do not circulate do not cite therapeutic enactments:...

DO NOT CIRCULATEDO NOT CITE

THERAPEUTIC ENACTMENTS:

WORKING IN RIGHT BRAIN

WINDOWS OF AFFECT TOLERANCE

ALLAN N. SCHORE

allanschore.com

UCLA DAVID GEFFEN SCHOOL OF MEDICINE

APRIL 2010

Last year’s talk: “A regulation model of clinicalexpertise for treatment of attachment trauma.’

In that and other presentations here at UCLA,suggested right brain is dominant in psychotherapy,and that incorporation of recent scientific studies ofright brain into updated clinical models allows for adeeper understanding of change process.

Schore (1991-2010): Regulation Theory, model ofdevelopment, psychopathogenesis, and treatment ofthe implicit self.

Further application of model to another complexclinical phenomenon, therapeutic enactment.

In 1994 Glen Gabbard began an AmericanPsychoanalytic Association panel on Enactment ofBoundary Violations with Freud’s letter to Jung that hehad not yet acquired “the necessary objectivity”:

“You still get involved, giving a good deal of yourselfand expecting the patient to give something in return.Permit me, speaking as the venerable old master, tosay that this technique is invariably ill-advised andthat…it is best to remain reserved and purelyreceptive. We must never let our poor neurotics driveus crazy.”

“I believe an article on ‘countertransference’ is sorelyneeded; of course, we could not publish it.”

Gabbard concluded by arguing that if we are toprevent destructive enactments of boundary violations,we must begin with a psychoanalytic understanding ofhow such enactments evolve.

Chused (1991): origin of enactment lies within thepsyche of patient, who is attempting to recreate thepast and gain gratification; counterproductive.

Chused (1997): therapeutic moment occurs whenclinician thwarts an enactment and provides a correctinterpretation instead.

By end of 90’s theoretical and clinical models ofenactment had evolved from a one personintrapsychic to a two person relational psychology.

Maroda (Psychoanalytic Psychology, 1998):

“Enactment is an affectively driven repetition ofconverging emotional scenarios from the patient’s andthe analyst’s lives.”

“Behaviorally, it may take the form of a heatedargument, a sadomasochistic exchange, aspontaneous hug or other physical gesture, ashortening or lengthening of a session, a failure tocollect the fees, an unexpected dissolution into tears,or a withdrawal into silent rejection.”

[Now clear that enactment may not be so dramatic]

Maroda (1998) on enactment: describes “just howubiquitous it is and how equally inevitable is theevocation of the analyst’s past in terms of re-creatingan emotional scenario.”

“It is not merely an affectively driven set of behaviors,it is necessarily a repetition of past events that havebeen buried in the unconscious due to associatedunmanageable or unwanted emotion.”

“It is his or her chance to relive the past, from anaffective standpoint, with a new opportunity forawareness and integration.”

Advice about avoiding enactments is senseless.

Here suggest we now have understanding of thiscomplex clinical phenomenon Gabbard was calling for.

Recent clinical and scientific knowledge is altering ourclinical approaches to both enactments and to changeprocess of psychotherapy.

Current ongoing paradigm shift allows for a deeperunderstanding of how regulated enactments are acentral mechanism of therapeutic action, especially forpatients with a history of attachment trauma, whetherthey be infants, children, or adults.

Schore (2009): plenary address APA Convention inToronto, “The paradigm shift: the right brain and therelational unconscious” (see allanschore.com)

Paradigm shift: “emotional revolution” deepensunderstanding of enactments

APA Panel (1992): all enactments contain twoessential elements: the stimulation of strong,unconscious affects and some resulting behavior.

Maroda (1998): enactments involve “the experience ofunconsciously strong or even overwhelming, affect.”

“Although it necessarily involves action, enactment isessentially an affective event.”

“Failing to appreciate the emotional intensity ofenactment constitutes its inevitability, rather than aparticular behavior, could lead to irresponsible acts onthe part of therapists.”

Paradigm shift: neuropsychoanalysis deepensunderstanding of enactments

Enactment can’t be understood without theory of UCS.Psychoanalysis, “the science of the UCS,” providesthis data.

Bargh & Morsella (Perspectives Psychol. Sci., 2008):“Freud’s model of the unconscious as the primaryguiding influence over every day life, even today, ismore specific and detailed than any to be found incontemporary cognitive or social psychology.”

Schore (JAPA,1996): early maturing RH representsdeveloping UCS system described by variouspsychoanalytic observers.


Schore (1994-2010): right lateralized “emotional brain”represents biological substrate of Freud’s UCS, a“relational unconscious.”

Freud (1915): “Unconscious ideas continue to existafter repression as actual structures in the systemUcs, whereas all that corresponds in that system tounconscious affects is a potential beginning which isprevented from developing.”

Sato & Aoki (2006): “Right hemispheric dominance inprocessing of unconscious negative emotion.”


Enactments = re-expression in real-time of earlyforming right brain automatic survival mechanisms.

Maroda (1998): “Enactment is a dynamic, naturallyoccurring manifestation of the transference andcountertransference merging into a living entity,making the past alive in the present.”

Freud (1933): transference is an “original, archaicmethod of communication between individuals.”

Schore (1994): right brain-to-right brain =transference-countertransference interaction ofpatient’s UCS and therapist’s UCS systems.

Paradigm shift: affective and developmentalneuroscience deepens understanding of enactments

Howard & Reggia (2007): “The right hemispheredevelops a specialization for cognitive functions of amore ancient origin and the left for a specialization forfunctions of more modern origin.”

Panksepp (2008): “Cognitive science must re-learnthat ancient emotional systems have a power that isquite independent of neocortical cognitive processes.”

McGilchrist (2009): “The right hemisphere, is…moreclosely in touch with emotion and the body (thereforewith the neurologically ‘inferior’ and more ancientregions of the central nervous system)…”

Paradigm shift: modern psychobiological traumatheory deepens understanding of enactments

Schore (2009): enactments more common in severepsychopathologies; histories of attachment trauma.

Borgogno (2008): “In patients whose psychic sufferingoriginates in…preverbal trauma…transference occursmostly at a more primitive level of expression thatinvolves in an unconscious way… not only the patientbut also the analyst…”

“These more archaic forms of the transference-countertransference issue - which frequently set asideverbal contents - take shape in the analytical settingthrough actual mutual enactments.”


Cassorla (Int. J. Psychoanal., 2008): enactment offers“a way of reaching deeply into traumatized areas.”

Maroda (1998): “The patient must be able to stimulatesomething in the [therapist] that is equally primitiveand split off, so that they can relive the drama in a realway together…Enactment thus involves mutualstimulations of repressed affective experience, ideallywith the patient taking the lead.”

Schore (2009): modern theory of relational traumanow available. Shift from repression to dissociation inunderstanding dynamics of enactment.


Schore (2001, 2009): dissociation represents earlyforming bottom-line right brain survival defenseagainst overwhelming, unbearable, emotionalexperiences, including attachment trauma.Detachment from unbearable situation, escape whenthere is no escape, last resort defensive strategy.

Effect of dissociation: intense negative affectsassociated with emotional pain are blocked fromconsciousness. Fundamental defense to the arousaldysregulation of overwhelming affective states.

Emily Dickinson (1862)

There is a pain--so utter---

It swallows substance up--

Then covers the Abyss with Trance--

So memory can step

Around--across--upon it--

As one within a Swoon--

Goes safely--where an open eye--

Would drop Him--Bone by Bone


Lanius (Biological Psychiatry, 2005): fMRI studyshowing RH activation in dissociation. Patientsdissociate “in order to ‘escape from’ the overwhelmingemotions associated with the traumatic memory.”

Recall enactments involve “unconsciously strong oreven overwhelming, affect.”

Schore (2003, 2009): UCS affect = dissociated affect.

Schore (2003): Enactment = release of dissociated notrepressed UCS affect. This can now potentially beinteractively regulated and integrated into implicit self.


Cassorla (2008): enactment “discharges” occur that“involve both members of the analytical dyad withouttheir being conscious of the fact.” Before affectiveeruption underlying traumatic situation in patient’s life“is frozen and unable to manifest itself openly.”

At moment enactment there is state shift, “a revival ofthe trauma, which had been frozen,” which “releasesthe plugged anxiety, with both seizing abruptly theanalytical field.” Acute enactment now serves ascatalyst to move the therapeutic process forward.


Relationship of enactment to specifically dissociation

Stern (2008): enactments are the only means ofencountering dissociated aspects of the patient.Offers an opportunity to “understand the unconsciousaspect of the patient on him, and then to use hisknowledge of this impact, and of his owndisequilibrium, to grasp parts of the patient’sexperience that the patient has no way to put intowords.”


Lebovici defines enactment as something “achieved ina truly extraordinary moment in which the analyst feelsin his own body an act which remains experiencedand not acted out” (cited in Zanocco et al., 2006).

Zanocco et al. (2006): “Enactment as contrast [toacting out] is related to primitive unconscious elementswhich find in the act their first expression.”

[Enactment is right brain expression of involuntarysmooth muscles of ANS. Acting out is expression ofCNS, left brain voluntary striated muscles.]

Paradigm shift: neuroscience deepens understandingof enactments

Schore (1994): enactments, re-expressions ofattachment trauma, represent right brain dysregulationof mind and body, CNS and ANS, “the physiologicalbottom of the mind.”

Porges (2007): “Consistent with the views that theright hemisphere appears to play a greater role inaffect, especially the adaptive expression of negativeaffect, the right hemisphere also appears to have agreater role in regulation of cardiac function…”

Schore (2003): adaptive bodily-based functions of RHlost in dysregulated hyperarousal and hypoarousal.

Paradigm shift: neurobiological psychodynamic modelview enactment as potential context of change:

Ginot (2007): “Increasingly, enactments areunderstood as powerful manifestations of theintersubjective process and as inevitable expressionsof complex, though largely unconscious self-statesand relational patterns.”

Such intense transference-countertransferenceaffective entanglements “bring to life and consequentlyalter implicit memories and attachment styles,” but atsame time “generate interpersonal as well as internalprocesses eventually capable of promoting integrationand growth.”

Paradigm shift: Schore’s Regulation Theory model ofenactment

Early growth-inhibiting social-emotional environmentsnegatively influence the ontogeny of right brainhomeostatic self-regulatory and attachment systems.

During pre- and postnatal critical periods of right braincortical-subcortical connections, unrepaired states ofdysregulated hyper- and hypoarousal shape a loweredlimbic-autonomic threshold for emotional turbulence, ahyperreactivity to novel environmental events, and areduced threshold for dissociation.

Patient brings into treatment an enduring imprint ofattachment trauma: an impaired capacity to regulatestressful affect and an over-reliance on the affect-deadening defense of pathological dissociation

Affect dysregulation = tendency to low-threshold, highintensity emotional reactions followed by slow return tobaseline. “Highs and lows are too extreme, tooprolonged, or too rapidly cycled and unpredictable.”

Patients automatically trigger right brain stressresponse at low thresholds of relational stress,frequently experience enduring states of high intensitynegative affect, and defensively dissociate at lowerlevels of stressful arousal.

Enactments expressions of dyadic affect-arousaldysregulation. These psychobiological dynamics re-enacted in therapeutic alliance. In heightened affectivemoments of transference-countertransferenceruptures, communication of intense negative rightbrain bodily-based UCS affects dysregulates both.

Therapeutic implicit change: Can rupture be repaired= can states of hyper- and hypoarousal beinteractively regulated? Can a responsive relationalcontext of therapeutic alliance reduce dissociativedefense, alter stress response threshold set points,and increase affect tolerance and affect regulation?

Working in right brain windows of affect tolerance(Schore, 2009).

Affective Dynamics of Clinical Enactments

Recent clinical relational models, enactmentsunderstood as intense affective eruptions withintherapeutic relationship that are part of the ongoingtherapeutic process, and not due to a failing of patientor psychological makeup and approach of clinician.

Romano (2008): “There is a growing consensus in thefield of psychotherapy that the personalities of theclient and the therapist, together with the therapeuticrelationship, play a critical role in psychotherapyprocesses and outcomes.”

Magnavita (2006): “The process of psychotherapyuses relational factors to stimulate healing and growth.The quality of the therapeutic relationship is probablythe most robust aspect of therapeutic outcome.

Luborsky et al. (1985): “The therapist’s ability to forman alliance is possibly the most crucial determinant ofhis effectiveness.”

In early phases of treatment, right brain-to-right brain

communications solidify therapeutic alliance and

increase positive transference.

Co-created emotional bond enables patient at an UCS

level to experience increasing trust and safety,

allowing defenses to be lowered.

Schore (1994): “The therapist's focus is on theempathic grasp of the experiential state of the patient.As a result the patient establishes an ‘archaic bond’with the therapist and thereby facilitates the revival ofthe early phases at which his psychologicaldevelopment has been arrested (Kohut, 1984).

The emotional bond between the patient and therapist,manifested in the working alliance, promotes theexploration of the individual's internal experience andaffective state. This strongly felt bond enables thepatient to confront inner states associated withfrightening aspects of the self.”

Bowlby (1988): therapeutic relationship reactivates

patient’s UCS expectations about responsiveness and

availability of others, including therapist.

Ongoing attuned right brain communications within

relationship facilitate re-expression of patient’s early

attachment experiences, stored and expressed in right

brain implicit/procedural autobiographical memory.

Gainotti (Psychoanalysis and Neuroscience, 2006):“the right hemisphere may be crucially involved inthose unconscious memories which must bereactivated and reworked during the…treatment.”

Experiences of relational attachment traumaare re-enacted in right brain-to-right brainnonverbal implicit (UCS) affectivecommunications within transference-countertransference relationship.

Valent (1999): “Transference-countertransference may be the only wayinfants or severely traumatized persons cancommunicate their stories of distress, and aretherefore central tools for discerningunprocessed or defended events.”

Bromberg (2006) on enactment as “reliving”:“Because trauma cannot be narrativelyrepresented in memory, traumatic experience isunsymbolized by language and thereforecannot be spoken ‘about’ as material. Attemptsto do so invoke a reliving of it as part of thetelling…”

Ulanov (2001): “The transference-countertransference field carries the agony thatwords cannot capture because injury occurredbefore words did.”

Maroda (2005): Transference is “an establishedpattern of relating and emotional responding that iscued by something in the present, but oftentimes callsup both an affective state and thoughts that may havemore to do with past experience than present ones.”

Shuren & Grafman, 2002): “The right hemisphereholds representations of the emotional statesassociated with events experienced by the individual.When that individual encounters a familiar scenario,representations of past emotional experiences areretrieved by the right hemisphere and are incorporatedinto the reasoning process.”

Quintessential context for an enactment is a right braintransferential-countertransferential nonverbalcommunication of a dysregulated emotional state, ashared heightened affective moment.

This communication occurs at implicit levels of thetherapeutic relationship = interaction between thepatient’s emotional vulnerability and the therapist’semotional availability.

Tutte (Int. J. Psychoanal., 2004): such work “implies aprofound commitment by both participants in theanalytical scenario and a deep emotional involvementon the [therapist’s] part.”

Kalsched (2003): “For our early trauma patientsto get well again, they will have to sufferthrough a re-traumatization in theirtransferences.

This repetition in the transference will be theperson’s way of remembering, and may actuallylead to the potential of healing of trauma,provided that the therapist and patient cansurvive the furor therapeuticus that suchtransformation requires.”

Maroda (2010): “[B]oth therapist and client aresimultaneously experiencing strong, unacceptableemotions originating in their past and they act theseout in their relationship. Enactment occurs when aclient unconsciously stimulates a strong, unplannedresponse by the therapist.”

“To fit the definition of enactment, both therapist andclient need to be unaware of what they are stimulatingin each other until some untoward event occurs.”

She states enactment results from mutual projectiveidentification.

Sands (Psychoanalytic Dialogues, 1997):“Patients will use projective identificationbecause they seek to bring into the therapeuticrelationship affective experience that has notbeen symbolically encoded.

Because it was encoded under traumaticconditions or because it pertains to a preverbalperiod, it remains in somatosensory form andmust be communicated in like manner.”

Schore (2003) chapter, “Clinical Implications of aPsychoneurobiological Model of ProjectiveIdentification.”

Slow motion analysis of rapid dyadic UCSpsychobiological communications that occur in aclinical heightened affective moment.

These right brain transactions occur in milliseconds, inthe temporal domain of Stern’s “present moment,” anevent that lasts 4 seconds or less.

Enactments, "events occurring within the dyad thatboth parties experience as being the consequence ofbehavior in the other," are mediated by rapid and thusnonconscious right brain communications.

Buchanan (Secret signals. Nature, 2009):

“A person’s responses can often be explained by“non-linguistic behaviours of other people and simpleinstincts for social display and response, without anyrecourse to conscious cognition.”

“This ‘second channel’ of human communication actsin parallel with that based on rational thinking andverbal communication, and it is much more importantin human affairs than most people like to think.”

“It is incredibly naïve”…to take conscious verbalcommunications as the primary way that peoplerespond to each other.”

Geller (Clin. Psychol., 2003) on “knowing about” vs.“experiential knowing:”

“Patients have two potential sources of knowledgeabout their therapists: knowledge that is dependent onwhat the therapist chooses to verbally reveal and theknowledge that is dependent on receiving theinformation that is available to the senses duringtherapy sessions.”

“Therapists have less conscious awareness of andcontrol over the messages conveyed by theircharacteristic level of expressivity than over themessages conveyed by intentional disclosures.”

“Analogously, patients have far more lessawareness of what they are learning about theirtherapists by receiving information duringtherapy sessions. In other words, theknowledge that patients acquire fromencounters with the ‘perceptual reality’ of theirtherapist often remains at a tacit or subliminallevel.”

“Consequently, a patient may know much morethan he or she knows about the therapist thaneither of them is willing to acknowledge.”

These subliminal right brain communications,imprinted in attachment relationship between infantand caregiver, are transmitted through same rightbrain mechanism between patient and clinician.

Recall, nonverbal mother-infant attachmentcommunications are “accompanied by the strongest offeelings and emotions, and occur within a context of“facial expression, posture, tone of voice, physiologicalchanges, tempo of movement, and incipient action”(Bowlby, 1969).

Keenan et al. (Cortex, 2005): “The right hemisphere,in fact, truly interprets the mental state not only of itsown brain, but the brains (and minds) of others.”

Enactment and right brain communications

Brancucci et al. (Phil. Trans. R. Soc. B., 2009):

“The neural substrates of the perception of voices,faces, gestures, smells and pheromones, asevidenced by modern neuroimaging techniques, arecharacterized by a general pattern of right-hemispheric functional asymmetry.”

“It appears clear that social perception based on non-verbal cues would depend mostly on the righthemisphere, as the left is ruled out of the story due toits major implication in linguistic processing.”

Mlot (1998): UCS processing of emotional stimulispecifically associated with activation of RH not LH

During enactment UCS bodily-based dysregulatedaffects transacted in moment-to-moment right brain-to-right brain nonverbal visual-facial, auditory-prosodic,and tactile-proprioceptive emotionally-chargedattachment communications, as well as in gesturesand body language.

Ginot (2009): “The analyst’s sensitivity, or her rightbrain readiness to be fully attuned to nonverbalcommunication, is a necessary therapeutic skill.Becoming entangled in an enactment, although at firstout of awareness, is a surprising facet of suchsensitivity.”

Definition of sensitivity: “susceptible to the attitudes,

feelings, or circumstances of others; registering very

slight differences or changes of emotion.”

Schore (2005): “the sensitive clinician’s oscillatingattentiveness is focused on barely perceptible cuesthat signal a change in state, and on nonverbalbehaviors and shifts in affects.”

Psychobiological affective communications impact notonly mental but psychobiological systems in bothpatient and therapist.

Aron (1998) observes, “patient and [therapist]mutually regulate each other’s behaviors,enactments, and states of consciousness suchthat each gets under the other’s skin, eachreaches into the other’s guts, each is breathedin and absorbed by the other...the analyst mustbe attuned to the nonverbal, the affective...tohis or her bodily responses.”

Schore (2005): intersubjective transactions

between empathic clinician and patient include

more than two minds, but two bodies.

During enactment patient’s bodily-based transferential

nonverbal communications elicit therapist’s somatic

countertransferential responses.

Schore (1994): “Countertransferential processes are

currently understood to be manifest in the capacity to

recognize and utilize the sensory (visual, auditory,

tactile, kinesthetic, and olfactory) and affective

qualities of imagery which the patient generates in the

psychotherapist…countertransference dynamics are

appraised by the therapist’s observations of his own

visceral reactions to the patient’s material.”

Ivey (Int. J. Psychoanal., 2008):“The cherished image of [therapist’s], as selftransparent, swiftly apprehending theirenactment participation while isolating andcomprehending the contribution played by theirconflictual residues, is a regrettable fiction…

This implies that the analysis of thecountertransference is as important, and,indeed, inseparable from the analysis of thetransference.”

Zanocco (2006): enactments are “processes anddynamics originating in the primitive functioning of themind” [and body] and they allow therapist to access away of interacting with patients who are not able togive representation to their instinctual impulses.

Schore (1994): relational UCS = RH primary processcommunications.

Dorpat (2001) describes “primary processcommunication,” expressed in “nonverbalcommunication” including “both body movements(kinesics), posture, gesture, facial expression, voiceinflection, and the sequence, rhythm, and pitch of thespoken words.”

“Affective and object-relational information istransmitted predominantly by primary processcommunication….Intuitions, images, and emotionsderived chiefly from the primary process systemprovide an immediate and prereflective awareness ofour vital relations with both ourselves and others.”

Recall, enactments “frequently set aside verbalcontents.” During these heightened affective momentsthe sensitive therapist is expert at processing not leftbrain explicit secondary process but right brain implicitprimary process nonverbal communications.

Since enactments are right brain primaryprocess emotional and not left brain rationallogical secondary process communications,explicit, conscious, verbal voluntary responsesare inadequate to prevent, facilitate, ormetabolize implicit emotional enactments.

Enactments = “an unconscious mental activitywhich does not follow the rules of consciousactivity. There is no verbal language involved.Instead, there is a production of images that donot seem to follow any order, and, even less,any system of logic” (Zanocco).

Eliade (1991): “Images by their very structureare multivalent. If the mind makes use ofimages to grasp the ultimate reality of things, itis just because reality manifests itself incontradictory ways and therefore cannot beexpressed by concepts. It is therefore theimage as a such, as a whole bundle ofmeanings that is true.”

Note allusions of imagery to implicit primaryprocess cognition and right brainrepresentations (see Figure).

This dyadic psychobiological mechanism thus allowsfor detection of UCS affects, and underlies premisethat “an enactment, by patient or analyst, could beevidence of something which has not yet been ‘felt’ bythem” (Zanocco et al., 2006).

Ginot (2009): “By allowing implicit relational andemotional patterns to be fully experienced within the[therapeutic] process, enactment enables bothparticipants, and especially the [therapist], to attain anunmediated connection with what cannot yet beverbalized, a connection that essentially construes anempathic resonance.”

Important to emphasize that maintaining empathicresonance during an enactment is clinicallychallenging, because it occurs during a stressfulbreach in transference-countertransferencerelationship and rupture of therapeutic alliance.

Aspland (Psychotherapy Res., 2008): “ruptures arepoints of emotional disconnection between client andtherapist that create a negative shift in the quality ofthe therapeutic alliance.”

Ruptures are “episodes of covert or overt behaviorthat trap both participants in negative complementaryinteractions..an interactive process that involves bothclient and therapist contributions.”

Refer to “the importance of therapists recognizing andacknowledging problems in the relationship…Anotherrepeated theme is the suggestion that ruptures canhave positive consequences if successfullyresolved…Therapists’ ability to attend to rupturesemerged as an important clinical skill.”

During these most stressful moments of treatment,clinical expertise related to therapist’s ability tomaintain an empathic right brain-to-right brainconnection during stressful enactment ruptures,moments of “a negative shift in the quality of thetherapeutic alliance.”

Davies (2004): “It seems to me intrinsic torelational thinking that….‘bad objectrelationships’ not only will but must bereenacted in the transference-countertransference experience, that indeedsuch reenacted aggression, rage, and envy areendemic to…change within the relationalperspective.”

Overwhelming affects in enactmentaccompanied by defense of dissociation.Cassorla (2008) enactment state shift, “arevival of the trauma, which had been frozen.”

Spitzer et al. (2007): insecurely attached dissociativepatients dissociate as a response to negativeemotions arising in psychodynamic psychotherapy,leading to a less favorable treatment outcome.

Spiegel (Recognizing traumatic dissociation, Amer. J.Psychiatry, 2006): “Dissociative disorders may beunderdiagnosed and undertreated.”

“These patients are difficult to treat…The therapistneeds to interact directly with all elements of thepatient’s emotional world. One has to participate in areal enough relationship with the patient so that onecomprehends the patient’s world…”

Bromberg (2006): “Clinically, the phenomenonof dissociation as a defense against self-destabilization…has its greatest relevanceduring enactments, a mode of clinicalengagement that requires an analyst’s closestattunement to the unacknowledged affectiveshifts in his own and the patient’s self-states.”

Russell (1998): “The most important source ofresistance in the treatment process is thetherapist’s resistance to what the patient feels.”

Bromberg (2009): “A therapeutic posture thatsystematically tries to avoid collisions betweenthe patient’s and analyst’s subjectivities iseventually experienced as disconfirming thevitality of the patient’s dissociated self-statesthat are trying to find relational existence.

If the analyst is not responding affectively andpersonally to these parts, they are robbed of ahuman context in which to be recognized andcome alive.”

A relational perspective clearly applies to thesynergistic effects of the therapist’s transient orenduring countertransferential affective“mindblindness” and the patient’s negativelybiased transferential expectation in the co-creation of an enactment.

Ginot (2009): “As these interactions might giveexpression to dissociated painful, angry, anddefensive self-states, the empathic aspects inenactments do not depend on the [therapist’s] abilityto experience empathy for the patient’s difficulties.

The empathic component is found in the [therapist’s]readiness and ability to resonate with what is notverbalized but nonconsciously transmittednonetheless.”

Schore (1997): in the heightened affective moment ofenactment both patient and therapist do not haveaccess to a higher reflective capacity.

In light of the principle that enactment can be a turningpoint therapy at points when therapeutic relationshipcharacterized by a mode of resistance /counterresistance these moments call for mostcomplex clinical skills of the therapist.

Making this work even more emotionally challenging,Renik (1993) observes enactments cannot berecognized until one is already in them.

Safran and Muran (1996) although ruptures are“deteriorations in the relationship between therapistand patient,” also represent “interpersonal markersindicating critical points in therapy for exploration.”

Schore (2003): spontaneous co-createdenactment can either blindly repeat apathological object relation through therapist’sdeflection of projected negative states andintensification of interactive dysregulation anddefensiveness….or

Creatively provide a novel relational experiencevia therapist’s autoregulation of projectednegative states and via interactive repair act asan implicit regulator of patient’s CS anddissociated UCS affective states.

Further thoughts on this change mechanism

Enactments: Working in Right Brain Windows ofAffect Tolerance

The nonconscious affective communications andpsychobiological dynamics of an enactment occurwithin patient’s right brain window of affect tolerance

Schore (2009): enactments occur at edges ofregulatory boundaries of window of affect tolerance,what Lyons-Ruth describes as the “fault lines” of self-experience where “interactive negotiations have failed,goals remain aborted, negative affects are unresolved,and conflict is experienced.”

Working at regulatory boundaries = both members oftherapeutic dyad in state of right brain dominance.

Wilkinson (2010) discusses “Ferenczi’s interest inexploring the degree of tension that a patient couldtolerate and his assertion that to work at the edge ofwhat was bearable could bring about therapeuticresults. If we look at the work of Ogden et al. (2006)and of Schore concerning the appropriate level ofarousal, we find that this latter assertion of Ferenczihas a curiously modern ring to it.”

Schore (2009): “Self-destabilization of the emotionalright brain in clinical enactments can take one of twoforms: high arousal explosive fragmentation versuslow arousal implosion of the implicit self.”

Paraympathetichyperarousal enactment:low arousal implosion ofright brain implicit self

Sympathetic hyperarousalenactment: high arousalfragmentation of right brainimplicit selfA

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Work at the edges ofwindows of affecttolerance - dualregulatoryboundaries

Large body of research shows that right brain(“emotional brain”, “social brain”) differs from left inmacrostructure, ultrastructure, physiology,neurochemistry, and behavior.

Sullivan & Dufresne (2006): “right hemisphericspecialization in regulating stress - and emotion-related processes.”

MacNeilage et al. (Scientific American, 2009):“The left hemisphere of the vertebrate brain wasoriginally specialized for the control of well-establishedpatterns of behavior under ordinary and familiarcircumstances. In contrast, the right hemisphere (is)the primary seat of emotional arousal.”

Schore APA Plenary Address (2009): Paradigm shift:not 2 halves of one brain, but 2 cortical-subcorticalsystems, each with unique structure and functions

Research moving from studies of individuals in state ofoptimal (mid-range, neutral) arousal (pleasantemotion) to current studies on trauma (intenseemotion) and right brain’s UCS detection of stressfulunexpected stimuli inducing states of hyperarousaland/or hypoarousal and rapid response to danger.

Each hemispheric system has its own window ofarousal tolerance.

LH window of tolerance = optimal range of arousal for“behavior under ordinary and familiar circumstances,”i.e., voluntary, controlled behavior, explicit, consciousthought, cold cognition, verbal communication.

These “cognitive and behavioral” functions aredependent upon a moderate rather than high or lowarousal range, represented by a classical “inverted U.”

This window of optimal verbal processing and overtbehavioral expression is regulated by left DorsolateralPFC (conscious emotion regulation).

Current counseling and cognitive-behavioral insight-driven clinical models operate in this arousal rangeand focus on these LH functions.

Moderate arousal: neutral affect (pleasant)LH dominant over RH.Domain of verbal transcript.

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In contrast RH, which is dominant for “emotionalarousal,” sustains arousal for involuntary behavior,implicit, unconscious processes, hot cognition,nonverbal communication. Domain of RightOrbitofrontal PFC and unconscious affect regulation.

Affective treatment focuses here. Long term therapypotential to alter UCS internal working models.

Right brain different range of arousal tolerance tosustain its nonconscious psychobiological functions,and can operate at a window of very high (sympatheticenergy-expending ANS hyperarousal) or a window ofvery low (parasympathetic energy conservingdissociation-hypoarousal) levels.

As result of increasing safety and trust, patient re-

experiences right brain attachment memories

Mancia (Int. J. Psychoanal, 2006): “The discovery of

the implicit memory has extended the concept of the

unconscious and supports the hypothesis that this is

where the emotional and affective - sometimes

traumatic - presymbolic and preverbal experiences of

the primary mother-infant relations are stored.”

These traumatic implicit memories are encoded in

high (hyperarousal) and low (hypoarousal) arousal

states, marked by dysregulated sympathetic and

parasympathetic dominant affects.

In following, central zone reflects operations of bothLH and RH activities in neutral affect; LH dominant instates of moderate arousal and autonomic balance.

Middle band of neutral affect bounded by:(1) upper band of RH sympathetic dominant energy-expending high arousal affects associated with tightengagement with the environment, and(2) lower band of RH parasympathetic dominantenergy-conserving low arousal affects anddisengagement from the external environment(Recordati, Autonomic Neuroscience, 2003).

Moderate arousal: neutral affect (pleasant)LH dominant over RH.Domain of psychotherapy verbal transcript.

Parasympathetic ANS hypoarousal:dysregulated shame, disgust, hopelessdespair = anaclitic depression.Energy conserving disengagement.

Sympathetic ANS hyperarousal:dysregulated rage, terror, pain.Energy expending engagement.

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Environment: outside and inside the body

Porges’ View of the ANS

Nervous System

Safety Danger Life threat

• Optimal arousal level• Rest and digest• Parasympathetic ventral vagal system• “Social Engagement System”• Eye contact, facial expression, vocalization

• Hyperarousal• Increased Heart Rate• Sympathetic System• Mobilization – “fight-flight”• Dissociated rage, panic

• Hypoarousal• Decreased Heart Rate• Parasympathetic dorsal vagal system• Immobilization–”freeze”• Dissociated collapse

The metaphor of safety

Wheatley-Crosbie, adapted from Porges, 2006

RegulatedNervousSystem

DysregulatedNervousSystem

Autonomic Nervous System Arousal

Arousal LevelHyperarousal

Optimal Arousal

Hypoarousal

Dominant ANS SystemSympathetic System• “fight-flight”• dissociated rage or panic

Parasympathetic System• “smart” ventral vagal• “Social Engagement System” *• rest and digest

Parasympathetic System• primitive dorsal vagal• immobility-“freeze”• dissociated collapse

Wheatley-Crosbie, adapted from Levine, *Porges, & Ogden

Safety LevelDanger

Safety

Life Threat

Emotional”, “social” right brain “windows of affecttolerance” refers to optimal ranges of arousal fordifferent right brain affects and motivational states,which vary in arousal intensity (e.g., hi arousal terror,rage, joy; low arousal shame, hopeless despair etc).

Yet each window of affect tolerance has limits, a rangewithin which it sustains a regulated affect.

Regulatory boundary at edges of the window aredomains of affect tolerance. Dysregulated stressresponse triggered at upper limit of boundary.

Following figure “windows of affect tolerance”associated with hyper- and hypo-arousal.

Stress response:ParasympatheticHyporarousalDysregulatedDissociation

Stress response:SympatheticHyperarousalDysregulated Fight-Flight

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Work at the edges ofwindows of affecttolerance - dualregulatory boundaries

Working at edges of regulatory boundaries of RHwindows of affect tolerance allows potential expansionof both negative and positive affect tolerance = majorgoal of affectively focused therapy.

Clinical principle of working at regulatory boundaries:sensitive empathic therapist allows patient to re-experience dysregulating affects in affectivelytolerable doses in the context of a safe environment,so that overwhelming traumatic feelings can beregulated and integrated into patient’s emotional life.

Bromberg (2006): therapeutic relationship must “feelsafe but not perfectly safe.”

Therapy that stays in the middle (= “toosafe”) will not access stressful affects andsubsequent regulation (Ogden)

Parasympathetichyporarousaldysregulation: toolittle arousal tointegrate right brain

Sympathetichyperarousaldysregulation: toomuch arousal tointegrate right brain

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Work at the edges ofwindows of affecttolerance - dualregulatory boundaries

Visualize 2 planes of one window of affecttolerance in parallel to another: one representsthe patient’s window of affect tolerance, theother the therapist’s.

At the edges of the windows, the regulatoryboundaries, the psychobiologically attunedempathic therapist, on a moment-to-momentbasis, implicitly tracks and matches patterns ofrhythmic crescendos / decrescendos of thepatient’s regulated and dysregulated ANS withher own ANS crescendos / decrescendos.

Affect processing windows are mirrored, thereforesynchronized. When patterns of synchronized rhythms(dynamic changes within purple segments) are ininterpersonal resonance this right brain-to-right brain“specifically fitted interaction” generates amplifiedenergetic processes of arousal, and this interactiveaffect regulation co-creates an intersubjective field.

RH dominant for “subjective emotional experiences.”Interactive “transfer of affect” between right brains ofmembers of therapeutic dyad best described as“intersubjectivity.”

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Mirroring windows ofaffect tolerance andco-creation of inter-subjective fields atregulatory boundaries

Schore (1994): “Affect, especially unconsciousaffect, is the focus of the psychoanalytically-oriented treatment of primitive emotionaldisorders. This affect is transacted between thetherapist and patient in transference-countertransference communications.

In such transactions empathic therapist ispsychobiologically attuned to patient's internalstate. In the initial stages of treatment thisallows for the creation of an intersubjectivefield.”

Dynamic intersubjective field described byStern (2005) as “the domain of feelings,thoughts, and knowledge that two (or more)people share about the nature of their currentrelationship…This field can be reshaped. It canbe entered or exited, enlarged or diminished,made clearer or less clear.”

Jung (1946): “The doctor must go to the limit ofhis subjective possibilities, otherwise the patientwill be unable to follow suit.”

Schore (2003): intersubjective fields are dynamic.

“The two right brain systems that process unconsciousattachment-related information within the co-constructed intersubjective field of the patient andtherapist are temporally co-activated and coupled, de-activated and uncoupled, or re-activated and re-coupled.”

“The unconscious minds and bodies of two selfsystems are connected and co-regulating,disconnected and autoregulating, or reconnected andagain mutually regulating their activity.”

Furthermore there are 2 intersubjective fields ofpsychobiological attunement, rupture, andinteractive repair of collision of subjectivities ormassive disengagement of subjectivities:sympathetic hyperarousal and parasympathetichypoarousal intersubjective fields.

Different primary process transference-countertransferences in 2 intersubjective fields

Interactive psychobiology of sympathetic higharousal and parasympathetic low arousalenactments.

Parasympathetic ANS lowenergy intersubjective field ofpsychobiological attunement,rupture, and interactive repair

Sympathetic ANS high energyintersubjective field ofpsychobiological attunement,rupture, and interactive repairA

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High energy charge intersubjective field

High arousal = hypermetabolic CNS-ANS limbic-autonomic circuits = sympathetic dominant, energy-expending psychobiological states.

Hi energy explosive dyadic enactments; fragmentingimplicit self. Focus on exteroceptive sensoryinformation. Sympathetic-dominant intersubjectivity;over-engagement with environment.

Somatic countertransference to communicated higharousal affects. Heart rate acceleration.

Regulation / dysregulation of hyperaroused affectivestates (aggression-rage; fear-terror; sexual arousal) ofhigh energy enactments.

Affective ambience of high energy intersubjective fielddescribed by Geller’s (1984) dysregulation of affectintensity:

“A chronically elevated state of diffuse excitation canrender an individual insensitive to significantalterations. When the nonspecific amplification whichintensity provides exceeds a critical value, thethreshold for irritability, agitation, upset, affect stormsand outbursts is significantly lowered.”

“Similarly, the diffuse and pervasive sense of beingkeyed up for action tends to interfere with the ability togauge accurately the alarm signals indicating thatone's stress quota has been reached.”

Low energy charge intersubjective field

Low arousal = hypometabolic CNS-ANS circuits =parasympathetic dominant energy-conservingpsychobiological states.

Low energy implosive dyadic enactments; collapsingimplicit self. Focus on interoceptive information.Parasympathetic-dominant intersubjectivity;disengagement/dissociation.

Somatic countertransference to communicated lowarousal affects. Heart rate deceleration.

Regulation / dysregulation of hyporaroused affectivestates (shame, disgust, depressive hopeless despair)of low energy enactments.

Affective ambience of low energy intersubjective fielddescribed by Ulanov (2001):

“Failure of environmental support at this level of beingresults in maiming. Clinically, I have found thatcommunication from this level of hurt takes a long timeto arrive and then announces itself as unspeakable.”

“A sense of desolation fills the space between analystand analysand; despair clods the atmosphere,eclipsing any bright hope for recovery. The analyticcouple dwells in a blighted landscape. Both feel thehopelessness that anything might grow here.”

It should be noted that just as emotionresearchers have over-emphasizedsympathetic dominant affects and motivations(fear, flight-fight), so have psychotherapistsoverly focused on the reduction of anxiety-fearor aggression-rage states.

One outstanding example of this continuingbias is the devaluation of the critical role ofdysregulated parasympathetic shame anddisgust states in all clinical models.

Similarly, psychodynamic models havehighlighted the roles of rage and fear-terror inhigh arousal enactments, and subsequentexplosive fragmentation of the high energyintersubjective field and the implicit self.

As a result there has been an under-emphasison the low energy parasympathetic dominantintersubjective field.

This is problematic, because clinical work withparasympathetic dissociation, “detachmentfrom an unbearable situation,” is alwaysassociated with parasympathetic shamedynamics.

The collapse of the implicit self is subtle,signaled by amplification of theparasympathetic affects of shame and disgust,and by the cognitions of hopelessness andhelplessness, common accompaniments oftraumatic experiences.

Working deep in the low arousal intersubjectivefield Bromberg (2006) observes that shame ispresent in those patients who ‘disappear’ whenwhat is being discussed touches uponunprocessed early trauma, and that shame isthe most powerful affect a person is unable tomodulate.

“The task that is most important, and simultaneouslymost difficult for the [therapist], is to watch for signs ofdissociated shame both in himself and in his patient -shame that is being evoked by the therapeutic processitself in ways that the [therapist] would just a soon nothave to face…”

The reason that seemingly repeated enactments arestruggled with over and over again in the therapy isthat the [therapist] is over and over pulled into thesame enactment to the degree he is not attending tothe arousal of shame.”

Schore (2009): therapist negotiates heightenedaffective moments of co-created intersubjective fieldsnot by explicit verbal secondary process cognition, butby implicit nonverbal primary process clinical intuition.

On a moment-to-moment basis therapist must retainright brain-to-right brain connection with patient and atthe same time access a rapid, emotional, andembodied right brain intuitive decision process tonavigate through the relational uncertainty of theenactment.

Volz and von Cramon (2006): intuition is “related tothe unconscious,” and is “often reliably accurate.”Derived from stored nonverbal representations, suchas “images, feelings, physical sensations, metaphors”

Dijksterhuis & Nordgren (Perspect. Psych. Sci.,2006):“immediate intuitions that were good were made byexperts (perhaps they have so much knowledge thatthey can think unconsciously very quickly).”

Expert clinical intuition is a form of “implicit relationalknowledge” used unconsciously to make rapidspontaneous decisions in heightened affectivemoments, such as enactments, stressful ruptures ofintersubjective field.

Regulated Enactments, Corrective EmotionalExperiences and Expansion of the Right BrainImplicit Self

Although enactments are most stressful moments oftreatment, in an optimal context therapist canpotentially act as an implicit regulator of patient’s CSand dissociated UCS affective states.

Ginot (2007): “This focus on enactments ascommunicators of affective building blocks alsoreflects a growing realization that explicit content,verbal interpretations, and the mere act of uncoveringmemories are insufficient venues for curative shifts.”

Bromberg (2006): “An interpretativestance…not only is thereby useless during anenactment, but also escalates the enactmentand rigidifies the dissociation” This clearlyimplies that resolution of enactments involvesmore than making the unconscious consciousby defense interpretations.

But if not explicit factors, then what implicitrelational experience is essential to therapeuticchange process in developmentally impairedpersonalities?

Schore (Neuropsychoanalysis, 1999): “implicit

relational knowledge stored in the nonverbal domain,

is at the core of therapeutic change (Stern, 1998).”

At most fundamental level implicit change mechanismmust certainly include a CS or UCS affectiveexperience that is communicated to empathic other.

But in addition, optimal intersubjective contextprovides not only right brain implicit affectivecommunication but also an opportunity for right braininteractive regulation of dysregulated intense affectivestates, core of the attachment dynamic.

Greenberg (Clinical Psychology Sci. and Pract., 2007)describes 2 forms of regulation:

A “self-control” form of emotion regulation involvinghigher levels of cognitive executive function thatallows individuals “to change the way they feel byconsciously changing the way they think.”

This explicit form of affect regulation is performed bythe verbal left hemisphere, and unconscious bodily-based emotion is usually not addressed in this model.

Notice this conscious mechanism is at core ofcognitive insight, heavily emphasized in not onlyclassical psychoanalysis, mentalization, and CBT.

In contrast to this conscious emotion regulationsystem, Greenberg describes a second, morefundamental implicit affect regulatory system isperformed by the right hemisphere.

Recall “the right hemispheric specialization inregulating stress - and emotion-related processes.”

This system rapidly and automatically processes facialexpression, vocal quality, and eye contact in arelational context.

“The field has yet to pay adequate attention to implicit

and relational processes of regulation.”

Greenberg (2007): this form of therapyattempts not control but the “acceptance orfacilitation of particular emotions.’’

Citing my work he asserts, “it is the building ofimplicit or automatic emotion regulationcapacities that is important for enduringchange, especially for highly fragile personality-disordered clients.”

Schore (Psych. Dial., 2005): therapy is not theleft brain “talking cure” but the right brain “affectcommunicating and regulating cure.”

Moderate arousal: neutral affect.LH verbal dominant over RH nonverbal.DLPFC voluntary explicit emotion regulation.

OFC involuntary implicit affect regulation ofstates of low emotional arousal

OFC involuntary implicit affect regulation ofstates of high emotional arousal

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Philips et al. (Biological Psychiatry, 2003):Two systems involved in the regulation of affectivestates and emotional behavior.

1. Ventral system, including orbitofrontal cortex,insula, anterior cingulate, and amygdala. Important forthe implicit identification of the emotional significanceof environmental stimuli and production of affectivestates.

Central to the “automatic regulation and mediation ofautonomic responses to emotional stimuli andcontexts accompanying the production of affectivestates.”

2. Dorsal system (dorsolateral cortex,hippocampus) involved in explicit, emotion-labeling tasks compared with more implicittasks; associated with the “verbal componentsof emotional stimuli.” Important for “the effortfulregulation of attention and affective states.”

“Different patterns of structural and functionalabnormalities, particularly within the ventralsystem, exist within these disorders and areresponsible for the generation of specificsymptoms.”

Greenberg (2007) implicit affect regulation includes“previously avoided emotions,” that now allows patientto tolerate and transform into “adaptive emotions.”

Affect regulation (and not mentalization) is essential toworking with early forming defense of dissociation.

Recall, enactments allow for encountering dissociatedaspects of the patient (Stern, 2008).

Bromberg (2009): “the reciprocal process of activeinvolvement with the states of mind of the otherperson allows a patient’s here-and-now perception ofself to share consciousness with the experience ofincompatible self-narratives that were formerlydissociated.”

This “reciprocal involvement” occurs via right brain-to-right brain psychobiological processing ofcommunicated unconscious dissociated affects.

“The empathically resonating therapist’s matching ofthe rhythmic crescendos and decrescendos of hersubjective state with the patient’s represents thepsychobiological attunement of her felt sense to thepatient’s felt sense.

The key to working with dissociated affect is the co-creation of an amplified stronger signal of the feltsense – the therapist serves as a source of autonomicfeedback of the patient’s dissociated unconsciousaffect.”

Whitehead (J Amer Acad Psychoanal DynamicPsychiatry, 2005):

“Every time we make therapeutic contact withour patients we are engaging profoundprocesses that tap into essential life forces inour selves and in those we work with.”

“Emotions are deepened in intensity andsustained in time when they areintersubjectively shared. This occurs atmoments of ‘deep contact.”

At moments of deep contact, intersubjectivepsychobiological resonance between patient’srelational unconscious and clinician’s relationalunconscious produces an amplification ofarousal and affect, and so unconscious affectsare deepened in intensity and sustained in time.

This increase of emotional intensity (increasedenergetic arousal) results from interactive affectregulation, and allows dissociated bodily-basedaffects beneath levels of awareness to emergeinto consciousness of both members of theintersubjective field.

Ogden (2005): psychotherapy change mechanism liesnot in verbal exchanges but rather in a background ofempathic clinician’s psychobiologically attunedinteractive affect regulation, a relational context thatallows patient to safely contact, describe andeventually regulate his/her inner experience.

Davies (2004): with patients traumatized in childhood,clinician “must be both the object of the patient’stransferential rage over abuse, abandonment, andbetrayal, as well as the one who helps the patientcontain, soothe, modulate, and ultimately come toterms with such experience.”

J. Schore & A. Schore (2008): clinicians vary in notonly implicit capacity of affect tolerance, but also abilityto implicitly regulate positive and negative affect states

Due to ongoing therapeutic right brain interactiveregulation of arousal and affect the patient’s implicitsense of safety and trust increases, defenses arelowered and ruptures of attachment bond withintherapeutic alliance are now more easily negotiated.

These negotiations involve not only nonverbal butverbal intersubjective communications, especially inspontaneous expressions that occur in the intimatecontext of a regulated heightened affective moment.

Schore (2003): Physical containment by the therapistof the patient’s disavowed experience needs toprecede its verbal processing. This allows fordevelopment of linguistic symbols to represent themeaning of an experience, while one is feeling andperceiving the emotion generated by the experience.

Seikkula & Trimble (Family Process, 2005):“The most difficult and traumatic memories are storedin nonverbal bodily memory. Creating words for theseemotions is a fundamentally important activity. For thewords to be found, the feeling have to be endured.”

Bromberg (2006): “When an analyst gives up hisattempts to ‘understand’ his patient and allows himselfto know his patient through the ongoing intersubjectivefield they are sharing at that moment, an act ofrecognition (not understanding) takes place in whichwords and thoughts come to symbolize experienceinstead of substituting for it.”

Panksepp (2008): refers to “two seemingly distinctstreams - propositional, logic-constrained, low-affectspeech consolidates within the left hemisphere, whilethe prosodic-emotional poetic stream flows moreforcefully through the right.”

Ross and Monnot (Brain and Language, 2008):“The traditional concept that language is a dominantand lateralized function of the left hemisphere is nolonger tenable.”

“Over the last three decades, there has been growingrealization that the right hemisphere is essential forlanguage and communication competency andpsychological well-being through its ability to modulateaffective prosody and gestural behavior, decodeconnotative (non-standard) word meanings, makethematic inferences, and process metaphor, complexlinguistic relationships and non-literal (idiomatic) typesof expressions.”

This right brain mechanism underlies Joseph’s(2008) clinical observation, “In my experience,fresh and heartfelt metaphorical language ordirect, straightforward, and even blunt languageis often the most direct route to truth, richness,and honesty. That is a type of language thatoften evokes an emotional outpouring fromothers.”

As opposed to left brain neutral, detachedsecondary process language, this emotionallanguage is saturated in right brain nonverbalprosodic, facial, and gestural communications.

Mundo (2006): “When patients are asked toremember the significant moments inducingchange during their treatment they usuallyremember affect-charged moments ofinteraction with the therapist rather than wheninterpretations that were offered.”

Maroda (1998): “The analyst’s affective participationmust be real, or the patient could not continue.”

“Believing that giving the patient an emotionally honestresponse, in the moment, is essentially therapeutic…isat the heart of accepting enactment as inevitable andpotentially useful.”

“Accepting that patient and analyst are fated to moveeach other in mysterious and unplanned ways leavesroom for accepting being both the recipient and thestimulator of intense, unexpected emotion. And thisacceptance leaves further room for exploring the mosttherapeutic ways in which to work through the re-created scenes from the past.”

Clinician’s capacity for real affective participation isessential during stressful ruptures of therapeuticalliance that occur in enactments. Right brainexpression in “self-disclosure.”

Ginot (1997). “Self-disclosure is not…a way topromote a sense of intimacy through seemingly similarshared experience. Rather, the emphasis here is onrevealing emotional data growing from and organicallyrelated to the intersubjective matrix.”

Renik (1999): “A willingness to self-disclose on thetherapist’s part facilitates self-disclosure by the patient,and therefore productive dialectical interchangebetween therapist and patient is maximized.”

Friedmann and Natterson (1999):“Enactments are interactions of analysand and analystwith communicative and resistive meanings that leadto valuable insight and can constitute correctiveemotional experiences.”

Alexander and French (1946):“In all forms of etiological psychotherapy, the basictherapeutic principle is the same: To re-expose thepatient, under more favorable circumstances, toemotional situations which he could not handle in thepast. The patient, in order to be helped, must undergoa corrective emotional experience suitable to repairthe traumatic influence of previous experiences.”

Greenberg & Pavio (1997): “Reliving the [traumatic]experience in therapy with the safety and security ofan empathic, supportive therapist provides the personwith a new experience.”

New experience: therapist’s interactive regulation ofpatient’s dysregulated right brain hyperaroused andhypoaroused affective states.

Recent data now clearly suggest that correctiveemotional experiences of the psychotherapeuticchange process involve not just cathartic dischargebut right brain interactive regulation of affect.

Adler (Journal of General Internal Medicine,2002): “Because people in a caring, i.e.,empathic relationship convey emotionalexperiences to each other, they also conveyphysiological experiences to each other, andthis sociophysiologic linkage is relevant to theunderstanding the direct physiologicconsequences of caring in the doctor-patientrelationship - for both parties.”

The art of the doctor-patient relationship…entails thesame kind of person-to-person attunement that isessential to the newborn (Schore, 1994).” Socialbonds of attachment reduce stress-induced arousal.

Individuals in empathic relationship co-regulate other’sautonomic activity. The therapeutic relationship canact as “the antithesis of the fight-flight response.”

“The experience of feeling cared about in arelationship reduces the secretion of stress hormonesand shifts the neuroendocrine system towardhomeostasis.”

Recall affect dysregulation = tendency to low-threshold, high intensity emotional reactionsfollowed by slow return to baseline.

Earlier question - can relational context oftherapeutic alliance alter the stress responsethreshold set point and increase affecttolerance and affect regulation?

Bromberg (2006): “The therapy proceeds…withthe therapist’s job being to try to enable theprocessing to be safer and safer so that theperson’s tolerance for potential flooding ofaffect goes up.”

Bromberg (2006): “The patient’s threshold for‘triggering’ increase, allowing her increasingly to holdon to the ongoing relational experience (the fullcomplexity of the here and now with the therapist) as itis happening, with less and less need to dissociate; asthe processing of the here and now becomes moreand more immediate, it becomes more and moreexperientially connectable to her past.”

Working at dual regulatory boundaries of right brainlow and high arousal states allows for broadeningwindow of affect tolerance (expansion of affect array).

Expanded Windows of ToleranceIncreased Conscious Positive + Negative

High/Low Arousal Affect

Original RH toleranceof High Arousal Affect

Original RH toleranceof Low Arousal Affect

What would a psychotherapeutic expansion in affecttolerance look like clinically?

Glaser et al. (J. Psychosomatic Research, 2006):“Childhood trauma may have long-lasting andenduring effects on adult psychological functioning, asexposed individuals continually react more strongly tosmall stressors occurring in the natural flow ofeveryday life…Emotional stress reactivity is mostpronounced for subjects who experienced traumaearly in life…The effects of trauma are moredetrimental when trauma occurs at a younger age.”

Lane (Psychosomatic Medicine, 2008):“Individuals who are more emotionally aware arebetter able to tolerate and consciously process intenseemotions than those who are less aware. Conversely,individuals functioning at a lower level are more likelyto behave impulsively and be less aware of what theyare feeling in the context of high arousal emotions.”

“This may be understood as a greater ability amongmore highly aware individuals to be cognizant of theirown emotional reactions in the context of higharousal…”

Therapeutic expansion in regulation not justregulation of negative but positive affect arousaland ability to tolerate novelty that accompaniesnew emotional experiences.

Processing of novel information accompaniedby positive affect of surprise, an affect that isassociated with a response to the unexpected,and that is central to all forms exploration andplay.

Recall early growth-inhibiting environments forattachment induce hyperreactivity to novelenvironmental events. Negative startle ratherthan positive surprise to interpersonal novelty.Relational trauma and few moments ofintersubjective play.

These clinical principles apply equally to playexperiences in adult and child therapy.

Commonly accepted that children with a historyof relational trauma repeatedly reenact theirtrauma during play.

Spontaneous play transforms an environment into anenriched environment, one that facilitates processingof novel information and thereby improves learningcapacity, including social-emotional learning.

Affectively-focused treatment increases patient’scapacity for psychotherapeutic internal exploration andintersubjective play.

Corrective emotional experience = novel negotiationsof regulated enactments are a potential source ofsurprise and co-created play experiences, and therebya psychotherapeutic growth-facilitating environmentfor positive arousal.

Winnicott (1971): “Psychotherapy takes place in theoverlap of two areas of playing, that of the patient andthat of the therapist. Psychotherapy has to do with twopeople playing together.

The corollary of this is that where playing is notpossible then work done by the therapist is directedtowards bringing the patient from a state of not beingable to play into a state of being able to play.”

Spontaneous intersubjective play in psychotherapyoccurs at both CS and UCS levels

Reik (1948): when unconscious materialbecomes conscious it emerges as “surprise.”

Oxford Dictionary: surprise = “the emotionaroused by something unexpected”

Bromberg (2009) on therapeutic “safesurprises”: “Interpersonal novelty is what allowsthe self to grow because it is unanticipated byboth persons, it is organized by what takesplace between two minds, and it belongs toneither person alone…”

“It is through the novelty and surprise of thisreciprocal process that the therapeutic action…takes shape, and it may well be what accountsfor the enhanced spontaneity and flexibility of apatient’s personality structure that results froma successful analysis.”

D.B. Stern (1997): effective psychotherapy isless a bringing to light pre-existing truth thanperceiving and interpreting novelty.

Loewald (1975): “the re-experience by re-enactment ofthe past - the unconscious organization of the pastimplied in repetition - undergoes changes during thecourse of treatment.”

Working at dual regulatory boundaries of windows ofaffect tolerance during enactments central toemotional changes of effective psychotherapy.

Bromberg (2006): change “takes place not throughthinking ‘If I do this correctly, then that will happen’but, rather, through an ineffable coming together oftwo minds, in an unpredictable way.”

Hayes et al. (2007): “Although change can happen ina gradual and linear way, there is increasing evidenceacross disciplines that it can also occur indiscontinuous and nonlinear ways.

This latter type of change is often preceded by anincrease in variability and a destabilization orloosening of old patterns that can be followed bysystem reorganization.

In post-traumatic growth, life transition, andpsychotherapy, destabilization often occurs in thecontext of emotional arousal which, whenaccompanied by emotional processing and meaning-making, seems to contribute to better outcomes.”

Schore (2003) on nonlinear change mechanismembedded in regulated enactments:

“It is important to note that the rapid, mutuallydisorganizing events occurring within episodes ofdefensive projective identification and clinicalenactments offer important possibilities for not only“grasping the patients inner world as it intersects withthe therapist’s own,” but also for structural growth ofinternal psychic structural systems that unconsciouslyprocess emotional communications and regulatestressful emotional states.”

Wilkinson (2010): “trauma is a brute fact thatcannot be integrated into a context of meaningat the time it is experienced because it tears thefabric of the psyche” (Bohleber (2007).

Enactment marked by an overwhelmingintensity of affect = arousal dysregulation, ultra-hi or ultra-low.

Recall Ginot’s assertion that enactments“generate interpersonal as well as internalprocesses eventually capable of promotingintegration and growth.”

Regulated enactment = interactive regulation ofstressful and disorganizing high or low levels ofaffective-autonomic arousal facilitates re-organization of “right hemisphericspecialization” for “regulating stress - andemotion-related processes,” and for processingemotional arousal, unconscious negativeemotion, and novel stimuli.

Regulated enactments facilitate top-down andbottom-up integration of right cortical andsubcortical systems.

Schore (2003): over treatment psychobiologicallyattuned clinician implicitly packages her affectivecommunications in interaction flow in such a way thatit promotes rather than interrupts the exchange.

Co-creation of enlargened intersubjective field canrelationally transact more complex affectiveinterchange.

Lyons-Ruth (2001) on the therapeutic conversation:“process leads content, so that no particular contentneeds to be pursued; rather the enlargening of thedomain and fluency of the dialogue is primary and willlead to increasingly integrated and complex content.”

McGilchrist (2009): RH dominant for “integration.”

Specializes “in bringing together in consciousnessdifferent elements, including information from the ears,eyes, and other sensory organs, and from memory, soas to generate the richly complex but coherent, worldwhich we experience.”

“The representation of the two hemispheres is notequal, and that while both contribute to our knowledgeof the world, which therefore needs to be synthesized,one hemisphere, the right hemisphere, hasprecedence, in that it understands the knowledge thatthe other comes to have, and is alone able tosynthesize what both know into a useable whole.”

“The paradigm shift: the right brain and the relationalunconscious” (Schore, 2009): not 2 halves of onebrain but two separate processors.

McGilchrist (The Master and His Emissary, 2009):differences between two brain hemispheres isprofound. Each creates a coherent, utterly differentand often incompatible versions of the world, withcompeting priorities and values.

“Ultimately if the left hemisphere is the hemisphere of‘what’, the right hemisphere, with its preoccupationwith context, the relational aspects of experience,emotion and the nuances of expression, could be saidto be the hemisphere of “how.”

“If what one means by consciousness is the part of themind that brings the world into focus, makes it explicit,allows it to be formulated in language, and is aware ofits own awareness, it is reasonable to link theconscious mind to activity almost all of which liesultimately in the left hemisphere.”

“The right hemisphere, by contrast, yields a world ofindividual, changing, evolving, interconnected, implicit,incarnate, living beings within the context of the livedworld, but in the nature of things never fully graspable,always imperfectly known - and to this world it exists ina relationship of care.”

“The LH is detail oriented, prefers mechanismsto living things, and is biased to self-interest,The right has greater breadth, flexibility, andgenerosity.

The left is the emissary of the right, which is itsmaster. The emissary, however, is willful,believes itself superior, and sometimes betraysthe master, bringing harm to the both.”

McGilchrist’s remarkable book discusses themeaning of this brain asymmetry for the currentprecarious nature of the human condition.

In terms of psychotherapy, change is not so muchabout increasing the left’s reasoned control overemotion, as the expansion of affect tolerance of theright lateralized “emotional brain” and the humanrelatedness of the right lateralized “social brain.”

McGilchrist (2009): “The right hemisphere…has themost sophisticated and extensive, and quite possiblymost lately evolved, representation in the prefrontalcortex, the most highly evolved part of the brain.”

This same RH, the biological substrate of the humanunconscious, is centrally involved in theme of thisconference, “the wholeness of mind, brain, body.”

do not circulate do not cite therapeutic enactments:...

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