Glaser et al' J' Psychosomatic Research, 2006:

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• Glaser et al. (J. Psychosomatic Research, 2006)
• Childhood trauma may have long-lasting and
  enduring effects on adult psychological
  functioning, as exposed individuals continually
  react more strongly to small stressors occurring
  in the natural flow of everyday life.
• Emotional stress reactivity is most pronounced
  for subjects who experienced trauma early in
  lifeThe effects of trauma are more detrimental
  when trauma occurs at a younger age.

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• Nemeroff et al., Proc. Natl. Acad. Sci., 2003,
  Differential responses to psychotherapy versus
  pharmacotherapy in patients with chronic forms of
  major depression and childhood trauma
• Large multicenter study reports that
  psychological therapy is superior to
  pharmacotherapy in patients with a history of
  early childhood trauma.
• Psychotherapy with such patients must attend to
  not only trauma induced affect dysregulation but
  to early forming defense that protects patient
  from consciously experiencing overwhelming
  traumatic painful negative emotions -
  dissociation.

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• Clinical research shows pathological
  dissociation, a primitive defense against
  overwhelming affects, a key feature in
• Pediatric maltreatment disorder
• Dissociative identity disorder
• Posttraumatic stress disorder
• Psychotic disorders
• Reactive attachment disorder of infants
• Eating disorders
• Somatoform disorders
• Substance abuse and alcoholism
• Borderline personality (self-mutilation of body)

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• Feinberg Keenan (Consciousness and Cognition,
  2005) The right hemisphere, particularly the
  right frontal region, under normal circumstances
  plays a critical role in establishing the
  appropriate relationship between the self and the
  world.
• Dysfunction results in a two-way disturbance of
  personal relatedness between the self and the
  environment that can lead to disorders of both
  under and over relatedness between the self and
  the world.
• Following on treatment of severe personality
  disorders

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• Kalsched (2003) For our early trauma patients
  to get well again, they will have to suffer
  through a re-traumatization in their
  transferences. This repetition in the
  transference will be the persons way of
  remembering, and may actually lead to the
  potential of healing of trauma, provided that the
  therapist and patient can survive the furor
  therapeuticus that such transformation requires.

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• Schore (2003) The therapists affect tolerance
  is a critical factor determining the range,
  types, and intensities of emotions that are
  explored or disavowed in the transference-countert
  ransference relationship and the therapeutic
  alliance.

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• General principle sensitive empathic therapist
  allows patient to re-experience dysregulating
  affects in affectively tolerable doses in the
  context of a safe environment, so that
  overwhelming traumatic feelings can be regulated
  and integrated into patients emotional life.

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• The development of systems of self-regulationmay
  be open to change in adult life, providing a
  basis for what is attempted in therapy (Posner
  Rothbart, 1998).
• The ability to modulate emotions is at the heart
  of the human experience and the use of
  emotional self-regulatory processes constitutes
  the core of several modern psychotherapeutic
  approaches (Beauregard, Journal of Neuroscience,
  2001).

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• All psychotherapies, psychodynamic,
  cognitive-behavioral, experiential, and
  interactional, show a similarity in promoting
  affect regulation (Bradley, Affect Regulation
  and the Development of Psychopathology, 2000)
• Among common elements of all forms of
  psychotherapy collaborative relationship between
  patient and therapist, the therapeutic alliance
  is most important (Greenberg Safran)
• Therapeutic alliance now defined as the
  regulation of the collaborative relationship
  between patient and analyst (Ponsi, 2000).

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• Therapeutic alliance describes the subtle,
  interactive dynamic relationship between patient
  and therapist.
• Does not in and of itself represent an
  intervention or technique rather it is the
  vehicle within which therapeutic progression is
  facilitated the matrix within which therapeutic
  effects are wrought (Meissner, 1996).
• Efficacy of all technical interventions rest upon
  individual clinicians ability to co-construct
  therapeutic alliance with a particular patient

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• Therapeutic alliance defined as patients
  attachment to therapist. Clinicians facilitating
  behaviors combine with patients capacities for
  attachment to permit development of alliance.
  Capacity emerges from positive aspects of
  mother-child relationship.
• Primary component of alliance is emotional bond
  between patient and therapist. Bond encompasses
  complex element of attachment between patient and
  clinician.

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• Direct relevance of developmental attachment
  studies to psychotherapeutic process commonality
  of implicit intersubjective right brain-to-right
  brain emotion-transacting and regulating
  mechanisms in caregiver-infant relationship and
  therapist-patient relationship (therapeutic
  alliance)

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• Decety Chaminade (2003) intersubjective
  processes, are largely dependent upon...right
  hemisphere resources
• Bugental (1987) refers to therapists continual
  attention to the patients inner experiencing,
  and it recognizes that the prime instrument
  needed for that attention is the therapists own
  subjectivity.

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• At most essential level, work of psychotherapy is
  not defined by what therapist does for the
  patient, or says to the patient (LH focus).
• Rather the key mechanism is how to be with the
  patient (RH focus), especially when her
  subjectivity is dis-integrating in real time.
• Affect-focused psychotherapy involves right
  brain/mind/body processes

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• Freud (1915) - work of psychotherapy always
  concerned with affect.
• Subjective emotional states are fundamentally
  psychobiological. Freuds dictum thus prescribes
  that psychotherapeutic explorations are more than
  cognitive interventions. Rather all forms of
  treatment involve bodily-based affective states.

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• Shaw (Psychotherapy Research, 2004)
• Psychotherapy is an inherently embodied process.
  If psychotherapy is an investigation into the
  intersubjective space between client and
  therapist, then as a profession we need to take
  our bodily reactions much more seriously than we
  have so far becausethe body is the very basis
  of human subjectivity

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• Schore (Psychoanalytic Dialogues, 2005)
• More so than verbalizations right brain nonverbal
  communications convey expressions of not only the
  personality of the patient, but the personality
  of the therapist.
• Right brain perspective of treatment allows for a
  deeper understanding of the critical
  intersubjective forces that operate at implicit
  levels of therapeutic alliance, beneath the
  exchanges of language and explicit cognitions
  core of change mechanism.

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• Implicit processes in therapy
• Schore, Neuropsychoanalysis, 1999 The right
  hemisphere is centrally involved in implicit
  learning (Hugdahl, 1995) and implicit
  relational knowledge stored in the nonverbal
  domain, is now proposed to be at the core of
  therapeutic change (Stern et al., 1998).

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• Implicit processes in therapy
• Schore (2003) During the treatment, the empathic
  therapist is consciously, explicitly attending to
  the patients verbalizations in order to
  objectively diagnose and rationalize the
  patients dysregulating symptomatology.
• But she is also listening and interacting at
  another level, an experience-near subjective
  level, one that implicitly processes
  moment-to-moment socioemotional information at
  levels beneath awareness.

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• Implicit processes in therapy
• Implicit listening Freud (1912), therapist
  should turn his own UCS like a receptive organ
  towards the transmitting UCS of the patient
• Just as the left brain communicates its states
  to other left brains via conscious linguistic
  behaviors so the right nonverbally communicates
  its unconscious states to other right brains that
  are tuned to receive these communications
  (Schore, 2003).

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• Implicit processes in therapy
• The left hemisphere is more involved in the
  foreground-analytic (conscious) processing of
  information, whereas the right hemisphere is more
  involved in the background-holistic
  (subconscious) processing of information (Prodan
  et al., 2001)
• While the left hemisphere mediates most
  linguistic behaviors, the right hemisphere is
  important for broader aspects of communication
  (Van Lancker Cummings,1999).
• Therapy is not the talking cure but the
  communicating cure

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• Implicit processes in therapy
• The role of the right hemisphere in emotional
  communication (Blonder et al.,1991).
• Whitehead (J Amer Acad Psychoanal Dynamic
  Psychiatry, 2005) Every time we make
  therapeutic contact with our patients we are
  engaging profound processes that tap into
  essential life forces in our selves and in those
  we work with.
• Connection at depth RH-RH implicit
  communications between implicit self of patient
  and therapist

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• Implicit processes in therapy
• Meares (2005) Not only is the therapist being
  unconsciously influenced by a series of slight
  and, in some cases, subliminal signals, so also
  is the patient. Details of the therapists
  posture, gaze, tone of voice, even respiration,
  are recorded and processed. A sophisticated
  therapist may use this processing in a beneficial
  way, potentiating a change in the patients state
  without, or in addition to, the use of words.

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• Burgoon (1985) 60 of human communication is
  nonverbal.
• Schachner et al. (2005) on nonverbal aspects of
  attachment applies to therapeutic alliance
  The ability to encode, or express, and to
  decode, or understand, nonverbal cues are crucial
  to effective communications of emotions.
• RH nonverbal attachment communications
  visual-facial, auditory-prosdic, tactile-gestural
  
• Right brain-to-right brain implicit, nonconscious
  communications within therapeutic alliance.

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• Implicit communications within therapeutic
  alliance RH and recognition of faces
• Hoshiyama et al (2003). RH dominance for
  subconscious perception of faces
• In daily life, we are surrounded by a
  bewildering array of signals, which are perceived
  and processed subconsciously. (Subliminal
  exposure to) very weak or brief, stimuli affects
  performance and changes in (brain) evoked
  potentials, although the stimuli themselves
  cannot be consciously detected Face
  recognitionmay be important or even vital for
  humans to live in a social setting.

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• Implicit communications within therapeutic
  alliance RH and expression of facial emotion
• Mandal Ambady (2004) The right side of the
  face (controlled by the left hemisphere) offers
  socially appropriate clues whereas its left side
  (controlled by the right hemisphere) divulges
  hidden personalized feelings.
• Wolf (1933) Left side of the face expresses more
  personalized, hidden and unconscious content
  while the right side of the face reveals more
  social, explicit and conscious content of
  personality, public mask-like emotion.

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• Implicit communications within therapeutic
  alliance RH and expression of facial emotion
• Mandal Ambady (Behavioral Neurology, 2004)
  Human beings rely extensively on nonverbal
  channels of communication in their day-to-day
  emotional as well as interpersonal exchanges. The
  verbal channel, language, is a relatively poor
  medium for expressing the quality, intensity and
  nuancing of emotion and affect in different
  social situationsthe face is thought to have
  primacy in signaling affective information

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• Implicit communications within therapeutic
  alliance RH and prosody
• Mitchell et al. (Neuropsychologia, 2003) fMRI,
  the importance of the right hemisphere in the
  processing of emotional prosody
• When listening to speech, we rely upon a range
  of cues upon which to base our inference as to
  the communicative intent of others. To interpret
  the meaning of speech, how something is said may
  be as important as what is actually said.
  Prosodyconveys different shades of meaning by
  means of variations in stress and pitch -
  irrespective of the words and grammatical
  construction.

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• Implicit communications within the therapeutic
  alliance RH and prosody
• Etchegoyen Mehler (Int. J. Psychoanal., 2004)
  The prosodic contour - a pattern of successive
  levels of pitch - of adults speech towards
  babies always conveys a communicative intent in
  the speaker, in response to the infants
  affective stateprosodic engagement precedes
  semantic understanding in language
  developmentthe clinician relies on his and the
  patients prosody for revealing communicative
  intent (or lack of it).

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• Implicit communications within therapeutic
  alliance RH and prosody
• Andrade (2005) It is the affective content of
  the therapists voice - and not the semantic
  content - that has an impact on the patients
  store of implicit memories. RH expression
• Modell (1993) The therapists empathic
  understanding of the patient is dependent upon
  the affective communications that accompany the
  patients words. RH reception

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• Implicit communications within therapeutic
  alliance RH and spontaneous gestures
• We respond to gesturesin accordance with an
  elaborate and secret code that is written
  nowhere, known by none and understood by all.
  (Sapir, 1927)
• Gallagher and Frith (Neuropsychologia, 2004)
  distinguish expressive gestures (which express
  inner feeling states) and activation of right
  superior temporal sulcus, from instrumental
  gestures (designed to influence the immediate
  behavior of another) and activation of a
  left-lateralized system associated with language
  and motor imitation.

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• Implicit communications within therapeutic
  alliance RH and empathy
• Watt (2005) Empathy has been long hypothesized
  as a critical, and possibly the most critical,
  outcome variable from therapist side in the
  therapeutic interaction, in many schools of
  psychotherapy.
• Meares (2005) The therapists capacity for
  empathy is the principal agent of beneficial
  change in the patient.

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• Implicit communications within the
  intersubjective field RH and empathy
• Adolphs et al. (J. Neuroscience, 2000)
  Recognizing emotions from visually presented
  facial expressions requires right somatosensory
  cortices...We recognize another individuals
  emotional state by internally generating
  somatosensory representations that simulate how
  the individual would feel when displaying a
  certain facial expression.

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• Implicit communications within therapeutic
  alliance RH and transference-countertransference
• Facial indicators of transference cues quickly
  appraised from therapists face in movements
  around the eyes and prosodic expressions from the
  mouth (Krause Lutolf, 1988).
• Every transference situation provokes a
  countertransference situation (Racker, 1968)
• Countertransference therapists autonomic
  responses that are reactions on an unconscious
  level to nonverbal messages (Jacobs, 1994)

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• Implicit communications within therapeutic
  alliance RH and transference-countertransference
• Spontaneous nonverbal transference-countertransfer
  ence interactions that take place at
  preconscious-unconscious levels represent right
  hemisphere-to-right hemisphere communications of
  fast acting automatic, regulated and dysregulated
  emotional states between patient and therapist

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• Implicit communications within therapeutic
  alliance RH and transference-countertransference
  
• Jung refers to transference-countertransference
  communications.
• In Psychology of the Transference Jung (1946)
  described UCS-to-UCS relationship between
  therapist and patient by referring to alchemical
  images of the Rosarium philosophorum.
• Image of King and Queen joining their left hands.

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• Implicit communications within therapeutic
  alliance RH and transference-countertransference
• The leftis the side of the heart, from which
  comes not only love but all the evil thoughts
  connected with it, the moral contradictions in
  human nature that are expressed most clearly in
  our affective life. The contact of left hands
  could therefore be taken as an indication of the
  affective nature of the relationship.

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• Implicit communications within therapeutic
  alliance RH and transference-countertransference
• RH stores transference-countertransference
• Shuren Grafman (Arch. Neurology, 2002) The
  right hemisphere holds representations of the
  emotional states associated with events
  experienced by the individual. When that
  individual encounters a familiar scenario,
  representations of past emotional experiences are
  retrieved by the right hemisphere and are
  incorporated into the reasoning process.

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• Implicit communications within therapeutic
  alliance RH and regulation
• Ogden et al. (Psychoanalytic Psychology, 2005)
  Interactive psychobiological regulation (Schore,
  1994) provides the relational context under which
  the client can safely contact, describe and
  eventually regulate inner experience.
• Rather than insight alone, it is the patients
  experience of empowering action in the context of
  safety provided by a background of the empathic
  clinicians psychobiologically attuned
  interactive affect regulation that helps
  effectchange.

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• Implicit communications within therapeutic
  alliance RH and regulation
• In these communications crescendos and
  decrescendos of empathic psychobiologically
  attuned therapist's affective state must be in
  resonance with similar crescendos and
  decrescendos of patients internal states of
  arousal.
• In a heightened affective moment the empathic
  therapists right brain can regulate the
  patients dysregulated right brain state.

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• Implicit communications within therapeutic
  alliance RH and regulation
• The therapeutic action of heightened affective
  moments is mediated through state transformations
  that potentially usher in opportunities for
  expanded self-regulatory range and altered
  patterns of mutual regulation (Beebe Lachmann,
  1996).
• Regulation of both positive and negative affects

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• In positively charged heightened affective
  moments co-created regulatory process of
  affective synchrony amplifies positive affect,
  and strengthens positive transference
  relationship.
• In negatively charged heightened affective
  moments psychobiological attachment mechanism
  interactively regulates misattunement-generated
  stress within negative transference (ruptures of
  the attachment bond and interactive repair)

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• Greenberg Pavio (1997) Reliving the
  traumatic experience in therapy with the safety
  and security of an empathic, supportive therapist
  provides the person with a new experience.
• New experience therapists interactive
  regulation of patients dysregulated right brain
  hyperaroused and hypoaroused affective states

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• Emergence of mentalization defined as capacity
  for affect regulation reflective function.
• Impaired self-awareness seems to be associated
  predominantly with right hemisphere dysfunction.
  (Andelman et al., 2004)
• Patient can now consciously reflect upon how his
  nonconscious implicit system operates how he/she
  self regulates affective states via interactive
  or auto-regulation.
• Ohnishi et al. (NeuroReport, 2004) fMRI right
  hemispheric dominance for mentalizing.

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• Physical containment by therapist of patients
  disavowed experience must precede verbal
  processing. This allows for development of
  linguistic symbols to represent meaning of an
  experience, while one is feeling and perceiving
  the emotion generated by the experience.
• Seikkula Trimble (Family Process, 2005)
  The most difficult and traumatic memories are
  stored in nonverbal bodily memory. Creating words
  for these emotions is a fundamentally important
  activity. For the words to be found, the feeling
  have to be endured.

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• Effective interpretations are addressed to the
  subjective, affective experiences of our patients
  to let them know that we can see their total
  selves and to help them recognize, label, and
  differentiate affective states and bodily needs
• Effective interpretations are not transference
  interpretations but focus on what is happening
  here and now between us (Stern et al, 1998).

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• Treatment facilitates the evolution of affects
  from their early form, in which they are
  experienced as bodily sensations, into subjective
  states that can gradually be verbally
  articulated.
• Therapeutic relationship heals by drawing into
  those methods of processing and regulating affect
  relied on by the patient for psychological
  survival and then transforming them.

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• Schore (1996) The emergence of the adaptive
  capacity to self-regulate affect is reflected in
  the appearance of more complex emotions that
  result from the simultaneous blending of
  different affects, and in an expansion in the
  affect array.
• LeDoux (2000) The broader the range of emotions
  that an individual experiences the broader will
  be the emotional range of the self that
  develops.

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• Amini et al. (1996) Psychotherapy works because
  it is an attachment relationship capable of
  regulating neurophysiology and altering
  underlying neural structure
• Psychodynamic therapy may be viewed as a
  long-term rebuilding and restructuring of the
  memories and emotional responses that have been
  embedded in the limbic system (Andreasen, Brave
  New Brain, 2001)
• Effective psychotherapy promotes changes in RH
  emotion-processing and regulating limbic circuits

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• Paquette et al. fMRI study (NeuroImage, 2003)
  Phobic patients treated with psychotherapy showed
  a reduced fear response and diminished blood flow
  in prefrontal areas of the nonverbal right
  hemisphere
• They conclude, changes made at the mind level,
  in a psychotherapeutic context, are able to
  functionally rewire the brain.
• There is no longer any doubt that psychotherapy
  can result in detectable changes in the brain
  (Etkin, Pittenger, Polan, Kandel, J.
  Neuropsychiatry Clin. Neurosciences, 2005).

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• Sullivan Dufresne (Brain Research, 2006)
  optimal stress regulation dependent upon changes
  in cortical development, namely, the right
  hemispheric specialization in regulating stress -
  and emotion-related processes.
• Ryan (Motivation Emotion, 2007)
  As we take interest in human
  performance, adaptation and wellness, issues of
  affect regulation and motivation are thus salient
  topics that can no longer be relegated to the
  periphery.
• Greenberg (Clin. Psychol. Sci. Prac., 2008)
  The field has yet to pay adequate attention
  to implicit and relational processes of
  regulation.

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• By casting the right hemisphere in terms of
  self, we have a revolutionary way of thinking
  about the brain. A new model of the brain,
  therefore, must take into account the primary
  importance of the right hemisphere in
  establishing and maintaining our sense of
  awareness of ourselves and others (Keenan,
  Gallup, Falk, The Face in the Mirror The
  Search for the Origins of Consciousness, 2003).