Alexandra Katehakis, MFT, CST-S, CSAT-S Patrick Mancuso, MA San Diego, CA September 23, 2011

1. Interpersonal Neurobiology and Therapist Self-Disclosure:Right Brain, Left Brain – the power and the pitfalls Alexandra Katehakis, MFT, CST-S, CSAT-S Patrick Mancuso, MA San Diego, CA September 23, 2011 www.thecenterforhealthysex.com

2. What is Interpersonal Neurobiology (IPNB)? • … “interpersonal neurobiology” is an integrated view of how human development occurs within a social world in transaction with the functions of the brain that give rise to the mind. • Dan Siegel, 1999.

3. Triangle of Human Experience – Siegel 2011 Relationships Mind Embodied Brain

4. Neural Integration = Mental Health • Our mental life is influenced by other people • Relationships are a fundamental part of our well-being • When a system connects differentiated elements into a functional whole you get an integrated system • Systems that move towards integration have greater complexity. • (Siegel 2011 personal communication)

5. Self-Unity • …Self-unity, the mysterious force that holds selfhood together and permits the coexistence of self-continuity and self-coherence across self-states is made possible by what happens between people. Bromberg, 2011 p.27

6. Integration of RH & LH in Therapy • Both hemispheres are involved in almost all mental processes and mental states • At the level of experience, each hemisphere has it’s own way of understanding the world • The world we experience at any point in time is dependent on which hemisphere’s version of the world comes to predominate • Not black & white but depending on the activity, we prefer one hemisphere over the other (McGilchrist, 2010)

7. “Not the ‘talking cure’ but… • “There’s only the brain according to the right hemisphere and the brain according to the left hemisphere. The two hemispheres that bring everything into being also, inevitably, bring themselves… p.175 • The major difference between the hemispheres lies in their relationship with the unconscious mind.” p. 187 McGilchrist, 2010

8. …the affect regulating cure”Schore, 2009 • The best way to integrate the right and left hemisphere, which is a goal of successful therapy, is by working with the implicit right hemisphere significantly more than the left hemisphere (Schore, 2009, Quillman, 2011)

9. Left Brain and Cognitive Behavioral TherapyCBT

10. Left Hemisphere of the Brain • Left hemisphere is responsible for conscious processing of emotional material and conscious response • It’s linear, logical, linguistic, and analytical and operates sequentially • Language is its way of constructing the world • It sticks to false conclusions • LH asks “how?”

11. Left Hemisphere • LH prioritizes local communication and the transfer of information within regions • It re-presents the living world the RH brings into being • LH requires a selective, highly focused attention • Focused attention associated (in part) with LOFC • LH focuses on what it knows suppressing meanings that aren’t relevant

12. Left Hemisphere • LH tends to deny discrepancies that don’t fit it’s generated schema of things (V.S. Ramachandrin). This is why patients can be argumentative when approaching their denial structures. (RH looks for discrepancies) • Patients will argue semantics. Looser semantic associations rely on RH. LH can actively suppress the RH to exclude distantly related semantics.

13. Left Hemisphere is… • Concerned with what is certain • Concerned with knowledge of the facts • Always engaged in purpose • Always has an end in view • Dependent on denotative language and abstraction • Yields clarity and power to manipulate things that are known, fixed, static, isolated, decontextualized, and ultimately, lifeless. McGilchrist 2010

14. The Therapists LH At Work • LH uses denotative language to verbalize RH experiences, either somatic or affective • Delivers interpretations (RH somatically receives the experience of interpretation) Quillman, 2011 • LH identifies by labels and not by context, identifying a diagnosis can be a relief for some pts. (eg. Bi-polar disorder) • Use of psycho-ed. about neurobiological matters is enormously helpful (eg. dissociation is the experience over life threat and pt. has no control over his ANS)

15. Cognitive/Behavioral Approach • Appeals to the LH which is most interested in that which is “known” and has a tendency to classify • Various task work begins to chip away at denial • Contain out of control behaviors with a highly structured plan and make explicit agreements with the patient

16. Left hemispheric self-disclosure… • …occurs when the therapist discloses his personal history or experiences outside of the therapy hour to the patient when relevant. • When appropriate, this is a cognitive choice in service of normalizing the patient’s experience or telegraphing that the patient is “not alone.”

17. Left hemispheric self-disclosure… • Client centered therapist have suggested that therapy-relevant self-disclosure cultivates trust, perceived similarity, credibility and empathic understanding. Additionally, by modeling openness, vulnerability and the sharing of feelings, therapy-relevant self-disclosure invites the client to do the same (Kottler, 2003; Knox, Hess, Peterson, & Hill, 1997).

18. Right Brain and Affect Regulation TherapyART

19. Right Hemisphere of the Brain • RH is longer, wider, larger, and heavier than the left • Complex, non-linear dynamic system • Greater dendritic overlap could mean greater interconnectivity compared to LH • More white matter than LH/greater transfer across regions • Responsible for every type of attention (global) except focused attention. Attention is broader and more flexible than LH

20. RH as “bullshit detector” • Does not know anything in a certain sense of knowledge. It knows from a place of intuition, instinct, and from the body, i.e. embodied knowing • It’s gaze is intrinsically empathic (ROFC) • Right amygdala has been called the seat of the unconscious which guides and drives us • RH is the source of attachment, feelings of love, and of being connected • RH is the source of insight, intuition, feelings, metaphor, images, and has its own language

21. Implicit relational knowing • RH has a disposition of care towards the world, rather than control • Relies on experience to get the big picture of the world • It relates to a longing towards something that lies beyond itself (LH only concerned with itself) • Is conscious of the Other McGilchrist 2010

22. Right brain, implicit relational knowing • “…the process of communication, or implicit relational knowing, rather than the content of the communication is the foundation for the therapeutic action of psychotherapy (Lyons-Ruth, 1998)

23. Right Orbitofrontal Cortex – senior executive of the emotional brain - functions as a dynamic filter of emotional stimuli (Rule, 2002, Schore 2011)

24. ROFC has millions of neural connections • The robust projections from limbic cortices to the posterior orbitofrontal cortex may provide signals pertaining to the internal, or emotional, environment. In summary, the rich connections of orbitofrontal cortex endow it with a panoramic view of the entire external environment, as well as the internal environment associated with motivational factors (Barbas, 2007 p. 239)

25. Internal guiding system - “gut feeling” • If the right orbito frontal does not effectively signal the lower sub-cortical levels (motivational systems) of the RH, which signals the ANS, we are emotionally handicapped • The ROFC forms “a kind of affective decision-making” (Happeney et al., 2004) • ROFC fluidly shifts bodily-based changes in response to external environment that it appraises to be meaningful (Schore, 2011)

26. Right hemispheric self-disclosure… • …is the therapist’s report of somatic cues and her affective experience in the moment with the patient, for the purpose of co-regulation leading to neural integration. • This process is intended to deepen the patient’s capacity for self-regulation thereby altering the patient’s internal working model and ANS. • Katehakis 2011, Quillman 2011

27. www.centerforhealthysex.com What constitutes clinical excellence?

28. Clinical Excellence and IPNB • Consistently, psychotherapy outcome research reports that the quality of the relationship between the patient and therapist is the component that has the largest impact on whether a therapy will be effective or not. www.scottmiller.com

29. What determines “effectiveness?” • The quality of the LH/Cognitive behavioral task work • OR • RH/Limbic resonance/Arousal Regulation • OR • Both

30. What determines that “effectiveness?” • The more therapists draw on key psychodynamic principles such as addressing patients’ avoidance or defenses, identifying recurring themes, and discussing the therapy relationship, the better the patients fared in both psychodynamic and cognitive-behavioral therapy. This means when the CBT therapist departs from their “playbook,” therapy is more beneficial. (Shedler, 2010)

31. Coupling and attunement

32. Coupled systems • “When a psychobiologically attuned dyad co-creates a resonant context within an attachment transaction, the behavioral manifestation for each partner’s internal state is monitored by the other, and this results in the coupling between the output of one partner’s loop and the input of the others to form a larger feedback configuration (Schore, 2001, p. 19)

33. Trust and Safety

34. Psychotherapy Definition “Psychotherapy is a form ofattachment relationshipin which the patient seeks proximity to the therapist, has a safe haven (is soothed when upset), and achieves an internal working model of security based on the patterns of communication between therapist and patient.”Siegel, 2003

35. Trust and Safety • These two factors are crucial in the first two years of life • If someone never had the experience of trust and safety or it was destroyed via abuse then it gets pushed into the unconscious system • Therapist has to co-create trust with the other on a non-conscious level • 2 brains and 2 bodies are at work creating an interpersonal and inter-subjective relationship

36. Therapist as Regulator • Therapist (affective) self-disclosure is a right brain to right brain communication • Creates a deepened sense of connection when the therapist’s makes his RB experience explicit • Makes the implicit experience of the patient explicit • Is a form of dyadic regulation

37. Therapist affective self-disclosure creates trust and safety • Decreases pt. anxiety about negative affect • Negative affect (pt. Or tx.) can lead to greater sense of connection and safety • Increases transformational power of positive affect for self regulation and reconfigures the internal world. • Quillman, 2011

38. LH language is used to communicate RH somatic experiences or affect • “My stomach is feeling queasy as you talk about how horrible your living conditions were as a child.” • “I notice I’m feeling sad and my eyes are tearing up as you talk about how bad things really were in that household.” • “I’m noticing the tightness in your fists and wondering if they could speak what they would say?”

39. Patient’s respond less to what we say than to how we say it • Unconscious prosody meaning pitch, rhythm, timbre of voice • Facial expression • Body gestures • Body posture • What the patient is saying and what the body is (“saying”)doing • Quillman 2011, Schore 2003, Siegel 1999)

40. Affective Disclosure & Empathy • Patient has to feel the therapist is feeling them or understanding them from the inside NOT cognitively – affective disclosure • This kind of sensitivity is crucial to the therapeutic alliance because it’s an emotional communication • Patient’s under or over regulate. Over-regulation is dissociative and a form of auto-regulation • Patient’s have to use the therapeutic bond in order to experience interactive regulation

41. Autoregulation – Tatkin, 2009 • Non-relational form of self-care. • Begins in infancy (gaze aversion to modulate arousal levels) • Does not require people • Dissociative, energy conserving and serves internal needs (Schore, 2009; Tatkin, 2006

42. Interactive regulation – Tatkin, 2009 • Involves two or more nervous systems in close proximity trying to maintain an attuned communication • Series of non-conscious micro- movements compromised of somatosensory experiences adjusting rapidly for error correction • Relies on the near senses with face-to-face visual data stream as being most important • When working well interactive regulation results in mutual perception of attunement • When mutual dysregulation occurs (and not rapidly repaired), heightened arousal and mutual threat will occur

43. Self-Regulation Self-regulation is a pro-social strategy for consciously regulating the self while interacting with other people (Tatkin, 2009) Self–regulation allows for the facility to hold and wait, tolerate frustration, make good moral choices, and respond contingently to interpersonal challenges. (Schore, 2001)

44. Pitfalls

45. Pitfalls of Therapist RH Self-Disclosure • Pt's who have damaged implicit systems (unconscious issues) • Pt’s damaged LH (conscious issues). • Pt. with Axis II issues will misperceive the therapist’s experience of him. • They will have trouble accurately assessing the RB to RB communications • Therapist misperceives patient due to their own dysregulation

46. Pitfalls of Therapist’s LH Self-Disclosure • Clients of self disclosing therapist’s felt burdened by their therapist’s self disclosure, less trusting of their therapist’s competence, and inhibited in their exploration of treatment issues due to wanting to protect the therapist’s feelings (Knox, Hess, Peterson, & Hill, 1997). • Self-disclosure blurs the boundaries of the therapeutic relationship (Knox, Hess, Peterson, & Hill, 1997).

47. Pitfalls of Therapist’s LH Self-Disclosure • Self-disclosure of relevant past struggles that have been successfully resolved may produce results that interfere with treatment, such as client’s censoring themselves out of fear they might negatively affect their therapist (Mallow, 1998). • Self-disclosure of similarities between the client and therapist has the potential of inhibiting client disclosure out of a sense of competition between client and therapist (Dilts, Clark, & Harmon, 1997).

48. Treatment Goals:Adapted from Stien & Kendall,2004 For the hyperaroused patient: Restore the natural hierarchy in the brain/body by decreasing the reactivity of the stress response and enhancing the (inhibitory) regulatory capacities of the cortex (ROFC) and the autonomic nervous system (body). Regulation of high arousal states occurs through soothing by the therapist. For the hypoaroused patient: Restore the natural hierarchy in the brain/body by decreasing overregulation of the stress response (due to high arousal states) and enhancing regulatorycapacities of the cortex(ROFC) and the autonomic nervous system (body) by up-regulating.Regulation of low arousal states occurs through amplification or up-regulation of play states by the therapist.

49. Treatment Goals:Adapted from Stien & Kendall,2004 Create a physiological state that promotes healthy brain development through the (modulation of emotion) regulation of emotion thereby increasing the capacity for self regulation. Enhance integrative functions by helping the patient to process experience through the various modes of experience, especially the body. Build, reorganize, and strengthen new brain circuitry through co-regulatory experiences that generate new ways of thinking, feeling and behaving due to the new capacity to self-regulate.

50. A two-person psychology • No formal technique • Requires an increase in clinical skills so that the clinician is willing to be in a state of “not knowing,” communicating via emotions in the body • Attention is on the: • Mind/body through implicit, relational knowing in order to create neural integration and a secure attachment