The only person who is educated is the one who has learned how to learn to change.
Carl Rogers
FORTUNATELY FOR US, the same evolutionary processes that gave rise to the sources of our emotional suffering also provided us with the tools to heal: our abilities to connect, attune, and empathize with others. Psychotherapy is not a modern intervention, but a relationship-based learning environment grounded in the history of our social brains. Thus, the roots of psychotherapy go back to mother-child bonding, attachment to family and friends, and the guidance of wise elders.
The potential success of therapy relies on three fundamental mechanisms of brain, mind, and relationships.
1. The brain is a social organ of adaptation, shaped by evolution to connect with and change through interactions with others. Psychotherapy leverages the ability of brains to attune and learn from one another in the service of adaptive change. This intimate interaction between human connection and learning has been forged over the eons in the crucible of social evolution.
2. Change depends upon the activation of neuroplastic processes. For any change to occur, our brains have to undergo structural changes that will be reflected in our thoughts, feelings, and behaviors. Thus, the success of psychotherapy depends upon the therapist’s ability to stimulate neuroplasticity in the brains of clients—to make new connections, inhibit others, and link previously dissociated neural networks.
3. Together, we co-create narratives that support neural and psychic integration while creating a template to guide experience into the future. Through the co-construction of coherent self-stories, we are able to enhance our self-reflective capacity, creativity, and maturation. It is especially valuable in coming to understand our past, for the consolidation of identity, and to heal from trauma.
The Tools for Healing
#1 The Social Brain
Everything can be found in isolation except sanity.
Friedrich Nietzsche
An interesting thing happened during the evolution of our social brains. The primitive processes of neuroplasticity became interwoven with the more recently evolved aspects of sociality. In other words, the quality of attachment relationships has evolved to regulate neuroplasticity and learning. Secure attachment relationships support flexible, adaptive learning and higher-order executive functioning; insecure attachments support reactive behavior and rigid, trauma-based learning. This is why establishing a secure attachment within the therapeutic relationship serves as the matrix for positive change. So the essence of what we do as therapists is to connect with our clients in an exchange of emotions and information. Like neurons, we send and receive messages from one another across a synapse—the social synapse.
Definition: The Social Synapse
The social synapse is the space between us through which we communicate. The bandwidth of the social synapse includes both conscious and nonconscious modes of communication. On the surface we can point to gestures, words, and body language while unconscious forms of communication include pupil dilation, microfacial expressions, and odors.
To establish a bridge of attunement, we rely on many neural systems that receive and send social and emotional information. We use all of this information to create theories about what is on the minds of others. We establish internal representations of what is happening within them by simulating their internal states within us. We rely on attachment circuitry to establish bonds and to know how to apply the optimal balance of challenge and support to help our clients grow. We utilize all of the networks of our social brains in an attempt to articulate experiences that clients are presently unable to articulate themselves.
As discussed earlier, an important remnant of our evolutionary past, the amygdala, rests at the core of the brain. This ancient executive center has retained veto power over our modern cortical executive centers when it detects a threat. It is also like an elephant; it never forgets. The only chance we have at getting over a fear is to do what my grandfather suggested to me as a child: “Get back on the horse that threw you.” This folk wisdom embodies the knowledge that fear becomes reinforced through avoidance and inhibited by confrontation. This is why a decrease in avoidance behavior is highly correlated with therapeutic success.
Approaching danger and surviving inhibits the amygdala’s tendency to trigger the fight-flight response. Such situations can range from picking up a spider, to finishing the last class to get a degree, or going out on a first date. Risking new and seemingly dangerous experiments in the service of positive change requires a combination of courage, emotional support, and the ability to imagine success. Thus, successful therapists learn to be “amygdala whisperers” by leveraging the social brain in order to help clients face their fears in experiments that are developed collaboratively during sessions.
#2 Neuroplasticity
Plasticity . . . means the possession of a structure weak enough to yield to an influence, but strong enough not to yield all at once.
William James
Most generally, neuroplasticity refers to the birth, growth, development, and connectivity of neurons—the basic mechanisms of all learning. Existing neurons grow by connecting their projections (dendrites) during learning. Neurons interconnect to form neural networks, and neural networks, in turn, integrate with one another to perform increasingly complex tasks.
Neuroscience Corner: Neuroplasticity
Neuroplasticity is a general term that refers to any changes among, between, and within neurons as a result of learning or the natural processes of healthy development. It is the ability of the nervous system to change in response to experience and to encode that experience into its structure.
Because a brain is such a complicated government of systems, the possibilities of disconnections, misconnections, and failures of adaptation are almost endless. And because our brains depend so much on experience to help them develop properly, a lot can go wrong. When one or more neural networks necessary for optimal functioning remain undeveloped, unregulated, or unintegrated with others, we experience the complaints and symptoms for which we seek therapy.
We now assume that when psychotherapy results in symptom reduction or experiential change, the brain has, in some way, been altered: new connections have been made, dysfunctional systems altered or inhibited, or disconnected networks reintegrated. This suggests that all psychotherapists are neuroscientists who work to change the structure of the brain. Although the principles of plasticity have not been understood until recently, the practices and strategies of psychotherapy have been guided by their invisible hand since the beginning. Through trial and error, therapists have learned what works and what doesn’t work, and we continue this work individually with our clients. What works is what optimizes plasticity and leads to positive change—we are all experimental neuroscientists.
Openness and trust are fragile creatures, even with the people we love most. The training of the therapist and the therapeutic context itself are designed to increase neuroplasticity in networks of the social brain to enhance support, trust, and availability. It turns out that a secure and positive therapeutic alliance generates a double neuroplastic punch. A positive emotional connection stimulates metabolic processes that activate plasticity while inhibiting stress.
Thus, safe and attuned connections create the possibility for both short-term and long-lasting modification of the brain. Through the security of a safe relationship, something new can be introduced into a previously closed and dysfunctional system. This is one of the ways in which relatives, friends, and tribe members enhance survival and lead to the emergence of culture. This is also why relationships are the most challenging aspect of life. Although there is endless debate about the relative merits of different forms of therapy, they all depend on the same underlying biopsychosocial-developmental mechanisms of change.
#3 Language, Storytelling, and Co-constructed Narratives
There is no greater agony than bearing an untold story inside you.
Maya Angelou
Human beings are natural storytellers, and the roots of the talking cure harken back to gatherings around ancient campfires. Through countless generations, we have shared stories of the hunt, the exploits of our ancestors, and morality tales of good and evil. The urge to tell stories and gossip is embedded in our psyches, wired into our brains, and woven into our DNA. This is why People magazine will always outsell Scientific American. For most of human history, oral communication and verbal memory were the repository of our collective knowledge. The drive of elders to repeatedly tell the same stories is matched only by the desire of young children to hear the same stories again and again. This lock-and-key information highway carries memories, ideas, and values across generations.
Stories also serve as powerful tools for neural network integration. The combination of a linear story line and visual imagery woven together with verbal and nonverbal expressions of emotion activates circuitry of both cerebral hemispheres, cortical and subcortical networks, the various regions of the frontal lobes, the hippocampus, and the amygdala. This integrative neural processing may also account, in part, for the positive correlations between coherent narratives and secure attachments. Further, shared stories contain images and ideas that stimulate imagination and link individuals to the group mind.
Narratives are also powerful because they allow us to have an objective distance on direct experience, creating the possibility of alternate viewpoints. Through stories, we can escape the emotions and influences of the moment and take time to reflect on our experience. We can also share versions of possible selves with others to receive input about our experiences and perspectives. Finally, we can experiment with new emotions, actions, and language as we edit the scripts of our lives.
Although it seems that children are little scientists discovering the world, we often miss that they are primarily engaged in discovering what the rest of us already know about them. As children we are told by others, and we gradually begin to tell others, who we are, what is important to us, and what we are capable of. This serves the continuity of culture from one generation to the next as parents reflexively strive to re-create themselves. This can be both good and bad depending on the parents and the goodness of fit with their children. 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.
The role of language and narratives in neural integration, memory formation, and self-identity make them powerful tools in the creation and maintenance of the self. Putting feelings into words has long served a positive function for many individuals suffering from stress or trauma. Even writing about your experiences supports top-down modulation of emotion and bodily responses. In listening to our clients, we reflexively analyze their narratives for inaccurate, destructive, and missing elements. We then attempt to edit their narratives in a manner we feel would better support their adaptation and well-being.
#4 Self-Reflective Capacity
The key to growth is the introduction of higher dimensions of consciousness into our awareness.
Lao Tzu
Self-reflective capacity, the ability to think about our thoughts, feelings, and behaviors, has been found to correlate with both secure attachment and successful psychotherapy. This same ability has been called psychological mindedness by psychoanalysts and mindfulness in the self-help world. Self-awareness is derived from and reinforced by parents and therapists through the creation of narratives that include subjective states as objects of communication. We also come to learn that we are capable of evaluating old habits and attaining a more objective view of the expectations of others and the mandates of our childhoods. Therapy attempts to leverage this metacognitive vantage point to make new and more adaptive decisions.
The purpose of sharing our stories with others is to gain active participation in the co-construction of new narratives. Our own stories tend to become closed systems in need of new input. Therapists hope to teach their clients that not only can they edit their present story, but they can also be authors of new stories. With the aid of self-reflection, we help clients to become aware of narrative arcs of their life story and then help them understand that alternative story lines are possible. As the writing and editing processes proceed, new narrative arcs emerge along with the possibility of experimenting with more adaptive ways of thinking, feeling, and acting.
#5 Abstract Thought and Imagination
Imagination is more important than knowledge.
Albert Einstein
As the size of primate groups expanded, grooming, grunts, and hand gestures were gradually shaped into spoken language. Language made far more precise, complex, and subtle forms of communication possible. As social groups grew larger and language became more complex, more cortical space was required to process a greater amount of social information. This expanded topography was a contributing factor in the emergence of abstract thinking and imagination.
The human brain is characterized by the growth of an area called the inferior parietal cortex. This area, in collaboration with parts of the prefrontal cortex, appear to have allowed us to do three things that border on the miraculous. First, we are able to construct three-dimensional models of external objects in our imaginations. Second, we can manipulate and modify these models in our heads. Third, we can transform these objects of imagination into objects in the external world. We can apply our imagination, not only to external objects, but to ourselves.
Thus, humans are capable of imagining alternative selves, creating new narratives to become these selves, and then using narratives as blueprints for changing their lives. Countless blueprints are created and discarded during development as children and adolescents try on different identities. As we progress, we naturally outgrow old identities like a snake outgrows its skin. As we grow older, we often forget that we can change our stories, and we may become symptomatic when an old identity no longer fits who we’ve become.
Our imaginations allow us to escape the present moment, create alternative realities, and then begin our journey to find our new narratives. The hero’s journey, found in the literature of every culture, is a reflection of an ancient drive to explore new worlds, which allowed early humans to survive and spread around the globe. As therapists, we can leverage this heroic instinct in the service of our clients to assist them in facing their fears and creating a new life story. This is the hero’s journey of every culture—with shamans, medicine women, wise elders, and psychotherapists serving as guides.
Real knowledge is to know the extent of one’s ignorance.
Confucius
We have yet to discover how the brain and mind construct consciousness. Our best guess is that conscious experience emerges through a convergence of sustained attention, working memory, learned behaviors, language, and culture. Because it’s still a guess, all of us who work with or possess minds need to be humble about what we think we know. One thing that I am certain of is that I’m not certain of much, but I think I have some good working models.
As we saw earlier, conscious experience is constructed by the brain and mind in approximately half a second. Amazingly, this is enough time for the brain to use some portion of our 100 billion neurons and 100 trillion synaptic connections to construct a conscious perception. If 90% of brain activity is dedicated to internal processing, then only 10% is focused on figuring out what’s going on in the external world. Natural selection has shaped conscious experience in the service of survival, so how we perceive things has been shaped to optimize our ability to live long enough to reproduce and protect our children. Remember—the way the brain and mind construct consciousness is dedicated to adaptation, not accuracy.
The brain is an organ of adaptation that predicts and controls outcomes in the service of survival. As such it has to learn from experience, organize automatic responses to all eventualities, and anticipate the future as fast as possible. This is why our perceptions are biased in the direction of making rapid decisions with minimal information. Whatever our decisions are, you may also notice that we tend to justify and rationalize our choices, even when we know they are wrong, to reduce ambiguity and uncertainty. The brain not only wants to make fast decisions, it wants us to act with certainty and congratulate ourselves, regardless of the outcome.
Using Our Minds to Change Our Brains
Shift happens.
Candace Perth
Why is it so hard for people to accept themselves? This is a complex question with a relatively simple answer. Our self-esteem, our ability to regulate our inner emotional world, and our comfort in relationships are all organized during the first year or two of life. During this time, there is a rapid downloading of our mothers’, fathers’, and other caretakers’ inner worlds into our implicit (unconscious) memory systems. Because we never remember learning any of these things, we come into self-consciousness later in life with most of our software already downloaded. Thus, we are full of emotions, reactions, and behaviors that we have to justify as we attempt to develop a coherent narrative about who we are as people.
We come to believe the narrative that we create, and we feel the need to be consistent with it even when it’s a bad fit. If we have a narrative that doesn’t fit us and we feel the instinctual need to adhere to it, we will inevitably become symptomatic. We seek therapy because of the symptoms (e.g., anxiety, depression, bad relationships), but we discover that the symptoms are the visible expressions of deeper issues. Our minds construct conscious experience based on three misperceptions: (1) we are experiencing the present moment; (2) we possess unlimited free will; and (3) we have access to accurate information about ourselves and the world. As you might imagine, the combination of these three illusions allows us to act with confidence and without hesitation. Let’s examine these three beliefs.
Primates, including humans, possess brains with complex neural networks that become activated as we observe and interact with those around us. We have circuits that analyze the actions and gestures of others to develop a theory of mind—what others know, what their motivations may be, and what they might do next. This ability to intuit about what’s on someone else’s mind helps us predict their behavior—a capacity that supports group coordination and self-defense. We also have mirror neurons that link sensory, motor, and emotional brain networks to generate behaviors and feelings within us that mirror what is likely to be going on in those we are interacting with.
The existence of these mirror neurons and the theory of mind system reflects the fact that millions of years of evolution have been dedicated to refining systems for reading the emotions, thoughts, and intentions of others. We are quick to think we know others because these processes, and the attributions and emotions they trigger, are preconscious, automatic, and obligatory. All of this dedicated circuitry makes us very good at coming up with ideas about the motives and intentions of other people. It also allows us to learn through observation and practice new behaviors in our minds.
Neuroscience Corner: Mirror Neurons
Mirror neurons, located in the premotor regions of our frontal lobes, fire when we observe someone engaging in a specific behavior, such as saying a specific word or grasping an object. Some mirror neurons are so specific that they fire only when an object is grasped in a certain way by particular fingers. The same neurons also fire when we perform the action ourselves. Mirror neurons link observation and action, allowing us to (1) learn from others through observation; (2) anticipate and predict the actions of others, which supports group coordination and self-defense; and (3) activate emotional states supportive of emotional resonance and empathy.
Of course, there is an obvious downside to this ability as well—we are fairly prone to misreading ourselves. One reason is that while evolution has equipped us with awareness of others, it has not as yet seen fit to invest much in self-awareness and personal insight. This is probably why it is easy to see what is wrong with someone else, but difficult for us to see what is wrong with ourselves. In fact, the capacity to challenge our self-perceptions may have even been selected against during evolution because it can lead to self-doubt, hesitation, and demoralization. This may be why humans have unconscious mechanisms that distort reality in our favor.
In fact, we often project our own thoughts and feelings (which we may not recognize as our own) onto others and assume it is their truth, not our own. While Freud saw these projective processes as defensive, they may be a natural by-product of how our brains have evolved to process social information. Projection is automatic and lessens anxiety, while self-awareness can generate anxiety and requires sustained effort. Self-analysis is difficult because our inner logic is so interwoven with our natural reflex to avoid anxiety by blaming others.
The answer to the question of why therapy works can be addressed by asking another, more fundamental question: What do humans need? Beyond the basic survival needs of food and shelter, humans need to feel that they are accepted members of their groups. For a child, this is first the mother and later the father, siblings, and extended family. The need to be accepted gradually expands to include peers and romantic connections during adolescence and later to work, spouses, and children during adulthood. For social animals, connection is a fundamental drive, and our place within social groups is of central concern. Most people come to therapy because they don’t feel accepted by others, and therefore, they don’t accept themselves.
As Dr. Salk observed decades ago, evolution solves old problems and creates new ones. While a number of adaptative strategies created the need for psychotherapy, others have provided us with the tools to heal. The first is the power of secure relationships. The second is that we can leverage these relationships to stimulate neuroplasticity and brain growth. And the third is the ability of the body and the conscious mind to use self-awareness, stories, emotions, and bodily awareness to reshape neural circuitry in the service of improved adaptation. We are now capable of becoming aware of our misperceptions and working against our inherent biases to gain a clear perception of external reality. The good news is that our capacity to connect our minds with the minds of others allows us to counterbalance some of evolution’s less than stellar decisions. The ability of brains and minds to attune and influence one another is at the heart of psychotherapy.
Neuroscience Corner: Genetics and Epigenetics
Our brains are built in the interface between experience and genetics, where nature and nurture become interwoven into a single process. Genes first serve as a template to organize the brain, activate relevant biological processes, and trigger sensitive periods of development. Genes then orchestrate the translation of experience into the structures of our brains through a process of transcription. Template genetics is the mechanism of action of the transmission of traits from one generation to the next. Transcription genetics is the translation of ongoing experience into the structure of the brain. Through transcription genetics, our experience becomes flesh, relationships shape the brain, and culture is passed across individuals and through time.
Since the discovery of the double helix in the 1950s, we have come to understand that the information that builds our brains and bodies is coded in four amino acid bases (adenine, thymine, guanine, and cytosine), which flow from DNA to messenger RNA to protein. Although this was a huge leap forward in our knowledge of the underlying processes of genetic transmission, it only accounts for about 2% of genetic expression. So what accounts for the other 98%?
This gets us back to the old nature-nurture debate: what do we inherit and what do we learn from experience? Our best guess is that almost everything involves an interaction between the two. While we inherit a template of genetic material (genotype), what gets expressed (phenotype) is guided by noncoded genetic information that is dependent on experience. Experience can include anything from toxic exposure to a good education; from high levels of sustained stress to a warm and loving environment; from feast to famine. An example of this process of particular relevance to emotional development and psychotherapy is the impact of early stress on the adult brain. Research with rats has demonstrated that early maternal deprivation downregulates the degree of neurogenesis and the response to stress during adulthood. Just as important for us, these processes are reversible later in life. As therapists, we attempt to reprogram these neural systems via a supportive relationship and the techniques we bring to bear during treatment. In other words, we are using epigenetics to change the brain in ways that enhance mental and physical well-being.