Brian Johnson

An exploration of the capacity to love as a treatment goal using current psychoanalytic and neuroscientific concepts

“The greatest thing you’ll ever learn, Is just to love and be loved in return”

In March we explored two current developmental approaches, the first neurophysiological and the second psychological, with the aim of using fundamental concepts from each to think about complex treatment goals that characterize long term analytic work.

These goals include capacities such as self-coherence, perspective, agency, and empathy. For me the core feature of all these goals is embodied in the capacity to love and be loved. This form of mature love is based not only on desire and identification, but also on the capacity of empathy.

Both models derive from attachment theory and assume that the human environment influences the expression of genetic tendencies. Alan Schore created the first model in which he elaborates a hypothesis about the centrality of the neurophysiological development of affect regulatory capacities in the orbitofrontal cortex of infants in the first two years of life. The second model, authored by Fonagy, Gergely, Jurist and Target, suggests psychological stages that an infant traverses in order to develop a” theory of mind”. These four authorities believe that early psychological and neurophysiological experience determines the depth to which the social environment may be processed and that sub-optimal development can undermine the individual’s capacity to interpret the mental states of others. Furthermore, mentalized affectivity, by which they mean the mature capacity for regulation of one’s own affects and the capacity to discover the subjective meaning states of one’s own affect lies at the heart of treatment.

“The greatest thing you’ll ever learn, Is just to love and be loved in return”

Our March presentation focused on an exploration of the capacity to love as a treatment goal using current psychoanalytic and neuroscientific concepts. These goals include capacities such as self-coherence, perspective, agency, and empathy. For me the core feature of all these goals is embodied in the capacity to love and be loved. This form of mature love is based not only on desire and identification, but also on the capacity of empathy.

During the first evening of the fall sequence we will begin with illustrative clinical material. Then we will review the concepts of mentalized affectivity and autobiographical memory capacities with the aim of using fundamental concepts from each concept to think about complex treatment goals, which characterize long term analytic work, including empathy and mature love.

INTRODUCTION

Freud’s revolutionary psychology, which had given us the best theory of mind in the 20^th century, had been codified into semi-scientific principles called metapsychology. Indeed, it was so powerful that terms such as instinct, libido, id, ego, superego, and oral anal and oedipal were folded into popular western culture. Mid-century ego psychology had moved our understanding of mental capacities beyond the unconscious defensive control of conflict, to include what are now seen as cognitive and emotional regulatory functions. Modell et al. feel that certain Freudian principles that will stand the test of time, including the dynamic unconscious, the repetition compulsion, conflict and resistance/defense and, of course, transference.

Thomas Kuhn, a philosopher of science, created the term paradigm shift in his book “The Nature of Scientific Revolutions.” He believed that a mature science, be it physics or psychoanalysis, involved puzzle solving within a paradigm. Over time researchers in a given field become aware of an accumulation of anomalies and make variations in the reigning paradigm to account for them. This leads to discontinuity, paradigm breakdown and a period of diversity. Extraordinary thinkers, exploring “out of the box” offer revolutionary new paradigms that then become the accepted model along which the field reconfigures itself.

My sense is that this is where psychoanalysis found itself in the seventies as the shift from intrapsychic instinct as primary motivation to attachment as primary motivation was under way. Prominent among the paradigm creators were Spitz, Harlow, Lorenz, and Bowlby, British Object Relations School and Winnicott, Bion, and Guntrip; Kohut and self-psychology and Main/Solomon and Attachment. They introduced us to intersubjectivity.

And presently psychoanalytic theory and practice is undergoing another major paradigm shift. The findings from the above mentioned investigators fueled the vision of infant developmental researchers, who, using the power of the video camera were able to explore and analyze the frame by frame interactions between infants and caretakers. More recently, there has been an explosion of knowledge from current brain imaging techniques, testing both adults and increasingly children. The task of synthesizing this new information with the old is enormous. Two leaders in this arena of synthesis are Alan Schore and Peter Fonagy and his colleagues.

Michael Basch states what many of us have thought for a long time: “The more I know about how we are designed to function – what neurophysiology, infant research, affect theory cognitive psychology, semantics, information theory, evolutionary biology, and other pertinent disciplines can tell me about human development – the better I am prepared to be empathic with a patient’s communication at a particular time in his or her treatment (1995, p.113).”

LOVE

What’s Love Got To Do With It?

For me, when I was a child, heaven was a canopy above the earth where both God and Santa Claus may have resided. In our contemporary world of multiverses the meaning of existence for many of us no longer resides in the heavens. Instead we have located it in the human ability to love better. Certainly the nature of love has occupied every time period and every culture. Twenty-five hundred years ago Plato said, “Who knows not love, walks in darkness”. Around the time of Freud, Nietzsche said “One must learn to love oneself … with a wholesome and healthy love, so one can bear to be with oneself and need not roam. Friedrich Nietzsche, in M & B p. 139.” And from Alfred de Musset, “Life is a deep sleep, of which love is the dream.”

However my favorite quote is “The greatest thing you’ll ever learn, Is just to love and be loved in return”[1]. I think it is my favorite because it is interpersonal and plebian.

Certainly Freud felt that psychoanalysis helped us to work and love better. But for the most part Freud used the word love to describe the sexual drive and sexual attraction. “Cure by love” came to mean the patient found a girl friend and lost interest in his analysis.

And in the hippie generation, love became “free love”, as young people threw off the shackles of sexual inhibition and glorified sexual gratification.

The kind of love I am describing today has more to do with nurturing both body and soul.

The contemporary philosopher Lear believes that within the human realm love becomes a far-reaching psychological force: “what is special about human life is that it develops in complexity and structure through the mind’s own activity (p. 12) as it relates to other minds (my italics, added because today the intersubjective aspect is crucial). “In so far as there is a natural developmental thrust by which the mind moves from archaic to more sophisticated formulations, the mind must be striving to understand its own activities (.p 8).” “In trying to understand human subjectivity, mind is trying to grasp its own activity (p. 8).

Lear feels that “Freud saw this development (of individuation; my addition) as fueled by love, but he did not work through the consequences as positing love as a basic force in nature (p. 12).”

Bowlby’s prescient ideas of attachment and imprinting were elaborated in object relations theory in the 1970’s. Then self psychology impacted our academy, followed by a theoretical and empirical exploration of attachment. Consequently, our understanding of the meaning of self-coherence, agency, curiosity, perspective, empathy and love matured beyond the classical functions of ego, ego ideal and SE. In our current psychoanalytic culture, introspection has matured into subjectivity through the absorption of the phenomenological perspective. It has become fashionable even in neuroscientific circles because of current imaging techniques. Lear notes, “For human reality is significantly constituted by subjectivity. What it is to be a person is shaped by what it is like for that person to be (p. 4).” As Wittgenstein said, a depressed man lives in a depressed world.

Probably all mammalian species have primitive empathy capacities since they are coincident with the evolution of social signaling in group animals. Here empathy involves the ability to copy the internal state of the other, i.e. identify by imitation, in order to decrease the distress of the other. However, the human evolved quality of self individuation allows us to elaborate this feeling capacity through thought. Then,

empathy, the compassionate understanding of oneself or of the other, involves both feeling and cognition. It includes the ability not just to intuit what the other is feeling but also as Modell notes (p. 175) to appreciate (and understand [my addition]) the similarity and difference between self and other. It is in this sense that mature love is based not just on desire and identification (merging) but also on empathy. I believe empathy and therefore mature love require the capacities of self-coherence, perspective, agency and self-awareness. All these qualities are also crucial aspects of mature mentalized affectivity (Fonagy et al.).

In my three and a half decades of clinical practice I have found that whether they are loud and chaotic in their complaints or silent and withdrawn, men and women who did not feel loved in early life especially by their mothers, are deeply traumatized, have difficulty maintaining self esteem and self cohesion, and are subject to psychological disorganization.

Freud and the Freudians felt that the proper application of psa was in the treatment of the neurosis. However, consistently over the decades, many clinicians developed “wider-scope” applications of psa and psa oriented therapy, explaining preoedipal psychopathogy using one of the accepted paradigms of the era, such as classical Freudian, ego psychological, object relations theory, self-psychology, and more currently, attachment theory and contemporary relational theory.

A basic distinction used to be made between the transference experience of neurotic individuals and character disordered individuals. The former usually experience inner conflict intrapsychically, using their autobiographical memory, whereas the latter can not contain the conflict internally and access autobiographical memory i.e. remember inner conflict using thoughts, feelings and words, in other words symbolically. Instead they “act out”, meaning that they conflate past and present and re-experience the transference conflict as initiated by the other in the intersubjective space. LeDoux uses the concepts of memory of an emotion (the cool memory) and emotional memory (the hot memory) to express these differences. The term “act out” was replaced by the less pejorative verb “to enact” in the last decade as we came to realize that enactment was their only route for the deepest intimate engagement. Therefore, by definition enactment implies an inability to access autobiographical memory and the symbolic mode of thought during emotionally charged exchanges. Furthermore, during these crisis treatment moments, which Paul Russell called “the crunch” these individuals are expressing core affective procedural memories and attitudes that are often dissociated from their more mature selves. I believe that this is what Joseph means by the notion that “learning and associated emotional responding may be completely inaccessible to the language centers of the brain” at certain times (p. 141, blue). One individual recently told me after many years of such conflict, that at the point when she becomes very angry at me, her mind becomes a white blank.

I have found myself involved in extraordinarily long treatments with a handful of unusually talented patients who have taught me the most. (My other most valued teaching activities were my own analysis and motherhood.)These amazing journeys require courage in both participants and are high risk, high gain endeavors. Because each journey is so unique, it can be seen as an experiment in how much change is possible and at what levels of mind/brain organization this change has occurred. I am deeply grateful to my fellow travelers and am pleased and excited by the gains they have instantiated in their lives. Over the past five years I have been noting that a number of them were acquiring and practicing high-level capacities that indicate very deep and very fundamental change, such as self-awareness, agency, empathy and the capacity to love and be loved. Schore’s and Fonagy’s current ideas are helping me to reconceptualize both the developmental process and the process of change.

One of the major challenges for many clinicians like me, in fact for many of us “the holy grail” is the nature of change and at what levels this change occurs, and how enduring this change is.

Freud talked of changing neurotic misery to common unhappiness. Ted Nadelson, who passed away a few months ago, wisely taught us back then that change is subtle and results in a happier, less conflicted person.

Kohut felt that “psychoanalysis cures by the laying down of psychological structure (1984; p.113, blue).”

My position this evening is as follows; when love is based on empathy, I think it offers us the most integrative goal of human existence. By extension, the most integrative treatment goal is the capacity to love oneself and another better. And if we are lucky, we are all life long students.

Please consider these notes inexact, of course subject to revision and not to be quoted.

Tonight I am including my notes on Schore’s psycho-social-biological model of the epigenetic unfolding of affect regulatory capacities in the first two years of life and, as well, Fonagy’s cognitive developmental model, which centers on mentalization. Mentalized affectivity, by which Fonagy et al. mean the mature capacity for regulation of one’s own affects and the capacity to discover the subjective meaning states of one’s own feelings, will only occur if the maturation of the R orbital frontolimbic system that Schore describes (red p. 53) has proceed well enough (cf. Winnicott’s good enough mothering). Schore’s and Fonagy’s models are complementary. Both are based on attachment theory and see the infant and mother as a psycho-social-physiological unit.

Some central ideas form Schore, other neurophysiologists and my notes

The newborn’s brain weighs 400 gm; the one year olds, 1000 gm; the adult’s about 1200 gm.

Eliot. Lise (1999). What’s Going on in There? How the Brain and Mind Develop in the First Five Years of Life

“Anyone who has ever studied nerve cells can tell you how remarkably plastic they are. The brain itself literally molded by experience: every sight, sound, and thought leaves an imprint on the specific neural circuits, modifying the way future sights, sounds, and thoughts will be registered. Brain hardware is not fixed, but living, dynamic tissue that is constantly updating itself to meet the sensory, motor, emotional, and intellectual demands at hand (p.4; Psychological Trauma and the Developing Brain, Stien & Kendall, p.11).”

“Mental functioning is directly related to the number of both neurons and synapses in the brain. Whereas the proliferation of new connections increases the potential for learning, new patterns of connectivity between neurons, which are strengthened and stabilized through use (neurons that fire together, wire together; D. Hebbs; my addition), result from actual learning. Huttenlocher, P. (1994) claims that the density of synapses reaches its peak about the age of three and remains at that level until age ten. By age sixteen, the number of synapses has dropped to adult levels. (p. 19 Stien & Kendall).” (see other stages)

“During the first two years of life our brains go into “fast forward”, producing numerous cyclical growth spurts. (Stien & Kendall, p.22). The R and L hemispheres alternate periods of rapid growth. A sequential growth spurt in the R hemisphere is first followed by bilateral growth, and then by rapid growth in the other hemisphere (Thatcher, 1994; Stien & Kendall, p. 24).

Between ages three and four, a major reorganization occurs right after the brain has just gone through just such a developmental cycle. Language related processes, which up to this time occur in both hemispheres of the brain, begin to shift predominantly to the left hemisphere and visual-spatial tasks become mainly the jib of the right hemisphere (p. 24)

Ornitz, E. (1996). There appear to be four periods of major structural change in brain development, which punctuate the progressive increases and decreases in the size of the brain and its structures at both the macroscopic and microscopic levels” (p.40, p.24).”

Some central ideas form Schore and other neurophysiologists

Schore, A., (2003). Affect Dysregulation and Disorders of the Self (red) and Affect Regulation and Repair of the Self (blue)

Schore presents a psycho-social-biological model of growth and development which is relevant especially in the first two years of life. It is captured by the phrase right mind-right brain (R. Ornstein, 1997).

Schore aligns himself with the pioneers of attachment research, infant development and self psychology, namely, Bowlby, Main, and Kohut. These authors along with psychoanalysts, such as Winnicott, Loewald, Sandler, etc. moved the concept of “the infant” away from the hundred year old Freudian model of a bundle of instinctual drives. In our age of intersubjectivity, we see the newborn as a developmentally immature being whose bond with mother creates a “psycho-bio-social dyad that helps to shape the architecture of her infant’s brain, at the fundamental level of neuronal growth and parcellation (architectural design through cell growth and cell death) that emerges as the genetic timetable of brain/mind development unfolds. The neonates mind, as well as its 400 gm brain, is linked to the mother’s in a “super ordinate organization, which allows for mutual regulation of vital endocrine, autonomic and central nervous systems of both mother and infant (Hofer, 1990).” As we used to say the mother functions as an auxiliary ego, who helps to create positive states, helps to repair negative states and facilitates state transitions.

Schore concentrates on the R orbitofrontal cortex, which is larger in the right hemisphere where it has greater reciprocal connections with limbic and subcortical areas.

However, the R ventromedial cortex is also involved in inhibiting lower centers and interpreting emotions. And the anterior cingulate, the last stop before consciousness, helps to decide what emotional information to pass on to the cortex to help process emotions and urges from the limbic system, and to help focus attention on thinking (Stien & Kendall, p.47).

begins to show activity on PET scans by age four months and shows full activity by 12 months. It appears to be fully myelinated by 15 months (p. 52 red).

(In the newborn lower brain centers (amygdala and thalamus) are active. She can use her emotions to respond to sensations. By three months, the cingulate cortex and several areas of the limbic system, including the hippocampus, show activity on PET scans (Stien & Kendall, p.43, 46).)

Schore believes that “The essential task of the first year of human life is the creation of a secure attachment bond of emotional communication between the infant and primary caregiver (p.113, red, Papousek et al., 1997, p. 42) Furthermore he boldly states that, “I believe that every type of early forming primitive disorder (i.e. character disorders) involves, to some extent, altered orbital prefrontal function (p.35, red).”

states that the orbital limbic and medial limbic prefrontal areas are extensions of the limbic system. They demonstrate the following features: 1. Lower cell density and different protein building qualities (more like limbic cortex) compared to the six layer eulaminate cortex. 2. More inputs than any other brain area except entorhinal cortex. 3. Connections from every external sensory modality (visual, auditory, somatosensory and olfactory cortices). 4. Also connections from limbic structures, emotions, viscera, long term memory (medial temporal or entorhinal). Connections between amygdala, thalamus, anterior cingulate, hypothalamus and sensory cortex are bidirectional. 5. Barbas feels this area endows events with emotional significance.

The R prefrontal cortex is central to the following functions (This does not imply a phrenological location of function. Rather it implies that without these areas, these functions may not exist or exist only in part.):

3. intuition (emotional hunch) and the perception of emotional states of others (Voeller, 1086, red p. )

5. emotionally centered cognition, procedural processing of affect laden meanings, especially complex ones

8. is essential to the capacity of inferring states of others (Baron-Cohen, 1995, red p. 53)

1. An important function, especially in the first year, is the generation of pleasurable states marked by positive affect. Mother helps to create positive states, monitors and helps to repair the dysphoric states and facilitates state transitions.

2. by 4-6 months, real expressions of anger appear and by 7-8 months, classic facial expressions of fear. As well, familiar faces are recognizable and an initial ability to compare past and present.

3. Toward end of first year, intentionality and joint attention are present. And “distinct patterns of infant facial expressions, indications of motor responses to emotion, are reliably coded (p. 15 red; Malatesta, 1989).

4. The orbitofrontal area, like the amygdala and fusiform gyrus contains neurons that specifically respond to the emotional expression of faces. At 10 months, corticolimbic system can generate and store abstract templates of prototypical facial emotional expressions. Neuroscientists call this internalized regulatory capacity, “the mother icon”. Psychoanalysts call these gestalts, subsymbolic or schematic representations (p. 16 red). This may be beginning of evocative memory.

5. This prefrontal system can now generate interactive representations- nonverbal internal working models of the infant’s transactions with the primary attachment figure that dyadically maximize positive and minimize negative emotions. At the end of the first year the infant can create “presymbolic” representations that encode his physiological-affective responses to the emotionally expressive face of the attachment figure. These interactive representations embody the expectation of being matched by, and being able to match the partner, as well as “participating in the state of the other” (Beebe and Lachmann, 1988b). “Ultimately, the affective core “biases the infant’s evaluation of a new situation and his interactive patterns even before the information arising from the situation has been processed (Tronick, et al. 1986).” This accords with Freeman’s preafference or expectation model.

7. The 10-13.5 months period (p. 16, red) appears to be a critical time window for the rapid growth of the energy mobilizing sympathetic part of the ANS. It is responsible for the excitatory positive feelings associated with Mahler’s practicing period.

8. At 12 months, along with increasing motor skill learning, stage II NREM sleep, which has been slowly increasing, peaks and then in the second year diminishes. This sleep phase consolidates and enhances motor memory (M. Walker, personal communication).

9. Then as the second year continues, and as voluntary activity increases in motoric, emotional, and cognitive spheres, the inhibiting, energy conserving parasympathetic system begins to mature. “Socializing capacities unfold, including sphincter control, the dynamic unconscious, and the attachment emotion, shame (p. 17, red). The parent’s task now extends to regulate the socialization process by setting limits that include shame in an effort to promote self-regulation. Schore feels that socializing shame interrupts the overly and at times inappropriately excited activity by putting the brakes on arousal (p. 26, blue).

10. at 16-18 months symbolic thought begins and is constituted by approximately the third year. In using symbols, the child can refer to an object in a way that is arbitrary, that is, not defined by its physical features.

11. at 18 months the dynamic unconscious is thought to come on line. Malatesta et al. feel that the infant is now able to have one set of inner feelings privately held and display another set of feelings publicly. Panksepp and Gainotti believe that only cortical material can be repressed (personal communication). Infant learns to anticipate reward, punishment, approval and disapproval, has initial capacity for ambivalence (love and hate) and object constancy, and has an initial image of herself and others (Stien & Kendall, p.51).

12. Also at eighteen months the infant begins to mentally “time travel” as it starts to integrate time past, present and future (Wheelan, Stuss, Tulving, 1997; p.121, blue).

The delayed response function is thought to be the major cognitive functional output of the orbital cortex. It enables the individual to react to situations on the basis of stored representations, rather than on information immediately present in the environment. (Edelman’s primary function of memory allows the individual to be off-line). The delayed response function is part of conscious and unconscious activity.

The R prefrontal cortex is felt to be the analyzing instrument, the internal reflecting and organizing agency (Solms, p. 105 blue).This is the senior executive center of the emotional brain, the thinking part of the emotional brain (Joseph, Devinsky, p.121 blue). It demonstrates plasticity and continuing experience dependent maturation (p. 107 blue)

The analyst’s stance demonstrates what I believe is a triad of self-reflecting functions. They include looking at or observation; thinking about oneself and the other in the present moment, in the past and into the future with feelings; and empathy, the ability to appreciate the similarities and differences in the position of the other with thought and compassionate feeling.

While “focusing on the totality of the patient and the totality of my response to the patient, I am aware that I am aware that I am focusing on the patient and on my response to her (Holmes, 1996, p. 86; blue, p. 95).”

Schore boldly states that, “I believe that every type of early forming primitive disorder (i.e. character disorders) involves, to some extent, altered orbital prefrontal function (p.35).” Given that the shape and function of the earliest maturing areas will influence the emergence of later areas, this is a logical argument. Trevarthen and Aitken (1994) call this class of developmental psychopathologies “empathy disorders.”

The orbitofrontal cortex ultimately is essential in inhibiting parts of the limbic system, particularly the amygdala.

It seems highly probable that when the inhibitory capacity does not function adequately, the individual is flooded by intense negative emotions. Conceptually, the right prefrontal area is flooded and the “hot” procedural memory systems of subcortical limbic system including the fear inducing amygdala express themselves. Thus cognition, emotion and motivation associated with secondary process functions break down in a psycho-physiological dissociative “braking” event. We should be looking at this area in our explorations of the dynamic unconscious.

A limited capacity to perceive the emotional states of others, to read subtle facial expression; misattribution of emotional states and of motivations of others (projection); inability to read inner cues of bodily states (desomatization, Krystal, 1997); limited ability to modulate the intensity and duration of biological primitive affects such as rage, fear, panic, excitement, disgust, shame.

Until about eighteen months, the urges from the limbic system that are relayed to the cortex inevitably lead to action. Then thinking and language come to the forefront. Sometime between eighteen and twenty-four months, toddlers begin to translate multisensory images in their minds into words.

Physiological Maturation, Bridges to Psychological Maturation and Psychological Representation

Some central ideas from Fonagy’s work and my notes that help us understand cognitive development especially after age two.

Affect Regulation, Mentalization, and Development of the Self (2002)

Fonagy, Gergely, Jurist, Target

The R orbital cortex matures in the middle of the second year, a time when the R hemisphere ends it’s growth phase and the left hemisphere begins one (Thatcher, 1994). Although Fonagy et al present rich and complex data on mental/cognitive development from birth, I am particularly interested in the phase that corresponds to the growth spurt of the L hemisphere. This includes more sophisticated motor co-ordination, sphincter control, the onset of the dynamic unconscious, verbal and cognitive (symbolic) skills, imagination/fantasy, mentalization, and autobiographic memory. This time period encompasses the traditional anal and oedipal phases.

In order to understand the text, it can be helpful to keep in mind several uses of the concept of self. The first is the conscious perspective of one’s own self, the Jamesian “I”, the subjective, conceptual “I”, the agent self, the observer self, the center of action and reflection; the “I am-ness”, or the “I am that I am” factor. The aspect of the Freudian ego that perceives signal anxiety, the observing ego, as well as the SE, and the Kohutian self belong to this category.

(Aspects of this conceptual self can be communicated through contagion of feelings and ultimately by words. Even then it remains highly private.) (In an fMRI study, the self-referential condition induced bilateral activation in the dorsomedial prefrontal cortex, whereas the other-referential condition induced activation in lateral prefrontal areas. Activation in the right dorsomedial prefrontal cortex was unique regardless of the valence of words. A widely distributed network of brain areas contributes to emotional processing. Among these regions, the right dorsomedial prefrontal cortex is one main area mediating self-reference. By providing a personal perspective in the evaluation of emotional stimuli, the right dorsomedial prefrontal cortex may mediate cognitive processes, such as those involved in psychotherapy, that guide self-regulation of emotional experience. AM J Psychiatry, 2003: 160: 1938-1945.)

The second use is the concept of “me-ness”, the observable, empirical or categorical self, which refers to the collection of attributes the person believes to be true of himself. This “me” self requires the mirroring other to complete its outline, or schema. It is the self we observe, literally in a mirror, or in our imagination. “Me-ness” rests on Vico’s philosophy of mind, about three hundred plus years old, namely, the notion that we fathom ourselves in others. And Sartre observed in the last century that, “I am the incontestable agent of my actions but I can see myself only through the recognition of others.” Ego functions and “the inner representational world” belong to the “me-ness” category.

And then there is Freud’s unconscious intrapsychic “self experience”, the Id, which is known by inference both by self and other.

Fonagy et al. contend that their ideas constitute a genuinely new direction for psychoanalysis and psychotherapy and I concur.

Their body of work is based on attachment research, but moves beyond the idea that attachment is an end unto itself. Rather, attachment exists in our species in order to produce a representational system that presumably has evolved to aid human survival (p.2).

So the main focus of the book is to describe the development of the representation of psychological states in the minds of infants and adults. This is an old psychoanalytic concept (see psychological representation).

I myself favor the neurobiologist, Walter Freeman’s belief that the function of the human mind and brain is to create meaning.

This process by which we realize that having a mind mediates our experience of the world the authors call Mentalization.

In addition, they hope to demonstrate that an infant’s experience of himself as an organism with a mind is not a genetic given but that it evolves through the interaction with more mature minds (p.4).

The task of the human mind is to make meaning. We cannot make constructive meaning as isolated minds/brains. Making meaning requires a dialectical engagement of our subjective, intrapsychic, private self with the other in the interpersonal space.

“Mentalization is the process by which we realize that having a mind mediates our experience of the world.”

· involves both a self-reflective and an interpersonal component (p.4) (Note that reflective function refers to operationalization of the mental capacities that generate mentalization. It is not synonymous with introspection; rather it is the capacity from which introspection grows.)

· is not just a cognitive process. Development begins with the “discovery” of affects through relationships

· once mentalization has occurred, the nature of affect regulation is transformed

· mentalized affectivity means the mature capacity for the regulation of affects and thus connotes the capacity to discover subjective meanings of one’s own affect states (p.5)

Nature, meaning gene expression, operates as a “potentialist” rather than “determinist” in development (p.6) and biology has culture on a “loose” rather than a “tight” leash (p.7).

This means that the manner in which the environment (human) is experienced acts as a filter in the expression of the geno into pheno type (p.7).

Intrapsychic representational processes are not just the result of nature and nurture but may act as moderators of the effects of the environment upon the unfolding of geno into pheno type (p.7).

Thus early psychological and neurophysiological experience determines the depth to which the social environment may be processed. I believe we need to contrast this depth in the interpersonal space with the depth to which an individual can be locked in his own psychic space. Suboptimal development can undermine the individual’s capacity to interpret the mental states of others, which is a large aspect of reality testing (p.7).

Thus the self is not merely open to influences from the human (and non-human) environment; it is in part constituted through them. The infant’s immature mind is held and nurtured by the mature minds of the care-givers. The capacity for the regulation of positive and negative emotional states is enhanced every time the care-giver mirrors the child’s inner experience empathically and the child “takes in” the image of the care-giver.

The crucial dimension in the image the child “takes in” is that the child “sees” not just the caregiver but also himself, while he is being held emotionally within the mind of caregiver (p.8). The self as agent arises out of the infant’s perception of his presumed intentionality in the mind of the caregiver (p.11).

This represents yet another subtle addition to the construct of “introject”. Over the decades we have shifted our construct from internalization of other/containing object (introject) to introjection of interaction with other/containing object (Loewald) to internalization of the thinking/feeling self as it is held in the mind of the other/containing object. Winnicott (1971 a) understood that the attuned mother gives back to the baby the baby’s own self (blue, p. 64). When primary identification of this positive nature occurs it relates to positive projective identification (Likierman, 1978), (blue, p. 66). This is reflected in the second part of Sartre’s quote, namely that we can see ourselves only through the recognition of others.

The authors call this image a second order representation that promotes affect regulation and impulse control. It is the model by which affects can be discharged safely internally, within the mind of the infant, as well as through action. It is also the bedrock of mentalization. (p. 8) and I believe of “deep” change.

The premises of the book rest on two intimately connected developmental theories.

Social Biofeedback Theory of Parental Affect Mirroring; Parents communicate with their infants by mirroring and infants learn control over their parents’ mirroring.

Parental affect-mirroring includes a pretend mode called markedness. This is instrumental in fostering the capacity for affect regulation. It is helpful for all overwhelming emotion, but especially for dysphoric emotions. This occurs when the care-giver mirrors the child’s inner experience empathically in exaggerated “pretend” form and the child “takes in” the image of the care-giver holding him in her mind.

I believe this communicative mechanism works because the parent does not react in a “gut” fashion to the infant’s emotions. Thus the infant’s fear/anger system is not stimulated further but calmed. Consequently, the infant is not caught up in an escalating cycle of anger and fear with her parent. Containment and safety are restored. The infant is able to incorporate a second order representation that includes repair of the attachment. When the parent reacts with genuine anger and fear, the infant automatically feels anger and fear and bad. To escape from these overwhelming feelings (sympathetic N. S.) the helpless infant may dissociate (parasympathetic N. S.). The infant’s mirroring of the parent’s internal states is dysfunctional, confusing and difficult to regulate and excludes the ability to create a second order representation.

How the therapist holds the patient in her mind can be seen as a crucial factor in the therapeutic dialogue. Ms. A: “I need to know how you see me, not how my mother saw me.” Mirroring between adults in a therapeutic environment does not usually contain markedness. However, the principle of not being overwhelmed by the patient’s enactments as she repeats early painful interpersonal experience that became intrapsychic experience, namely, part of her affective procedural memory, is the same. When the therapist loses the capacity to contain, she feels the raw anxiety, and perhaps, fear, and anger. The therapeutic frame is shattered and needs to be repaired. These are the necessary repetitions. The repairs allow more mature deep emotional responses to evolve in the patient along with second order representations.

The “nature of psychic equivalence” is the nature of subjectivity before mentalization. Young children behave as though their own and other’s thoughts faithfully mirror the world (p.258). Here ideas and fantasies are not psychic representations but direct replicas of reality and therefore true (p. 256). The ability to imagine false beliefs, where the assumption of equivalence between appearance and reality is untenable, marks a significant growth step for the child.

If the ability is not developed to perceive the difference between a second order representation and the actual inner mental state, then psychic equivalence (.e. that internal reality is external reality) continues to dominate the subjective world (p.8). With patients who communicate intimately using projective indentification, this mode is present in the regression.

Autobiographical Memory

Fonagy and colleagues feel that the reflective function or mentalization requires the uniquely human “I” self, the cognitive self-concept that is a precondition for autobiographical (episodic) memory which comes on-line as the hippocampus matures at about age three. The reflective function allows children to respond to the conception of the other’s feelings, beliefs and intentions. It gives children a “theory of mind” that enables them the “read” other people’s minds and so makes others behavior meaningful and predictable (p. 24). Povinelli (1999) feels that the two year old can hold a single representation of the world in mind. This is the “present self”. By age four, memory is multi-tasking. The child can hold multiple representations of the world simultaneously, establish temporal and causal relationships among memories and causally evaluate the relevance of previous states of self to the present self (p. 245, 247).

A three year old was on a boat trip with his parents off Gloucester when he remembered a similar trip in Bermuda a month ago. The parents say this was “a first.” “Mommy, boat in Bermuda much bigger and water blue.” (Field memory is transformed into first person observer memory.) It will take another year or two before he will be able to say, Mommy, I remember when we were on the boat in Bermuda. It was much bigger and the water was so blue. I had such a good time eating ice cream.” Here the child demonstrates coherent, causal-temporal organization of the autobiographical self, the “I am-ness” self.

The Sandlers noted in 1977 that, “the child will create increasingly complex representations of the interactions, the relationships, the dialogues between himself and his objects … [W]ith selfobject differentiation … another constant object with an equally enduring identity also emerges for the child. This is the child’s own self … the child constantly and automatically also has a dialogue with his own self…” (Sandler and Sandler, 1978, p.294).

I believe that there is a triad of introspective functions which elaborate on the core self-reflecting ability. These include the capacity to look at oneself; as well the thought process of thinking about oneself with feelings at this moment in time, or in the past or in the future. This refers to the Sandlers’ concept of the infant having a dialogue with himself. And the triad expands to include empathy when we are looking at/thinking about the other, feeling compassionately for the other, especially when that other’s perspective is different. In a parallel manner, we can develop empathy for ourselves, and evolve from a judgmental, shaming response.

Depth and Interdependence

The work of changing emotional patterns we learned subconsciously as children is a remarkably difficult task. Paul Russell noted that the manner in which we organize the self in the absence of a good enough other creates our disabilities. We may assume implicitly that it is also in the presence of another that recontextualization of emotional experience may occur at the deepest level. Early psychological and neurophysiological experience determines the depth to which the social environment may be processed. We clinicians want to contrast this depth in the interpersonal space to the depth to which an individual can be locked in his own psychic space. The freer we are in our ability to unselfconsciously show ourselves to the social environment, the more we can take useful feedback in from that environment and evolve. The deeper and entrenched our private parts of being are, the less authentic we are in social interchange and the more unchanged we remain at the deepest level.

The cycle of change and core change

I firmly believe that the psychoanalytic enterprise offers individuals the potential to change at subconscious and conscious levels of mind/brain. This engagement requires that we make visible to another our most painful, hidden parts. Modell notes that when meaning is constructed, a transformation takes place in the brain that is experienced by the mind. This is how matter becomes imagination (Imagination and the Meaningful Brain). In recontextualization, the new context is the new containing space in which exists the new capacity to be connected differently. My sense is that change begins in the intersubjective space as a result of the co-constructed verbal and non-verbal dialogue. But deep change represents a change in the affective procedural sensibility of the person. Doug Watt calls affective procedural memory the core of personality. Kohut called this process of change, transmuting internalization. However, in order for this change to develop into insight, I believe it must be verbalized. Then a sense of ownership or agency is established and the issue is transformed from a schematic, implicit representation to a symbolic representation.

For example, a patient spent years telling me largely indirectly that I wouldn’t give her what she needed and that she would not ever get what she needed. Then she said, “For the first time I can feel a warmth and a sense of presence of you in my gut. I never felt that with my mother or father. The language of feeling was like learning a foreign language. The nuances of feelings like lonely, sad, jealous, joy were all new to my vocabulary when I was talking about myself.” This experience of taking in the presence of the other while she holds you in mind as a good, worthwhile, and loveable person can be understood both as a transmuting internalization and as an adaptive positive projective identification.

But in her ability to verbalize it, to be aware of it conceptually, through words, the patient changed the schematic representation into a symbolic representation, which she can learn to control voluntarily, and, therefore repeat consciously.

[1] Eden Ahbez, 1948. I want to thank Jennifer Jenks for finding the source for me.

	Projective Identification: How does it work? Neuro-Psychoanalysis. 4(2): 187. PDF		These articles are provided here for download, courtesy of *Neuro-psychoanalysis,* Journal of the International Neuro-Neuro-Psychoanalysis Society, and its publisher, Karnac Books.
	Greatrex, T. (November, 2003). What's Love Got to do with it. Paper presented in Building Bridges from Psychoanalysis to Neuroscience, Affect, Attachment, and Cognitive Development. Boston Psychoanalytic Society and Institute, Members Seminar. Recent work in the neurophysiology of development correlates with Fonagy’s developmental model of emotion and cognition. He and his colleagues suggest that mentalized affectivity, by which they mean the mature capacity for regulation of one’s own feelings and the capacity to discover the subjective meaning of states of one’s own feelings, lies at the heart of treatment. This complex capacity, which includes the ability for appreciating similarity and difference between self and other, as well as agency and self-awareness, is embodied in mature love. The hypothesis is that these changes represent not just maturing psychological capacities but have neurophysiological correlates.
	Draft of PEFB TALK, OCTOBER 6, 2004 Toni Greatrex, M.D. please do not copy without permission What’s Love Got To Do With It? An exploration of the capacity to love as a treatment goal using current psychoanalytic and neuroscientific concepts “The greatest thing you’ll ever learn, Is just to love and be loved in return” Eden Ahbez, 1948 In March we explored two current developmental approaches, the first neurophysiological and the second psychological, with the aim of using fundamental concepts from each to think about complex treatment goals that characterize long term analytic work. These goals include capacities such as self-coherence, perspective, agency, and empathy. For me the core feature of all these goals is embodied in the capacity to love and be loved. This form of mature love is based not only on desire and identification, but also on the capacity of empathy. Both models derive from attachment theory and assume that the human environment influences the expression of genetic tendencies. Alan Schore created the first model in which he elaborates a hypothesis about the centrality of the neurophysiological development of affect regulatory capacities in the orbitofrontal cortex of infants in the first two years of life. The second model, authored by Fonagy, Gergely, Jurist and Target, suggests psychological stages that an infant traverses in order to develop a” theory of mind”. These four authorities believe that early psychological and neurophysiological experience determines the depth to which the social environment may be processed and that sub-optimal development can undermine the individual’s capacity to interpret the mental states of others. Furthermore, mentalized affectivity, by which they mean the mature capacity for regulation of one’s own affects and the capacity to discover the subjective meaning states of one’s own affect lies at the heart of treatment. October 6, 2004 What’s Love Got To Do With It? “The greatest thing you’ll ever learn, Is just to love and be loved in return” Eden Ahbez, 1948 Our March presentation focused on an exploration of the capacity to love as a treatment goal using current psychoanalytic and neuroscientific concepts. These goals include capacities such as self-coherence, perspective, agency, and empathy. For me the core feature of all these goals is embodied in the capacity to love and be loved. This form of mature love is based not only on desire and identification, but also on the capacity of empathy. During the first evening of the fall sequence we will begin with illustrative clinical material. Then we will review the concepts of mentalized affectivity and autobiographical memory capacities with the aim of using fundamental concepts from each concept to think about complex treatment goals, which characterize long term analytic work, including empathy and mature love. INTRODUCTION Freud’s revolutionary psychology, which had given us the best theory of mind in the 20^th century, had been codified into semi-scientific principles called metapsychology. Indeed, it was so powerful that terms such as instinct, libido, id, ego, superego, and oral anal and oedipal were folded into popular western culture. Mid-century ego psychology had moved our understanding of mental capacities beyond the unconscious defensive control of conflict, to include what are now seen as cognitive and emotional regulatory functions. Modell et al. feel that certain Freudian principles that will stand the test of time, including the dynamic unconscious, the repetition compulsion, conflict and resistance/defense and, of course, transference. But a paradigm shift was under way as it is in every age. Thomas Kuhn, a philosopher of science, created the term paradigm shift in his book “The Nature of Scientific Revolutions.” He believed that a mature science, be it physics or psychoanalysis, involved puzzle solving within a paradigm. Over time researchers in a given field become aware of an accumulation of anomalies and make variations in the reigning paradigm to account for them. This leads to discontinuity, paradigm breakdown and a period of diversity. Extraordinary thinkers, exploring “out of the box” offer revolutionary new paradigms that then become the accepted model along which the field reconfigures itself. My sense is that this is where psychoanalysis found itself in the seventies as the shift from intrapsychic instinct as primary motivation to attachment as primary motivation was under way. Prominent among the paradigm creators were Spitz, Harlow, Lorenz, and Bowlby, British Object Relations School and Winnicott, Bion, and Guntrip; Kohut and self-psychology and Main/Solomon and Attachment. They introduced us to intersubjectivity. And presently psychoanalytic theory and practice is undergoing another major paradigm shift. The findings from the above mentioned investigators fueled the vision of infant developmental researchers, who, using the power of the video camera were able to explore and analyze the frame by frame interactions between infants and caretakers. More recently, there has been an explosion of knowledge from current brain imaging techniques, testing both adults and increasingly children. The task of synthesizing this new information with the old is enormous. Two leaders in this arena of synthesis are Alan Schore and Peter Fonagy and his colleagues. Michael Basch states what many of us have thought for a long time: “The more I know about how we are designed to function – what neurophysiology, infant research, affect theory cognitive psychology, semantics, information theory, evolutionary biology, and other pertinent disciplines can tell me about human development – the better I am prepared to be empathic with a patient’s communication at a particular time in his or her treatment (1995, p.113).” LOVE What’s Love Got To Do With It? For me, when I was a child, heaven was a canopy above the earth where both God and Santa Claus may have resided. In our contemporary world of multiverses the meaning of existence for many of us no longer resides in the heavens. Instead we have located it in the human ability to love better. Certainly the nature of love has occupied every time period and every culture. Twenty-five hundred years ago Plato said, “Who knows not love, walks in darkness”. Around the time of Freud, Nietzsche said “One must learn to love oneself … with a wholesome and healthy love, so one can bear to be with oneself and need not roam. Friedrich Nietzsche, in M & B p. 139.” And from Alfred de Musset, “Life is a deep sleep, of which love is the dream.” However my favorite quote is “The greatest thing you’ll ever learn, Is just to love and be loved in return”[1]. I think it is my favorite because it is interpersonal and plebian. Certainly Freud felt that psychoanalysis helped us to work and love better. But for the most part Freud used the word love to describe the sexual drive and sexual attraction. “Cure by love” came to mean the patient found a girl friend and lost interest in his analysis. And in the hippie generation, love became “free love”, as young people threw off the shackles of sexual inhibition and glorified sexual gratification. The kind of love I am describing today has more to do with nurturing both body and soul. The contemporary philosopher Lear believes that within the human realm love becomes a far-reaching psychological force: “what is special about human life is that it develops in complexity and structure through the mind’s own activity (p. 12) as it relates to other minds (my italics, added because today the intersubjective aspect is crucial). “In so far as there is a natural developmental thrust by which the mind moves from archaic to more sophisticated formulations, the mind must be striving to understand its own activities (.p 8).” “In trying to understand human subjectivity, mind is trying to grasp its own activity (p. 8). Lear feels that “Freud saw this development (of individuation; my addition) as fueled by love, but he did not work through the consequences as positing love as a basic force in nature (p. 12).” Bowlby’s prescient ideas of attachment and imprinting were elaborated in object relations theory in the 1970’s. Then self psychology impacted our academy, followed by a theoretical and empirical exploration of attachment. Consequently, our understanding of the meaning of self-coherence, agency, curiosity, perspective, empathy and love matured beyond the classical functions of ego, ego ideal and SE. In our current psychoanalytic culture, introspection has matured into subjectivity through the absorption of the phenomenological perspective. It has become fashionable even in neuroscientific circles because of current imaging techniques. Lear notes, “For human reality is significantly constituted by subjectivity. What it is to be a person is shaped by what it is like for that person to be (p. 4).” As Wittgenstein said, a depressed man lives in a depressed world. Probably all mammalian species have primitive empathy capacities since they are coincident with the evolution of social signaling in group animals. Here empathy involves the ability to copy the internal state of the other, i.e. identify by imitation, in order to decrease the distress of the other. However, the human evolved quality of self individuation allows us to elaborate this feeling capacity through thought. Then, empathy, the compassionate understanding of oneself or of the other, involves both feeling and cognition. It includes the ability not just to intuit what the other is feeling but also as Modell notes (p. 175) to appreciate (and understand [my addition]) the similarity and difference between self and other. It is in this sense that mature love is based not just on desire and identification (merging) but also on empathy. I believe empathy and therefore mature love require the capacities of self-coherence, perspective, agency and self-awareness. All these qualities are also crucial aspects of mature mentalized affectivity (Fonagy et al.). In my three and a half decades of clinical practice I have found that whether they are loud and chaotic in their complaints or silent and withdrawn, men and women who did not feel loved in early life especially by their mothers, are deeply traumatized, have difficulty maintaining self esteem and self cohesion, and are subject to psychological disorganization. Freud and the Freudians felt that the proper application of psa was in the treatment of the neurosis. However, consistently over the decades, many clinicians developed “wider-scope” applications of psa and psa oriented therapy, explaining preoedipal psychopathogy using one of the accepted paradigms of the era, such as classical Freudian, ego psychological, object relations theory, self-psychology, and more currently, attachment theory and contemporary relational theory. A basic distinction used to be made between the transference experience of neurotic individuals and character disordered individuals. The former usually experience inner conflict intrapsychically, using their autobiographical memory, whereas the latter can not contain the conflict internally and access autobiographical memory i.e. remember inner conflict using thoughts, feelings and words, in other words symbolically. Instead they “act out”, meaning that they conflate past and present and re-experience the transference conflict as initiated by the other in the intersubjective space. LeDoux uses the concepts of memory of an emotion (the cool memory) and emotional memory (the hot memory) to express these differences. The term “act out” was replaced by the less pejorative verb “to enact” in the last decade as we came to realize that enactment was their only route for the deepest intimate engagement. Therefore, by definition enactment implies an inability to access autobiographical memory and the symbolic mode of thought during emotionally charged exchanges. Furthermore, during these crisis treatment moments, which Paul Russell called “the crunch” these individuals are expressing core affective procedural memories and attitudes that are often dissociated from their more mature selves. I believe that this is what Joseph means by the notion that “learning and associated emotional responding may be completely inaccessible to the language centers of the brain” at certain times (p. 141, blue). One individual recently told me after many years of such conflict, that at the point when she becomes very angry at me, her mind becomes a white blank. I have found myself involved in extraordinarily long treatments with a handful of unusually talented patients who have taught me the most. (My other most valued teaching activities were my own analysis and motherhood.)These amazing journeys require courage in both participants and are high risk, high gain endeavors. Because each journey is so unique, it can be seen as an experiment in how much change is possible and at what levels of mind/brain organization this change has occurred. I am deeply grateful to my fellow travelers and am pleased and excited by the gains they have instantiated in their lives. Over the past five years I have been noting that a number of them were acquiring and practicing high-level capacities that indicate very deep and very fundamental change, such as self-awareness, agency, empathy and the capacity to love and be loved. Schore’s and Fonagy’s current ideas are helping me to reconceptualize both the developmental process and the process of change. One of the major challenges for many clinicians like me, in fact for many of us “the holy grail” is the nature of change and at what levels this change occurs, and how enduring this change is. Freud talked of changing neurotic misery to common unhappiness. Ted Nadelson, who passed away a few months ago, wisely taught us back then that change is subtle and results in a happier, less conflicted person. Kohut felt that “psychoanalysis cures by the laying down of psychological structure (1984; p.113, blue).” My position this evening is as follows; when love is based on empathy, I think it offers us the most integrative goal of human existence. By extension, the most integrative treatment goal is the capacity to love oneself and another better. And if we are lucky, we are all life long students. Notes on Schore and Fonagy et al. Please consider these notes inexact, of course subject to revision and not to be quoted. Tonight I am including my notes on Schore’s psycho-social-biological model of the epigenetic unfolding of affect regulatory capacities in the first two years of life and, as well, Fonagy’s cognitive developmental model, which centers on mentalization. Mentalized affectivity, by which Fonagy et al. mean the mature capacity for regulation of one’s own affects and the capacity to discover the subjective meaning states of one’s own feelings, will only occur if the maturation of the R orbital frontolimbic system that Schore describes (red p. 53) has proceed well enough (cf. Winnicott’s good enough mothering). Schore’s and Fonagy’s models are complementary. Both are based on attachment theory and see the infant and mother as a psycho-social-physiological unit. Some central ideas form Schore, other neurophysiologists and my notes General Information about Neurophysiological Maturation The newborn’s brain weighs 400 gm; the one year olds, 1000 gm; the adult’s about 1200 gm. Eliot. Lise (1999). What’s Going on in There? How the Brain and Mind Develop in the First Five Years of Life “Anyone who has ever studied nerve cells can tell you how remarkably plastic they are. The brain itself literally molded by experience: every sight, sound, and thought leaves an imprint on the specific neural circuits, modifying the way future sights, sounds, and thoughts will be registered. Brain hardware is not fixed, but living, dynamic tissue that is constantly updating itself to meet the sensory, motor, emotional, and intellectual demands at hand (p.4; Psychological Trauma and the Developing Brain, Stien & Kendall, p.11).” “Mental functioning is directly related to the number of both neurons and synapses in the brain. Whereas the proliferation of new connections increases the potential for learning, new patterns of connectivity between neurons, which are strengthened and stabilized through use (neurons that fire together, wire together; D. Hebbs; my addition), result from actual learning. Huttenlocher, P. (1994) claims that the density of synapses reaches its peak about the age of three and remains at that level until age ten. By age sixteen, the number of synapses has dropped to adult levels. (p. 19 Stien & Kendall).” (see other stages) “During the first two years of life our brains go into “fast forward”, producing numerous cyclical growth spurts. (Stien & Kendall, p.22). The R and L hemispheres alternate periods of rapid growth. A sequential growth spurt in the R hemisphere is first followed by bilateral growth, and then by rapid growth in the other hemisphere (Thatcher, 1994; Stien & Kendall, p. 24). Between ages three and four, a major reorganization occurs right after the brain has just gone through just such a developmental cycle. Language related processes, which up to this time occur in both hemispheres of the brain, begin to shift predominantly to the left hemisphere and visual-spatial tasks become mainly the jib of the right hemisphere (p. 24) Ornitz, E. (1996). There appear to be four periods of major structural change in brain development, which punctuate the progressive increases and decreases in the size of the brain and its structures at both the macroscopic and microscopic levels” (p.40, p.24).” Some central ideas form Schore and other neurophysiologists Schore, A., (2003). Affect Dysregulation and Disorders of the Self (red) and Affect Regulation and Repair of the Self (blue) Schore presents a psycho-social-biological model of growth and development which is relevant especially in the first two years of life. It is captured by the phrase right mind-right brain (R. Ornstein, 1997). Schore aligns himself with the pioneers of attachment research, infant development and self psychology, namely, Bowlby, Main, and Kohut. These authors along with psychoanalysts, such as Winnicott, Loewald, Sandler, etc. moved the concept of “the infant” away from the hundred year old Freudian model of a bundle of instinctual drives. In our age of intersubjectivity, we see the newborn as a developmentally immature being whose bond with mother creates a “psycho-bio-social dyad that helps to shape the architecture of her infant’s brain, at the fundamental level of neuronal growth and parcellation (architectural design through cell growth and cell death) that emerges as the genetic timetable of brain/mind development unfolds. The neonates mind, as well as its 400 gm brain, is linked to the mother’s in a “super ordinate organization, which allows for mutual regulation of vital endocrine, autonomic and central nervous systems of both mother and infant (Hofer, 1990).” As we used to say the mother functions as an auxiliary ego, who helps to create positive states, helps to repair negative states and facilitates state transitions. Schore’s Line of Thought Schore concentrates on the R orbitofrontal cortex, which is larger in the right hemisphere where it has greater reciprocal connections with limbic and subcortical areas. However, the R ventromedial cortex is also involved in inhibiting lower centers and interpreting emotions. And the anterior cingulate, the last stop before consciousness, helps to decide what emotional information to pass on to the cortex to help process emotions and urges from the limbic system, and to help focus attention on thinking (Stien & Kendall, p.47). R prefrontal cortex begins to show activity on PET scans by age four months and shows full activity by 12 months. It appears to be fully myelinated by 15 months (p. 52 red). (In the newborn lower brain centers (amygdala and thalamus) are active. She can use her emotions to respond to sensations. By three months, the cingulate cortex and several areas of the limbic system, including the hippocampus, show activity on PET scans (Stien & Kendall, p.43, 46).) Schore believes that “The essential task of the first year of human life is the creation of a secure attachment bond of emotional communication between the infant and primary caregiver (p.113, red, Papousek et al., 1997, p. 42) Furthermore he boldly states that, “I believe that every type of early forming primitive disorder (i.e. character disorders) involves, to some extent, altered orbital prefrontal function (p.35, red).” Helen Barbas, B.U. neurophysiologist: states that the orbital limbic and medial limbic prefrontal areas are extensions of the limbic system. They demonstrate the following features: 1. Lower cell density and different protein building qualities (more like limbic cortex) compared to the six layer eulaminate cortex. 2. More inputs than any other brain area except entorhinal cortex. 3. Connections from every external sensory modality (visual, auditory, somatosensory and olfactory cortices). 4. Also connections from limbic structures, emotions, viscera, long term memory (medial temporal or entorhinal). Connections between amygdala, thalamus, anterior cingulate, hypothalamus and sensory cortex are bidirectional. 5. Barbas feels this area endows events with emotional significance. Functions of R prefrontal cortex The R prefrontal cortex is central to the following functions (This does not imply a phrenological location of function. Rather it implies that without these areas, these functions may not exist or exist only in part.): 1. attention, intention and motivation 2. self-regulation of body and motivational states 3. intuition (emotional hunch) and the perception of emotional states of others (Voeller, 1086, red p. ) 4. unconscious evaluation of facial expression (including trustworthiness) 5. emotionally centered cognition, procedural processing of affect laden meanings, especially complex ones 6. the thought unknown (Bolas) 7. self-reflective awareness 8. is essential to the capacity of inferring states of others (Baron-Cohen, 1995, red p. 53) 9. mediates empathic cognition (Voeller, 1086, red p. 53) Developmental Progression of R prefrontal cortex 1. An important function, especially in the first year, is the generation of pleasurable states marked by positive affect. Mother helps to create positive states, monitors and helps to repair the dysphoric states and facilitates state transitions. 2. by 4-6 months, real expressions of anger appear and by 7-8 months, classic facial expressions of fear. As well, familiar faces are recognizable and an initial ability to compare past and present. 3. Toward end of first year, intentionality and joint attention are present. And “distinct patterns of infant facial expressions, indications of motor responses to emotion, are reliably coded (p. 15 red; Malatesta, 1989). 4. The orbitofrontal area, like the amygdala and fusiform gyrus contains neurons that specifically respond to the emotional expression of faces. At 10 months, corticolimbic system can generate and store abstract templates of prototypical facial emotional expressions. Neuroscientists call this internalized regulatory capacity, “the mother icon”. Psychoanalysts call these gestalts, subsymbolic or schematic representations (p. 16 red). This may be beginning of evocative memory. 5. This prefrontal system can now generate interactive representations- nonverbal internal working models of the infant’s transactions with the primary attachment figure that dyadically maximize positive and minimize negative emotions. At the end of the first year the infant can create “presymbolic” representations that encode his physiological-affective responses to the emotionally expressive face of the attachment figure. These interactive representations embody the expectation of being matched by, and being able to match the partner, as well as “participating in the state of the other” (Beebe and Lachmann, 1988b). “Ultimately, the affective core “biases the infant’s evaluation of a new situation and his interactive patterns even before the information arising from the situation has been processed (Tronick, et al. 1986).” This accords with Freeman’s preafference or expectation model. 7. The 10-13.5 months period (p. 16, red) appears to be a critical time window for the rapid growth of the energy mobilizing sympathetic part of the ANS. It is responsible for the excitatory positive feelings associated with Mahler’s practicing period. 8. At 12 months, along with increasing motor skill learning, stage II NREM sleep, which has been slowly increasing, peaks and then in the second year diminishes. This sleep phase consolidates and enhances motor memory (M. Walker, personal communication). 9. Then as the second year continues, and as voluntary activity increases in motoric, emotional, and cognitive spheres, the inhibiting, energy conserving parasympathetic system begins to mature. “Socializing capacities unfold, including sphincter control, the dynamic unconscious, and the attachment emotion, shame (p. 17, red). The parent’s task now extends to regulate the socialization process by setting limits that include shame in an effort to promote self-regulation. Schore feels that socializing shame interrupts the overly and at times inappropriately excited activity by putting the brakes on arousal (p. 26, blue). 10. at 16-18 months symbolic thought begins and is constituted by approximately the third year. In using symbols, the child can refer to an object in a way that is arbitrary, that is, not defined by its physical features. 11. at 18 months the dynamic unconscious is thought to come on line. Malatesta et al. feel that the infant is now able to have one set of inner feelings privately held and display another set of feelings publicly. Panksepp and Gainotti believe that only cortical material can be repressed (personal communication). Infant learns to anticipate reward, punishment, approval and disapproval, has initial capacity for ambivalence (love and hate) and object constancy, and has an initial image of herself and others (Stien & Kendall, p.51). 12. Also at eighteen months the infant begins to mentally “time travel” as it starts to integrate time past, present and future (Wheelan, Stuss, Tulving, 1997; p.121, blue). Essentially, the R prefrontal cortex mediates Empathy The delayed response function is thought to be the major cognitive functional output of the orbital cortex. It enables the individual to react to situations on the basis of stored representations, rather than on information immediately present in the environment. (Edelman’s primary function of memory allows the individual to be off-line). The delayed response function is part of conscious and unconscious activity. The R prefrontal cortex is felt to be the analyzing instrument, the internal reflecting and organizing agency (Solms, p. 105 blue).This is the senior executive center of the emotional brain, the thinking part of the emotional brain (Joseph, Devinsky, p.121 blue). It demonstrates plasticity and continuing experience dependent maturation (p. 107 blue) The analyst’s stance demonstrates what I believe is a triad of self-reflecting functions. They include looking at or observation; thinking about oneself and the other in the present moment, in the past and into the future with feelings; and empathy, the ability to appreciate the similarities and differences in the position of the other with thought and compassionate feeling. While “focusing on the totality of the patient and the totality of my response to the patient, I am aware that I am aware that I am focusing on the patient and on my response to her (Holmes, 1996, p. 86; blue, p. 95).” Difficulties in R brain Dysfunction Schore boldly states that, “I believe that every type of early forming primitive disorder (i.e. character disorders) involves, to some extent, altered orbital prefrontal function (p.35).” Given that the shape and function of the earliest maturing areas will influence the emergence of later areas, this is a logical argument. Trevarthen and Aitken (1994) call this class of developmental psychopathologies “empathy disorders.” The orbitofrontal cortex ultimately is essential in inhibiting parts of the limbic system, particularly the amygdala. It seems highly probable that when the inhibitory capacity does not function adequately, the individual is flooded by intense negative emotions. Conceptually, the right prefrontal area is flooded and the “hot” procedural memory systems of subcortical limbic system including the fear inducing amygdala express themselves. Thus cognition, emotion and motivation associated with secondary process functions break down in a psycho-physiological dissociative “braking” event. We should be looking at this area in our explorations of the dynamic unconscious. Clinically we observe the following: A limited capacity to perceive the emotional states of others, to read subtle facial expression; misattribution of emotional states and of motivations of others (projection); inability to read inner cues of bodily states (desomatization, Krystal, 1997); limited ability to modulate the intensity and duration of biological primitive affects such as rage, fear, panic, excitement, disgust, shame. Until about eighteen months, the urges from the limbic system that are relayed to the cortex inevitably lead to action. Then thinking and language come to the forefront. Sometime between eighteen and twenty-four months, toddlers begin to translate multisensory images in their minds into words. Physiological Maturation, Bridges to Psychological Maturation and Psychological Representation Fonagy, Tronick, Stern, Trevarthen, Sandler, Bebe and Lachmann, Tomasello etc. write about important aspects of the first year, especially mutuality of gaze and of interaction with the other. The newborn faces two challenges: to regulate arousal and to focus on external stimuli. Faces, voices, soothing touch, rhythmic movements, both to calm his mind and to stimulate it (Stien & Kendall, p.43). Daniel Stern (1995). The Motherhood Constellation introduces the schema-of-being-with-another, a complex amalgam of perceptual, conceptual, sensorimotor and event representation formats, combined with emotion (the temporal feeling shape) into the time structured protonarrative envelope of experience. He notes that these “representations” are not put into the inside of the infant by persons or events. Nothing is “taken in.” Rather they are constructed from within, from the experience of the self being with another. (This accords with W. Freeman’s model that we only construct meanings in our brains.) Edelman, G. (2004), p.72, Wider than the Sky: The following is Edelman’s description of primary consciousness which he sees as residing in the right brain. “[D]uring development and early experience, [t]he earliest discriminations of consciousness must concern perceptual categorizations related to the body itself. [S]ignals from “self” systems report the relation of the body to both the inside and outside environments. [They] include so-called proprioceptive, kinesthetic or somatosensory, and autonomic components. They regulate bodily functions of which, as mature individuals we are only dimly aware [and exist] at the deep center of conscious experience. The early bodily-based consciousness of self is likely to provide the initial guidelines of our qualia space, out of which all subsequent memories, based on signals from the world (“non-self”), are elaborated. Thus, even before higher-order consciousness appears, a bodily- based neural reference space or body-centered scene will be built up. An animal or a newborn baby will experience a scene in reference to a self [primary consciousness] but will have no namable self that is differentiable from within. Such a nameable self emerges in humans as higher-order consciousness develops during the elaboration of semantic and linguistic capabilities and social interactions.” Awareness, or consciousness, also implies a sense-of-self: the subject who is aware or conscious (Glenn Saxe, p. 44 Trauma Systems Therapy). Damasio defines consciousness a “the unified mental pattern that brings together the object and the self” (The Feeling of What Happens, p.11). Consciousness is an evolutionary advance that allows an individual to be aware of the environment and internal states in order to decide on the most adaptive response for a given stimulus (or object). Beebe and Lachmann. The infant is organizing a “representational world” of the first half of the first year, prior to the emergence of symbolic capacity (p.326). These various infant capacities for memory, cued-recall, matching, cross-modal perceptions, constitute an early representational system in the first year, prior to the development of symbolic functioning and language and prior to recall independent of external experience (p.312). Symbolic thought begins at 16-18 months (as the L hemisphere development accelerates; my addition) and is constituted by approximately the third year. In using symbols, the child can refer to an object in a way that is arbitrary, that is, not defined by its physical features. The child is now capable of imitating a model that is not physically present (p.312). Presymbolic representations and misattunement, (p. 326) resist restructuring because they operate largely outside conscious awareness (p.331). Lakoff, G. (1987). Women, Fire and Dangerous Things. Lakoff is a linguist who created the concept of ICM’s. Idealized Cognitive Models are functionally embodied gestalts that use four kinds of structuring principles; propositional structure, image-schematic structure, metaphoric mappings and metonymic mappings. ICM’s generate basic level mental/emotional prototypes. . Some central ideas from Fonagy’s work and my notes that help us understand cognitive development especially after age two. Affect Regulation, Mentalization, and Development of the Self (2002) Fonagy, Gergely, Jurist, Target The R orbital cortex matures in the middle of the second year, a time when the R hemisphere ends it’s growth phase and the left hemisphere begins one (Thatcher, 1994). Although Fonagy et al present rich and complex data on mental/cognitive development from birth, I am particularly interested in the phase that corresponds to the growth spurt of the L hemisphere. This includes more sophisticated motor co-ordination, sphincter control, the onset of the dynamic unconscious, verbal and cognitive (symbolic) skills, imagination/fantasy, mentalization, and autobiographic memory. This time period encompasses the traditional anal and oedipal phases. In order to understand the text, it can be helpful to keep in mind several uses of the concept of self. The first is the conscious perspective of one’s own self, the Jamesian “I”, the subjective, conceptual “I”, the agent self, the observer self, the center of action and reflection; the “I am-ness”, or the “I am that I am” factor. The aspect of the Freudian ego that perceives signal anxiety, the observing ego, as well as the SE, and the Kohutian self belong to this category. (Aspects of this conceptual self can be communicated through contagion of feelings and ultimately by words. Even then it remains highly private.) (In an fMRI study, the self-referential condition induced bilateral activation in the dorsomedial prefrontal cortex, whereas the other-referential condition induced activation in lateral prefrontal areas. Activation in the right dorsomedial prefrontal cortex was unique regardless of the valence of words. A widely distributed network of brain areas contributes to emotional processing. Among these regions, the right dorsomedial prefrontal cortex is one main area mediating self-reference. By providing a personal perspective in the evaluation of emotional stimuli, the right dorsomedial prefrontal cortex may mediate cognitive processes, such as those involved in psychotherapy, that guide self-regulation of emotional experience. AM J Psychiatry, 2003: 160: 1938-1945.) The second use is the concept of “me-ness”, the observable, empirical or categorical self, which refers to the collection of attributes the person believes to be true of himself. This “me” self requires the mirroring other to complete its outline, or schema. It is the self we observe, literally in a mirror, or in our imagination. “Me-ness” rests on Vico’s philosophy of mind, about three hundred plus years old, namely, the notion that we fathom ourselves in others. And Sartre observed in the last century that, “I am the incontestable agent of my actions but I can see myself only through the recognition of others.” Ego functions and “the inner representational world” belong to the “me-ness” category. And then there is Freud’s unconscious intrapsychic “self experience”, the Id, which is known by inference both by self and other. Fonagy et al. contend that their ideas constitute a genuinely new direction for psychoanalysis and psychotherapy and I concur. Their body of work is based on attachment research, but moves beyond the idea that attachment is an end unto itself. Rather, attachment exists in our species in order to produce a representational system that presumably has evolved to aid human survival (p.2). So the main focus of the book is to describe the development of the representation of psychological states in the minds of infants and adults. This is an old psychoanalytic concept (see psychological representation). I myself favor the neurobiologist, Walter Freeman’s belief that the function of the human mind and brain is to create meaning. This process by which we realize that having a mind mediates our experience of the world the authors call Mentalization. In addition, they hope to demonstrate that an infant’s experience of himself as an organism with a mind is not a genetic given but that it evolves through the interaction with more mature minds (p.4). The task of the human mind is to make meaning. We cannot make constructive meaning as isolated minds/brains. Making meaning requires a dialectical engagement of our subjective, intrapsychic, private self with the other in the interpersonal space. *“Mentalization* is the process by which we realize that having a mind mediates our experience of the world.” · involves both a self-reflective and an interpersonal component (p.4) (Note that reflective function refers to operationalization of the mental capacities that generate mentalization. It is not synonymous with introspection; rather it is the capacity from which introspection grows.) · affect regulation is a prelude to mentalization (p.5) · is not just a cognitive process. Development begins with the “discovery” of affects through relationships · once mentalization has occurred, the nature of affect regulation is transformed · mentalized affectivity means the mature capacity for the regulation of affects and thus connotes the capacity to discover subjective meanings of one’s own affect states (p.5) · mentalized affectivity is at the core of psychotherapy Nature, meaning gene expression, operates as a “potentialist” rather than “determinist” in development (p.6) and biology has culture on a “loose” rather than a “tight” leash (p.7). This means that the manner in which the environment (human) is experienced acts as a filter in the expression of the geno into pheno type (p.7). Intrapsychic representational processes are not just the result of nature and nurture but may act as moderators of the effects of the environment upon the unfolding of geno into pheno type (p.7). Thus early psychological and neurophysiological experience determines the depth to which the social environment may be processed. I believe we need to contrast this depth in the interpersonal space with the depth to which an individual can be locked in his own psychic space. Suboptimal development can undermine the individual’s capacity to interpret the mental states of others, which is a large aspect of reality testing (p.7). Thus the self is not merely open to influences from the human (and non-human) environment; it is in part constituted through them. The infant’s immature mind is held and nurtured by the mature minds of the care-givers. The capacity for the regulation of positive and negative emotional states is enhanced every time the care-giver mirrors the child’s inner experience empathically and the child “takes in” the image of the care-giver. The crucial dimension in the image the child “takes in” is that the child “sees” not just the caregiver but also himself, while he is being held emotionally within the mind of caregiver (p.8). The self as agent arises out of the infant’s perception of his presumed intentionality in the mind of the caregiver (p.11). This represents yet another subtle addition to the construct of “introject”. Over the decades we have shifted our construct from internalization of other/containing object (introject) to introjection of interaction with other/containing object (Loewald) to internalization of the thinking/feeling self as it is held in the mind of the other/containing object. Winnicott (1971 a) understood that the attuned mother gives back to the baby the baby’s own self (blue, p. 64). When primary identification of this positive nature occurs it relates to positive projective identification (Likierman, 1978), (blue, p. 66). This is reflected in the second part of Sartre’s quote, namely that we can see ourselves only through the recognition of others. The authors call this image a second order representation that promotes affect regulation and impulse control. It is the model by which affects can be discharged safely internally, within the mind of the infant, as well as through action. It is also the bedrock of mentalization. (p. 8) and I believe of “deep” change. The premises of the book rest on two intimately connected developmental theories. Social Biofeedback Theory of Parental Affect Mirroring; Parents communicate with their infants by mirroring and infants learn control over their parents’ mirroring. Parental affect-mirroring includes a pretend mode called markedness. This is instrumental in fostering the capacity for affect regulation. It is helpful for all overwhelming emotion, but especially for dysphoric emotions. This occurs when the care-giver mirrors the child’s inner experience empathically in exaggerated “pretend” form and the child “takes in” the image of the care-giver holding him in her mind. I believe this communicative mechanism works because the parent does not react in a “gut” fashion to the infant’s emotions. Thus the infant’s fear/anger system is not stimulated further but calmed. Consequently, the infant is not caught up in an escalating cycle of anger and fear with her parent. Containment and safety are restored. The infant is able to incorporate a second order representation that includes repair of the attachment. When the parent reacts with genuine anger and fear, the infant automatically feels anger and fear and bad. To escape from these overwhelming feelings (sympathetic N. S.) the helpless infant may dissociate (parasympathetic N. S.). The infant’s mirroring of the parent’s internal states is dysfunctional, confusing and difficult to regulate and excludes the ability to create a second order representation. How the therapist holds the patient in her mind can be seen as a crucial factor in the therapeutic dialogue. Ms. A: “I need to know how you see me, not how my mother saw me.” Mirroring between adults in a therapeutic environment does not usually contain markedness. However, the principle of not being overwhelmed by the patient’s enactments as she repeats early painful interpersonal experience that became intrapsychic experience, namely, part of her affective procedural memory, is the same. When the therapist loses the capacity to contain, she feels the raw anxiety, and perhaps, fear, and anger. The therapeutic frame is shattered and needs to be repaired. These are the necessary repetitions. The repairs allow more mature deep emotional responses to evolve in the patient along with second order representations. The “nature of psychic equivalence” is the nature of subjectivity before mentalization. Young children behave as though their own and other’s thoughts faithfully mirror the world (p.258). Here ideas and fantasies are not psychic representations but direct replicas of reality and therefore true (p. 256). The ability to imagine false beliefs, where the assumption of equivalence between appearance and reality is untenable, marks a significant growth step for the child. If the ability is not developed to perceive the difference between a second order representation and the actual inner mental state, then psychic equivalence (.e. that internal reality is external reality) continues to dominate the subjective world (p.8). With patients who communicate intimately using projective indentification, this mode is present in the regression. Autobiographical Memory Fonagy and colleagues feel that the reflective function or mentalization requires the uniquely human “I” self, the cognitive self-concept that is a precondition for autobiographical (episodic) memory which comes on-line as the hippocampus matures at about age three. The reflective function allows children to respond to the conception of the other’s feelings, beliefs and intentions. It gives children a “theory of mind” that enables them the “read” other people’s minds and so makes others behavior meaningful and predictable (p. 24). Povinelli (1999) feels that the two year old can hold a single representation of the world in mind. This is the “present self”. By age four, memory is multi-tasking. The child can hold multiple representations of the world simultaneously, establish temporal and causal relationships among memories and causally evaluate the relevance of previous states of self to the present self (p. 245, 247). A three year old was on a boat trip with his parents off Gloucester when he remembered a similar trip in Bermuda a month ago. The parents say this was “a first.” “Mommy, boat in Bermuda much bigger and water blue.” (Field memory is transformed into first person observer memory.) It will take another year or two before he will be able to say, Mommy, I remember when we were on the boat in Bermuda. It was much bigger and the water was so blue. I had such a good time eating ice cream.” Here the child demonstrates coherent, causal-temporal organization of the autobiographical self, the “I am-ness” self. The Sandlers noted in 1977 that, “the child will create increasingly complex representations of the interactions, the relationships, the dialogues between himself and his objects … [W]ith selfobject differentiation … another constant object with an equally enduring identity also emerges for the child. This is the child’s own self … the child constantly and automatically also has a dialogue with his own self…” (Sandler and Sandler, 1978, p.294). I believe that there is a triad of introspective functions which elaborate on the core self-reflecting ability. These include the capacity to look at oneself; as well the thought process of thinking about oneself with feelings at this moment in time, or in the past or in the future. This refers to the Sandlers’ concept of the infant having a dialogue with himself. And the triad expands to include empathy when we are looking at/thinking about the other, feeling compassionately for the other, especially when that other’s perspective is different. In a parallel manner, we can develop empathy for ourselves, and evolve from a judgmental, shaming response. Depth and Interdependence The work of changing emotional patterns we learned subconsciously as children is a remarkably difficult task. Paul Russell noted that the manner in which we organize the self in the absence of a good enough other creates our disabilities. We may assume implicitly that it is also in the presence of another that recontextualization of emotional experience may occur at the deepest level. Early psychological and neurophysiological experience determines the depth to which the social environment may be processed. We clinicians want to contrast this depth in the interpersonal space to the depth to which an individual can be locked in his own psychic space. The freer we are in our ability to unselfconsciously show ourselves to the social environment, the more we can take useful feedback in from that environment and evolve. The deeper and entrenched our private parts of being are, the less authentic we are in social interchange and the more unchanged we remain at the deepest level. The cycle of change and core change I firmly believe that the psychoanalytic enterprise offers individuals the potential to change at subconscious and conscious levels of mind/brain. This engagement requires that we make visible to another our most painful, hidden parts. Modell notes that when meaning is constructed, a transformation takes place in the brain that is experienced by the mind. This is how matter becomes imagination (Imagination and the Meaningful Brain). In recontextualization, the new context is the new containing space in which exists the new capacity to be connected differently. My sense is that change begins in the intersubjective space as a result of the co-constructed verbal and non-verbal dialogue. But deep change represents a change in the affective procedural sensibility of the person. Doug Watt calls affective procedural memory the core of personality. Kohut called this process of change, transmuting internalization. However, in order for this change to develop into insight, I believe it must be verbalized. Then a sense of ownership or agency is established and the issue is transformed from a schematic, implicit representation to a symbolic representation. For example, a patient spent years telling me largely indirectly that I wouldn’t give her what she needed and that she would not ever get what she needed. Then she said, “For the first time I can feel a warmth and a sense of presence of you in my gut. I never felt that with my mother or father. The language of feeling was like learning a foreign language. The nuances of feelings like lonely, sad, jealous, joy were all new to my vocabulary when I was talking about myself.” This experience of taking in the presence of the other while she holds you in mind as a good, worthwhile, and loveable person can be understood both as a transmuting internalization and as an adaptive positive projective identification. But in her ability to verbalize it, to be aware of it conceptually, through words, the patient changed the schematic representation into a symbolic representation, which she can learn to control voluntarily, and, therefore repeat consciously. [1] Eden Ahbez, 1948. I want to thank Jennifer Jenks for finding the source for me.

What’s Love Got To Do With It?

INTRODUCTION

LOVE

What’s Love Got To Do With It?

Some central ideas form Schore, other neurophysiologists and my notes

Some central ideas form Schore and other neurophysiologists

Schore, A., (2003). Affect Dysregulation and Disorders of the Self (red) and Affect Regulation and Repair of the Self (blue)

Affect Regulation, Mentalization, and Development of the Self (2002)

Fonagy, Gergely, Jurist, Target

Autobiographical Memory

Depth and Interdependence

The cycle of change and core change