regulation theory and affect regulation psychotherapy: a clinical primer

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Regulation Theory and Affect RegulationPsychotherapy: A Clinical PrimerJudith R. Schorea & Allan N. Schoreb

a Sanville Institute and Reiss-Davis Child Study Center, Los Angeles,California, USAb David Geffen School of Medicine, University of California, LosAngeles, Los Angeles, California, USAPublished online: 08 Aug 2014.

To cite this article: Judith R. Schore & Allan N. Schore (2014) Regulation Theory and AffectRegulation Psychotherapy: A Clinical Primer, Smith College Studies in Social Work, 84:2-3, 178-195,DOI: 10.1080/00377317.2014.923719

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Smith College Studies in Social Work, 84:178–195, 2014Copyright © Taylor & Francis Group, LLCISSN: 0037-7317 print/1553-0426 onlineDOI: 10.1080/00377317.2014.923719

Regulation Theory and Affect RegulationPsychotherapy: A Clinical Primer

JUDITH R. SCHORESanville Institute and Reiss-Davis Child Study Center, Los Angeles, California, USA

ALLAN N. SCHOREDavid Geffen School of Medicine, University of California, Los Angeles, Los Angeles,

California, USA

This article offers an essay on the influence of advances indevelopmental neuroscience and neuropsychoanalysis for ourunderstanding of the interpersonal neurobiological change mech-anisms embedded in the mother–infant and client–therapist rela-tionship. Regulation theory and affect regulation therapy arereviewed, along with attachment, affect regulation, and the devel-opment of the right brain. Right-brain communications within thetherapeutic alliance are described, leading to the conclusion thatthe right brain is dominant in psychotherapy. Changes in not onlythe client’s but also the clinician’s brain over long-term clinicalexperiences are discussed.

KEYWORDS regulation theory, affect regulation therapy, rightbrain, unconscious, psychotherapy

We want to thank Dennis Miehls and Jeffrey Applegate for inviting us tocontribute to this important edition of the Smith College Studies in ClinicalSocial Work. It is a privilege to be a part of this distinguished group ofclinicians who have incorporated neurobiology in their theory and practice.As one of us (J. Schore, 2012) has recently written in this journal, interper-sonal neurobiological models mesh nicely with the biopsychosocial-culturalperspective of clinical social work, perhaps more than any other area ofthe social work profession. Psychodynamic social workers are now actively

Received 2 May 2014; accepted 2 May 2014.Address correspondence to Judith R. Schore, PhD, 9817 Sylvia Avenue, Northridge, CA

91324, USA. E-mail: [email protected]

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Affect Regulation Therapy 179

integrating recent scientific and theoretical advances into more complex yethighly pragmatic models of individual and social change that translate intomore effective and profound therapeutic approaches.

For more than two decades our own contributions toward that efforthave focused on two essential questions of human development. First, howdo relational experiences structuralize the early maturation of the right lat-eralized “emotional brain,” and thereby indelibly affect its essential role inall later social-emotional, intersubjective, and stress-regulating functioning,including those operating in the therapeutic relationship? And the paral-lel question, how do object relational experiences at the beginning of lifefundamentally influence the growth of the unconscious mind, especially inintimate contexts? (see A. N. Schore, 1994, 2003, 2012; J. R. Schore & Schore,2008, 2010).

Grounded in Freud’s (1895/1966) “Project for a Scientific Psychology,”his primordial attempt to construct a model of the mind in terms of itsunderlying neurobiological mechanisms, and in The Interpretation of Dreams(1900/1953), his seminal description of the central role of the unconsciousin everyday life, the body of our neuropsychoanalytic work has offeredan evidence-based, clinically relevant model of the right hemisphere as thebiological substratum of the human unconscious mind. Extending the pio-neering work of developmental psychoanalysts such as Winnicott, Bowlby,Stern, and others, our ongoing studies of the early relational, interpersonalneurobiological origins of the subjective implicit self-represent a coherenttheory of the development of the unconscious mind, over the course of thelife span (for recent updates, see A. N. Schore, 2013b; J. R. Schore, 2012).

Indeed a considerable amount of interdisciplinary research now sup-ports the assertion that early relational, bodily based experiences, muchof it operating at nonconscious levels and occurring before the maturationof the verbal conscious mind, indelibly influences all future development(see A. N. Schore, 1994, 2003, 2012). Mirroring this research, a large bodyof clinical studies also indicates that the development of adaptive nonver-bal social-emotional functions and not verbal cognitions lie at the core ofthe unconscious right lateralized brain/mind/body, the “subjective self.” Asa result, updated models of psychotherapy are focusing on emotion andchanges in intersubjective affective processes that operate beneath consciousawareness. We have therefore emphasized the relevance of developmental,affective, and social neuroscience (more so than cognitive neuroscience) forthe theory and practice of psychotherapy.

Essentially, the contributions of regulation theory (A. N. Schore, 1994)to the field of interpersonal neurobiology attempt to explain how these earlyexperiences indelibly affect and alter the developing right brain, which forthe rest of the life span is centrally involved in the innate psychobiolog-ical need for affiliation and social connection, and thereby for emotionregulation and personal growth. The work continues to describe, in some

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180 J. R. Schore and A. N. Schore

detail, the psychoneurobiological mechanisms by which the early attach-ment relationship cocreates the organization of the developing personality,expressed in the individual’s adaptive or maladaptive abilities to cope withlater stress, especially relational stress. In other words, the emotional envi-ronment provided by the primary caregiver shapes, for better or worse, theexperience-dependent maturation of the brain systems involved in attach-ment affect communicating and affect regulating functions that are accessedthroughout the life span (see A. N. Schore, 2013b, for a recent applicationof the theory for the early assessment of attachment and autistic spectrumdisorders).

In this article, we offer the reader not so much a documentation of scien-tific evidence for regulation theory as an essay on the influence of advancesin developmental neuroscience and neuropsychoanalysis for our understand-ing of the interpersonal neurobiological change mechanisms embedded inthe mother–infant and client–therapist relationship.

REGULATION THEORY AND AFFECT REGULATION THERAPY (ART)

Regulation theory specifically models how relational experiences affect thedevelopment of what has previously been termed “psychic structure,” whichwe identify with more complex right-brain bodily based systems that oper-ate beneath conscious awareness. We contend that neuroscience can domore than confirm or disconfirm existing clinical theories. Rather it canexpand our clinical interventions and allow us to work more deeply andmore broadly, at conscious and especially unconscious levels, with a widerarray of psychopathologies.

Knowledge of brain ontogeny teaches us that the right hemisphere (theunconscious mind) evolves earlier than the left (the conscious mind), thusemphasizing its unique properties of nonverbal, intuitive, holistic process-ing of emotional information and social interactions (see Decety & Lamm,2007; Hecht, 2014; McGilchrist, 2009; A. N. Schore, 2012; and Semrud-Clikeman, Fine, & Zhu, 2011, for recent comprehensive descriptions of righthemispheric functions).

Updated brain–mind–body models that integrate biology and psychol-ogy can thus serve as a source for more effective treatment interventionsfor a wide range of disorders. As opposed to past trends that comparedand contrasted one form of psychotherapy with another, we believe that wecan now finally move toward a deeper understanding of the common psy-choneurobiological mechanisms that underlie the change processes commonto infants, children, adolescents, and adults. It is important to have theo-ries that don’t need to invent concepts and assume or project meaning intothe infant’s unconscious mind. The arcane, convoluted early psychoanalyticconstructs were used because they didn’t understand how the biological

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development of the brain–mind–body really worked. We now have simpleryet more comprehensive and understandable models with which to moreaccurately describe the rapid attachment communications of the relationalunconscious that occur within any emotionally intimate dyad.

Indeed, in the last 10 years, the rapid growth in attachment theory hasallowed it to become the most complex theory of the development of thebrain–mind–body available to science. We think the reason for this is thatattachment theory, as opposed to other developmental theories, from itsorigins has always been an integration of psychology and biology. In hisclassic 1969 volume, Attachment, Bowlby used the perspectives of Freud andDarwin to understand the instinctive mother–infant bond in terms of psycho-analysis and behavioral biology, and even speculated about the brain systemsinvolved in the evolutionary mechanism of attachment. Today it is clear thatframing attachment solely in terms of psychological constructs is limited andinadequate. This principle applies to the expression of attachment dynamicsin the early developmental and later psychotherapeutic contexts. At presentresearchers and clinicians are exploring the essential neurological and bio-logical mechanisms that underlie all psychological functions. Neuroscienceallows us to know in greater detail and in real time the mechanisms ofearly attachment relationships and how they shape the formation of deep,internal psychic structures across the life span, especially within “in depthpsychotherapy.”

Classical chroniclers of child development such as Spitz, Winnicott,Erikson, Mahler, and Bowlby (all psychotherapists), coupled with the mod-ern “up close,” intimate, intersubjective infant research of Beebe, Tronick,and Lyons-Ruth (also psychotherapists) provide a solid developmentalpsychoanalytic base for regulation theory, including a modeling of thechanges in the core of the personality that can result from optimal and less-than-optimal intersubjective, psychosocial contexts. What we have clinically,intuitively known about how humans change, about how character is formedis now mirrored, confirmed, and expanded by science—biological develop-ment occurs in a psychosocial context. It is not an isolated unfolding of aself in a psychological vacuum, without an intimate other. Human infantsare dependent on the physical, relational, emotional environment not onlyfor their actual survival, but also for the social matrix out of which theywill emerge as individuals with their own psychic structure. Each individual“hatches” and grows in a relational context, for better or worse. It is thebusiness of social work to pay attention to this on a micro- and macrolevel.

A major theme of our ongoing studies has been to integrate aninterpersonal neurobiological perspective into a developmentally informed,affectively focused model of psychotherapy. Our work on regulation theory,on the centrality of affect regulation for attachment, right-brain matura-tion, and social emotional development lies at the core of our clinicalmodel of treatment, affect regulation therapy (ART). This understandingof the therapeutic change process focuses on strengths and limitations in

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affect regulation and social intersubjective functions across a wide variety ofself-pathologies and personality disorders.

In the following sections we offer a primer on regulation theory,beginning with a condensed explication of the right-brain interpersonalneurobiology of the early mother–child relationship, and then the reac-tivation of the same unconscious mechanisms in the therapist patientrelationship. The clinical model, ART, is thus anchored in the developmentalmodel of regulation theory, which we term modern attachment theory (J. R.Schore & Schore, 2008).

ATTACHMENT, AFFECT REGULATION, AND DEVELOPMENT OFTHE RIGHT BRAIN

In the last two decades two major trends of research have converged toconfirm the basic tenets of regulation theory. Number one, from psychol-ogy: as opposed to earlier models that posited the beginnings of personalitybetween the 3rd and 4th year, we now have good evidence that the prenataland postnatal stages of human infancy represent the critical period for theorganization of the central dimensions of the personality. Number two, fromneuroscience: the peak interval of attachment formation overlaps the mostrapid period of massive human brain growth that takes place from the lasttrimester of pregnancy through the end of the 3rd year.

We now know that the evolutionary mechanism of attachment doesmore than just provide the baby with a sense of safety and security (A. N.Schore, 2013a). Rather, attachment drives brain development, five sixths ofwhich happens postnatally. In fact the brain grows more extensively andmore rapidly in infancy than at any other stage of life. Forty thousandnew synapses are formed every second in the infant’s brain (Lagercrantz& Ringstedt, 2001), and cortical and especially subcortical brain volume dou-bles in the first year (Knickmeyer et al., 2008). Importantly, this brain growthis influenced by “social forces” and therefore is “experience-dependent.” Itrequires not only nutrients, but also the emotional experiences embedded inthe relationship it cocreates with the primary caregiver.

According to neurobiologically informed modern attachment theory(J. R. Schore & Schore, 2008) the essential task of the first year of human lifeis the cocreation of a secure attachment bond of emotional communicationbetween the infant and his or her primary caregiver. The baby communicatesits burgeoning positive emotional states (e.g., joy, excitement) and negativeemotional states (e.g., fear, anger) to the caregiver so that she can thenregulate them. The attachment relationship shapes the ability of the babyto communicate with not just the mother, but ultimately with other humanbeings. This survival function—the capacity to communicate one’s own sub-jective internal states to other human beings and to receive their resonantresponses—is the basis of all later social relations.

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Thus, the major developmental accomplishments of human infancy arethe capacity to communicate emotional states, and subsequently the capac-ity for self-regulation, that is, the ability to auto-regulate emotional states.At the most fundamental level, the attachment relationship represents morethan mental communications—rather, they are psychobiological, and bod-ily based. We repeat—the essential nonverbal communication involved inattachment formation in the first year is fundamentally nonverbal and emo-tional, more so than verbal and cognitive. It is not until the middle of the2nd year that the left hemisphere and the speech centers in Broca’s andWernicke’s language areas come online. The baby’s ability to communicatehis or her emotional states is thus essential, and nature has made sure thatemotion circuits come online before the verbal language circuits.

Bowlby (1969) originally stated that mother–infant attachment com-munications are “accompanied by the strongest of feelings and emotions”(p. 242). We think in some ways our psychotherapy fields have lost sightof this, with such a heavy emphasis on cognition, and even mind overbody. Developmental neuroscience research demonstrates that the limbicsystem processes emotional information, and the autonomic nervous systemis responsible for the bodily based/somatic aspects of emotion. Studies showthat both are in a critical period of growth in the first and much of the 2ndyear, and that the maturation of these emotional brain circuits is significantlyinfluenced by early socioemotional experience. We also know that the righthemisphere is more connected into the limbic and autonomic systems, andthat it develops pre- and postnatally, before the left hemisphere. The bodilybased brain systems involved in attachment and emotion are thus locatedin the right hemisphere (for recent neuroscience research, see A. N. Schore,2012, 2013a, 2013b).

Attachment forms through communications that occur essentiallybetween the right brain of the baby and the right brain of the primarycaregiver. They are not transmitted through language, or semantics (a find-ing that is significant to our understanding of attachment at all points ofthe life span including attachment dynamics in psychotherapy). Rather, fromthe beginning of human development, these are nonverbal, social-emotionalcommunications. Specifically, attachment communication is expressed in(1) visual, face-to-face transactions; (2) auditory expressions of the emo-tional tone of the voice; and (3) tactile-gestural cues of the body. All of theseare performed very rapidly by the right brains of the infant and mother. Forthe rest of the life span, we use these nonverbal communication skills in allof our interpersonal relationships.

Here is another new insight about attachment, informed byneuroscience. Bowlby thought that the key to the attachment bond was thatthe mother was soothing, or regulating the baby’s negative fear states. Thereis now strong evidence that the secure primary attachment figure not onlydown-regulates negative fear states, but also up-regulates positive emotions

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in loving and play states. When we are evaluating an attachment relationship,we should be looking at not only the ability to calm and soothe, but alsothe ability to stimulate the baby into states of joy, interest, and excitement.These positive emotions are important for brain development. So what wehave in the attachment relationship is the developing ability of the child tocommunicate and to regulate positive and negative emotional states, whichare components of healthy self-esteem.

Right-brain development is not just genetically encoded; it is shapedby “epigenetic” social forces and requires these human intimate experiencesfor its optimal growth. What the child is looking for, and what the childis gaining from the attachment relationship and imprinting into the circuitsof its maturing right brain, are these critical emotional, right brain-to-rightbrain experiences. How those experiences are provided or not provided bythe primary caregiver is going to affect the wiring of the circuits of thatright brain. The mother’s history of her own secure or insecure emotionalexperiences, including when she was an infant with her own mother, arestored in her right brain, creating what we call the epigenetic transmissionof attachment patterns across generations.

Regulation theory also offers a model of psychopathogenesis—earlysocial-emotional experiences may be either predominantly regulated ordysregulated, imprinting secure or insecure attachments. Developmentalneuroscience clearly demonstrates that all children are not “resilient” butrather are “malleable,” for better or worse (A. N. Schore, 2012). In markedcontrast to the earlier described optimal growth-facilitating attachmentscenario, in a relational growth-inhibiting early environment of attach-ment trauma (abuse and/or neglect) the primary caregiver of an insecuredisorganized-disoriented infant induces traumatic states of enduring nega-tive affect in the child (A. N. Schore, 2003). This caregiver is too frequentlyemotionally inaccessible and reacts to her infant’s expressions of stressfulaffects inconsistently and inappropriately (intrusiveness or disengagement)and therefore shows minimal or unpredictable participation in the relationalarousal regulating processes. Instead of modulating she induces extremelevels of stressful stimulation and arousal levels, very high in abuse and/orvery low in neglect. Because she provides little interactive repair, the infant’sintense negative affective states are long lasting. Over the last few yearsneurobiological research is now exploring not just disorganized insecureattachments, but organized “insecures,” looking at the impact of maternaldismissive attachments on the infant’s brain (see Ammaniti & Gallese, 2014).

A large body of research now highlights the central role of insecureattachments in the psychoneuropathogenesis of all psychiatric disorders(A. N. Schore, 2003, 2012, 2013b). Watt observed, “If children grow upwith dominant experiences of separation, distress, fear and rage, then theywill go down a bad pathogenic developmental pathway, and it’s not just abad psychological pathway but a bad neurological pathway” (2003, p. 109).More specifically, during early critical periods, frequent dysregulated and

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unrepaired, organized, and disorganized-disoriented insecure attachment his-tories are “affectively burnt in” the infant’s early developing right brain.Not only traumatic experiences but also the defense against overwhelmingtrauma, dissociation, is stored in implicit-procedural memory as well.

In this manner attachment trauma (“relational trauma”; A. N.Schore, 2001) is imprinted into right cortical-subcortical systems, encodingdisorganized-disoriented insecure internal working models that are noncon-sciously accessed at later points of interpersonal emotional stress. Theseinsecure working models are of central interest in affectively focused psy-chotherapy of early forming self-pathologies and personality disorders. Suchdeficits in right-brain relational processes and resulting affect dysregulationunderlie all psychological and psychiatric disorders. All models of therapeu-tic intervention across a span of psychopathologies now share a commongoal of attempting to improve emotional auto-regulatory and interactive reg-ulatory processes (see A. N. Schore, 2003, for a discussion of these dualregulatory processes).

ATTACHMENT, AFFECT DYSREGULATION, AND RIGHT-BRAINCOMMUNICATIONS WITHIN THE THERAPEUTIC ALLIANCE

Bowlby (1988), a psychoanalyst, asserted that the reassessment of non-conscious internal working models of attachment is a primary goal ofany psychotherapy. These interactive representations of early attachmentsencode strategies of affect regulation and contain coping mechanisms formaintaining basic regulation and positive affect in the face of stressfulenvironmental challenge. Acting at levels beneath conscious awareness thisinternal working model is accessed to perceive, appraise, and regulate social-emotional information and guide action in familiar and especially novelinterpersonal environments. Regulation theory dictates that in “heightenedaffective moments” the patient’s unconscious internal working model ofattachment, whether secure or insecure, is reactivated in right-lateralizedimplicit-procedural memory and reenacted in the psychotherapeutic rela-tionship (A. N. Schore, 2003, 2012).

In light of the commonality of nonverbal, intersubjective, implicit rightbrain-to-right brain emotion transacting and regulating mechanisms in thecaregiver–infant and the therapist–client relationship, developmental attach-ment studies have direct relevance to the treatment process. The earlyresponding right brain, which is more “physiological” than the later respond-ing left, is involved in rapid bodily based intersubjective communicationsof dysregulated affect within the therapeutic alliance. At all life stages theright hemisphere holistically and nonverbally processes threats and mediatesstates of fear and vulnerability (A. N. Schore, 1994; Hecht, 2014). From thefirst point of intersubjective contact the psychobiologically attuned clinician

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tracks not just the verbal content but the nonverbal moment-to-momentrhythmic structures of the patient’s internal states and is flexibly and flu-idly modifying his or her own behavior to synchronize with that structure,thereby cocreating with the patient a growth-facilitating context for theorganization of the therapeutic alliance.

Decety and Chaminade’s (2003) characterization of higher functionsof the right brain is directly applicable to the psychotherapeutic relationalcontext:

Mental states that are in essence private to the self may be sharedbetween individuals . . . self-awareness, empathy, identification withothers, and more generally intersubjective processes, (and) are largelydependent upon . . . right hemisphere resources, which are the first todevelop. (p. 591)

As the right hemisphere is dominant for subjective emotional experiences(Wittling & Roschmann, 1993), the communication of affective states betweenthe right brains of the client–therapist dyad is thus best described as“intersubjectivity.”

In accord with a relational model of psychotherapy, right-brain pro-cesses that are reciprocally activated on both sides of the therapeutic alliancelie at the core of the psychotherapeutic change process. These implicitclinical dialogues convey much more essential organismic informationthan left-brain explicit, verbal information. Rather, right-brain interactions“beneath the words” nonverbally communicate essential nonconscious bod-ily based affective relational information about the inner world of theclient (and therapist). Rapid communications between the right-lateralized“emotional brain” of each member of the therapeutic alliance allow formoment-to-moment “self-state sharing,” a cocreated, organized, dynamicallychanging dialogue of mutual influence. Bromberg (2011) noted, “Self-statesare highly individualized modules of being, each configured by its ownorganization of cognitions, beliefs, dominant affect, and mood, access tomemory, skills, behaviors, values, action, and regulatory physiology” (p. 73).In this relational matrix both partners match the dynamic contours of differ-ent emotional-motivational self-states and simultaneously adjust their socialattention, stimulation, and accelerating/decelerating arousal in response tothe other’s signals.

Regulation theory models the mutual psychobiological mechanismsthat underlie any clinical encounter, whatever the verbal content. Lyons-Ruth (2000) described the affective exchanges that communicate “implicitrelational knowledge” within the therapeutic alliance. Neuroscience charac-terizes the role of the right brain in these nonverbal communications. At allstages of the life span, “The neural substrates of the perception of voices,

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faces, gestures, smells and pheromones, as evidenced by modern neuroimag-ing techniques, are characterized by a general pattern of right-hemisphericfunctional asymmetry” (Brancucci, Lucci, Mazzatenta, & Tommasi, 2009,p. 895). More so than conscious left-brain verbalizations, right brain-to-rightbrain visual-facial, auditory-prosodic, and tactile-gestural subliminal commu-nications reveal the deeper aspects of the personality of the client, as wellas the personality of the therapist (see A. N. Schore, 2003, for a right brain-to-right brain model of projective identification, a fundamental process ofimplicit communication between the relational unconscious systems of clientand therapist).

To receive and monitor the client’s nonverbal bodily based attach-ment communications the affectively attuned clinician must shift fromconstricted left hemispheric attention that focuses on local detail to morewidely expanded right hemispheric attention that focuses on global input(Derryberry & Tucker, 1994), a characterization that fits with Freud’s(1912/1958) description of the importance of the clinician’s “evenly sus-pended attention.” In the session, the empathic therapist is consciously,explicitly attending to the client’s verbalizations to objectively diagnose thepatient’s dysregulating symptomatology. However, she is also listening andinteracting at another level, an experience-near subjective level, one thatimplicitly processes moment-to-moment attachment communications andself-states at levels beneath awareness. Bucci (2002) observed, “We recog-nize changes in emotional states of others based on perception of subtleshifts in their facial expression or posture, and recognize changes in ourown states based on somatic or kinesthetic experience” (p. 194). In thismanner the empathic clinician is able to resonate with the client’s uncon-scious communications, so he or she can feel at an implicit level how thisperson experiences the world “from the inside out” (Bromberg, 2011). Thisenables the therapist to find ways of relating with this specific client thatallows the patient’s right brain to shift toward more integration and vitality.

Writing on therapeutic “nonverbal implicit communications,” Chused(2007) asserted,

It is not that the information they contain cannot be verbalized, only thatsometimes only a nonverbal approach can deliver the information in away it can be used, particularly when there is no conscious awareness ofthe underlying concerns involved. (p. 879)

These nonverbal communications are examples of “primary process commu-nication.” According to Dorpat (2001), “The primary process system analyzes,regulates, and communicates an individual’s relations with the environment”(p. 449). He proposed,

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Affective and object-relational information is transmitted predominantlyby primary process communication. Nonverbal communication includesbody movements (kinesics), posture, gesture, facial expression, voiceinflection, and the sequence, rhythm, and pitch of the spoken words.(Dorpat, 2001, p. 451)

The right brain thus processes “the music behind the words.”The organizing principle for working with unconscious primary process

communications dictates that just as the left brain communicates its states toother left brains via conscious linguistic behaviors, so the right nonverballycommunicates its other states to other right brains that are tuned to receivethese communications. Bromberg (2011) observed,

Allan Schore writes about a right brain-to-right brain channel of affectivecommunication – a channel that he sees as “an organized dialogue” com-prised of “dynamically fluctuating moment-to-moment state sharing.” Ibelieve it to be this process of state sharing that . . . allows . . . “a goodpsychoanalytic match.” (p. 169)

Writing in the psychiatry literature, Meares (2012) described “a form oftherapeutic conversation that can be conceived . . . as a dynamic interplaybetween two right hemispheres” (for other clinical examples of right brain-to-right brain tracking, see Chapman, 2014; Marks-Tarlow, 2012; Montgomery,2013; A. N. Schore, 2012).

THE RIGHT BRAIN IS DOMINANT IN PSYCHOTHERAPY

On the matter of the verbal content, the words in psychotherapy—it haslong been assumed in the psychotherapeutic literature that all forms of lan-guage reflect left hemispheric functioning of the conscious mind. Currentneuroscience now indicates this is incorrect. In an overarching review Rossand Monnot (2008) concluded, “Thus, the traditional concept that languageis a dominant and lateralized function of the left hemisphere is no longertenable” (p. 51). These authors pointed out that

the right hemisphere is essential for language and communicationcompetency and psychological well-being through its ability to mod-ulate affective prosody and gestural behavior, decode connotative(non-standard) word meanings, make thematic inferences, and processmetaphor, complex linguistic relationships and non-literal (idiomatic)types of expressions. (p. 51)

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Other studies reveal that the right hemisphere is dominant for the processingof, specifically, emotional words (Kuchinke et al., 2006). These data stronglysuggest that the use of language in emotional and relational contexts such asintimate moments of the therapy involves right- and not left-brain languagefunctions.

Left-brain interactions, that is, interpretations and rational explanations,are not the essential work of intersubjective psychotherapy, especially inheightened affective moments of the treatment. In fact, left-brain analy-ses will only contain and manage temporarily in a specific context. Insightwill not solve long-standing emotional and interpersonal problems in relat-ing. Right-brain-challenged clients will look to psychotherapy for left-brainsolutions—conscious, willed changes in thoughts, intentions, and strategies,when what they need for lasting change is someone to emotionally engagewith them right brain to right brain. What should this look like? In essenceright-brain communications are experience-near in a reliable and consistentmanner. For the therapist, “The key mechanism is how to be with the patient,especially during affectively stressful moments when the patient’s implicitcore self is dis-integrating in real time (right brain focus)” (A. N. Schore,2012, p. 103, italics added).

We maintain that the core skills of any effective psychotherapist areright-brain implicit capacities which include empathy, the regulation ofone’s own affect, the ability to receive and express nonverbal communi-cation, the sensitivity to register very slight changes in another’s expressionand emotion, and an immediate awareness of one’s own subjective andintersubjective experience. All other techniques and skills sit atop this essen-tial relational substratum. As Valentine and Gabbard (2014) eloquently stated,“Technique, in general, should be invisible. The therapist should be viewedby the patient as engaging in a natural conversational dialog growing out ofthe patient’s concerns; the therapist should not be perceived as applying astilted, formal technique” (p. 60).

The most important part of the therapist’s trying to understand theclient’s “attachment emotional narrative” (much of which is nonverbal) isthus a spontaneous affective resonance that echoes the moment-to-momentshifts in client’s affective and bodily states. The therapist tracks the intensityand direction of the affective charge, providing interactive affect regulationthat allows for a safe holding of this interpersonally shared moment as itemerges without interpretation. The safety created by this new experience ofbeing felt and regulated by another is repeated many times, so that the clientwill eventually be able to stay with this amplified affective state as it emergesin the interpersonal context of the therapeutic alliance, and ultimately evenbegin to talk about it or reflect on its meaning to her. In this process,unconscious affect becomes experienced, sustained, regulated affect, whichcan then become organized as a subjectively experienced emotional stateand integrated into an expanding right-lateralized autobiographical self. The

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interactively regulated relationship with the therapist begins to provide analternative to the defensive auto-regulatory withdrawal from others to pro-tect the vulnerable self. The client learns to be with himself differently aswell, within this safe connection with the attuned, engaged therapist.

As the client is able to contact, describe, and regulate his own emotionalexperience within the relational field, right-brain insight comes organically,building upon the emotional experience. The client develops a more com-plex ability to feel the connections between remembered history, sense ofself, and working models of relationships. This right-brain insight includesa deeper awareness as a feeling/thinking/choosing person, and the cre-ation of a more meaningful and authentic personal narrative. In terms ofneuroscience, this change reflects more interconnectivity in his right brain,horizontally and laterally, more brain systems involved in the processing,communication, and regulation of emotion, thereby increasing the neuro-plasticity of the emotional brain. Resultingly, the client becomes increasinglyable to experience a broader range of and more complexity in emotions,as well as less rigidity in defenses. This more developed way of being, ofself-regulation, will prove to be more flexible and useful than the previouscharacterological reliance on defensive affect-deadening dissociation. Theclient’s bodily-based affective states, rather than being experienced as threatsto self-cohesion, will now promote the development and unification of hersense of self. This emotional growth, in turn, allows her to be in a better posi-tion to intersubjectively communicate positive and negative affective states,to solve relationship problems with more resilient right-brain strategies, andto find emotional connection and satisfaction in interpersonal relationships(A. N. Schore, 2012).

Intersubjectivity is more than a communication or match of explicit ver-bal cognitions or overt behaviors. Regulated and dysregulated bodily basedaffects are communicated within an energy-transmitting intersubjective fieldcoconstructed by two individuals that includes not just two minds but twobodies. At the psychobiological core of the coconstructed intersubjective fieldis the attachment bond of emotional communication and interactive regula-tion. Implicit intersubjective communications express bodily based emotionalself-states, not just conscious cognitive “mental” states. The essential bio-logical function of attachment communications in all human interactions,including those embedded in the therapeutic alliance, is the regulation ofright brain–mind–body states. Intersubjective, relational, affect-focused psy-chotherapy is not the “talking cure,” but the “affect-communicating cure.”Neurobiologically informed relational infant, child, adolescent, and adult psy-chotherapy can thus potentially facilitate the intrinsic plasticity of the rightbrain, the biological substrate of the human unconscious.

The experience of being known and held in the understanding andaffirming gaze of the therapist is what heals a broken or underdeveloped selfand enables the client to grow emotionally: not insight, catharsis, or strategies

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to change behaviors and thoughts. Any lasting change in the deeper subjec-tive sense of self can only emerge in the emotional presence of the therapists’empathy, authenticity, and unconditional positive regard. This has been writ-ten about since the middle of the last century, when Carl Rogers (1951)placed it at the core of client-centered therapy. Within psychoanalysis HeinzKohut (1971) continued this central focus on empathic attunement. Morerecently the Boston Change Process Study Group (2010) highlighted whatthey call “now moments” that occur between therapist and client that havethe power to alter and expand “implicit relational knowledge,” what a clientimplicitly or unconsciously knows about how relationships really work andwho he is in them. In earlier writings we identified the right hemisphere asthe processor of implicit relational knowledge (J. Schore & Schore, 2010).Furthering this idea, we now propose that the shared social-emotional expe-riences of the intimate psychotherapeutic context can affect brain plasticityand expand the client’s “social intelligence,” a right-brain capacity for “identi-fying social stimuli, understanding the intentions of other people, awarenessof the dynamics in social relationships, and successful handling of socialinteractions” (Hecht, 2014, p. 1).

CODA: LONG-TERM CLINICAL EXPERIENCE AND CHANGES IN THECLINICIAN’S BRAIN

Regulation theory models changes in not only the client, but also in the clin-ical social worker. With clinical experience (the proverbial “10,000 hours”needed for the development of “expertise”) psychotherapists of all schoolscan become expert in nonverbal intersubjective processes and implicit rela-tional knowledge that enhance therapeutic effectiveness. The professionalgrowth of clinicians reflects progressions in right-brain relational processesthat underlie clinical skills. These right-brain expert functions of the emo-tionally sensitive therapist are expressed implicitly in an expanded abilityto intuitively communicate with the bodily based unconscious minds acrossa wide variety of different client populations. The clinical experiences ofpsychodynamic psychotherapists also cultivate an implicit ability to regulateunconscious affect.

On this matter—the neuropsychoanalytic perspective of ART focusesattention on the increasing complexity of therapist’s right-brain clinicalintuition, more so than left-brain analytic reasoning, and on an expandingability to process right brain-to-right brain dynamics within the cocon-structed therapeutic alliance. The source of the most complex professionallearning is what we learn from our clients, if we are open to this knowledge.Some of this knowledge can only be gained by exposing oneself to thedarker side of the human experience. Other forms of this self-knowledgecome from the intense intimacy and relational play that one encounters

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in deep psychotherapy. Our work leads us to believe that certain parts ofour personalities can only grow in the presence of a receptive, emotionallycommunicating “other.”

There is a limit to what we can learn by moving into a space apartfrom others, and self-reflecting. Mindfulness is often a left-brain attempt toauto-regulate and is thus self-limiting in terms of more efficient interactivelyregulated emotional experiences. Reflective consciousness (“mentalization”)can only get one so far in terms of “understanding” oneself, especiallythe relational implicit self that interacts with another implicit self. We needtrusted, empathic, resonant others who can mirror and amplify our deepestunconscious self-states and thereby bring them into working memory andawareness (see J. R. Schore, 2012, for a discussion of implicit and explicitmemory systems).

The clinical model of regulation theory, ART, is a blend of classicattachment theory, internal object relations theory, self-psychology, andcontemporary relational theory, all informed by neuroscience and infantresearch. The practice of psychotherapy is fundamentally relational: the ther-apeutic alliance, the major vector of change, is, in essence, a two-personsystem for (implicit) self-exploration and relational healing. At all pointsin the life span, this emotional growth of the self that supports emotionalwell-being is facilitated in relational contexts. The importance of “context”is currently highlighted by all scientific and clinical disciplines. For mostof the last century science equated context with the organism’s physicalsurround; this has now shifted to the social, relational environment. Allhuman interactions, including those between therapist and client as wellas researcher and experimental subject, occur within a relational context,in which essential nonverbal communications are transmitted and regu-lated at levels beneath conscious awareness, thereby activating/deactivatingbasic homeostatic processes in both members of an intersubjective dyad.We suggest that the inclusion of right-brain neuroscience and neuropsycho-analysis into a developmentally oriented, affectively focused treatment modelcan offer us more complex understandings of the science and the art ofpsychotherapy.

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Judith R. Schore, PhD, is a clinical social worker in private practice, dean ofstudents and core faculty at the Sanville Institute, associate director of ClinicalTraining and Curriculum Development at Reiss-Davis Child Study Center, andfaculty at The Graduate Center for Child Development and Psychotherapy.

Allan N. Schore, PhD, is on the clinical faculty of the UCLA DavidGeffen School of Medicine, editor of the Norton Series on InterpersonalNeurobiology, and the recipient of a number of awards from the AmericanPsychological Association and the American Psychoanalytic Association.He is the cochair of the child section of the upcoming PsychodynamicDiagnostic Manual (2nd edition).

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regulation theory and affect regulation psychotherapy: a clinical primer

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