Allan Schore on the Science of the Art of Psychotherapy

Allan Schore: Absolutely. The title of my book, The Science of the Art of Psychotherapy (2012), attempts to more clearly understand the relationship between the two, because on the one hand, as so much clinically relevant research now shows us, there is a science that underlies the clinical domain. And there is a certain amount of information and knowledge that we as clinicians must have in order to succeed in the particular area of expertise that we’re in—psychotherapeutic change processes.

Yet, at the same time it’s also an art, something that is extremely subjective and personal. For most of the last century it was thought that subjectivity was outside the purview of science. But we now understand psychotherapy changes more than overt behavior and language—it also acts on subjectivity and emotion. As you know, the left hemisphere is dominant for language and overt behavior; the right for emotion and subjectivity. This dichotomy fits nicely with left versus right brain functions. The two cerebral hemispheres process information from the outside—and inside—world in different ways: one from an objective stance, the other from a more subjective perspective. The two brains use different ways of perceiving the world and of being in the world.

Neuroscience has legitimized subjectivity in psychology and in therapy. Both science and clinical theory agree that psychotherapy is basically relational and emotional, and so we now think that emotionally and intersubjectively being with the patient is more important than rationally explaining the patient’s behavior to himself. The core self system is relational and emotional, and lateralized to the right hemisphere, and not the analytical left brain. As we empathically “follow the affect” and facilitate the patient experiencing a “heightened affective moment,” we’re intuitively inhibiting the dominance of the left and “leaning right.”

AS: Let me try to give a broad overview. In the critical moments of any session the patient must sense that we’re empathically with them. Research shows a difference between the left brain understanding of cognitive empathy and right brain bodily-based emotional empathy. In other words, we’re experiencing and sharing the patient’s right brain emotional subjective states, being with the patient rather than doing to the patient. In this therapeutic context we have to also be in the right brain to make therapeutic contact, and for the patient to make contact with her deeper emotions. Later we may engage our left brains to more cognitively understand the emotional state, but while we’re attempting to “listen beneath the words” in order to “reach the affect” and work with the affect we must, as Reik said, abandon “sweet reason” and “rigidly rational consciousness” and “abandon yourself” to intuitive hunches that emerge from the unconscious.

Intuition and empathy are right brain functions, and both operate at levels beneath conscious awareness. Bion said we must leave conscious expectation behind in order to really hear the whole patient. So getting back to Jung, he also said “Man’s task is to become conscious of the contents that press upward from the unconscious.”

These two different brains, the conscious mind and the unconscious mind, must work together. As my colleague Iain McGilchrist has shown, we are currently out of hemispheric balance. I think psychology has placed too great an emphasis on the conscious mind, and we are now challenging the long-held idea that reason must overcome bodily-based emotion. That the conscious mind needs to control and suppress the unconscious mind, that science and art are always in conflict, and that they would never mesh together. As I’ve written, with the ongoing interdisciplinary paradigm shift our perspective has changed, and not incidentally the gap between the practice and the theory of psychotherapy has really collapsed in the last two decades.

Getting back to your Jung citation, at the very beginning of our clinical education we’re learning techniques, and we’re learning the psychological science of psychotherapy. But as we learn our craft and gain clinical experience, ultimately the bulk of our learning comes from being with and learning from our patients—about them as well as self-knowledge. As I see it, our growing clinical expertise expands within the psychotherapeutic relationships we share with our patients. It’s what our patients are teaching us, if we are open to it. It’s not just about them and the deeper psychological realms within them. It’s at the same time becoming more familiar with the deeper core of our own self system. Being psychodynamically focused, this involves the use of both our conscious left and especially the unconscious “right mind.”

I believe that we’ve overvalued the analytic left mind. So lately I’ve looked more carefully at the neuroscience for the overt and subtle difference between the left and right brain/mind. This has shifted my clinical focus from the explicit to the implicit, from cognitive mental content to affective psychobiological process. I now see the change mechanism acting beneath the words—in process more than content. We now have a better idea what this process is about, and how relational interactions literally can change that process and thereby change character structure.

My idea about science is that we need to update ourselves about what is objectively known about the brain and what is known about the body, as well as “knowing” more about our own subjectivity. And that’s a continual journey. Fundamentally, our psychotherapeutic exploration of somebody else’s subjectivity, which is bodily-based subjectivity, is also an exploration of our own subjectivity. So, there are two types of knowledge here that really underlie psychotherapy change processes: the explicit knowledge of the broader biological and psychological scientific theories, and the “implicit relational knowledge of self and other.”

AS: The neurobiologically informed psychodynamic perspective that I use emphasizes a clinical focus on not only explicit conscious but implicit unconscious processes. All schools of psychotherapy are now interested in these essential functions that take place beneath awareness. And all are accessing attachment internal working models, which Bowlby said operate at unconscious levels and can be changed by therapy. So I’m interested in not only the patient’s overt behavior, but also her internal world, what cognitive scientists call internal schemas.

My work is fundamentally about how to work with affect, and so clinically I’m exploring with the patient not only conscious but unconscious cognition and, importantly, unconscious affect. The patient may have no awareness of what neuroscience is now describing as “unconscious negative emotion.” Research has now established that fear isn’t necessarily conscious; you can experience it without being aware that you’re experiencing it. So how do we detect these unconscious affects?

And then there’s the matter of the communication of emotions within the therapeutic alliance that are so rapid that they occur beneath conscious awareness. The alliance is a central mechanism in not only psychodynamic therapy but CBT, EMDR, experiential, body psychotherapy, etc. This gets to what used to be called the common factors that impact all forms of treatment. I’m interested in the change mechanisms that occur in all psychotherapeutic modalities, but especially in the right brain, which is dominant for emotional and social functions and stress regulation.

AS: Let me just go wide for a second and then we can kind of dive in here, because the truth of it is that the last two decades have been remarkable in terms of the changes in the field of psychology across the board. I’m thinking about the early ‘90s when there was a huge split between researchers and clinicians, where there were divisions within the different schools of psychotherapy, and where the focus was very much on verbal content of the session. Although there were breaks away from classical psychoanalytic theory, the focus was still on undoing repression, making the unconscious conscious, and with interpretations being the major vectors of the treatment. Emotion really had not come into the forefront. But that’s the key to the change.

Over the ‘70s we had been moving into a behavioral psychology and from that to a behavioral psychotherapy. Then it transitioned into a cognitive psychology where suddenly, we went beyond just overt behavior and into covert cognition, which became a legitimate field of study. Out of that came cognitive behavioral therapy and then in the ‘90s the emotional revolution, as it’s been called, began, which posited that affect is primary, as well as affect regulation. And that’s where my studies really began, in the early 1990’s.

AS: Not contact, but I was well aware of them and I’m pretty sure they were aware of me.

AS: Their work has held up, and its impact continues. There’s now an intense interest in gaining a deeper understanding of what used to be called the non-specific mechanisms of change, in all forms of psychotherapy. They were onto that really early.

My first book, Affect Regulation and the Origin of the Self, tied together the social-emotional change processes in early development and in psychotherapy. This was in 1994 and, incidentally, the term “self” was not being used that much back then. Psychodynamic people were still more or less using the term “ego” rather than “self.” As I’m sure you’re well aware, Jung had put his money on “self” and was much closer to describing the core system than Freud’s “ego.”

The early developmental models of the time were dominated by the cognitive models of Piaget. Everyone had been attempting to try to squeeze Piaget into a psychotherapeutic mechanism. It proved to be kind of an awkward fit. Emotion was the key to attachment.

And so the subtitle of my book was The Neurobiology of Early Emotional Development. That same year Antonio Damasio had come out with his book Descartes' Error, and the whole idea of emotion, which had been ignored by science, began to come out of the closet.

Twenty years later it’s well established that emotion is primary in early human development, that affect dysregulation lies at the core of psychopathology, and that affective communications are essential in all forms of psychotherapy.

The second area of basic change is the matter of the interpersonal neurobiology of attachment—a shift from the intrapsychic to the interpersonal. Many people had been looking at attachment theory, but even attachment theory was hard to anchor clinical process in. That had to be worked out: other than the “strange situation” and the AAI [Adult Attachment Interview], how were clinicians going to use Bowlby’s attachment theory and information about early development? That has been a remarkable change. Now just about every clinician has some understanding of the centrality of early development and how that interpersonal developmental mechanism plays out in the therapeutic relationship.

Indeed, early development really has come into the fore in all forms of psychotherapy, with all patient populations. Interpersonal neurobiology—how early relationships shape the brain—has transformed attachment theory. This transformation from what I call “classical attachment theory” to “modern attachment theory” focuses on not only regulation but also dysregulation and ideas of psychopathogenesis, which have also been major themes of my work. My efforts have been to generate a more integrated theory of mind and body, of psychology and biology. In essence I’ve attempted to synthesize these fields in order to create a coherent psychobiological model of how the self develops, how dysregulation and disorders evolve, and then ultimately how to treat these disorders.

A couple of other things to mention: another change over the last two decades has been the reemergence of psychodynamic theory and the revitalization of psychoanalysis, the science of unconscious processes. It took a while, because as you know, classical psychoanalysis was seen as apart from science, and was cast out of academia for a long period of time.

But this reemergence has paradoxically been fostered by neuroscience, and its interest in rapid implicit processes. Neuroimaging research has established that most essential adaptive processes are so rapid that they take place beneath conscious awareness. I’ve suggested that the self system is located in the right brain, the biological substrate of the human unconscious. This differs from Freud’s dynamic unconscious, which mainly contains repressed material, banished from consciousness. At any rate there is now great interest in implicit unconscious processes, and I think we’re now coming back to a modern expression of psychodynamic theory. Indeed all forms of therapy are now looking at right brain to right brain transference and countertransference communications, and how these are expressed in the therapeutic alliance, beneath the words.


One other major change has been the rediscovery of brain lateralization, and the appreciation of the different structural organizations of the right and left brain. Each has different critical periods and growth spurts, and ultimately different specialized functions. For me the terra incognita literally has always been the early developing right brain, the unconscious. More so than the surface conscious mind my interest has been in deeper early forming nonverbal bodily-based survival processes. I became especially interested in how we could bring these survival processes into the open, and how these could be studied. As a clinician-scientist, everything that I’ve authored has had to be clinically relevant. It has to fit the way that I work with my patients, as well as scientifically grounded. My theories are heuristic, and not only open to research but able to generate experimental hypotheses that can be tested.

AS: The first person to bring up the idea that all language is not only in the left hemisphere, just for the record, was Freud in 1891 in On Aphasia, which still is studied by neurologists. But the idea that everything that is verbal has to, by definition, reside in the left brain is still held by many people. Current neuroscience shows this is not the case. The right also has language. The right stores our own names, and processes emotional words. Prosody, the emotional tone of the voice, is right lateralized, as well as novel metaphors, and making thematic inferences. So when a patient all of a sudden is in an emotional state and is using an emotional word, the right is tracking that also. Right hemispheric language creates the intimate feeling of “being with.”

AS: Absolutely!

AS: Yes. Because the processing of what is familiar is left and the processing of novelty is right. Essentially we’re looking for, not the bottom line preexisting truth, but for the ability to process novelty, especially novelty in social emotional interactions. And for many patients intimacy is novelty. So, yes, anything that is new pops into the right brain first, and you actually get bursts of noradrenaline in the right hemisphere, the hemisphere that is dominant for attention. In fact, I’m now citing studies which indicate that the highest levels of human cognition—the “aha” moment of insight, intuition, creativity, indeed love, are all expressions of the right and not left brain.

AS: Correct. Essentially, the left has the illusion that it has just discovered something new, but the truth of it is the right has discovered it, and now the left is putting into words what the right just found out about the self, especially in relation to other self systems. My colleague Darcia Narvaez is showing that morality is also a very high right brain process. A body of research indicates that the right is dominant for affiliation, the left for power.

This gets into some of the matters that Jung and others were talking about— these very high symbolic mechanisms are in the right hemisphere. Here’s another example of how neuroscience has changed our ideas about the human experience. It used to be thought that all symbolic processes are a product of the verbal left brain, so the goal was to get the patient to use words, and once there was conscious verbalization, then the patient can understand, and then the unconscious becomes conscious and change occurs. We’re now saying that’s not quite the case. The ultimate expression of the right brain is a conscious emotion. The ultimate expression of the left brain is a conscious thought. Becoming aware of our bodily-based emotions is more essential than becoming aware of our thoughts.

The right brain and the unconscious mind are more connected into the visceral body. As you know the body has been rediscovered in the last couple of decades. And that’s been an enormous change for psychology and psychiatry.

AS: Partly that. But also the developmental work on attachment theory and attachment trauma. Clearly, modern trauma theory, which did not really exist until around the late ‘90s, has also been one of the important transformations of the last two decades—the idea that “the body keeps the score,” as Bessel van der Kolk put it. But even beyond that, I would suggest it’s the re-discovery of the autonomic nervous system that is the major player here. It’s now an accepted principle that in order to understand the human experience it’s not just the voluntary behavior of the central nervous system, but also the involuntary behavior of the autonomic nervous system—mind and body. And that’s why much of my bodily-based attachment model involves the autonomic nervous system. The mother is literally a regulator of crescendos and de-crescendos of the baby’s developing autonomic nervous system.

These same bodily-based processes are also involved in the therapist’s right brain psychobiological attunement to and regulation of the patient’s emotional states. So the body has now embedded itself into the core of models of subjectivity—an embodied subjectivity which is not just an abstraction of the left brain, but right brain processes. The body is now seen as essential to right brain to right brain intersubjectivity. In my own work I’ve argued that this conceptual advance has impacted clinical models, such as somatic countertransference—the therapists’ own bodily reactions to patients’ conscious and especially unconscious communications. Also, there is the idea that a major function of the therapist is to regulate the patient’s autonomic arousal, a clinical concept that has challenged the older idea of neutrality, and that expands the previous concept of containment. This perspective attends more to right brain unconscious process than left brain conscious content. Once again, these scientific advances have transformed our clinical models.

AS: Absolutely the case. Except not “repressed,” but dissociated. There’s also been a shift in defenses, from an earlier clinical model that emphasized insight and the undoing of repression, a model of therapeutic action based on bringing to the patient’s consciousness repressed unconscious material. Trauma theory emphasizes working with the deadening of affective consciousness by this other bodily-based survival defense, dissociation. Clinicians are learning to differentiate the two and recognize the latter.

But, yes, the idea about disruptions and repairs came out of the developmental data and was incorporated into my modern attachment theory. My writings emphasize that rupture and repair, both in the developmental and psychotherapeutic contexts, involve important opportunities for interactive regulation of dysregulated affective states.

At the most fundamental level I’m interested in the mechanisms of change, especially in the early developing right brain self system. To use an earlier language, what I’m exploring is how the object relational sequences between the mother and the infant shape emerging psychic structure. In more modern terms these are investigations of interpersonal neurobiology. An interpersonal neurobiology of human development enables us to understand that the structure and function of the mind and brain are shaped by experiences, especially those involving emotional relationships, and to understand how brains align their neural activities in social interactions.

The tie in from my developmental work to my clinical work is that the same right brain to right brain social emotional processes that are setting up between the mother and the infant later play out in the therapeutic alliance. The model links the right brain growth in early development with later changes in the social/emotional context. And as you pointed out rupture and repair are potential contexts of emotional growth. So I’ve paid attention to the work of other developmental psychoanalytic researchers like Beatrice Beebe and Ed Tronick and Karlen Lyons-Ruth, who are also studying ruptures and repairs.

In my most recent writings I’ve focused on the essential role of these repairs in re-enactments of attachment trauma, which really is at the heart of the therapeutic change mechanism. I’m describing how both patient and therapist co-construct both the rupture and the repair, and that these ruptures are not technical mistakes, but literally—

AS: Beautifully put. Enactments represent communications of previous ruptures that triggered negative affects so intense and so painful that they were dissociated and banished from consciousness. As the therapy progresses and the attachment bond in the therapeutic alliance strengthens, there is enough safety for the patient to dis-assemble the dissociative defenses and let the affects come online more frequently. And then, what has been buried and packed down underneath dissociation surges into bodily awareness in the presence of a regulating other, now offering a possibility of interactive repair. Jung, who studied dissociation, described how the enduring emotional impact of childhood trauma “remains hidden all along from the patient, so that not reaching consciousness, the emotion never wears itself out, it is never used up.” He also stated the trauma may suddenly return: “it forces itself tyrannically upon the conscious mind. The explosion of affect is a complete invasion of the individual. It pounces upon him like an enemy or a wild animal.”

In my model of “relational trauma” I’ve suggested that it’s not just misattunements that lead to the traumatic predisposition. It’s also the lack of the repair, and that repair and interactive regulation requires a very personal, authentic response on the part of the therapist. Attachment trauma was originally relational, and so the healing must be relational, a mutual process. In Sullivan’s words, the therapist is not neutral and detached, but a “participant observer.”

AS: Obviously the original context of attachment trauma was a very intimate context. I mean the relationship between the mother and the infant defined an intimate context. Her ability to down regulate negative affect in rupture and repair and up-regulate positive affect in mutual play shaped the attachment bond and the infant’s developing right brain. In a secure attachment the intimate context is characterized by mutual love, and over the course of my studies I’m increasingly using the term love to describe the intensity of the emotional bond. This is more than just pleasant affect. This is intense emotion.

And that love, incidentally, between the mother and the infant also is the mother’s ability to pick up communications that are not only joy but also distress and to be able to hold and to feel that in herself, and then to regulate that and communicate back to the baby.

The idea about being able to hold the pleasure and the pain really is the key to this. In the cases of other intimate dyads, this also applies. A number of clinicians are now focusing on the same right brain psychobiological mechanisms in couple’s work. The couples’ therapist who is working with attachment is able to hold the dyad, to regulate each member of the dyad. She’s also facilitating and reading nonverbal emotional communications within the dyad, and bringing to awareness affective moments in which they are engaging and disengaging, and switching between various emotional states.

The therapeutic action with couples is to allow each member to become more aware of these rapid automatic processes, and how each is communicating or blocking transmissions from the other. As always the clinical principle is to follow the affect, especially authentic affect, whether positive or negative. And again, rupture and repair are important contexts for right brain development and emotional growth. But even beyond couples therapy, interpersonal neurobiology and affective neuroscience are now being incorporated into group psychotherapy. The focus is on what group members are communicating beneath the words, at conscious and unconscious levels, and how right brain emotional communications and regulatory transactions are occurring in the group relational context.

So, although the emotional contact between humans originates in the mother-infant dyad, it ultimately becomes the way in which individual human beings communicate with other human beings. These deeper communications and miscommunications have little to do with left-brain language functions. They have more to do with right-brain abilities to nonconsciously read the spontaneous facial expression, tone of voice, and gestures of other humans.

AS: Most of my ideas about the self come from neuroscience and psychoanalysis, including Jung and others. But the idea of self/nonself and multiple self states have been a focus. In current relational psychoanalytic writings the concept that comes closest to my own is Philip Bromberg’s idea about multiplicity of self-states: that we all have a variety of self states associated with different affects and motivations. Some of these are operating on a conscious level, others of these on unconscious levels. He calls these latter states “not-me” states as opposed to “me” states (a concept he borrowed from Harry Stack Sullivan).

Depending upon context we nonconsciously switch through these states. Each of these self states is tied into a motivational system (fear, aggression, shame, depression, joy etc.). In other words, when threatened, the fear motivational system is triggered. My right brain is attending to and tracking the external threat outside. In that self state noradrenaline and adrenaline is higher, cortisol is elevated, the physiology and attentional systems are altered. The memory system is also altered. When the threat passes or I’ve regulated and coped with it, I become relieved and switch into another self state, say a quiet alert state or a positively valenced exploratory state. So due to self regulating mechanisms we switch through these self-states. Resilience and flexibility is the adaptive ability to fluidly switch depending upon what is occurring in the context and what is meaningful at that point in time.

On the matter of Buddhism’s concept of self—that self state of consciousness that is associated with meditation, as I understand the concept, aims to control and still the fluctuations of the mind. The self (mind, awareness) identifies itself with fluctuating patterns of consciousness. Yoga, for example, is a form of mastering or eliminating such fluctuations and the attainment of stable concentration of attention and non-attachment to sensory experiences. With practice a change from evaluative to non-evaluative self-monitoring occurs during meditation. That said, neuroscience studies show that “compassionate meditation” does have more of a right brain, limbic focus.

I’ve written that self regulation can take two forms: interactive regulation in affiliative interconnected contexts, and autoregulation in autonomous contexts. In yoga the meditating self is acting as an autoregulatory system. My interests in development and in psychotherapy are relational, so I’ve been more interested in interactive regulation that occurs between human beings.

That said, the key is being able to switch between these two modes of self regulation. Both of these derive from the early interactive regulation of the attachment relationship. Going inward to control emotion is different from reaching outwards to others at moments of loss or joy. The inability to emotionally connect with others is at the core of any relational affect focused psychotherapy. As I look at the significant problems of the larger world I’m convinced that we need more connection, not separation and autonomy. For me, where we are in this world right now, really what we desperately need, what’s being thinned down on a daily basis, is this capacity for interactive regulation.

We also have the problem that the US and Western cultures emphasize the value of autonomous and independent personalities; they are highly valued over interdependent ones. As I mentioned, the left hemisphere is associated with power and competitiveness, the right with affiliation and pro-social motivations. So, again, that’s the reason why I’ve been more interested in the higher right hemisphere, which processes not only emotional states and higher cognitive functions, but spiritual and moral experiences. It is here in the right where the self is transcended, where the self becomes larger and expanded. In these states the grandiosity of the self literally is collapsed down and there is some understanding that one is part of a much larger organism, a much larger sense of being alive. This sounds like the Buddhist autoregulatory self state.

But let me repeat, interactive regulation is the key to the therapeutic alliance. There is now a push into the relational trend in all forms of psychotherapy. Actually in psychoanalysis the relational emphasis has always been there. I’m thinking of Ferenzci, Jung, Kohut and more recently relational intersubjective psychoanalysis. This relational trend now is coming into mainstream psychology, and is seen as the central mechanism of psychotherapy.

I point this out because psychologists on the one hand can be teaching meditative skills, but can also be accessing relational expertise in the therapeutic alliance.

AS: Right. But I suggested that a certain form of mindfulness, including a bodily awareness, must take place in a relational context. The idea being that there are certain parts of the self that cannot be discovered, that cannot come into awareness, unless they are being mirrored by another human being.

AS: That’s a great cultural metaphor—sharing someone’s joy as well as pain.

AS: Exactly. One of the central concepts that I’ve written about is resonance. In physics, a property of resonance is the tendency of one resonance system to enlarge and amplify through matching the resonance frequency pattern of another resonance system. In psychology, a state of resonance exists when one person’s subjectivity is empathically attuned to another’s inner state, and this resonance then interactively amplifies, in both intensity and duration, the affective state in both members of the dyad. This resonance can occur rapidly at levels beneath conscious awareness, and it generates what has been called “a third subjectivity.” For example, in mutual play states dyadic resonance ultimately permits the inter-coordination of positive affective brain states, shared joy, which increase curiosity and exploration.

AS: Yes, again, it’s more than mirroring, it’s an intensification of positive arousal and thereby an energetic mechanism, which is a form of interactive regulation.

AS: Sure. The first thing that comes to mind is what has been termed as “the quiet alert state.” This is the flexible state that the mother accesses to pick up her infant’s varying emotional expressions. It’s associated with a state of autonomic balance between the energy expending sympathetic and energy conserving parasympathetic branches of the autonomic nervous system. Within attachment communications the caregiver sets the ranges of arousal, the set points of the infant’s resting quiet alert state. It’s relationally tuned, and later affects the individual brain’s default state. In other words, regulation is the key to the quiet mind.

But I’m also thinking about right and left hemispheric balance, and individual differences in “hemisphericity.” For example, in a resting state greater right hemisphericity is associated with a history of more frequent negative affect, lower self esteem and difficulties in affect regulation. Greater left hemisphericity, on the other hand, is associated with heavy inhibition of the right brain, repression of emotions, and over-regulation of disturbances. Consciousness is dominated by continuous left brain chatter, and thereby an inability to be emotionally present, to be “in the moment.” There are individuals for whom that chatter is always so intense, so continuous, and even so loud they cannot quietly be with themselves. They can’t tolerate internal silence, and so they can’t monitor what’s coming from the body and from deeper strata of the unconscious. They’re always in a state of “doing” rather than “being.”

AS: Right. When it comes to emotion and emotion dysregulation, for a long time people were thinking only about under-regulation, that the emotions are so powerful and so strong that they interfere with the logical and rational capacities of the left hemisphere. But there is also another problematic state—where it’s over-regulated. In that case the person is habitually packing down emotions, out of awareness, and whose left hemisphere is so dominant that it’s always “in control.” They “live in the left,” and use words to move away from affect. They’re talking about rather than experiencing emotion, from the other side of the callosal divide, not actually allowing themselves to disinhibit the right and to feel what is in the body. And yet, “the body keeps the score.” In the most extreme cases they’re dissociative and alexithymic.

These are patients who use words in order not to feel; they are over-inhibited and susceptible to over-regulation disturbances. Think about overly rational, insecure, avoidant personalities who overemphasize verbal cognition and dismiss emotion. Returning to our earlier discussions of recent changes in the science of affect, dysregulation can be either under-regulation or over-regulation, an avoidance strategy versus an anxious strategy.

AS: A few things come to mind from your observations. The classical idea of brain laterality is that the right processes visual and spatial images while the left is involved in language.

But when it comes to imagery, the truth is we forget much of the time that imagery can be in any modality. We usually think about the visual image, as in your example of someone having an image of a bus hitting a pedestrian, or a building falling. Or a patient will come up with metaphors that are loaded with visual images. Also think of visual images of faces, especially emotionally expressive faces. But imagery can also be auditory—as when our consciousness becomes aware of a song melody or olfactory images, of an emotionally evocative smell or odor.

So, for those of us who are highly auditory, like both of us, we used to think that was verbal. But as you know, there are nonverbal auditory cues. Aside from the verbal content the voice itself is communicating essential information, even more important in an intimate moment than the verbal. Most psychotherapists are highly auditory and attuned and very sensitive to even slight changes in the prosodic tone of voice of the patient. It’s at that point where we will lean in, so to speak. But we also use our voice as a regulatory tool. In a well-timed moment we intuitively and spontaneously express our calming and soothing voice, or at other times we’ll come in with a more energizing voice, or even a limit-setting voice. Or we’re expressing an auditory metaphorical image.

So I think that when we talk about imagery, especially emotional imagery, we’re usually thinking of visual images. But there also are tactile images. As in an image of what it feels like at this moment, including what it feels like in your body and in my body, because I can pick this up and put that together with another’s facial expression.

But also there’s a difference between implicit visual recognition and explicit visual recall. I may not be able to have a conscious memory of a visual representation. But if there’s a subtle change in an emotional expression on a patient’s face, I can pick it up quickly. And let’s remember that when it comes to processing the meaning of nonverbal facial and auditory expressions, this is not occurring at conscious awareness. These interpersonal cues that denote changes in affects and subjectivity are detected and tracked by the right amygdala, at levels beneath awareness. Again, we’re listening beneath the words, and these signals are triggering unconscious memory systems of various sensory modalities—auditory and tactile, as well as vision.

AS: I agree. Remember with the right brain, you’re talking about not only long-term visual memory, but also ultra-short working memory, what has been called the visuo-spatial sketchpad. We hold a momentary image in consciousness long enough to see if it matches with our memory of affectively charged personally meaningful experiences. At a reunion, when you emotionally see your daughter’s face your right brain can immediately detect that there’s something wrong, or that she’s experiencing shame or joy. That right brain function is essential to our ability to be in close relationships. Someone who is mind-blind to facial expressions will have problems with intimacy.

AS: Well now I’m thinking about Winnicott’s idea about being alone in the presence of the other. Remember?

AS: Winnicott talked about the child in the second year achieving a complex developmental advance—the adaptive ability to be alone, and the creation of true autonomy. That is, to be separate, to be processing one’s own individuality and one’s own self system in the presence of another. The other is a background presence, so it doesn’t get swept into the child. But they’re literally both individuating in their presence together. And this is a kind of silent being together without having a need to take care of the other or support the other, of literally that kind of comfort.

So, on the one hand there is the joining of joy, which would be more active so to speak. And on the other hand there is this idea about being alone in the presence of the other, which is more passive. The self-system has stability at that point in time. It can shift out of that state if it needs to, but again, I would suggest to you that comes close to what you’re talking about. And that gets into the importance of solitude, the importance of privacy, which in this day and age is being completely forgotten. The poet Rilke said so eloquently, “For one human being to love another, that is perhaps the most difficult of all our tasks, the ultimate, the last test and proof, the work for which all other is but preparation. I hold this to be the highest task for a bond between two people: that each protects the solitude of the other.”

AS: Absolutely the case.

AS: In my recent lectures I’m describing the interpersonal neurobiological emergence of mutual love between the mother and infant. Studies on the functional neuroanatomy of maternal love document that the loving mother is capable of empathizing and feeling in her own body what the baby feels in his body, whether it be a joy state as well as a pain state. When the securely attached mother is in the fMRI scanner viewing emotional videos of her infant in a joy state or in a cry state, positive emotions such as love and motherly feeling coexisted with negative ones such as anxious feeling and worry in the mother herself.

Other studies show that insecure dismissive-avoidant mothers cannot hold the distressed baby’s painful negative states. The narcissistic mother only stays connected when the baby is mirroring back a positive state, and is unable to tolerate and repair shame states. So this ability to hold onto both positive and negative affect, and not engage in splitting is essential. In fact, in developmental studies, Ed Tronick has shown that even the secure mother is only attuned about 30 percent of the time. The key is not only the misattunement, but the interactive repair. These misattunements are common—my colleague Philip Bromberg describes frequent collisions of subjectivities within an intimate dyad.

Returning to our earlier discussion, it’s the ability to interactively repair these collisions that allows for the strengthening of an emotional connection between an intimate couple. Clinically, it’s the emerging ability of the therapeutic dyad to co-create and co-regulate ruptures that allows us to tolerate the negative transference and strengthen the positive transference—to move together from positive to negative and back to positive affective states. That really strengthens the bond and it leads to resilience. For me that’s what Kierkegaard’s intuition is describing.

AS: But while the moments of emotional connection are important, so are the moments of shared solitude, of being alone in the presence of the other, moments of shared silence. It’s very limiting to think that everything has to be filled with words or interpretations. For some therapists, when there’s too much silence they’ll start to fill it up with words, for their own regulatory needs.You know, for some therapists, when there’s too much silence they’ll start to fill it up with words, for their own regulatory needs. The matter that I’m raising here is that attachment is about the capacity for intimacy. Are intimacy and the capacity for mutual love expanded in long-term psychotherapy? Can patients use what they’ve experienced in therapy to expand the abilities for forming close and personally meaningful bonds with others, as in deep friendships and long term romantic relationships? Can they use these relationships as a source of more intense brain/mind body interactive regulation and autoregulation, and therefore have both interdependence and autonomy?

Both clinical theory and interpersonal neurobiology agree that in optimal social emotional environments the self-system evolves to more and more complexity. Not only the growth of the left brain conscious mind but also the right brain unconscious mind can be enriched and expanded in deep psychotherapy. By emotionally interacting with other right brains, a secure right brain self can continue to grow and develop to more complexity over the later Eriksonian stages of the life span. The secure self is not a static end state but a continuously expanding dynamic system that is capable of both stability and change.

Freud said that, in the end, therapy, and indeed life, was about love and work. Today we might think about that in terms of the expression of the development of the affiliative right and agentic left brains. My work has been an exploration of the primacy of the emotional development of the right brain, over the life span. In The Art of Loving, Eric Fromm described the intense emotional experience of love as “the experience of union with another being” and proposed that “beloved people can be incorporated into the self.” Here’s an example of self expansion that occurs within and between two people.

AS: Yes. For almost two decades I’ve continued to meet with study groups here in Los Angeles. I also have ongoing groups in Berkeley-Alameda, as well as Boulder, and in the Northwest.

AS: Yes, I Skype with clinicians and researchers in Seattle, Vancouver, and Portland. I’m about to start a Skype group in Australia, also.

AS: Same on my side, and thanks for today, David. I also greatly enjoyed this back and forth dialogue. As you said at the beginning the key was to have a spontaneous conversation.