14

JAMES BENNETT-LEVY LEANS forward in his chair. With a look of concern, he asks, ‘And how can I help you?’ His spectacles concentrate the interest expressed by his eyes.

‘I want to feel useful again,’ I say. ‘Be my prefrontal cortex; tell me what to do.’ I explain my concentration limit for new things: two hours per day three days a week is probably all I can manage for the time being.

He nods in agreement.

After the debacle of the vocational psychologist’s work recommendations and then Kathy’s more informed report, I made contact with James Bennett-Levy, associate professor of mental health at the health-research unit that Leanne, the speech pathologist, had recommended to me. When we first spoke, James said that he remembered me from a positive review I wrote of one of his books, years earlier; I’d forgotten about this, but was glad for the connection.

Today he runs through a list of activities that he could use a volunteer to help with. They’re all possibilities, although nothing grabs me. But my ears prick up at the last item on his list. He runs regular training programs in cognitive behaviour therapy, and has been asked by the university to design a psychotherapy course for mental-health professionals that incorporates the latest neuroscientific findings. Am I interested in neuroscience?

‘I am,’ I say. How serendipitous.

In fact, over the last few weeks, as my brain’s improved, I’ve been doing a lot of reading on the subject. I’ve finished The Brain That Changes Itself, and it’s given me new ways to reflect on my trauma experiences.

Norman Doidge says that the principle of neuroplasticity can be used not only to improve cognitive and motor function after brain injury, but also to aid in emotional recovery. If we can focus the mind away from worries or troubling images and instead dwell upon something pleasant, this rewires the brain for more positive associations — like a train being switched onto different railway tracks. I interpret this to mean that if I’m in a ruminating mood, I should distract myself with an activity that takes me out of my rumination. It’s not important whether this is gardening, a coffee with friends, reading, swimming, or playing music; it’s just important to do something.

Doug has read Doidge’s book too, and he says that he’s learnt to visualise his mind as an old-style telephone exchange. ‘If I can see that a thought is not good for me, I pull that one out,’ he says, demonstrating with his hands, ‘and plug in a flower.’

I’m still doing psychotherapy with Wayne, and I’ve realised that the therapeutic progress I’m making has a neurological dimension. Traumatic memories are scorched into my brain because of the sensory and emotional impact of the original experience. In addition, when I recall a traumatic memory, with its emotional tone and patchwork of sensory associations, I’m reinforcing the memory’s neural network: reimagining activates the same network all over again, etching the memory trace deeper, further sensitising me to potential threats. Wayne has reminded me that the threats I faced in the past are no longer present, so I no longer need to react. Yet my brain acts as if it doesn’t know this: it still behaves as though those threats are real. In my hypervigilant state, my threat system is easily triggered: the demands of creditors, the children being difficult, and even a stern look from Anna are all enough to set it off sometimes. Present-day threats — or what I perceive as threats — set me off more than they should, even when I know that they have no direct connection with past trauma experiences.

When I can see that my emotional response to a past threat is outdated, new neural connections are made: an alternative network is created. As with learning any new skill, I need to keep activating the alternative network, separating the present from the past. For consolidation, this neuroplastic change requires that the connections in the older neural network weaken as the connections in the alternative network strengthen. In time, I will respond to what is actually happening around me, rather than what I imagine is happening.

Doidge refers to the work of neuropsychiatrist Eric Kandel. I remember excitedly reading an article a few years before in which Kandel was cited as saying that neuroscience has demonstrated that psychotherapy (‘talk therapy’) leads to physically observable, positive changes in the brain. When we re-experience trauma memories and uncontrollable emotions, blood flow to the prefrontal cortex is reduced, meaning that our threat-based brain structures take over. The neurological aim, therefore, is to activate the prefrontal cortex as much as possible before, during, and after these experiences. Talk therapy restores the prefrontal cortex’s involvement in emotional response. As I read Doidge’s description of this, I picture cerebral blood flow seesawing throughout my brain, as my prefrontal cortex and my limbic system wrestle with each other.

I also find out that psychological trauma causes the hippo-campus to shrink, through the release of glucocorticoids (a class of hormones), especially cortisol. Prolonged release of cortisol, which occurs with depression and chronic stress, destroys cells in the hippocampus, causing memory loss. As people recover from depression, their hippocampal neurons can grow back, improving memory. So it’s likely that even before the stroke, the ongoing financial stress, the post-traumatic stress disorder, and the depression caused shrinkage in my hippocampi; this is what the neuropsychologist was getting at. I wasn’t imagining the memory and decision-making difficulties I had: there was a biological basis for them. Given that part of my left hippocampus was damaged in the stroke, it’s fortunate for me that the hippocampus is one area of the brain where new neurons can grow from stem cells.

Antidepressant medications and St John’s wort — and possibly psychotherapy too — can also increase the number of stem cells in the hippocampus. The creation of new neurons may be the indirect reason that antidepressant medication increases serotonin levels. Neuronal growth in the hippocampus improves a person’s capacity to learn and remember, and to re-engage.

This gives me great hope. When James mentions his interest in the application of neuroscience to psychotherapy, I am already primed, keen to assist him in bringing these findings into the hands of other therapists.

After James sorts out the administration details that allow me to become an unpaid member of the research unit, he suggests a program of readings. We will meet up each month to discuss and summarise our findings. I am to concentrate on the authors Daniel Siegel, Louis Cozolino, and John Arden initially, reading their books to get an overview of the area of neuroscience and psychotherapy. Then, from time to time he will give me specific research articles to go through. Best of all, I can do this work at home, at my own pace. I’ll need to make summary notes of what I read as I go, I tell him, or I’ll forget it all. ‘That would be great,’ he says.

In fact, I’ve already started on Daniel Siegel’s Mindsight. Siegel is a psychiatrist and an educator who pulls together neuroscience, psychotherapy, mindfulness, and case histories in a fluent way I’ve not come across before. My meeting with James has given me the impetus to finish it quickly. Soon, I move on to his earlier book The Mindful Brain.

What I learn here astounds me: Siegel says that mindfulness meditation changes the structure and function of the brain for the better. The key area is the prefrontal cortex (PFC), left and right. This is the foremost area of our brain — part of the frontal lobe — and it sits behind our eyes and forehead. The PFC is the thinking part of the brain; it gives humans the capabilities that most distinguish us from all other animals. It is divided into different areas: the medial PFC, the dorsolateral PFC, the ventrolateral PFC, the ventromedial PFC, and the orbitofrontal cortex. In those spending time practising mindfulness meditation, two parts of the brain — the medial prefrontal area on both sides, and the insula, especially that on the right side of the brain — thicken. Siegel mentions the orbitofrontal cortex, the anterior cingulate cortex, and the ventromedial PFC as the most affected areas.

Siegel cites the work of neuroscientist Richard Davidson, who found a shift in brain function to the left frontal lobe when people experienced positive emotions, those associated with facing challenges; and conversely, a shift to right frontal dominance when they experienced negative emotions, the type associated with avoidance. This left-brain shift also correlated with improved immune function and physical health. Davidson and others have observed that during meditation, practitioners show increased activation of the left PFC and less of the brain activity associated with mind-wandering: random thinking. They also exhibit greater brainwave synchrony — a finding consistent with better mental health.

The right hemisphere has a more direct link with raw sensory experience than the left hemisphere, and it processes distress and uncomfortable emotions. The left hemisphere has a narrator function that tries to make sense of our life experiences, and likes to put names to these experiences. But our autobiographical memories, in a non-verbal form, are located primarily in the right hemisphere. Mindfulness practice makes it more likely that a person will approach difficult situations (a behaviour associated with the left side) rather than avoid them (a behaviour associated with the right side). In addition, it stimulates the brain in ways that promote growth in the cortical regions that control emotions.

So I have a picture of a brain gym: I need to activate the left PFC to get me in approach mode and to get the different regions of the brain working together, allowing it to become unstuck from overriding emotions. Writing down my experiences and talking them through with Wayne are ways of making narratives, of making sense of events and activating my left PFC.

But I wonder, can I, or someone in a similar situation, find a way to not overreact, to stop seeing threats that aren’t there? Non-reactivity, I find out, can be thought of as a way of pausing before making a response. And the key for doing this is strengthening the control the PFC has over the limbic system — the amygdala, the thalamus, the hypothalamic-pituitary-adrenal (HPA) axis, and the inner surfaces of the cerebral cortex. The limbic system is implicated in unconscious emotions: impulses such as sex, anger, pleasure, and the threat response.

The research tells me that mindfulness changes the connections between the PFC and the limbic system, tipping the balance more in favour of the PFC. The stronger the PFC’s control — the left’s especially — the more chance there is of a pause before responding to a limbic-system alert.

Meditation trains the mind to hold steady. It enhances the function of the anterior cingulate cortex. This cortex is an important link between the limbic system and the PFC, critical in snap decision-making, and, therefore, in the regulation of emotional arousal. Mindfulness is the microscope for seeing, or being in touch with, inner experiences. Through mind training, meditation is the dial for turning up the magnification.

Siegel says that there is no definitive explanation as to how focusing attention in the present moment, as in mindfulness, activates neural circuits in the way it does and leads to physiological, psychological, and interpersonal wellbeing. But I learn that mental noting, or the labelling of inner experiences, is a mindfulness practice that increases non-reactivity. People who use words to describe their internal states are more flexible and more able to regulate their emotions. Noting ‘I am angry’ or ‘I am hungry’ is a left-sided approach: it’s a way of acknowledging an internal state, a form of approach rather than of avoidance. The act of labelling feelings is associated with reduced blood flow in the left and right amygdala, and increased blood flow in the prefrontal cortex — a physiological sign of greater PFC activation.

Siegel says something that particularly strikes me. We all experience the pain of loss, disappointment, and death — these are universal events. But our minds create mental anguish by grasping onto conceptualisations and reacting automatically. When our minds seize onto preconceived ideas of how something should be, rather than how it is, it creates tension. Instead, mindful moment-to-moment awareness that does not fix on judgements is a way of attuning the physical and psychological experiences of reality.

AS I CONTINUE with my reading and my meditation practice, I think I’m getting a better handle on the concept of mindfulness. Mindfulness is remembering to be aware of what I’m doing while I’m doing it, noticing what I’m thinking when I’m thinking it, noting what I’m feeling when I’m feeling it. This is creating the pause that I need to facilitate non-reactive actions.

It is my amygdala that sends me into a spin of fear over something small: the telephone ringing during business hours, a knock at the front door (our friends and family always come to the side entrance), an official-looking letter arriving in the post. I recognise my fear response as a feeling of dread: my body quivers with alertness; even the pores in my skin sense danger in the air. The dread tells me that something bad is about to happen. The feeling can last for hours or days. I wonder what is around the corner, what intention the stranger walking towards me on the footpath has, whether an unexpectedly loud sound or the shout of someone across the street means that something terrible has happened. The dread is malevolent; it wants to destroy my family and me.

But if the threat is like a ghostly presence that never solidifies; if I can’t surmise its shape, texture, or colour; if I can’t work out if it is large or small, quick or slow, how do I respond to it?

In the mornings, there is a peewee out the back of our house. It perches on the end of the clothesline, peering at the door of the garage. It’s a black-and-white bird, a small version of a magpie, with a tiny face and a determined beak. It attacks the windowpane in the door, repeatedly flying into it — backwards and forwards from the clothesline. It must see its own reflection in the window and think there is another peewee in its territory.

Bang! Bang!

Surely this must hurt?

I sit in the downstairs office each morning and hear it, day after day, railing against its hollow enemy, while I rail against mine.

I am beginning to see that the threat is internal as much as external. Yes, there are external threats — in particular, the prospect of bankruptcy and what this will mean for the family. But no one is going to kill us. No one is harming us, even if it feels this way.

The cortical response and the limbic response are two different pathways. The limbic response is unconscious; it works at lightning speed, makes gross generalisations, and activates the body immediately for fight, flight, or freeze. Some call it the ‘low road’. The low road is what saves us in an emergency, compelling us to act immediately and ask questions later. The hypothalamus and the pituitary and adrenal glands — the HPA axis — are the workhorses of the fight-or-flight response. The HPA axis causes the pupils to dilate, the heart to beat faster and more strongly, breathing to quicken, stomach and bowel activity to slow, the bladder to constrict, and blood pressure to rise.

The cortical response, directed by the prefrontal cortex, is the conscious voice of reason. Some call it the ‘high road’. The high road is like the parent who intervenes in a squabble between two siblings — quieting them sufficiently to hear what the squabble is about and then deciding what is to be done.

This takes time.

My blow-up with Anna and the children prior to my stroke, when they were watching television, was my ‘low road’ in action. The subcortical region of the brain took over my body and I temporarily lost rational control. The family weren’t the real threat; they were the trigger. My amygdalae were already in an overheated state from the stressors of the day, and, with my mental fatigue, it didn’t take much to tip me into the fight response: rage. So I couldn’t help my initial ‘low road’ reaction. It was when my PFC came online again that I regained conscious control — my humanness. The ‘low road’ might never have been activated if I had been functioning normally.

The neural pathway from the amygdala to the PFC is thicker, and therefore transmits information faster, than the pathway going from the PFC to the amygdala. This enables the amygdala, with the limbic system, to dominate the PFC for a time. If the PFC decides that the threat is not real, or has passed, it cools the amygdala’s response through the release of the neurotransmitter gamma-aminobutyric acid (GABA). Oxytocin, a neurohormone associated with trust and safety, also ‘cools’ the amygdala. And more serotonin in the limbic system means less of the fight-or-flight response.

Pleasurable social activities, such as watching an enjoyable movie, being with friends and caring people, playing music, and swimming in the ocean, increase serotonin and oxytocin levels. These activities also take my conscious attention away from internal triggers: bodily sensations, thoughts, and memories that elicit dread. Physical activity uses up the adrenaline in my body, just as the fight-or-flight response was designed to do.

LATER THAT OCTOBER, James and I attend a two-day professional workshop on the brain and anxiety, given by a clinical psychologist. It’s the first such workshop I’ve come across. James is keen to see how someone else teaches this stuff.

It’s held in a large metropolitan hospital, and I’ve booked two nights’ accommodation within walking distance — the prospect of driving in the city is too frightening, and I want to conserve my mental energy. Getting out of the lift, I bump into an acquaintance, causing us both to do a double take. I learn that he’s here for treatment of a substance addiction; he’s equally surprised to find out that I’m here for my brain.

After registration, I enter the conference room: there are easily more than one hundred people sitting in closely spaced chairs. I can’t see James, and I scramble over bags and umbrellas spilling around people’s feet to get to a vacant chair in one of the rows towards the back. Brain science and anxiety is clearly a hot topic.

The psychologist, Pieter, reminds us that psychotherapy changes the brain, and that understanding the brain’s processes will make us more patient with the rate of psychological change. He says that a healthy-functioning left PFC is required for good mental health in most people. Usually the left PFC is able to inhibit the activity of the right, and information flows from the right PFC to the left.

The left PFC’s functions include categorising, problem-solving, detailing, and rational analysis. It puts events in order, and in time and place. It is primarily involved in verbal work and in making meaning of events. The right PFC specialises in non-verbal recognition and emotional memory. It recognises faces, reads others’ emotions, and assesses the emotional significance of events. It is involved in creative, non-verbal problem-solving, and in spatial relationships, such as rhythm in speech, music, and movement. It has a primary role in the processing of sensory data.

We learn that during trauma and the re-experiencing of trauma memories, blood flow to the left PFC temporarily drops relative to the blood flow in the right PFC; the left PFC’s influence diminishes, while the right PFC dominates. Anxious thoughts and emotions become ‘stuck’ in the right hemisphere when cut off from the left’s means of processing. I remember the assertion in Mindfulness-Based Cognitive Therapy for Depression that you ‘can’t think your way out of depression’. Depression requires action and not avoidance to get through it. Trauma causes hypersensitivity to the cues of trauma: anything that might remind the person of the original trauma. For example, seeing smoke rising in the air became a cue for my ambulance-driver client, who was traumatised after seeing incinerated bodies in a car crash.

Pieter gives us an explanation that shows why my dread has such a hold on me. He says that fear drives the mental error that the symptoms of fear are evidence of a serious threat, when in fact there is no real threat. The more the brain goes into panic, the more sensitised it becomes to future attacks of fear. He confirms what I have taken from my reading of Dan Siegel and others: if I am to get well and get my brain back in balance, I need to activate my left PFC more. I need to reduce the physiological triggers causing the fight-or-flight response.

Pieter says that activation of the left PFC cannot be done chemically, but he gives a number of strategies to do it. Exercise dissipates adrenaline, noradrenaline, and cortisol in the body, and uses up the energy released in the stress response. It raises the level of serotonin and endorphins, promoting a positive mood. He recommends a brisk walk of up to forty-five minutes five to seven times a week. I put up my hand and ask about yoga and Pilates. Pieter says that these activities do not release the same level of endorphins as exercise, but they do promote mindfulness of the body. Yes, I’ve noticed this, with Pilates especially.

Good-quality sleep is also critical for brain function, he says. Brainwave patterns allow the hippocampus to send information to the left PFC and into long-term memory. Rapid eye movement (REM) sleep relieves stress. During REM, more neurotransmitters are produced, through the process of regeneration. I remember that Norman Doidge mentions something similar in his book: he states that sleep, and REM sleep in particular, facilitates neuroplastic change, as it assists the growth of new neurons and of myelin. During sleep, the brain sifts through the short-term memories of day-to-day events, consolidating the important ones into long-term memories. So I need to do whatever I can to sleep better. Wayne has already told me this too; now I’ve got further confirmation.

According to Pieter, changing the pattern of fearful thoughts requires mindfulness: conscious awareness of thoughts and sensations in the body. Writing about personal experiences activates the left PFC and can create a sense of safety and control. The writing process increases blood flow in the left PFC. I remember how writing out a list of trauma memories the day before the stroke was the only way I could get them ‘out’ of my head.

Art therapy reduces thought loops in the right PFC by allowing the expression of emotions in a non-verbal form. Music activates the left PFC by forcing the brain to think in sequences and to remember; listening to music is less effective than making it, I learn. Conversing with a friend activates the left PFC. Travel and walking also enhance neuroplasticity, Pieter says.

Novelty — being in new situations or learning new skills — challenges the brain, keeping existing neurons alive. It is the old catch-cry of ‘use it or lose it’. Novelty promotes new neural connections, stimulates the growth of myelin, and can trigger neurogenesis. The more concentration it involves, the more neuroplastic change it induces. I think of my music: singing lessons with Lily, duets with Nick. These are new experiences and new skills, challenging my brain. I’m heartened to learn how much I’m doing right.

Someone asks how long it takes for brain changes to occur with therapy. Pieter tells us that with psychotherapy, consisting of one or two weekly sessions and daily homework exercises, it will take about four months for the therapeutic change and new neural pathways to become established. He says that psychological resistance can be thought of as a reversion to the old neural pathway.

The course is hard-going: I have a long sleep during lunchtime on the first day, which re-energises me for the afternoon. On the second day, after lunch, I can feel rubber brain setting in, but I want to stay on because it is so valuable. Yet by the mid-afternoon tea break, it’s clear that I’m not taking anything in. I catch up with James and tell him that I’m leaving; he’ll get a copy of any new notes for me and we’ll chat about the workshop at our next meeting.

I realise after the course that one thing Pieter didn’t address specifically is food for the brain. Over the next few days, as I’m reviewing my notes on the course, I consult various articles. I learn that the omega-3 fatty acids found in fish oil promote neuronal growth, improve mood, and slow cognitive decline. I read that vitamin B is critical in the synthesis of many neurotransmitters, and that vitamin E is the main antioxidant in the cellular membranes of the brain. I think I get enough Vitamin E in my diet, but I’m not sure about B.

My newest treatment practitioner is Doctor Franklin. On my fourth session with Doctor Banister, after the stroke diagnosis had been confirmed, he had seemed preoccupied and said he needed to make a home visit straight after our interview. He offered me few useful insights or advice. He was the most expensive doctor I’d seen, and I had difficulty paying his fees. I had never liked having a client of mine terminate sessions with me, but I was not happy with the service Doctor Banister was providing. I spoke with a GP acquaintance I bumped into, and she encouraged me to change psychiatrists, saying that I did not need to give a reason. I decided to move to Doctor Franklin, who has a private practice. (In our last session together, Doctor Banister said I could return to treating anxiety clients, but not traumatised ones; he was really out of touch with what was happening with me.)

So on my next visit to Doctor Franklin, I ask about vitamins. He encourages me to take omega-3, but insists that I take 1000 milligrams of the DHA and EPA combination per day. He explains how to read the information panel on the side of the bottle to assess the percentage of these fatty acids in each capsule, so I can determine how many I need to take to reach 1000 milligrams. He mentions vitamin B12 as especially important for me because I do not have a high-meat diet, although I have an adequate intake of fruit and vegetables. I’ve still been taking 100 milligrams of aspirin daily as a blood thinner, on Doctor Small’s advice, and the St John’s wort. So each morning and evening, I set up my collection of pills on the kitchen bench, pleased that I seem to have all bases covered.