In this field we are merely at the foothills of an enormous mountain range…unlike other areas of science, it is still possible for an individual or small group to make important contributions.
—Eric Kandel
Psychotherapists are applied neuroscientists who create individually tailored enriched learning environments designed to enhance brain functioning and mental health. We are skilled at teaching clients to become aware of unconscious processing, take ownership of their projections, and risk anxiety in the service of emotional maturation (Holtforth et al., 2005). In our work, illusions, distortions, and defenses are exposed, explored, and tested or modified with understandings closer to reality. Implicit memory—in the form of attachment schemas, transference, and superego—are made conscious and explained as expressions of early experiences. We use a combination of empathy, affect, stories, and behavioral experiments to promote neural network growth and integration.
Through all of this work, subcortical networks that store memories of fears, phobias, and traumas are activated and made accessible for integration with cortical inhibitory circuitry. This essential integration allows for linkage among explicit and implicit circuits, conscious awareness, and the control of negative memories, sensations, and emotions. Regardless of the client’s particular problem, psychotherapy teaches a method to help us better understand and use our brains. And as the dialogue between psychotherapy and neuroscience continues to evolve, an increasing number of scientific findings will be applied to both theory and clinical practice.
Important factors in the therapeutic process have been identified as an empathic and supportive relationship, maintenance of moderate states of arousal, activation of both cognition and emotion, and co-construction of narratives. A safe and empathic relationship establishes an emotional and neurobiological context conducive to neural plasticity. It also serves as a scaffold within which a client can better tolerate the stress required for neural reorganization. We have already seen that birds are able to learn their songs after sensitive periods when exposed to other birds singing, but are unable to learn the same songs heard from a tape recorder (Baptista & Petrinovich, 1986). Under certain conditions, birds require positive social interactions and nurturance in order to learn (Eales, 1985). And the stronger the relationship between human trainers and their birds, the greater the learning will be for both (Pepperberg, 2008). These studies, combined with what we know about changes in biochemistry during interpersonal interactions, suggest that a positive and attuned relationship enhances neural plasticity and learning. The nearly insatiable drive of adolescents to be in constant contact with one another may reflect the underlying drive for neural stimulation during this crucial developmental period. Emotional expression and modulation have been incorporated into psychotherapy because of their impact on these underlying biological processes.
The importance of the activation of both emotion and cognition is recognized by most psychotherapists. Releasing emotions associated with painful memories, facing a feared situation, or experimenting with new interpersonal relationships all involve some sort of stress, anxiety, or fear. Although this way of thinking has been accepted clinically, we now have considerable evidence to support the idea that moderate levels of arousal optimize the production of neurotransmitters and neural growth hormones that enhance LTP, learning, and cortical reorganization (Cowan & Kandel, 2001; Zhu & Waite, 1998).
Trauma undoubtedly changes us in many ways, from our startle response to our attachments and self-identity. Dissociation in reaction to trauma represents a breakdown of neural integration and plasticity. In therapy, we use moderate levels of arousal to access cortical mechanisms of plasticity in controlled ways with specific goals. The safe emergency of therapy provides both the psychological support and the biological stimulation necessary for rebuilding the brain. Much of neural integration and reorganization takes place in the association areas of the frontal, temporal, and parietal lobes serving to coordinate, regulate, and direct multiple neural circuits of memory and emotion.
The importance of the co-construction of narratives is grounded in the coevolution of the cerebral cortex and language, reflecting the evolution of our brains as social organs. Language within significant relationships has shaped the brain during evolution and continues to do so throughout our lives. Because of this, narratives embedded within an emotionally meaningful relationship (like psychotherapy) are capable of resculpting neural networks throughout life. Through the use of autobiographical memory, we can create narratives that bridge processing from various neural networks into a cohesive story of the self. Narratives allow us to combine—in conscious memory—our knowledge, sensations, feelings, and behaviors supporting underlying neural network integration.
The co-construction of narratives with parents serves as a medium of transfer of the internal world of the parent to the child, from generation to generation. These narratives reflect the implicit values, problem-solving strategies, and worldviews of the parents. They also serve to define us to ourselves and others, and guide us through our complex social world. The more inclusive our narratives are in terms of blending sensation, emotion, and cognition, the greater our ongoing ability to integrate multiple neural networks. Research in attachment has demonstrated that the coherence and inclusiveness of narratives correlate with both attachment security and self-reflective capacity (Main, 1993; Fonagy, Gergely, Jurist, & Target, 2002).
In the process of evolution, different levels of language have emerged that appear to parallel different layers of consciousness:
Although the first two levels of language occur spontaneously, self-reflective language requires higher levels of neural network integration, affect regulation, and cognitive processing. Reflexive language keeps us in the present moment, while reflective language demonstrates our ability to escape from the present moment, gain perspective on our thoughts and feelings, and make decisions about what we would like to change and how to change it. Attaining and utilizing this level of language is one goal of psychodynamic psychotherapy.
Three levels of language sharing a common lexicon can result in a great deal of confusion. Many people report feeling crazy because of the simultaneous and contradictory beliefs they struggle with on a day-today basis. Psychotherapy often involves sorting out these audio tracks in order to provide us with a clearer idea of just what is going on in there. The co-construction of narratives, in the context of a healing relationship, which sort out these inner contradictions may well be the optimal context for significant plasticity in socioemotional neural networks.
Diagnosis and Treatment
The principal activities of brains are making changes in themselves.
—Marvin L. Minsky
Functional brain imaging has opened a window to the living human brain in the acts of motor tasks, imagining a feared situation, being empathic, or telling a lie. An examination of areas activated during these and many other behaviors has enhanced our understanding of which neural networks participate in various human functions. Although the application of scanning technology to psychopathology is still in its infancy, there have already been many important and provocative findings. As scanning techniques become more precise and the hardware more affordable, they will no doubt become incorporated into the practice of psychotherapy.
Neuroimaging has the potential to aid in diagnosis, treatment selection, and the prediction of treatment outcome (Etkin et al., 2005; Linden, 2006). As part of an initial assessment, it could help therapists pinpoint areas of neural activation and inhibition. Treatment planning will eventually come to include specific psychotherapeutic and pharmacological interventions to enhance the growth and integration of affected networks. Regular scans during the course of therapy may someday be a useful adjunct to psychological tests, as ways of fine-tuning the therapeutic process and measuring treatment success.
Associations between psychiatric symptoms and changes in the relative metabolism of different areas of the brain are in the process of being uncovered. We have already seen lower levels of metabolism in the left prefrontal cortices of depressed patients (Baxter et al., 1985, 1989) and increased metabolism in the right prefrontal and limbic region of patients with PTSD (Rauch et al., 1996). The importance of the right frontal region in PTSD is supported by clinical evidence such as the onset of PTSD after injury to the right frontal area (Berthier, Posada, & Puentes, 2001) and a “cure” of PTSD symptoms after a right frontal lobe stroke (Freeman & Kimbrell, 2001). The inhibition of Broca’s area during intense fear states is already a focus of cognitive-behavioral therapies, and a reactivation of the language centers may become a standard measure of success in the treatment of PTSD and other anxiety-related disorders. All of these findings support the existence of specific circuitry involved in the recognition, reaction, and regulation of anxiety and fear in the aftermath of traumatic experiences.
The focus of this new work, however, is somewhat different than the old localization theories that attributed disorders of behavior to specific areas of the brain. We now understand that each region of the brain participates in multiple neural systems with highly complex interactions and homeostatic functions. Thus, it is actually the relationship between clinical symptoms and relative activity levels of specific neural networks that are salient. The neurobiology of obsessive-compulsive disorder (OCD) has been of particular interest in this regard. A neural circuit thought to mediate OCD includes the ompfc and subcortical structures called the caudate nucleus, globus pallidus, and thalamus. This cortical-subcortical circuit, involved with the primitive recognition of and reaction to contamination and danger, becomes locked into an activation loop in patients with OCD (Baxter et al., 1992). It is hypothesized that the ompfc, or some other component of the OCD circuit, activates the circuit with a worry signal, decreasing inhibition of the thalamus, which in turn excites the ompfc and caudate (Baxter et al., 1992). The result is a feedback loop that is highly resistant to inhibition or shutting down.
Network Homeostasis and Treatment Outcome
The constant conditions which are maintained in the body might be termed equilibria.
—Walter Cannon
Considerable evidence supports the idea that the reregulation of neural networks parallels some of the symptomatic changes we witness in psychotherapy. In general, decreases in fear and anxiety correlate with activation reductions in bottom and right hemisphere regions. In OCD, there is a reduction in activation in a region dedicated to the control and inhibition of impulses (ompfc). In the successful treatment of social and spider phobias, there is a decrease in activation in limbic and primitive cortical areas and in right hemisphere processing, paralleling the decreased fear activation that goes along with symptom reduction. In situations where there is a deficit in cognitive processing such as in schizophrenia and brain injury, we see symptom reduction correlated with increased frontal activation. Keep in mind that the correlations do not prove causal relationships; changes in brain activation patterns could also be secondary to symptomatic changes, or both could be due to some third unknown factor.
Patterns of brain activation in both panic disorder and PTSD are a bit more complex. In both of these disorders, sensory and memory networks are hijacked by the amygdala and become internal sources of fear. While studies have not yet focused on changes in brain activation related to positive treatment outcome, we can speculate that positive treatment response would correlate with decreased activation in the amygdala, sensory motor areas, and the cerebellum (Bryant et al., 2008; Pissiota et al., 2002), along with increased ompfc activation (Phan et al., 2006; Williams et al., 2006). There would also be a decreased activation in regions dedicated to autobiographical memory, and an increase in the processing of information from the current external environment (Sakamoto et al., 2005).
Psychotherapy outcome research with a number of disorders has found changes in brain activation paralleling symptomatic improvement. In each case, treatment seems to have reestablished a homeostatic balance between interactive neural networks that were previously out of balance. Table 18.1 outlines the studies that have been performed to measure the neural correlates of successful therapy across a variety of patient populations.
TABLE 18.1
Successful Psychotherapy and Changes in Neural Activation
|
Diagnosis and Treatment |
Result |
|
OCD | |
|
BT vs. fluoxetine |
Both: Decreased metabolism in right caudate1 |
|
BT vs. fluoxetine |
BT: Left ompfc activation correlated with positive response |
|
Fluoxetine: changes in the opposite direction2 | |
|
BT vs. controls |
Decreased CBF in right caudate3 |
|
CBT |
Decreased metabolism in right caudate |
|
CBT and fluoxeitine |
Increased bilateral grey matter4 |
|
Increased right parietal white matter5 | |
|
Social phobia |
|
|
CBT vs. citalopram |
Both: decreased amygdala, hippocampal, and adjacent cortex activation |
|
CBT: decreased periaqueductal gray activation | |
|
Citalopram: decreased thalamic activation6 | |
|
Spider phobia |
|
|
CBT |
Decreased activation in parahippocampal gyrus and dlpfc7 |
|
CBT |
Decreased PFC activation biased toward right hemisphere8 |
|
CBT |
Decreased activation in the insula and anterior cingulate9 |
|
Post-traumatic stress disorder |
|
|
EMDR (case study) |
Increased activation in anterior cingulate and left frontal lobe10 |
|
Panic disorder |
|
|
CBT vs. |
CBT: RH decreases in inferior temporal and frontal regions |
|
Antidepressants |
LH increases in inferior frontal, medial temporal, and insula |
|
Antidepressants: RH decreases in frontal and temporal lobes | |
|
CBT |
Decreased activation in right hippo campus, left ACC, left cerebellum and pons |
|
Increased activation in medial prefrontal cortex12 | |
|
Major depressive disorder |
|
|
CBT vs. paroxetine |
CBT: decreased frontal activation / increased limbic |
|
Paroxetine: changes in the opposite direction13 | |
|
CBT vs. venlafaxine |
Both: decreased bilateral opfc and left mpfc activation and increased activation in right occipital-temporal cortex14 |
|
IPT vs. venlafaxine |
IPT: increased activation in right posterior cingulate and right basal ganglia |
|
Venlafaxine: increased activation in right posterior temporal and right basal ganglia15 | |
|
IPT vs. paroxetine |
Both: decreased activation in prefrontal cortex |
|
Both: increased activation in inferior temporal and insula16 | |
|
IPT vs. paroxetine |
Both: symptom reduction with decreased frontal activation |
|
Both: positive correlation with cognitive symptoms17 | |
|
Schizophrenia |
|
|
Cognitive rehab |
Increased frontal activation with improved performance18 |
|
Cognitive rehab |
Increased activation in right inferior frontal cortex and occipital lobe19 |
|
Traumatic brain injury |
|
|
Cognitive rehab |
Global activation increase in 3 of 5 patients20 |
The results shown in this table should be considered preliminary because of small sample sizes and variations in methodology.
BT, behavior therapy; CBT, cognitive-behavioral therapy; IPT, interpersonal therapy; EMDR, eye movement desensitization and reprocessing. Adapted and expanded from Roffman et al. (2005).
Functional scan studies have demonstrated that improvement of OCD symptoms is correlated with decreased activation of the ompfc and caudate nucleus (Rauch et al., 1994). Especially interesting to psychotherapists is the fact that these changes in brain metabolism are the same whether patients are successfully treated with psychotherapy or medication (Baxter et al., 1992; Schwartz et al., 1996). Although psychotherapy and medication are the first choices for treatment, they are not always successful. Scan-guided psychosurgery for patients who do not respond to any other forms of treatment can disrupt runaway feedback by severing neural links within the OCD circuit (Biver et al., 1995; Irle, Exner, Thielen, Weniger, & Ruther, 1998; Rubino et al., 2000).
Because symptoms can have multiple underlying causes, diagnoses aided by neural network activity could improve diagnostic accuracy. Increased specificity will naturally lead to increasingly specific psychotherapeutic and pharmacological interventions. Tourette’s syndrome—a disorder characterized by involuntary vocalizations and motor tics—often occurs in individuals who also suffer with OCD, enuresis, or ADHD. This is not a coincidence, because these disorders share underlying neural circuitry and neurotransmitters (Cummings & Frankel, 1985). They all stem from problems with the inhibition of subcortical impulses by the frontal cortical areas. Thus, structural, biochemical, and regulatory abnormalities in these interrelated top-down networks can result in all four conditions. When this circuit is more fully understood, symptoms of OCD, ADHD, enuresis, and Tourette’s syndrome may all become subsets of some future diagnosis referred to by the neural networks responsible for these functions.
In anxiety and depression, some studies show that therapy achieves results through increased cortical versus subcortical activation, while others show changes in the activation patterns within the frontal lobes (Porto et al., 2009). And while psychotherapy and medication can both lead to symptom reduction, there is only partial neuroanatomical overlap in how they achieve their results (Roffman et al., 2005). In other words, the same results can be achieved by different treatment strategies and through changes in the balance among different neural networks. This is in no way bad news for psychotherapy. Cognitive therapy by experienced therapists is equally efficacious as medication in moderate to severe depression (DeRubeis et al., 2005). For depressed patients with a history of child abuse, psychotherapy has been shown to be more effective, with the addition of medication showing small benefits (Nemeroff et al., 2003).
The Centrality of Stress
It’s not stress that kills us, it is our reaction to it.
—Hans Selye
Although some stress is a normal part of life, early, prolonged, or severe stress can result in significant and long-term impairments in learning, attachment, and physiological regulation (Glaser, 2000; O’Brien, 1997; Sapolsky, 1996). Stress plays a role in the expression and severity of most, if not all, psychiatric and medical disorders. Therefore, assessing and targeting stress as a focus of psychotherapeutic intervention should always be an aspect of healing relationships. Since therapists are trained to think in terms of diagnostic categories and treatment modalities, stress often flies under our diagnostic radar. Understanding and working to regulate our clients’ stress is central to psychotherapeutic success because of its impact on neuroplastic processes.
An emerging concept in treatment involves buffering victims of stress from neural compromise by altering their neurochemistry. One way of accomplishing this is to block the secretion or uptake of norepinephrine and glucocorticoids soon after a traumatic experience (Brunet et al., 2008; Liu et al., 1997; Meaney et al., 1989; Watanabe, Gould, Daniels, Cameron, & McEwen, 1992). It has also been found that the neurotransmitter neuropeptide-Y is found in higher concentrations in the amygdalas of individuals who respond more favorably to high levels of stress (Morgan et al., 2000). Artificially increasing levels of neuropeptide-Y may buffer the nervous system from some of the damaging effects of stress.
Chemical blockade or disruption of particular amygdala circuits may decrease some of the symptoms of PTSD such as the startle and freeze responses (Goldstein, Rasmusson, Bunney, & Roth, 1996; Lee & Davis, 1997). It has even been suggested that stimulation of the amygdala could lead to the extinction of conditioned fear (Li, Weiss, Chaung, Post, & Rogawski, 1998). Understanding the role of LTP and other forms of plasticity in the amygdala, as well as its role in fear conditioning, may provide another avenue for future interventions in psychosis and PTSD (LaBar, Gatenby, Gore, LeDoux, & Phelps, 1998; Rogan & LeDoux, 1996; Rogan, Staubli, & LeDoux, 1997).
We have seen that higher levels of maternal attention in rats decrease the pups’ subsequent HPA activation in response to stress (Liu et al., 1997). Although I doubt that encouraging human mothers to lick their children will be of much help, human infants demonstrate the same pattern in response to maternal massage (Field et al., 1996), and within securely attached relationships (Spangler & Grossman, 1993). Maternal depression, separation, and deprivation are severe stressors for infants, resulting in a variety of negative biological, emotional, and social consequences (Gunnar, 1992). Aggressive treatment of depression in new mothers, along with teaching them how to massage and better interact with their infants, may counteract some of the negative impact of maternal depression. Therapy focused on resolving a mother’s attachment difficulties or past trauma prior to giving birth may also be helpful in reducing stress in their infants, children, and adolescents (Trapolini, Ungerer, & McMahon, 2008).
An increased appreciation of the effects of maternal separation may guide us as to the advisability of optional infant–mother separation. Where separation is unavoidable in cases of illness and death, the ability to lessen the impact of stress hormones via interpersonal and chemical interventions may prevent problems later in life. Given the amount of exposure in our society to stressful events such as abuse, neglect, abandonment, and community violence, the impact of severe stress on mothers and the developing brains of their children should be a serious public health concern (Bremner & Narayan, 1998).
Research findings suggest that early stress leads to a vulnerability to depression later in life (Widom, DuMont, & Czaja, 2007). This, in part, is mediated by deficient organization of frontal circuitry, and the establishment of lower levels of excitatory neurotransmitters and growth hormones during sensitive developmental periods. Early childhood experiences leading to a bias toward right hemisphere activation may also play a role in the long-term development of depression. As we discussed in the chapter on laterality, magnetic stimulation of the left hemisphere of depressed patients and the right hemisphere of patients with mania has shown promising results and may serve as a future alternative to electroconvulsive therapy (Grisaru et al., 1998; Klein et al., 1999; Teneback et al., 1999; Pascual-Leone et al., 1996).
In line with these findings, activation of the left hemisphere through sensory stimulation results in a higher degree of self-serving attributions and positive affect (Drake & Seligman, 1989). Relative left frontal activation appears linked to a state of mind of “self-enhancement,” which may decrease the risk for psychopathology and be manipulated by changes in attitude or practices such as mindfulness meditation (Tomarken & Davidson, 1994). The more we understand the relationship between laterality and affect, the more we may be able to incorporate techniques of selective activation of right and left hemispheres into multimodal treatments for mood disorders and other psychiatric difficulties.
PTSD is primarily mediated and maintained by neurobiological processes outside conscious control. The activation of Broca’s area in the face of high levels of affect appears to be an important mechanism of action in most interventions with patients suffering from PTSD and other anxiety disorders. We know that the ompfc modulates and inhibits amygdala activity, the very circuit we are activating when we help clients to employ cognition to inhibit their fears.
Despite new theories connecting neural communication and psychopathology, no major form of psychotherapy has emerged with the stated goal of neural network integration. This being said, techniques such as the caloric test and the eye movements used in EMDR seem to involve left-right and top-down integration as an active element. Previously, we discussed the phenomenon of sensory neglect, which occurs when there is damage to the right parietal lobe (assumed to be responsible for the integration of sensory and motor information from both sides of the brain). In the caloric test, stimulation with cold water to the left ear results in rapid side-to-side eye movements while activating regions of the right temporal lobe (Friberg et al., 1985). Although there has been one report of permanent remission of sensory neglect with this treatment, for most the cure is only temporary (Rubens, 1985). The bilateral activation of attentional centers in reaction to the caloric test results in increased integration of previously dissociated attention and information-processing systems (Bisiach et al., 1991).
In the treatment of PTSD with EMDR, past traumatic events are recalled and subjected to a protocol that involves focusing attention on ideas, self-beliefs, emotions, and bodily sensations. In addition, EMDR uses periodic stimulation through watching the therapist’s hand going back and forth or having the legs touched alternately (Shapiro, 1995). This bilateral and alternating (side-to-side) stimulation may serve to activate attention centers in both temporal lobes in a manner similar to the caloric test. Alternating activation may, in fact, enhance neural network connectivity and the integration of traumatic memories into normal information processing.
Techniques such as EMDR may thwart or reverse the brain’s tendency toward neural network dissociation secondary to trauma. Bilateral stimulation may enhance the reconsolidation of traumatic memories with cortical-hippocampal circuits providing contextualization in time and place. Activation of these same circuits creates the possibility of building descending inhibitory links to subcortical sensory-affective memory circuits (Siegel, 1995). Thus, the right-left stimulation of attention may simultaneously trigger integration of affect with cognition, sensation, and behavior throughout the brain.
Once the relationships among neural circuits are more fully understood, psychotherapists may employ these and other noninvasive techniques to stimulate the brain in ways that enhance neural network integration. Could activation of right hemisphere emotional regions during therapy with alexithymic patients aid in the integration of emotional processes with left hemisphere linguistic circuitry? Could activation of the left hemisphere during emotional dyscontrol in borderline patients enhance their ability to gain cognitive perspective and emotional regulation?
For conditions involving too much emotional inhibition, new learning may be stimulated by creating moderate levels of affect in therapy; this learning, in turn, may create a biochemical environment more conducive to the integration of emotional circuitry into consciousness (Bishof, 1983; Chambers et al., 1999). This may be the underlying neurobiology of Freud’s belief that the presence of affect is necessary for change. Simultaneous activation of neural networks of emotion and cognition may result in a binding of the two in a way that allows for the conscious awareness and integration of emotion.
Treatment Rationales and Combinations
Sometimes I lie awake at night, and ask, “Where have I gone wrong?” Then a voice says to me, “This is going to take more than one night.”
—Charles Schulz
The fundamental premise put forth in this book is that any form of psychotherapy is successful to the degree to which it positively impacts the underlying neural network growth and integration. I expect future research to continue supporting this basic hypothesis. Furthermore, evolving technologies will provide us with increasingly accurate ways of measuring activity within the brain and a greater understanding of exactly what it is we are measuring. My hope is that including neural network activity in our case conceptualization may help to establish a common language for us to select, combine, and evaluate the treatments we provide. It will, one hopes, help us to move past debates between competing schools of thought to a more inclusive approach to psychotherapy.
One long and hard-fought debate about treatment continues between supporters of psychopharmacology and psychotherapy despite empirical support for both approaches, individually and in combination. Brain functioning offers us a way to look more deeply into the effects of both talk and medication in regulating the brain and stimulating neuroplasticity. Patients who come to see me for psychotherapy are often adamant in their refusal to consider medication. Some feel frightened or shamed if I suggest the use of drugs as an adjunct to psychotherapy. At the same time I know that many discount talk therapy and will only seek help from therapists who will prescribe medication. All clients could benefit from education about brain functioning and the potential (even synergistic) power of both interventions. On the one hand, the therapeutic alliance supports positive expectancy, medication compliance, and psychological well-being. On the other, medication can help to achieve a state of body and mind that allows clients to benefit from psychotherapy.
Many patients who suffer brain damage resulting from accidents participate in multimodal rehabilitation programs that include physical, cognitive, and psychosocial interventions. The general approach to rehabilitation after brain injury is to first assess which systems have been damaged and which have been spared. The next step is to develop a program that plays to the patients’ strengths and attempts to compensate for their weaknesses. Traffic and industrial accidents often result in damage to the frontal cortex, making disorders of attention, concentration, memory, executive functioning, and emotional regulation common in neurological rehabilitation. These same difficulties are common in many forms of psychological distress and psychiatric illness.
The traditional split between mind and brain has resulted in the separate development of the fields of psychotherapy, neuropsychology, and rehabilitation. When psychological difficulties are conceptualized in the context of a brain–behavior relationship, applying techniques from cognitive rehabilitation in psychotherapy becomes an interesting possibility. For example, abnormalities of frontal lobe functioning have been found in OCD, depression, and ADHD. Because these disorders share many symptoms afflicting patients with brain injury, psychotherapy patients with these and other psychiatric diagnoses may benefit from the strategies of cognitive rehabilitation (Parente & Herrmann, 1996).
An example of this was given in an earlier chapter, when I discussed how the simple memory strategies I used to assist my patient Sophia in remembering her appointments helped us to establish a solid alliance. My working assumption was that a combination of decreased hippocampal volume due to chronic stress and hypometabolism in the temporal lobes related to depression created real, brain-related memory dysfunctions (Bremner, Scott, et al., 1993; Brody et al., 2001). The success of cognitive-behavioral treatments with depressed and anxious patients underlines the importance of focusing on basic issues of reality testing, focused attention, and emotional regulation in order to support prefrontal functioning (Schwartz, 1996).
Findings with borderline clients of damage or dysfunction of the frontal and temporal lobes support the use of cognitive rehabilitation techniques with this population (Paris et al., 1999; Swirsky-Sacchetti et al., 1993). This may help explain why borderline patients require increased levels of structure to scaffold their erratic executive control and emotional instability. Manipulation and organization of the physical environment, sensory stimulation, and the type and amount of activity all impact brain functioning. Psychoeducation and enlisting family and friends in the therapeutic process (as utilized extensively in rehabilitation after brain damage) are also potential mechanisms of change. A good example of this is dialectical behavioral therapy (Linehan, 1993), which combines exposure, cognitive modification, skills development, and problem-solving skills to support prefrontal functioning.
Diagnostic and treatment approaches focused on cognitive deficits serve to decrease shame and help to create a stronger treatment alliance. Highly structured skill-building techniques, in the context of support and understanding, may provide disorganized patients the opportunity for early and clearly measurable success experiences. As our understanding of neural networks related to memory, affect, and behavior expands, prosthetic aids to these systems will be created and applied in the psychotherapy context. Increasing interdisciplinary coordination of this kind will require more comprehensive training for psychotherapists, not only in neuroscience but also in cognition, memory, and rehabilitation science. Removing the traditional barriers between psychotherapy and rehabilitation may lead to a higher quality of care and greater treatment success.
Why Neuroscience Matters to Psychotherapists
In science the important thing is to modify and change one’s ideas as science advances.
—Herbert Spencer
The psychotherapist as healer exists within a long tradition of rabbis, priests, medicine women, and shamans. At the same time, findings in social neuroscience make it clear that we are also in the current scientific mainstream. In contrast to technological medicine, we understand our profound personal role in the healing relationship while simultaneously respecting the subjective experience of our clients. In the absence of a brain-based model of change, the leaders of our fields have learned to stimulate and guide neuroplastic processes to help build, integrate, and regulate our clients’ brains. But why does an academic understanding of neuroscience make any difference to our work? Here are a few thoughts.
On a practical level, adding a neuroscientific perspective to our clinical thinking allows us to talk with clients about the shortcomings of our brains instead of the problems with theirs. The truth appears to be that many human struggles, from phobias to obesity, are consequences of brain evolution and not deficiencies of character. Identifying problems that we hold in common and developing methods to circumvent or correct them is a solid foundation upon which to base a therapeutic alliance.
As we come to better understand the neural correlates of mental health and emotional well-being, we may be able to use this knowledge to aid us in diagnosis and treatment. Neuroscience may also someday provide us with a rationale for an informed eclecticism as well as additional means of evaluating outcome. We will be able to see which combination of treatments impacts targeted neural networks and how changes in the activation of these circuits correspond with symptom expression. Neuroscience can also provide a common language to communicate with physicians, pharmacologists, and neurologists who may also be treating our clients. Finally, if you are anything like me, you might find a neuroscientific perspective to be an exciting addition to many case conceptualizations.
Some therapists bristle at the integration of neuroscience and psychotherapy, calling it irrelevant or reductionistic. I think I understand their perspective and concerns—if you have a model of therapy that works, why bother with the brain? Would Rogers, Kohut, or Beck have been better therapists if they had been trained as neuroscientists? Probably not. On the other hand, it is hard for me to grasp how the brain could be irrelevant to changing the mind. And while I dislike reductionism as much as the next person, doesn’t a tendency toward reductionism say more about the thinker than the nature of natural phenomena? Our knowledge of neuroscience highlights the fact that we primates have complex and imperfect brains and should remain skeptical about what we think we know. In other words, primates would be wise to doubt their beliefs and remain open to new ideas.
It is humbling and more than a little frightening to realize that we rely on what may be the most complex structure in the universe with little knowledge of how it works. But even though we are only at the dawn of understanding the brain, an appreciation of its evolutionary history, developmental sculpting, and peculiarities of design can surely encourage us to begin to use it more wisely. Practical things—like understanding the neural damage resulting from drugs, stress, and early deprivation—should influence everything from personal decision making to public policy. The neural network dissociation that often results from exposure to combat should make us pay closer attention to those whom we put in harm’s way. Even our tendencies to distort reality in the direction of personal experience and egocentric needs should lead us to examine our beliefs and opinions more carefully.
We now know that mind and brain are indivisible and that disorders traditionally thought of as psychological need to be reconceptualized to include their neurobiological mechanisms. And if brain dysfunction is central to a client’s difficulties, the “most illuminating interpretation” may not be as valuable as a little accurate neurobiological knowledge (Yovell, 2000).
Self-awareness is a relatively new phenomenon in evolutionary history. Psychotherapy increases neural integration through challenges that expand our experience of and perspective on ourselves and the world. The challenge of expanding consciousness is to move beyond reflex, fear, and prejudice to a mindfulness and compassion for ourselves and others. Understanding the promise and limitations of our brains is but one essential step in the evolution of human consciousness.
In conclusion, our brains are inescapably social, their structures and functioning deeply embedded in the family, tribe, and society. And while the brain has many shortcomings and vulnerabilities, our ability to link with, attune to, and regulate each other’s brains provides us with a way of healing. This is why the power of human relationships is at the heart of psychotherapy. From my perspective, the value of neuroscience for psychotherapists is not to explain away the mind or generate new forms of therapy, but to help us grasp the neurobiological substrates of the talking cure in an optimistic and enthusiastic continuation of Freud’s Project for a Scientific Psychology.