Crescendos and Descrescendos: A review of Allan Schore’s “Clinical Implications of a Psychoneurobiological Model of Projective Identification,” which explains a mechanism of change in Synergetic Play Therapy
Introduction
“The therapist turns his own unconscious like a receptive organ towards the transmitting unconscious of the patient so the doctor’s unconscious is able to reconstruct the patient’s unconscious” Freud p.77 blue
Synergetic Play Therapy treats children exhibiting troubling or unexpected behavior and behavior that is emotionally younger than their chronological age. These children may have experienced early developmental trauma, attachment challenges, invalidating caregivers, or non-relational trauma. Psychological concepts that underlie therapists’ choices in Synergetic Play Therapy include emotional literacy and regulation, stages of child development, projective identification, hyper- and hypo-arousal states, and empowerment.
SPT is an effective play therapy where the narrated regulation of induced affects characterizes the therapists’ activity in session. A basis for understanding the efficacy of this treatment is found in Allan Schore’s “Clinical Implications of a Psychoneurobiological Model of Projective Identification” (Chapter 3, Schore, 2003). Schore explains projective identification as the process that induces affects in the therapist, and that projective identification has a “fundamental role” in developmental treatment (p.64). The child learns to manageably experience affective states, sensation, and feelings through right brain to right brain unconscious communication with the therapist, who is accurately attuned to the child.
Schore’s chapter includes findings from research that offer scientific support for the phenomenon play therapists experience when working in the Synergetic Play Therapy model. Explaining “how play therapy works” engages colleagues and increases parents’ confidence in the process. Topics in the chapter include defining projective identification, neurological bases for projective identification, interactions with dissociation, therapist receptivity, and therapist responses that facilitate relational processing.
Synergetic Play Therapy
SPT is a two-mind therapy where the child naturally, unconsciously, projects difficult, unmanageable, and overwhelming emotions into the therapist, who then receives, narrates and regulates the experience. Over the course of therapy the “feeling in the room” changes as the child-therapist dyad experiences and processes emotional content. At first there may be strong feelings of tiredness, confusion, fear, or overwhelm that gradually shift to feelings of interest, friendliness, relationship, and joy. A child “looping” or “escalating” in play themes is seen as a bid for the therapist, who may be consciously or unconsciously defending against the induced feelings, to “get it.” The child plays out themes that indicate different emotional ages, “going back” to process intense experience from various times in the child’s history.
SPT and Schore agree that “therapeutic regulation and not interpretation … is the key to the treatment of developmentally disordered patients” (Schore p. 63).
Clinical Vignette
Caleb is an 8 year old boy in a two-parent system along with his younger sister. Caleb presents with daily “meltdowns” usually lasting many hours, where parents are struck, items are thrown, and the child bites himself and others and hurts himself by hitting furniture. His parents are tired and distraught, and fearing growing feelings of hate toward Caleb. Caleb’s talk of “jumping off the deck” and other suicidal talk are frightening his parents. Cognitive approaches, cranial-sacral therapy, diet changes, and supplements have not helped. Caleb’s behavior is reasonable at school, although his bids for inclusion in peer groups are stifled.
In early sessions the therapist suffers a barrage of padded swords, tossed toys, and the feelings of chaos, lack of control, hopelessness, and helplessness. Matching the intensity of the experience in affect, the therapist names his internal sensations, feelings, and thoughts, and narrates a process for regulating feelings. This is the foundational tactic while also assessing play for emotional or narrative themes that can be discussed with the child’s mother.
Over the course of twenty sessions, including some intensive treatment where four sessions were scheduled into two days, the child’s play moved through various themes and the emotional quality of the experience changed. Eventually the child is relational, inviting the therapist into age-appropriate construction or competitive play, and the emotional tone is lighter and joyful.
Defining Projective Identification
“psychoanalysis has long been intrigued yet baffled by the mechanism of intersubjective unconscious communication.” (Schore, p. 76)
Originally coined by Melanie Klein (1946), projective identification labels processes where both good and bad parts of the self are unconsciously projected onto another, who is unconsciously induced into the projected state. For example, a ‘bad part’ maybe a psychobiological state where the child feels overwhelmed by complicated directions or witnessing conflict between parents. The child in play therapy throws many items at the therapist’s head, projecting overwhelm into the therapist. Disgust may be split off and then induced in others through encopresis or smearing feces. A ‘good part’ such as “I am valued and valuable” may be defensively split off from the child’s conscious self by repeated neglect, misattunement, or abuse, and so the child projects “value” onto toys such as the contents of treasure box, or exaggerates the value of activities, objects, or people. Anxiety about the future, losses of the past, and fear of loss can be split and then unconsciously projected by compulsively stealing. The ‘other’, for example a mom discovering money gone from her purse, is now holding the loss, as well as the fear of future loss.
Development of Projective Identification as a Defense
“[The development of] defensive projective identification is deeply influenced by the events of the first year of life” Schore p.66
Besides overt behaviors, subtle behaviors such as facial expression, stance, and gaze direction induce states in others. Schore (p. 61) credits the right hemisphere of the brain, which “is anatomically connected into the limbic system” which “derives subjective information in terms of emotional feelings that guide behavior” (MacLean, 1985, p. 220). Citing research, Schore asserts “the right hemisphere is dominant for the perception of nonverbal emotional expressions embedded in facial and prosodic stimuli, even at unconscious levels, for nonverbal communication, and for implicit learning,” and that “emotional face-to-face communications occur on an unconscious level.”
Adaptive projective identification happens in securely attached relationships as “a process of rapid, fast acting, nonverbal, spontaneous emotional communications” p. 66. The process benefits the child since the attuned caregiver can receive a piece of the child’s emotional process, “detoxify” it, and return it to the child (Doucet, 1992, p. 657 / Schore p. 66). If the caregiver is not attuned, the child “is often unable to induce affect-regulating responses” and left to regulate themselves.
First there is an intense “bid for interactive regulation” through crying, screams, and changes in orientation of the head, spine, and extremities. Unanswered, there is a shift to a dissociated slump that “involves numbing, avoidance, compliance, and restricted affect” p. 67. Porges (2008) describes an hierarchical organization of the autonomic nervous system (ANS) that begins with social-engagement, and then under stress devolves to hyperarousal (“fight or flight”), and then devolves to a dissociated “freeze” state (Levine, 2012). These last two states have been observed and labelled by Bowlby as “protest” and “despair”, Perry as “hyperarousal” and “dissociation”, and Schore as “activation of the energy-expanding sympathetic ANS” and “then, the energy-conserving parasympathetic branch” p. 67 In Tronick’s “still face” experiments, the devolution through these states is easily witnessed in less than 40 seconds (video, Tronick, 2007). Synergetic Play Therapy refers to these states as “hyper” and “hypo” (Dion, 2013).
This process of switching from the hyper state to the dissociated state is rapid. The child “experiences intense affect dysregulation, projects a distressing emotional communication, and then instantly dissociates” p. 68. Emotions come to be experienced as subjectively painful, and the child learns to manage the pain through defensively projecting and then dissociation. In time this shift happens at lower levels of stress and the state persists for longer periods of time where the child is “shut down to the external environment, totally closed and impermeable to attachment communications, interactive regulation, and … verbal interventions” (p. 69). The dissociative strategy leads to “permanent alterations in the maturing brain” and “increase the use of dissociation in later life” p. 69
Therapist Receptivity, Unhelpful, and Helpful Responses
In Synergetic Play Therapy, the therapist is receptive to the child’s defensive projective identification, willing to experience the induced emotions, and able to regulate, thereby giving the child the experience of interpersonal regulation and also teaching the child that “auto-regulation” or regulation of affect “on their own” is possible. Indeed, through the course of play therapy, the child becomes more adept at self-regulation.
The process of right brain to right brain communication is so quick as to be invisible. Science offers “the right brain … can appraise facially expressed emotional cues in less than 30 milliseconds far beneath levels of awareness.” p. 71 Research shows “the importance of facial indicators … which are quickly appraised from the face … in the regions around the eyes and from prosodic [vocal tone and pace] expressions” (Krause & Lutolf 1988 / Schore p. 72). The process between the child and therapist happens rapidly and below consciousness, and is “actually a very rapid sequence of reciprocal affective transactions” p. 73. Within this mechanism, the child projects primitive emotions that the child has not been able to process such as “excitement, elation, rage, terror, disgust, shame, and hopeless despair” p 73.
The therapist develops receptivity to these induced emotions through practice and could need support through therapy, supervision, and observation to understand what’s happening and expand tolerance for undesired affect. The therapist with unexamined parts could split, and “use defensive projective identification to evacuate unwanted ‘toxic’ aspects … back into the patient” p. 91 Quoting Epstein (1994, p. 100)
“The projected affects often involve the therapist’s hidden feeling of shame, envy, vulnerability and impotence. The hidden shame is signalled by the therapist’s use of ‘attack other’ defenses such as sarcasm, teasing, ridicule, and efforts to control the patient in some way. Later on, the tragic projection comes full circle when the patient feels humiliated, exploited, betrayed, abandoned, and isolated.”
An illustration occurred in intensive training for Synergetic Play Therapy where the trainee was unconscious of his refusal to engage in attachment forming behavior. When the child would sit close to the therapist the therapist would dissociate from feelings of fear of intimacy and the child would “loop” in the behavior of running from one corner of the room to the other. The supervisor queried the trainee in regards to this disruption, which she could detect and the trainee couldn’t.
“What’s it like for you when the child sits close next to you?”
“Well… I notice energy in my stomach and heart and the thought occurs to me that me and this little guy aren’t going to see eachother after this weekend.”
“So you resist just being in relationship with him?”
“I guess so.”
“So go back in there and sit there with him and feel your feelings. Relationships end and that’s natural and yes it’s sad. But if you can’t tolerate it, you can’t help him, and in fact he’s doing the work of regulating you.”
The therapist that has consciousness of their feelings and sensations, and has experience self-regulating will be able to receive the child’s unwanted affect, digest it, and continue on with receptivity. In this manner the child experiences the interpersonal regulation, and learns that regulation can happen without the participation of another, and becomes empowered to handle a broader range of emotions. Schore (p. 95) writes,
“The essential step in creating a holding environment in which an affect-communicating reconnection can be forged is the therapist’s ability, initially at a nonverbal level, to detect, recognize, monitor, and [self-regulate] the countertransferential stressful alterations in his/her bodily state that are evoked by the patient’s transferential communication.”
Conclusion
Synergetic Play Therapy seeks to assist children in developing tolerance for strong affect and skills at interpersonal regulation and self-regulation. Understanding the mechanism of play therapy benefits the development of an effective play therapist. What is demanded is not immediately obvious to those approaching the field. “Resonating with the dissociated, negative affectively charged chaotic bodily states of personalities manifesting ‘primitive emotional disorders’ is indeed, no easy matter” (p. 83). In his chapter, Schore explains the underlying right brain activity that manifests as defensive projective identification, how that behavior is experienced by the therapist, and how the therapist’s responses can benefit, or hinder, the client. Looking for metaphors in childrens’ selection of toys, wondering about the story the child is telling through play, or ignoring or correcting play that are clearly bids for the therapist to “feel,” shut down the process that is necessary for the child to gain regulatory skill. “Therapeutic regulation and not interpretation is the key to the treatment” p. 63. Receptivity is the key. “The clinician’s receptive orientation allows for a condition of resonance …, the crescendos and decrescendos of the empathic clinician’s psychobiological state with similar crescendoes and decrescendos of the patient’s state.”