Therapy Notes

GlamoramaBrideAndGroomI’ve been reading Allan Schore’s “The Science of the Art of Psychotherapy.” Schore is starting to convince me about the efficacy of psychoanalytic techniques in relation to what is being discovered in neuroscience about trauma response, affect regulation, the myriad ways we dissociate and how that all stems from early development of the right brain in relation to attachment styles.

It all starts with the adverse childhood experiences ( ACE’s – see the Kaiser Permanente/CDC study(s): ), that cause insecure attachment.

For example: maybe my mother was deeply depressed, dissociated much of the time, not a bad mom, but the infant brain associated that with a terrorizing sense of neglect – the infant brain needs to tune in to the caregiver, for right brain formation, to regulate safety and fear. When mom isn’t dissociated she lashes out in frustration, an occasional rage perhaps. Again the infant cannot tune, and regulate safety or fear in right brain formation. Mom’s ‘spaced out’ state Schore and others would call ‘hypoarousal’. The agitated state is ‘hyperarousal’.

These states are not regulated states (cortical thinking brain regulates limbic emotional brain), they are dissociated states (limbic/emotional, fight, flight, or freeze states prevail). The infant feels a terrifying sense that its very survival could be compromised. More importantly, the infant, suggests Schore and others, actually develops it’s own right brain ability to regulate emotion, and tune in empathically to others, from the caregiver’s ability to mirror that in the first precious moments of life, and first few years of life. If the infant does not experience that, the infant’s empathic attunement with others is impaired.

Mom persisting in these dissociated states, characterized by hyperarousal (rage, fear, distrust, “someone/thing is always messing with me”) or hypoarousal (space out, tune out with drugs or alcohol, withdraw into cocoon) almost insures that the infant/toddler will develop that tendency also.

This is the face of disoriented, disorganized attachment. This is what can cause what psychoanalysts call ‘personality disorder’. (a much broader concept for psychoanalysts than you will find in the DSM – see their PDM).

The individual, because of the early attachment trauma, has various ways of dissociating through those arousal states, throughout life, in response to interpersonal relations, making interpersonal relations extremely difficult, and obviously seriously effecting their lives and their ability to get along with other people. They have an impaired ability to tune in empathically with others. They live out of the limbic system (fight, flight or freeze), not having that regulated by the higher right brain cortical centers in ways that regulate affect. To have developed that ability would have required a caregiver in infancy that gave the infant a sense that their fears could be repaired, to help them feel safe, or that everything was always going to be alright in the end. (what Donald Winnicott would have called ‘the good-enough mother’), the mother who helps create a secure attachment.

The therapist now, in the therapeutic alliance and process, must help the client reconstruct those lost states. Schore and others believe that the methods of psychoanalysis, with its emphasis on transference and counter-transference, being in the field intuitively with the client, not cognitively detached, works best. He believes that the repair needs to go back to right brain formation, back to the pre-verbal time when the client was an infant – that the client will eventually regress to or reenact that state in therapy and the therapist must seek to reconstruct the repair intuitively.

Cognitive insight oriented interventions (such as you have with cognitive-behavioral or family systems and other modalities) are verbal and left-brain oriented. The client might get some relief from insight and learning, and in the case of behavioral methods some training and conditioning, but, says Schore, these don’t persist over time. The damage was done pre-verbal and needs to be solved there with empathic attunement, allowing the client to regress to primitive states, uncomfortable for the therapist, staying in those states intuitively (without escaping in some cognitive left-brain way), and helping the client repair the primordial wound. I still have lots to learn about that!