not the later forming verbal-linguistic left, is the substrate of affectively-laden autobiographical memory (Fink et al. 1996).
Current psychobiological models refer to representations of the infant's affective dialogue with the mother which can be accessed to regulate its affective state (Polan & Hofer 1999). The orbitofrontal area 'is particularly involved in situations in which internally generated affective representations play a critical role' (Zaid & Kim 1996). Because this system is responsible for 'cognitive-emotional interactions' (Barbas 1995), it generates internal working models. These mental representations, according to Main, Kaplan and Cassidy (1985), contain cognitive as well as affective components and act to guide appraisals of experience. Recent findings - that the orbitofrontal cortex generates nonconscious biases that guide behavior before conscious knowledge does (Bechara et al. 1997), codes the likely significance of future behavioral options (Dolan 1999), and represents an important site of contact between emotional information and mechanisms of action selection (Rolls 1996) - are consonant with Bowlby's (1981) assertion that unconscious internal working models are used as guides for future action.
According to Fonagy and Target (1997) an important outcome of a secure attachment is a reflective function, a mental operation that enables the perception of another's state. Brothers (1995,1997) describes a limbic circuit of orbitofrontal cortex, anterior cingulate gyrus, amygdala, and temporal pole which functions as a social 'editor' that is 'specialized for processing others' social intentions' by appraising 'significant gestures and expressions' (Brothers 1997, p. 27) and 'encourages the rest of the brain to report on features of the social environment' (p. 15). The editor acts as a unitary system 'specialized for responding to social signals of all kinds, a system that would ultimately construct representations of the mind' (p. 27). A recent neuropsychological study indicates that the orbitofrontal cortex is 'particularly involved in theory of mind tasks with an affective component' (Stone et al. 1998, p. 651).
As previously mentioned, the orbitofrontal control system plays an essential role in the regulation of emotion. This frontolimbic system provides a high level coding that flexibly coordinates exteroceptive and interoceptive domains and functions to correct responses as social conditions change, processes feedback information, and thereby monitors, adjusts, and corrects emotional responses and modulates the motivational control of goal-directed behavior. It thus acts as a recovery mechanism that efficiently monitors and regulates the duration, frequency and intensity of not only positive but negative affect states. Damasio's recent publication emphasizes that developmental neurological damage of this system in the first two years leads to abnormal development of social and moral behaviors (Anderson et al. 1999).
The orbital cortex matures in the middle of the second year, a time when the average child has a productive vocabulary of less than 70 words. The core of the self is thus nonverbal and unconscious, and it lies in patterns of affect regulation. This structural development allows for an internal sense of security and resilience that comes from the intuitive knowledge that one can regulate the flows and shifts of one's bodily-based emotional states either by one's own coping capacities or within a relationship with caring others. In developmental neurobiological studies, Ryan and colleagues (1997) conclude that the operation of the right prefrontal cortex is integral to autonomous regulation, and that the activation of this system facilitates increases in positive affect in response to optimally challenging or personally meaningful situations, or decreases in negative affect in response to stressful events. Confirming earlier proposals for a central role of the right orbitofrontal areas in essential self functions (Schore 1994, 1996), current neuroimaging studies now demonstrate that the processing of self occurs within the right prefrontal cortices (Keenan et al. 2000), and that the self concept is represented in right frontal areas (Craik et al. 1999).
The functioning of the 'self-correcting' orbitofrontal system is central to self-regulation, the ability to regulate flexibly emotional states through interactions with other humans - interactive regulation in interconnected contexts via a two-person psychology, and without other humans - autoregulation in autonomous contexts via a one-person psychology. The adaptive capacity to shift between these dual regulatory modes, depending upon the social context, emerges out of a history of secure attachment interactions of a maturing biological organism and an early attuned social environment. The essential aspect of this function is highlighted by Westen (1997, p. 542), who asserts that 'The attempt to regulate affect - to minimize unpleasant feelings and to maximize pleasant ones - is the driving force in human motivation'.
The Right Hemisphere, Attachment Theory, and the Empathic Reception of Unconscious Emotional Communications
Earlier I described an optimal developmental scenario, one that facilitates the experience-dependent growth of an efficient regulatory system in the right hemisphere that supports functions associated with a secure attachment. On the other hand, growth-inhibiting environments negatively impact the ontogeny of self-regulatory prefrontal systems and generate attachment disorders, and such early disturbances of personality formation are mechanisms for the transmission of psychopathology. Recall Bowlby's (1978) prediction that:
In the fields of etiology and psychopathology [attachment theory] can be used to frame specific hypotheses which relate different family experiences to different forms of psychiatric disorder and also, possibly, to the neurophysiological changes that accompany them.
Very recent neuropsychiatric research demonstrates that reduced volume of prefrontal areas serves as an 'endophenotypic marker of disposition to psychopathology' (Matsui et al. 2000, p. 155).
In a number of works I have provided clinical and neurobiological evidence to show that various forms of attachment pathologies specifically represent inefficient patterns of organization of the right brain, especially the right orbitofrontal areas (Schore 1994, 1996, 1997b; see 2001b for a theory of trauma). Yet all share a common deficit - due to the impaired development of the right cortical preconscious system that decodes emotional stimuli by actual felt emotional responses to stimuli, individuals with poor attachment histories display empathy disorders, the limited capacity to perceive the emotional states of others. An inability to read facial expressions leads to a misattribution of emotional states and a misinterpretation of the intentions of others. Thus there are deficits in the processing of socioemotional information.
In addition to this deficit in social cognition, the deficit in self-regulation is manifest in a limited capacity to modulate the intensity and duration of affects, especially biologically primitive affects like shame, rage, excitement, elation, disgust, panic-terror, and hopeless-despair. Under stress such individuals experience not discrete and differentiated affects, but diffuse, undifferentiated, chaotic states accompanied by overwhelming somatic and visceral sensations. The poor capacity for what Fonagy and Target (1997) call mentalization leads to a restricted ability to reflect upon their emotional states. Right cortical dysfunction is specifically associated with alterations in body perception and disintegration of self-representation (Weinberg 2000). And Solms has also described a mechanism by which disorganization of a damaged or developmentally deficient right hemisphere is associated with a 'collapse of internalized representations of the external world' in which 'the patient regresses from whole to part object relationships' (Solms 1996, p. 347), a hallmark of early forming personality disorders.
There is now consensus that the psychotherapy of these 'developmental arrests' is directed toward the mobilization of fundamental modes of development (Emde 1990) and the completion of interrupted developmental processes (Gedo 1979). This development is specifically emotional development. Recall Winnicott's dictum that the therapist must understand, at an intuitive level, specifically the emotional history of the patient:
In order to use the mutual experience one must have in one's bones a theory of the emotional development of the child and the relationship of the child to the environmental factors. (Winnicott 1971, p. 3, my italics)
With patients, especially those manifesting early forming attachment pathologies and therefore developmental disorders of self-regulation, the psychotherapeutic interaction functions as an attachment relationship. Very recent models suggest that affect dysregulation is a fundamental mechanism of all psychiatric disorders (Taylor etal. 1997), that all psychotherapies show a similarity in promoting affect regulation (Bradley 2000), and that the goal of attachment-focused psychotherapy is the mutual regulation of affective homeostasis and the restructuring of interactive representations encoded in implicit-procedural memory (Amini et al. 1996).
In 1913 Freud proclaimed, 'It remains the first aim of treatment to attach him [the patient] to it [the process of analysis] and to the person of the doctor' (Freud 1913a, p. 139). What can current ideas about attachment as the dyadic regulation of emotion and research on the right brain tell us about this process? The direct relevance of developmental attachment studies to the psychotherapeutic process derives from the ; commonality of interactive right brain to right brain emotion-transacting mechanisms in the caregiver-infant attachment relationship and in the clinician-patient therapeutic relationship (Schore 1994, 1997c, 1998c, 1999b, in press a, b). A number of authors ' have pointed out the direct parallels between the clinical attributes of an effective ; therapist and the parental characteristics of the psychobiologically attuned intuitive . caregiver of a securely attached child (e.g. Holmes 1993a; Dozieretal. 1994; Schore
1994; Sable 2000); Embedded in Freud's description of the aim of the treatment is the centrality of the ,- concept of attachment to the operational definition of the therapeutic alliance. For a working alliance to be created, the therapist must be experienced as being in a state of | vitalizing attunement to the patient, that is, the crescendos and decrescendos of the therapist's affective state must be in resonance with similar states of crescendos and decrescendos of the patient (Schore 1994, 1997c). Studies of empathic processes between the 'intuitive' attuned mother and her infant demonstrate that this affective synchrony is entirely nonverbal and that resonance is not so much with his mental (cognitive) states as with his psychobiological (affective-bodily) states. Similarly, the intuitive empathic therapist psychobiologically attunes to and resonates with the patient's shifting affective state, thereby co-creating with the patient a context in which the clinician can act as a regulator of the patient's physiology (Schore 1994, 1997c; Amini et al. 1996).
The right cortical hemisphere, which is centrally involved in attachment functions, is dominant for the perception of the emotional states of others, by a right posterior cortical mechanism involved in the perception of nonverbal expressions embedded in facial and prosodic stimuli (Schore 1994, 1999a). It is also dominant for 'subjective emotional experiences' (Wittling & Roschmann 1993) and for the detection of subjective objects (Atchley & Atchley 1998). The interactive 'transfer of affect' between the right brains of the members of the mother-infant and therapeutic dyads is thus best described as 'intersubjectivity'. So what can current developmental neuropsychoanalysis tell us about psychotherapeutic intersubjectivity?
The right brain is centrally involved in unconscious activities and, 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. Freud asserted that 'It is a very remarkable thing that the Ucs. of one human being can react upon that of another, without passing through the Cs' (Freud 1915c, p. 194, my italics). He also proposed that the therapist should 'turn his own unconscious like a receptive organ towards the transmitting unconscious of the patient... so the doctor's unconscious is able... to reconstruct [the patient's] unconscious' (Freud 1912, p. 115). He called the state of receptive readiness 'evenly suspended attention'. Bion (1962) referred to 'reverie' or 'dream state alpha', clearly implying a right brain state. Indeed, Marcus has recently written that 'the analyst, by means of reverie and intuition, listens with the right brain directly to the analysand's right brain' (Marcus 1997, p. 238).
This same right brain to right brain system is described in the neuropsychological literature by Buck as 'spontaneous emotional communication':
Spontaneous communication employs species-specific expressive displays in the sender that, given attention, activate emotional preattunements and are directly perceived by the receiver... The 'meaning' of the display is known directly by the receiver... This spontaneous emotional communication constitutes a conversation between limbic systems... It is a biologically-based communication system that involves individual organisms directly with one another: the individuals in spontaneous communication constitute literally a biological unit. (Buck 1994, p. 266, my italics)
Buck (1994) emphasizes the importance of specifically the right limbic system, and localizes this biologically-based spontaneous emotional communication system to the right hemisphere, in accord with other research that indicates a right lateralization of spontaneous gestures (Blonder et al. 1995) and emotional communication (Blonder et al. 1991). Earlier I pointed to Bowlby's (1969) speculation that human feelings are recognized through facial expressions, posture, tone of voice, physiological changes, tempo of movement and incipient action.
Indeed, this right brain process lies at the heart of the nonverbal relational communications between patient and therapist. Lyons-Ruth (2000), a member of Stern's Study Group (Stern et al. 1998a, 1998b), describes the centrality of the 'recognition process' that occurs in the 'ordinary moments of change in psychoanalytic treatment':
[Most relational transactions rely heavily on a substrate of affective cues that give an evaluative valence or direction to each relational communication, and these communications are carried out at an implicit level of rapid cueing and response that occurs too rapidly for simultaneous verbal translation and conscious reflection. (Lyons-Ruth 2000, pp. 91-92)
Recall that the right hemisphere recognizes emotions from visually presented facial cues (Adolphs et al. 2000), is specialized for 'implicit learning' (Hugdahl 1995), and performs rapid (80 msec) valence-dependent, automatic appraisals of emotional facial expressions (Pizzagalli et al. 1999).
Furthermore, the right hemisphere uses an expansive attention mechanism that focuses on global features while the left uses a restricted mode that focuses on local detail (Derryberry & Tucker 1994), a characterization that fits with Freud's 'evenly suspended attention'. And, in contrast to the left hemisphere's activation of 'narrow semantic fields', the right hemisphere's 'coarse semantic coding is useful for noting and integrating distantly related semantic information' (Beeman 1998, p. 279), a function which allows for the process of free association. Bucci (1993) has described free association as 'following the tracks of nonverbal schemata', by loosening the hold of the verbal system on the associative process and giving the nonverbal mode the chance to drive the representational and expressive systems, that is, by shifting dominance from a left to right hemispheric state. In this manner, as Freud describes, the clinician uses 'the derivatives of the unconscious which are communicated to him to reconstruct that unconscious, which has determined the patient's free associations' (Freud 1912, p. 116).
In recent writings I have suggested that, if Freud was describing how the unconscious can act as 'a receptive organ', Klein's concept of projective identification (Schore 2000d, in press a) attempts to model how an unconscious system acts as a 'transmitter', and how these transmissions will then influence the receptive functions of another unconscious mind. Klein proposed that, although this primitive process of communication between the unconscious of one person and the unconscious of another begins in early development, it continues throughout life. These moments of right brain to right brain communication represent an alignment of what Zeddies (2000) calls the 'nonlinguistic dimension' of the 'relational unconscious' of both the therapist and the patient.
There is now a growing consensus that, despite the existence of a number of distinct theoretical perspectives in psychoanalysis, the clinical concepts of transference (Wallerstein 1990) and countertransference (Gabbard 1995) represent a common ground. In my ongoing work I propose that nonverbal transference-countertransference interactions that take place at preconscious-unconscious levels represent right hemisphere to right hemisphere communications of fast-acting, automatic, regulated and dysregulated emotional states between patient and therapist. Transferential events clearly occur during moments of emotional arousal, and recent neurobiological studies indicate that 'attention is altered during emotional arousal such that there is a heightened sensitivity to cues related to the current emotional state' (Lane et al. 1999, p. 986).
Current psychoanalytic research highlights the role of 'fleeting facial expressions' that act as indicators of transference and countertransference processes (Krause & Lutolf 1988; Schore 1994, 1998c; Andersen et al. 1996). These cues are nonconsciously appraised from movements occurring primarily in the regions around the eyes and from prosodic expressions from the mouth (Fridlund 1991). Since the transference-countertransference is a reciprocal process, facially communicated 'expressions of affect' that reflect changes in internal state are rapidly communicated and perceptually processed within the affectively synchronized therapeutic dialogue. This finding is relevant to the 'reciprocal process', described by Munder Ross, in which the therapist has access to 'the subliminal stimulation... that emanates from the patient' (Munder Ross 1999, p. 95). In fact, these very same spontaneously communicated and nonconsciously perceived visual and auditory cues represent 'the intrapsychic edge of the object world, the perceptual edge of the transference' (Smith 1990, p. 225).
Only in a right hemispheric dominant receptive state in which 'a private self is communicating with another 'private self can a self-selfobject system of spontaneous affective transference-countertransference communications be created. Fosshage (1994), a self psychologist, notes that when the self-object seeking dimension is in the foreground, the analyst must resonate at the deepest layers of his/her personality to be sufficiently available to the patient's developmental and self-regulatory needs. In other words, a state of resonance exists when the therapist's subjectivity is empathically attuned to the patient's inner state, one that may be unconscious to the patient, and this resonance then interactively amplifies, in both intensity and duration, the affective state in both members of the dyad. Sander (1992) states that 'moments of meeting' between patient and therapist occur when there are 'matched specificities between two systems in resonance, attuned to each other'. Loewald (1986) describes 'resonances between the patient's and the analyst's unconscious'.
Resonance phenomena are now thought to play one of the most important roles in brain organization and in CNS regulatory processes (Schore 2000c, in press a). Although this principle is usually applied to the synchronization of processes within different parts of a whole brain, I have suggested that it also describes the resonance phenomena that occur between the two right brains of the psychobiologically attuned mother-infant dyad. So this also applies to the moments within the treatment process when two right brains, two emotion-processing unconscious 'right minds' within the therapeutic dyad, are communicating and are in resonance. In a recent issue of the Journal of the American Psychoanalytic Association, Kantrowitz (1999, p. 72) suggests that 'It is in the realm ofpreconscious communication that the interwovenness of intrapsychic and interpersonal phenomena becomes apparent', and emphasizes the importance of 'attunement and resonance'.
This leads to the following proposals: empathic resonance results from dyadic attunement, and its induces a synchronisation of patterns of activation of both right hemispheres of the therapeutic dyad. Misattunement is triggered by a mismatch, and describes a context of stressful desynchronization between and destabilization within their right brains. Interactive reattunement induces a resynchronization of their right brain states. These brain state shifts occur rapidly at levels beneath awareness. In other words, the two right brain systems that process unconscious attachment-related information within the co-constructed intersubjective field of the patient and therapist are temporally co-activated and coupled, de-activated and uncoupled, or re-activated and re-coupled. The unconscious minds and bodies of two self systems are connected and co-regulating, disconnected and autoregulating, or reconnected and again mutually regulating their activity. Recall that self regulation occurs in two modes, autoregulation, via the processes of a 'one-person psychology', or interactive regulation, via a 'two-person psychology'.
Implications of a Psychoneurobiological Model of Emotional Development for Clinical Practice
Even more specifically, during the treatment, the empathic therapist is consciously attending to the patient's verbalizations in order to objectively diagnose and rationalize the patient's dysregulating symptomatology. But she is also listening and interacting at another level, an experience-near subjective level, one that processes socioemotional information at levels beneath awareness. According to Kohut (1971), the empathically immersed clinician is attuned to the continuous flow and shifts in the patient's feelings and experiences. Her 'oscillating attentiveness' (Schwaber 1995) is focused on 'barely perceptible cues that signal a change in state' (Sander 1992), in both patient and therapist, and on 'nonverbal behaviors and shifts in affects' (McLaughlin 1996). The attuned, intuitive clinician, from the first point of contact, is learning the nonverbal moment-to-moment rhythmic structures of the patient's internal states, and is relatively flexibly and fluidly modifying her own behavior to synchronize with that structure, thereby creating a context for the organization of the therapeutic alliance.
Freud asserted that the work of psychotherapy is always concerned with affect. Perhaps the most important clinical advances in this realm have come from those working in 'the nonverbal realm of psychoanalysis' (e.g. Jacobs 1994; Schore 1994;Schwaber 1998; Stern et al. 1998a, 1998b; Hollinger 1999). The current emphasis in developmental studies on 'heightened affective moments' and in emotion studies on 'actual moments of experience' is mirrored in very recent psychotherapy research which is exploring 'significant moments' in the therapeutic hour. And learning research on the importance of the implicit perception of affective information is echoed in the clinical principle that, in order for implicit affective learning to take place, the patient must have a vivid affective experience of the therapist (Amini et al. 1996).
Neurobiology is also delving into this theme - studies demonstrate the involvement of the right hemisphere in implicit learning (Hugdahl 1995) and nonverbal processes (see Schore 1994), and the orbitofrontal system in implicit processing (Rolls 1996), and procedural (Rolls 1996) or emotion-related learning (Rolls et al. 1994). Such structure-function relationships may elucidate how alterations in what Stern and his colleagues (1998b) call nonverbal 'implicit relational knowledge' are at the core of therapeutic change. In light of the central role of the limbic system in both attachment functions and in 'the organization of new learning', the corrective emotional experience of psychotherapy, which can alter attachment patterns, must involve unconscious right brain limbic learning.
But a dyadic-transactional perspective entails not only more closely examining the patient's emotion dynamics, but also bringing the therapist's emotions and personality structure more into the picture. During a therapeutic affective encounter, the therapist is describing his psychobiological state of mind and the counter-transference impressions made upon it by the patient's unconscious transference communications. These are expressed in clinical heightened affective moments when the patient's internal working models are accessed, thereby revealing the patient's fundamental transferential modes and coping strategies of affect regulation (Schore 1997c).
(...) continues in next post.