Dr Allan Schore UCLA DAVID GEFFEN SCHOOL OF MEDICINE THE SCIENCE OF THE ART OF PSYCHOTHERAPY

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1 Dr Allan Schore UCLA DAVID GEFFEN SCHOOL OF MEDICINE THE SCIENCE OF THE ART OF PSYCHOTHERAPY Working with the right brain: a model of clinical expertise for treatment of attachment trauma Recorded at Confer in London, 2012 Dr Allan Schore these slides may not be copied without the author s permission

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3 Neurobiologically Informed Clinical Work with Attachment Trauma and UCS Dissociated Affect Schore ( ): right brain dominant in psychotherapy. Alvarez (Journal of Child Psychotherapy, 2006): Schore points out that at the more severe levels of psychopathology, it is not a question of making the unconscious conscious: rather it is a question of restructuring the unconscious itself. Expert clinician optimally co-creates growth facilitating context that increases complexity of patient s UCS - restructures right brain emotional self. Change mechanism not primarily mediated by insight.

4 The Science of the Art of Psychotherapy: organizing principles of regulation theory. clinical Affects at psychobiological core of communications between relational unconscious of patient and relational unconscious of empathic therapist. Regulation of conscious and unconscious feelings is placed in the center of the clinical stage. Both patient s and therapist s right brain emotionalrelational processes are essential to psychotherapy. This perspective emphasizes therapist s skills in the reception, expression, and regulation of patient s conscious and especially unconscious affective bodilybased communications.

5 Diener (Amer. J. Psychiatry, 2007): clinical research shows the more therapists facilitate affective experience / expression of patients, the more patients exhibit positive changes. Therapist affect facilitation is a powerful predictor of treatment success. Research indicates that contemporary psychodynamic therapies place greater emphasis on encouraging experience and expression of feelings compared with cognitive behavior therapies. Berenbaum et al. (Clinical Psychology: Practice and Science, 2003): Emotional disturbances are common to almost all psychopathological conditions, ranging from eating disorders to schizophrenia.

6 Principles of relational affective dynamics and interpersonal neurobiology have implications for treatment of all forms of psychopathology, especially early forming personality disorders. These patients show implicit deficits, lack reflective function, refractory to insight-driven cognitive/behavioral interventions. Effective treatment of patients whose subjectivity is dominated by chronic dysregulated and dissociated affects requires more than clinical techniques that focus on content analysis and accurate interpretations in order to change UCS self cognitions.

7 General therapeutic principle of working with relational trauma and severe disturbances of affect regulation: empathic therapist helps patient re-experience trauma in affectively tolerable doses in the context of a safe environment, so that overwhelming traumatic feelings can be regulated and adaptively integrated into patient s emotional life. Work guided by principle that focus of treatment is not on exact reconstruction of infantile traumatic setting but on effects of early relational attachment trauma on character structure, right brain structure and deficits in adaptive functions.

8 In this clinical work, right brain-to-right brain communications within patient-therapist attachment system facilitate re-expression of the patient s early attachment experiences, UCS self images stored and expressed in right brain implicit / procedural autobiographical memory. Theoret (Cognitive Brain Res., 2004): RH processing of self-images, at least when self-images are not consciously perceived. Gainotti (Psychoanal. & Neurosci., 2006): the right hemisphere may be crucially involved in those unconscious memories which must be reactivated and reworked during the psychoanalytical treatment.

9 Bowlby (1988): therapeutic relationship reactivates patient s UCS expectations about responsiveness and availability of others = transference. Pincus, Freeman & Modell (2007): neuropsychoanalytic models contend that no appreciation of transference can do without emotion, and that transference is distinctive in that it depends on early patterns of emotional attachment with caregivers. Maroda (2005): transference is an established pattern of relating and emotional responding that is cued by something in the present, but oftentimes calls up both an affective state and thoughts that may have more to do with past experience than present ones.

10 Freud (1933): In referring to transference he describes an original, archaic method of communication between individuals. Schore (1994): transference-countertransference expressed in right brain-to-right brain nonverbal communications between patient and therapist. Shuren & Grafman (Arch. Neurology, 2002): The right hemisphere holds representations of the emotional states associated with events experienced by the individual. When that individual encounters a familiar scenario, representations of past emotional experiences are retrieved by the right hemisphere and are incorporated into the reasoning process.

11 Freud (1912) [Therapist] should withhold all conscious influences from his capacity to attend, and give himself completely to his unconscious memory. Schore: all technique sits atop therapist s ability to access implicit realm via right brain UCS memory. Rizzuto (2008): Unconscious memory includes affective memory with its atemporal register of a great variety of emotional states and its exquisite capacity to tune in the the sound and the whispers of the human voice I suggest that the [therapist] listens with his or her entire unconscious memory as a tool, that is, an affective, relational, and representational memory to be able to hear the whole patient.

12 Right brain implicit memory stores not only history of affect dysregulation, but also survival strategies, affect dampening defense of dissociation, detachment from an unbearable situation, the escape when there is no escape, a last resort defensive strategy. Schore (Infant Mental Health J.,2001): attachment trauma source of characterological dissociation. Schore (Australian NZ J. Psychiatry, 2002): pathological dissociation = inability of right brain cortical-subcortical system to recognize and co-process (integrate) external stimuli (exteroceptive information coming from environment) and internal stimuli (interoceptive information from body).

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14 Spitzer et al. (J. Neuropsychiatry Clin. Neurosci., 2004): Dissociation may involve a... lack of integration in the right hemisphere. Helton et al. (Consciousness and Cognition, in press): the integration of experiences, which rely heavily on right hemispheric activation (e.g., negative emotion, sense of self with reference to the experience, may be compromised in high dissociators. Enriquez and Bernabeu (Consciousness and Cognition, 2008): dissociation is associated with dysfunctional changes in the right hemisphere which impair its characteristic dominance over emotional processing.

15 Clinical research shows pathological dissociation, a primitive defense against overwhelming affects, key feature in: Pediatric maltreatment disorder Reactive attachment disorder of infants Dissociative identity disorder Posttraumatic stress disorder Psychotic disorders Eating disorders Somatoform disorders Addiction, including substance abuse and alcoholism Borderline personality

16 Spitzer et al. (Aust. NZ J. Psychiatry, 2007): insecurely attached patients dissociate as a response to negative emotions arising in psychodynamic psychotherapy, leading to a less favorable treatment outcome. Clinical expertise: how does therapist detect and recognize dissociated = UCS negative affect? Freud (1915): Unconscious ideas continue to exist after repression as actual structures in the system Ucs, whereas all that corresponds in that system to unconscious affects is a potential beginning which is prevented from developing. Sato & Aoki (Brain & Cognition, 2006): neuroscience describes unconscious negative emotion.

17 Dissociation and it s affect deadening effects are a major inhibitor of psychotherapeutic progression. Clinical descriptions of dissociation: Patients report that they are tuned out, and they are not aware of anything to which they are tuned in. Some patients indicate that they go beyond feeling spacey to being utterly blank or gone, as if they are in the blackness or a void. At the extreme, they sit and stare, almost as if in a catatonic or comatose state. When patients are in such states, others find it extremely difficult to engage their attention and to help the resume a normal state of consciousness.

18 Chefetz & Bromberg (2004): How can the therapist attune to patient s dissociated affective states? Stop, look, and listen. What do we see if we stop, and focus our attention on looking at our patients? We see that shifting from one set of thoughts and feelings to another is accompanied by a physiological change of state that parallels the thoughts and feelings. Like a musical score of a movie, the memory of a thought or a feeling is encoded with contextual physiologic accompaniment.

19 If we want to know about unconscious process, then we need to become keen observers of our patient s physiology and the associated bodily changes. Typical changes are: change in body position, shift in facial expression, shift in eye gaze, eye closure, swallowing, and skin flush tears that flow onto cheeks and tears that well up but do not flow Refer to physiologic countertransference = projective identification. Changes in the therapist s body indicate that something has shifted in the patient. Paradigm shift in defences: clinical work with UCS affect shifts from repression to dissociation.

20 Personalities with pathological dissociation are not only cut off from their bodies and therefore affect(subjective deficits), but also cut off from others (intersubjective deficits) Leavitt (J. Clinical Psychology, 2001): individuals who extensively dissociate may become socially dysfunctional by virtue of the fact that large chunks of personal situations and social experiences fail to be noticed and therefore can not be used to orient to or noticed and therefore can not be used to orient to or meaningfully interact with broad aspects of experience that are essential to normal social intercourse.

21 Sands (1994): Dissociative defenses serve to regulate relatedness to others The dissociative patient is attempting to stay enough in a relationship with the human environment to survive the present while, at the same time, keeping the needs for more intimate relatedness sequestered but alive. Schore (Ann. New York Academy of Sciences, 2009): these personalities unconsciously passively disengage and shut down affects in intimate contexts Clinical focus on patient s inability to consciously experience UCS dissociated negative affect.

22 UCS negative affects must be communicated and shared, then interactively regulated. Bucci (Psychoanalytic Inquiry, 2002): In the session, the threatening dissociated affect must be activated to some degree, but in trace form, regulated sufficiently so as not to trigger new avoidance, and with some transformation of meaning. The questions of how much and when to activate or to permit this activation, so as to repair the dissociation rather than reinforce it, must be addressed specifically for each patient.

23 Tutte (2004): Such work implies a profound commitment by both participants in the analytical scenario and a deep emotional involvement on the [therapist s] part. [= therapeutic expertise] Spiegel (2006): These patients are difficult to treat The therapist needs to interact directly with all elements of the patient s emotional world. One has to participate in a real enough relationship with the patient so that one comprehends the patient s world. Problem of clinical expertise in working with attachment trauma.