A Primary Role for Nonverbal

Communication in Psychoanalysis

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

How a person speaks says as much, if not more, than what they
say. Nonverbal cues, such as facial expression, posture and tone
of voice are part of all interpersonal relatedness. Nonverbal cues
not only express emotion, but also regulate the body physiology,
emotions and behaviors between individuals. The homeostatic
regulatory mechanisms and affective exchanges between mother
and infant proceed nonverbally. Neuroscience data now indicates
these same nonverbal mechanisms occur between adults to
facilitate attachment, regulate affect and physiology and to
provide a sense of being understood. The impact of nonverbal
cues is mediated by circuits involving limbic structures in the
brain which activate nonverbal cues along with changes in
hormone levels, neurotransmitters and the autonomic nervous
system. Clinical vignettes are used to illustrate how nonverbal
cues function in the analytic treatment setting to shape both
transference and countertransference phenomena. Since
nonverbal mechanisms can be activated without conscious
awareness, neither patient nor analysand may be directly aware
of their impact. Analysts must pay attention to their own
feelings, behaviors and body sensations as indirect indicators
of the affective state and meanings of the patient.

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

clinical professor of psychiatry at UCLA.

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72 REGINA PALLY

The advent of language is a very mixed blessing [Stern, 1985,

p. 177].

H OW A PERSON SPEAKS says as much as if not more than, what he or

she says. In fact there are some aspects of experience, such as
feelings of attachment, empathy, and the subtleties of emotion, that
are better expressed nonverbally than verbally. Psychoanalytic
technique traditionally relies on verbal exchange and gives privileged
status to language. However, since words alone never quite capture
lived experience, more attention needs to be given to nonverbal
aspects of communication.
Nonverbal communication includes cues of behavior, facial
expression, gesture, tone of voice, and the visceral changes of
blushing, pallor, and sweating. Perception of these nonverbal cues
relies on the peripheral sense organs, predominantly the eyes and
ears, and the internal sensory channels of the bodys visceral organs.
The evolutionary anthropologist Deacon (1997) believes that
nonverbal signals communicate in a different way than does language.
While nonverbal signals enhance and clarify spoken exchange, they
also can operate relatively independent of language and
consciousness.
It is the thesis of this paper that a number of nonverbal forms of
communication exist in a nonverbal realm of interpersonal
exchangebody to body, biology to biology. Both the empathic
understanding of emotion and the need for responses from others,
for the purpose of self-regulation of physiology and affect, can occur
without the intervention of words. Even more pertinent for
psychoanalysis is that essentially all interpersonal relatedness
includes unconscious, biologically operating nonverbal elements,
which, in certain instances, are better designed than words as a way
of transferring meanings between individuals. With the use of clinical
vignettes, I intend to illustrate how analysts need to spend more time
being aware of the body to body connections along with the mind
to mind connections with their patients. The analysts involuntary,
innate, often unconscious nonverbal behaviors and visceral responses
to the patient provide additional sources of understanding the meaning
of the patients material. As a corollary issue, I will address the use
of the couch as a technical tool in relation to these points.
NONVERBAL COMMUNICATION 73

Stern (1985) points out that, while linguistic acquisition enables

the child to symbolically represent experience, negative effects of
verbal development exist as well. Language is inadequate to the
task of communicating internal states (p. 178). Although language
permits abstract reasoning, self-reflection, and the ability to conjure
up the past and plan for the future, language also causes a rupture
between what one says and how one feels, the verbalizable self and
the experiencing self. By privileging verbal communication,
psychoanalysis accentuates this rupture and sacrifices the
understanding of states that cannot be verbalized. One root of this
problem, according to Jacobs (1994), is that while Freud was an astute
observer of nonverbal behavior, his theories developed more in
relation to spoken communication.
The recent burgeoning of psychoanalytic interest in nonverbal
communication, nonverbal behavior, and somatizing disorders is an
encouraging trend. Jacobs (1994) provides vignettes that illustrate
how nonverbal behaviors contain unconscious meanings. Gedo (1997)
considers various forms of somatic symptoms as nonverbal bodily
communications having either symbolic meanings or else reflecting
the patients affect state. He argues that some elements of nonverbal
somatic responses are the result of alexithymia, a failure to develop
out of the sensorimotor stage into the verbal one. The analyst is to
understand the symptoms as having a communicative function and
to translate the nonverbal into words. While highlighting the
importance of nonverbal signals, Jacobs and Gedo still give special
status to verbal communication. Schwartz (1992) argues that
nonverbal expression plays a pivotal role in how human beings
understand one another. Each affect has a distinct pattern that
combines facial configuration, muscle tonus, gesture, posture, and
vocal qualities. Anger can be expressed as clenched jaw, curled upper
lip, bared teeth, growling tone of voice, and so on. The visible and
audible changes are detected as the signature of a particular affect.
The analyst by recognizing the clinically evident stereotypies can
with some precision identify which affects are currently close to or
at the surface (p. 455). The nonverbal clues of affect are guides
for formulating interventions. However, Schwartz limits the analysts
role to conscious detection and decoding. In a novel experiment
(Freedman and Lavender, 1997) designed to understand the
connection between nonverbal behaviors and countertransference,
74 REGINA PALLY

therapists were videotaped during treatment sessions. Therapist

nonverbal behaviors that rhythmically match the patients rhythm
correlate with empathic listening. Therapist nonverbal behaviors out
of sync with the patients rhythms reflect the therapists need to self-
regulate and correlate with countertransference reactions in which
the analyst feels a need to be shielded from the patients transference.
While the analysts behaviors are not conscious, they are presented
as a response to the spoken content of the transference material.
Encouraged by Cooper and Oldss (1997) recent editorial inviting
cross fertilization, I intend to explore data from other disciplines
that support the idea that nonverbal mechanisms are important in
their own right and not just in relation to spoken language.

Animal Nonverbal Cues Trigger Responses in Others

The first extensive account of unconsciously processed nonverbal

communication was written over a century ago by Charles Darwin,
detailing the specific bodily responses that comprise the nonverbal
expression of emotion in man and animals. Remarkably
contemporary, Darwin (1872) was aware that emotional expressions
result from activity of the nervous system and operate outside of
conscious awareness. Expression of emotion developed because of
its survival value, by promoting the nurturant caretaking of infants,
enhancing social group relatedness, and protecting the individual
against threats from outside the group. Many nonverbal expressions
are unlearned. Even congenitally blind children smile, laugh and clap
their hands for joy, despite their inability to see how others express
joy.
Animal research reveals that nonverbal behaviors are not simply
expressive, either of emotion or of semantic content. Often their
primary function is to trigger or release nonverbal behaviors in others
(Eibl-Eibesfeldt, 1980). Threat displays release submissive behaviors
in other animals. Male mating displays trigger presentation displays
in females.
In humans, smiling can serve as an invitation for face-to-face social
engagement and can control aggression in others by expressing
friendly intent. Direct eye contact, conversely, can function as a threat
and activate aggression in others, although a tilt of the head to the
side can counteract the threat. Gaze aversion also serves to decrease
NONVERBAL COMMUNICATION 75

the aggression, arousing effect of direct eye contact. Complete gaze

aversion, where eye contact is not resumed after initial aversion, can
initiate attempts at repair. Schore (1994) has identified this as one of
the factors in the shame response. The child lowers its head in shame
and, if prolonged, activates in the caretaker a repair response to
reconnect and soothe the child. The infant distress cry in humans,
which nonspecifically reflects the infants hunger, pain, or loneliness,
innately activates the nurturant response in the parent to search for
how to relieve the infants distress (Brazelton and Cramer, 1990).
Animal alarm vocalizations were believed to have semantic
meaning, which the animal intends to communicate regarding what
kind of predator and what action to take. Cheney and Seyfarth (1990),
studying vervet monkeys in the wild, argue that the call does not
carry symbolic meaning in the way a blue triangle may symbolize an
apple. There is no evidence that either the signaler or recipient
understands the meaning of the sound nor that the signaler intends
for the recipient to act. When, following a vervet alarm call, another
vervet monkey runs up a tree, their research suggests that the
behavioral response is related to the vocalization, not through any
process that decodes or is aware of semantic meaning, but from the
context of the situation. Neither animal need be aware of what the
other intends or feels.
Observations of humans, as well, demonstrate that some nonverbal
behavior can be understood in terms of its consequences for social
interaction. Studies support the notion that nonverbal expressions of
stress are designed to elicit comforting responses in others. (Dixon,
Huber, and Wasler, 1989). Alexithymia, a condition of impaired verbal
expression of emotion, also exhibits deficits in the nonverbal
expression of emotion. As a result of nonverbal deficits, these
individuals suffer interpersonal impairments (Troisi et al., 1996).
They show difficulty in identifying emotion in others. They often
lack facial expression, show postural rigidity, and overall give few
outward behavioral nonverbal signals, despite the fact that autonomic
nervous system measurements indicate states of tension and anxiety.
The lack of the outward emotional expression of stress may deprive
them of the capacity to elicit empathy in others (Brothers, 1989).
Crying promotes behavior in which the crier and others mutually
interact to alleviate distress (Gross, Frederickson, and Levenson,
1994). The human grief reaction, even without crying, is a stress
76 REGINA PALLY

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

Infants and Caretakers Activate

Nonverbal Responses in One Another

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

Smell and Touch

While not as yet readily applicable to analytic work with adults, smell
and touch are the earliest modalities of nonverbal communication
and deserve comment. The odor of her breast milk is perhaps the
most fundamental nonverbal communication a mother directs to her
infant (Leon, 1992). By 6 weeks of age, breast milk odor stimulates
the infant to orient toward the breast and make sucking movements.
Communication through odor ensures that the baby will be able to
find the breast even in the dark.
Touch serves as an integral ingredient of physiologic regulation
of the infant. (for a complete review see Barnard and Brazelton, 1990).
Skin to skin touch increases feeding and weight gain in premature
infants and prevents the profound physiologic and behavioral changes
which accompany maternal separation. Touch promotes the
attachment bond. Anxiously attached children frequently have
mothers who show an aversion to close body contact.

Activation of the Nurturant Response

Infant nonverbal cues activate the nurturant response in caretakers,

a constellation of attentional focus, feelings, and behaviors. Bowlby
(1958) identifies that infant sucking, clinging, grasping, crying, and
NONVERBAL COMMUNICATION 77

smiling are the behaviors that stimulate this response. In addition,

according to Brazelton and Cramer (1990), infant signs of babyish-
ness, soft rounded face, fine hair, delicate skin, short limbs, and
tiny hands that helplessly reach out activate parents to want to reach
out for and take care of these helpless creatures. Other nonverbal
cues such as uncontrolled thrashing movements activate a parents
sense of protectiveness and gentle nurturing of the fragile offspring.
The nurturant response synchronizes the caretaker to infant states
of arousal, attention, physiology and affect. The caretaker s
nurturance promotes physiologic and affect regulation, which
maximizes the infants attention and learning (Linnemeyer and
Porges, 1986; Hofer, 1996b).
In analysis, the patients nonverbal cues of distress may activate
in the analyst a kind of nurturant response, in which the analyst is
able to focus attention with nonjudgemental listening, feels concern,
and has a desire to help. The analyst becomes synchronized with the
patients attentional focus and affect state and is more able to deliver
interpretations at the level of the patients tolerance.

Developing the Back and Forth of Communication

By 2 months of age, in what Bateson terms protoconversation, the

infant of 715 weeks old focuses on the face and voice of the mother
and reacts in a give-and-take, listen and reply manner
(Trevarthen, 1993). The babys body movements, hand gestures, facial
expression (smiles/pouts), and vocalization (coos/fretful cries)
communicate its inner state to the mother. The infant is not merely
imitating maternal responses but is entering into a back and forth
exchange with the mother.
Of relevance to psychoanalysis is that the back and forth of all
forms of conversation is regulated by nonverbal cues. Kendon (1992)
describes how some gestures and body movements function simply
as a way for participants to regulate their attention to the frame of
the conversation. Orientation of gaze, body posture, and vocal
qualities signal who is talking to whom and who is paying attention
to whom. To speak to someone who is speaking, a connection is
made by taking up their vocal cadence and moving in synchrony
with them. Adopting the same posture and gesture helps two
individuals identify each other as participating in a 1:1 exchange.
78 REGINA PALLY

When there is an intention to change the frame of the conversation,

nonverbal cues are sent out by the speaker as trial balloons before
any spoken change occurs. Listeners nonverbally signal back their
willingness to accept or not accept the change, also before any verbal
alteration has occurred. This implies that the flow of verbal exchange
between patient and analyst may be highly sensitive to the nonverbal
exchange between them.

Mirroring, Expectancy, and Attachment

During the first 6 months of life, the mother mirrors her infants
nonverbal expressions within the same modality: vocalization to
vocalization, facial expression to facial expression, gesture to gesture
(Beebe and Lachmann, 1988). To show she has gotten it, she does
not simply imitate the baby but adds and elaborates upon the infants
nonverbal display. Infants of 34 months and their mothers, in face-
to-face interactions, use eye gaze, facial expression, head position,
and vocalization to reciprocally communicate emotion along a
continuum of ascending affect intensity followed by descending affect
intensity. The infant gaze averts when arousal is too great. It appears
they mutually regulate one anothers nonverbal expression of affect
intensity, with the mother influencing infant and infant influencing
mother along the crescendos and decrescendos.
By 89 months of age, mirroring includes multimodal responses
(Stern, 1985). Vocalizations can be responded to with body
movements, facial expressions responded to with vocalizations. This
same period is when the affect intensity reached during face-to-face
exchanges reaches its peak level (Schore, 1994). Schore provides
evidence that the brain circuits that subserve the capacity for high-
intensity affect are specifically stimulated to grow by these face-to-
face encounters.
The age of 9 months also correlates with the cementing of the
attachment bond. While Shore considers these peak face-to-face
encounters as the critical element of attachment, Hofers (personal
communication) view is that attachment emerges as the culmination
of the multiple experiences of sychronicity and mirroring with
caretakers since birth, in all the different sensory modalities.
Beebe and Lachmann (1988) emphasize that nonverbal affect
matching leads to the presymbolic storage of experiences of
NONVERBAL COMMUNICATION 79

understanding and being understood and the expectancy of matching

and being matched. Alkon (1992) proposes that memory is essentially
an expectancy system, in which repeated experiences are stored in
order to predict future occurrences. Equilibrium is maintained if
expectancies are realized. Disequilibrium results if expectancies fail
to occur. In analysis patients may either expect matching or expect
nonmatching depending on prior experiences.
Just as matching of nonverbal cues results in attachment of the infant
to its caretakers, matching also facilitates affiliation between adults.
When strangers talk together, the ones that more often match each others
cues are more likely to feel a sense of warmth and friendship toward
one another, even if they are completely unaware of their matching
(Feldstein and Welkowitz, 1978). The experience of nonverbal matching
probably facilitates the affiliative cooperative aspects of treatment, as
well as cementing the transference attachment bond.

Empathy and a Theory of Mind

The ability to empathize requires recognition that others have mental

states that can be known and are different from ones own, often
called a theory of mind (Brothers, 1989). This capacity does not
emerge until about 4 years of age. A step toward its development
occurs at about 9 months in an interaction called the shared point of
view, in which when the mother points at an object, the infant looks
at the object and not at the mothers hand (Lachmann, and Beebe,
1996). In repeated games the infant points and the mother looks and
vocalizes; then the mother points and the infant looks and vocalizes
in turn. The infant shares interest in the object and simultaneously
shares in an internal mental state of the mother.
Shared attentional states are essential for effective conversation
between adults (Kendon, 1992). In analysis the patients nonverbal
cues may signal what is emotionally important to pay attention to,
and the analysts nonverbal cues may signal that the analyst is
attending. One analytic patient, a professor, would literally point at
me from the couch when I would make an astute comment. At first
this seemed to mean that he was professor and I a clever student.
However, eventually, we discovered that this happened spontaneously
when I really had captured something true about him and he felt it
deeply, even if he could not say so.
80 REGINA PALLY

Nonverbal Systems Regulate Exploratory Behavior

Social referencing (Emde and Sorce, 1983) is a means by which

the infant regulates exploration and discovery. In a well-known
experiment, a 1-year-old crawls over an artificial cliff, an optical
illusion creating the impression of a sheer drop. The infant looks to
the mother for a sign from her facial expression as to whether it
should proceed. If the infant shows a joyful state of exploration, but
the mother looks sad, the child will switch to perplexity, progressing
to sadness, and he or she stops crossing. If on the other hand the
infant is hesitant but the mother smiles, within a few moments the
doubting child will begin to smile and continue to crawl on.
In the beginning of the second year of life, the shame response
emerges (Broucek, 1982; Schore, 1994). Shame occurs as a result of
the abrupt interruption of positive exploratory behavior, such as when
the mother sternly says No you cant play with my necklace!
(Tomkins, 1963). The child inhibits its behavior and signals shame
by body posture and a lowering of the eye gaze and head position.
Schore correlates this state of shame with parasympathetic nervous
system activity, which leads to decreased arousal, decreased heart
rate and other physiologic parameters. The attuned mother is
activated to respond to the nonverbal signals of shame by
reconnecting with the child, comforting, reassuring, stimulating, and
thus reactivating the childs affect and physiology. If this shame state
persists for too long, Schore postulates that the parasympathetic
changes can become permanently encoded into the nervous system
as maladaptive excessive shame responses. These mechanisms are
probably involved in how the analyst intuitively knows the patients
tolerance for silence.
The mutual construction of childhood narratives also involves
similar nonverbal mechanisms of exploration and inhibition. As the
child talks with caretakers about daily experiences in the form of
narratives, the gestures, facial expression, and vocal qualities, as well
the listeners words, influence what the child says (Ochs and Capps,
1996). Since narrative links a persons past, present, and future and
contributes to the development of a self that exists cohesively over
time, the nonverbal messages of the listener shape the speakers sense
of self. Verbal narratives facilitate conscious awareness of experience
and enhance encoding in long-term memory (Siegel, 1995). The
NONVERBAL COMMUNICATION 81

nonverbal responses of the listener therefore may influence what is

stored in memory and later what will be retrieved from memory. In
analysis, by influencing what the patient says, the analysts nonverbal
cues may influence what the patient becomes conscious of.

Brain Processing of Nonverbal Cues Link Minds,

Bodies, and Behaviors Between Individuals

The left hemisphere is specialized for speech and language. The right
hemisphere is equally specialized, but for emotion and nonverbal
communication. Lesions in the right brain can interfere with the
ability to read the nonverbal cues of others and to express them
oneself (Voeller, Hanson, and Wendt, 1988; Henry, 1993).
The components of nonverbal communication are developed in
utero (Trevarthen, 1993). By the second trimester the fetus engages
in the specific coordinated movements it will use to engage with
caretakers upon birth, such as facial expressions.

Social Signals, Group Cohesion, and Empathy

The exquisite degree of specialization for nonverbal processing

exhibited by the primate brain is illustrated in experiments by
Brothers (1989, 1992) using monkeys. Sections of the amygdala,
anterior temporal lobe, and orbitofrontal cortex contain individual
cells, each of which has a specific nonverbal cue it is specialized to
detect. For example, there are individual cells that detect direct eye
contact, others that detect arched eyebrows and others that detect an
open mouth. Some cells are specialized to detect complex nonverbal
gestalts, such as a full yawn display or a threatening face.
To maintain the complex social group interactions characteristic
of primates, members of the group rely on social signals, in the form
of nonverbal cues, to know what others are feeling and intending.
Are they angry, hungry, or lonely? Do they want to fight, mate, or
play? Brothers (1989) believes that in humans the brain circuits that
detect nonverbal cues are the neuronal substrate of empathy. The
importance of these cues is illustrated by damage to the amygdala in
humans, in which individuals are unable to detect the facial expression
of fear (LeDoux, 1995).
82 REGINA PALLY

Facial Expression

Many aspects of nonverbal communication are the result of activity

in the autonomic nervous system (ANS): pallor, flushing, sweating,
tears, labored breathing, and shaky voice. Experiments by Ekman
(1990, 1993) indicate that facial expressions of emotion are linked
with specific ANS responses for six basic emotionsanger, fear,
sadness, disgust, happiness, and surprise. In the directed task
Ekman instructs subjects how to contract the muscles of their face to
create the facial expression of each of the 6 emotions. When subjects
voluntarily contract their facial muscles in the pattern associated with
one of these emotions, a high percentage of people actually feel the
emotion. In the lived experience task, subjects are asked to imagine
a situation in which they would feel each emotion. The patterns of
ANS activity that distinguish among emotions are: heart rate increases
with anger/fear/sadness and decreases with disgust; skin conductance
is significantly larger with fear and disgust than with happiness and
surprise; finger temperature increases with anger and decreases with
fear. The more an individual can reproduce the correct facial expression,
the more likely that individual is to show a distinct ANS pattern.
When a person either voluntarily or for unconscious defensive
purposes masks the facial expression of emotion, although they do
not show the usual facial display, individual contractions of facial
muscles and ANS changes can still be detected (Ekman, 1993). Other
nonverbal channels, such as voice, can continue to express the facially
suppressed emotion. People easily suppress verbal expression
(Harrigan et al., 1996). Facial expression is harder to suppress and
vocal qualities the hardest to suppress. When signals of emotion are
discrepant, people are more likely to rely on facial expression and
vocal qualities, rather than on what a person says.

Nonverbal Responses Integrate Emotion and Reason

Damasio (1994) affirms that body changes are an integral part of

emotion. Serving as a form of communication to oneself, the body
changes play a crucial role in reason and adaptive problem solving.
A brief schematic version of emotional processing is given to illustrate
these points.
NONVERBAL COMMUNICATION 83

The amygdala (AMG) and the orbitofrontal cortex (OFC) appraise

stimuli with regard to personal salience. Is this familiar or
unfamiliar? Is it good or bad for me? Do I want to approach or
avoid it? As a result of these appraisals, the AMG and OFC send
signals to the hypothalamus (HYP) and brain stem, which produce a
number of biobehavioral responses. The HYP produces oxytocin and
vasopressin, neuropeptide hormones involved in pair bonding,
parental care of infants, and attachment (Insel, 1997). The
hypothalamic-pituitary-adrenal cortex axis regulates production of
the hormone cortisol. Cortisol readies the body to cope with stress
by increasing glucose metabolism and increasing blood pressure. The
HYP and brain stem modulate the ANS. All the organs of the body,
such as heart, lungs, larynx, stomach, intestines, bladder, skin, blood
vessels, and lachrymal glands, are innervated by sympathetic (SNS)
and parasympathetic (PNS) branches of the ANS. The SNS and PNS
act in opposite directions. The SNS promotes coping with external
situations such as threat and stress, readies the body for action if
necessary, and is associated with the fight or flight response. The
PNS promotes internally directed functions such as growth, digestion,
and reproduction, and is associated with the relaxation response.
As mentioned previously, visceral responses mediated by the ANS
contribute to nonverbal communication, such as blushing or quivering
voice. The HYP and brain stem also activate striatal muscle responses,
such as the freeze response to danger or the muscle contractions
associated with facial expression.
Damasio (1994) proposes that feedback of the somatic responses
to the OFC influences reason. Feedback from the internal viscera
and muscles serves to communicate to the self regarding how one is
reacting to a situation. Feedback from the body becomes associatively
linked with the events of the situation, which is how the individual
learns whether a situation is good or bad, rewarding or punishing,
satisfying or unsatisfying. The OFC draws upon memory stores of
these associations between event and body reaction as the basis for
forming adaptive responses to the current environment. Patients with
lesions in the OFC lose the ability to apply knowledge derived from
past situations to current problems, because of disruption to these
feedback circuits from the body. This implies that patients need to
be connected to their feelings in order to function adaptively.
84 REGINA PALLY

Matching

Humans automatically and unconsciously match the nonverbal cues

of others (Basch, 1988; Beebe and Lachmann, 1988). Since nonverbal
communication is linked with ANS changes, matching recreates the
physiology of one individual in the other person, facilitating knowing
what another is feeling and intending. The link between nonverbal
responses and body physiology, coupled with the fact that individuals
match each others nonverbal cues may be one mechanism by which,
not only infants and adults, but also adult dyads, can regulate each
others physiology and behavior during affective exchanges.

Nonverbal Cues Link Biologic Systems Between Individuals

Studies with animals and humans, infants as well as adults, suggest

that behavioral and visceral nonverbal signals link individuals
psychologically via mechanisms that link their biology. Hofer (1984,
1996a, b) integrates his own research with rats and that of others
with animals and humans in a model for understanding how the
biobehavioral interactions of mother and infant are internalized as
object representations and continue to operate in interpersonal
interactions between adults.
The mother regulates the infants behavior and physiology,
including activity level, hormones, sleepwake cycle, heart rate, and
body temperature. When the infant is separated from the mother, this
triggers characteristic infant separation responses as a result of the
loss of the mothers regulatory function. The most characteristic
mammalian response to separation is the infant distress cry. Other
physiologic and behavioral responses to separation include decreased
activity to the point of quiescence, ignoring food but increased
nonnutritive sucking, decreased investigation of new stimuli,
decreased body temperature, decreased heart rate, and increased
corticosteroids. If the mother is nearby, she will respond to the distress
cry by searching and retrieving her infant and engaging in comforting
behaviors (which, in rats, include licking and nursing) that return
the infant to physiologic regulation and stimulate the cessation of
crying. Regulatory mechanisms are mediated by neurotransmitters
such as GABA-benzodiazapines, opiates, and serotonin. For example,
benzodiazapine agonists decrease the distress cry upon separation,
and benzodiazapine antagonists increase the distress cry.
NONVERBAL COMMUNICATION 85

Tactile contact and behavioral interaction can counteract the effect

of maternal separation in infants. Underweight premature infants
in incubators show increased weight gain, increased head
circumference, and improved behavioral indices when provided with
added tactile contact (Field et al., 1986). Rhesus monkeys separated
from their mother but provided with a cloth surrogate still show
abnormal behaviors such as rhythmic rocking, increased nonnutritive
sucking, increased distress vocalizations, and self clasping. If the
cloth surrogate is attached to a long rope that permits the baby to
swing, back and forth, the monkey will hold on, swing and jump on
and off. This eliminates the abnormal rocking movements in the
infant.
Initially, the mother regulates all the infants functions. Eventually,
some functions become internalized within the individuals
autonomous homeostatic processes, and others continue to be
regulated by external factors such as light/dark cycles, time of day,
and interaction with other caretakers as well as peer relation-
ships. Hofer proposes that the grief reaction is an indication that
loved ones function as regulators of the self. He emphasizes that
the grief response parallels the infant separation response, with
an initial acute protest phase of crying followed by a longer despair
phase of physiologic and behavioral dysregulation such as alterations
of sleep, eating, activity, cardiovascular status, and immune
response.
Hofers ideas are readily applicable to psychoanalysis. He believes
that the brain automatically associates behavioral interactions such
as feeding and holding with olfactory, auditory, and visual cues that
denote mother. These interactions are established as memory traces
that form internal working models and object representations.
Depending on the nature of the early infant/caretaker interactions,
nonverbal signals in current adult relationships can activate
expectations of biobehavioral dysregulation, which may explain why
some patients avoid closeness.
Kalin, Shelton, and Lynn (1995) identify specific reunion behaviors
that rhesus monkeys engage in following separation: clinging and a
vocalization called girning. These behaviors increase the infant and
mothers endogenous opiates. Kalins research implies that affiliative
and attachment behaviors are modulated by the endogenous opiate
reward system, which may explain the tenacity of attachments to
caretakers.
86 REGINA PALLY

Hormonal Factors Regulating Nonverbal Behavior

According to Henry (1993) the usual biologic mechanisms for coping

with stress involve an initial elevation of catecholamines, which
promotes coping with the danger situation. As stress increases,
cortisol levels also rise, in turn activating oxytocin release, which
promotes maternal care, attachment, and social group connectedness.
Individuals with PTSD, particularly those who show signs of
alexithymia, show the increase in catecholamines without the
subsequent rise in cortisol. He postulates that this leads to impaired
coping, since these individuals cannot utilize attachment mechanisms
as a means for coping with stressful situations. Individuals who lack
the rise in cortisol also demonstrate deficits in transfer of right
hemisphere emotional material across the corpus callosum to verbal
centers on the left. For Henry, this explains the dissociation between
words and feelings that can occur in extreme stress states.

The Relation Between Nonverbal and Verbal Systems

Nonverbal aspects of emotion and communication, such as facial

expression, verbal prosody (rhythm, pitch, timber), gesture, and
visceral responses, are the domain of the right hemisphere and
influences spoken language primarily via corpus callosum
connections to the left hemisphere (Gazzaniga, 1992). Gazzaniga
believes the left brain serves as an interpreter of right-brain
nonverbal and emotional functioning.

InfantCaretaker Interactions Applied to Work with Adults

There is a growing awareness that many of the ways adults

communicate with adults resemble the ways infants and caretakers
communicate. Emde (1988) believes it is the nature of the infant
caregiver relationship that becomes internalized and is repeatedly
reactivated in similar relationship contexts throughout life.
Lichtenberg (1996) states that infantcaretaker patterns of interaction,
reflective of motivational systems, are paralleled by patientanalyst
interactions.
Kiersky and Beebe (1994) hypothesize that motherinfant
interactions can be used to understand emotionally constricted adults.
NONVERBAL COMMUNICATION 87

Infants expect a reciprocal response to their positive affect. If when

the infant smiles at the mother, her smile is not forthcoming, the
infant at first tries to get the mother to engage; finally, the infant
gives up and appears limp and immobilized. Such an unresponsive
pattern is evident in the case of a 34-year-old woman who appears
frozen and reports not feeling things. She avoids the analysts
gaze, talks in a flat monotone, closes her eyes at emotional moments,
and seems disinterested both in what she has to say and what the
analyst has to say. She fears closeness will lead to the analyst
becoming indifferent toward her. Using data from her history, a model
scene is constructed of a frozen baby who fails to be able to engage
an unresponsive mother or who has to avoid an overstimulating father.
Lachmann and Beebe (1996) propose the theory that an analyst
may be compelled to engage in a nonverbal interaction with an adult
patient, similar to the reciprocally responsive interactions in infancy.
They provide a clinical vignette of a 36-year-old divorced woman
with a pessimistic, hopeless outlook on life, who enters treatment
expecting that the analyst has nothing to offer. As a young child she
was cared for by a loving housekeeper who departed, leaving her
with an emotionally cold mother. In the analysis, the dread of
reexperiencing the void of emotional responsivity emerges in the
transference. She requires the analyst to intuitively understand her,
lapsing into silences or continually demanding that the analyst
guess what she is feeling. Although the analyst is frustrated by the
patients guessing games and demands for correct answers, she comes
to understand this form of interaction as the reestablishing of a
nonverbal bond based on the expectation of acceptance and being
understood. The patient mistrusts the analysts positive feelings about
the treatment, experiencing them as misattunements to her
hopelessness. The patients responses regulate the analyst to
downshift her own optimism at being able to help the patient, in
order to stay to attuned to the patients hopelessness.
Pally (1996) proposes that nonverbal communications can
unconsciously activate the nurturant response even between adults.
A 27-year-old professional woman is anxious during the beginning
of analysis, continually considering stopping the process. The analyst
begins to develop imagery of being in the nursery with a howling
terrified infant. At one level the analyst perceives the womans manner
and speech as mature, articulate, and coherent. She seems quite able
88 REGINA PALLY

to take in transference interpretations regarding her anxiety. However,

at the same time, nonverbal cues of fragility and waif-like
vulnerability are also present, which communicate at a different level
that this woman is experiencing the helpless terror of an infant and
is quite unable to take in anything. The analyst involuntarily finds
herself using tone of voice, rhythm of speech, and rocking body
movements to calm what feels to her to be a frightened helpless baby.
The analyst theorizes that the patients nonverbal cues are activating
in her the same kind of innately programmed nurturant response that
occurs between infants and caretakers. Later in the analysis it emerges
that the patients mother had been very depressed during her infancy
and that awareness of this distressed infant part of her was not yet
available to her conscious mind. The analyst suggests that her
soothing nonverbal responsiveness was as equally important as her
words to enable the patient to develop enough trust in order to attach
to the process of the analysis.

Clinical Vignette

Nonverbal interactions in analysis need not only reflect infantile

patterns of relatedness. Observable nonverbal behaviors and
expressions, as well as internal body visceral responses, exist
unconsciously in all aspects of interpersonal exchange.
Charles is a 40-year-old attorney, who sought treatment for feelings
of numbness and detachment. His father worked much of the time.
His mother was controlling and overprotected him. At work he
despised the jockeying for money and power among the lawyers at
his corporate law firm. His disgust toward his profession is palpable,
expressed with facial expression, tone of voice, and gesture. However,
despite the fact that I shared his views, I had difficulty empathizing
with his feelings. Eventually, I began to notice that I often felt a
visceral disgust listening to his anger and felt guilty for being
unempathic. When I considered whether the patient was activating
these visceral responses in me, I became aware that I was feeling he
was trying to force feed me his feelings, shove them down my
throat, and I was gagging, wanting to vomit them back up. I became
aware of my own reluctance to swallow what he was telling me,
perhaps because my own controlling mother tried to force me to see
the world her way and I was resisting the pressure. I said to Charles,
NONVERBAL COMMUNICATION 89

I feel you are trying to force me to see the world as you do, to
literally feel inside my body the same kinds of intense responses
your body has in your rage and disgust toward the legal profession.
Perhaps only if I actually feel as you do will you feel supported and
understood. This helped the patient better understand that he
alienates people with his wish to literally create disgust and rage in
them, rather than to simply accept their ability to understand his
painful feelings.
Another set of interactions with this patient occurred in which he
made me feel awkward and confused. He quizzed me about current
events and asked, Whats your opinion? He would say, I know
its not allowed but perhaps we could talk better over lunch. I tried
to understand the meaning of these behaviors, and to explore them
in terms of transference themes related to anger. Since his comments
made me feel awkward and unsure of what level to respond to, I
asked whether he was aware of wanting me to feel confused or
uncomfortable in some way. He was annoyed that I considered any
meaning beyond his wanting to know me better. Continuing to explore
my own reaction, I realized I felt caught off-guard and startled. When
I shared this with him, he explained he needed to connect to the real
me. My off-guard reactions of startle made me behave with
characteristic body movements and facial expression, which he then
described to me. He knew when I behaved this way, it was my
automatic, uncensored response, even as I am trying to carefully
choose my words. The automatic, spontaneous behaviors that I was
completely unaware of and therefore did not hide from him was what
he sought as a means to be close with me. As a result of this, we were
able to further understand his beliefs that no one really wanted to be
close with him and how hard it was to feel that what people say are
signs of their closeness with him. It was by the process of our mutual
awareness of my nonverbal response that both he and I identified the
meaning of our interaction.

Discussion

Nonverbal behaviors and visceral responses unconsciously shape

language, and language unconsciously shapes nonverbal responses
(LeDoux, 1995). I have focused on the nonverbal in isolation, only
to tease apart the role it plays in interpersonal interaction.
90 REGINA PALLY

In the analytic setting the nonverbal behaviors, expressions, and

visceral responses of the patient unconsciously activate nonverbal
behaviors, expressions, and visceral responses in the analyst, which
influence the flow and content of spoken exchange and serve as the
basis for empathic understanding of emotion and need states. The
unconscious matching of these nonverbal cues is one means by which
patient and analyst establish a sense of trust, affiliation, and feelings
of being cared about and understood and therefore are an important
factor in the development of a working alliance and positive
transference. Perhaps these same mechanisms are the means by which
the patient unconsciously internalizes the analysts analytic functions.
From the perspective of countertransference phenomena, the
analysts involuntary nonverbal responses may be innately activated
by the patient, not as a defense or regressive manifestation, but as an
expression of how human beings normally function with one another.
In many instances human beings activate in one another nonverbal
responses as a means for signaling what is important to listen to, to
activate regulating behaviors in others in response to stress, and to
promote feelings of being cared for and understood.
Countertransference phenomena probably involve the automatic
somatic responses of the analyst to the nonverbal, as well as the verbal
expressions of the patient. How the analyst feels compelled to behave
toward the patient may be the result of innately encoded responses
to the nonverbal signals of the patient, which are the result of humans
needs for affection, attachment, understanding, and soothing. The
visceral and behavioral responses activated in the analyst can
unconsciously facilitate empathy but can also be experienced as
dysphoric countertransference reactions depending on associative
links in the memory traces of the analyst. Conversely, if the patient
suffers from alexithymia, there may be insufficient nonverbal signals
to activate empathic understanding and regulatory responses on the
part of the analyst. In the experiments of Freedman and Lavender
(1997), it may be the patients nonverbal cues, as much as verbal
expression of transference, that activated self-protective responses
in the analyst, interfering with empathic listening.
If nonverbal cues of the analyst signal separation or dysregulation,
the patient may literally shut down and become depressed as infants
do when separated from their mother and adults do with the loss of a
loved one. Nonverbal signals of empathic matching by the analyst
NONVERBAL COMMUNICATION 91

may even trigger biobehavioral states of anxiety in the patient for

whom early internalized dysregulated interactions make them feel
unprepared to deal with the unfamiliar, unexpected interaction of
being understood.
The nonverbal mechanisms of human interaction have significant
implications with regard to the use of the couch. Strong evidence
exists for the importance of face-to-face contact in the communication
of emotion and mutual responsiveness so important to eliciting
empathy and feelings of affiliation. At times, the ability to feel
understood, accepted, even attached, may require face-to-face
visual exchange of nonverbal cues. Conversely, nonverbal cues of
facial expression and gesture place limits on verbal exchange by
constraining who talks when and about what, limiting the free
associative flow of material. Therefore, for any given patient, both
sitting up and lying down each have facilitating, as well as limiting,
factors that should be taken into consideration to maximize the
therapeutic effectiveness of the treatment.
Just as motherinfant interactions are innate, unlearned, automatic,
and generally unconscious, so too are many of the nonverbal
interaction patterns between adults. How the patient impels the
analyst to feel and behave may be as important a factor in the analysis
as what patient and analyst say. While it is useful to pay attention
and verbalize these nonverbal processes and to understand their
defensive, dynamic meanings, this is not the complete picture. People
are designed by nature to interact nonverbally at all times. The
implication of this paper is that, whether the patients nonverbal
expression is defensive or not, the analyst may first be impelled
involuntarily to react before knowing what to say. As a result of
bringing together these separate strands of data, nonverbal
communication may soon be given its full recognition. In the not too
distant future, perhaps, psychoanalysis may be considered the
nontalking, as well as the talking, cure.

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