This is a right-brain-to-right-brain connection—what Allan Schore calls "implicit nonverbal affect-laden communication [that] directly represents the attachment dynamic . . . nonverbal primary process clinical intuition." At the same time, the therapist must maintain a left-brain-to-left-brain connection with the client in order to co-create a coherent narrative about the client's unarticulated, even formerly undefined, emotional experience. Therapists need "binocular vision," says Wallin, to keep "one eye on the patient, and one eye on ourselves." In fact, the therapist may need something like "triocular" vision as he tries to be in the client's mind, in his own mind, and in between the two minds, establishing and maintaining between himself and the client mutually resonant affective, cognitive, and physical states of being.
Attachment Theory in Action
While some believe that attachment-based therapy sounds an awful lot like a souped-up version of psychodynamic therapy, Siegel disagrees, arguing that its foundation is in the empirical, neurobiological study of how relationships actually shape neural processes and emotional regulatory capacities throughout life. "You use your sensitivity to the client to engage in contingent communication in a way that can establish new pathways in the person's brain that increase his capacity for self-regulation, "he says. "That means the client learns to tolerate emotions he couldn't handle before." Furthermore, claims Siegel, by helping the client become more capable of self-regulation, the therapist is actually helping him coordinate and balance neural firing patterns and promote greater integration of different areas of the brain—right and left hemisphere, for example.
To illustrate how all this works in practice, Siegel describes a case of how attachment-based therapy might work with a dismissing client, one who had had an avoidant attachment as a baby and child to an emotionally unavailable and rejecting parent. Since this person rarely or never experienced an emotionally attuned and predictable relationship with his parent, he had to learn to adapt, psychologically and neurobiologically, to not getting it. As a result, he grew up without much access to—or conscious desire for—emotional awareness or bodily feeling. Because autobiographical memory is mediated primarily through the right hemisphere, such a person often has few or no childhood memories. Typically, as an adult, he's isolated, unaware of the emotional poverty of his life, and disdainful of the idea that he might even want or need more personal connection. In fact, he'd probably never show up in therapy unless his partner—wanting a warmer, less distant relationship—insisted.
In an assessment session, Siegel says he picks up in his own resonating mirror neuron system the client's usual feeling state. "With such a client, I usually feel distant and bored. There's a dull quality to the connection, as if there were no 'we' in the room, just a separate person," he says. "My own immediate experience reflects the client's own impaired access to his right hemisphere—which has direct access to the body and to emotional states. He's just bringing me his dominant left hemisphere, thoughts without feelings, ideas without access to any sense of his own body."
If Siegel were to try too hard to connect with him right-brain to right-brain at this stage—to overdo emotional empathy or try directly to elicit his feelings—therapy would be doomed right out of the gate: "People with avoidant attachment histories are too closed down to have access to experience their right-hemisphere processes," he says. "If someone asks them how they feel or what's going on in their bodies, they will say 'I don't really know what you mean,' or 'I don't know what you're talking about.' They live in the 'Land of the Left,' and if you try to go right-hemisphere to right-hemisphere with them too soon, they become emotionally flooded." Siegel often begins with a left-brain approach, explaining attachment and the brain to these clients. "I explain to them how their relationship with a primary parent helped shape their brains in a way that was highly adaptive to the circumstances they found themselves in. 'You survived, you adapted, you did the best you could, but now, do you want to go on living with half a brain when you can have a whole one?'"
Therapy with dismissing people can sound like a slow, tedious trek through (and often detouring around) a seemingly endless, neatly clipped formal garden of Left Brain Land toward the far-off land of Right Hemisphere's lush, untamed forests. Siegel invites the client "to experience a new way of being present inside himself with me, reflect on the process of attachment itself. I talk about how synaptic shadows create constraints on how a person has been, teach him how his own brain regulates itself partly inside himself, partly between the two of us." To help him get a richer right-hemispheric representation of himself—the beginnings of an integrated right-brain/left-brain autobiographical self—Siegel might ask him to consciously become aware of and remember what it was like to walk to his office from the parking lot. In The Developing Mind, Siegel describes introducing a dismissing client to guided imagery and drawing exercises based on Betty Edwards' book, Drawing on the Right Side of the Brain, through which he gradually became aware of an entire new world of "sensations, intense emotions, visual scenes, thematic struggles, and new perspectives on dilemmas of which the left-sided individual was quite unaware." For example, he experienced the notion that he'd better let his "wilting" marriage "blossom" by buying his wife roses when she didn't expect them—something he'd never done without a logical reason (a birthday or anniversary). "He got the roses simply because it 'felt' right. He couldn't explain it at the time, but he just followed his gut instinct. His right hemisphere took his wife's internal world into account, provided him with a metaphor for her needs, and enabled him to feel her feelings."
Although such cut-off clients initially don't welcome this flood of new experiences—according to Siegel, they consider the unaccustomed onset of feeling "weird and useless"—eventually, the payoff can be very rich. A person who's perhaps not really felt much of anything since earliest childhood or even infancy can gradually learn to express and articulate emotion, to experience what it's like to live within a warm, living, breathing body. One client, Siegel reports, exclaimed, "Oh my God, so this is what it feels like to have warmth in my heart!" Recently, a client told him, "I'm really changing—there is something truly different about me, now."
In contrast to cognitive-behavioral work, much or even most of this therapy is intuitive, played out in "enactments"—what Allan Schore calls emotionally charged moments between therapist and client that are "fundamentally mediated by non-verbal unconscious relational behaviors within the therapeutic alliance." Through these behaviors, therapist and client co-create a coherent story, or a chapter of a story, that helps the client make sense of his own inner turmoil. As Schore puts it, "Enactment is an affectively driven repetition of converging emotional scenarios from the patient's and the analyst's lives. . . . It is his or her chance to relive the past, from an affective standpoint, with a new opportunity for awareness and integration." According to Schore, the most important "enactments occur at the edges of the regulatory boundaries of affect tolerance." In other words, it's when therapy feels worst that it's doing its best work.