There is no greater agony than bearing an untold story inside you.
—Maya Angelou
It appears that nature has retained a fundamental strategy of connecting things—be they neurons, neural networks, or individual people—into more complex organizations. As we zoom in to look at groups of neurons and zoom out to look at groups of people, the same basic principles of connectivity and homeostatic balance appear to hold true. As we learn about the necessary synergistic connectivity of neural networks, we are also coming to understand the relationship between network imbalance and mental distress. From extreme PTSD to everyday neurosis, we all exhibit a pattern of integration and dissociation reflective of our adaptational history and the health of our brains. At the level of the experience of self, networks dedicated to sensation, perception, and emotion seamlessly integrate into the emergence of conscious experience ( Damasio, 1994; Pessoa, 2008; Fox et al., 2005). Let’s take a look at the impact of a somewhat simple breakdown of neural network integration on the experience of self.
A few years ago, a young man in his late teens came in for a therapy session. The previous September, Craig had left home to attend his first year of college, but by mid-December, something had gone haywire. His parents were called by the dean and told that Craig had not been going to classes for weeks. They were also informed by the resident advisor that 5 days earlier, Craig had locked himself in his room, thrown all of his and his roommate’s possessions out of the window, and was listening to the same song 24 hours a day. His parents raced to campus to find him in the middle of an acute psychotic episode.
Craig had been released from the hospital where I worked just a few weeks earlier and it was good to see him once again independent and active. As he walked across my office, I could see his movements were slowed by the medications that were keeping his hallucinations at bay. I had seen Craig in individual and group therapy for approximately a month. His symptoms had slowly cleared and he was released to his parents’ care a week earlier. This was his first session since being discharged. After he settled in, I asked him how things had been going since he left the hospital. Slowly, and in a soft voice, he told me that life was pretty good and that he enjoyed playing his guitar and working on some new songs. He wasn’t feeling paranoid or hearing voices like he had been weeks ago, his sleep and appetite were okay, and he felt like he was ready to return to school. “There’s only one problem, Doc. I don’t feel comfortable at home because my parents and brother have been replaced by doubles.”
“Doubles?” I asked him. “What do you mean, doubles?”
Craig started by saying that he had gotten a strange feeling about his parents and brother when they came to visit him in the hospital, but he figured he was off because of the medication. But once he got home, he discovered the reason for his strange feelings. “After a while I realized that they’ve been replaced by doubles!”
I gave him my best quizzical therapist expression and asked what made him think they were doubles. Craig described how they were excellent copies and well prepared to trick him. He asked them scores of questions he thought only his parents and brother could answer and, sure enough, they got them right. “Whoever is doing this to me is good!” he said with nervous admiration. When I asked him again how he could be so sure they were replacements, he replied with annoyance, “Don’t you think I would know my own parents?”
This syndrome of suspecting impostors, called Capgras syndrome, can occur alone but usually appears in tandem with some other brain dysfunction such as schizophrenia, temporal lobe epilepsy, or head injury (Serieux & Capgras, 1909). Although the neurobiology of Capgras syndrome is not definitively understood, there has been ongoing speculation that it is a disconnection syndrome that somehow separates networks of perception, emotion, and conscious analysis (Alexander, Stuss, & Benson, 1979; Merrin & Silberfarb, 1979). An EEG study found “abundant and severe EEG abnormalities” in 21 Capgras patients in the area of the temporal lobes. This led the authors to suggest that the delusion of impostors may be caused by a “dysrhythmia” of brainwaves in networks responsible for matching faces with emotional familiarity (Christodoulou & Malliara-Loulakaki, 1981).
Capgras syndrome does not affect the neural networks responsible for recognizing familiar faces. Craig could see that these people he took for imposters were physically identical to his parents and brother. But Craig’s experience was that they no longer felt like his parents—the emotional “glow” of recognition of loved and familiar people was missing (Hirsten & Ramachandran, 1997). We can hypothesize that a disconnection or lack of coherence occurrs between the circuits of the temporal lobes responsible for face recognition and the ompfc-amygdala axis, which would add the emotional reaction of seeing a loved one. With this connection somehow disrupted, Craig’s still intact left hemisphere explanatory circuitry created a delusion of imposters; an explanation that is logical if you accept the experiential premise. The people in Craig’s home looked and acted like his family, but without the usual input from the emotional circuitry responsible for the feeling of familiarity, his left hemisphere interpreter concluded that they must be imposters.
Most of us have felt the firing of these familiarity circuits in an exaggerated form when we unexpectedly run into a friend in an unusual place. Our shock of recognition leads to the inevitable, “Oh my God, what are you doing here?” Craig was experiencing what amounts to the opposite of this experience. He expected to have the feeling of recognition but didn’t. This is probably what he was referring to when he said, “Don’t you think I would know my own parents?” Capgras syndrome may well be the opposite of a déjà vu experience, where something which is actually new is paired with a feeling of familiarity. Déjà vu is likely a random firing of familiarity circuits in an unfamiliar setting. The fact that strong déjà vu experiences are often reported by patients with temporal lobe epilepsy suggests that their out-of-control electrical firing is activating the amygdala, which is deep within the temporal lobes.
The delusion of impostors generated by the left hemisphere interpreter may be similar to the attributions made about déjà vu experiences such as past lives, clairvoyance, and other paranormal beliefs. This very normal impulse to make sense of nonsense is also seen in schizophrenics, who attempt to create a logical explanation for their bizarre sensory experiences (Maher, 1974). In the face of experiencing thoughts being inserted in their heads, patients ask themselves, “Who would have the technology to do such a thing?”
When I worked in Boston, patients pointed the finger at MIT, while the people I treated in Los Angeles suspected Cal Tech. Delusional beliefs can become quite central to a client’s life as well as tenacious and difficult to dislodge. For example, when three patients, each of whom believed they were Christ, were housed together, each came to believe that the other two were delusional (Rokeach, 1964).
Pathways of Integration
All organs of an animal form a single system…and no modification can appear in one part without bringing about corresponding modifications in all the rest.
—George Cuvier
The long and circuitous path of brain evolution has not provided us with a brain that is simple in function or straightforward in design. We have already seen how the brain consists of different memory systems, two hemispheres with different processing capabilities, and multiple executive systems controlling different skills and abilities. We have also explored how, when these systems get out of sync, psychotherapy attempts to reconnect and balance them.
Although we are just beginning to understand functions and the complexities of our neural pathways, some consistent findings are beginning to emerge. As we discussed in an earlier chapter, the two main pathways to consider are top-down and left-right. It is also important to always keep in mind that they are not independent of one another because top and left areas have developed certain special connections, as have the bottom (subcortical) and the right hemisphere. Another important point to keep in mind is that these top-down and left-right systems involve multiple structures along the way, each with its own unique contribution and potential role in network functioning. We should also add two more specific pathways, the relationships between regions within the frontal lobes (the ompfc and the dlpfc), and between the hippocampus and amygdala. These systems also have particular associations with both top-down and left-right integration.
Let’s review the general map of the brain’s pathways of integration. In Table 9.1, notice the alignment of these four pathways. Top-down, left hemisphere, dlpfc, and the hippocampus are aligned on the left because they tend to be connected more heavily with one another than with those in the column on the right. They also tend to be involved with conscious, rational, and language-based functions. Bottom-up processing, the right hemisphere, the ompfc, and the amygdala appear to have more dense connectivity among themselves and are more likely to be involved with unconscious, somatic, and emotional functions. So, for example, Capgras syndrome may reflect a disconnection of bottom-up emotional processing involving the amygdala and right hemisphere from the top-down and left hemisphere cognitive analysis of sensory experience.
TABLE 9.1 Pathways of Integration
|
Top (cortical) |
|
Bottom (subcortical) |
|
Left hemisphere |
|
Right hemisphere |
|
dlpfc |
|
ompfc |
|
Hippocampus |
|
Amygdala |
There is presently a great deal of research focused on breaking down these functional networks into finer and more precise distinctions and generating models of processing paths and organizational patterns. Separating the roles of each region of the brain in each hemisphere is also under exploration, as is the mapping of patterns of activation (instantiations) for different symptoms and diagnostic groups (Dougherty et al.,2004). As with all of this research, we have to keep in mind that age, gender, and life experiences all play a role in how these networks organize and function in each individual. For our present purposes, I have chosen to focus on these general categories because of their obvious applicability to psychotherapy and mental health.
Top-Down–Bottom-Up
The complexity of the nervous system is so great, its various association systems and cell masses so numerous, complex and challenging, that understanding will forever lie beyond our most committed efforts.
—Ramon y Cajal
Although there are many vertical circuits that cut across the horizontal strata of the brain, important top-down networks for psychotherapists are those connecting the ompfc and amygdala. The ompfc and the amygdala are connected by dense bidirectional networks that feed physiological and emotional information upward to the cortex while allowing the ompfc to modulate the output of the amygdala to the autonomic nervous system (Ghashghaei & Barbas, 2002; Ghashghaei et al., 2007; Hariri et al., 2000, 2003). Think of the amygdala as a primitive structure designed to link immediate threat with a rapid survival response. Think of the ompfc as having the ability to gather and update information and use it to predict potential outcomes and shape behavior (Dolan, 2007; Rosenkranz, Moore, & Grace, 2003). Perhaps a good analogy is a squad of soldiers trained to fight and survive (amygdala and anatomic nervous system) and a general who is an expert strategist who continues to keep an eye on the entire battlefield, update his strategy, and adjust long-range goals (ompfc).
In the normally functioning brain, the balance of ompfc–amygdala activation reflects a dynamic moment-to-moment balance of focused attention and emotional arousal (Simpson, Drevets, et al., 2001; Simpson, Snyder, et al., 2001). When faced with a psychosocial stress, we see elevated cortisol levels along with increased activation in the amygdala and lower levels of activation in the ompfc (Kern et al., 2008). Higher levels of ompfc activity are believed to reflect an inhibition of affective processes and an enhanced focus on the outside world, while a decrease suggests a shifting of attention to internal processes. As negative affect decreases, so does amygdala activation, while activation in the ompfc increases (Urry et al., 2006). It is now believed that each of us has a unique homeostatic balance of this circuitry which shapes our emotional regulation and affective style (Davidson, 2002).
Let’s think about what happens in the human brain during public speaking. For most individuals, getting up in front of a group to speak results in increased cortical activation. This makes sense because we need our cortex to process the cognitive demands of giving a talk. But when socially phobic individuals get up to speak, there is a decrease in cortical activity and an increase in amygdala firing along with bodily symptoms of anxiety and panic (Tillfors et al., 2001). This may help us understand the phenomenon of stage fright, where people either forget their lines or find it impossible to speak when faced with an audience. High levels of cortisol, dopamine, and bottom-up inhibition from the amygdala can all take the prefrontal cortex “off-line” during stress (Arnsten & Goldman-Rakic, 1998; Bishop, Duncan & Lawrence, 2004). This “amygdala hijack,” as it is called in the self-help literature, is the takeover of executive functioning by the amygdala and other subcortical systems (Goleman, 2006).
The balance and integration of the ompfc and amygdala are influenced by everything including past trauma, current stress, and serotonin levels (Hariri, Drabant, & Weinberger, 2006; Heinz et al., 2005). When people suffer from symptoms of depression or anxiety, there is a general decrease in cortical activation and an increase in anterior regions of the cingulate and insula (Kennedy et al., 2007; Mayberg et al., 1999). This balance reverses as mood lightens with or without treatment (Kennedy et al., 2001). It has also been found that pretreatment metabolism in these and other regions predicts response to antidepressant medication (Davidson, Irwin, et al., 2003; Pizzagalli et al., 2001; Saxena et al., 2003; Whalen et al., 2008; Wu et al., 1999).
As we saw earlier, sadness and depression also reflect a left-right imbalance. Left-biased prefrontal activation downregulates negative affect in nondepressed individuals while depressed individuals show bilateral frontal activation (Johnstone et al., 2007). These findings highlight the fact that the modulation of mood is likely to occur simultaneously on multiple planes of homeostatic balance—top-down, left-right, and so on. Thus, a shift away from depression may reflect a dual regulatory shift from right and down to top and left activation. Keep in mind that conflicting results have also been found, so our understanding of these processes is still just developing (Holthoff et al., 2004).
Within this broad top-down system there are likely numerous subsystems involved in emotional regulation. Different studies have demonstrated a variety of activation patterns in broad top-down networks in tasks of affect regulation and the voluntary suppression of emotions (Anderson & Green, 2001; Beauregard, Lévesque, & Bourgouin, 2001; Phan et al., 2005). For example, the coordination of activity between the amygdala and the anterior cingulate has been shown to be correlated with trait anxiety and a susceptibility to depression (Pezawas et al., 2005). Suppressing cigarette craving correlates with increased activation in the cingulate cortex and an inhibition of sensory and motor regions as subjects respond to smoking-related stimulus cues (Brody et al., 2007).
The anterior cingulate, amygdala, and insula are modulated by the processing of internal somatic experience during biofeedback training while the anterior insula is involved with the interaction between the accuracy and sensitivity of the feedback (Critchley et al., 2002). This may be the same circuitry activated during therapy as we integrate conscious awareness with somatic, emotional, and memory processing. Simultaneous top-down and left-right inhibition is likely responsible for what Freud called repression. As prefrontal and anterior cingulate regions are inhibiting conscious recall of explicit memories, left frontal networks can be simultaneously inhibiting negative somatic and emotional memories stored in right-biased systems (Anderson & Green, 2001). The result would be a lack of conscious recall of a threatening experience and a dissociation of experience from conscious awareness.
Left Hemisphere–Right Hemisphere
The interpretive mechanism of the left hemisphere is…constantly looking for order and reason, even when there is none—which leads it continually to make mistakes.
—Michael Gazzaniga
As we saw in an earlier chapter, left-right integration is required for proper language functioning, bodily awareness, emotional regulation, and many other essential human processes. As we will soon discuss, the emergence of storytelling and narrative structure as universal aspects of human culture may have emerged, in part, to assist in the integration and coordination of the two very different brains.
A greater left-hemisphere advantage in verbal processing has been shown to be a predictor of a more favorable outcome in cognitive-behavioral therapy (Bruder et al., 1997). This suggests that those individuals with more left-lateralized language abilities may also have stronger inhibitory capacities over emotional experience stored in the right. It has been shown that good readers have less interhemispheric connectivity and are better at processing rapidly changing sensory input (Dougherty et al., 2007). For some tasks, less integration and cooperation are an advantage, especially when speed or focus of attention are factors. Having the input of both hemispheres may be quite adaptive when we are solving complex social and emotional problems, but is likely to slow us down and make us stumble if we need to engage in fast and automatic behavior (Cozolino, 2008).
A form of treatment used to readjust right-left balance is transcranial magnetic stimulation (TMS). TMS is a noninvasive, painless technique for the stimulation and inhibition of neural firing. A coil of wires is placed on the scalp that generates a magnetic field strong enough to penetrate the skull. This magnetic field is transformed into current flow in the brain that temporarily excites or inhibits select areas, which can be applied either as a single pulse or repetitively (rTMS). Depending on its frequency, it either increases or decreases cortical excitability—fast rTMS increases activation while slow rTMS decreases it (Daskalakis, Christensen, Fitzgerald, & Chen, 2002).
In several studies, patients with treatment-resistant depression experienced symptomatic improvement after a series of fast rTMS treatments applied to the left prefrontal cortex (Pascual-Leone et al., 1996; George et al., 1997; Figiel et al., 1998; Teneback et al., 1999; Triggs et al., 1999). These repeated magnetic pulses to the left hemisphere may have increased activity and shifted the balance of mood in a more positive direction. Slow rTMS applied to the right prefrontal cortex resulted in similar improvements in depressive symptoms (Klein et al., 1999; Menkes et al., 1999). Slower frequency rTMS to the right prefrontal cortex was thought to inhibit right frontal functioning and have less adverse side effects (Schutter, 2009).
Studies of rTMS and depression lead us to the conclusion that the technique’s ability to both stimulate the left hemisphere and inhibit the right hemisphere may prove equally useful in depressed patients. Current views take the position that restoring the balance between left and right prefrontal cortex activity is more important in treating depression than establishing clear increases in left-sided activity. If rTMS can have a positive effect on depressive symptoms, might it work in the reverse manner for mania? Studies in this area are less extensive, but findings do suggest some effectiveness of rTMS in the treatment of mania when it is applied at high frequency to the right prefrontal cortex (Belmaker & Grisaru, 1999; Grisaru et al., 1998; Michael & Erfurth, 2002; Saba et al., 2004). The procedure has been approved by Health Canada for clinical use but not in the United States, where its application is limited to clinical research.
Dlpfc–Ompfc
Modern Psychology takes completely for granted that behavior and neural function are perfectly correlated, that one is completely caused by the other…. It is quite conceivable that some day this assumption will have to be rejected.
—Donald Hebb
As a whole, the prefrontal cortex sculpts experience and behavior through a complex array of inhibitory and excitatory activities (Knight, Staines, Swick, & Chao, 1999). You will recall that the prefrontal cortex is divided into four regions and that the dorsal and lateral regions tend to engage in coordinated activity as do the orbital and medial areas. Because of these connections they are often referred to as the dlpfc and ompfc. The location of prefrontal activation varies depending on the emotional salience of the task; the more emotional the task, the more ompfc activation—the more cognitively demanding a task, the more the dlpfc takes center stage (Goel & Dolan, 2003; Northoff et al., 2004; Schaefer et al., 2002). As the cognitive demands of a task increase, there is a decrease in activation not only in the ompfc, but also in the amygdala and anterior cingulate, which are closely linked to the ompfc (Pochon et al., 2002; Rushworth & Behrens, 2008). This is likely the reason why engaging in cognitive tasks, like word or math problems, often reduces anxiety.
The dlpfc exerts control over neural processing based on higher order rules (environmental context, prediction, etc.) while the ompfc does the same from the perspective of lower order rules (impulse, drives, emotions, etc.). From this we get the sense that top-down and bottom-up processing is interwoven with the balance of activation between the dlpfc and ompfc, respectively. Interestingly, when people make decisions congruent with implicit racial and gender biases, the ompfc and amygdala become more active, while the dlpfc shows more activity when we express beliefs that are incongruent with prejudice (Knutson, Mah, Manly, & Grafman, 2007). This reflects what we already know—more primitive impulses drive prejudice while education and expanded perspective allow us to go beyond our reflexive limitations.
Experiencing the world from a first-person perspective and tasks of self-regulation activate ompfc regions while situation-focused regulation activates dlpfc systems (Ochsner et al., 2004). The ompfc becomes involved in diverse tasks that require differing kinds and degrees of self-referential knowledge (Ochsner et al., 2005). Within the ompfc, the decoding of the mental states of others based on observable cues such as facial expressions may rely on the right ompfc while reasoning about their mental states may be lateralized to the left ompfc (Sabbagh, 2004). When we consider the types of issues brought into psychotherapy, it is likely that we are working to build, integrate, and balance the ompfc and dlpfc.
Consider what we do when we assist clients in shifting from their own perspective to looking at a situation from another point of view, to thinking about the situation once again from a more objective perspective. We are calling upon the ompfc and dlpfc in different ways as we attempt to guide them to a more holistic perspective of a life situation. This process most likely enhances the growth of ompfc and dlpfc systems, while building new brain networks to bridge the two for higher level awareness. Optimal functioning necessitates coordination, flexibility, and complementarity between these modes of functioning. When the ompfc and dlpfc are in proper balance, they create the possibility of true cognitive-emotional integration (Gray et al., 2002). In situations of stress and trauma the ompfc and dlpfc are capable of either mutual dissociation or inhibition (Roberts & Wallis, 2000). An inability of the ompfc to modulate stress will result in a decrease of activation in the dlpfc during a cognitive memory task and cause a performance deficit (Dolcos & McCarthy, 2006; Drevets & Raichle, 1998). Building strong connections between ompfc-dlpfc circuits creates resilience to stress and a hedge against resorting to dissociation, as well as greater affect tolerance and ego strength.
Hippocampus–Amygdala
Emotions have taught mankind to reason.
—Marquis De Vauvenargues
The hippocampus and amygdala both play central roles in learning and memory. The amygdala (in connection with the ompfc) organizes emotional experience and (in moderate states of arousal) signals the hippocampus about what is important to learn. On the other hand, the hippocampus (along with the dlpfc) participates in the cognitive evaluation of situations that will inform the amygdala when to ramp up or back down on its emotional reaction. In other words, I can see that the dog is wagging his tail so perhaps I don’t need to be as afraid of being bitten. Since the activation of emotion and the cognitive analysis of experience are both necessary for normal functioning, the proper regulatory balance of the hippocampus and amygdala is vital.
The hippocampus is necessary for forming new explicit memories while the amygdala organizes highly stressful and traumatic learning. At low levels of arousal, amygdala activation supports hippocampal learning by boosting the biochemical aspects of neural plasticity. At higher levels of arousal, the amygdala stimulates HPA activation, which interrupts hippocampal learning while supporting fear-based amygdala learning (Kim, Koo, Lee, & Han, 2005; Kim, Lee, Han, & Packard, 2001). In essence, during states of high arousal, hippocampal and amygdala networks become dissociated, resulting in a disconnection between visceral-emotional (amygdala) and declarative-conscious (hippocampal) processing (Williams et al., 2001). Thus, optimal learning requires a balance of amygdala and hippocampal participation.
Many people, perhaps even the majority of clients in psychotherapy, do not come for treatment of a major psychiatric illness. Most clients who are somewhat “less ill” have so far not been included in extensive (and expensive) outcome research that includes brain imaging studies. Many people seek psychotherapy simply because, as they often say themselves, life has somehow gotten out of balance. This may mean that their fears and worries have taken control of their lives and limited their ability to function or find happiness in the world. Others find themselves devoid of emotion and without empathy for others, leading them to seek therapy to save their marriages and relationships with their children. Many have the sense that they are not living up to their potential or get in their own way when it comes to worldly success and emotional satisfaction.
These clients are often referred to as the “worried well,” implying that they should somehow get over themselves and get on with life. My sense is that this group of patients, in which I would include myself, also suffer various versions of a homeostatic imbalance. An exaggerated reliance on intellectual defenses, overemotionality, or a negative attachment experience can become established as self-perpetuating patterns that lead to social isolation and underperformance. All of these suboptimal lifestyles are most likely reflected in biased patterns of neural activation, which become the focus of psychotherapy. While psychotherapy is a relatively recent and culture-specific development in human history, talking to one another, seeking out advice, and exchanging stories likely go back to the first humans. Thus, the talking cure exists within a matrix of beings who share the gift of gab. I suggest to you that the evolution of the brain and the development of narratives have gone hand in hand.
From Neural Networks to Narratives
[Words] leave finger marks behind on the brain, which in the twinkling of an eye become the footprints of history.
—Franz Kafka
The evolution of the human brain is inextricably interwoven with the expansion of culture and the emergence of language. Thus, it is no coincidence that human beings are storytellers. Through countless generations, humans have gathered to listen to stories of the hunt, the exploits of their ancestors, and morality tales of good and evil. It has long been supposed that these stories support the transmission of culture while promoting psychological and emotional stability. Stories connect us to others, prop up our often fragile identities, and keep our brains regulated. Thus, I believe that both the urge to tell a tale and our vulnerability to being captivated by one are deeply woven into the structures of our brains.
Narratives perform an array of important functions including:
For most of human history, oral communication and verbal memory were the medium and repository of our accumulated knowledge. The ongoing value of stories to each of us is highlighted in today’s world by the energy we invest in television, movies, magazines, and everyday gossip. The drive of older folks to repeatedly tell the same stories is matched by the desire of young children to hear them again and again. This inter-locking conduit of culture across generations carries memories, ideas, and ideals through time. The importance of narratives in human evolution is further underscored by the fact that our ability to remember and recall stories is essentially limitless. In fact, the astonishing abilities of memory experts rely on placing discrete pieces of information into narratives that expand the capacity of working memory to the limits of their imagination.
Although stories may appear imprecise and unscientific (Oatley, 1992), they serve as powerful tools for high-level neural network integration (Rossi, 1993). The combination of a linear storyline and visual imagery woven together with verbal and nonverbal expressions of emotion activates and utilizes dedicated circuitry of both left and right hemispheres, cortical and subcortical networks, the various regions of the frontal lobes, and the hippocampus and the amygdala. The cooperative and interactive activation involved in stories may be precisely what is required for sculpting and maintaining neural network integration while allowing us to combine our sensations, feelings, and behaviors with conscious awareness. Further, stories link individuals into families, tribes, and nations and into a group mind linking each individual brain. It is likely that our brains have been able to become as complex as they are precisely because of the power of narratives and the group to support neural integration.
Much of neural integration takes place in the association areas of the frontal, temporal, and parietal lobes, which serve to coordinate, regulate, and direct multiple neural circuits. They are our conscious switchboard operators, able to use language and stories to link the functioning of systems throughout the brain and body. An inclusive narrative structure provides the executive brain with the best template and strategy for the oversight and coordination of the functions of mind. A story well told, containing conflicts and resolutions, gestures and expressions, and thoughts flavored with emotion, connects people and integrates neural networks.
A Story Well Told
Man’s mind, once stretched by a new idea, never regains its original dimensions.
—Oliver Wendell Holmes
Have you have ever watched the faces of small children as they listen to a gifted storyteller? You can see the unfolding drama reflected in their eyes, on their faces, and throughout their bodies. Listeners will experience a range of drastically shifting emotions, be absorbed in every detail, and even shout out warnings to characters in danger. Narratives allow us to place ourselves within alternate points of view and increase our understanding of the experience of ourselves and others. We can escape our bodies in imagination to other possible selves, ways of being, and worlds that have yet to be created.
Through stories we have the opportunity to ponder ourselves in an objective way across an infinite number of contexts. In life and in therapy, we can use stories to imagine our problems happening to someone else or view ourselves at a distance (externalization). We can share versions of possible selves and receive input from others. Finally, we can experiment with new emotions, actions, and language to edit the scripts of our lives (Etchison & Kleist, 2000). Our ability to edit narratives summons us to try on new ways of being. (Recall the case of Sheldon and his magic tricycle.)
What makes for a good story? Why can I sit through Pretty Woman or A Few Good Men over and over again, even though I know exactly how they end? If you take a screenwriting class you learn that there is a formula for successful narrative structure. Every story needs a hero, a protagonist with whom we can identify. The protagonist is facing an external challenge and possesses an inner wound that causes him persistent pain. For both Richard Gere and Tom Cruise, this pain came from their emotional estrangement from their fathers. At first the hero either avoids the challenge or fails, leading him to question his ability to succeed or even his desire to change. The challenge confronting the hero is at first resisted, then rejected, and eventually accepted. During the journey, the hero leaves behind old definitions of self and travels into uncharted territory. Some inner transformation takes place that allows him to face his demons, succeed in his worldly challenge, and solidify his identity. Richard Gere accepts Julia Roberts and Tom Cruise faces down Jack Nicholson.
This is essentially the universal Myth of the Hero, describing the transition from adolescence to adulthood (Campbell, 1949). Redemption—a word commonly used for this transition—can happen at any age. The adolescent struggling to attain adult status, the emotionally shut-down Scrooge faced with his history of loss, or a client trying to make sense of early deprivation have, at their core, a wound that needs healing. My explanation would be that what we share in common—brain, culture, language, and the fight for growth and survival—are the underlying motives of the heroic narrative. Another way of saying this is that what we share in our common struggle for survival and meaning is deeper and more powerful than those things which make us appear different.
Narratives and Emotional Regulation
Good psychiatry is a blend of science and story.
—Jeremy Holmes
As the language areas of the left hemisphere enter their sensitive period during the middle of the second year of life, grammatical language in the left integrates with the interpersonal and prosodic elements of communication already well developed in the right. As the cortical language centers mature, words are joined together to make sentences and can be used to express increasingly complex ideas flavored with emotion. As the frontal cortex continues to expand and connect with more neural networks, memory improves and a sense of time slowly emerges and autobiographical memory begins to connect the self with places and events, within and across time. The emerging narratives begin to organize the nascent sense of self and become the bedrock of our sense of self in interpersonal and physical space.
As our experience of self and the stories we tell about ourselves become interwoven, self-identity becomes the center of narrative gravity (Dennett, 1991). As children we are told by others, and gradually begin to tell others, who we are, what is important to us, and what we are capable of. These self-stories are shaped by culture and co-constructed with parents and peers. And although it does sometimes seem that children are little scientists discovering the world, what we often miss is that they are primarily engaged in discovering what the rest of us already know, especially about them (Newman, 1982). This serves the continuity of culture from one generation to the next as we reflexively strive to recreate ourselves.
The role of language and narratives in neural integration, memory formation, and self-identity makes them a powerful tool in the creation and maintenance of the self (Bruner, 1990). Stories are powerful organizing forces that serve to perpetuate both healthy and unhealthy forms of self-identity. There is evidence that positive self-narratives aid in emotional security while minimizing the need for elaborate psychological defenses (Fonagy, Steele, Steele, Moran, & Higgitt, 1991). In the same way, anxious and traumatized parents pass along their negative experiences in the stories they tell. The recognition of the negative power of personal narrations containing negative self-statements stimulated the development of rational and cognitive-based therapies (Ellis, 1962). Let’s look at the role of a positive narrative for a young boy.
Seven-year-old Trevor was brought to see me because his parents were concerned that he might have “something troubling him.” He was very close to his grandfather who had passed away 6 months earlier, but he didn’t seem to have a reaction to this loss. While his parents felt they had done everything they could to encourage him to talk about his feelings, he didn’t have that much to say. Trevor seemed to be a normal kid with interests in science, video games, and computers. As he became comfortable, we hung out, played, and talked about all kinds of things. During our second session, he mentioned that he liked doing puzzles, so I purchased a few and brought them to the office.
Before our session, I spread one of the puzzles out on my desk. I put together a few pieces to give him a jump start and had to quell my own compulsive impulse to keep going. He was excited when he noticed it and asked if he could help me work on it. “Certainly,” I said, and we sat down to a session of puzzling. It didn’t take long for me to realize that he was having difficulty and I wondered if I had chosen one that was too difficult for him. The last thing I wanted to do was to give him a failure experience.
I offhandedly suggested that we didn’t have to work on the puzzle if he would prefer to do something else. “Maybe this one is too hard for us,” I said. “No,” he replied, “don’t give up. We’ll get it.” Impressed by his determination, we continued to move pieces around in search of colors and patterns. Every once in a while, I would leave a piece in front of him that I knew would fit with something he was holding. I became more and more amazed at his patience and dedication. Many boys his age would move on to something else or just clear the table with the swipe of an arm.
After a while, I heard Trevor mumbling under his breath. He was repeating something over and over like a song or mantra. I leaned over, slowly putting my ear closer and closer to him so I could make out his words. Finally I could hear, “I think I can, I think I can.” He was chanting the theme of “The Little Engine That Could.” He was the little train that kept on keeping on. I immediately felt my eyes well up and had to resist the urge to hug him. Sure enough, he slowly got the hang of it and made lots of progress.
I later found out from his parents that the Little Engine was his favorite story and one his grandfather loved to tell him. They told me he wanted to hear it exactly the same way each time and if they made a mistake on any word he would stop and correct them. It was clear that this Little Engine was a kind of hero to him, and he used it when he was stressed by a challenging situation to regulate his anxiety and keep himself moving ahead. Part of this heroic story was likely the memory of a loving grandfather whom he carried inside of him. The Little Engine became a way for us to share about his grandfather. Trevor was showing me the power of a story to soothe and inspire. I came to realize that his grandfather had done a wonderful job of becoming part of Trevor’s experience of himself and preparing him for his death. I learned that Trevor’s loss was complicated because, in many ways, he still had his grandfather with him. I believe that Trevor’s ability to use narrative in this way and his internalization of his grandfather’s love bode well for his healing.
To serve their important role in emotional regulation, narratives need to have a brief summary or hook that can be held in mind in the present moment. This summary, which can be a word, a phrase, a visual image, or even a gesture, can instantaneously evoke the beginning, middle, and end of the narrative, and especially its message. In Trevor’s case, it was the phrase “I think I can.” This decreased his anxiety, enhanced his problem solving, and allowed him to discover his true competence.
Putting feelings into words (affect labeling) has long served a positive function for many individuals suffering from stress or trauma. Labeling emotions correlates with decreased amygdala response and an increase in right prefrontal activation (Hariri et al., 2000). It has also been found that amygdala–right frontal activation are inversely correlated and that this homeostatic balance is mediated by the ompfc (Lieberman et al., 2007). This suggests that the labeling process may require both the lateral and medial prefrontal regions in order for cognitive processes to have a modulatory impact on our emotional activation (Johnstone et al., 2007). The narrative, which simultaneously activates an array of networks, enhances metabolic activity and neural balance.
The perception of control has been shown to reduce emotional arousal and stress. It is likely that cognitive processes involved in prediction and control activate frontal functioning and downregulate amygdala activation. In other words, thinking we have some control puts us in a state of mind that prepares us to think and activates prefrontal functioning, which reduces our emotionality. As a self-fulfilling prophecy, believing you are an efficacious person stimulates frontal activation, making you a more efficacious person (Maier et al., 2006).
Even writing about your experiences supports top-down modulation of emotion and bodily responses. In a large series of studies, James Pennebaker (1997) and others have instructed subjects to journal about emotional issues of personal importance, especially experiences related to close personal relationships. These studies have revealed increased well-being including a reduction in physical symptoms, physician visits, and work absenteeism (Pennebaker & Beall, 1986; Pennebaker, Kiecolt-Glaser, & Glaser, 1988). This sort of journaling has also been found to correlate with greater T-helper response, natural killer cell activity, and hepatitis B antibody levels as well as lower heart rate and skin conductance levels (Christensen et al., 1996; Petrie et al., 1995; Petrie, Booth, & Pennebaker, 1998). Journaling about emotional issues likely increases prefrontal activation, downregulating the negative emotional activation of the amygdala (Dolcos & McCarthy, 2006). Our ability to tame the amygdala (and the HPA axis) in this way results in a cascade of positive physiological, behavioral, and emotional effects.
Levels of Language and Self-Awareness
The less men think, the more they talk.
—Baron de Montesquieu
Language is not one entity used for a single purpose. During the evolution of culture, types and uses of language expanded along with the sophistication of the brain. Through self-reflection, most of us become aware that we seem to shift back and forth among different perspectives, emotional states, and ways of using language. Introspection provides us with a window to shifts in states of mind that reflect the activation and integration of different neural networks. I am aware of at least three levels of language processing that take place within my clients and myself during these shifting states of mind; a reflexive social language, an internal dialogue, and a language of self-reflection.
Reflexive social language (RSL) is a stream of words that services the maintenance of ongoing social relatedness and communication. Primarily a function of left hemisphere processing, RSL mirrors activity within the interpersonal world and is designed to grease the social wheels. Verbal reflexes, clichés, and overlearned reactions in social situations provide a loose but meaningful web of connections. Most of us experience this whenever we automatically say something positive to avoid conflict, or tell people we are fine regardless of what’s troubling us. The natural clichés of RSL are as automatic to us as walking and breathing. This level of language serves the same purpose as grooming in most types of primates.
In addition to RSL, we are also aware of the conversations we seem to carry on with ourselves inside our heads. This internal dialogue often departs in content and tone from what we express to others. And while RSL is driven by social cooperation, internal dialogue is shaped by personal emotions and is usually experienced as a conversation between two aspects of the self. Internal dialogue may have evolved on a separate track from social language to allow for private thought as well as deceiving others. It may also be one of the primary ways in which right hemisphere processing participates in conscious awareness. RSL and internal dialogue are like overlearned motor skills that serve to maintain preexisting attitudes, behaviors, and feelings. Like RSL, internal dialogue is primarily reflexive and based on semantic routines and habits reflecting our learning history. We hear in our heads the supportive or critical voices our parents implanted early in life. So while RSL keeps us in line with the group, internal dialogue keeps us in line based on early programming.
When we find ourselves reflecting on RSL and internal dialogue, a new level of language seems to emerge, one of self-reflection. In this state of mind, our thoughts and words focus on the reflexive thoughts, feelings, and behaviors we usually engage in. This third level of language is less a mechanism of social control than a vehicle of thoughtful consideration and potential change. It employs executive function and serves to develop a theory of our own mind. Much of therapy consists of uncovering and exploring reflexive social language and internal dialogue, both of which reflect unconscious aspects of the self. In this process we develop the language of self-reflection, learning that we are not only our social reflexes plus the voices that haunt us but are also the one that can observe, listen, and judge what we hear these voices say.
As the language of self-awareness is expanded and reinforced, we learn we are capable of evaluating and choosing whether to follow the expectations of others and the mandates of our childhoods. The language of self-reflection, when contrasted with RSL and internal dialogue, most likely reflects a higher level of integration. In this language, cognition is blended with affect so that there can be feelings about thoughts and thoughts about feelings. At a very deep level, this language leads us to meditation, where we learn to quiet our thoughts and move beyond words.
Therapy attempts to create this metacognitive vantage point from which the shifting states of mind that emerge during day-to-day life can be thought about. This is accomplished by interweaving the narratives of client and therapist and hopefully leading them in a more healthful direction. You begin by making clients aware of one or more of the narrative arcs of their life story and then help them understand that change is possible and offering alternative story lines. As the editing process proceeds, new narrative arcs emerge, as do possibilities to experiment with new ways of thinking, feeling, and acting. The importance of the unconscious processes of both parent and therapist is highlighted by their active participation in the co-construction of the new narratives of their children and patients. This underscores the importance of the proper training and adequate personal therapy for therapists who will be putting their imprint on the hearts, minds, and brains of their clients.
In essence, therapists hope to teach their clients that they are more than their present story but can also be editors and authors of new stories. When we evolved the capacity to examine our narratives (metacognition) and see them as one option among many, we also gained the ability to edit and modify our lives (White, 2001). The narrative process allows us to separate story from self. It is like taking off your shirt to patch a tear and then putting it back on. This allows us to have the experience of a self that is separate from our behaviors, feelings, actions, and problems. The fact that someone can say, “I’m not myself today,” implies the capacity for self-reflection and comparison between a current state of mind and our everyday self-narrative. The ability to take other perspectives also enhances our empathy for others.
Abbey
Do not dwell in the past, do not dream of the future, concentrate the mind on the present moment.
—Buddha
Like most things, our narratives are both good and bad. Unexamined, they keep us in negative patterns. Seen and understood, they provide a means of change. Thus, unraveling all of the conscious and unconscious material that supports a narrative arc can take considerable time and bring many challenges. Here is an example.
Abbey, an extremely bright and charismatic woman, came to my office with tears in her eyes and a smile on her face. Even before she sat down, Abbey launched into a description of all the positive events that had happened to her and her family over the last week. Seeing the pain in her eyes and the rigidity of her body, my face must have reflected the sadness I was feeling. My expression seemed to make Abbey avoid my eyes and speak even faster. From time to time, I would attempt to break in and ask her what she was feeling.
Abbey ignored my questions, talking at an ever faster pace. She reminded me of how, as a child, I would cover my ears and hum when my mother was about to say, “Bedtime!” I soon realized that all I could do was sit, listen, and wait. I sat across from her and tried to remain true to my feelings, allowing them to show in my eyes and facial expressions. Eventually her speech slowed and she became quiet and hung her head. Her feelings seemed to have finally caught up with her, the impulsive stream of reflexive social language finally coming to a halt.
I was considering what to say when she spoke: “I caught myself blabbing on.” It was good to see that Abbey could employ her language of self-reflection and share her observations with me. I asked her what she had been thinking about while sitting in silence. Abbey replied, “I was thinking of what an idiot I am and how I must bore you with endless prattle about my stupid life.” Now she was sharing the content of her internal dialogue, likely programmed early in life. She seemed deflated, depressed, and ashamed of herself. As a reaction against her own shame, she attacked. “What a stupid job you have, sitting in this office every day, listening to people’s problems. Why don’t you get out of here and get a life?” Abbey soon lowered her face into her hands and began to sob. I could see that not only was she sharing with me the voices in her head and her fears and doubts, but she was also projecting onto me her anger, confusion, and frustration. Her internal dialogue was hurting her and she wanted me to know how she felt. I said, “Being criticized can be really painful.” She instantly knew I was talking about the victimization by her inner voices now, and by her parents as a child.
When she spoke again, she told me of the emptiness she felt from the loss of her husband a few months earlier (until this point she had denied its having much impact on her). It had become clear to her over the last few minutes that she had been coping with her sadness by burying herself in a flurry of words, social activities, and taking care of others. After a few minutes of silence and deep sighs, Abbey began to talk about how much she missed his hugs, good advice, and the feeling of safety of having him around. Abbey was now speaking in the language of self-reflection. She was able to mourn the death of her husband in this state of mind.
When clients shift to the language of self-reflection, the changes in their tone, manner, and mood are palpable. I imagine at this moment that clients have the clearest perspective on their thoughts, behaviors, and feelings. They speak more slowly because the organization of sentences takes time when they no longer rely on clichés and semantic habits. Emotions bubble up and clients feel safe enough to express them in a process that enhances affect regulation. This is when I feel most confident about a client’s ability to join me as a collaborator in the therapeutic process. These states are usually fleeting and often not supported by family, friends, or the day-to-day demands of modern life. Therapy sometimes needs to become somewhat subversive and conspiratorial as client and therapist attempt to work against all the forces of habit and social momentum that keep us consistently unhealthy. It has been said that the challenge of increased self-awareness is remembering we are more than our reflexes and defenses (Ouspensky, 1954).
Summary
The focus on integration exists at each level of nature’s complexity from neurons to narratives to nations. As systems become more complex, it takes more sophisticated mechanisms and increasing amounts of energy to support their continuing interconnection and homeostatic balance. In this chapter we have explored the axes of neural integration as well as the narratives that help us coordinate the government of systems that comprise our brains and construct our conscious experience. Although psychotherapy deals in stories, it turns out that they emerged from brain evolution to serve the purposes of increasing complexity, coordination, and connectivity between us. This is one of the many connections between interpersonal relationships and brain functioning that make psychotherapy a neuroscientific intervention.