Dr. Allan Schore

So in the very first session, what's happening? The therapist is listening to the verbalizations of the patient in order to diagnose and understand the symptomatology. But the therapist is also listening beneath the words.

And the patient is tracking the attachment relationship underneath it, tracking the arousal and the arousal dysregulation underneath that, tracking it in his own body, so to speak, et cetera. And again, that is a different type of listening. Again, the therapist is listening to a left brain, but more or less the therapist is listening to the right brain.

And the question is, how does the therapist do that And in order, just for the record, for the therapist to be able to get to the attachment dynamics, which are right lateralized, the therapist has got to switch out of the left into the right. And there's a term for that. The term for that is surrender. Surrender. You cannot consciously, purposely put yourself into the right. You've got to let go.

You've got to let go.

All right. What I'm suggesting here is that essentially the therapist is listening left brain to left brain, but the therapist also is always listening beneath the words, et cetera, and he's listening to the right brain to right brain communications. And the patient now who is depressed is coming out with right brain communications that There's sadness in the voice.

The face is clearly dysregulated. And essentially, as the therapist is tracking that, the emotional arousal, whether it's into hypoarousal and depression or hyperarousal into anxiety, the first thing there is to synchronize with that patient so that my physiology is syncing with their physiology. And now, through the right insula,

Interceptively, I now literally am feeling in my body what the patient is feeling in their body. I now understand that patient from the inside out. And incidentally, what I'm picking up in my body about the dysregulation of that patient may be very different than the verbal report that that patient is giving at that time. But the key here, literally, just like the mother,

is synchronizing with that baby's crescendos and the decrescendos of that autonomic state, of those emotional state. I'm picking up those points where they are shifting into and out of an emotional state. I'm synchronizing with that. And then ultimately, when I'm in sync with that kind of thing, then at that point, purely implicitly,

I'm now starting to slow the tone of my voice if I want to reduce that arousal down, or I'm up-regulating the voice. At that point in time, I am now interactively regulating, and we are now synchronized together. So essentially what's going to happen is that as we synchronize, as they're going to dysregulation, we're now synchronizing together as we're going down into regulation.

And you'll see it on my face. Face, voice, gesture. You'll see it on my face. You'll see it in the tone of my voice. You'll see it in my gestures. Those three sensory modalities are now going back and forth between us.

So the key of the first session, literally, is not only to diagnose, really it's to start to begin to synchronize with that patient and to form a therapeutic alliance with that patient. And at the end of the first session, the patient may say, I don't know why, but I'm feeling better, and I have some idea that you can understand, but it's got to be more than that, what I am feeling, literally.

Essentially here, what you have is over time, partly because of this synchrony. First of all, let me spell synchrony with a capital S. What I mean by that is in the last five years, a huge amount of information has come out about this idea about interpersonal synchrony. The term synchrony comes from the Greek, synk meaning the same, chrony, time, same time.

So that literally two people literally are synchronized. We are feeling something in the same moment, and we are feeling it spontaneously between ourselves. We are feeling that kind of situation. So again here, the key to the mother really even more than the order regulation, the key is interactive regulation, number one. Number two, it's occurring at an implicit level.

The mother literally is doing this without any conscious awareness. She's doing this intuitively. The right hemisphere is intuitive and it's imagistic. It's not rational and logical. The key to any disorder, whatever it is, is the regulation of a particular state. The regulation of rage, the regulation of loss, the dysregulation of shame and disgust. So essentially what you have is...

the regulation of all of these emotions, but that regulation I want to point out is all implicit. And here's where the skill of being with patients over long periods of time is the key here. Because the key to making changes in the patient is not what you say to the patient or what you do to the patient, It's how to be with the patient.

You understand the difference, how to be with that patient, especially while that person's being is in a dysregulated state. Now, by definition, when they're coming in on the first session, they are in a dysregulated state. So again, it's implicit, it's not explicit. If explicit regulation is an intellectual understanding of my symptoms,

Implicit is an unconscious understanding at a physiological level, at a psychobiological level of that. And incidentally, synchrony is the mechanism underneath empathy. Now, we know empathy literally has to be there. But empathy is a right brain function. And there is a difference. I said there's a difference in the hemispheres.

There's a difference between emotional empathy, where I am feeling what you are feeling, and we are sharing the same feeling. And I don't have to think about that literally. I know at that point in time we are in the same place. There's a difference between emotional empathy on the right and cognitive empathy on the left. Cognitive empathy is an understanding. It makes no changes.

Because essentially what we're attempting to do is make the changes in the right. Now the changes in the right are going to be in the right axis. They're going to be the orbital frontal cortex, which is the executive regulator of the right brain. The dorsolateral cortex is the executive regulator of the left brain.

The orbital frontal cortex now starts to form new connections with the cingulate, the insula, and the amygdala. And that's where you're now going to see the changes. But again, the changes are due to the regulation. So you'll see the personnel starting to come into more regulated states. And the key is synchrony. So what's happening here, there's a strong therapeutic alliance, safety and trust.