The techniques of behavior therapy and psychotherapy have relied on the principles of brain plasticity, generally without realizing it, for nearly one hundred years.
—Nancy Andreasen
Like other scientific discoveries, psychotherapy developed from a combination of trial-and-error learning, the intuition of its founder, and plain luck. Each school of psychotherapy offers an explanation of mental health and illness as well as why its strategies and techniques are effective. Fortunately, the effectiveness of an intervention does not depend on the accuracy of the theory used to support it. For example, there was a time when psychoanalysts attributed the success of electroshock therapy to the need of a depressed person to be punished. The treatment worked and still works despite the lack of a solid understanding of its mechanisms of action.
Although each approach to psychotherapy is experienced as a fundamental truth by its disciples, all modes of therapy are actually heuristics. Heuristics are interpretations of experience or ways of understanding phenomena. The value of a heuristic lies in its ability to organize, explain, and predict what we observe. Neuroscience is another heuristic, one that we are using in the present discussion to explain the mechanisms of action of psychotherapy; in other words how and why it works. It is my belief that neuroscience is a helpful heuristic that will lead us to a fuller understanding of the process of psychotherapy and may also serve as a rational means of selecting, combining, and evaluating treatment modalities.
In this chapter we examine, in broad strokes, some of the primary approaches to psychotherapy. These overviews are presented in order to provide a context in which to understand and organize the neuroscientific concepts in the coming chapters. In taking a sample of general theoretical approaches to psychotherapy, we will look for common elements among them, and how these elements may relate to neural network development and change. Remember, from the perspective of neuroscience, psychotherapists are in the brain-rebuilding business.
Psychoanalytic and Psychodynamic Therapies
Being entirely honest with oneself is a good exercise.
—Sigmund Freud
Freud’s psychoanalysis, the original form of psychodynamic therapy, has spun off countless variants in its century-long existence. Ego psychology, self-psychology, and schools of thought connected to names such as Klein, Kernberg, and Kohut have all attracted considerable followings. Despite their differences, psychodynamic forms of therapy share theoretical assumptions such as the existence of the unconscious, the power of early childhood experiences, and the existence of defenses that distort reality in order to reduce anxiety and enhance coping.
The exploration of the unconscious and its connection to our evolutionary past may be Freud’s greatest legacy. He remained true to Charcot by exploring the multiple levels of human awareness and designed many techniques to bring the unconscious into conscious awareness. The power of trauma, especially during childhood, and its ability to shape the organization of the mind were also examined in great detail. Freud theorized that early attachment and relational difficulties, neglect, or trauma result in developmental arrests or “fixations” that delay or derail the adult’s potential to love and work. From the standpoint of neurobiology, most of Freud’s work addressed the discontinuities and dissociations between networks of conscious and unconscious processing. Freud focused on the role of overwhelming emotion as the cause of unintegrated neural processing.
Freud’s psychic self contains the primitive drives (id), the demands of civilization to conform for the benefit of the group (superego), and those parts of the self (ego) that attempt to negotiate the naturally occurring conflicts between the two. In its role as a diplomat in the fight between id and superego, the ego utilizes many elaborate defenses to cope with reality. Ego strength, or our ability to navigate reality with a minimum of defensiveness, reflects the integration of neural networks of emotion and thought, and the development of mature defenses. The more primitive or immature the defense mechanism, the more reality is distorted and the more functional impairment occurs. Sublimation, for example, enables us to convert unacceptable impulses into constructive and prosocial goals. Mature defenses, like sublimation or humor, allow us to assuage strong feelings, keep in contact with others, and remain attuned to a shared social reality.
Less mature defenses, such as denial and dissociation, result in greater distortion of reality and difficulties in both work and relationships. Defenses are often invisible to their owners because they are organized by hidden layers of neural processing that are inaccessible to conscious awareness. What Freud called defenses can be seen as ways in which neural networks have adapted to cope with emotional stress. People seek treatment when their defense mechanisms cannot adequately cope with repressed emotions, or when symptoms become intolerable.
Despite a conscious awareness that something may be wrong, the hidden layers of neural processing continue to organize the world based on the prior experiences that shaped them. As we will see in later chapters, the neural circuitry involved with fear has a tenacious memory and can invisibly influence conscious awareness for a lifetime. Part of psychodynamic therapy is an exploration and uncovering of this unconscious organization of experience. Freud’s projective hypothesis described the process by which our brains create and organize the world around us. As the clarity of a situation decreases, the brain naturally generates structure and projects it onto the world. The way we organize and understand ambiguous stimuli gives us clues about the architecture of the hidden layers of neural processing (how our unconscious organizes the world). From the projective hypothesis came the invention of projective tests such as Rorschach’s ink blots, free association, and an emphasis on the importance of dreams as the “royal road to the unconscious.”
As part of the projective hypothesis, psychodynamic therapists often provide minimal information about themselves, allowing the client to project onto them implicit (unconscious) memories from past relationships. This form of projection, transference, results in the client placing expectations and emotions from earlier relationships on the therapist, which allows them to be experienced and worked through firsthand. It is through this transference that early relationships for which we have no conscious recollection are brought fully into therapy. Freud felt that the evocation and resolution of the transference was a core component of a successful analysis. In Freud’s words, only transference renders “the invaluable service of making the patient’s buried and forgotten love emotions actual and manifest” (Freud, 1975, Chapter 7).
Resistance represents aspects of implicit memory presented by the client that it is up to the therapist to decipher. Early experiences of rejection, criticism, or neglect from parents result in shame, which can evolve into a child’s negative self-image. The resultant self-criticism (superego) manifests in disrespect for anyone who shows the child love or respect. An example of this is expressed in the Groucho Marx line, “I’d never join a club that would have me as a member.” In therapy, this may manifest as a strong distrust of the therapist’s intentions or his or her ability to be of help.
Interpretations are one of the psychodynamic therapist’s most important tools. Sometimes called the “therapist’s scalpel,” interpretations attempt to make the unconscious conscious. Based on observations of all levels of the client’s behavior, the therapist attempts to bring the processing of the hidden layers to the client’s attention. Repeated and skillful attention to unconscious material via interpretations, confrontations, and clarifications results in a gradually expanding awareness of unconscious processes and the integration of dissociated top-down and right-left processing networks.
Accurate, successful interpretations are sometimes accompanied by feelings of disorganization, anger, or depression. This is because when defenses are made conscious and are exposed for what they are, they lose their effectiveness, leading to a disinhibition of the emotions that they have been successfully defending against. In other words, the networks containing the negative emotions become disinhibited and activated. For example, if intellectualization is being used to avoid the shame and depression related to early criticism, recognition of the defense will bring these feelings and related memories to awareness.
Emotions play a central role in the success of psychodynamic therapies. The neural networks that organize emotions are often shaped to guide us away from thoughts and feelings for which we were punished or abandoned. Unconscious anxiety signals continue to shape our behavior, leading us to remain on tried-and-true paths and avoid situations that trigger our unremembered past. An emphasis on the evocation of emotion and cognition is an important contribution of psychoanalysis and reflects fundamental underlying neurobiological processes of health and illness.
Across psychodynamic forms of therapy, conscious awareness is expanded, emotions are explored, and the expression of repressed or inhibited emotions is encouraged. Feelings, thoughts, and behaviors are repeatedly juxtaposed, combined, and recombined in the process of working through. The assumptions and narratives from the past are edited based on new information, and those about the present and future are reevaluated. The overall goal is combining emotion with conscious awareness and rewriting the story of the self. These processes, when successful, enhance the growth, integration, and flexibility of neural networks and human experience.
Rogerian or Client-Centered Therapy
The curious paradox is that when I accept myself just as I am, then I can change.
—Carl Rogers
Against the dominant background of psychoanalysis, Carl Rogers (1942) emerged with a form of therapy he referred to as “client-centered.” In stark contrast to a theory-based analysis of the patient, Rogers emphasized creating a relationship that maximized the individual’s opportunity for self-discovery. Rogers’s approach gained rapid acceptance in the nonmedical community and by the 1960s came to be the dominant form of counseling (Gilliland & James, 1998).
When different approaches to therapy are compared for effectiveness, the general agreement is that the perceived quality of the client–therapist relationship has the highest correlation with reported treatment success. Some have gone as far as saying that the curative element is the therapeutic relationship itself, rather than any specific techniques. This would certainly have been Rogers’s belief, for he believed that the curative aspects of therapy were the therapist’s warmth, acceptance, genuineness, and unconditional positive regard. His emphasis on interpersonal congruence foreshadowed the focus on emotional resonance and empathic attunement in later-emerging forms of psychotherapy such as object relations and intersubjectivity (Kohut, 1984; Stolorow & Atwood, 1979).
Over the last century, the therapist attributes suggested by Rogers and what we have come to think of as the best possible attitudes for optimal parenting have become essentially identical. Rogerian principles lead to a minimized need for defensiveness and shame while maximizing expressiveness, exploration, and risk taking. Rogers was likely describing the best interpersonal environment for brain growth during development and neural plasticity in psychotherapy when he stated that client-centered therapy “aims directly toward the greater independence and integration of the individual rather than hoping that such results will accrue if the counselor assists in solving the problem. The individual and not the problem is the focus. The aim is not to solve one particular problem, but to assist the individual to grow, so that he can cope with the present problem and later problems in a better-integrated fashion” (Rogers, 1942, Chapter 2).
During my training in client-centered therapy, I was struck by the power of Rogers’s approach. I found it immensely difficult to maintain his supportive stance, and often struggled to keep myself from directing my clients, giving advice, and pushing them to change. To my astonishment, I found that providing clients with a supportive relationship led to insights on their part that mirrored the interpretations I struggled to suppress. Clients often expressed a mixture of sadness and appreciation when they realized how much they longed to be listened to without fear of judgment and shame.
What might be going on in the brain of a client in client-centered therapy? In the Rogerian interpersonal context, a client would most likely experience the widest range of emotions within the ego scaffolding of an empathic other. The activation of neural networks of emotion makes feelings and emotional memories available for reorganization. Rogers’s nondirective method activates clients’ executive networks and their self-reflective abilities. Supportive rephrasing and clarification of what clients say may also enhance executive functioning. This simultaneous activation of cognition and emotion, enhanced perspective, and the emotional regulation offered by the relationship may provide an optimal environment for neural change. Clients, scaffolded by the therapist’s support and stimulated by his or her words, can then work to rewrite their stories.
We know that social interactions early in life result in the stimulation of both neurotransmitters and neural growth hormones that participate in the active building of the brain. By recreating a positive parenting relationship, it is likely that the empathic connectedness promoted by Rogers actually stimulates biochemical changes in the brain capable of enhancing new learning. For example, studies with birds have demonstrated that the ability to learn their songs is enhanced when exposed to live singing birds versus tape recordings of the same songs (Baptista & Petrinovich, 1986). Other birds are actually unable to learn from tape recordings and require positive social interactions and nurturance in order to learn (Eales, 1985). We will see later how maternal contact and nurturance in rats protect the brain from the damaging effects of stress (Meaney, Aitken, Viau, Sharma, & Sarrieau, 1989; Plotsky & Meaney, 1993).
Studies such as these demonstrate that social relationships have the power to stimulate the neural plasticity required for new learning. The interpersonal and emotional aspects of the therapeutic relationship, referred to as a nonspecific factor in the psychotherapy outcome literature, may be the primary mechanism of therapeutic action. As we will see in a later chapter, these nonspecific factors are, in fact, quite specific, as early maternal care has been linked to increased neural plasticity, emotional regulation, and attachment behavior. In other words, those who are nurtured best survive best within a positive and safe environment. Unfortunately, the social isolation created by certain psychological defenses reinforces the rigidity of neural organization as the client avoids the interpersonal contexts required to promote healing. In these instances, the therapeutic relationship may serve as a bridge to once again connect with others.
Cognitive Therapies
It’s not what happens to you, but how you react to it that matters.
—Epictetus
Cognitive therapies highlight the centrality of a person’s thoughts, appraisals, and beliefs in guiding his or her feelings and actions. They emphasize that negative thoughts, skewed appraisals, and erroneous beliefs can create psychological problems. Cognitive therapy focuses on the identification and modification of dysfunctional thoughts with the ultimate goal of improved affect regulation (Beck, Rush, Shaw, & Emery, 1979; Ellis, 1962). The primary targets of cognitive-behavioral therapy have been depression, anxiety, obsessive-compulsive disorder, phobias, and panic disorders.
Depressed patients tend to evaluate their world in absolute terms, take details out of context, and experience neutral comments and events as negative. Common depressive thoughts include the expectation of failure despite many past successes, and thoughts that one is alone despite being surrounded by friends and family. In cognitive therapy, the patient is educated about these common distortions and encouraged to engage in reality testing and self-talk designed to counteract negative reflexive statements.
In anxiety disorders, fear comes to organize and control the patients’ lives. High levels of anxiety inhibit and distort rational cognitive processing. Cognitive interventions with these patients often include educating them about the physiological symptoms of anxiety such as a racing heart, shortness of breath, and sweaty palms. These patients are taught that feelings of dread are secondary to autonomic symptoms and should not be taken as seriously as they feel. A focus on understanding normal biological processes usually redirects the client away from catastrophic attributions that serve to increase anxiety.
With clients suffering with phobias or PTSD, psychoeducation is combined with exposure and response prevention, in which the client faces the feared stimulus (e.g., venturing outside or thinking about a negative event) without being allowed to retreat back to the safety of home or a state of denial. Exposure is usually systematic, gradual, and paired with relaxation training used to aid in the downregulation of physiological arousal. This process combines increased cortical processing (thought) with subcortical activation (emotion) to allow for integration with cortical circuitry in order to permit habituation, inhibition, and eventual extinction via descending cortical networks.
How does this translate into what is going on in the brain during cognitive therapy? Research has demonstrated that disorders of anxiety and depression correlate with changes in metabolic balance among different brain regions. For example, symptoms of depression correlate with activation imbalance within the prefrontal cortex—lower levels of activation in the left and higher levels in the right (Baxter et al., 1985; Field et al., 1988). This supports the hypothesis that mental health correlates with the proper homeostatic balance between neural networks. Symptoms of obsessive-compulsive disorder correlate with changes in activation in the medial (middle) portions of the frontal cortex and a subcortical structure called the caudate nucleus (Rauch et al., 1994). Posttraumatic flashbacks and states of high arousal correlate with higher levels of activation in right-sided limbic and medial frontal structures. Importantly, high arousal also correlates with decreased metabolism in the expressive language centers of the left hemisphere (Rauch et al., 1996).
Of all the different types of therapy, specific links have been found between successful cognitive-behavioral therapy and changes in brain functioning. As described in the last chapter, changes in brain functioning and symptomatology in both obsessive-compulsive disorder and depression have been found after successful psychotherapy (Baxter et al., 1992; Brody, Saxena, Mandelkern, et al., 2001; Brody, Saxena, Schwartz, et al., 1998; Schwartz et al., 1996). These findings strongly suggest that therapists can utilize cognition to alter the relationship among neural networks in a way that impacts their balance of activation and inhibition. In striving to activate cortical processing through conscious control of thoughts and feelings, these therapies enhance left cortical processing, inhibiting and regulating right hemispheric balance and subcortical activation. The reestablishment of hemispheric and top-down regulation allows for increases in positive attitudes and a sense of safety that counteract the depressing and frightening effects of right hemisphere and subcortical (amygdala) dominance (Ochsner & Gross, 2008).
Although cognitive-behavioral therapy is carried out in an interpersonal context of collaboration and support, it places far less emphasis on the therapeutic relationship than do Rogerian and psychodynamic approaches. The inherent wisdom of this approach with depressed and anxious patients lies in the fact that disorders of affect need activation of cortical executive structures. Given that emotions are contagious, a deeper emotional connection might result in the therapist attuning to dysregulated states and sharing in the patient’s depressed, anxious, and panicky feelings. While emotional attunement with these feelings is helpful, it has been my experience that after the working relationship is established, challenging thoughts and encouraging new behaviors can often be far more beneficial to the therapeutic process than empathy alone. The structured aspect of cognitive-behavioral therapy may protect both therapist and patient from the power of negative affect.
Systemic Family Therapy
We must not allow other people’s limited perceptions to define us.
—Virginia Satir
There is increasing evidence that neural networks throughout the brain are stimulated to grow and organize by interaction with the social environment. Early relationships become encoded in networks of sensory, motor, and emotional learning to form what dynamic therapists call inner objects. These inner objects have the power to soothe, arouse, and dysregulate, depending on the quality of our attachment experiences with significant others. These unconscious memories organize our inner worlds when we are with others and when we are alone. Thus, we constantly experience ourselves in the context of others.
This is one reason systems therapists question the validity of diagnosing and treating people in isolation. They believe that in our day-to-day experience we simultaneously exist in two realities: our present families and our multigenerational family histories. This perspective is especially relevant when working with children who have yet to form clear ego boundaries between themselves and their family. Some adult patients who have not successfully individuated also demonstrate unclear boundaries between their own thoughts and feelings and those of family members. Regardless of age, however, the basic principles are the same.
Murray Bowen, a prime contributor to systems thinking, presented a model that is compatible with an exploration of the underlying neuroscience of psychotherapy. His perspective is based on the recognition that a family provides both emotional regulation and a platform for differentiation. He defines differentiation as the development of autonomy—a balance between the recognition of the needs of self and others. Differentiation involves the regulation of anxiety and a balance of integration of affect and cognition. Bowen would say that anxiety is the enemy of differentiation. That is, the more frightened people are, the more likely they are to dissociate and the more dependent and primitive they become in their interaction with others (Bowen, 1978).
When this regression occurs, family members try—consciously and unconsciously—to shape the family in a manner that reduces their own anxiety. The alcoholic needs the problem to go unmentioned, while the family needs to put on a good front to the outside world. Dysfunctional family patterns such as this one sacrifice the growth and well-being of one or more members (often the children) to reduce the overall level of anxiety in the family. The cognitive, emotional, and social world of an alcoholic family is shaped by the avoidance of feelings, thoughts, and activities that expose their shameful secret to conscious awareness and the outside world. The development of the children becomes distorted by the adaptations necessary for their survival within the pathological system. Unfortunately, the roles and rules of the family designed to decrease anxiety maintain the pathologies of some and create new pathologies in others.
Over time, the dysfunction becomes embedded in the personality and neural architecture of everyone in the family and they collude to maintain the system, because they now all require the status quo in order to feel safe. These experiences become embedded into their neural architecture and are carried forward into adult relationships. As a result, many of us re-create the dysfunction from our family of origin in our choice of partners and how we shape the families we build as adults. Each family’s problems are determined by the multigenerational, unconscious shaping of both neural structure and behavior. The functioning of brains and family dynamics reflects how they have been organized. The dysfunctional brain, like the dysfunctional family, is shaped by the avoidance of thoughts and feelings, resulting in the dissociation of neural systems of affect, cognition, sensation, and behavior, as well as a lack of human differentiation.
As in other forms of psychotherapy, the goal of systems therapy is to integrate and balance the various cortical and subcortical, left and right hemisphere processing networks. This process requires a decrease in anxiety from high to low or moderate levels. High levels of affect block thinking, whereas moderate levels enhance neuroplastic processes, which in turn support cognition and emotion. In essence, Bowen is highlighting that the simultaneous activation of cognition and emotion leads to neural integration. Increased differentiation of individuals within a family will decrease the overall rigidity of the system. This process also allows family members to become more responsive to the needs of others and less reactive to their own inner conflicts.
The first step in systems therapy is to educate the family about these concepts and to explore the history of both sides of the family through the past few generations. In the context of systems theory and family history, the problems brought into relief often become more understandable. Uncovering family secrets and reality testing around the myths and projections of each family member allow for cortical processing of primitive and unconscious defenses. The process of family therapy involves a series of experiments with increasingly higher levels of differentiation. Communication skills, assertiveness training, and exercises in new forms of cooperation can all increase cortical involvement with previously reflexive or regressive emotions and behaviors. Often the person with the symptoms needs to take more responsibility, while pathological caretakers must learn to accept nurturance. Each member of the family needs to achieve a balance between autonomy and interdependence. Ultimately, psychological, interpersonal, and neural integration are different levels and manifestations of the same process.
Reichian and Gestalt Therapy
I am not in this world to live up to other people’s expectations, nor do I feel that the world must live up to mine.
—Fritz Perls
Wilhelm Reich, one of Freud’s early disciples, felt that memory and personality are shaped and stored not just in the brain but throughout the entire body. Because of this, Reich not only paid careful attention to his clients’ musculature, posture, and breathing, but also encouraged them to express themselves physically during analysis. By beating their fists, stomping their feet, and using exaggerated breathing techniques, they attempted to release normally inhibited emotions. Reich highlighted the importance of the therapist’s interpretation of the nonverbal messages of the body, making them available for conscious consideration. His theories led to the development of Rolfing (which uses deep body massage to evoke and process memories) and Gestalt therapy (which focuses on drawing attention to nonverbal aspects of communication and increased self-awareness).
Reich (1945) believed that the major focus of psychotherapy should be the analysis of the character, something he saw as similar to Freud’s notion of ego. While Freud focused on verbal communication, Reich’s major contribution was to draw more attention to the nonverbal and emotional aspects of the therapeutic interaction. He contended that the problems people bring to therapy are embedded in their character armor, shaped during development as an adaptation against real or imagined danger. Character armor forms as a result of misattunement, neglect, or trauma at the hands of caretakers. This armor is preverbal and organizes during the first years of life. According to Reich, early defenses take shape at all levels of the nervous system, become encoded in our entire being, and are, like the air we breathe, utterly invisible to us. The defenses identified by Reich reflect emotional memories from early preverbal experiences that are stored in sensory, motor, and emotional networks of early memory. Because character armor is invisible to its owner, the therapist’s job is to make the client aware of its existence, expression, and meaning.
Gestalt therapy is a unique expression of Reichian theory that is particularly relevant to the notion of neural integration. Gestalt, a German word meaning “whole,” reflects the orientation of bringing together an awareness of conscious and unconscious processes; in other words, seeing the whole picture. Gestalt therapy’s charismatic founder, Fritz Perls, used the term safe emergency for the experience that psychotherapists strive to create in treatment (Perls, Hefferline, & Goodman, 1951). A safe emergency is a challenge for growth and integration in the context of guidance and support. It is also a wonderful way to describe an important aspect of good parenting. Therapists create this emergency by exposing clients to unintegrated and dysregulating thoughts and feelings while offering them the tools and nurturance with which to integrate their experiences. Safety is provided in the form of a supportive and collaborative therapeutic relationship, often in the context of a group. The emergency is created by an unmasking of defenses, making unacceptable needs and emotions conscious, and by bringing into awareness dissociated elements of consciousness.
The stories a patient tells about his or her problems are often seen, in the Gestalt context, as self-deceptions. They serve to keep from awareness those feelings that are relevant to healing but less acceptable. Unconscious gestures, facial expressions, and movements are first brought to awareness, then exaggerated, and finally given a voice with the purpose of understanding and integrating experience. The therapist points out contradictions, such as making positive statements while shaking the head “no,” or smiling while talking about a painful experience. These contradictions are explored as indications of internal conflicts to be brought into awareness. Again, the focus is on bringing to conscious (cortical) awareness the automatic, nonverbal, and unconscious processes primarily organized in right hemisphere and subcortical neural networks.
Gestalt therapy emphasizes the identification and exploration of projection, identifying it as an avenue for discovering aspects of the self that have been difficult or impossible to accept. In the popular “empty chair” technique, patients alternately play the role of different parts of themselves to fully articulate the different sides of inner conflicts. The Gestalt therapist believes that maximizing awareness of all aspects of the self—including cognition, emotion, behavior, and sensation—will result in increased maturation and psychological health. This process depends on the integration of the neural networks responsible for each of these functions.
Common Factors
My work as a psychoanalyst is to help patients recover their lost wholeness and to strengthen the psyche so it can resist future dismemberment.
—C. G. Jung
In reviewing these different psychotherapeutic modalities, a number of principles emerge that unify the various therapeutic schools. The first is that psychotherapy values openness, honesty, and trust. Each form of psychotherapy creates an individualized experience designed to examine conscious and unconscious beliefs and assumptions, expand awareness and reality testing, and encourage the confrontation of anxiety-provoking experiences. Each perspective explores behavior, emotion, sensation, and cognition in an attempt to increase awareness of previously unconscious or distorted material. The primary focus of psychotherapy appears to be the integration of affect, in all its forms, with conscious awareness, and cognition.
Intellectual understanding of a psychological problem in the absence of increased integration with emotion, sensation, and behavior does not result in change. All forms of treatment recognize the need for stress, from the subtle disruption of defenses created by the compassion of Carl Rogers to the exposure to feared stimuli in exposure therapies. There is a recognition that the evocation of emotion coupled with conscious awareness is most likely to result in symptom reduction and personal growth. Whether it is called symptom relief, differentiation, ego strength, or awareness, all forms of therapy are targeting dissociated neural networks for integration.
When theories of neuroscience and psychotherapy are considered side by side, a number of working hypotheses emerge. First, given that the human brain is a social organ, safe and supportive relationships are the optimal environment for social and emotional learning. Empathic attunement with the therapist provides the context of nurturance in which growth and development occur. By activating processes involved in secure attachment, empathic attunement likely creates an optimal biochemical environment for neural plasticity.
Second, we appear to experience optimal development and integration in the context of a mild to moderate level of arousal or what we might call optimal stress. Suboptimal affect regulation during development can result in symptoms, maladaptive defenses, and psychopathology. Optimal stress will create the most favorable neurobiological environment for neural plasticity and integration. Although stress appears important as part of the activation of circuits involved with emotion, states of mild to moderate arousal seem ideal for consolidation and integration. In states of high arousal, sympathetic activation inhibits optimal cortical processing and disrupts integration functions. The ebb and flow of emotion over the course of therapy reflects the underlying neural rhythms of growth and change.
Psychodynamic therapies alternate confrontations and interpretations with a supportive and soothing interpersonal environment (Weiner, 1998). The systematic desensitization of cognitive-behavioral therapy pairs exposure to feared stimuli with psychoeducation and relaxation training in the presence of a coach and ally (Wolpe, 1958). Bowen’s family systems approach focuses on pairing anxiety reduction with experiments in increasing levels of independent and differentiated behavior (Bowen, 1978). All forms of successful therapy strive to create safe emergencies in one form or another.
A third hypothesis is that the involvement of affect and cognition appears necessary in the therapeutic process in order to create the context for integration of neural circuits with a high vulnerability to dissociation. It has been said that, in psychotherapy, “understanding is the booby prize.” It is a hollow victory to end up with a psychological explanation for problems that remain unchanged. On the other hand, catharsis without cognition does not result in integration either. The ability to tolerate and regulate affect creates the necessary condition for the brain’s continued growth throughout life. Increased integration parallels an increased ability to experience and tolerate thoughts and emotions previously inhibited, dissociated, or defended against. Affect regulation may be the most important result of the psychotherapeutic process across orientations, because it allows for a reconnection with the naturally occurring salubrious experiences in life.
Repeated simultaneous activation of networks requiring integration with one another most likely aids in their integration. Repetitive play in children and the phrase “working through” in therapy best reflect this process. This concept parallels the principle from neuroscience that “neurons that fire together, wire together” (Hebb, 1949; Shatz, 1990). The simultaneous activation of neural circuits allows them to stimulate the development of connections within association areas to coordinate and integrate their functioning.
Fourth, the co-construction of narratives between parent and child or therapist and client provides a broad matrix supporting the integration of multiple neural networks. Autobiographical memory creates stories of the self capable of supporting affect regulation in the present and the maintenance of homeostatic functions into the future. Memory, in this form, may maximize neural network integration as it organizes vast amounts of information across multiple processing tracks. Thus, language is an important tool in both neurological and psychological development.
Sam and Jessica
The deepest principle in human nature is the craving to be appreciated.
—William James
Being human mean communicating with others. Humans have many channels of communication, including touch, eye contact, tone of voice, and words. Through our interactions we have the power to impact one another at every level. One of my most powerful experiences of the truth of this fact did not take place in a seminar or consulting room, but rather at the home of a friend. I had volunteered to watch his two young children for a few hours while he ran some errands. I had known Jessica and Sam, 4 and 6 years old, all their lives. I was someone on an outer ring of their universe, an attractive combination of familiar and new, and completely unprepared for what was about to happen. The minute their father left, they shifted from low to medium to high gear and I found myself in the midst of a frenzy of excitement.
Toys began flying out of closets and storage containers; games were begun and tossed aside; videos were started, stopped, and replaced—a succession of Indian princes, mermaids, lion kings, ladies, and tramps. After what felt like hours, I glanced at my watch to find only 15 minutes had passed! Four more hours at this pace? I wasn’t sure I could survive. I kept trying to refocus Sam and Jessica’s activity, to no avail. At one point, as we dashed from bedroom to den to living room, I sank to the floor in the hall, and propped myself up against the wall. When they realized that I wasn’t right behind them, they ran back to find me.
They stood panting, one on either side of me, wondering what new game I had concocted. My suggestion that we sit and talk for awhile passed unnoticed. After a few seconds, Sam looked at his sister and yelled, “Show Lou how you burp your dolly!” Both let out a scream and Jessica soon returned with an adorable squishy doll. As I reached for the doll to hold and admire it, Jessica threw the doll on the floor face first and drove her fists into its back. As Jessica and Sam took turns crushing the doll into the carpet, I watched in horror, completely identifying with the doll. I had to hold back my urge to save the poor thing from her vicious attackers.
I quickly reminded myself that I was feeling sorry for a ball of cotton and that I should turn my attention back to the children. I also realized that rescuing the doll would be scolding Sam and Jessica for their behavior, which I did not want to do. I struggled to make sense of what was happening and asked myself if there might be some symbolic message in the way they were treating this doll. Jessica and Sam had experienced a great deal of stress in their brief lives in the forms of severe physical illness, surgery, drug addiction in the family, and an understandably overwhelmed support system. The frantic activity I was witnessing may have reflected the accumulated anxiety from all they had gone through, mixed with normal childhood exuberance. But how might knowing this be helpful to these two beautiful children?
As I reflected on these things I was hit by the notion that perhaps the doll represented both Sam and Jessica. This doll needed to be burped. It needed the help of an adult to alleviate its discomfort and regain a sense of comfort and equilibrium. Perhaps Sam and Jessica were showing me that when they needed to be comforted, they were met with more pain, or, at the very least, insufficient understanding and warmth. Might their behavior be a message? “Please, we need nurturance and healing!” Their world seemed chaotic and unsafe, a whirlwind; these were the same feelings they had created within me during the last half hour. Was their behavior a form of communication?
They had each taken a number of turns “burping” the doll and I suspected that their attention would soon turn to me. What to do or say? I didn’t want to burp the baby their way, and my thoughts about what was happening would be meaningless. I could feel my anxiety growing when finally, they both turned to me and cried in unison: “Your turn!” I hesitated. The chant of “Burp the baby, burp the baby” began to rise. I looked at both of them and said, “I know another way to burp a baby. Here’s how my mom burped me.” A cheer went up. I suspect they assumed that I was going to set the doll on fire or put it in the microwave.
I gently picked up the doll and brought it to my left shoulder. Rubbing its back in a circular motion using my right hand, looking down at it with tenderness, I quietly said, “This will make you feel better, little one.” A silence fell over the hallway. I looked up to find Jessica and Sam transfixed, as if hypnotized. Their eyes followed the slow circles of my hand, heads tilted like puppies. Their bodies relaxed, their hands limp at their sides, calm for the first time.
After following the movement of my hand for about 30 seconds, Jessica looked up at me and softly asked, “Can I have a turn?” “Of course you can,” I told her. At first I thought she meant that she wanted a turn burping the baby. But then carefully, almost respectfully, she took the doll from me and placed it on the floor with its back against the wall. She stepped over to me, climbed over my crossed legs and put her head on my shoulder where the doll’s head had been. She turned to me and almost inaudibly said, “I’m ready now.” As I rubbed Jessica’s back, I felt her growing more and more limp as she melted into my shoulder and chest. I half expected Sam to tear her off, climb on himself, and turn it into a wrestling match. When I looked over to him, I could see that he was in the same posture and state of mind he had been in watching me burp the doll. He eventually looked up at me and asked, “Can I have a turn?” Before I could answer, Jessica lifted her head slightly and told him, “In a minute.”
After a while, she gave up her spot on my shoulder and Sam had his turn being “burped.” It felt wonderful to hold them in this way and give them something they seemed to need so badly. After a few turns for each of them, we went into the den, curled up on the sofa, one of them under each of my arms, and watched a movie. Actually, I watched the movie—they dozed off after only a few minutes. While my eyes followed the frenetic animation on the screen, my breathing paced theirs and I shared the peace they seemed to be feeling.
I marveled at how they managed to communicate their pain and confusion by creating these same feelings in me. Emotion is truly contagious and a powerful source of human connection. By having them set the initial pace of our play, I told them I respected their way of coping. Through the use of the doll, they communicated that when they needed soothing their anxiety was often met with more of the same. When I burped their doll in a caring and loving way, I showed them that I was capable of soothing them if they were feeling bad. By asking me to burp them, they told me I was trusted. In falling asleep, they said, “We feel safe and we know you will watch over us while we rest.” While none of this was spoken, the communication was clear.
Our interactions with the doll changed Sam and Jessica’s state of mind and body as well as my own. I believe that it not only impacted their attitudes and behaviors that afternoon, but may have also changed their brains in some small but perhaps permanent way. I could see this reflected in their faces and hear it in the tone of their voices; something fundamental had changed that affected their entire beings. I provided them with a metaphor through which they could reorganize their experience, have their needs met, and regulate their emotions. Together, the three of us co-constructed a new narrative for them to use as a way of soothing themselves and each other.
Were this process to be repeated enough times, their brains could reorganize around this metaphor of nurturance and holding and enhance communication between networks of cognitive and emotional processing. Perhaps Sam and Jessica could internalize a model of self-holding and nurturance that would help them navigate future challenges. This kind of interaction is at the heart of all forms of psychotherapy, regardless of philosophy or technique. All forms of therapy have their own versions of integrative metaphors, serving to reorganize neural networks and alter human experience, hopefully, for the better.
Summary
In this chapter we have discussed some of the basic principles connecting the historical and conceptual connections between psychotherapy and neuroscience. Four common factors related to the nature of social relationships, optimal stress, the activation of affect and cognition, and the co-construction of narratives emerge from the review. In the chapters to come, we will explore the components and organizing principles of the nervous system. These basic concepts will help us understand the neural mechanisms of the building and rebuilding of the brain.