broad-perspective perceptual disorder of the right...

Neuropsychology Review, Vol. 15, No. 1, March 2005 ( C© 2005)DOI: 10.1007/s11065-005-3585-5

Broad-Perspective Perceptual Disorderof the Right Hemisphere

Larry E. Schutz1,2

Traditional accounts of right-posterior brain injury describe a syndrome of low-level perceptualsequelae producing marked acute dependency and transient safety concerns. The syndrome is alsoheld to spare cognition and to carry a generally favorable long-term prognosis. The present paperreviews publications and anecdotal data that challenge this picture. Recent theoretical expositions andempirical studies stipulate three major cognitive functions of the right posterior association cortex:processing novel input, guiding reactions to emergencies, and anticipating consequences. Appearingbenign after acute recovery, the impairment of these processes produces vocational, social and maritaldysfunctions that increase as a function of chronicity, ultimately becoming more broadly disablingthan focal injuries in other cortical loci. The unique symptom picture and serious implicationssuggest that the long-term syndrome should be labeled (Broad-Perspective Perceptual Disorder)and incorporated in future clinical taxonomies, underscoring the need for extraordinary long-termassistance and specialized therapeutics. Procedures for assessment and differential diagnosis areoutlined.

KEY WORDS: brain injury prognosis; right hemisphere; right parietal syndrome; posterior association cortex;hemispheric specialization; anosagnosia; aprosodia; nonverbal learning disability.

The right posterior association cortex provides spe-cialized, high-level perceptual capabilities that are es-sential for effective complex cognition and adaptation.Jackson (1876) pronounced this region to be of paramountimportance, but his conception was rejected (Jackson,1893; Joanette and Goulet, 1990; Roth, 1999) in favorof the prevailing view of a “minor hemisphere” that madeno cognitive contributions (Kolb and Whishaw, 2003). Re-cent papers describe a right hemisphere with a number ofspecific, important cognitive functions (Mesulam, 2000a),but these discoveries and the implications for medicalcare and rehabilitation treatment have not been incorpo-rated into most clinical texts (e.g., Adams et al., 1997;Bannister, 1992; Lezak, 1995; Reitan and Wolfson, 1985a;Rowland, 1995; Sohlberg and Mateer, 2001; Zillmer andSpiers, 2001).

1Rehabilitation Neuropsychology Associates of Orlando, Florida andthe University of Central Florida.

2To whom correspondence should be addressed at RehabilitationNeuropsychology Associates, 6001 Vineland Road, Suite 116, Orlando,Florida 32819, USA; e-mail: [email protected].

A brain deprived by injury of its nonverbal–perceptual guidance sees what it expected to see beforeinjury, ignoring emergent obstacles and hazards and un-derestimating the urgency of those that make themselvesobvious. Planning and problem-solving are crippled bynaively optimistic forecasting of outcomes. Social in-tercourse is conducted with a blanket disregard for thefeelings, wishes, needs and expectations of others. Theresulting disabilities have an insidious onset because re-liance on the pre-injury perceptual schemata becomesprogressively less functional as situations evolve overtime. Hence spouses, children, friends and employers,satisfied with early recovery, become increasingly alien-ated by a track record of poor decisions and bad con-duct over the ensuing years. Extended follow up findsunusually high levels of divorce, unemployment, and so-cial isolation. This pattern of long-term deficit may besufficiently distinctive and pronounced to merit inclusionin the clinical taxonomy. The label of Broad-PerspectivePerceptual Disorder (BPPD) is proposed. Three criticalcognitive symptoms and their cumulative effects onadaptation will be described, explained and illustrated,

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followed by a discussion of neuropsychological assess-ment strategies.

TRADITIONAL DESCRIPTIONS OF“RIGHT PARIETAL SYNDROME”

Jackson (1864) introduced the concept of right-posterior cortical dominance for visuospatial percep-tion. Lateralized circuitry for spatial coordinate map-ping (Kosslyn and Koenig, 1992; Lynch, 1980) and aunique, “wide-screen” view of the world (Deouell et al.,2003; Kaplan, 1989; Milberg et al., 1996; Posner andRaichle, 1994) augment somatosensory, topographical,and spatial localization and visual search (Damasio et al.,2000; Farah, 2003; Vallar, 1999). The lateralized apti-tude for complex pattern recognition (Walsh and Darby,1999; Zaidel, 1985) supports object recognition, and con-figural and gestalt perception. The “right parietal syn-drome” produced by focal damage (Meier et al., 1987;Mesulam, 2000a) impairs these perceptual skills (Bentonand Tranel, 1993) and causes dense contralateral neglect(Heilman et al., 2003a,b; Mesulam, 1985b; Rafal, 1997a).Associated practical problems include getting lost easily(Butters et al., 1970), falling (Diller and Weinberg, 1970),crashing vehicles into obstacles (Joseph, 1997; Websteret al., 1995), and handling objects clumsily (Hecaenand Albert, 1978). The syndrome also impairs percep-tion of social–emotional signals (Code, 1987; Heilmanet al., 2003b; Ross, 2000; Segalowitz, 1983), a homologueof receptive aphasia (Ross, 1985) impacting interpreta-tion of implicit messages and speaker’s intent (Povinelli,2001; Sabbagh, 1999) and mental state (Adolphs, 2003;Bowers et al., 1993; Ornstein, 1997; Winner et al.,1998). Finally, patients fail to recognize their own im-pairments, a symptom termed anosagnosia (Adair et al.,2003).

Because the syndrome is traditionally conceptual-ized only in terms of basic perceptual deficits, thereis no warning of the long-term compromise of highercognition and macroscopic-level adaptive behavior re-sulting from the loss of perceptual guidance. More-over, most post-acute patients present well and soundbright and expressively fluent, creating an impressionof cognitive intactness that misleads even expert eval-uators (Critchley, 1953; Hebb, 1949). Hence the cur-rent standard of care is to release these patients fromrestrictions and terminate their treatment upon recov-ery of basic perception (Joseph, 1997), usually achievedwithin six months (Cassidy et al., 1998; Nelson et al.,1994; Sisson, 1998; Stone et al., 1992; Tham et al.,2000).

CRITICAL COGNITIVE-BEHAVIORALSYMPTOMS OF BPPD

Higher cognition relies extensively on the afferentpattern-comparator (Calvin, 1989; Kosslyn and Koenig,1992; Neisser, 1967), which evolved for object recogni-tion (Hofstadter, 2001) but is “borrowed” for advancedmental skills such as problem solving and induction(Carlson, 1997; Gattis, 2001; Jerison, 2001; Pinker, 1997).The analyzer is also used to search the posterior cortex’sgnostic library quickly and exhaustively to determine thepotential adaptive impact of emergent stimuli and situa-tions (Gibson, 1979; Luria, 1973), and to compare planswith anticipated outcomes (Gross, 1982) in order to nar-row the choice of goals and plans to those that are mostpractical (Miller et al., 1960; Schlesinger, 1962). Theprocess requires a coordinated interplay of the executiveand afferent analyzers (Gross and Schutz, 1986), executedthrough the frontoparietal distributed network (Mesulam,2000a). (Extended explanation of the functions of this net-work is beyond the scope of this paper, and is deferred toa future discussion.) The afferent data are accessed by thenetwork through the parietal integrating area (Geschwind,1965; Goldberg and Costa, 1981). Damage to the posteriorend of the network thus disconnects the executive from theguidance system, and consequently impacts three majornetwork functions.

The Inability to Assimilate Novelty

The right brain possesses special capabilities for pro-cessing novel stimuli (Goldberg and Costa, 1981; Pribram,1981; Regard and Landis, 1989; Rogers, 2000). There isfull access to input from the peripheral (Cook and Beech,1990) and distal (Hellige, 1993; Mesulam, 1985a) spatialfields, the most common entry points for new stimuli,and only the right brain can redirect attention to new pe-ripheral targets in both hemifields (Posner and Raichle,1994). It also excels in perceiving fleeting and poorlyilluminated stimuli (Gazzaniga et al., 1998) A novel stim-ulus triggers immediate release of norepinepherine mainlyin the right hemisphere (Edelman and Tononi, 2000;Goldberg, 2001; Mesulam, 2000a), and the noradrenergicneurons resist habituation, holding the attentional gateswide open to take in a generous exploratory data base(Tucker and Williamson, 1984). The input is then exploredby induction, which utilizes pattern matching (Edelmanand Tononi, 2000; Gentner et al., 2001) to define theboundaries (Barlow, 1985) and properties (Gattis, 2001;Hofstadter, 2001; Thagard, 2000) of the newly-discoveredphenomena. This pattern matching is a right-hemisphere

Broad-Perspective Perceptual Disorder of the Right Hemisphere 13

function (Gregory, 1970; Smith, 1989), as demonstratedby EEG (Molle et al., 2000) and functional MRI (Goebelet al., 1997; Shuren and Grafman, 2002), and verifiedby lesion studies (Bradshaw and Mattingly, 1995; Walkeret al., 2001).

This “furious pattern matching” (Reason, 1990)requires great data-integrating power. The right brain’sintegrative assets include more white matter and a largerposterior association cortex (Kolb and Whishaw, 2003),denser association fibers (Goldberg and Costa, 1981),greater interconnection of neuronal columns (identifiedin the temporal lobe) (Gazzaniga et al., 1998), and largerintegrative structures (Galaburda, 1995; Hochberg andLeMay, 1975) in the perisylvian area (Cummings, 1985;Gorelick and Swiontoniowski, 1989), the posterior–inferior parietal lobe (Dimond et al., 1980; Janckeet al., 1994; Kolb and Whishaw, 2003), and particularlyintraparietal area PEG (Edelberg and Galaburda, 1984).Right-sided structures that detail the properties of peopleand things (Farah, 2003; Ungerleider and Mishkin, 1982),including Heschl’s gyrus and the superior temporalgyrus, are also larger (Campain and Minckler, 1976;LeMay, 1976; Whitaker and Osemann, 1977). Neuronalorganization is mirrored by the circulatory system: Themain venous drainage on the left (the vein of Labbe) liesin the temporal language area, while the main right-sideddrainage (vein of Trolard) is offset into the parietalintegrating area (Witelson, 1980). Superior integration isverified by stronger intrahemispheric intercorrelations ofEEG tracings (Liotti and Tucker, 1995) and the greateroverlap of cortical projection zones for somatosensory(Semmes et al., 1960; Teuber et al., 1960) and auditoryinputs (Milner, 1975) on the right side, improvingheteromodal processing (Semmes, 1968) and recognitionof broad patterns (Beeman et al., 2000; Broadbent, 1977;Christman, 1997; Ivry and Robertson, 1998; Sergent,1982; Valenstein, 1999) such as main themes (Gardner,1975; Hellige, 1993), complex arrays (Hellige, 1995;Young and Ratliff, 1983; Zaidel, 1985), and perceptualgestalten (Nebes, 1978; Ratey, 2002). Broad patterns arethe starting point in exploring novelty (Krech and Calvin,1953; Navon, 1977; Neisser, 1967). The lesions of BPPDmaximally disrupt this global processing (Doyon andMilner, 1991; Heinze and Munte, 1993; Rafal, 1997b;Robertson et al., 1988).

The right brain’s powerful integrative processingstation can perform complex multivariate data analyses(Goldberg and Costa, 1981) in parallel (Bradshaw andNettleton, 1981; Cohen, 1973). Right-brain problem solv-ing generates a matrix of alternative solutions, as con-trasted with the left brain’s single solution of best fit(Brownell, 1988; Tucker and Williamson, 1984). This an-

swer matrix remains active while alternative solutions areexplored (Richards and Chiarello, 1997), a method suit-able for the open-ended possibilities inherent in a novelsituation.

The learning of new skills takes place in the het-eromodal association cortex (Prigatano, 1991), wherethe right brain starts the process by building a generalconceptual framework, subsequently using it to choreo-graph the left brain’s acquisition of fine discriminations(Kinsbourne, 1982). Novices learning music, Morse code,geometry, or interior decorating show more arousal on theright side (Goldberg and Costa, 1981). The differentialactivation shifts to the left side after extensive practice(Goldberg, 2001), even for a “spatial” skill like tap danc-ing (Falk, 1992) or playing a musical instrument (Beverand Chiarello, 1974). In a similar vein, novel tasks areexecuted better in left hemispace (Gardner, 1975; Sperry,1985). Right-sided lesions differentially impair early lan-guage acquisition (Goldberg, 2001), recall of novel terms(Mills et al., 1993; Thal et al., 1991), stories (Segalowitz,1983), maze routes (Rausch, 1985), semantic associations(Seger et al., 2000), symbols (Koul and Lloyd, 1998;Zaidel, 1985), faces (Damasio et al., 2000), and ges-tures (Goldenberg and Strauss, 2002), and identificationof unusual uses for common objects (Diggs and Basili,1987), pictorial incongruities (Milner, 1975), and unex-pected (Wapner et al., 1981) or bizarre material that wasinserted into stories (Gardner et al., 1983).

Many developmental years are required to learn byinduction the massive catalogue of social rules and ritu-als (Goffman, 1967), the gnostic base of the social skills(Schore, 1994). “Right-hemisphere deficit disorder,” a de-velopmental syndrome including all of the major fea-tures of BPPD (Rourke, 1989), is associated with mas-sive knowledge gaps concerning approved and forbiddenforms of conduct (Ratey, 2002). Although bright and ver-bally fluent, these children seem unable to learn lessonsabout age-specific expectations, rules and routines fromobservation or experience, repeating immature responsesand other sanctioned behaviors again and again. Theiractions appear unacceptably “weird” to peers, leading torejection and isolation (Casey and Strang, 1994; Rourke,1989; Rourke and Fisk, 1988; Weintraub and Mesulam,1983; Worling et al., 1999). The most disabled tend tohave posterior lesions (Myklebust, 1975; Voeller, 1986).

Impaired gnosis from damage to the posterior as-sociation cortex prevents updating existing perceptualschemata as well as creating new ones (Luria, 1973). Forexample, right-hemisphere lesions focally impair learningthe topography of new settings (Cogan, 1966). Patientswith right-parietal lesions take longer to learn new routes(Barrash, 1998), follow maps less effectively, get lost more

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often (Critchley, 1953; Cummings, 1985; Damasio, 1985),and forget where things were put (Butters et al., 1970).They take long walks searching for the car in a parkinglot. One outpatient insisted on trying to leave the clinicthrough a back-corridor bifold closet door. Another com-plained that staff had moved the elevator. A CVA patientwith a master’s degree needed 3 hr to shop because shecould not learn the scheme of the market.

Right CVA patients show no updating of theirschemata for self-guidance after receiving performancefeedback (Gordon, 1987; Kihlstrom and Tobias, 1991;Mizuno, 1991; Ramachandran, 1995; Rausch, 1985). So-cial schemata for familiar persons become closed tonew information after right-posterior damage (Damasio,1994), while schemata for new persons are impoverishedand superficial (Segalowitz, 1983; Sergent, 1995; Wapneret al., 1981). Empathy seems to depend upon the function-ing of the right parietal integrating and right somatosen-sory areas (Adolphs, 2003; Adolphs and Damasio, 2000),and may be markedly limited after right posterior lesions(Heilman, 1999a). BPPD patients often ignore tragediesthat befall their spouses and associates, for example,health or business crises or the death of a parent. They alsoignore changes in social partners’ feelings toward them,particularly problematical when the others have becomealienated by a long-standing pattern of inconsiderate andunreliable behavior.

The most extensive revision of existing schemata re-quired after brain injury incorporates the “harsh reality”(Prigatano, 1987) of new limitations and flaws into theself-concept (Haney, 1986; Kelly, 1955; Prigatano, 1999).Deficit awareness is a generic problem in acquired braininjury (Fisher, 1989; Weinstein and Kahn, 1955): Damageto any functional system inhibits feedback about the sys-tem’s defects (Bisiach and Geminiani, 1991; Prigatanoand Schachter, 1991). However, focal damage to the asso-ciation cortex, for example, in the prefrontal region, inter-feres with deficit awareness more extensively (Damasioand Anderson, 2003; Goldberg, 2001; Stuss, 1991). Themost dramatic and enduring symptoms of anosagnosia areseen for lesions of the right hemisphere (Heilman, 1991;Prigatano, 1994), especially in the posterior associationcortex (Goldberg and Barr, 1991; Roth, 1949; Sohlbergand Mateer, 2001). This is the primary locus for recog-nition of behavioral errors (Barco et al., 1991; Bisiachand Geminiani, 1991), feelings of concern about accuracyof self-perception (Mesulam, 2000a,b), and the monitor-ing and revision of the self-image (Johnson et al., 2002;Maddock et al., 2001; Maguire et al., 2001). Right-sideddamage impairs self-perception (Prigatano, 1987), “freez-ing” the self-concept at the time of onset (Damasio, 1994)and blocking recognition of changes even in personality

traits (Kihlstrom and Tobias, 1991; Luria, 1973; McGlynnand Schachter, 1989). In BPPD, the self-concept growsincreasingly obsolete by because it is based on “old infor-mation growing older by the second” (Damasio, 1994).According to Crosson et al. (1989), this deficit is oftenpermanent.

Postmorbid life imposes many novel demands on thebrain-injury survivor (Haney, 1986, Prigatano, 1999), andpatients with BPPD have unusual difficulty in adapting tothem. The rehab clinic is a strange situation, less control-ling and arbitrary than a medical facility (Howard, 1998;Plovnick, 1998) but more demanding than a commer-cial service business. Patients with BPPD break rules byfalling asleep in sessions (Gordon, 1987), skipping assign-ments, being late or absent without good cause, or cheat-ing on self-scored exercises. Patients are less successfulin learning to perform familiar tasks in novel (compen-satory) ways (Diller, 1962; Gardner, 1975; Joseph, 1997),and more insistent on using nonfunctional, familiar ap-proaches (Damasio, 1994) after right-sided lesions fromposterior tumor (O’dell et al., 1998), ischemic infarction(Macciocchi et al., 1988), ruptured aneurysm (Clinchotet al., 1997) and CVA (Alexander, 1994; Joseph, 1997;Scranton et al., 1970; Ween et al., 1996), even at 3–24-month follow-ups (Cherney et al., 2001; Chester andMcLaren, 1989; Jehkonen et al., 2000; Katz et al., 1999;Kinsella et al., 1993; Robertson et al., 1997; Schutz,2002; Stone et al., 1993). Moreover, in right CVA, theleast successful accommodations are made in the pres-ence of posterior association cortex lesions (Damasio,1994; Gordon et al., 1978; Heilman, 1999b; Prigatano andWong, 1999; Saecki et al., 1994) or nonverbal perceptualdeficits (Jongbloed, 1986, reviewing 33 studies) such assomatosensory loss (Patel et al., 2000; Reding and Potes,1988; Sterzi et al., 1993), left neglect (Cassidy et al., 2001;Denes et al., 1982; Fullerton et al., 1988; Hier et al., 1983;Katz et al., 1999; Pedersen et al., 1996; Ring et al., 1997),topographical disorientation (Kwakkel et al., 1996; Szeet al., 2000), and constructional apraxia (Suhr and Grace,1999).

Pathological Indifference and the Breakdownof the Emergency Warning System

The right brain specializes in the perception ofnegatively valenced stimuli (Heilman, 1999b). Aversivestimuli such as unpleasant video images (Davidson,1984, 1995; Gainotti, 1997), threats of punishment(Davidson, 1995; Tucker et al., 1977), and noxioussmells (Ehrlichmann, 1987) and tastes, even in new-borns (Davidson and Fox, 1988), elicit stronger EEGresponses over the right hemisphere. Negative voice tone


(Bryden and MacRae, 1989) and facial expressions (Natleet al., 1983) consistently evoke stronger reactions in lefthemispace.

Only right-sided lesions produce anosodiaphoria(Critchley, 1953; Mesulam, 1985a), a pathological in-difference and non-responsiveness to negative stimuli(Adolphs and Damasio, 2000; Tucker, 1987) such asgraphic surgical pictures (Gainotti and Caltagirone, 1989),faces displaying negative emotions (Adolphs et al., 2001;Jansari et al., 2000; Mandal et al., 1991), task failures andmention of the subject’s symptoms (Cummings, 1997;Gainotti, 1972; Gordon, 1987). Indifference to the risk ofmissing contralesional stimuli helps to explain why leftneglect is so extreme and lasts so long (Bisiach and Vallar,1988; Egly et al., 1994; Mesulam, 2000b). Right-lesionpatients with anosagnosia seem incapable of depression(Joseph, 1997; Prigatano, 1987); many in the current se-ries were unable to muster as much distress as the best-adjusted neurology patients showed, even after incurringserious setbacks.

The right hemisphere operates a distributed networkfor rapid responding to danger and other urgent prob-lems (Mesulam, 2000b). It preferentially processes en-vironmental challenge, stress and pain (Gainotti, 1997;Wittling, 1995) and manages self-protective responses(Gazzaniga, 1998; Geschwind and Galaburda, 1985;Moscovich, 1983; Simon, 1967; Webster, 1977) such asavoidance (Hugdahl, 1995) and escape (Bannister, 1992;Davidson, 1984, 1995; Ornstein, 1995). The emergencynetwork’s activities are coordinated by the right posteriorassociation cortex (Jackson, 1874; Kastner et al., 1998;Tucker and Williamson, 1984), which links stimuli withtheir historic adaptive consequences (Gibson, 1979) suchas doing harm (Janis and Mann, 1977a) via visual images(Jackson, 1874; Luria, 1973). Screened for motivationalurgency across a link with the limbic system at the cin-gulate gyrus (Heilman et al., 1993a; Mesulam, 1981),images trigger arousal (Heilman et al., 2003, b) and emo-tion felt in the right somatosensory area (Adolphs andDamasio, 2000; Mesulam, 2000a) and interpreted con-textually (Ben-Ze’ev, 2000) in the right parietal cortex(Heilman et al., 1993b). Recognition of danger promptsthe right brain to release norepinephrine, which locksawareness on the stimulus and generates compelling nega-tive emotions such as hostility, dread and fear (Bear, 1983;Ochsner and Schachter, 2000; Tucker and Williamson,1984). Such emotion interrupts other, ongoing activi-ties (Allport, 1989) and seizes the whole brain’s focus(Heilman and Van Den Abell, 1980; Mesulam, 1981)through the primary network for directed attention andvigilance (Mesulam and Geschwind, 1978; Tucker et al.,2000), which extends from the right parietal lobe to the

thalamus and reticular activating system (Dimond, 1979;Mesulam, 1985b; Nadeau, 1999). Emotionality compelsrapid decisions (Geschwind, 1978), made in fragmentsof a second (Janis and Mann, 1977a). Gnostic imageryof the habitual self-protective response to a threat, sentto the prefrontal cortex (Barlow, 1985), is implementedimmediately, bypassing the planning process in the nameof haste (Damasio, 1994; Markman and Moreau, 2001;Mountcastle et al., 1975). Emotionality is thus the rightbrain’s “red phone,” compelling the mind to handle urgentmatters without delay.

The narrowed perspective of right-lesion victimsoverlooks, and thus prevents addressing, urgent hazardsendemic to specific situations. Some make no effort toavoid public displays of poor hygiene or immodesty inthe hospital (Kirshner, 1986). A fastidious woman with aright parietal intracerebral hemorrhage knocked over her32-ounce beverage, staring as the contents slowly emp-tied out onto the conference table. Though she spilledfood and drink almost daily, she never took precautionsto avoid doing so. A computer engineer hospitalized for aright parietal infarct eloped after removing his wrist alarmand stopped at the hospital cafeteria’s ATM to withdrawa getaway bankroll. When apprehended 1 hr later, he stillsat across from the ATM, unconcerned about completinghis escape.

Right-sided lesions sometimes induce frank alex-ithymia (Cummings, 1997; Heilman, 1994; Schore, 1994),a total indifference to discomforts like starvation (Brown-Sequard, 1874), sexual deprivation (Goldstein, 1952;Tucker and Frederick, 1989), and even the pain of pres-sure sores (Harrington, 1995). One patient’s electrolyteimbalance from the inadvertent deprivation of food anddrink started a seizure disorder. Patients premorbidly pro-ficient in dietary control of their diabetes induced dia-betic crises after injury. Some patients remained in clubswith loud music and light shows despite phonophobia andphotophobia.

Survivors remain indifferent to threats even whenthey grow progressively more serious over time. A womanwith right-sided cortical atrophy after peripartum anoxiaand a young man struck with right carotid dissection andocclusion in the delivery room continued living in theirmothers’ homes after 4 years, passive and complacentas spouses petitioned for divorce, older children becamemore bitter and distant and their newborns grew up asstrangers. An executive with a grade three right posteriortemporal astrocytoma postponed surgery for two years.A physician planned a healthy lifestyle after diabetes andcholesterol led to his right parietal CVA, but he smokedand ate with abandon until his death one week after hisrehabilitation discharge.

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Certain social situations demand urgent responding,and non-response to the signals of urgent need evokesextreme ill feelings (Goffman, 1967). An intact brainremains vigilant for such signals, while one with right-hemisphere damage monitors carelessly and ignores mes-sages that are received, resulting in frequent inappropriateomissions (Joseph, 1997). Survivors of right-sided, andparticularly posterior, lesions fail to respond to others’ ur-gent requests and complaints (Molloy et al., 1990; Searle,1979; Segalowitz, 1983; Weylman et al., 1989), acutedistress (Adolphs and Damasio, 2000; Heilman, 1999a;Taylor, 1987), or appeals for help (Damasio, 2003); eventhe most urgent warnings of therapists are often ignored.Such unresponsiveness is usually interpreted as indiffer-ence, lack of commitment, or disrespect (Jones et al.,2001; Miller, 2001; Stemmer et al., 1994), rather thanneurobehavioral malfunction (Goldberg, 2001).

The tendency to ignore or minimize urgent warningscan have a devastating impact in the workplace: Supervi-sory complaints and even warnings of impending termi-nation are often ignored, especially when delivered in thepolite style (Hawkins, 1977) of the white-collar employer(Chiarello, 1999). A young technical worker with a rightparietal CVA dismissed so many important complaintsfrom his supervisor that he was slated for firing. He cor-rected errors and kept his job only after explicit feedbackwas conveyed in writing. A young attorney with a rightparietal contusion denied receiving ongoing criticisms forhis on-the-job errors. Even a half-hour stern, formal re-view of the infractions aroused no suspicion that he hadlost his job.

Forewarning–Foresight Blindness

Visual imagery is the medium for the cognitive func-tion of anticipation (Bortner, 1968; Horowitz, 1972), ac-complished by “constructing an image or model, runningthe model faster than the environment, and predicting thatthe environment will behave as the model does.” (Galanterand Gerstenhaber, 1956; see also Calvin, 1989). Antici-pation of future events and consequences is the respon-sibility of the “response selector mechanism” situated inthe parietal cortex (Battelli et al., 2003; Corbetta et al.,2000; Corbetta and Shulman, 2001; Schlesinger, 1962;Tulving et al., 1994). It depicts the results and effectsof each response option (Gregory et al., 1982; Milleret al., 1960) to guide planning (Goldberg, 2001), pre-venting errors (Reason, 1990; Walter, 1953) by identify-ing the option with the best cost-benefit ratio (Damasio,2003): “Achievement of the most effective and economi-cal organization of action depends in large measure on. . .

anticipation. . .(It) is essential to adequate performance.”(Kahneman, 1973). Superior anticipation afforded by theevolutionary expansion of the parietal lobes (Bradshaw,1997; Eccles, 1989; Kolb and Whishaw, 2003) lies at theheart of the human cognitive advantage (Bogdan, 2000;Bronowski, 1973; Deacon, 1997; Leakey and Lewin,1977; Smith, 1989).

The most complex imagery for hypothetical con-structs is generated by right hemisphere activity (Beemanet al., 2000; Bryden and Ley, 1983; Kasher et al., 1999;Pegna et al., 1997; Ratcliff, 1987), and right-sided lesionssometimes block anticipatory imagery (Crosson et al.,1989; Tulving, 1992), eliminating a view of the futurefrom the temporal perspective. For example, a veteran de-partment manager stopped making major decisions afterher right parietal CVA because she no longer pictured theoutcomes. A design engineer could no longer imagine theend-product of his modifications. A fabricator of custommachine parts turned over most of his work to his employ-ees. In each instance, the afflicted individuals reportedhaving been exceptionally reliant on visual imagery priorto the injury.

For the modal adult, the right brain supplies the im-ages of negative outcomes and side-effects (Bradshaw,1997; Hellige, 1991; Rourke, 1989). The right posteriorcortex not only previews failures and disasters but alsofeels their emotional impact in advance, stiffening re-solve to avoid them (Damasio, 1994). BPPD survivorsreport feeling avoidant prompts so weak that they are notheeded. When anticipation fails, hazards are not avoided(Janis and Mann, 1977a) and maladaptive courses of ac-tion are pursued (Janis and Mann, 1977b). Children withright-brain deficit disorder ignore task obstacles, acceptimpossible challenges, make grossly inadequate efforts(Rourke, 1989), and are stunned by the poor outcomes(Johnson and Myklebust, 1967). These children act fear-less because they overlook “the dangers inherent in thesituation” (Rourke, 1989). In the same manner, adultswith right-brain injuries are prone to make impulsive er-rors (Binder et al., 1987; Joseph, 1997; Mesulam, 1985a;Pimental and Kingsbury, 1989).

Here are examples from the author’s series. A post-polio victim with a right parietal CVA was careful aboutfalling, but he rocketed his electric scooter down a fa-miliar flight of stairs. A teen runaway with a right pari-etal contusion, exiled to a distant state, dove out of asecond-story window at his first chance and got lost inthe woods. A widow with right parietal CVA nightly tra-versed an unlit grand staircase covered with cats whilewearing a floor-length nightgown. Only hours after be-ing approved to drive, a woman with a temporoparietalremoval shopped for a safe SUV, but purchased the one


that was scandalously prone to lethal rollovers. A manwith right frontoparietal contusions and a 10-pound lift-ing restriction loaded 50-pound bags of rocks into his car“without thinking.” Driving restricted for his right parietalCVA, a man drove his noisy sports car up to the outpa-tient unit, blasted a questioning therapist with vulgarities,and challenged her to try to stop him from driving. Adentist, whose right parietal contusion occurred when hisenraged girlfriend deliberately drove into his car, plannedhis discharge into her care.

Navigation of social relationships relies upon antic-ipation of the social partner’s future reactions (Goldberg,2001; Mithen, 1996; Pinker, 1997). Patients with right-brain injury generate erroneous and illogical behavioralpredictions (Beeman, 1993; Brownell et al., 1997). Chil-dren with right-brain deficit disorder fail to anticipatepredictable negative reactions to their verbose, impulsive,immature communication style, which contributes to theirrejection and isolation (Johnson and Myklebust, 1967;Rourke, 1989). Adults with BPPD fail to anticipate nega-tive reactions to violations of important social rules suchas reciprocity (Trivers, 1985). For example, the physicianwith the right parietal CVA sold and replaced his wife’scar without discussing it with her, never suspecting thatshe would resent his presumption. While voicing grati-tude for his stalwart support during her convalescence,a young manager with a right parietal contusion returnedher suitor’s ring, proposed that they end their cohabitation,and allotted no time to see him without anticipating that hewould feel rejected and respond in kind. A trauma victimwith a right parietotemporal contusion stalked her formerlover, unwilling to admit that the bogus police report ofhis sexual abuse she made a year earlier had brought theirrelationship to a close.

Oversimplified planning in BPPD ignores the pos-sibility of failure because of the combined effects ofdefective anticipation and anosagnosia (Damasio andAnderson, 2003; Dormer, 1996). Over-optimistic expecta-tion of easy success (Bisiach and Geminiani, 1991) elicitscursory planning (Kunda, 1999) and casual implementa-tion (Damasio, 1994). When the crudely planned and ex-ecuted actions produce incorrect behaviors, the damagedperceptual system’s persistent illusion of adequate per-formance (Heilman, 1991; Kihlstrom and Tobias, 1991;Prigatano, 1991) blocks recognition of any need for mid-course corrections (e.g., Joanette et al., 1990; Molloyet al., 1990). For example, a neurosurgeon agreed thatthe massive right parietal damage from carotid dissec-tion shown by his CT scan would be totally disablingto his patients, but he planned to resume doing surgeryand driving immediately. A right temporoparietal traumapatient decided to quit her job to become a vocalist with-

out worrying about recent difficulties in carrying a tune.Though he failed at eight marketing jobs in six years, abusiness school graduate with a right parietal contusioncontinued to seek similar positions. A tennis prodigy witha right posterior temporal CVA resumed playing despite apoor prognosis, struggling for four years before admittingthat his neglect, impaired aim and slow reactions had de-stroyed his tennis career. A receptionist with right parietalcontusion did not adjust her job search strategy despite22 consecutive unsuccessful interviews. Unable to antic-ipate future difficulties, right-lesion patients frequentlydeny any need for rehabilitation treatment (Adair et al.,2003; Calvanio et al., 1993; Diller, 1987; Gerstein, 1975;Gorelick and Swiontoniowski, 1989; Prigatano, 1999).

CUMULATIVE EFFECTS:GLOBAL MALADAPTATION

Perceptual guidance is needed most for unusuallychallenging tasks and roles (Mesulam, 2000a): Explor-ing unfamiliar environments, avoiding serious hazards,and making on-line decisions to exacting specifications.During postacute recovery, patients progress from tightlycircumscribed lifestyles to full responsibilities, with de-clining tolerance for errors. Thus the need for perceptualguidance grows gradually, and the BPPD deficits surfaceonly after a delay.

The deterioration of social networks typically be-gins in the second six months or second year post onset(Lehr, 1990). The limited social circles, abbreviated ro-mances, and stressed marriages of chronic patients testifyto the interpersonal impact of BPPD. Members of a long-term support group describe the members with BPPD as“high maintenance” due to inconsiderate behavior, de-mandingness, rule-breaking, and unreliability. As theirrelationships deteriorate, they neither acknowledge thedecline nor make changes, which only amplifies partners’alienation. Damasio (2003) notes the correlation of rightparietal damage with divorce and filial estrangement.

The author (Schutz, 2002) investigated marital stabil-ity as an aspect of functional recovery in a sample includ-ing 48 discharged rehab patients with BPPD. The subjectswere working at onset, referred for intensive post-acutecognitive rehabilitation, and available for follow-up inter-view held between 3 months and 11 years post discharge(mean interval 16.5 months, standard deviation of 21.4).They ranged in age from 18 to 67. Inclusion in the BPPDgroup was based on CT or MRI evidence of a lesion in theright parietal or right parietotemporal area. The etiologywas traumatic brain injury in approximately two-thirds ofthe cases and cerebrovascular accident in the remaining

18 Schutz

Table 1. Sample Description and Outcomes from Schutz (2002)

BPPD sample Non-BPPD sample

SampleNumber of cases 48 48Mean age (SD) 33.02 (12.0) 34.02 (15.4)Mean education (SD) 14.78 (3.4) 13.16 (2.6)Months chronicity at f/u (SD) 32.07 (18.1) 28.30 (15.4)

EtiologyClosed head injury 63% 64%Penetrating brain wound 6% 2%Cerebrovascular accident 31% 33%

Findings at follow-upUnemployed 84% 51%Divorced 52% 15%24-hr supervision 30% 18%

third. A comparison group with focal lesions located inother regions was matched for severity, etiology, age, andtime post discharge (See Table 1). Of the 21 patients withBPPD who were married at onset, 11 or 52% had di-vorced by the time of the follow-up, in contrast to 15%for the non-BPPD group. The marital estrangement didnot surface until the second year, as spouses became in-creasingly aware of the survivor’s high-maintenance fea-tures and more alienated and offended by poor conduct.In some cases, the divorce did not occur until the third tofifth year post discharge. Survivors also became estrangedfrom adolescent or adult children during this phase.

Expert clinicians designate right-sided lesions andanosagnosia as risk factors for vocational failure (Lezak,1987; Prigatano and Schachter, 1991; Weinstein, 1991).The rate of stable competitive employment with BPPDwas 16% compared to the non-BPPD group’s 49%(Schutz, 2002). An earlier study (Knapp, 1959) of youngerCVA patients found none of the 10 with left hemiparesisemployed while 54% of 11 with right hemiparesis heldjobs. In another study, most of the unemployed penetrat-ing wound cases had right-sided foci and constructionaldeficits (Kaufman et al., 1985). Finally, neuropsycholog-ical tests maximally sensitive to BPPD lesions are amongthe best predictors of vocational outcome (Boake et al.,1997; Dennerl et al., 1966; Dikmen and Morgan, 1980;Heaton et al., 1978; Heaton and Pendleton, 1981; Ruffet al., 1993).

Patients with impaired visual imagery fail to prior-itize their actions to assure a satisfying life (Damasio,2003). Many BPPD survivors have become isolated andlonely, but very few have even attempted to replace lostspouses, friends and associates. Only four single youngladies started new romances, and all of them were short-lived. A few former patients retraced old paths of relation-ship conflict, reuniting unsuccessfully with ex-spouses or

abusive parents. Career change was also rare; only six evenattempted it. Four of these are presently unemployed, oneis in supported employment, and one works for minimumwage in a competitive job.

The ultimate test of long-term recovery is the overalladaptation to the demands of life (Symonds, 1970). Thecriteria for mental health (Jahoda, 1959) are compromisedfor almost all of the patients in the author’s series. Beyondthe above-captioned loss of opportunities for love andwork, reality awareness is distorted by excessive expecta-tions, autonomy is compromised by poor decision makingand safety judgment, and effective pursuit of future goalsis rare (see also Damasio, 2003). In these terms, only2 of the 52 former patients could be described as well-adjusted. Additionally, personal problems tend to go unre-solved. For example, children with right-brain syndromedecline in adjustment with age, accumulating problemsinstead of solving them (Greiffenstein and Baker, 2002;Johnson and Myklebust, 1967). By adulthood, they haveaccumulated enough psychosocial difficulties to display“among the worst (prognoses) that can be imagined from apsychological perspective” (Rourke, 1989). On this basis,the survivors appear to be at risk for further declines inadjustment over time.

DIFFERENTIAL DIAGNOSIS OF BPPD

Focal lesions in grey matter of the inferior parietallobe and parieto-occipito-temporal junction of the righthemisphere produce the symptoms of BPPD (Hecaen andAlbert, 1978; Luria, 1973; Mesulam, 1985a). The 52 casesin the present series all have radiographically or neu-rosurgically documented lesions in this region. Similarsymptoms result from focal lesions of the white mattertracts projecting to and from the posterior associationcortex (Filley, 2001; Geschwind, 1965; Mesulam, 2000b;Rourke, 1989), especially those severing the tracts thatdirectly underlie the junction (Leibovich et al., 1998;Vallar and Perani, 1986). Furthermore, lesions of uni-modal perceptual zones in the occipital, temporal andsuperior parietal lobes and of the reticulo-cortical tractsinvolved in activating the system can produce similarsymptoms (Goldberg, 2001). The syndrome can also oc-cur without focal findings, for example, in some casesof cerebral anoxia without radiographic abnormalities orin milder trauma cases. In such cases, the syndrome isrevealed by behavioral symptoms, such as those shownon neuropsychological tests.

Diagnosis by analysis of test behavior is hazardous.The symptoms of BPPD converge with deficits seenin both the dorsolateral- and orbital-prefrontal focal


syndromes (Goldberg, 2001; Stuss and Benson, 1986).The overlap is due in large measure to the conjoint partic-ipation of the anterior and posterior association cortices inthe distributed network for planning and problem-solving(Goldberg and Costa, 1981; Mesulam, 2000a) mentionedabove. Damage to either region results in planning and ex-ecution errors. Careful investigation reveals a dissociationin how the errors are made, with anterior lesions impairingexecutive functions such as initiation, set shifting and se-quential organization while posterior lesions compromiseperceptual guidance (Husain et al., 2000; Luria, 1980). Forexample, frontal impulsivity reflects the loss of abilities toinhibit and plan accurately, while BPPD produces casualplanning and careless execution because easy success isassumed. Simple cuing to anticipate errors corrects themonly in BPPD, which shows that full control of the efferentfunctions is preserved. The symptom patterns of frontallobe damage and damage to the right and left posteriorassociation cortices are presented in Table 2.

Association cortex disorders can produce any of sev-eral patterns of defective test performance (Prigatano andKlonoff, 1990; Trexler et al., 1994). Thus testing for pari-etal lobe syndrome must examine a heterogeneous collec-tion of functions (Kolb and Whishaw, 2003; Luria, 1980):“A greater variety of clinical manifestations is likely toarise from disease of the parietal lobe . . . than any other.”(Walsh and Darby, 1999). BPPD is associated with threepatterns of impaired test performance, which may be seenindividually or in combination. The first pattern consistsof prominent deficits in basic visual perception and hemi-field awareness, including neglect on line bisection, fig-ure drawing and visual search tests, and defects in visualsearch accuracy and perception of size, shape or angula-tion on such measures as the Visual Search and Atten-tion Test and Benton’s Visual Form Discrimination andJudgment of Line Orientation. This pattern is associatedwith defective maze performance due to problems withanticipatory gaze tracking and leftward route-finding. Ro-tational errors are seen on procedures such as the SymbolDigit Modalities Test. Finally, slow time scores may be

achieved on Trail-Making and pegboard tasks because ofslow, inaccurate, targeting and balky target shifting.

The second pattern of impaired constructional praxiscan be elicited by Kaplan’s Parietal Lobe Battery of theBoston Aphasia Exam on figure drawing tasks and onWAIS Block Design (Hellige, 1993; Lezak, 1995). Qual-itative features such broken contours (Kaplan, 1989), de-sign rotations and(or a trial-and-error response style (Joyet al., 2001) often accompany poor scores.

The third pattern consists of topographic disorienta-tion and somatosensory dysfunction, as demonstrated ontests of stereognosis and real-world route finding (Barrash,1998; Butters et al., 1970). The third pattern, and to someextent the other two, are associated with impairment onthe most sensitive measure, the Tactual Performance Test(Teuber and Weinstein, 1954). TPT requires not only tac-tile exploration and learning of a form board, but cross-modal integration of sensorimotor stimuli into a spatialmap (Reitan and Wolfson, 1985b). Along with impairedtotal time and often a peak on the nondominant handscore, search excursions may go off the board, poorlytargeted movements push placed blocks out of their slots,and reaches to pick up blocks make misguided return tripsto place them in particular slots on the board. Blocks tendto be tried repeatedly in slots of grossly incorrect shape(e.g. hexagon into rectangle, star into triangle).

CONCLUSIONS

The pivotal contribution that broad-perspective per-ception makes to adjustment and adaptation becomes ob-vious in the long-term follow-up of cases of acquireddamage. When maps to navigate the physical and so-cial world cannot be upgraded or replaced, decisions andgame plans guided by the narrowed perspective shift far-ther off-target as the lesion ages. Blinded to dangers andrisks, survivors casually choose and implement unsafeand unwise courses of action. Unable to anticipate, rec-ognize or understand others’ reactions, they take actions

Table 2. Cognitive-Perceptual Symptoms of Focal Lesions by Region

Symptom Right posterior AC Left posterior AC Frontal

Neglect/hemi-inattention Persistent/left Temporary/right MinimalPerceptual defects Panoramic/gestalt Foveal/detail MinimalAphasia None Receptive ExpressiveAprosodia Receptive None ExpressiveAnosagnosia Severe/global Limited to language ModerateImperception of novelty Severe None InconsistentEmergency responding Disengaged Intact DisorganizedPlanning/problem solving Can’t foresee risks Lacks confidence Executive deficits

20 Schutz

that frustrate, disappoint, offend, betray and alienate themost important people in their worlds with increasingfrequency until they have destroyed most of their rolesand relationships. The loss of these major components ofthe lifestyle only serves to accelerate the obsolescenceof the old navigational programs (Horn, 1992), while theindividuals remain unable to imagine any new directionto take. Awareness of this syndrome and its profoundlong-term consequences alerts health care providers toprepare patients and families for their difficult futures,prompts cognitive rehabilitation specialists to developcompensatory procedures that specifically target BPPDsymptoms, and encourages follow-up researchers to chartthe late progression of the adaptative deficit closer to itsend-point.

ACKNOWLEDGMENTS

The author is grateful to reviewers for their insightfulcomments and suggestions. He is particularly appreciativeof the support and feedback volunteered by Rick Wanlass,Pat Gorman, Judi Schutz, Steve Rosenberg, Doug Dedo,Vince Salveston, and Anna-Lise Christiansen.

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INTERSUBJECTIVITY ANDNEUROSCIENCE

Understanding Enactments and Their TherapeuticSignificance Within Emerging Paradigms

Efrat Ginot, PhDNew York University Postdoctoral Program

in Psychotherapy and Psychoanalysis

Evolving views of enactments as interpersonal manifestations of dissociatedrelational styles are increasingly finding support in attachment studies and neuroscientific research. Understanding enactments as an aspect of the intersubjectiveprocess and as the ultimate communicators of the patient’s neurally encodedearly experiences, this paper examines what enactments convey, and explorestheir interpersonal and neural underpinnings. Unconsciously triggered and com-municated within the intersubjective interaction, enactments reveal the partici-pants’ implicit, neurally encoded relational and emotional patterns that inevi-tably come alive within the analytic dyad. It is suggested that the analyst’seventual self-awareness of her own participation, followed by self-disclosure ofher experience, promote a conscious, verbally articulated encounter with thepatient’s unconscious relational styles, creating opportunities for emotional andneural integration.

Keywords:enactments, attachment styles, neuroscience, self–disclosure

Increasingly, enactments are understood as powerful manifestations of the intersubjectiveprocess and as inevitable expressions of complex, though largely unconscious self-statesand relational patterns. This focus on enactments as communicators of affective buildingblocks also reflects a growing realization that explicit content, verbal interpretations, andthe mere act of uncovering memories are insufficient venues for curative shifts. Rather, agrowing emphasis has been given to the transformational power embedded in unconsciousaffective interactions that bring to life and consequently alter implicit memories andattachment styles (Bromberg, 1998; Fonagy, 1999; Kandel, 1999; Schore, 2005; Stern etal., 1998; Watt, 2000). As intense manifestations of transference–countertransferenceentanglements, enactments seem to generate interpersonal as well as internal processes

Correspondence concerning this article should be addressed to Efrat Ginot, PhD, 111 West 13thStreet, New York, NY 10011. E-mail: [email protected]

Psychoanalytic Psychology Copyright 2007 by the American Psychological Association2007, Vol. 24, No. 2, 317–332 0736-9735/07/$12.00 DOI: 10.1037/0736-9735.24.2.317

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eventually capable of promoting integration and growth. Recently, our understanding ofthe nature and role of enactments has been enhanced by attachment and neuroscientificstudies, highlighting the ubiquity of unconscious communications in early life and thecentrality of implicit brain functioning. Expressed and revealed through enactments areimplicit, neurally encoded, early representations and relational patterns with all theiraffects, defensive adaptations, and behavioral manifestations. By setting the stage fordirect and nonverbal access to the patient’s representational world, enactments take usbeyond transference and interpretations and provide us with a new appreciation of whatit means to know the other.

Construed of mutually reactivated dissociated memories and self-states, enactmentscontain within them entangled implicit relational schemas of both patient and analyst(Stern, 2004; Watt, 2000), and as such serve as a gateway to the patient’s relationalpatterns. In this article, I examine what enactments convey, through what possiblemechanisms, and how the analyst’s self-disclosure of his or her own experience in thedyad contributes to the patient’s self-awareness and growth. Underpinning the discussionare recent and exciting data from attachment and neuroscientific research, two fields thatare emphasizing the importance of neural and emotional integration (Siegel, 2001) andfinding important links between brain and mind, between early experiences and enduringattachment styles, revealing how neurally encoded relational patterns come to life in anenactment.

Enactments, Implicit Memory Systems, and Relational Patterns

Often described as relational impasses, enactments create an intersubjective field in whichboth patient and analyst find themselves in an ongoing emotional entanglement thattemporarily diminishes the likelihood of meaningful reflection (Chefetz & Bromberg,2004; Chused, 1998; Goodman, 1998; Jacobs, 1998). What was a conscious collaborativeeffort seems in danger of collapsing under the weight of difficult, threatening, andseemingly inexplicable feelings and behaviors in both patient and analyst. At their mostextreme, enactments threaten to halt the analytic process altogether or get out of control.Whether sudden or insidious, early or late in analysis, or long or short in duration,enactments are almost always a surprise. Whether resulting from a patient’s raw trans-ferential feelings and distorted perceptions that find conscious and unconscious emotionalechoes in the analyst or from a pervasive, deadened atmosphere of being stuck and notmoving, enactments indicate that something is out of sync. This “something” and itsremarkable implications for clinical practice are the focus of the following discussion. Toexplore enactments within the context of both attachment and neuroscientific studies, thefollowing vignette, which took place about 2 years into the analysis, highlights howunconscious intersubjective processes embody and reveal early relational styles and alsointroduces the important role of the analyst’s self-disclosure.

A professional, middle-aged woman, married with two children, Tina had been inanalysis before and, according to her, learned a great deal about herself and her relation-ship with her parents, both Holocaust survivors, now deceased. Explaining her wish tobegin analysis again, Tina said that she was aware of some recurring behaviors she wishedto change. She did not like how oppositional she was and how easily argumentative shebecame in many situations. She suspected that her automatic opposition to others’opinions was really hurting her ability to achieve more and have easier relationships. She

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also wanted to further understand her difficulties with “needing others,” a lifelong problemshe attributed to her need to take care of her emotionally devastated mother and “cure” herof feelings of grief and sadness.

Tina related all this with an earnest, optimistic demeanor, interspersed with cynicismand self-deprecating humor. She would give this process a trial, she said, adding thatmaybe what was behind her opposition “is something so dark and scary that we would notbe able to deal with it.” This was not said with a warning tone or with hostility. It did noteven feel like a challenge, but rather like a neutral, matter-of-fact statement. In any case,she said, “Not to worry, I’ll be a good patient.” Listening to her, I was surprised to findmyself feeling both optimism and dread, reacting to what was said, but more so to someunuttered and unidentified feelings as well. I felt worried about future clashes and at thesame time was aware of a wish to provide her with the opportunity to safely encounterwhat was clearly too painful to be integrated and become part of her conscious sense ofherself.

Tina indeed started as a “good” patient. She easily talked about her past treatment, heroverprotected and yet emotionally demanding upbringing, and her problematic relation-ship with her husband. Rather quickly, it became apparent that Tina was well rehearsedin telling her story. It’s not that her words did not resonate or lacked affect. She expressedfeelings of anxiety and sadness, especially when recalling how miserable and griefstricken her mother always seemed to her. What seemed stale was Tina’s assured way ofpresenting her feelings and thoughts. It was as if she was not curious at all about any newpossibilities or discovering something fresh about herself.

With time, Tina settled into a challenging and bantering way of relating, interspersedwith being compliant and seeking recognition for it. When she was argumentative, Tinawas not openly hostile or contemptuous, but rather playfully thwarting, needing to besmart, be right, and have the last word. At other times, she seemed eager to please,agreeing with me and complimenting me for my interventions. Tina’s compliments andcompliance made me feel uneasy and anxious. I was vaguely aware of fearing retaliation,devaluation, and a pending attack. At the same time, I had the odd feeling that Tina’sflattering words were not really directed at me; they felt more like a generic, well-practiced brush-off, an attempt to keep me at bay. It became clear that even when she wasagreeing with me, Tina was not really agreeing. She somehow molded and shaped anyintervention to suit her own known frame of reference. When feeling frustrated andirritated, I would ask myself whether unconsciously I was somehow contributing to thegrowing staleness of our sessions.

When I discussed my experience with Tina, she quickly agreed with me. She said thatshe was again reverting to her “old habit of being in control” of herself and of thesituation, a control that protected her from becoming vulnerable and needy. She acknowl-edged how guarded she was of letting anybody help her; it was “too unfamiliar” for her,and she did not really know how to do it. Tracing her behavior to her depressed mother,Tina felt that there was very little room in any relationship for her to be overtly needy.Being self-sufficient and feisty was most comfortable and natural for her. Her caretakingrole as a child with both her anxious and sad parents again moved to the forefront.However, these discussions as well would quickly drift to known territories and, ratherthan opening up the inquiries to additional emotional memories and experiences, seemedto close them off.

As time went by, I realized that the core of our interaction was construed around adance that Tina performed with great expertise. Somehow, using her abilities to analyze,explain, joke, and thwart, Tina exerted unwavering control over her emotional responses

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and over the emotional atmosphere of our interaction. My various interventions wereheard, examined, and then subtly dismissed. Tina, it seemed, simply could not take muchfrom me in any meaningful way. Although I understood and could even empathize withTina’s need to be self-sufficient, a topic that was frequently discussed in relation to herhistory with her parents, I still felt superfluous, diminished, and unimportant. Tina coulddo the analysis very well without me. She already knew it all, and what she needed of mewas an ongoing validation of her insights and conclusions. Often I would catch myselfdrifting away, too reluctant to reengage, preferring my own private world, feeling thatputting any real stamp on the process was mostly useless.

With a growing sense of anxious unease, I realized that the more Tina talked abouther need to take care of her mother in that old familiar way, the more suffocated andstifled I felt. What I was not aware of yet was my growing inner rebellion againstbeing so often thwarted and pushed away. Consequently, our interactions exceedinglyreflected largely unconscious mutual communications that could not yet be reflectedon and understood—in essence, an entanglement of implicit relational patterns ema-nating from both of us. Unaware, I became more active and verbal than ever before,repeatedly attempting to direct our interaction, in essence trying to wrestle somecontrol away from Tina. Over a period of a few sessions, I relentlessly challengedTina’s expressed feelings and explanations, deeming them too intellectual, rehearsed,and in the service of her defenses. It was not that my interventions were dynamicallyincorrect; some of the interpretations and observations had been discussed before.Rather, the emotional context of these interventions, my lack of felt empathy, myfeelings of suffocation, and my overly active and controlling behaviors should all havealerted me to the fact that I was deeply involved in an enactment. At the time,however, although feeling uncomfortable and anxious with feeling suffocated andrendered useless, I was not aware of my actions.

After these sessions, Tina would leave the office angry, defiant, and visibly distressed.But when she described her feelings and reactions during the next session, what I heard,however, was not Tina’s vulnerability but more of the same; an unreflected-on, consumingneed to fight me and thwart my attempts to help her. All through these few weeks, myfeelings of suffocation and deadness became more and more palpable, lodging themselvesin my body, which at times felt paralyzed and listless.

During one especially difficult session, when my behavior seemed to communicate toTina that wherever she was, was not where I wanted her to be, Tina burst into tears, herface and body displaying great agitation. Amid sobs, she described how pushed andprodded she felt, how very anxious and alone. She said that she really wanted to pleaseme, but did not know how, and now she felt deeply disappointed in both of us. Just as withher former analyst, she felt hopeless, lost, and misunderstood. I wanted something fromher, and she did not know what it was. All she felt was pushed and coerced. My initialreactions were a mix of guilt, defeat, and a sense of failure. Not only could I not reachTina, I utterly misunderstood her. At the same time, I also became aware of a growingfeeling of sadness, a sadness that not only echoed Tina’s emotional state, but also seemedto have generated in some unnamed deep well of sorrow and despair. The more familiarfeelings of being controlled and suffocated no longer seemed urgent or threatening.Becoming painfully aware of my insistent, pushy participation and feeling on shakyground, I verbally acknowledged to Tina that indeed I had been blind to how I wasbehaving in the last few sessions and oblivious to how it made her feel. I also describedthe overwhelming sadness that I had just experienced, wondering aloud how I came to feelso intensely sad.

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Tina felt deeply wounded and held me responsible for “totally missing the boat.”“Why is it so important to you to control what I need to say, to push your agenda?” sheasked, with tears and bewilderment. Still feeling defensive, I answered that I was not quitesure what had taken place during the last few sessions, and for some time before, but I wascertain that as difficult as the experiences between us were, we needed to understand whatthey meant. I apologized for my behavior again, for being pushy and hurtful, but also saidthat what had happened, our mutual emotional misses, had been building up for a while.They seemed to be part of something bigger than us, something that could teach us a greatdeal about her internal world and mine. As the session ended, I did not yet have a chanceto describe the feeling that was most disturbing to me, the sense of deadening suffocation.

Tina left that session still feeling agitated. At the next session, she reported thefollowing dream: We are both sitting in my office and she is asking me, “Why are wehere? There are no windows in this office.” She feels a growing panic, and with dreadrealizes that I can’t help her, nobody can. She feels on the verge of suffocating and forcesherself to wake up. While discussing the dream (noting that in reality the office has a big,light-filled window), Tina for the first time experienced and expressed her thoughts andfeelings in direct and immediate ways. She was clearly and openly angry, sad, andfrightened. All at once, she became fully aware of an intolerable sensation of beingenclosed, held down, and suffocated. Her heart was racing, and her head felt light withpanic. She felt like her chest and her head were going to explode.

While disclosing to Tina my own frequent sense of being controlled and suffocated byher and how closely these feelings echoed her own, Tina’s distressed intensified. But shewas not running away from her frightening feelings and experiences this time. On thecontrary, she desperately wanted to understand our tumultuous interactions. As we talked,it became clear to both of us that something very important was embedded in ourseemingly mismatched communications. It was not only her need to take care of hermother that colored Tina’s interactions, nor was it her argumentative and evasive behav-ior. Fully dissociated was her enormous dread of being emotionally invaded and con-trolled. The painful, protracted enactment exposed core, unconscious relational patternsand affective memories that characterized almost all of Tina’s interactions with oth-ers—an intense fear of being emotionally violated and forced to adapt to the other andmyriad automatic defenses all designed to preserve her sense of autonomy. Unaware, Icame to embody both the emotionally invasive mother and Tina’s own dissociatedself-state, one that could find its own voice only through creating a refuge in stubbornwithholding and fighting back.

A growing visceral understanding of Tina’s tortured relationship with her motherbrought into focus a relational pattern characterized by an intense desire to be a gooddaughter, to ease and erase the mother’s unbearable past, and concurrently also by a strongfeeling that she was entirely taken over by the very despair she was attempting to releaseher mother from. It was not her mother’s verbal communications that made Tina feel takenover and suffocated, but rather what Tina felt to be an all-encompassing sense of sadnessand despair that was constantly and nonverbally transmitted to her. Dissociated memoriesand experiences from her unmentioned traumatic past permeated many of the mother’sunconscious communications to her daughter. There was no place for Tina to hide; hermother’s unprocessed experiences resided in the basic modes of her interactions withherself and with the world. Having a close, loving relationship meant succumbing to andinhabiting her mother’s emotional life. At the same time, feeling increasingly suffocated,Tina also needed to carve out for herself her own sense of an independent subjectivitythrough defiance and argumentativeness that she was driven to use with others in her life.


Exchanging unconscious communications, we both simultaneously reacted to andtriggered implicit affective memories, fantasies, and defenses. In our subsymbolic(Bucci, 2001, 2005) interchange, I was the one called on to enact what was mostfrightening, almost annihilating, becoming through my behavior the emotionallyoppressing mother. And like Tina, in the face of her emotional control I alsoexperienced an increasing pressure to resist the feeling of suffocation, to withdraw andpreserve my own subjectivity. Unaware, I embodied Tina’s dissociated self-states, notfully recognizing their ferocious emotional depth and meaning until after the enact-ment took place.

The defensive control Tina exerted on the sessions was observed and talked aboutnumerous times, but merely acknowledging and analyzing it did not create theinterpersonal space in which to authentically experience and understand its multilay-ered meaning. On the contrary, talking only seemed to perpetuate and strengthen theoscillation between compliance and defiance. My introjection of Tina’s projecteddread of being invaded by an oppressive emotional state that did not belong to her, andmy participation in an enactment that conveyed both the fear of suffocation and thedefenses against it, enabled us to become aware of dissociated self-states that oftenrepeated themselves. The unarticulated sense that passive compliance was the condi-tion for maintaining any relationship and the simultaneous fight to preserve her ownsense of autonomy underpinned many of Tina’s close relationships, including the onewith her husband. Maintaining an “optimal” distance from others, draining andunsatisfying as it was, became Tina’s unconsciously constructed compromise. Havingan insight into her “tendency to oppose and argue” was not sufficient for integrationand growth. Rather, an intersubjective stirring of Tina’s implicitly encoded earlyemotional and interpersonal attachment patterns gave voice to what was sensed butstill not a part of a conscious sense of self. By being enacted and thus remembered,these early implicitly encoded patterns had the opportunity to be recognized, analyzed,and integrated.

Indeed, Bromberg (in Chefetz & Bromberg, 2004) spoke of enactment as thepatient’s effort to negotiate dissociated self-states that, owing to traumatic experi-ences, are not verbally symbolized. Similarly, D. B. Stern (2004) viewed enactmentas the interpersonal manifestations of unformulated dissociated self-states not allowedto conflict with conscious ones. Noting the inevitable relational impasses that accom-pany enactments, some clinicians see them as venues for communication whose realmessage to the analyst is to get engaged with the patient truly and authentically. Suchan engagement, guided by the analyst’s countertransference, can help uncover andresolve painful attachment patterns originating from the patient’s implicit memoriesand fantasies that left unexplored are doomed to repeat themselves (Chefetz &Bromberg, 2004; Chused, 1998; Goodman, 1998; Jacobs, 1991, 1998; Pizer, 2003;Renik, 1998). By embodying inevitable repetitions of early learned and internalizedemotional and defensive patterns, enactments are in essence an expression of therepetition compulsion process whose unconscious form needs to be made consciousand integrated (Freud,1914/1958; Watt, 2000).

This theoretical and clinical view of enactments as interpersonal manifestations andembodiments of the patient’s dissociated self-states is increasingly finding a strong echoin both attachment and neurological research. Data from both these fields help furtherdecipher what enactments communicate in such gripping and, at the same time, disownedand indirect ways.

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Enactments, Attachment Studies, and Neuroscience

Recent neuroscientific findings have provided convincing data that interactional patternsbetween infants and caregivers create lasting neural changes in the brain’s networks,resulting in enduring attachment styles, affect regulation patterns, and modulatory emo-tional set points that last from infancy through adulthood (Beutel, Stern, & Silversweig,2003; Cozolino, 2002; Schore, 1994, 2005; Siegel, 1999, 2001). Although the exactneurobiological mechanisms that underlie neurodevelopment are not yet fully explicated,the role of the amygdala in establishing fear (LeDoux, 2002) and the emotional andinterpersonal qualities of the right brain (Schore, 2005) are among the neuropsychologicalmodels extensively researched. Fulfilling an evolutionary function to detect and respondto threatening stimuli that may affect survival, the amygdala, active from birth, mediatesthe infant’s emotional responses to his or her environment (Cozolino, 2202; LeDoux,1996, 2002). Encoding the visceral sensations and affective qualities that accompany earlyinterpersonal events, the amygdala and its related neural pathways establish implicitmemory systems, defensive adaptations, and attachment schemas.

As demonstrated by LeDoux (1996, 2002), fear conditioning by the amygdala is animplicit form of learning occurring without conscious awareness from early infancy. Inaddition to storing implicit memories pertaining to perceived danger situations in its owncircuits, the amygdala also modulates the formation of explicit memories in the circuits ofthe hippocampus. An emotional environment that is primarily one of anxiety and misat-tunement results in the more frequent activation of the fear systems and of automaticdefenses geared to deal with the felt anxiety (Cozolino, 2002; LeDoux, 2002). Conse-quently, parallel learning processes shaped by different emotional, cognitive, and memorystorage networks are generated. According to Cozolino, in such an environment thedeveloping neural systems become skewed toward creating and repeating self-statescharacterized by heightened interpersonal anxiety and poor affect regulation rather than bypositive affect and openness. As a result, split and conflictual attachment modes develop,such as those I experienced with Tina. The degree of neural dissociation between theserepresentational networks will determine which attachment state will be most oftenemotionally reactivated and repeated. Into adulthood, regardless of actual experiences, theamygdala networks, drawing on early fear conditioning, will continue to focus on whatthey perceive as interpersonally threatening and anxiety inducing (Cozolino, 2002;LeDoux, 2002; Schore, 1994; Siegel, 1999). These neurally encoded emotional andinterpersonal patterns constitute, according to Lyons-Ruth (2003, p. 88), “enactive rep-resentations that are developed in infancy before the explicit memory system associatedwith consciously recalled images or symbols is available.”

The early-maturing right brain also seems to be involved in implicit emotionallearning that precedes verbal development (Schore, 2005), and as such “represents thebiological substrate of the dynamic unconscious” (p. 831). Unlike the more conscious andexplicit processes tied to the left hemisphere, the right hemisphere has been connected toearly implicit information processing and to emotional memories and experiences thatunderpin the self-schema and the individual’s sense of self (Happaney, Zelazo, & Stuss,2004; Miller et al., 2001). Following these findings, Schore (2005) described howaffective attachment interactions between mothers and children shape the neurodevelop-ment of the right brain limbic system, dominant for implicit emotional patterns.

Indeed, attachment studies have demonstrated strong connections between interac-tional patterns of mothers and infants and subsequent styles of secure, avoidant, anxious–ambivalent, and disorganized attachment (Diamond, 2004; Fonagy, 1999, 2001; Fonagy et


al., 2002, 1999; Hesse & Main, 1999; Main, 1993; Siegel, 1999). Recent longitudinalstudies have found that disorganized attachment behaviors in infancy endured as disso-ciative symptomatology at age 19 and were related to patterns of parent–infant affectivecommunication and interaction (Lyons-Ruth, 2003). Infants evaluated as displayingdisorganized attachment showed conflictual and contradictory behaviors toward themother, as well as frozen, disorganized, and undirected behaviors. The caretaking behav-iors that were most consistently related to disorganized attachment and then to a disso-ciative structure were emotional unavailability, disruptive responses, and maternal self-absorption that overrode the infant’s needs. Consistent with previous findings (Fonagy,2001), the study found that unmentalized and therefore unintegrated self-states in thecaregivers themselves were also highly connected to disorganized attachment styles.

Paralleling LeDoux’s (2002) emphasis on amygdaloid fear conditioning and defensivereactions such as withdrawal, aggression, and submission and Schore’s emphasis on theright brain, Lyons-Ruth (2003) concluded that attachment strategies designed to deal withaffectively stressful interactions are early defensive adaptations that develop due to thecaregiver’s failure to provide soothing responses in the face of the infant’s stress or fear.Underlying the infant’s quick, automatic coping responses to nonverbal affective cues arepreverbal implicit neural processes (Lyons-Ruth, 1999). Dovetailing with these observa-tions, Siegel (1999, 2001) has also demonstrated that the quality of the early attachmentrelationships determines social and emotional development by affecting brain structuresthat mediate these experiences.

Of special significance is the realization that before the full development of highercortical systems, when the emotional brain is the active entity, children seem to beespecially vulnerable to misattunement of affect and gesture, to fear-inducing interactions,and to parental projections and attributions (Beebe & Lachman, 2002, 2003; Blatt & Levy,2003; Fonagy et al., 2002; Lieberman, 1999; Siegel, 1999, 2001). Considering the role ofthe amygdala and its related neural networks in emotional learning, attachment patternsare essentially implicit procedural schemas containing sensory, motor, emotional, andcognitive memory systems. These multiple memory networks, dissociated from theconscious sense of self, but highly repetitious, are enacted in any relationship that triggersold emotional patterns and defenses that proved successful in dealing with them(Cozolino, 2002; LeDoux, 2002; Siegel, 1999, 2001). Tina’s repetitious but dissociatedemotional conflicts and defenses come to mind. It is important to note here, however, thatin further trying to understand the nature of enduring relational patterns, highly complexinteractions between various predispositions and the environment should also be consid-ered. Most likely, this will be the next frontier in neuropsychoanalytic research.

Enactments and Retrieval Cues

Embedded in the psychoanalytic relationship is the patient’s hope to be emotionallyknown and understood (Bromberg, 1998). Accompanying these wishes, however, areimplicit affective memories, repeating conflicted and tortured attachment styles. Thisunique mix of promise, on the one hand, and the perceived threat triggered by it, on theother, seems to rekindle and reproduce the neurally encoded memory networks. Intersub-jective by nature, but inherently asymmetrical at the same time (Aron, 1996; Lyons-Ruth,2003), the analytic relationship, as well as the analyst’s unique personality traits, serve asretrieval cues (Carroll, 2003; Rustin & Sekael, 2004) for the early interactional patternsand schemas. Similarly, according to Bucci (2001, 2005), the therapeutic relationship

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activates the dreaded, dissociated, maladaptive emotional schema that brought the patientinto treatment in the first place. At the same time, these very same patterns are the ones“that he simultaneously wants to examine and to avoid” (Bucci, 2005, p. 861).

Frequently, however, retrieval cues cannot be readily identified as starting in orbelonging to either of the participants separately; they develop in a complex but uncon-scious back-and-forth mutual communication. The analyst’s own emotional experienceswith the patient are at once a reaction and a source. They may express the process ofintrojective identification, but at the same time they also constitute unconscious emotionaltriggers (Davies, 2004; Watt, 2000). My own personal resistance to being pushed andforced into an emotional stance was an unconscious echo of Tina’s reactivated emotionalschema with her mother. But the more I unconsciously protected my sense of self bydisconnecting from the emotional impact of her experience, the more insistent shebecame.

Here we encounter the heart of an enactment, in which the interaction that is beingcreated contains within it unconscious relational elements of the two participants, con-sciously and unconsciously reacting to and affecting each other. And just as betweenparents and children, awareness of the experience is the remedy, creating in analysis theopportunity for meaning and symbolization (Bromberg, 1998; Lyons-Ruth, 2003). As isargued later, this awareness can be greatly helped through the analyst’s self-disclosure ofhis or her own experience, a process that can only occur once one of the participantsrealizes that an enactment has taken place. Having examined what enactments commu-nicate, in the following segment I consider the role of unconscious communication inenactments.

Enactments as Mediators of Unconscious Communications

The ways in which neurally encoded attachment patterns are transmitted within an intersub-jective interaction are relevant for both parent–child and patient–analyst dyads. An extensivebody of infant research as well as clinical observations have documented unconsciouscommunications embedded in facial expressions, gestures, and verbal and behavioral displays(Beebe & Lachman, 2002, 2003; Bromberg, 1998, Chefetz & Bromberg, 2004; Diamond,2004; Fonagy et al., 2002; Freeman, 2000; Lyons-Ruth, 2003; Schore, 1994, 2000; Siegel,1999; Stern, 1985). Projective identification and its complementary process of introjectiveidentification have largely been considered as the intersubjective process capable of transmit-ting dissociated affects, expectations, and defensive strategies, in essence “forcing” the otherto comply internally and behaviorally with the projected disowned (Davies, 2004; Lieberman,1999; Ogden, 1986, 1994; Racker, 1968; Seligman, 1999; Silverman & Seligman, 1999).

Schore’s (1994, 2000, 2005) findings regarding the development of the social brainvalidate the process of unconscious transmission of parental self-states. Innately regulatedby the attunement between the right hemispheres of both mother and infant, the mother’sself-states are transmitted to the child’s through myriad nonverbal communications. Beingextensively connected to the limbic system and thus sensitive to interpersonal appraisaland emotional processing, the right hemispheres of both mother and child are especiallyactive in the infant’s first 2 years. During this time, according to Schore, the mother’s righthemisphere is the child’s first reality. Her emotional preoccupation with the infant and herefforts at attunement are the bedrock for implicit memories and relational modes, pro-jected to the child’s receptive right hemisphere (Cozolino, 2002; Schore, 2000, 2005).


Further supporting the role of the right brain in processing nonverbal communicationis Schore’s (2005) conclusion that the development of the infant’s ability to efficientlyprocess visual cues from the caregiver resides in the right hemisphere and not the left. Apositron emission tomography study of 2-month-old infants looking at images of awoman’s face detected activation in the infants’ right visual area, the right fusiform gyrus(Tzourio-Mazoyer et al., 2002). Similarly, a functional MRI study (Ranote et al., 2004) ofinfants 4 to 8 months old demonstrated that mothers looking at videos of their infantsshowed activation of their right brain visual areas, the right anterior inferior temporalcortex responsible for processing facial emotional recognition and expression, and theoccipital gyrus, involved in visual familiarity. LeDoux (2002) also maintained that facialmisattunements register in the infant’s right hemisphere and are perceived as danger in theamygdala region.

Within the intersubjective interaction in the psychoanalytic dyad, similar implicitcommunication is constantly taking place. On the basis of recent neurobiological findings,Schore (2005) maintained that the ability to receive and process implicit communicationsis “optimized when the clinician is in a state of right brain receptivity” (p. 842). Accordingto Adolphs, Damasio, Tranel, Cooper, and Damasio (2000) and Damasio (1994), the righthemisphere is involved in recognizing other people’s emotional expressions and isfacilitated by internally generated bodily sensations interpreted by the right brain and notby the more analytical left hemisphere. Thus, the analyst’s right brain, according to Schore(2005), allows the analyst to know the patient in the most immediate and direct way.Schore concluded that the intersubjective field contains within it not just an emotionalinterchange but a bodily one as well.

Further understanding of the mechanisms underlying unconscious emotional exchangeis provided by new research exploring mirror neurons found in the inferior frontal andposterior parietal cortex. Mirror neurons are activated not only when one participant isobserving another, but also when the participant is engaged in an active relationalinteraction with the observed, such as an expressive imitation of the action or affect(Gallese, Fadiga, Fogassi, & Rizzolatti, 1996; Gallese, 2003; Pally, 2001; Wolf, Gales,Shane, & Shane, 2001). Furthermore, mirror neurons in humans are involved not only inaction recognition but also in grasping the intention of others and automatically inferringforthcoming new goals. This new finding broadens their perceived function from mereimitation and recognition to instantaneous understanding of goal and intent (Iacoboni etal., 2005).

Gallese (2003) proposed that a similar neural mechanism “could underpin our capacityto share feelings and emotions with others. . .sensations and emotions displayed by otherscan also be ‘emphasized’ and thereforeimplicitly understood, through a mirror matchingmechanism” (p. 176). Mirror neurons in Gallese’s model can further explicate therelationship between affective interaction and empathy and between empathy and bodilysensation. Emotional links and sensory responses to others are activated through com-municated gestures, vocal tones, postures, and facial expressions, creating an intuitive oran implicit knowledge of them and, according to Gallese, an expanded notion of empathy.Thus, mirror neurons, which have been found in both children and adults, create anactively shared intersubjective space where the other’s emotions can be implicitly per-ceived, and only then understood.

Indeed, mirror neurons have been implicated in the activation of limbic systemnetworks such as the amygdala, which are critical to emotional learning and processing.Among those tested with functional MRI, the observation and, more so, the imitation offacial expressions significantly activated areas in the amygdala involved with emotional

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behavior and the recognition of emotional expressions in others (Carr, Iacoboni, Dubeau,Mazziotta, & Lenzi, 2003). Most likely engendering the dual processes of projective andintrojective identification, unconscious communications mediated by mirror neurons giverise to enactments, eventually enabling the analyst to use his or her own emotional andbodily “sense” of the patient to identify attachment patterns.

Enactments as Intersubjective Ways of Knowing

The realization that the verbal content of an interaction constitutes only a part of a muchlarger whole is highlighted by the findings that most of the information encoded and usedoperates out of awareness (Cozolino, 2002; Edelman, 2004; LeDoux, 2002; Stern et al.,1998). The psychoanalytic echo of the mirror neuron studies can be found in the work ofthe Process for Change Group (Stern et al., 1998) that has explored the noninterpretivemechanisms of therapeutic change. Emphasizing the shared relationship, they see apowerful therapeutic action within implicit intersubjective communication and knowl-edge, termed amoment of meeting.The foundation of the “shared implicit relationship” islocated in “the primordial process of affective communication, with its roots in the earliestrelationships” (Stern et al., 1998, p. 918).

The implicit relational knowledge that is part of the shared relationship can be seen,then, as culminating in an enactment that by its enmeshed nature allows the analyst’sunmediated experience of the patient’s enduring relational patterns. Paradoxically, in spiteof the inherent difficulties and uncertainties that accompany them, enactments can alsoprovide the most significant and direct ways for both patient and analyst to connect withwhat needs to be known, recognized, and integrated as part of a developing sense of self.In this context, enactments contribute to an intersubjective mode of empathy based notonly on an emotional echo of the patient’s explicitly expressed feelings, but on anunconscious experience that directly connects with the patient’s dissociated emotions,defenses, and attachment patterns (Bolognini, 1997; Chefetz & Bromberg, 2004; Ginot,1997, 2001; Racker, 1968; Tansey & Burke, 1995).

The very immediacy that enables enactments to become an authentic encounter canalso present the analytic process with potential pitfalls. A thin line may exist betweensuccessfully understanding and analyzing an enactment and succumbing to its destructivepotential to derail the analytic treatment. Much further study is needed to better know howto navigate it. It is proposed here that the analyst’s self-disclosure of his or her ownexperience may constitute an important clinical aspect of enactments and may provide oneof the most powerful tools toward conscious growth and integration.

Enactments, Self-Disclosure, and Integration

The importance of integrated self-states as well as of neural networks for the experienceof well-being, self-awareness, and effective functioning is underscored both in clinicalwork and in the neurosciences. Paralleling the clinical observation of dissociative self-states and attachment styles is the notion of weakened neural integration. Both Siegel(1999, 2001) and Schore (1994, 2005) maintained that the emotional regulation estab-lished in the early mother–infant interactions contributes to the organization and integra-tion of various neural networks critical to affect and self-regulation and explicit memoryfunctions. Similarly, LeDoux (1996, 2002, Panksepp (2003), and Cozolino (2002) em-phasized the centrality of integration between the emotional brain and higher cortical


functions, and in Bucci’s (2005) model the integration between the subsymbolic and thesymbolic systems is enhanced in analysis through a connecting or a “referential” process.

From a psychoanalytic point of view, as well as from a neuroscientific perspective, thetherapeutic endeavor seeks to strengthen integration between networks of affect andcognition (top, cortical/down, limbic system) and between networks of the right and theleft hemispheres (Cozolino, 2002). Whereas the right hemisphere is more densely con-nected to the brain stem and the limbic system and mediates feeling, sensing, andunderstanding one’s own mind as well as others’, the left is more linked with higherexecutive functioning and is thought to be the “interpreter” or “explainer” of experiences.Impaired neural integration prevents the conscious recognition of overwhelming experi-ences of trauma or grief, resulting in a greater influence of the lower impulsive andemotional regions of the brain at the expense of reflective, more rational processes (Siegel,2001). Enhanced integration of these various networks is essential for symbolization andacceptance of affect and experience, for affect tolerance, and for fluid connectionsbetween implicit and explicit memory systems. A growing integrative capacity, accordingto Siegel (2001), may enable the individual to establish a “coherent dyadic state” (p. 87),creating the capacity for compassion. Siegel further hypothesized that such a capacity isthe basis of secure attachment.

The implications for clinical work are obvious and important. According to Cozolino(2002), integration is made possible through “the simultaneous or alternating activation ofconscious language production (top and left) with more primitive, emotional and uncon-scious processes (down and right) that have been dissociated due to undue stress duringchildhood or trauma” (p. 31).

Paradoxically, it is the analyst’s subjective experience, gained through bypassingcognitive functions, that also enables the analyst to promote integration. The analyst’srealization that his or her part in an enactment is not entirely his or her own, that in somefundamental way it echoes, possibly through mirror neurons, the patient’s earliest attach-ment styles, gives the act of self-disclosure its transformational power. This stance canprovide for both patient and analyst some missing links, some new understanding aboutburied memories and relentlessly self-defeating relational patterns. The mutual reflectiveexamination enables the patient to become conscious of and integrate formerly implicitpatterns stored and activated in pathways more closely related to the limbic system andlink them to higher cortical functioning (Beutel et al., 2003; Bromberg, 1998; Cozolino,2002; Fonagy, 1999; LeDoux, 1996, 2002; Schore, 1994, 2000, 2005; Siegel, 1999, 2001).

Neuroscientific findings have also confirmed clinical observations that without signif-icant affective experiences, any analytical movement toward change is short lived at best.Indeed, neuroscientists have demonstrated that stress and emotional stimulation changeneural connectivity and brain plasticity, most likely through a changed biochemicalenvironment (Cozolino, 2002). Cowan and Kandel (2001) concluded that affective arousalresults in the increased presence of neurotransmitters that consequently allow for neuralrelearning and cortical reorganization. Certainly, the raw emotional environment gener-ated by an enactment provides the necessary emotional arousal conducive to neuralchanges. The analyst’s self-disclosure provides the other element contributing to growth,an authentic encounter through which difficult feelings can be experienced, verbalized,understood, and integrated.

Analyst self-disclosure is only one possible resolution to an enactment, but a poten-tially effective one. The analyst does not know better how the patient feels and what thepatient needs; rather, through being part of an enactment the analyst inevitably feels whatbelongs to the patient as well. Containing the experience of the two participants as one unit

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in the intersubjective space renders the analyst’s self-disclosure an interpersonal actproviding a holding environment (Ginot, 1997, 2001). It is important to note at this pointthat the issue of the analyst’s self-disclosure is not considered here as a general analyticaltechnique. Disclosure of general personal information is not encouraged, nor is it regardedas an acceptable way to promote a sense of intimacy. Rather, self-disclosure is seen hereas an integral element in the resolution of enactments: It represents the essence of thecollaborative efforts of both participants, giving voice to the hidden and dissociated.

Conclusion

No other aspect of the psychoanalytic process represents its enormous interpersonalcomplexity, its great opportunities for change, and its potential pitfalls and quagmires asdoes the presence of an enactment. And no other interpersonal event in psychoanalysisgenerates quite the same quality and range of affect, confusion, and unconscious behaviorsin both participants. Capable of temporarily thwarting a mutual and reflective analyticalexchange, an enactment can sometimes create an impasse that threatens to derail theanalytic process. By embodying the most intense manifestations of the transference–countertransference interaction, enactments expose and repeat some of the fundamentalbuilding blocks of the patient’s earliest self- and other representations while simulta-neously engaging some of the analyst’s own unconscious relational schemas. The ensuingcomplex and inevitable intersubjective processes within the psychoanalytic dyad provideboth patient and analyst with enormous opportunity for reflective interpretive work basedlargely on interpersonal interactions that reveal the patient’s relational style.

The introduction of neuroscientific findings to further explore and understand in-tensely emotional intersubjective processes such as enactment opens up important newways to integrate clinical work and the insights it provides with the growing informationregarding the complex functioning of the brain. Using recent findings from the field ofneuroscience and attachment studies, I have examined how implicit, neurally encodedattachment styles unconsciously find repeated expression throughout life and come to lifein enactments. This article is a part of a growing body of work attempting to enrich ourtheoretical knowledge and clinical efficacy through an integrated clinical approach, takinginto account how the brain forms its complex neural networks and how they, in turn, shapeour human experience.

The newly created bridges between brain and mind will steadily and continuouslycontribute to the psychoanalytic endeavor, providing increasingly clearer, multilayeredcontexts for enhanced psychodynamic and clinical understanding. The discovery of mirrorneurons, for example, has shed important light on the intersubjective process and theunderpinning of empathy. Similarly, the proposition that enactments are intersubjectivemanifestations of neurally encoded attachment patterns acquired within the context of theprimary relationships is an example of how seemingly unconnected areas, in this caseintersubjectivity, attachment, and neuroscience, inevitably intersect with and illuminateeach other.

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