A Primary Role for NonverbalCommunication in Psychoanalysis

R E G I N A P A L L Y, M.D.

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Regina Pally, M.D. is a psychiatrist in private practice in Los Angeles and a

clinical professor of psychiatry at UCLA.

How a person speaks says as much, if not more, than what theysay. Nonverbal cues, such as facial expression, posture and toneof voice are part of all interpersonal relatedness. Nonverbal cuesnot only express emotion, but also regulate the body physiology,emotions and behaviors between individuals. The homeostaticregulatory mechanisms and affective exchanges between motherand infant proceed nonverbally. Neuroscience data now indicatesthese same nonverbal mechanisms occur between adults tofacilitate attachment, regulate affect and physiology and toprovide a sense of being understood. The impact of nonverbalcues is mediated by circuits involving limbic structures in thebrain which activate nonverbal cues along with changes inhormone levels, neurotransmitters and the autonomic nervoussystem. Clinical vignettes are used to illustrate how nonverbalcues function in the analytic treatment setting to shape bothtransference and countertransference phenomena. Sincenonverbal mechanisms can be activated without consciousawareness, neither patient nor analysand may be directly awareof their impact. Analysts must pay attention to their ownfeelings, behaviors and body sensations as indirect indicatorsof the affective state and meanings of the patient.

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The advent of language is a very mixed blessing [Stern, 1985,p. 177].

OW A PERSON SPEAKS says as much as if not more than, what he orHshe says. In fact there are some aspects of experience, such asfeelings of attachment, empathy, and the subtleties of emotion, thatare better expressed nonverbally than verbally. Psychoanalytictechnique traditionally relies on verbal exchange and gives privilegedstatus to language. However, since words alone never quite capturelived experience, more attention needs to be given to nonverbalaspects of communication.

Nonverbal communication includes cues of behavior, facialexpression, gesture, tone of voice, and the visceral changes ofblushing, pallor, and sweating. Perception of these nonverbal cuesrelies on the peripheral sense organs, predominantly the eyes andears, and the “internal sensory” channels of the body’s visceral organs.The evolutionary anthropologist Deacon (1997) believes thatnonverbal signals communicate in a different way than does language.While nonverbal signals enhance and clarify spoken exchange, theyalso can operate relatively independent of language andconsciousness.

It is the thesis of this paper that a number of nonverbal forms ofcommunication exist in a nonverbal realm of interpersonalexchange—body to body, biology to biology. Both the empathicunderstanding of emotion and the need for responses from others,for the purpose of self-regulation of physiology and affect, can occurwithout the intervention of words. Even more pertinent forpsychoanalysis is that essentially all interpersonal relatednessincludes unconscious, biologically operating nonverbal elements,which, in certain instances, are better designed than words as a wayof transferring meanings between individuals. With the use of clinicalvignettes, I intend to illustrate how analysts need to spend more timebeing aware of the “body to body” connections along with the “mindto mind” connections with their patients. The analyst’s involuntary,innate, often unconscious nonverbal behaviors and visceral responsesto the patient provide additional sources of understanding the meaningof the patient’s material. As a corollary issue, I will address the useof the couch as a technical tool in relation to these points.

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Stern (1985) points out that, while linguistic acquisition enablesthe child to symbolically represent experience, negative effects ofverbal development exist as well. “Language is inadequate to thetask of communicating” internal states (p. 178). Although languagepermits abstract reasoning, self-reflection, and the ability to conjureup the past and plan for the future, language also causes a rupturebetween what one says and how one feels, the verbalizable self andthe experiencing self. By privileging verbal communication,psychoanalysis accentuates this rupture and sacrifices theunderstanding of states that cannot be verbalized. One root of thisproblem, according to Jacobs (1994), is that while Freud was an astuteobserver of nonverbal behavior, his theories developed more inrelation to spoken communication.

The recent burgeoning of psychoanalytic interest in nonverbalcommunication, nonverbal behavior, and somatizing disorders is anencouraging trend. Jacobs (1994) provides vignettes that illustratehow nonverbal behaviors contain unconscious meanings. Gedo (1997)considers various forms of somatic symptoms as nonverbal bodilycommunications having either symbolic meanings or else reflectingthe patient’s affect state. He argues that some elements of nonverbalsomatic responses are the result of alexithymia, a failure to developout of the sensorimotor stage into the verbal one. The analyst is tounderstand the symptoms as having a communicative function andto translate the “nonverbal” into words. While highlighting theimportance of nonverbal signals, Jacobs and Gedo still give specialstatus to verbal communication. Schwartz (1992) argues thatnonverbal expression plays a pivotal role in how human beingsunderstand one another. Each affect has a distinct pattern thatcombines facial configuration, muscle tonus, gesture, posture, andvocal qualities. Anger can be expressed as clenched jaw, curled upperlip, bared teeth, growling tone of voice, and so on. The visible andaudible changes are detected as the “signature” of a particular affect.The analyst “by recognizing the clinically evident stereotypies canwith some precision identify which affects are currently close to orat ‘the surface’” (p. 455). The nonverbal “clues” of affect are guidesfor formulating interventions. However, Schwartz limits the analyst’srole to conscious detection and decoding. In a novel experiment(Freedman and Lavender, 1997) designed to understand theconnection between nonverbal behaviors and countertransference,

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therapists were videotaped during treatment sessions. Therapistnonverbal behaviors that rhythmically match the patient’s rhythmcorrelate with empathic listening. Therapist nonverbal behaviors outof sync with the patient’s rhythms reflect the therapist’s need to self-regulate and correlate with countertransference reactions in whichthe analyst feels a need to be shielded from the patient’s transference.While the analyst’s behaviors are not conscious, they are presentedas a response to the spoken content of the transference material.

Encouraged by Cooper and Olds’s (1997) recent editorial inviting“cross fertilization,” I intend to explore data from other disciplinesthat support the idea that nonverbal mechanisms are important intheir own right and not just in relation to spoken language.

Animal Nonverbal Cues Trigger Responses in Others

The first extensive account of unconsciously processed nonverbalcommunication was written over a century ago by Charles Darwin,detailing the specific bodily responses that comprise the nonverbalexpression of emotion in man and animals. Remarkablycontemporary, Darwin (1872) was aware that emotional expressionsresult from activity of the nervous system and operate outside ofconscious awareness. Expression of emotion developed because ofits survival value, by promoting the nurturant caretaking of infants,enhancing social group relatedness, and protecting the individualagainst threats from outside the group. Many nonverbal expressionsare unlearned. Even congenitally blind children smile, laugh and claptheir hands for joy, despite their inability to see how others expressjoy.

Animal research reveals that nonverbal behaviors are not simply“expressive,” either of emotion or of “semantic” content. Often theirprimary function is to trigger or release nonverbal behaviors in others(Eibl-Eibesfeldt, 1980). Threat displays release submissive behaviorsin other animals. Male mating displays trigger “presentation” displaysin females.

In humans, smiling can serve as an invitation for face-to-face socialengagement and can control aggression in others by expressingfriendly intent. Direct eye contact, conversely, can function as a threatand activate aggression in others, although a tilt of the head to theside can counteract the threat. Gaze aversion also serves to decrease

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the aggression, arousing effect of direct eye contact. Complete gazeaversion, where eye contact is not resumed after initial aversion, caninitiate attempts at repair. Schore (1994) has identified this as one ofthe factors in the shame response. The child lowers its head in shameand, if prolonged, activates in the caretaker a repair response toreconnect and soothe the child. The infant distress cry in humans,which nonspecifically reflects the infant’s hunger, pain, or loneliness,innately activates the nurturant response in the parent to search forhow to relieve the infant’s distress (Brazelton and Cramer, 1990).

Animal alarm vocalizations were believed to have semanticmeaning, which the animal intends to communicate regarding whatkind of predator and what action to take. Cheney and Seyfarth (1990),studying vervet monkeys in the wild, argue that the call does notcarry symbolic meaning in the way a blue triangle may symbolize anapple. There is no evidence that either the signaler or recipientunderstands the meaning of the sound nor that the signaler intendsfor the recipient to act. When, following a vervet alarm call, anothervervet monkey runs up a tree, their research suggests that thebehavioral response is related to the vocalization, not through anyprocess that decodes or is aware of semantic meaning, but from thecontext of the situation. Neither animal need be aware of what theother intends or feels.

Observations of humans, as well, demonstrate that some nonverbalbehavior can be understood in terms of its consequences for socialinteraction. Studies support the notion that nonverbal expressions ofstress are “designed” to elicit comforting responses in others. (Dixon,Huber, and Wasler, 1989). Alexithymia, a condition of impaired verbalexpression of emotion, also exhibits deficits in the nonverbalexpression of emotion. As a result of nonverbal deficits, theseindividuals suffer interpersonal impairments (Troisi et al., 1996).They show difficulty in identifying emotion in others. They oftenlack facial expression, show postural rigidity, and overall give fewoutward behavioral nonverbal signals, despite the fact that autonomicnervous system measurements indicate states of tension and anxiety.The lack of the outward emotional expression of stress may deprivethem of the capacity to elicit empathy in others (Brothers, 1989).

Crying promotes behavior in which the crier and others mutuallyinteract to alleviate distress (Gross, Frederickson, and Levenson,1994). The human grief reaction, even without crying, is a stress

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state that activates social relatedness between the mourner and others(Averill, 1968).

Infants and Caretakers ActivateNonverbal Responses in One Another

From the moment of birth, the mother and infant engage in distinctpatterns of nonverbal interaction, involving olfactory, tactile, auditory,visual, and motor systems. As verbal capacities develop, what hasbeen learned nonverbally is integrated with linguistic systems.Nonverbal systems that begin in infancy also continue their own linesof development into more mature forms of nonverbal relatednessbetween adults. I will briefly summarize a few mother–infantnonverbal interactions that continue to be important even in adult–adult interactions.

Smell and Touch

While not as yet readily applicable to analytic work with adults, smelland touch are the earliest modalities of nonverbal communicationand deserve comment. The odor of her breast milk is perhaps themost fundamental nonverbal communication a mother directs to herinfant (Leon, 1992). By 6 weeks of age, breast milk odor stimulatesthe infant to orient toward the breast and make sucking movements.Communication through odor ensures that the baby will be able tofind the breast even in the dark.

Touch serves as an integral ingredient of physiologic regulationof the infant. (for a complete review see Barnard and Brazelton, 1990).Skin to skin touch increases feeding and weight gain in prematureinfants and prevents the profound physiologic and behavioral changeswhich accompany maternal separation. Touch promotes theattachment bond. “Anxiously attached” children frequently havemothers who show an aversion to close body contact.

Activation of the Nurturant Response

Infant nonverbal cues activate “the nurturant response” in caretakers,a constellation of attentional focus, feelings, and behaviors. Bowlby(1958) identifies that infant sucking, clinging, grasping, crying, and

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smiling are the behaviors that stimulate this response. In addition,according to Brazelton and Cramer (1990), infant signs of “babyish-ness,” soft rounded face, fine hair, delicate skin, short limbs, andtiny hands that helplessly reach out activate parents to want to reachout for and take care of these helpless creatures. Other nonverbalcues such as uncontrolled thrashing movements activate a parent’ssense of protectiveness and gentle nurturing of the fragile offspring.

The “nurturant response” synchronizes the caretaker to infant statesof arousal, attention, physiology and affect. The caretaker ’snurturance promotes physiologic and affect regulation, whichmaximizes the infant’s attention and learning (Linnemeyer andPorges, 1986; Hofer, 1996b).

In analysis, the patient’s nonverbal cues of distress may activatein the analyst a kind of nurturant response, in which the analyst isable to focus attention with nonjudgemental listening, feels concern,and has a desire to help. The analyst becomes synchronized with thepatient’s attentional focus and affect state and is more able to deliverinterpretations at the level of the patient’s tolerance.

Developing the “Back and Forth” of Communication

By 2 months of age, in what Bateson terms “protoconversation,” theinfant of 7–15 weeks old focuses on the face and voice of the motherand reacts in a give-and-take, “listen” and “reply” manner(Trevarthen, 1993). The baby’s body movements, hand gestures, facialexpression (smiles/pouts), and vocalization (coos/fretful cries)communicate its inner state to the mother. The infant is not merelyimitating maternal responses but is entering into a back and forthexchange with the mother.

Of relevance to psychoanalysis is that the “back and forth” of allforms of conversation is regulated by nonverbal cues. Kendon (1992)describes how some gestures and body movements function simplyas a way for participants to regulate their attention to the frame ofthe conversation. Orientation of gaze, body posture, and vocalqualities signal who is talking to whom and who is paying attentionto whom. To speak to someone who is speaking, a “connection” ismade by taking up their vocal cadence and moving in synchronywith them. Adopting the same posture and gesture helps twoindividuals identify each other as participating in a 1:1 exchange.

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When there is an intention to change the frame of the conversation,nonverbal cues are sent out by the speaker as “trial balloons” beforeany spoken change occurs. Listeners nonverbally signal back theirwillingness to accept or not accept the change, also before any verbalalteration has occurred. This implies that the flow of verbal exchangebetween patient and analyst may be highly sensitive to the nonverbalexchange between them.

Mirroring, Expectancy, and Attachment

During the first 6 months of life, the mother mirrors her infant’snonverbal expressions within the same modality: vocalization tovocalization, facial expression to facial expression, gesture to gesture(Beebe and Lachmann, 1988). To show she has “gotten it,” she doesnot simply imitate the baby but adds and elaborates upon the infant’snonverbal display. Infants of 3–4 months and their mothers, in face-to-face interactions, use eye gaze, facial expression, head position,and vocalization to reciprocally communicate emotion along acontinuum of ascending affect intensity followed by descending affectintensity. The infant gaze averts when arousal is too great. It appearsthey mutually regulate one another’s nonverbal expression of affectintensity, with the mother influencing infant and infant influencingmother along the crescendos and decrescendos.

By 8–9 months of age, mirroring includes multimodal responses(Stern, 1985). Vocalizations can be responded to with bodymovements, facial expressions responded to with vocalizations. Thissame period is when the affect intensity reached during face-to-faceexchanges reaches its peak level (Schore, 1994). Schore providesevidence that the brain circuits that subserve the capacity for high-intensity affect are specifically stimulated to grow by these face-to-face encounters.

The age of 9 months also correlates with the cementing of theattachment bond. While Shore considers these peak face-to-faceencounters as the critical element of attachment, Hofer’s (personalcommunication) view is that attachment emerges as the culminationof the multiple experiences of sychronicity and mirroring withcaretakers since birth, in all the different sensory modalities.

Beebe and Lachmann (1988) emphasize that nonverbal affectmatching leads to the presymbolic storage of experiences of

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understanding and being understood and the expectancy of matchingand being matched. Alkon (1992) proposes that memory is essentiallyan expectancy system, in which repeated experiences are stored inorder to predict future occurrences. Equilibrium is maintained ifexpectancies are realized. Disequilibrium results if expectancies failto occur. In analysis patients may either expect matching or expectnonmatching depending on prior experiences.

Just as matching of nonverbal cues results in attachment of the infantto its caretakers, matching also facilitates affiliation between adults.When strangers talk together, the ones that more often match each other’scues are more likely to feel a sense of warmth and friendship towardone another, even if they are completely unaware of their matching(Feldstein and Welkowitz, 1978). The experience of nonverbal matchingprobably facilitates the affiliative cooperative aspects of treatment, aswell as cementing the transference attachment bond.

Empathy and a Theory of Mind

The ability to empathize requires recognition that others have mentalstates that can be known and are different from one’s own, oftencalled a “theory of mind” (Brothers, 1989). This capacity does notemerge until about 4 years of age. A step toward its developmentoccurs at about 9 months in an interaction called the “shared point ofview,” in which when the mother points at an object, the infant looksat the object and not at the mother’s hand (Lachmann, and Beebe,1996). In repeated games the infant points and the mother looks andvocalizes; then the mother points and the infant looks and vocalizesin turn. The infant shares interest in the object and simultaneouslyshares in an internal mental state of the mother.

Shared attentional states are essential for effective conversationbetween adults (Kendon, 1992). In analysis the patient’s nonverbalcues may signal what is emotionally important to pay attention to,and the analyst’s nonverbal cues may signal that the analyst isattending. One analytic patient, a professor, would literally point atme from the couch when I would make an “astute comment.” At firstthis seemed to mean that he was professor and I a clever student.However, eventually, we discovered that this happened spontaneouslywhen I really had captured something true about him and he felt itdeeply, even if he could not say so.

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Nonverbal Systems Regulate Exploratory Behavior

“Social referencing” (Emde and Sorce, 1983) is a means by whichthe infant regulates exploration and discovery. In a well-knownexperiment, a 1-year-old crawls over an “artificial cliff,” an opticalillusion creating the impression of a sheer drop. The infant looks tothe mother for a sign from her facial expression as to whether itshould proceed. If the infant shows a joyful state of exploration, butthe mother looks sad, the child will switch to perplexity, progressingto sadness, and he or she stops crossing. If on the other hand theinfant is hesitant but the mother smiles, within a few moments thedoubting child will begin to smile and continue to crawl on.

In the beginning of the second year of life, the shame responseemerges (Broucek, 1982; Schore, 1994). Shame occurs as a result ofthe abrupt interruption of positive exploratory behavior, such as whenthe mother sternly says “No you can’t play with my necklace!”(Tomkins, 1963). The child inhibits its behavior and signals shameby body posture and a lowering of the eye gaze and head position.Schore correlates this state of shame with parasympathetic nervoussystem activity, which leads to decreased arousal, decreased heartrate and other physiologic parameters. The “attuned” mother isactivated to respond to the nonverbal signals of shame byreconnecting with the child, comforting, reassuring, stimulating, andthus reactivating the child’s affect and physiology. If this shame statepersists for too long, Schore postulates that the parasympatheticchanges can become permanently encoded into the nervous systemas maladaptive excessive shame responses. These mechanisms areprobably involved in how the analyst intuitively knows the patient’stolerance for silence.

The mutual construction of childhood narratives also involvessimilar nonverbal mechanisms of exploration and inhibition. As thechild talks with caretakers about daily experiences in the form ofnarratives, the gestures, facial expression, and vocal qualities, as wellthe listener’s words, influence what the child says (Ochs and Capps,1996). Since narrative links a person’s past, present, and future andcontributes to the development of a self that exists cohesively overtime, the nonverbal messages of the listener shape the speaker’s senseof self. Verbal narratives facilitate conscious awareness of experienceand enhance encoding in long-term memory (Siegel, 1995). The

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nonverbal responses of the listener therefore may influence what isstored in memory and later what will be retrieved from memory. Inanalysis, by influencing what the patient says, the analyst’s nonverbalcues may influence what the patient becomes conscious of.

Brain Processing of Nonverbal Cues Link Minds,Bodies, and Behaviors Between Individuals

The left hemisphere is specialized for speech and language. The righthemisphere is equally specialized, but for emotion and nonverbalcommunication. Lesions in the right brain can interfere with theability to “read” the nonverbal cues of others and to express themoneself (Voeller, Hanson, and Wendt, 1988; Henry, 1993).

The components of nonverbal communication are developed inutero (Trevarthen, 1993). By the second trimester the fetus engagesin the specific coordinated movements it will use to engage withcaretakers upon birth, such as facial expressions.

Social Signals, Group Cohesion, and Empathy

The exquisite degree of specialization for nonverbal processingexhibited by the primate brain is illustrated in experiments byBrothers (1989, 1992) using monkeys. Sections of the amygdala,anterior temporal lobe, and orbitofrontal cortex contain individualcells, each of which has a specific nonverbal cue it is specialized todetect. For example, there are individual cells that detect direct eyecontact, others that detect arched eyebrows and others that detect anopen mouth. Some cells are specialized to detect complex nonverbalgestalts, such as a full yawn display or a threatening face.

To maintain the complex social group interactions characteristicof primates, members of the group rely on social signals, in the formof nonverbal cues, to know what others are feeling and intending.Are they angry, hungry, or lonely? Do they want to fight, mate, orplay? Brothers (1989) believes that in humans the brain circuits thatdetect nonverbal cues are the neuronal substrate of empathy. Theimportance of these cues is illustrated by damage to the amygdala inhumans, in which individuals are unable to detect the facial expressionof fear (LeDoux, 1995).

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Facial Expression

Many aspects of nonverbal communication are the result of activityin the autonomic nervous system (ANS): pallor, flushing, sweating,tears, labored breathing, and shaky voice. Experiments by Ekman(1990, 1993) indicate that facial expressions of emotion are linkedwith specific ANS responses for six basic emotions—anger, fear,sadness, disgust, happiness, and surprise. In the “directed task”Ekman instructs subjects how to contract the muscles of their face tocreate the facial expression of each of the 6 emotions. When subjectsvoluntarily contract their facial muscles in the pattern associated withone of these emotions, a high percentage of people actually feel theemotion. In the “lived experience task,” subjects are asked to imaginea situation in which they would feel each emotion. The patterns ofANS activity that distinguish among emotions are: heart rate increaseswith anger/fear/sadness and decreases with disgust; skin conductanceis significantly larger with fear and disgust than with happiness andsurprise; finger temperature increases with anger and decreases withfear. The more an individual can reproduce the correct facial expression,the more likely that individual is to show a distinct ANS pattern.

When a person either voluntarily or for unconscious defensivepurposes masks the facial expression of emotion, although they donot show the usual facial display, individual contractions of facialmuscles and ANS changes can still be detected (Ekman, 1993). Othernonverbal channels, such as voice, can continue to express the faciallysuppressed emotion. People easily suppress verbal expression(Harrigan et al., 1996). Facial expression is harder to suppress andvocal qualities the hardest to suppress. When signals of emotion arediscrepant, people are more likely to rely on facial expression andvocal qualities, rather than on what a person says.

Nonverbal Responses Integrate Emotion and Reason

Damasio (1994) affirms that body changes are an integral part ofemotion. Serving as a form of communication to oneself, the bodychanges play a crucial role in reason and adaptive problem solving.A brief schematic version of emotional processing is given to illustratethese points.

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The amygdala (AMG) and the orbitofrontal cortex (OFC) appraisestimuli with regard to personal salience. “Is this familiar orunfamiliar?” “Is it good or bad for me?” “Do I want to approach oravoid it?” As a result of these appraisals, the AMG and OFC sendsignals to the hypothalamus (HYP) and brain stem, which produce anumber of biobehavioral responses. The HYP produces oxytocin andvasopressin, neuropeptide hormones involved in pair bonding,parental care of infants, and attachment (Insel, 1997). Thehypothalamic-pituitary-adrenal cortex axis regulates production ofthe hormone cortisol. Cortisol readies the body to cope with stressby increasing glucose metabolism and increasing blood pressure. TheHYP and brain stem modulate the ANS. All the organs of the body,such as heart, lungs, larynx, stomach, intestines, bladder, skin, bloodvessels, and lachrymal glands, are innervated by sympathetic (SNS)and parasympathetic (PNS) branches of the ANS. The SNS and PNSact in opposite directions. The SNS promotes coping with externalsituations such as threat and stress, readies the body for action ifnecessary, and is associated with the “fight or flight” response. ThePNS promotes internally directed functions such as growth, digestion,and reproduction, and is associated with “the relaxation” response.As mentioned previously, visceral responses mediated by the ANScontribute to nonverbal communication, such as blushing or quiveringvoice. The HYP and brain stem also activate striatal muscle responses,such as the “freeze response” to danger or the muscle contractionsassociated with facial expression.

Damasio (1994) proposes that feedback of the somatic responsesto the OFC influences reason. Feedback from the internal visceraand muscles serves to communicate to the self regarding how one isreacting to a situation. Feedback from the body becomes associativelylinked with the events of the situation, which is how the individuallearns whether a situation is good or bad, rewarding or punishing,satisfying or unsatisfying. The OFC draws upon memory stores ofthese associations between event and body reaction as the basis forforming adaptive responses to the current environment. Patients withlesions in the OFC lose the ability to apply knowledge derived frompast situations to current problems, because of disruption to thesefeedback circuits from the body. This implies that patients need tobe connected to their feelings in order to function adaptively.

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Matching

Humans automatically and unconsciously match the nonverbal cuesof others (Basch, 1988; Beebe and Lachmann, 1988). Since nonverbalcommunication is linked with ANS changes, matching recreates thephysiology of one individual in the other person, facilitating knowingwhat another is feeling and intending. The link between nonverbalresponses and body physiology, coupled with the fact that individualsmatch each other’s nonverbal cues may be one mechanism by which,not only infants and adults, but also adult dyads, can regulate eachother’s physiology and behavior during affective exchanges.

Nonverbal Cues Link Biologic Systems Between Individuals

Studies with animals and humans, infants as well as adults, suggestthat behavioral and visceral nonverbal signals link individualspsychologically via mechanisms that link their biology. Hofer (1984,1996a, b) integrates his own research with rats and that of otherswith animals and humans in a model for understanding how thebiobehavioral interactions of mother and infant are internalized asobject representations and continue to operate in interpersonalinteractions between adults.

The mother regulates the infant’s behavior and physiology,including activity level, hormones, sleep–wake cycle, heart rate, andbody temperature. When the infant is separated from the mother, thistriggers characteristic infant separation responses as a result of theloss of the mother’s regulatory function. The most characteristicmammalian response to separation is the infant distress cry. Otherphysiologic and behavioral responses to separation include decreasedactivity to the point of quiescence, ignoring food but increasednonnutritive sucking, decreased investigation of new stimuli,decreased body temperature, decreased heart rate, and increasedcorticosteroids. If the mother is nearby, she will respond to the distresscry by searching and retrieving her infant and engaging in comfortingbehaviors (which, in rats, include licking and nursing) that returnthe infant to physiologic regulation and stimulate the cessation ofcrying. Regulatory mechanisms are mediated by neurotransmitterssuch as GABA-benzodiazapines, opiates, and serotonin. For example,benzodiazapine agonists decrease the distress cry upon separation,and benzodiazapine antagonists increase the distress cry.

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Tactile contact and behavioral interaction can counteract the effectof maternal separation in infants. Underweight premature infantsin incubators show increased weight gain, increased headcircumference, and improved behavioral indices when provided withadded tactile contact (Field et al., 1986). Rhesus monkeys separatedfrom their mother but provided with a cloth surrogate still showabnormal behaviors such as rhythmic rocking, increased nonnutritivesucking, increased distress vocalizations, and self clasping. If thecloth surrogate is attached to a long rope that permits the baby toswing, back and forth, the monkey will hold on, swing and jump onand off. This eliminates the abnormal rocking movements in theinfant.

Initially, the mother regulates all the infant’s functions. Eventually,some functions become internalized within the individual’sautonomous homeostatic processes, and others continue to beregulated by external factors such as light/dark cycles, time of day,and interaction with other caretakers as well as peer relation-ships. Hofer proposes that the grief reaction is an indication that“loved ones” function as regulators of the self. He emphasizes thatthe grief response parallels the infant separation response, withan initial acute “protest phase” of crying followed by a longer “despairphase” of physiologic and behavioral dysregulation such as alterationsof sleep, eating, activity, cardiovascular status, and immuneresponse.

Hofer’s ideas are readily applicable to psychoanalysis. He believesthat the brain automatically associates behavioral interactions suchas feeding and holding with olfactory, auditory, and visual cues that“denote” mother. These interactions are established as memory tracesthat form internal working models and object representations.Depending on the nature of the early infant/caretaker interactions,nonverbal signals in current adult relationships can activateexpectations of biobehavioral dysregulation, which may explain whysome patients avoid closeness.

Kalin, Shelton, and Lynn (1995) identify specific reunion behaviorsthat rhesus monkeys engage in following separation: clinging and avocalization called girning. These behaviors increase the infant andmother’s endogenous opiates. Kalin’s research implies that affiliativeand attachment behaviors are modulated by the endogenous opiatereward system, which may explain the tenacity of attachments tocaretakers.

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Hormonal Factors Regulating Nonverbal Behavior

According to Henry (1993) the usual biologic mechanisms for copingwith stress involve an initial elevation of catecholamines, whichpromotes coping with the danger situation. As stress increases,cortisol levels also rise, in turn activating oxytocin release, whichpromotes maternal care, attachment, and social group connectedness.Individuals with PTSD, particularly those who show signs ofalexithymia, show the increase in catecholamines without thesubsequent rise in cortisol. He postulates that this leads to impairedcoping, since these individuals cannot utilize attachment mechanismsas a means for coping with stressful situations. Individuals who lackthe rise in cortisol also demonstrate deficits in transfer of righthemisphere “emotional material” across the corpus callosum to verbalcenters on the left. For Henry, this explains the dissociation betweenwords and feelings that can occur in extreme stress states.

The Relation Between Nonverbal and Verbal Systems

Nonverbal aspects of emotion and communication, such as facialexpression, verbal prosody (rhythm, pitch, timber), gesture, andvisceral responses, are the domain of the right hemisphere andinfluences spoken language primarily via corpus callosumconnections to the left hemisphere (Gazzaniga, 1992). Gazzanigabelieves the left brain serves as an “interpreter” of right-brainnonverbal and emotional functioning.

Infant–Caretaker Interactions Applied to Work with Adults

There is a growing awareness that many of the ways adultscommunicate with adults resemble the ways infants and caretakerscommunicate. Emde (1988) believes it is the nature of the infant–caregiver relationship that becomes internalized and is repeatedlyreactivated in similar relationship contexts throughout life.Lichtenberg (1996) states that infant–caretaker patterns of interaction,reflective of motivational systems, are paralleled by patient–analystinteractions.

Kiersky and Beebe (1994) hypothesize that mother–infantinteractions can be used to understand emotionally constricted adults.

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Infants expect a reciprocal response to their positive affect. If whenthe infant smiles at the mother, her smile is not forthcoming, theinfant at first tries to get the mother to engage; finally, the infantgives up and appears limp and immobilized. Such an unresponsivepattern is evident in the case of a 34-year-old woman who appears“frozen” and reports “not feeling” things. She avoids the analyst’sgaze, talks in a flat monotone, closes her eyes at emotional moments,and seems disinterested both in what she has to say and what theanalyst has to say. She fears closeness will lead to the analystbecoming indifferent toward her. Using data from her history, a modelscene is constructed of a “frozen baby” who fails to be able to engagean unresponsive mother or who has to avoid an overstimulating father.

Lachmann and Beebe (1996) propose the theory that an analystmay be compelled to engage in a nonverbal interaction with an adultpatient, similar to the reciprocally responsive interactions in infancy.They provide a clinical vignette of a 36-year-old divorced womanwith a pessimistic, hopeless outlook on life, who enters treatmentexpecting that the analyst has nothing to offer. As a young child shewas cared for by a loving housekeeper who departed, leaving herwith an emotionally cold mother. In the analysis, the dread ofreexperiencing the void of emotional responsivity emerges in thetransference. She requires the analyst to intuitively understand her,lapsing into silences or continually demanding that the analyst“guess” what she is feeling. Although the analyst is frustrated by thepatient’s guessing games and demands for correct answers, she comesto understand this form of interaction as the reestablishing of anonverbal bond based on the expectation of acceptance and beingunderstood. The patient mistrusts the analyst’s positive feelings aboutthe treatment, experiencing them as misattunements to herhopelessness. The patient’s responses regulate the analyst todownshift her own optimism at being able to help the patient, inorder to stay to attuned to the patient’s hopelessness.

Pally (1996) proposes that nonverbal communications canunconsciously activate the “nurturant response” even between adults.A 27-year-old professional woman is anxious during the beginningof analysis, continually considering stopping the process. The analystbegins to develop imagery of being in the nursery with a howlingterrified infant. At one level the analyst perceives the woman’s mannerand speech as mature, articulate, and coherent. She seems quite able

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to take in transference interpretations regarding her anxiety. However,at the same time, nonverbal cues of fragility and “waif-like”vulnerability are also present, which communicate at a different levelthat this woman is experiencing the helpless terror of an infant andis quite unable to take in anything. The analyst involuntarily findsherself using tone of voice, rhythm of speech, and rocking bodymovements to calm what feels to her to be a frightened helpless baby.The analyst theorizes that the patient’s nonverbal cues are activatingin her the same kind of innately programmed nurturant response thatoccurs between infants and caretakers. Later in the analysis it emergesthat the patient’s mother had been very depressed during her infancyand that awareness of this distressed infant part of her was not yetavailable to her conscious mind. The analyst suggests that hersoothing nonverbal responsiveness was as equally important as herwords to enable the patient to develop enough trust in order to “attachto” the process of the analysis.

Clinical Vignette

Nonverbal interactions in analysis need not only reflect infantilepatterns of relatedness. Observable nonverbal behaviors andexpressions, as well as internal body visceral responses, existunconsciously in all aspects of interpersonal exchange.

Charles is a 40-year-old attorney, who sought treatment for feelingsof numbness and detachment. His father worked much of the time.His mother was controlling and overprotected him. At work hedespised the jockeying for money and power among the lawyers athis corporate law firm. His disgust toward his profession is palpable,expressed with facial expression, tone of voice, and gesture. However,despite the fact that I shared his views, I had difficulty empathizingwith his feelings. Eventually, I began to notice that I often felt avisceral disgust listening to his anger and felt guilty for being“unempathic.” When I considered whether the patient was activatingthese visceral responses in me, I became aware that I was feeling hewas trying to “force feed” me his feelings, “shove them down mythroat,” and I was gagging, wanting to vomit them back up. I becameaware of my own reluctance to “swallow” what he was telling me,perhaps because my own controlling mother tried to force me to seethe world her way and I was resisting the pressure. I said to Charles,

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“I feel you are trying to force me to see the world as you do, toliterally feel inside my body the same kinds of intense responsesyour body has in your rage and disgust toward the legal profession.Perhaps only if I actually feel as you do will you feel supported andunderstood.” This helped the patient better understand that healienates people with his wish to literally create disgust and rage inthem, rather than to simply accept their ability to understand hispainful feelings.

Another set of interactions with this patient occurred in which hemade me feel awkward and confused. He quizzed me about currentevents and asked, “What’s your opinion?” He would say, “I knowit’s not allowed but perhaps we could talk better over lunch.” I triedto understand the meaning of these behaviors, and to explore themin terms of transference themes related to anger. Since his commentsmade me feel awkward and unsure of what level to respond to, Iasked whether he was aware of wanting me to feel confused oruncomfortable in some way. He was annoyed that I considered anymeaning beyond his wanting to know me better. Continuing to exploremy own reaction, I realized I felt caught off-guard and startled. WhenI shared this with him, he explained he needed to connect to the “real”me. My “off-guard” reactions of startle made me behave withcharacteristic body movements and facial expression, which he thendescribed to me. He knew when I behaved this way, it was myautomatic, uncensored response, even as I am trying to carefullychoose my words. The automatic, spontaneous behaviors that I wascompletely unaware of and therefore did not hide from him was whathe sought as a means to be close with me. As a result of this, we wereable to further understand his beliefs that no one really wanted to beclose with him and how hard it was to feel that what people say aresigns of their closeness with him. It was by the process of our mutualawareness of my nonverbal response that both he and I identified themeaning of our interaction.

Discussion

Nonverbal behaviors and visceral responses unconsciously shapelanguage, and language unconsciously shapes nonverbal responses(LeDoux, 1995). I have focused on the nonverbal in isolation, onlyto tease apart the role it plays in interpersonal interaction.

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In the analytic setting the nonverbal behaviors, expressions, andvisceral responses of the patient unconsciously activate nonverbalbehaviors, expressions, and visceral responses in the analyst, whichinfluence the flow and content of spoken exchange and serve as thebasis for empathic understanding of emotion and need states. Theunconscious matching of these nonverbal cues is one means by whichpatient and analyst establish a sense of trust, affiliation, and feelingsof being cared about and understood and therefore are an importantfactor in the development of a working alliance and positivetransference. Perhaps these same mechanisms are the means by whichthe patient unconsciously internalizes the analyst’s analytic functions.

From the perspective of countertransference phenomena, theanalyst’s involuntary nonverbal responses may be innately activatedby the patient, not as a defense or regressive manifestation, but as anexpression of how human beings normally function with one another.In many instances human beings activate in one another nonverbalresponses as a means for signaling what is important to listen to, toactivate regulating behaviors in others in response to stress, and topromote feelings of being cared for and understood.Countertransference phenomena probably involve the automaticsomatic responses of the analyst to the nonverbal, as well as the verbalexpressions of the patient. How the analyst feels compelled to behavetoward the patient may be the result of innately encoded responsesto the nonverbal signals of the patient, which are the result of humans’needs for affection, attachment, understanding, and soothing. Thevisceral and behavioral responses activated in the analyst canunconsciously facilitate empathy but can also be experienced asdysphoric countertransference reactions depending on associativelinks in the memory traces of the analyst. Conversely, if the patientsuffers from alexithymia, there may be insufficient nonverbal signalsto activate empathic understanding and regulatory responses on thepart of the analyst. In the experiments of Freedman and Lavender(1997), it may be the patient’s nonverbal cues, as much as verbalexpression of transference, that activated self-protective responsesin the analyst, interfering with empathic listening.

If nonverbal cues of the analyst signal separation or dysregulation,the patient may literally shut down and become depressed as infantsdo when separated from their mother and adults do with the loss of aloved one. Nonverbal signals of empathic matching by the analyst

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may even trigger biobehavioral states of anxiety in the patient forwhom early internalized dysregulated interactions make them feelunprepared to deal with the unfamiliar, unexpected interaction ofbeing understood.

The nonverbal mechanisms of human interaction have significantimplications with regard to the use of the couch. Strong evidenceexists for the importance of face-to-face contact in the communicationof emotion and mutual responsiveness so important to elicitingempathy and feelings of affiliation. At times, the ability to feelunderstood, accepted, even “attached,” may require face-to-facevisual exchange of nonverbal cues. Conversely, nonverbal cues offacial expression and gesture place limits on verbal exchange byconstraining who talks when and about what, limiting the freeassociative flow of material. Therefore, for any given patient, bothsitting up and lying down each have facilitating, as well as limiting,factors that should be taken into consideration to maximize thetherapeutic effectiveness of the treatment.

Just as mother–infant interactions are innate, unlearned, automatic,and generally unconscious, so too are many of the nonverbalinteraction patterns between adults. How the patient impels theanalyst to feel and behave may be as important a factor in the analysisas what patient and analyst say. While it is useful to pay attentionand verbalize these nonverbal processes and to understand theirdefensive, dynamic meanings, this is not the complete picture. Peopleare “designed by nature” to interact nonverbally at all times. Theimplication of this paper is that, whether the patient’s nonverbalexpression is defensive or not, the analyst may first be impelledinvoluntarily to react before knowing what to say. As a result ofbringing together these separate strands of data, nonverbalcommunication may soon be given its full recognition. In the not toodistant future, perhaps, psychoanalysis may be considered the“nontalking,” as well as the “talking, cure.”

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