The Relationship is the Therapy: Applying Interpersonal Neurobiology in Psychotherapy
In 1978, when I was 13 years old and struggling with the vicissitudes of puberty, I was fortunate to be taken under the wing of my middle school vice principal. He listened to me and asked questions, sometimes giving advice that did not resonate for me, but his attention and concern had a profound positive impact. Luckily for me, he also offered me experiences to develop affect regulation through a practice of focusing my energy and attention in my belly while breathing and listening to Gregorian chants. A year of this relationship launched me from depression to empowerment and from isolation to connection, fostering enough resilience in me to help me thrive, despite difficulties at home.
Now, with nearly 30 years practicing relational psychotherapy and 15 as a clinical supervisor, I have observed that the experience of the therapy relationship, and especially what unfolds within it, offers powerful transformative potential for our clients. While psychoanalytic thinkers have explored, theorized and refined their approaches to the therapeutic relationship for more than a century, we now have the powerful added benefit of two decades of research within various fields of neuroscience. This research illuminates the interpersonal neurobiological underpinnings of development across the life span, the roots of psychopathology, and the nature of the psychotherapy relationship (Badenoch, 2018; Cozolino, 2010; DeYoung, 2015; Schore, 2012; Siegel, 1999, 2010; Wallin, 2007).
Still, there is persistent over emphasis in the therapy world upon technique-driven approaches to psychotherapy that rely on the left-hemisphere processes of the brain and minimize or ignore right-hemisphere processes. Every day my inbox is inundated with invitations to attend free webinars that teach techniques to address suffering. Even much of what is considered experiential in psychotherapy is also technique driven, and these approaches, while helpful to varying degrees, are missing the salient and central focus on the embodied-self-with-other dimension that is growing less and less attended to in our modern, fast-paced, global, wired and wireless world.
I know I’m in good company with many who believe that today, more than ever, we therapists need to anchor our attention in the present, emergent moments in therapy, fully tending to the vital, too often unmet, relational needs that people have for presence that is open, receptive, attuned, inclusive, not controlling, and not walled off. Technique-based psychotherapy methods increase the likelihood of relational intrusion and/or abandonment, with the risk of re-wounding our clients. Even therapists who intuitively offer the qualities of attuned relationship to their clients may get too focused on what they have so often been trained to do (apply techniques) and lose sight of the necessity to connect with the client’s current state. Lou Cozolino (2010) states that:
Psychotherapy can be thought of as a specific type of enriched environment that promotes social emotional development, neural integration, and processing complexity. The way the brain changes during the therapy will depend on the neural networks involved in the focus of treatment. (p. 20)
A neuroscientist, mental health nurse and survivor of complex relational trauma, Haley Peckham (2017), made powerful statements about neuroplasticity and reparative experiences in her keynote address at the Victorian Collaborative Mental Health Nursing Conference, explaining how therapeutic conversations impact biology. In the following excerpt, she passionately and humbly describes how the talking cure is biological:
The new paradigm of neuroplasticity recognizes that early experiences of relational trauma (including chronic invalidation, neglect and abuse) in infancy and childhood, biologically shape the brain and all neural systems defensively, to anticipate similar experiences. If we want to change what we anticipate in the world we may have to seek out reparative experiences, to give our brains and neural systems some new data to adapt to, and to anticipate a new future from.
Peckham also states that “experience is the invisible sculptor of brains” (2017, para. 1) and makes the case for empathy as the essential reparative experience that supports outcomes that may include growing capacity for affect regulation and reduction of toxic shame.
Since our therapeutic models influence the kinds of changes that people make in therapy, let us move increasingly toward models that support the kinds of change that our world needs; namely, to become more relational, collaborative, and inclusive. Relational psychotherapists focus specifically on the reparative experience of the therapeutic relationship. Pat DeYoung (2015) states:
The relationship between client and therapist matters so much because the client’s early relationships are the genesis of this distress. Psychoanalytic and psychodynamic therapists have believed this to be true since Freud. Now, as Allan Schore does with reference to hundreds of brain studies, relational therapists can support their belief with neuroscience. (p. 60)
[wlm_private “1 Year Subscription|2 Year Subscription|3 Year Subscription|Staff|NPT Basic|NPT Standard|NPT Premium”]So, what does relational neuroscience tell us about the qualities of a transformative relationship? In addition to insights from other clinicians and brilliant researchers, clinical examples from my own work spring to mind as I reflect on these questions. While there are many important capacities that develop in us over time as therapists, I will focus on two aspects of how we use our relational presence in therapeutic relationships: first, through right brain to right brain presence, which supports affect regulation, and second, through the clinical use of empathic attunement to support the client’s process in bringing what is implicit into explicit knowing.
Right Brain to Right Brain—Affect Regulating
Much has been written about the primary necessity of the right brain to right brain presence, and there are many useful descriptions of how this process works. In the context of therapy, it can be understood as the therapist’s capacity and sensitivity to notice the subtle cues from the client’s tone of voice and prosody, body language, facial cues, and so forth, which convey the moment to moment emergence of the client’s unconscious experience. It also involves the therapist’s capacity to respond with accuracy and sensitivity in a well-timed attuned response, so that the client can feel emotionally accompanied and engaged (Badenoch, 2018; Cozolino, 2010; DeYoung, 2015; Schore, 2012; Siegel, 2010; Wallin, 2007).
Allan Schore emphasizes that these capacities are the prerequisites, or the scaffold, on which any techniques may be utilized within therapy. He states:
We suggest that clinical expertise . . . relies more on nonconscious, nonverbal right-brain than conscious, verbal left-brain functions. Clinical efficacy is more than exquisite left-hemispheric technical skill in interpretation. Rather, increasing levels of clinical effectiveness with the broader spectrum of patients fundamentally involves more complex learning of a number of nonconscious functions of the therapist’s right brain that are expressed in the therapeutic alliance. All technique sits atop these right-brain implicit skills which deepen and expand with clinical experience: the ability to receive and express the nonverbal affect of communications; clinical sensitivity; use of subjectivity/intersubjectivity, empathy, and affect regulation. (2012, p. 42)
David Wallin, in discussing right brain to right brain attunement, shares his client’s description of how he notices Wallin is attuned with him: “I say something and then you get this look on your face, so I know that you know what I feel” (2007, p. 107).
What kind of state of mind in the therapist supports this kind of right brain to right brain attunement? Stephen Porges and Bonnie Badenoch refer to the essential need of the therapist to be aware of their own state, and to be anchored within the ventral vagal parasympathetic branch of the autonomic nervous system, which Porges (2011) has called the social engagement system. Wallin (2007) posits that when therapists cultivate the mindful state of being present, open and in the moment, rather than preoccupied or distant (p. 107), they are in an ideal position to attune to their client’s emergent process. Bonnie Badenoch (personal communication, 2015) captures this state in the phrase an open bowl of receptivity, and Daniel Siegel (2010) describes it this way:
Being open means cultivating the receptive states within ourselves that rest below the surface layers of judgement and expectation. To reach and maintain a state of openness requires that we monitor our internal reactivity, sensing when, for example, we are on automatic pilot and becoming thrown by the ways in which emotions distort our perception of others. (p. 102)
In my own practice, as often as I am able, I sit in my chair a few moments before going to greet my clients, and while closing my eyes, I notice what is happening in my body, and envision myself as Badenoch’s open bowl of receptivity. Then I hold my client(s) in mind, breathing in and out with the intention to extend my own ventral vagal parasympathetic state of safety to my clients in the waiting room. I want to meet them where they are at in the moment, so that I may accompany them in session with my embodied, regulated, right brain to right brain presence.
I will illustrate the right brain to right brain process with a case example. Daniel (name changed) easily moved into a state of dysregulation when his children weren’t responding to him as quickly or attentively as he wished. His tension would sky rocket when they didn’t follow his directions, and he’d launch at them ferociously, repeatedly clapping his hands and getting intrusively close to them. The children’s mother reported that his yelling would continue despite the children unravelling with screaming and tears. My client described feeling furious when he wasn’t being listened to.
While exploring his experience, I noticed my genuine curiosity about what goes on for him in these moments, as well as my knowing that how I am with him in this moment may truly support his transformation with his children, allowing him to manifest his better intentions. Early in our work together I began to inquire if he had experienced something similar in his life. This line of inquiry served as a foundation to our work together. He responded “no” despite the fact that he was pummeled routinely by his stepfather’s fists. Further, he proclaimed that his children have it a lot better than he did, insisting that he deserved to be listened to. In response, I stayed open and calm during our conversation, offering warm eye contact, and kept the pace of my words nice and slow, with a tone of gentleness paired with earnestness in my voice. With my hand on my heart, and leaning a little toward him, I expressed my belief that his children do have it better than he did, and how I understood that he wants more than anything to give them a better life than he had. He was meeting my eyes for moments, nodding, with his brow furled, which I read as his connection with me and what I was saying. This gave me the sense that he could tolerate me going a little further, so I added the suggestion that I think he is frightening his children with his clapping while being so angry with them. He seemed to be with me, nodding further, appearing to be reflecting, but a moment later his face shifted to rage and he launched to a standing position stating loudly: “I am not an abuser! I have always promised myself that I won’t be like him!” His face was red and I noticed my own heart rate quicken, sensing that he might lose his temper with me. He was a tall man and I felt alarmed by both his state and his stature. While noting this and measuring a nice slow out-breath to regulate myself, I used his name, and offered:
Daniel, I see the good in you and I trust with every cell in my being that you are doing your best, and that even when triggered, you are not hitting like your stepfather did. When you clap your hands, you are staying away from hitting and this seems like evidence of how hard you are working to protect your kids from the kind of rage that landed in you from your stepfather.
He was listening and looking at me, while still standing. I was concerned that he might bolt, but I saw his face soften slightly, and his shoulders seemed to relax a little. I had the sense that he would soften more if I further differentiated his frightening behavior from his stepfather’s, and I wanted to very gently push his accountability for his own growth. I used the pronouns we and our to communicate my perception of our shared humanity, offering what Porges (2011) would call a cue of safety for my client’s autonomic nervous system. I added:
Sometimes our task as parents is to protect our children from the fragments from our parents that land in us when we were innocent children; and that as a child, he couldn’t help but take in harsh energy from his stepfather.
This time, he sat back down and cried, stating how much he loved his kids, expressing his determination to not frighten his children anymore.
Following this breakthrough, I was able to accompany Daniel through the hard work of therapy where he was able to integrate harsh implicit memories and transform his behavior to the point where he was no longer clapping his hands at his children. His partner also reported that the clapping had completely stopped. Instead, he learned to get down on the floor with his children rather than towering above them, or to pause and walk away when he was too triggered.
Stephen Porges’ (2011) work on polyvagal theory illuminates some of what was happening inside my client, and Bonnie Badenoch’s (2017) description of his contributions elaborates what happens for us with cues of danger:
We telegraph danger to one another through face and voice. In other words, we are constantly looking toward one another for guidance about whether we are safe or not. What we discover there influences our autonomic nervous system (ANS) to respond adaptively to keep us safe. These ANS fluctuations underlie our bodily feelings and direct our behaviors. (p. 6)
In our work together, my client came to understand that his children not listening to him was a perceived threat to him, and in turn he learned that his tone of voice and body language were threatening to his children. He eventually developed the capacity to observe, and then to regulate his states as best he could. In keeping with this, Pat DeYoung (2015) states:
The therapy process depends on accurate attunement and felt being-with, or in other words, on reliable repetitions of right-brain interactions and resonances that help expand right-brain capacities. The right brain is the home of the capacities damaged by early relational trauma. Not all right-brain trauma develops into a full-blown psychiatric disorder; however, according to Schore, affect dysregulation is a fundamental mechanism of all psychiatric disorders. Even for a highly functional adult, right-brain limitations are likely to become problems in emotional and interpersonal functioning. A person who can’t solve personal and social problems in right-brain ways will come to rely on left-brain, explicit analytical reasoning. But left-brain analysis will only contain and manage, not solve, emotional and interpersonal problems. (p. 63)
I believe that this right-brain capacity for growth was demonstrated by my client. Through his focusing on his love for his children as well as developing trust in me to accompany him in therapy, he became less frightening and more responsive rather than reactive.
Attunement and Making the Implicit Explicit
The next case example demonstrates the importance of therapeutic presence and the incredible potency of making the implicit explicit through the use of empathic attunement, which for some can be a long process. For example, another client named Jen (name changed), who struggled with self-harm, took years to allow the empathy and good enough attunement that I offered during our work together to sink in before her harmful behavior ceased. This client would use boiling water to scald her arms, which she discovered was linked to self-hate and the internalized yet untrue belief that she was responsible for her little cousin’s untimely death. By exploring her impulses to self-harm when overwhelmed by self-hate, we had traced back through years of abuse she had suffered in her family. Her cousin’s death was a result of neglectful care, however, she had been told that the death was her fault, because he choked on a part of a toy kettle she had given him. Jen had never before shared this story. On hearing this, it dawned on me that she had previously told me about a ritual of boiling water in a kettle in preparation for her self-harm. Empathy and sadness for her decades of suffering swelled in my chest, and my eyes moistened, a tear rolling down my cheek. I said, Jen, then paused, and held her eyes in my tender gaze for a few moments, amplifying the significance of the what she had shared:
I am so very, very sorry that you were blamed like that. I feel so tender toward little you who lovingly gave that gift to your cousin. It was so unfair and so wrong for you to be blamed. It wasn’t your fault and you never should have been blamed or punished for it.
I paused again, offering time and space for her to take in my empathy, and so that I could assess if she was ready to hear more. She looked contemplative, her eyes locked on mine, and I felt a strong connection, so I proceeded.
Jen, I understand more than ever before why you pour boiling water on yourself when your self-hate gets intolerable. You’ve been punishing yourself the way you were punished as a little kid. I am so sorry that happened to you.
She slumped and looked at her feet, head in her hands, quiet for a while. I believe that she felt my empathy, (felt me feeling for her), and that this allowed her to begin to integrate the connection between scalding herself and the kettle toy she had given her cousin, which had not been consciously associated prior to my suggesting this.
There is such incredible power in empathic attunement, amplifying emotional moments, pacing, slowing the conversation, reading our clients’ cues, and making the unconscious conscious, or the implicit explicit. As it turned out, my client reported to me much later that after that pivotal session she never again scalded herself, and in fact it was a wonderful turning point in her life. For me, it was yet another example of the potency of sensitively tuning in to clients’ emergent cues of affect and physiological state, with embodied presence that is trustworthy enough.
In conclusion, I want to express that I imagine most therapists implicitly know the value of the kind of presence that is open, receptive, attuned, inclusive, not controlling, and not walled off. I think this seems deceptively simple, and to the left brain perhaps it is. We must carry this knowing explicitly in order to bring about the changes that will make the world a kinder place. Perhaps the most difficult aspect of this work lies in the long-term and always evolving developmental work of nourishing and anchoring in our right brains. It is my hope that the work of Allan Schore, Pat DeYoung, Bonnie Badenoch, Haley Peckham and others will become the central organizing model for therapist training, so that the therapeutic relationship can roar back into the limelight as the transformational gift that it is. I’d like to leave the reader with this beautiful passage from Bonnie Badenoch (2017):
New technologies have opened doors for us to just begin to glimpse the wondrous neural universe within. We are standing on the shore of new territory, and even with these little wisps of understanding, we are finding a different kind of foundation developing beneath our feet. At least two consistent patterns are emerging from these discoveries: our embodied brains are far more capable of recovery/rewiring than we ever imagined; and a cradle of safe, warm, responsive relationships provides the support most in tune with our brain’s inherent developmental and healing processes. It turns out that neuroplasticity—the brain’s ability to change in response to experience—abounds, and nonjudgmental, agenda-less presence is the soil in which healing and meaning grow. (p. 1)
Badenoch, B. (2017, March). A symphony of gifts from relational neuroscience: How understanding our brains can support lives of hope and resilience [Neuroscience Training Summit, Sounds True]. Retrieved from https://www.soundstrue.com/store/neuroscience-summit
Badenoch, B. (2018). The heart of trauma: Healing the embodied brain in the context of relationships. New York, NY: W.W. Norton.
Cozolino, L. (2010). The neuroscience of psychotherapy: Healing the social brain (2nd ed.). New York, NY: W.W. Norton.
DeYoung, P. (2015). Understanding and treating chronic shame: A relational and neurobiological approach. New York, NY: Routledge.
Peckham, H. (2017, December 19). The talking cure is biological. Keynote address presented at the Victorian Collaborative Mental Health Nursing Conference, The University of Melbourne, School of Health Sciences. Retrieved from https://healthsciences.unimelb.edu.au/departments/nursing/about-us/centre-for-psychiatric-nursing/news-and-events/neuro-plasticity,-trauma-and-experience-collab-2017-keynote
Peckham, H. (2017, May 1). Experience: The invisible sculptor of brains [Web log post]. Retrieved from https://haleyscomment.blog/2017/05/01/first-blog-post/
Schore, A. (2012). The science of the art of psychotherapy. New York, NY: W.W. Norton.
Wallin, D. J. (2007). Attachment in psychotherapy. New York, NY: Guilford.[/wlm_private]