The most recent advances in interpersonal neurobiology
For those of you not familiar with his work, Schore has been working as an interdisciplinary giant, bringing together psychoanalysis, neuroscience and the affective cognitive sciences, as well as developmental psychology and attachment theory. In his famous trilogy of books:
- Affect Regulation and the Origin of the Self (Lawrence Erlbaum Associates; 1 edition 1994)
- Affect Dysregulation and Disorders of the Self (WW Norton & Company, 2003).
- Affect Regulation and Repair of the Self (WW Norton & Company, 2003)
as well as numerous articles and chapters, he has documented the significant advances that have been made in our understanding of early human development and in the application of this developmental information to models of psychopathogenesis and psychotherapy.
His Regulation Theory, grounded in developmental neuroscience and developmental psychoanalysis, focuses on the origin, psychopathogenesis, and psychotherapeutic treatment of the early forming subjective implicit self. His contributions appear in multiple disciplines, including developmental neuroscience, psychiatry, psychoanalysis, developmental psychology, attachment theory, trauma studies, behavioral biology, clinical psychology, and clinical social work. His groundbreaking integration of neuroscience with attachment theory has lead to his description as "the American Bowlby" and with psychoanalysis as "the world's leading expert in neuropsychoanalysis.
You can access many of his papers on his website: http://allanschore.com/bio.php
Others before me have pointed out the irony of how he tends to deliver his teaching on these kinds of events: it boggles the mind how the greatest champion of right-brain-to-right-brain attunement can spend 6 straight hours talking from his left brain (abbreviated as LH for left hemisphere) at yours, reading out his PowerPoint notes (of which you are given a hard-copy to help you keep up), extolling the virtues of right-brain (abbreviated as RH for right hemisphere) spontaneity and reverie, imagining that this constitutes optimum engagement and learning for the audience.
But that doesn't take anything away from the intellectual and interdisciplinary substance he was trying to get across. Except for some detailed neuro-biochemistry after lunch which went over my head, he did get most of it across to me (although from talking to other participants, it looks like I was a bit of an exception – others people’s left brains had apparently checked out much earlier in the day).
The main purpose of this report is to share this substance with you, whilst offering you also some kind of critique as we go along.
It's not so easy to find biographical detail regarding Schore's training or his own experience of analysis or analytic training, so I am not sure how they shaped his way of being as a therapist. The strongest influences - always in the background of Schore's thinking - seem to be attachment theory and the self psychology tradition within psychoanalysis (the titles of his first books followed Kohut's on the origin, disturbances and repair of the self). In terms of neurobiology he is, of course, an interdisciplinary giant, drawing on a wide range of neuroscientists, but high-profile in the lecture were references to Ian McGilchrist's book 'The Master and his Emissary'.
Bringing together infant studies, attachment and the intersubjectivity of early development with affective neuroscience is what Schore is famous for, leading to the crucial recognition that the development of the child's brain (right down into the detail of anatomy and brain chemistry) and mind are dependent on the early emotional environment and attachment relationships. Being involved in the painstaking nitty-gritty of the actual scientific research, he has been instrumental in milking the neuroscience towards that insight and putting it on the map, which has then been popularised by many others (e.g. Sue Gerhardt "Why Love Matters").
He has also made crucial contributions to drawing the parallels between attachment in early development and the equivalent attachment dynamics in therapy, manifesting in his statement that therapy is mainly about ‘right-brain-to-right-brain’ attunement between client and therapist. These days, throughout the psychotherapeutic field, we take these parallels for granted (sometimes, arguably, too much, to the point of oversimplification), and it's easy to forget just how significant an influence these neuroscientific validations of traditional therapeutic intuitions have been.
Whereas in his earlier writing Schore seemed to be quite wedded to psychoanalytic technique (with interpretation, however, always embedded in the primacy of the empathic attunement and dependent upon it), in this lecture I was surprised by the breadth of authors that he quoted from, drawing strongly also from Jungian analysts (e.g. Kalsched, Ullanov), especially in his clinical vignettes. I guess the Jungians have always been ahead of the rest of the field when it comes to recognition of the therapist’s own wounds, based on explixit inspiring statements about the wounded healer and the therapist’s own complexes by Jung himself. The vignette most relevant to the topic of mutual regression was a direct reading from a case study by Kalsched which involved the transformation of a pretty full-blown enactment. But most of the rest of the lecture, especially theory, was drawing on quotes from different phases of the history of psychoanalysis. There was a mention of Carl Rogers as the greatest psychologist, so, overall, there was a refreshing integrative atmosphere to Schore’s wide-ranging influences.
When you study Schore’s writings in sequence, it is apparent that his shift towards two-person psychology and the notion of enactment is much more recent. I gather he was influenced by being part of an interdisciplinary study group that included Philip Bromberg (who is, of course, one of the elders in relational psychoanalysis). As we will see, a good chunk of my critique hinges around Schore’s notion of enactment, and what appears to me an unacknowledged, un-integrated and confusing co-existence of clashing paradigms, mainly between ‘one-and-a-half-person psychology’ assumptions to do with neuroscientifically inspired ideas of regulation, and ‘two-person psychology’ notions around enactment.
What role for the body-oriented tradition?
The person who would have been most delighted with Schore's lecture is probably Wilhelm Reich, except - as has happened throughout Reich's life and since his death - he was not mentioned and was not even on the radar. But just about all the themes that occupied Reich and to which he made significant contributions were being (re-)discovered by Schore: intense affect (i.e. the distinction between social feelings and raw emotion – in Schore’s terms: between the RH and the primitive brain stem), repression, character, defences, regression - Schore formulated them as crucial to the process of deep psychotherapy (i.e. transforming deeply embedded attachment and character styles). It's unfortunate that Schore is not familiar with the Reichian and post-Reichian tradition – I specifically went up to him and asked him about that; he has, of course, heard about Reich, but doesn't seem to recognise just how significant the body-oriented tradition could be to just about everything he touched upon in this lecture, especially in terms of translating Schore's propositions and model into actual therapeutic practice.
There are three major ways in which the body-oriented community of practitioners has developed skills and understandings that can contribute to that fairly urgent task of application in practice:
- the therapist's embodied presence and self awareness as bodymind process (i.e. a detailed and differentiated body awareness underpinning 'implicit relational knowing')
- a whole host of techniques and interventions that facilitate what Schore is proposing as priorities: a de-emphasising of LH, a deliberate invitation of RH, and most importantly active techniques for bringing the raw affect of the brainstem into awareness and into the interpersonal contact
- a developing understanding of enactment as bodymind process (most of you reading this will appreciate that I've been preoccupied with this point for 20 years now, and as I have only published one very condensed indication of this, it's not entirely surprising that it hasn't acquired the status of common knowledge).
The problem with bringing back Reich is the same as bringing back the transformative potential of regression generally: Reich - like many of the psychoanalysts that Schore draws from historically in his re-valuing of regression - was firmly embedded in a ‘one-person psychology’ perspective. So whilst there is some sense that we are re-inventing the wheel of regression, any new wheel based upon traditional principles is indeed in need of being revised and re-visioned through a two-person psychology lens.
Coming from the US, Schore equates body psychotherapy with Somatic Psychology as it’s known there, first and foremost represented by Pat Ogden (who I think was part of the same study group with Philip Bromberg, which - as far as I know - is where she acquired an interest in enactment, too; for the last few years she has made comments about enactment being the cutting-edge of innovation). It appears that the embodied-relational tradition, as we have developed it here in the UK, has not made an impact and is not being widely recognised in the US yet.
So one of my underlying contentions in writing this review is that there is a small section of the embodied-relational community which has developed a way of working which is in line with Schore's abstract principles and propositions already. One of the main questions from the audience was: whilst we see the rationale for the kind of therapy that involves mutual regression in enactment, we don't see any training that prepares us for it - how do you help students and therapists learn this way of practising therapy?
I will stick my neck out and venture to say that it isn't via listening to PowerPoint presentations. Because of the fleeting subliminal nature of ‘right-brain-to-right-brain’ communication, it certainly requires experiential training. It obviously also requires here-and-now attention to the therapist's own internal bodymind process, and their own woundedness as well as their characterological defences.
As soon as you neatly compartmentalise training into theoretical seminars and experiential process, every student's characterological defence has already adjusted to the training format, and found ways of manouvering the training in a way which avoids their own wounds manifesting. We need to find ways of learning that allow attention to the student’s habitual position as a therapist and how they unconsciously construct the therapeutic space (this also is a bodymind process). So if we want to include attention to spontaneous bodymind process, there is no way around live sessions in the training context. In order to maximise the action and reflection cycles for the therapist in the learning process, and to catch enactment dynamics whilst they are building up, live sessions probably need to be interrupted by judicious breaks for shared reflection, where the therapist can receive on-the-hoof supervision and then go back into the session.
a) A two-person psychology at the spontaneous mind-brain-body interface
In a nutshell, Schore is systematically combining two paradigm shifts, to lay the theoretical foundations for a 'deep' psychotherapy of the future:
- the neuroscience-inspired reversal from left-hemisphere (LH) cognitive dominance to the valuation of right-hemisphere affective supremacy (RH) and - as he calls it: the mind-brain-body interface
- the consequent re-vision of all one-person psychology ideas and their re-conceptualisation into two-person psychology formulations
Once a towering interdisciplinary and scientifically-oriented mind like Schore’s has got hold of a new paradigm, it is well capable of consequently applying and transferring its principles across the whole domain. There are any number of therapeutic ideas and concepts which go back to the days of classical psychoanalysis (including Reich), and which therefore originated within a taken-for-granted ‘one-person psychology’ paradigm. All of these ideas, with all the kernels of wisdom and validity they contain, are candidates for wholesale re-visioning and reformulation. What intersubjectivists call the Cartesian 'myth of the isolated mind' has spawned countless foundational ideas in psychology, all of which need revisiting through a two-person perspective – a project which on an abstract level is well underway, and Schore’s new thinking represents another leap in that direction. As we will see, it’s the application to practice that requires a lot more attention still.
b) The double-edged sword of regression and its possible therapeutic action
The key idea being revisited for this particular day with Schore was regression. In the olden days, this was clearly a one-person psychology notion, and indeed a pejorative one because regression was classified as a defence. But even then, from the beginning it was understood as containing both dangers and therapeutic potential. Freud already used the phrase "reculer pour mieux sauter" (to draw back in order to make a better jump), recognising that regression could serve therapeutic progression (or in Kris's later, but better-known phrase "regression in the service of the ego" which is a questionable formulation in my opinion). Schore spent quite a good chunk of his presentation initially on the history of regression, spelling out its ambiguous nature, but overall re-validating it as an essential ingredient in 'deep' psychotherapy. This fits in with his overall policy of reversing the culturally dominant left-brain over right-brain supremacy, and in his presentation (using Freud's original abbreviations CS for conscious system and UCS for unconscious) he says:
"Regression as the act of going back; a return to the place of origin, including early right-brain emotional development and the origin of the self; regression from LH conscious analytical mind to RH unconscious mind and bodily-based emotions, from verbal LH secondary process to non-verbal RH primary process cognition; from later-forming CS left-brain-to-left-brain verbal communication versus early forming UCS right-brain-to-right-brain non-verbal communication."
Part of my critique would be the oversimplifying idealisation which occasionally comes across in lumping everything therapeutically good with the right brain, and everything emotionally questionable with the left brain. But an important point (which we also need to get back to in more detail), is a relatively new addition to his model: the idea of neurobiological regressions not only between (left and right) but also within cerebral hemispheres. This is finally beginning to do justice to what body-oriented therapists have been saying for decades (although not in as sophisticated and scientifically validated ways) - he quotes Lehtonen (2006): "The classical approach in psychoanalysis, while centering on metaphoric and symbolic work within fully developed psychoanalytic object relations, has not traditionally included in this work the meaning of the body and the earliest layers of the personality, due to their preverbal and unconscious nature."
In the course of discussing the history of regression within psychoanalysis, he, of course, draws on Michael Balint's (1968) seminal work and his distinction between malign and benign regression (a distinction that we would need to question in its categorical and apparently neat binary division). But we need to give Schore credit for sticking his neck out and comprehensively validating regression as a possible new beginning and an essential ingredient (i.e. a potential turning point) in the therapeutic process.
c) Mutual regression and the wounded healer as the home ground of therapy
But what is revolutionary beyond Schore’s attempt to bring regression in from the cold, is his unashamed and unambiguous declaration of it as a mutual process. In my language, I would usually refer to that principle as the therapist's embracing of the wounded healer archetype, but because Schore formulates mutual regression as part and parcel of therapeutic enactment, his affirmation of regression goes way beyond abstract philosophical principle into the nitty-gritty of therapeutic interaction. The idea that the therapist's regressed state, the therapist's wounded subjectivity, is not only a valid ingredient in the therapeutic position, but actually necessary for therapy to work, is groundbreaking.
In my opinion, this was Schore blazing a trail in the therapeutic jungle, especially vis-à-vis the perennial notion of ‘treatment’, and why I had been attracted immediately to the title of the day. Any therapist who can surrender to their own regressive states in service of the therapeutic process has effectively deconstructed the dualistic doctor-patient split and transcended an exclusively treatment-oriented paradigm.
As far as I'm concerned, Schore’s formulation finally puts the therapeutic horse before the cart, turns the uprooted tree of therapy into its natural position by putting its roots firmly into the ground, and finally gives therapy a place to stand in its home territory of subjectivity. In my opinion, therefore, this formulation of Schore's deserves spreading far and wide throughout the field - whatever we mean by 'relational' therapy, this is a central and foundational idea and it gains substance, validation and credibility from Schore's authority.
d) Iatrogenic effects of traditional, left-brain dominated, theory-led psychotherapy
Schore did not present the idea of mutual regression as a desirable optional add-on to ‘deep’ therapy. It is an essential feature without which therapists cannot do justice to what they are supposedly offering. Without it they cannot deliver what clients - and what they themselves - expect them to deliver if change of characterological patterns is on the agenda.
If mutual regression is not understood, appreciated, embraced and actively worked with, what are we left with?
We are left with either superficial therapy of the reassuring, symptom-reducing kind. Or we are left with the actively harmful, counter-therapeutic effects of the therapist’s own repressive and dissociative defences, enshrined in their habitual therapeutic position.
Schore talked vehemently about the iatrogenic effect of traditional one-person psychology interventions, which he formulated quite clearly as the therapist's counter-resistance (although he didn't use that term). He is exhorting therapists to drop their LH investment in traditional stances and techniques, and regress and surrender into the receptivity of the RH which then becomes a communication channel for picking up the client's dissociated unbearable affects.
He made repeated, passionate statements unambiguously criticising - in his terms: the left-hemisphere (LH) dominated - assumptions of traditional psychotherapy. He doesn't quite say so in simple, straightforward language, but if I translate it, I would summarise the gist as: in their therapeutic and human presence, the therapist needs be able to inhabit as well as model non-defensive authenticity. Any investment or clinging to any therapeutic persona or identity mainly rooted in cognitive or intellectuallising left-brain bias - or role-bound habitual defensiveness - is counter-therapeutic.
He implied that he sees just about most of CBT as hopelessly lost in LH domination, and therefore, as far as deep psychotherapy is concerned, somewhere between useless, misleading and dangerous (these are my words, translating his implicit message).
But he explicitly applied his critique also to much of traditional psychoanalysis (of the interpreting ‘one-person psychology’ kind). So the upshot is: in order to reach the client's unconscious experience beyond their repressive and dissociative defences, and make any impact on early attachment styles and character patterns, the therapist needs to let go of - in Schore's terms - their own LH bias and defensiveness, and needs to be capable of surrendering into RH 'presence' - 'being' as well as 'doing'.
e) Two forms of therapy: a short-term symptom-reducing, long-term deep growth-promoting
Schore made clear that he does not postulate his model of mutual regression for all kinds of therapy, but only for ‘deep’ therapy that addresses early attachment and character patterns, that correlate to relational ‘working models’ stored in RH pre-reflexive implicit memory. The distinction itself, of course, rehearses a long-standing way of thinking about different depths and time-frames of therapy, and at first sight should not cause much controversy.
However, as we will see later in other respects, it does raise questions in my mind: the idea that therapeutic enactments are relevant only for early, pre-verbal woundings, leading to severe disturbances (like ‘personality disorders’), where dissociation is the main defence and where LH ‘talking therapy’ interventions can’t reach is based on several assumed equivalences that I find too limiting. Certainly the equivalence of symptom-reducing and short-term with more LH cognitive approaches does not match my experience (I guess it depends on what kind of symptoms we are talking about – anything involving psychosomatic symptoms rather than plain mental ones does not respond well to purely cognitive interventions, I think).
Also, rather than a binary distinction, I would prefer a spectrum of client configuration that calls for a range of therapeutic responses, from CBT to counselling to psychotherapy to depth psychotherapy or analysis.
f) A comprehensive model of dissociative and repressive defences
I have hinted at it above, but another substantial point worth sharing is Schore’s new more comprehensive model of defences distinguishes early developmental dissociative defences (more primitive) from later developmental repressive defences (more ego functions are required to make repression work), which in turn correspond to two types of regression (counter those respective defences) – a distinction which at the same time elegantly brings together Freud's topographical and structural models. All these ideas are anchored, as usual, in brain hemispheres and functions, giving it that neuroscientific grounding which Schore is famous for.
Schore relates Freud’s topographical model (system CS = conscious on top of – or repressing - system UCS = unconscious) to an inter-hemispheric repression defence of LH against RH, and correspondingly a therapeutic regressive shift (from LH to RH).
He relates Freud’s structural model (Superego on top of Ego on top of Id) to an intra-hemispheric dissociation defence of RH cortex against the deeper RH brainstem, and correspondingly a therapeutic regressive shift (from RH cortex to RH).
 If you do not want to invest in buying the three books, there are various papers of his available on the internet, which give good summaries and overviews:
For the body psychotherapists, there is also a very comprehensive commentary on Schore’s work by David Boadella, comparing and contrasting it with Biosynthesis: “Affect, attachment and attunement - thoughts inspired in dialogue with the 3-volume work of Schore”
“Schore studies regulation in relation to the following five major areas of relevance for the understanding of human health, neurosis and disease, and treatment or therapy: the body, the brain, the mind and personality including the formation of the self, the bio-psycho-social fields in which development takes place, and the therapeutic processes which seek to repair disturbances to the self. I will try to give an overview of some central concepts Schore presents, in each of these five areas.”
Biosynthesis, according to Boadella, draws on the following fields which overlap and correspond with Schore’s theory of regulation:
“a) Cellular bio-energetic: autonomic nervous system; psycho-neuro-immunology and molecules of emotion (Candace Pert)
- b) Functional neurology: tripartite brain studies based on embryological development
- c) Attachment theory: developed by John Bowlby
- d) Attunement theory: […] The emphasis is on the dance-like interaction between mother and baby, in the early non-verbal periods of the developing self, which form a somatic foundation of the verbal self which develops in the third year of life. In Biosynthesis we work with a model of dialogue, invasion and deprivation. Dialogue corresponds to a flow of contact through touch, eye contact, tone of voice and empathic resonance: these contact forms are aspects of good attunement. Invasion and deprivation, which correspond in Stern's model to over-stimulation and under-stimulation, can be seen as opposite forms of disturbed relationship.
- e) Dynamic Systems theory: including study of non-deterministic change (chaos theory & catastrophe theory)”
“The energies of the autonomic nervous system, which is central to the regulation of all the organ systems of the body, is divided into two major functional systems. The sympathetic nervous system is an energy-arousing system, which is characterised as ergo-tropic: tending to activate, arouse, and energise. The parasympathetic nervous system, on the other hand, is an energy-conserving system which ischaracterised as tropho-tropic: supporting reductionof arousal, withdrawal, rest, and lower levels of energisation.”
“There are three principal forms of imbalance:
- a) Extreme hyper-arousal
- b) Extreme hypo-arousal
- c) Double autonomic activation: extreme hyper-arousal and extreme hypo-arousal co-exist in a paradoxical condition […], and is a basis of bio-systemic insights into trauma. Schore describes it poetically as equivalent to driving the car with full acceleration with the brakes on.”
“Schore's fundamental message, throughout all his writings, is that the body, brain and person, the self, develops out of the interaction of organismic processes (genetic, somatic, neurological) and the quality of care which the infant receives.”
“We can define four major groups of disciplines which have been strongly interacting during the last decades of the previous century, and which continue to build integration between disciplines concerning the body, the mind, the human environment and the soul.
- biological sciences (physiology, embryology, neurology, classical medicine, energy medicine)
- psychological sciences (psychodynamics, behav- ioural psychology, cognitive science)
- socio-educationalsciences(developmentalpsychol- ogy, psycho-therapy,family systemics)
- phenomenological sciences (consciousness studies,transpersonaI psychology)
From a systemic perspectivethese four domains: bio- psycho-social-spiritual are all overlapping, interacting, mutually connecting. When these four domains are taken account of in therapeutic work with the human being, then we have the possibility of a bio-psycho-socio-spiritual therapy.”
 Just to clarify it upfront: I am not criticising the coexistence of different paradigms. I'm not advocating that all traditional ‘one-person psychology’ be superseded by 'proper' ‘two-person psychology’ - on the contrary: I have long argued for an integration of these modes, popularised through the seminal book by Stark. To me, relationality requires an appreciation of how the different modes not only come and go and interweave, but how they are simultaneously present and conflicted, pulling the therapist in contradictory directions which reflect the client's internal conflicts. This is not to deny that usually the therapist's own conflicts, woundedness and subjectivity are also involved. But I am arguing that these conflicts and dilemmas appear in the countertransference, even when the therapist's own conflicts are not actively constellated.
 and indeed, the first question from the audience, in those short spells when questions were allowed and possible, was regarding the integration of the hemispheres for optimal healthy functioning, rather than a reversal of the current dominance from LH to RH. I did not think this question was ever fully addressed, so for me the anti-left and pro-right bias lingered throughout the day - a point we need to come back to later
 However, there seemed to be an inherent contradiction in his presentation: whilst criticising the LH-dominant implications of classical psychoanalysis, most of his quotations substantiating the positive potential of regression (Reik, Kris, Loewald, etc, but with repeated mentions of Carl Rogers as one of the greatest psychologists of the 20th century) came from the same period of psychoanalysis which he was criticising. This is not as grave a contradiction as it might at first seem: we can find throughout the canon of psychoanalytic writing early intuitions of modern convictions and corroboration of just about every point we care to make. But as we shall see later, the contradiction is not without some substance.
 What he didn't say is that those iatrogenic reactions by the therapist are one manifestation of the enactment, which - if caught and attended to - can be traced back to the therapist's defence against their own regression (as part of the mutual regression). It is not defensive reactions on the therapist’s part per se that are iatrogenic, but whether these reactions are attended to and processed by the therapist as enactments. So a more sophisticated appreciation of enactment would lead to a more differentiated analysis of iatrogenic reactions in the therapist, a point we will have to come back to later. It is only when such defensive reactions are habitually structured into the therapist's position, and taken for granted as normal and therefore unavailable for reflection as enactments, that we can call them definitively iatrogenic (my assumption is that Schore was using the term in that sense and context).