John Goldie is a retired GP and medical educator
Just suppose, a routine afternoon surgery, the kind where time slips by and you realize you’re falling behind. A familiar female patient with fibromyalgia arrived for a “medication review.” But her body told a different story—the way she sat, shoulders drawn in, eyes lowered, voice thin.*
I almost missed it. My instinct was to dive into the prescription screen. But something in her silence caught me. I paused and softened my voice. “You seem like you’re carrying a lot today.”
She looked up, startled. Then the tears came.
But something in her silence caught me. I paused and softened my voice. “You seem like you’re carrying a lot today.”
What followed wasn’t dramatic. She spoke about her son leaving home after a bitter argument. I didn’t offer solutions; I simply stayed with her—steady eye contact, a nod, a quiet acknowledgement. After a few minutes, she exhaled. “I didn’t think I’d talk about this today. But I feel lighter.”
We returned to the medication review, but the deeper work had already happened. I didn’t fix anything; I just showed up. Sometimes, that’s enough.
In general practice, we often underestimate these micro-moments. We are trained to listen to words, but healing often begins in the spaces between them—in a glance, a pause, or a shift in breath. These moments regulate affect, restore dignity, and remind patients (and us) they are not alone. This encounter was a neurobiological exchange, not just “good listening.”
Neuropsychiatric research helps explain why such moments matter. Reflecting later, I recognized this as right-hemisphere communication—a nonverbal, intersubjective connection that bypasses explicit cognition and reached something more fundamental. Allan Schore describes this as the psychobiological core of the therapeutic alliance.¹ It is not about insight or advice, but about presence.
Both hemispheres work together, but the right leads in emotionally charged encounters.² It processes facial expression, tone, posture, and other cues that shape our sense of safety, operating largely outside conscious awareness. The right orbitofrontal cortex continuously tracks shifting emotional states, allowing us to follow another person’s feelings in real time and adjust our behaviour accordingly.³ This synchrony unfolds too rapidly for deliberate reflection.⁴
The left hemisphere, by contrast, manages language, logic, and explanation — essential tools in medicine, but not sufficient for connection. Explanation is different from attunement.
Early development is dominated by right-to-right communication between infant and caregiver. These exchanges underpin intersubjectivity—the sharing of emotional states—while attachment provides external regulation of arousal.⁵⁻⁶ Before the later developing left hemisphere supports conscious strategies, the infant depends on implicit right-hemisphere communication to manage emotional intensity. When caregiving is inconsistent or frightening, the right hemisphere may encode maladaptive patterns that later surface as difficulties in regulation or tolerating emotional overwhelm.
These ideas are vital for practice. Good care involves listening carefully to what a patient says — the story they tell about symptoms and meaning. But this is only part of the interaction. The clinician must also attune to a quieter layer: shifts in tone, rhythm, and energy. In emotionally charged encounters, a sensitive clinician matches the patient’s arousal, adjusting their presence in response. This interpersonal synchrony helps the patient feel understood at an embodied level.
When care is continuous, each encounter builds on the last, layering experiences that consolidate into stable, adaptive ways of responding.
Emerging hyperscanning studies show real-time synchronization between the right temporoparietal junctions of patient and clinician during emotionally focused sessions.⁷⁻⁸ This region involves social understanding and empathic attunement, largely outside conscious awareness; notably, synchrony appears more pronounced with experienced practitioners.
Right-brain circuits involved in attachment, affect regulation, and implicit relational knowing are highly plastic. Attuned, safe GP encounters promote adaptive rewiring, while rushed or shaming encounters promote maladaptive plasticity.⁹ Relationships grounded in collaboration, empathy and positive regard genuinely support healing.10
Even a brief GP encounter can reshape the brain. When a clinician offers a grounded presence, the patient’s nervous system often settles; this co-regulation is a primary way relational experiences influence neural circuitry. Gentle reframing can then loosen fear-based interpretations, allowing new, less threatening pathways to take hold. When care is continuous, each encounter builds on the last, layering experiences that consolidate into stable, adaptive ways of responding.
In the pressured tempo of primary care, these moments are easy to miss, yet they are often the most therapeutic thing we offer. The most sophisticated instrument in the room is not the computer, but the clinician’s regulated, responsive presence.
*Author’s note: this patient is a distillation of many patients I saw over the years and not any specific patient living or deceased.
References
- Schore AN. Affect Regulation and the Origin of the Self: The Neurobiology of Emotional Development. New York: Routledge; 2016.
- Goldie J. The implications of brain lateralisation for modern general practice. Br J Gen Pract. 2016;66(642):44–45.
- Goodkind MS, Sollberger M, Gyurak A, Rosen HJ, Rankin KP, Miller B, et al. Tracking emotional valence: the role of the orbitofrontal cortex. Hum Brain Mapp. 2012; 33:753–62.
- Ferenczi S. Psychogenic anomalies of voice production. In: Ferenczi S, Rickman J, editors. Further Contributions to the Theory and Technique of Psychoanalysis. London: Karnac Books; 1957.
- Lyons‑Ruth K. The two-person unconscious: intersubjective dialogue, enactive relational representation, and the emergence of new forms of relational organization. Psychoanal Inq. 1999.
- Schore AN. The interpersonal neurobiology of intersubjectivity. Front Psychol. 2021; 12:648616.
- Zhang Y, Meng T, Hou Y, Pan Y, Hu Y. Interpersonal brain synchronization associated with working alliance during psychological counseling. Psychiatry Res Neuroimaging. 2018; 282:103–9.
- Zhang Y, Meng T, Yang Y, Hu Y. Experience-dependent counselor–client brain synchronization during psychological counseling. eNeuro. 2020; 236:1–10.
- Davidson RJ, McEwen BS. Social influences on neuroplasticity: stress and interventions to promote well‑ Nat Neurosci. 2012;15(5):689–95.
- Norcross JC, Lambert MJ. Psychotherapy relationships that work III. Psychotherapy. 2018; 55:303–15.
Featured Photo by Stormseeker on Unsplash
