CHAPTER 20

Neuroscience, Psychotherapy, and Neuropsychotherapy

It is difficult to overstate the importance BRIEF OVERVIEW______of understanding mirror neurons and their function. They may well be central During the past two decades, major advances in to social learning, imitation, and the cul- neuroscience havedistribute changed our knowledge of tural transmission of skills and attitudes— the brain and the role it has in mental health and perhaps even of the pressed together clus- mental illness (Andreasen, 2001). A paradigm ters we call words. shift has takenor place from the four previous forces in psychotherapy to one involving the use of neu- —V. S. Ramachandran, The Tell- roscience to inform psychotherapy (Arden, 2010; Tale Brain: A Neuroscientist’s Quest Rossouw, 2013). It is essentially a paradigm shift for What Makes Us Human from focusing primarily on the so-called talking therapy to emphasizing the therapeutic relation- Early experience shapes the structure and ship as an engagement with the whole person, his function of the brain. This reveals the post,or her brain/mind, genetics/body, environment, fundamental way in which gene expres- and spirit. sion is determined by experience. This chapter is written to empower clinicians to —Daniel Siegel, The Developing use neurobiological information as a psychothera- Mind: How Relationships and the peutic tool in their armamentarium of interven- Brain Interact to Shape Who We Are tions. It is designed to shed light on how their work copy, in psychotherapy might change their clients’ very brains. Neuroscience provides either a new frame- The problem is, when you depend work or an additional way for conceptualizing on a substitute for love, you never get clients’ problems and presenting issues. It has the enough. capacity and the tools to reveal what is happening not —Louis Cozolino, in a client’s brain as he or she works with a thera- The Neuroscience of Human pist (Cozolino, 2010). Previously, therapists could Relationship: Attachment and the only theorize about what might be happening in a Do Developing Social Brain client’s brain. Moreover, neuroscience emphasizes

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Copyright ©2016 by SAGE Publications, Inc. This work may not be reproduced or distributed in any form or by any means without express written permission of the publisher. holistic treatment of individuals, treatment that theory for psychotherapy that puts recent find- involves not only their mental health issues but ings on memory reconsolidation at center stage also other factors in their environment that might (Tucker, Hully, & Ticic, 2012). Two other brain- be impinging on their mental health, such as the based theories introduced in this chapter are effects of poverty on the brains of young children eye movement desensitization and reprocessing and the influence of trauma in their homes and (EMDR), developed by Francine Shapiro (2001), neighborhood on their being able to learn in school and brainspotting, developed by David Grand (Grawe, 2007). (2013). “Brainspotting is based on the profound This chapter has four basic goals, the first of attunement of the therapist with the patient, which is to present a detailed examination of the finding a somatic cue and extinguishing it by connection between neuroscience and psychother- down-regulating the amygdala. It isn’t just PNS apy. Brief historical sketches are provided for sev- (Parasympathetic Nervous System) activation that eral key figures who have connected neuroscience is facilitated, it is homeostasis” (Robert Scaer, MD, with psychotherapy. These are not the only major “The Trauma Spectrum,” cited on the What Is Brain contributors to neuroscience and psychotherapy; Spotting website https://brainspotting.pro/page/ however, to write a factual account of historical fig- what-brainspotting). ures in neuroscience and psychotherapy is beyond the scope of this chapter. • Brainspotting is a powerful,distribute focused treatment A second goal is to provide a framework method that works by identifying, processing for neuropsychotherapy based on the principles and releasing core neurophysiological sources of that have already been established in the broad emotional/bodyor pain, trauma, dissociation and a fields of neuroscience and neuropsychology. This variety of other challenging symptoms. chapter does not attempt to provide a full-blown • A “Brainspot” is the eye position which is theory of neuropsychotherapy, primarily because related to the energetic/emotional activation of a traumatic/emotionally charged issue within I am not a neuroscientist. Instead, throughout the brain, most likely in the amygdala, the hip- this chapter, the reader will be introduced (a) to pocampus, or the orbitofrontal cortex of the various psychologists and medical doctors who post,limbic system. Located by eye position, paired are using neuroscientific principles and findings with externally observed and internally experi- and infusing these findings within their already enced reflexive responses, a Brainspot is actually established psychotherapy frameworks and (b) to a physiological subsystem holding emotional psychotherapists who are working on developing experience in memory form. (https://brainspot- a theory of neuropsychotherapy. For the first cat- ting.pro/page/what-brainspotting) egory of psychotherapists, who infuse neuroscien- tific principles in their psychotherapy, I refer the The developers of these new brain-based reader to consider the work ofcopy, Eric Kandel (1998, approaches had the fascinating idea that there 2005), Louis Cozolino (2010), Daniel Siegel (1999, are brain-based procedures therapists can use to 2010, 2013), and Rick Hanson (2013). These writ- assist clients in actually erasing—not just coping ers have incorporated neuroscientific principles with—painful memories. One does not have to within their alreadynot established psychodynamic spend the rest of one’s life grappling with the issue approach to therapy. of a rejecting parent, sexual abuse, and other trau- Additionally, this chapter discusses the work matic events in one’s life. These authors believe that of several individuals who have developed what they have uncovered how the brain circuitry works is termedDo in the neuroscience literature as brain- in memory consolidation as well as in memory based therapies. For example, I present in sum- reconsolidation and have developed a process of mary form the work of Bruce Ecker and his activating a distressing memory, destabilizing it, colleagues (2012) on coherence therapy, a new and reconsolidating a new memory in its place so

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Copyright ©2016 by SAGE Publications, Inc. This work may not be reproduced or distributed in any form or by any means without express written permission of the publisher. that the terrifying memory no longer has its power A disclaimer Inner Reflections to create problems for the person. should be made In presenting a beginning framework for regarding the content When you hear the word developing a theory of neuropsychotherapy, I con- of this chapter. For neuroscience, what comes sider key concepts such as neuroplasticity, implicit instance, the chap- to mind? memory, explicit memory, memory reconsolida- ter does not pretend Do you feel that tion, mirror neurons, and right-brain to right-brain to be an exhaustive your background in therapy. The chapter also examines mental health examination of the neuroscience is sufficient and illness from a neuroscientific perspective, the field of neuroscience, enough for you to role of the neuropsychotherapist, and therapeutic and it does not deal incorporate some of its techniques that some neuroscientists use in their with rehabilitation principles in your work clinical practice. of the brain due to with clients? A third goal of this chapter is to explore the traumatic injury or concept of cultural neuroscience. What is the neurologic injury. It What would you like to impact of our culture on our brains? Are the brains does, however, pres- learn about neuroscience of people raised in an Eastern culture different ent a fairly readable and psychotherapy? from those reared in a Western culture? Do cultural introduction to neu- values condition people to prefer using the right- roscientific thinkingdistribute brain hemisphere over the left? that holds the promise of revolutionizing how psy- Finally, Goal 4 is to present the case study of chotherapy is conducted and tested for its efficacy. Justin from a neuropsychotherapy perspective. or Because the neuroscientific perspective empha- MAJOR CONTRIBUTORS______sizes holistic counseling, factors such as Justin’s wellness, his diet, the environment in which he The current neuroscientific paradigm is not con- lives, and his level of brain development are con- nected to a single person, and therefore, this sec- sidered in this case study. Two implicit questions tion presents three key individuals who have a link raised in the case study are “What might be helpful with neuroscience and psychotherapy: Sigmund for the counselor to know about Justin’s developingpost, Freud, Donald Hebb, and Eric Kandel. Only a brief young brain?” and “What might be the relationship description of their contributions is provided. between Justin’s impulsive behavior and his adoles- cent brain development?” Sigmund Freud (1856–1939) This chapter raises some ethical issues for therapists and helping professionals in general. For When most people think of Sigmund Freud instance, does a therapist have an ethical respon- (1856–1939), they think about him as the founder sibility to learn about braincopy, development? What of psychoanalysis and as the person who created ethical issues does the neuroscience paradigm have a theory of personality development—the id, for practicing therapists and counselors? Should ego, and superego. Few people know that Freud psychology, social work, and counseling programs was a neuroscientist before he became a psycho- introduce theirnot students to the developments in the therapist. He is included as one of the historical neuroscientific revolution, or should they just con- figures in neuroscience because of his early work tinue to ignore it and focus primarily on theories of in neurology and because he represents a major psychotherapy that were created during the 1940s, link between neuroscience and psychoanalytic psy- Do1950s, 1960s, and 1970s? Should our professional chotherapy. He is also represented as a major con- organizations that credential individuals in the tributor because of his work on the unconscious, helping professions require that new entrants have an important construct in the neuroscientific view competency in neuroscience? of implicit memory.

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Copyright ©2016 by SAGE Publications, Inc. This work may not be reproduced or distributed in any form or by any means without express written permission of the publisher. Freud began his career investigating the central lives resides beneath the tip of the iceberg—in nervous system (Zillmer, Spiers, & Culbertson, the unconscious. Both neuroscience and psycho- 2008). In 1883, Freud worked under Meynert, a analysis emphasize the importance of attachment neurosurgeon and psychiatrist, and he confined and the mother–infant feedback loop in which himself to to studying the nervous system. For 2 mother and child regulate each other’s minds and years, Freud concentrated on the medulla of the bodies. brain stem, and he published three articles. From 1885 to February 1886, Freud studied with Jean- Martin Charcot, the famous neurologist. In 1891, Donald Hebb (1904–1985) he published his first book, An Understanding of Hebb’s Law: Neurons That Aphasia, which got only a tepid reception from Fire Together Wire Together scholars (Zillmer et al., 2008). Freud’s psychoanalytic model for personal- Donald Hebb was born in Chester, Nova ity is loosely related to brain processes (Zillmer Scotia, Canada, and was raised by parents who et al., 2008) that are at the center of neuroscientific were physicians. Although he graduated in 1925 research. For instance, Freud’s id, which is based from Dalhousie University with a desire to be a on the pleasure principle, can be conceptualized as novelist, he decided to choose the more practical developing out of the reptilian brain. The superego field of education and, distributeshortly after graduation, is linked with the prefrontal lobe processes that accepted a position as are involved in forming abstract concepts such as a school principal Inner Reflections morality, guilt, planning, and inhibition. The ego, in the provinceor of which is based on the reality principle, can be asso- Quebec (Brown & Reflecting on Hebb’s ciated with the complex brain processes in the cor- Milner, 2003). In discovery that neurons tex (Zillmer et al., 2008). In his book On Narcissism 1936, he earned a that fire together wire (1959), Freud proposed that all ideas in psychology Ph.D. degree from together, what neurons in would one day be explained by organic substrates. Harvard in the area your brain have fired and Freud actually coined the term agnosia, which of the effects of early wired together? came from the Ancient Greek word Γγνωσία post,visual deprivation on (meaning “ignorance” or “absence of knowledge”) size and brightness Consider, for a moment, and refers to a loss of ability to recognize objects, perception in the your basic values related persons, and sounds, usually associated with brain rat. Donald Hebb’s to family, friends, and injury or neurological illness. contribution was work, what neurons fired Neuroscience has given psychoanalysis and that he made criti- together such they have the psychodynamic perspective in psychotherapy cal discoveries about created strong neural a new resurgence. Regina Palleycopy, (2000), a psy - the brain’s wiring. In pathways in your thinking? chiatrist and psychoanalyst, maintains that both 1942, Hebb accepted the neuroscience of emotion and psychoanalysis a position at the center on unconscious mechanisms. While neu- Yerkes Laboratory of Primate Biology, where roscience emphasizesnot what one might consider a he began working on a book that was later pub- biological unconscious governed by the rules and lished in 1949, The Organization of Behavior: A constraints of neural circuitry and neuropsychol- Neuropsychological Theory (Hebb, 1949). In this ogy, psychoanalysis focuses on a psychological book, Hebb presented a theory that became known unconscious.Do Both psychoanalysis and neuro- as Hebb’s law: Neurons that fire together wire science assert that conscious feelings form only together. Hebb’s law explains associative learn- the tip of the iceberg of human experience. The ing in which a simultaneous activation of neuron truly meaningful information for most people’s cells leads to an increase in the synaptic strength

638 PART V THE FIFTH FORCE IN PSYCHOTHERAPY

Copyright ©2016 by SAGE Publications, Inc. This work may not be reproduced or distributed in any form or by any means without express written permission of the publisher. between these neurons. The more the neurons fire Principle 3: Social or developmental factors can in a given sequence, the stronger the neural con- exert actions on the brain to produce mental dis- nections become. order. Learning-dysfunctional behavior produces alterations in gene expression. Principle 4: Alterations in gene expression brought Eric Kandel (1929– ) on by learning leads to changes in the patterns of Eric Richard Kandel was born on November neuronal connections. 7, 1929, in Vienna, Austria, the younger of the two Principle 5: When psychotherapy is effective, it sons of Herman Kandel and Charlotte Zimels, who does so through learning, by producing changes owned a toy store where both worked. In 1939, in gene expres- the Kandels left Austria and moved to Brooklyn, sion that change New York, to live with Charlotte’s parents. Kandel the strength of Inner Reflections attended Erasmus Hall High School in Brooklyn. synaptic connec- Eric Kandel was awarded He entered Harvard, majored in 19th- and 20th- tions and struc- the Nobel Prize because of century European history and literature, and gradu- tural changes that his work on memory and ated in 1952. In 1956, he earned his medical degree change the ana- tomical pattern of the brain. from New York University’s medical school, and in interconnections Could you ever see 1956, he married Denise Bystryn. In 2000, Kandel between nervedistribute yourself as a Nobel was awarded the Nobel Prize in Physiology or cells of the brain. Medicine for his groundbreaking research reveal- Prize recipient? For what ing what happens to the brain when memories Kandel’sor prin - accomplishment might are formed. Kandel had conducted studies on the ciples sent shock you be awarded the Nobel single-cell sea slug Aplysia to learn how nerve cells waves through the Prize? (neurons) change during learning (Kandel, 2000). leaders in the field, Do you agree or disagree His research on the sea slug Aplysia revealed the basis who were trying to with Kandel that all of short-term memory and long-term memory. For infuse neuroscien- psychiatric illnesses are more information on Kandel, his history, andpost, the tific principles about disorders of the brain? basis for the Nobel Prize, refer to http://www.nobel- the brain in their psy- prize.org/nobel_prizes/medicine/laureates/2000/ chotherapy practices. kandel-bio.html. The following is a brief paraphras- His principles emphasized the neuroplasticity of ing of the five principles Kandel mentioned in his the human brain and that a central component of 1998 article on neuroscience and psychotherapy. psychotherapy was that it affected clients’ brains. Kandel’s Principles for Neuroscience and Psychotherapy copy, TOWARD A THEORETICAL Principle 1: All mental processes, even the most FRAMEWORK FOR complex psychological processes, come from opera- tions of the brain. The mind is a range of functions NEUROPSYCHOTHERAPY______carried outnot by the brain. Behavioral disorders that This section provides a framework that might be characterize psychiatric illness involve disturbances used to formulate a theory of neuropsychotherapy. of brain function. The term neuropsychotherapy has been used in Principle 2: Genes are important determinants of various ways throughout the literature (Grawe, Dothe interconnections between neurons in the brain 2007). One definition is that and the details of their functioning. A person’s genetics contributes to the development of major neuropsychotherapy is an integrative approach mental illnesses. to therapy that takes into account the dynamic

CHAPTER 20 NEUROSCIENCE, PSYCHOTHERAPY, AND NEUROPSYCHOTHERAPY 639

Copyright ©2016 by SAGE Publications, Inc. This work may not be reproduced or distributed in any form or by any means without express written permission of the publisher. interplay between the mind, body, social interac- develop the language of neuroscience and acquire tion, and the environment on a person’s well- a beginning level of competency in understanding being with a focus on neuroscientific research. By the impact of their words and behaviors on their understanding the mechanisms of our biology (an clients’ brains. This section discusses a number of in particular our neurology), the processes of our key concepts that might be included in either a the- psychology, and the influences of social interaction, ory of neuropsychotherapy or a practice that uses it is believed a holistic therapeutic practice can be formulated. (Neuropsychotherapy, Changing Minds. neuroscientific principles within an established Retrieved from http://www.neuropsychotherapist theoretical framework, such as psychodynamic or .com/about/neuropsychotherapy) cognitive-behavioral approaches.

In addition, the term neuropsychotherapy The Brain has been used to refer to any psychotherapeutic approach that has been informed by neuroscience The brain is a three-pound mass of tissue com- (Grawe, 2007). posed of gray and white matter. It used to be routine For the most part, however, information about to say that the brain consists of 100 billion cells neuropsychotherapy is scattered in diverse books (Zillmer et al., 2008). However, a recent study by and articles. There is no standard theory of neu- Azevedo et al. (2009) has found that an adult male ropsychotherapy that is generally accepted in the human brain contains “ondistribute average 86.1 ± 8.1 billion field of psychotherapy—although Klaus Grawe NeuN-positive cells (‘neurons’) and 84.6 ± 9.8 bil- (2007) proposed the beginnings of one such theory lion NeuN-negative (‘nonneuronal’) cells” (p. 532), before his death. Essentially, neuropsychotherapy or approximatelyor only 86 billion cells. The brain is advocates promoting therapists’ greater in-depth the receiver of information from both inside and knowledge of the workings of the brain as well as outside a person. Current neuroscience conceptual- other features of the human biology to enhance izes the brain as a dynamic structure that shapes and their therapeutic practice, regardless of their theo- can be shaped, that changes and can be changed, retical orientation. Neuropsychotherapy seeks to and that gets mired down in neural firing patterns change the brain. As Grawe (2007) has stated, post,but can heal or repair itself to become unstuck. The brain is a social organ. Our human inter- Neuropsychotherapy aims to change the brain, personal interactions basically shape the construc- but it does not directly target primarily the brain tion of our brains (Cozolino, 2010). A person’s brain but focuses on the life experiences encountered by is fundamentally shaped during the attachment the person. The brain specializes in the processing process with a primary caregiver. Cozolino (2010) of life experiences. Life experiences are meaning- maintains that “there are no single brains” (p. 6), and ful with regard to the needs that are embedded in making this assertion, he puts attachment con- within the brain structures ofcopy, each human being. Neuropsychotherapy strives to shift the brain into a structs and relationships at the heart of the develop- state that enables these basic needs to be fully satis- ment of both adaptive and maladaptive behaviors fied. The best method for improving the health of in children and adults. The brain is also an organ of the brain, then,not is to ensure basic need satisfaction. adaptation, and its structures are built in interaction (p. 424) with other people and with the environment (Figure 20.1). Recent advances in brain imaging have found that the brain is an organ that continually builds and KEY CONCEPTS______rebuilds itself by one’s life experiences. MostDo of the important concepts in neuropsycho- therapy are related to the brain, its structures, and Characteristics of the Brain. The brain has a its functions. It is important that therapists begin to number of characteristics, only a few of which are

640 PART V THE FIFTH FORCE IN PSYCHOTHERAPY

Copyright ©2016 by SAGE Publications, Inc. This work may not be reproduced or distributed in any form or by any means without express written permission of the publisher. Figure 20.1 Brain: (a) View of the Interior Features of the Human Brain and (b) Lobes and Functional Areas on the Surface of the Hemispheres

(a)

distribute or (b)

post,

copy, not

discussed herein. First, a neuroscientific view of many actions automatically and below the level of Dothe brain is that people are emotional beings who conscious control. Third, automatic functions that think, rather than thinking beings who have emo- occur within the brain are located primarily in the tions (LeDoux, 1996). Second, the brain conducts occipital, parietal, and temporal lobes—the back,

CHAPTER 20 NEUROSCIENCE, PSYCHOTHERAPY, AND NEUROPSYCHOTHERAPY 641

Copyright ©2016 by SAGE Publications, Inc. This work may not be reproduced or distributed in any form or by any means without express written permission of the publisher. top, and side of the brain, respectively. In contrast, research has found that the construction of meaning conscious control actions take place in the cerebral is very different from the processing of information. cortex (e.g., the forebrain—the front of the brain; According to Modell (2003), the metaphor is the Restak, 2006). Fourth, the brain is plastic; the brain brain’s primary way of understanding and remem- changes due to influences from the environment. bering the world (Table 20.1). Because of the influence of the environment on the brain, no two people are identical in the neural wiring of their brains. Fifth, not all brains are alike, Neurons even though they are basically similar. Tancredi Neurons may be defined as the electrically (2005) has pointed out the neurobiology of the excitable cells that process and transmit informa- differences between female and male brains (e.g., tion within the brain by electrical–chemical sig- females evidence greater empathy). Sixth, human naling. A synapse is the structural space between brains differ from nonhuman brains. Seventh, neurons in the nervous system. The word synapse

Table 20.1 The Brain and Its Four Lobes

Brain Lobe Function Results of Improperdistribute Functioning Frontal lobe The emotional control center of the brain It is more common to injure the responsible for forming one’s personality frontal lobe than any of the other and for making decisions. It is located at the lobesor of the brain because it is front of the central sulcus where it receives located at the front of the skull or information from other lobes of the brain. brain. Damage to the frontal lobe often results in personality changes, Most functions of the frontal lobe focus on difficulty controlling sexual urges, regulating social behavior. The following are and other impulsive and risk-taking some important functions of the frontal lobe: post, behaviors. •• Cognition, problem solving, and reasoning •• Impulse control •• Regulating emotions •• Regulating sexual urges •• Planning •• Motor skill development •• Partscopy, of speech Parietal lobe Parietal lobe has several functions including Damage to the parietal lobe may sensation, perception and spatial reasoning. result in problems with spatial This lobe processes sensory information reasoning, reading, writing, notfrom various parts of the body. Some specific understanding symbols and language. functions of the parietal lobe include: Right-side damage to the parietal area can impact a person’s ability to dress •• Sensing pain, pressure, and touch himself or herself. Left-side damage •• Regulating and processing the body’s to the parietal lobe can result in five senses Do language disorders and disorders with •• Movement and visual orientation perception. •• Speech •• Cognition and information processing.

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Copyright ©2016 by SAGE Publications, Inc. This work may not be reproduced or distributed in any form or by any means without express written permission of the publisher. Brain Lobe Function Results of Improper Functioning Temporal lobe: •• The main function of the temporal lobes •• The type of impairment that result There are two is to process auditory sounds. Other from damage to the temporal lobe temporal lobes functions include: varies according to where the located on both sides •• The temporal lobe contains the damage took place. of the brain that are hippocampus, the part of the brain •• Temporal lobe damage can result located near the ears. responsible for transferring short-term in difficulty processing auditory memories into long-term one. Therefore sensations and visual perceptions, the temporal lobe helps to form long- problems concentrating on visual term memories and process new auditory stimuli, long-term information. memory problems, changes in •• It helps to form visual and verbal personality, and changes in sexual memories. behavior. •• It is involved in the interpretation of smells and sounds. Occipital lobe: •• The occipital lobe is the primary visual •• Damage to the occipital lobe is This lobe is the processing center of the brain. Other less likely to occur than damage smallest of the four functions include: to distributethe other lobes because the lobes of the brain. It skull protects the occipital  Visual-spatial processing is located near the lobe.  Movement and color recognition posterior region of or•• Severe damage to the occipital the cerebral cortex lobe can result in loss of color near the back of the recognition, visual hallucinations skull. or illusions, and problems recognizing objects. post, comes from the Greek and means “point of con- Neurotransmitter tact.” Synapses, or specialized connections between neurons, allow signaling from one neuron to A neurotransmitter is a chemical that is another to take place (Zillmer et al., 2008). Neurons released from a nerve cell that transmits an impulse communicate with each other within the brain and from one nerve cell to another nerve, muscle, down the spinal cord. Neuronscopy, are interconnected organ, or other tissue. It is essentially a messenger into networks that have chemical and electrical of neurologic information from one cell to another communication systems. The brain functions as a (Zillmer et al., 2008). Neurotransmitters contrib- complex system of neuronal circuits (Figure 20.2). ute to a person’s cognitive, emotional, psycho- Three primary types of specialized neurons logical, and behavioral responses or patterns in life exist withinnot the nervous system: (1) sensory neu- (Table 20.2). A person’s production of neurotrans- rons, which respond to touch, light, sound, and mitters has been linked to environmental stressors other stimuli; (2) motor neurons, which cause and his or her lifestyle (including diet, coping muscle contractions, influence glands within the strategies, and leisure time). Many of the problems Dobody, and receive signals from the brain and the that clients mention during therapy and counseling spinal cord; and (3) interneurons, which connect can be traced to their brain chemistry and to either neurons in the same region of the brain or spinal overproduction or underproduction of specific cord (Zillmer et al., 2008). neurotransmitters (Zillmer et al., 2008).

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Copyright ©2016 by SAGE Publications, Inc. This work may not be reproduced or distributed in any form or by any means without express written permission of the publisher. problem behaviors that often bring people to Figure 20.2 Neuron therapy: (1) acetylcholine, a neurotransmitter that is critical for learning, optimal cognitive functioning, and emotional balance and con- trol (deficiency causes deterioration of memory, increased forgetfulness, lack of emotional control, and increased aggression); (2) serotonin, a per- son’s natural mood stabilizer and sleep promoter (deficiency of serotonin causes depression, dif- ficulty sleeping, a sense of being disconnected, lack of joy); (3) dopamine, a person’s natural energizer; and (4) gamma-amino butyric acid (GABA), which helps reduce anxiety and induces sleep (deficiency causes the feeling that it is hard to relax) (Farmer, 2009). Therapy and counseling strategies that tend to release acetylcholine include exercis- ing and using meditationdistribute on a consistent basis. Because serotonin deficiencies are associated with depression, therapists can help clients by assisting themor to develop action-based strate- gies that produce new meaning in their lives. Dopamine production may be increased within a person via massages. Studies have reported that when patients with cancer and other medical disorders receive massage therapy, Although there are more than 100 they experience increased levels of dopamine, neurotransmitters, 4 are directly connected to post,serotonin, oxytocin, endorphins, and natural

Table 20.2 Neurotransmitters and Their Functions

Neurotransmitter Functioncopy, Imbalances Acetylcholine Important for memory, learning, A deficiency produces a deterioration optimal cognitive functioning, of memory, increased confusion, emotional balance and control. forgetfulness, cognitive disorganization not Affects attention, alertness, and and eventually as one ages leads to voluntary muscle movement. Alzheimer’s disease.

Dopamine Regulates movement, emotional An oversupply of dopamine has wellness, and pleasurable feelings. been linked to schizophrenia and an Do undersupply has been associated with Parkinson’s disease.

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Copyright ©2016 by SAGE Publications, Inc. This work may not be reproduced or distributed in any form or by any means without express written permission of the publisher. Neurotransmitter Function Imbalances

Serotonin Influences how a person thinks, An undersupply of serotonin is linked behaves, and feels, and is vital to to depression and obsessive compulsive sleep and anxiety control. It is a “feel disorder. good” chemical that affects sleep, mood, appetite, and impulsiveness. Antidepressant drugs raise serotonin levels.

High levels of it, or sensitivity to it, are associated with serenity and optimism.

Norepinephrine Affects alertness, sleep, and learning Undersupply of norepinephrine can depress one’s mood.

Too much norepinephrine can produce an agitated state.

GABA (gamma-amino Helps reduce anxiety and induces Too little GABA is associated with anxiety butyric acid) relaxation and sleep disorders.distribute Inhibitory Inhibits excitation and anxiety neurotransmitter or Endorphins Pleasurable sensations and control Undersupply can cause stress, pain, of pain oversupply can cause euphoria or dependence (opiate addiction).

Glutamate Glutamate supply has been linked to post, neurological disorders. Oversupply can stimulate brain, producing migraines or seizures (which is why some people need to avoid MSG, mono sodium glutamate, in food)

killer cells (Goodfellow,copy, 2003; Hernandez-Reif human mind emerges from patterns in the flow et al., 2004). of energy and information within the brain and between brains. 2. The mind is created within the Mind interaction of internal neuro-physiological pro- not cesses and interpersonal experiences” (p. 2). The mind emerges from the brain, and it is shaped by interpersonal relationships. The mind Neuroplasticity can be defined as a process that regulates the flow Doof energy and information. Human relationships The term neuroplasticity refers to the brain’s shape the neural connections from which a person ability to change and adapt as a result of life expe- mind emerges. According to Siegel (1999), “1. The riences (Butz, Worgotter, & van Ooyen, 2009;

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Copyright ©2016 by SAGE Publications, Inc. This work may not be reproduced or distributed in any form or by any means without express written permission of the publisher. Inner Reflections Holtmaat & Svoboda, described as left-mode processing (Badnoch, 2009). Research has 2008), meaning the management of information It has been said that the demonstrated that and information processing. The left side of the mind is formed by the the brain continues brain is good at tasks that involve logic, language, relationships that we have. to create new neural and analytical thinking. It is better at factual/ pathways through- semantic memory, critical thinking, numbers, How would you describe out one’s life and that and reasoning. your mind? it modifies existing The right hemisphere, which is involved in What relationships were neural pathways to right-mode processing, controls sensory input critical in forming your adapt to new expe- (auditory and visual awareness) processing, cre- mind? riences, learn new ative abilities, and spatial and temporal awareness. information, and What mindsets have you The right brain manages a person’s creative abili- create new memories formed? ties and emotional responses. In the majority of (Siegel, 1999, 2010). mental processes, there is usually a bipartisan par- Neuroplasticity ticipation of the two hemispheres. Whereas the left is moderated by hemisphere deals with externally focused attention genetic factors and by dynamic epigenetic changes and action, the right hemisphere concentrates on that influence the expression of genes without internally focused attentiondistribute and action. Studies changing the DNA sequence. Psychologists and have reported that the right hemisphere is primar- other helping professionals are interested in epi- ily responsible for reading social and emotional genetic processes because their external triggers cues from otheror people. The right hemisphere of (e.g., parental care, attachment, diet, drug abuse, the brain seems to be more capable than the left and stress) can influence a person’s vulnerability to hemisphere of regulating states of bodily arousal. many diseases, including mental or psychiatric dis- Both the right and the left hemispheres of orders (Volkow, 2010). In future decades, research- the brain are involved in different ways of know- ers will most likely gain additional insights about ing the world. The right hemisphere seems to be what forms the basis of neuroplasticity. able to perceive pat- post,terns within a holistic Inner Reflections framework, observ- Two Cerebral Hemispheres: ing spatial arrange- Although research says that Right-Brain and ments that the left the two brain hemispheres Left-Brain Development hemisphere cannot work as an integral unit, sense. The right brain some people believe that The human brain consistscopy, of two cerebral construes the overall people are more right- or hemispheres—a right and a left brain. The brain meaning of events. left-brain oriented. works as a unified system, even though it has Some abilities asso- different structures and two hemispheres. Each ciated with the right Would you describe brain hemisphere is associated with different hemisphere include yourself as being more functioning in thenot cortex. For instance, the left the following: recog- right- or left-brain oriented hemisphere controls the four Ls of functioning nizing faces, express- in your daily dealings with in the cortex: language (speech and reasoning), ing emotions, music, people? logic (stepwise reasoning and analysis), literality reading emotions, Are the things you really (factsDo and details), and linearity (“straight-line” intuition, and cre- like to do more associated thinking) (Siegel, 2012). The left hemisphere ativity. It develops with the right- or left-brain of the brain (the cerebral cortex and the struc- earlier, sees the world hemispheres? tures of the midbrain) conducts what has been holistically, is largely

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Copyright ©2016 by SAGE Publications, Inc. This work may not be reproduced or distributed in any form or by any means without express written permission of the publisher. nonverbal, uses metaphors, contains autobiograph- is both unconscious and unintentional. This type ical memory, recognizes faces, expresses emotions, of memory is also called nondeclarative memory likes music, reads emotions, recognizes color and because a person is usually not able to consciously images, is intuitive, and is creative. bring it into awareness. Implicit memories are often termed procedural memories, like hitting a base- Memory ball. A person does not have to recall consciously how to perform procedural memories. Although Explicit Memory procedural memories are not recalled specifically, a person can still perform an activity after a break— All therapists deal with some form of client such as riding a bicycle again, even though one has memory. Information that a person has to con- not ridden one in 20 years. sciously remember is known as explicit memory. When an individual is trying to intentionally remember something (e.g., an algebraic formula), Memory Consolidation this information is stored in explicit memory. We During the process of psychotherapy, clinicians use explicit memory on a daily basis, for example, work with a client’s memory. Clinicians want to to recall the time of a dinner date or a doctor’s know how clients remember the things that have appointment. Explicit memory is also known as happened to them distributebecause such memories indi- declarative memory. There are two types of explicit cate how they have constructed an interpretation memory: (1) episodic memory, which contains of their lives. Memory consolidation is a neuro- a person’s long-term memories of specific events logical processor that involves gradually convert- and a person’s internal sense of “I am remember- ing information from short-term into long-term ing,” and (2) semantic memory, which consists memory (Zillmer et al., 2008). A person’s short- of memories of facts, concepts, names, and other term memories are stored for only about 20 to 30 general knowledge information. Episodic memory seconds. If information is to be retained so that is autobiographic. A woman may recall a sense of it can be retrieved and used later, the contents of self as a high school student, as a new mother,post, and short-term memory must be moved into long-term as a mother of teenage children. memory (Kandel, 2005). Episodic memories are often communicated The memory consolidation process starts at to therapists as stories about oneself. Siegel (1999) the synaptic level as the brain begins to form new describes a 35-year-old woman who began to pathways to the information that comes to its atten- recount her experiences of having been raised by a tion. This process can take place over a period of violent, alcoholic father. He states, days, weeks, months, or even years. Memories are spread out throughout the entire brain. The When she began to tellcopy, her story, her eyes became brain creates a neural map of the information so filled with tears, her hands began to tremble, and she turned away from her therapist. She stopped that memories can be retrieved at a later point. speaking and seemed to become frozen, with a look Memory consolidation is the process involved in of terror on her face. For the therapist, the feeling in coding a memory so that it can be retrieved at a the roomnot was intense and consuming. The patient later moment (Kandel, 2005). Without memory began to speak again, but this time she spoke of her consolidation, there would be no way for a person father’s “positive attributes.” (p. 43) to store information in the brain. Do The hippocampus appears to assume an Implicit Memory important role in memory formation and storage. Rapid eye movement sleep also seems to assist with Implicit memory consists of things that a the process of memory consolidation, and sleep person does not purposely try to remember; it overall is thought to help the brain refresh itself.

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Copyright ©2016 by SAGE Publications, Inc. This work may not be reproduced or distributed in any form or by any means without express written permission of the publisher. Although memory consolidation usually occurs responses stored in long-term implicit memory are over an extended period of time, studies of people indelible—unerasable and permanent during a involved in learning tasks have found that the brain person’s lifetime. The can consolidate a memory successfully in less than existence of recon- an hour (Kandel, 2005). Rehearsal and memoriza- solidation implies Inner Reflections tion strategies are techniques that can promote that the brain’s built- Think about an event you faster memory consolidation. Repeating the same in neurodynamics have experienced in your information over and over can cause synaptic allow a person to life that you would like to changes in the brain that lead to rapid consolida- experience free- erase or reconsolidate. tion of memory. It is important that counselors dom from negative understand the process of memory consolidation emotional learnings What is this memory? for clients. The process involved in memory con- formed early in life. Do you have any solidation is also important in a number of the The reconsolida- symptoms connected to newer brain therapies, including EMDR (Shapiro, tion hypothesis has this memory? If so, what 1995, 2001). important implica- are they? tions for psycho- Repeatedly pair the Memory Reconsolidation therapy. Memory research supports a distributenegative memory with a Just as there is memory consolidation, there nonpathologizing meaningful positive one, is also a process called memory reconsolidation. model of analyzing such that each time the Imagine that all of the precious memories that a person’s symptomor negative memory comes you painstakingly made were suddenly erased? production that forth, you activate a That thought is frightening to most people. Yet is caused by a per- positive one alongside it. recent studies have revealed that every time you son’s unconscious Has the negative memory recall a specific memory, you make it necessary emotional learning become destabilized or for that memory to be reestablished (Kandel, contained in one’s changed in any way? 2005). The term used to describe this memory post,emotional memory. How? process is reconsolidation—a term that recognizes Ecker and Toomey the characteristic that long-term memories, when (2008) have provided formed initially, are labile and subject to disruption evidence of such a clinical process, named coher- over a period of hours. The good news for people ence therapy (Ecker et al., 2012). The basic tenets who have experienced trauma in their lives is that of coherence theory and eliminating symptoms of previously long-established memories are also psychological issues using memory reconsolida- subject to disruption specificallycopy, during that period tion are discussed in the section on new brain- immediately after each time they are recollected. based therapies. Reactivated memories must be put back into long- term storage by a process similar to that involved Mirror Neurons in the initial consolidation period—hence, the term reconsolidation. not Neuroscientific knowledge of mirror neurons Studies related to memory reconsolidation is based on the work of the Italian researcher (Nader, Schafe, & LeDoux, 2000; Sara & Hars, 2006; Gallese, who in 1995 studied macaque monkeys Sara, 2000) have shown that a consolidated mem- and found that a certain neuron fired when one ory couldDo again become susceptible to impairment monkey observed another monkey performing for a discrete period of time after retrieval. The an action, which in this case was reaching for a memory reconsolidation hypothesis overturned peanut (Gallese, Fadiga, Fogassi, Rizzolatti, 1996). the belief that emotional learnings and acquired Mirror neurons may be summarized as follows:

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Copyright ©2016 by SAGE Publications, Inc. This work may not be reproduced or distributed in any form or by any means without express written permission of the publisher. When a person observes another person engaging The better therapists can mirror the neural in a behavior, certain brain areas are activated, and activity in their clients’ brain, the more likely that these are the same brain areas that are activated they will be able to understand them (Newberg whenever the first person performs the same & Waldman, 2013). When therapists are able to behavior (Rizzolatti & Sinigaglia, 2008). accurately mirror their clients’ feelings, they create Mirror neurons connect visual and motor neural resonance between them. As Newberg and experiences and are involved in social functions Waldman (2013) have stated, such as learning, the development of gestures and verbal language, and empathic attunement. If you really want to understand what the other Commenting on the impact of observing another person is saying, you have to listen and observe person’s hand gestures and speech, Newberg and the other person as deeply and fully as possible. Waldman (2012) have asserted, Otherwise your brains won’t mirror each other. If we can’t simulate in our own brains what another A recent neuroimaging study showed that hand person is thinking and feeling, we won’t be able to gestures and speech originate in the same language- cooperate with them. (p. 81) related area of the brain. This overlap between words and gestures appears to be associated with a rare cluster of brain cells called “mirror neurons.” Neuroscience The neurons that fire in someone’s brain when they and the Environmentdistribute make a specific gesture also fire in your brain as you observe them. (p. 45) Neuroscience provides an enlarged role for the influenceor of the environment on people. Brain Mirror neurons in the human brain help us development in humans is influenced by both understand the actions and intentions of other heredity (genes) and environment. Environment people (Gallese & Goldman, 1998). Both clients is conceptualized in two fundamental ways: first, and therapists experience neural activation when one’s early environment that shaped one’s ini- clients talk about their problems during therapy. tial brain development and patterns of thinking, When clients describe in detail their challengespost, or feeling, and behavior and, second, the current problems, mirror neurons are activated in the thera- environment in which the client finds himself or pist’s brain as he or she is engaged in deep listening herself. A client’s current environment includes and close observation of clients’ behaviors. Schulte- housing arrangements, relational affiliations, work Ruther, Markowitsch, Shah, Fink, and Piefke (2007) situation, financial status, and any other significant have pointed out that the “same neuronal activity environment variable. patterns occur in the same areas of an observer’s Therapists can no longer ignore the impact brain as in the brain of acopy, closely observed and felt of the environment on individuals’ behaviors, other person” (p. 1362). Neurological mirroring is including their mental disorders. Most likely the facilitated when the emphasis on environment will strike a responsive Inner Reflections interpersonal inter- chord for clinicians who perceive themselves to actions between ther- be multiculturalists and social justice counselors. Do you see notany connection apist and client are Clinicians need to understand that the neuro- between mirror neurons experienced as being plasticity of the brain suggests the possibility of and empathy? nonjudgmental, change, even for mental illnesses that have strong How might you go about positive regarding, hereditary links; for example, individuals suffering Doincreasing neurological respectful, accept- from schizophrenia can recover and lead produc- mirroring with your ing, and empathic tive lives. They, too, can hope for a positive future. clients? in nature (Schulte- While medication may be part of the treatment Ruther et al., 2007). equation, it is only part of it.

CHAPTER 20 NEUROSCIENCE, PSYCHOTHERAPY, AND NEUROPSYCHOTHERAPY 649

Copyright ©2016 by SAGE Publications, Inc. This work may not be reproduced or distributed in any form or by any means without express written permission of the publisher. Neuroscience and Social Justice stated in his landmark, Nobel Prize–winning arti- cle, “A New Intellectual Framework for Psychiatry,” Neuroscience may contribute to a greater emphasis on social justice as more and more studies We are in the midst of a remarkable scientific are conducted on the effects of the environment on revolution, a revolution that is transforming our children’s and adults’ brains. Krugman (2008) has understanding of life’s processes—the nature of asserted that poverty poisons the brains of chil- disease and of medical therapeutics. . . . [it] will dren. Neuroscientists are beginning to point out have a profound impact on our understanding of that children who grow up in poverty experience mind. (para. 79) unhealthy levels of stress hormones, which hinders their neural development. Racism, sexism, and Kandel (1998) has commented on how therapy cultural oppression emit damaging cortisol in the affects clients’ brains: brain. Ivey, Ivey, Zalaquett, and Quirk (2009) have maintained that clients need to be informed about [W]hen a therapist speaks to a patient and the how social systems affect their personal grown. patient listens, the therapist is not only making eye These researchers have stated: contact and voice contact, but the action of neuronal machinery in the therapist’s brain is having an indi- rect and one hopes, long lasting effect on the neuro- As counselors, we can nal machinery in the patient’sdistribute brain; and quite likely Inner Reflections help clients under- vice versa. Insofar as our words produce changes in stand that the issue To what extent do you our patient’s mind, it is likely that these psychothera- does not lie in them, peutic interventions produce change in the patient’s believe that therapists but in oppressive or brain. From this perspective the biological and should be involved in systems. They should sociopsychological approaches are joined. (para. 76) social justice issues related avoid self-blame to their clients? and self-pity. We can build strengths Neuroscience research has shown how psycho- How might school through a wellness therapy or “talking therapies” change the behavior counselors work in approach and a focus of the brain, its chemical operations, and its struc- their schools to include on positive gender post,ture (Linden, 2006; Rossouw, 2013). For instance, principles established by and cultural iden- Arthur Brody and his colleagues (2001) have neuroscientific studies? tity. Neuroscientists reported metabolic brain changes in clients with have found that the depression treated with interpersonal therapy. brain fires most when They found that subjects treated with interpersonal seeing faces that resemble one’s own. This is psychotherapy experienced a 38% decrease in their an important component of antiracism train- ing. . . . A social justice approachcopy, includes helping scores on the Hamilton Depression rating scale, clients find outlets to prevent oppression and work while those treated with the drug paroxetine had with schools, community action groups and others a greater mean decrease in their scores. Both sub- for change. (para. 24) groups “showed decreases in normalized prefrontal cortex (paroxetine-treated bilaterally and interper- not sonal psychotherapy-treated on the right) and left Psychotherapy anterior cingulate gyrus metabolism, and increases Changes Your Brain in normalized left temporal lobe metabolism” (p. 631). Similar findings supporting psycho- NeuroscienceDo has uncovered a number of therapy’s impact on a client’s brain were reported aspects about our human life that may revolution- by Stephen Martin (2001) and his colleagues, who ize how we conduct psychotherapy (LeDoux, 1998, identified blood flow changes in depressed clients 2003; Siegel, 1999, 2010). As Eric Kandel (1998) has treated with interpersonal psychotherapy. The

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Copyright ©2016 by SAGE Publications, Inc. This work may not be reproduced or distributed in any form or by any means without express written permission of the publisher. investigation that showed interpersonal psycho- researchers are calling for a form of psychotherapy therapy resulted in both limbic blood flow increase that is based primarily on neuroscience. and basal ganglia blood flow. In addition, other studies have also found sup- port for the assertion that psychotherapy changes Mental Health From clients’ brains. Thomas Furmark and colleagues a Neuroscientific Perspective (2002) reported that social phobic patients who underwent psychotherapy showed significantly Neuropsychotherapists present mental health reduced blood flow in amygdala-limbic circuits. in a manner different from the traditional Western Goldapple’s (2004) team of researchers showed way of thinking. One way to view mental illness the effect of cognitive-behavioral therapy on cor- is that one or more systems of the brain did not tical-limbic brain pathways for clients with major develop adequately and/or there is an absence of depression. Schnell and Herpertz (2007) conducted integration between various systems in the brain. functional magnetic resonance imaging (fMRI) To have a balanced mood, both right and left hemi- studies on clients diagnosed with borderline disor- spheres have to be actively involved in an equal ders and found that dialectical behavioral therapy or democratic way and reciprocally balance each produced significant changes in the right prefron- other (Cozolino, 20103). For instance, if a person tal cortical regions. Beutel (2010) and his team of has too much activationdistribute of the right side of the pre- researchers found that short-term psychodynamic frontal cortex, he or she will experience depression inpatient therapy produced changes in brain activa- and shame. If a person has too much activation of tion in frontal-limbic patterns. Radu et al. (2011) the left sideor of the prefrontal cortex, he or she will used cognitive-behavioral therapy to help obses- tend to have euphoria or mania. sive-compulsive clients reduce their compulsivity. The environment assumes a prominent role Findings that support the belief that psycho- in activation of both right and left hemispheres of therapy changes clients’ brains present certain ethi- the brain—especially a person’s attachment pat- cal and professional responsibilities for therapists tern formed with a primary caretaker. Attachment and helping professionals. What are the fundamen- with a primary caregiver establishes one’s emo- tal basics that every ethical practicing therapistpost, tional regulation and one’s feelings about oneself should know about neuroscience and clients’ brains and others. If during the attachment process, a during therapy? How might practicing clinicians child gets the message that he or she is not valued, incorporate knowledge gained from neuroscience shame and negativity will predominate in the right about the human brain in their everyday clini- hemisphere. cal practice? Therapists have tended to approach Moreover, a key component of mental health is neuroscience from two perspectives. First, some the integration of cognition (left-hemisphere activ- have begun to incorporatecopy, basic neuroscience ity) and emotion (right-hemisphere activity). For findings into estab- instance, some individuals might react emotionally Inner Reflections lished practices that to most things, while others respond intellectually are framed in psy- to emotional events. To achieve mental health, How comfortablenot do you choanalysis and in there must be a balance between one’s emotional feel about incorporating cognitive-behavioral, and cognitive expressions and approaches to life. neuroscience in your work humanistic, or social Cozolino (2010) uses the concept of the social with clients? constructivist theo- brain to challenge the Western value of individu- DoWould you ever see retical approaches alism. Instead of saying that healthy “people are yourself using a theory of (Cozolino, 2010; those who are autonomous and independent,” he neuropsychotheraphy? Davidson & Begley, contends that because one’s social brain is basically 2012). Second, some shaped in interaction with other people, healthy

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Copyright ©2016 by SAGE Publications, Inc. This work may not be reproduced or distributed in any form or by any means without express written permission of the publisher. people are those who rely on others throughout technology has found that specific brain path- their lives for strength and development of their ways, mostly located in the prefrontal cortex, are abilities. This interdependent view of healthy implicated in major mental disorders (Davidson & personality development resembles closely that of Begley, 2012). As a result of neuroimaging break- some Eastern cultures that emphasize the role of throughs, researchers have begun to study mental the group and the subordination of the individual disorders as brain circuit disorders, with an empha- to the group. Cozolino’s (2010) view of the healthy sis on normal and abnormal conduction between personality is consistent with several psychologi- brain areas and circuits (LeDoux, 2003). Mental cal theories, including relational theory (Mitchell, illness is characterized by thwarted neural growth. 1988, 1997) and attachment theory (Schore, 2000). What causes circuit disorder in the brain? Some Healthy relationships between people produce scientists and practitioners trace the damaged cir- mentally healthy people. In contrast, disturbed cuit wiring in the brain to early attachment issues relationships lead to mentally unhealthy indi- and parenting and to the individual’s contact with viduals. Poor interpersonal relationships produce his or her surrounding environment (Arden, 2010; disorders of the social brain. Because the brain is Cozolino, 2010; LeDoux, 2003; Siegel, 2010). Even an organ that adapts to its environment, one can though these early relationship issues are highly change brain circuitry through relationships. significant, most neuroscientists contend that the Cozolino (2010) asserts that optimal sculpting faulty circuit wiring in thedistribute brain can be changed of the prefrontal cortex shapes our sense of our- with the appropriate psychotherapy interven- selves, our trust in tions (Arden, 2010; Davidson & Begley, 2012). Inner Reflection others, our intellec- Neuroscientists orassert that only human beings can tual and emotional help heal other humans. As Cozolino (2010) has In your opinion, does intelligence, and our stated, “Human brains have vulnerabilities and labeling a mental illness ability to regulate our weaknesses that only other brains are capable of as a brain disorder emotions. He also mending” (p. 307). An individual’s mental health increase or decrease its maintains that the is then connected to the quality of human relation- stigmatizing effect? “Polyvagal Theory of ships that he or she experiences. The emerging para- Social Engagement” post,digm of neuropsychotherapy explains scientifically permits people to individuals’ behavior, which was previously only seek closeness to others without activating their “guessed about” in other schools of psychotherapy. fight-or-flight responses. When a person has good vagal regulation, one may become angry, upset, or THE THERAPEUTIC PROCESS____ anxious with a loved one without withdrawing or becoming physically aggressivecopy, toward them. The Therapeutic Relationship From a Neuroscientific Perspective Maladaptive Mental Neuroscience offers a new conceptual frame- Behavior and Mental work for clinicians’ understanding of what takes Disorders asnot Brain Disorders place during the therapy hour. Therapy involves a clinician’s assisting clients to restructure old neural The Decade of the Brain redefined mental pathways and to build new ones to help them deal disorders as brain disorders. During this historical with their challenges and to lead a more satisfying renaissance,Do neuroscientists focused on uncovering life. When one uses the neuroscience conceptual the brain processes involved in such disorders, and framework, talk within the therapy hour becomes neuroimaging became the dominant tool in such much more purposeful and intentional rather than investigations (Brockman, 2002). Neuroimaging hit or miss. The therapist is intentionally helping

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Copyright ©2016 by SAGE Publications, Inc. This work may not be reproduced or distributed in any form or by any means without express written permission of the publisher. clients to engage in the process of neuroplasticity. what their clients are Inner Reflection Therapy may be considered successful to the extent saying about their that therapists are able to help create a therapeutic life situations, and Should the therapist be experience that results in creating neuroplasticity especially what they interested in fostering for clients (Cozolino, 2010). are saying about therapeutic attachment Neuroscience can be used to help a therapist themselves, such as with clients? Why or why conceptualize what is happening in a client’s brain. their difficulty trust- not? From the neuroscience worldview, psychotherapy ing others, problems is an interaction between two human brains and in establishing and the neural pathways that therapist and client have maintaining relationships, low self-esteem, or poor created for themselves as a result of the interaction anger management. Helping professionals must between their genetics and their life experiences. understand that the already established neural net- Additional support for this conceptualization is works in their clients’ brains are based on their own provided by Beitman and Viamontes (2006), who life experiences. If clients do not have an established described the therapeutic relationship as “a rela- network for something, then they do not have a ref- tionship between two brains and their bodies” erence point for change. As clinicians identify clients’ (p. 214). Both neuroscientists and clinicians have neural networks, they can then begin to consider maintained that therapists can help a client develop experiences that mightdistribute help them build new neural new neural pathways as a result of establishing a networks that are more satisfying and less problem- caring and safe therapeutic relationship that com- atic. Clinicians might consider experimenting with municates that they understand and accept him or brain sensoryor inputs such as art therapy, music ther- her unconditionally (Hanson, 2013; Kandel, 1998, apy, therapeutic stories, and psychodrama. Sensory 2007; Siegel, 2010). inputs tend to engage clients’ neural networks to The therapeutic relationship can “enhance become active and open to learning new informa- or replace an attachment relationship, based on tion. It is important that clients feel that they are how the right brain develops (the hemisphere that in control of changing the neural networks in their controls emotions) and continues to function in brains. adulthood” (Farmer, 2009, p. 122). Therapeuticpost, How might a therapist help clients see a con- attachment facilitates neural restructuring in the nection between their own brains and what they right brain of clients (Farmer, 2009). In working are working on in therapy? Both Cozolino (2010) with clients, therapists deal with more than just and Hanson (2010) have pointed out that when a negative emotions, self-imposed limits, and bad therapist translates psychological issues into neural memories. When therapists are engaged during the terms, such issues become demystified, normal- therapy hour, they deal with the very strategies that ized, and de-stigmatized. The client is taught to their clients use to encountercopy, and cope with life. recognize how the neural networks associated Clients generate neurological pathways of behavior with the amygdala, for instance, bring about states in their brains. They even become addicted to their of fear and anger. It is not that the client is crazy own brain chemicals as they repeat again and again or weird but rather that the client might have to life strategiesnot that may not have been working for deliberately and intentionally change the wiring of a long period of time. In essence, clients become his or her neural networks by having new affirming addicted to their behavioral strategies that they life experiences not built on fear (Arden, 2010). use for living. Neural restructuring can change a Doperson’s habitual neurological pattern of behavior. Goals of Neuropsychotherapy The first step in helping clients change their neural networks is to identify them. To achieve this The neuroscience perspective maintains that goal, clinicians must engage in deep listening to therapy is a matter of helping clients to build new

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Copyright ©2016 by SAGE Publications, Inc. This work may not be reproduced or distributed in any form or by any means without express written permission of the publisher. positive neural pathways that emphasize clients’ clients’ interpersonal Inner Reflection strengths and to repair or extinguish neural path- relationships on their ways that impair clients’ functioning in their inner emotions and behav- Could you ever see and outer worlds (LeDoux, 2002). An important ior (Grawe, 2007). A yourself becoming a goal is to activate positive emotions and deactivate neuropsychothera- neuropsychotherapist? negative ones. pist uses a multidis- Another goal of neuropsychotherapy is to help ciplinary approach to clients integrate their brains, especially the two working with clients. A neuropsychotherapist is cerebral hemispheres, the neural circuits, and their one who understands the different levels of a per- functioning. According to Siegel (1999), neural son’s being and conducts therapy within a neuro- integration is basic to self-organization and to the biopsychosocial framework. ability of the brain to create a sense of self. Tucker, Kandel (2006) has suggested that client care Luu, and Pribram (1995) have suggested that inte- is the therapist’s most important responsibility. gration within the brain may deal with specific Therapists must develop an understanding of anatomic circuits: (1) vertical, (2) dorsal–ventral, the neuropsychological principles that govern and (3) lateral. not only their own behavior but also that of their A client’s autobiographical narrative can reveal clients. Therapists whose practice is informed by integration or incoherence. A client evidences a neuroscience learn how distributeto cultivate their client’s coherent autobiographical narrative when his or neuroplasticity. They must also be conscious of cre- her narrative reflects a blending of left- and right- ating mirror neurons when working with clients. hemisphere processes. When a client has limited Therapy shouldor produce new pathways of neural access to the right hemisphere’s representational firing through the creation of a safe therapeutic processes, his or her autobiographical narrative environment and a corrective emotional experi- may be incoherent. In contrast, when an indi- ence (Allison & Rossouw, 2013). One role for a vidual is able to draw on the right hemisphere, therapist is to help a client down-regulate his or the left brain is able to make sense by integrating her stress response so that new patterns of neural a coherent life story. Integration of left- and right- activation can take place. The therapist provides hemisphere processes produces coherent client post,an environment in which a client’s basic needs narratives (Siegel, 1999). for safety and control are met so that a shift can take place from client patterns of avoidance and protection to patterns of approach. As Allison and Role of the Neuropsychotherapist Rossouw (2013) have stated, Who Is a Neuropsychotherapist? copy, New neural patterns can be activated by down regu- A neuropsychotherapist may be defined as a lating the stress response and enhancing the basic psychotherapist (who may be eclectic or prepared needs of attachment and control. Safety is thereby educationally in a specific theoretical school of facilitated through the development of new neural psychotherapy) who uses neuroscience to enhance pathways that shift unhelpful patterns of thinking, his or her psychotherapeuticnot interventions. A feeling, and behaving. (p. 22) neuropsychotherapist has a solid knowledge of the neurobiological foundation of individuals’ Cozolino (2010) has maintained that a thera- mental states and behavior. The ideal neuropsy- pist can use neuroscientific principles to improve chotherapistDo has substantial insight into the activ- therapy by (a) using multiple means to influence ity of a specific neural network involved with, for the brain, (b) choosing and combining different example, a client’s fear, as well as a cultural and treatments for clients, (c) educating clients about environmental understanding of the impact of brain functions, (d) encouraging the rewriting of

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Copyright ©2016 by SAGE Publications, Inc. This work may not be reproduced or distributed in any form or by any means without express written permission of the publisher. self-narrative by honoring the malleability of mem- (Fossati et al., 2003).Therapists’ interpretations that ory, and (e) emphasizing optimism and growth as emphasize the negative circumstances of a client’s possible outcomes of satisfying relationships. life stimulate anxiety, while positive statements stimulate relaxation. Put in an alternate way, if a What Happens If a Therapist therapist focuses on a client’s strengths (strengths- Focuses on a Client’s Negative Life Events? based therapy), the client will begin to experience a sense of peacefulness in herself or himself as well For decades, therapists have focused on their as toward others. The client’s thalamus responds clients’ problems and negative life events. The belief to the therapist’s incoming message of strength was that it was therapeutic for therapists to spend instead of weakness, and it then relays this message hours talking about a client’s negative reactions to the rest of the brain. As a consequence of the to his or her father or about a client’s feelings of strength message, the client is likely to experience being left out and ridiculed as a child and as an the release of pleasurable brain chemicals such as adolescent. Yet recent research in neuroscience has dopamine, the reward system of the brain will be indicated that such a focus may harm rather than stimulated, and client anxiety and self-doubts are help clients (Seligman, Steen, Park, & Peterson, likely to dissipate (Brassen, Gamer, & Buchel, 2011; 2005). The very moment a person or a therapist Fredrickson, 2009). expresses even the slightest degree of negativity, a Concentrating distributeon a client’s strengths to deal sense of negativity is increased in both the speaker’s with life challenges causes a client’s body to relax. and the listener’s brains (Fredrickson, 2009). Strengths-based therapy stimulates a client’s neo- Negative words or even repeatedly uncovering cortex. Repeatedor highlighting of client’s strengths or analyzing the negative events in a client’s life may may even increase the thickness of the neocortex only serve to remind clients of their failures and and shrink the size of the client’s amygdala, the inadequacies. Clients become mired down in the fight-or-flight response mechanism in the brain therapeutic quicksand of “My mother never loved (Newberg & Waldman, 2013). me,” “No one on both sides of my family liked me,” or “I was always considered a problem child.” When therapists have clients continually rehearse thepost, neg- Role of the Client ative circumstances of their lives, they send alarm The role of the client in neuropsychotherapy is messages to the client’s brain—the amygdala. The similar to that for the other theoretical perspectives quicker therapists are able to stop talking about the discussed in this book. A major difference may lie client’s negative life events, the more readily they in the tools that a neuropsychotherapist might use, are able to generate a sense of safety and well-being such as neuroimaging. Clients may also be asked within the therapy hour. Newberg and Waldman to be open to using the expressive arts and other (2013) have explained thatcopy, if you focus on a word sensory techniques to engage the right hemisphere such as peace or love, the emotional centers in of their brains. In addition, therapists who actively the brain become calm. Even though the outside use neuroscience techniques also recommend world has not changed, you feel safe and secure that clients engage in the practice of mindfulness just by focusing on these words. This illustration not (Hanson, 2013). demonstrates the neurological power of positive thinking, which has been supported by hundreds of well-designed studies. Therapy as Right-Brain DoWhen therapists work with clients to reframe to Right-Brain Interaction negative thoughts and worries into positive affir- mations, the therapeutic process improves, and Neuroscience has helped reconceptualize the client regains self-control and confidence therapy as partly a process that involves both

CHAPTER 20 NEUROSCIENCE, PSYCHOTHERAPY, AND NEUROPSYCHOTHERAPY 655

Copyright ©2016 by SAGE Publications, Inc. This work may not be reproduced or distributed in any form or by any means without express written permission of the publisher. left-brain to right-brain and right-brain to right- as right-brain to right-brain therapy because he or brain interaction between the therapist and the she has to be able to conceptualize and label what client. Therapists have changed not only what they is taking place within the client and during therapy. think about therapy but also what they believe hap- Schore (2003) has emphasized right-brain to right- pens during therapy and how they can influence brain therapy because it serves as a counterbalance the therapeutic process. For instance, from the to the dominance of the left brain in therapists’ early days of Freud, psychotherapy has been pri- usual dealings with clients. The focus is on the cli- marily about using words—a left-brain process— ent’s feelings and emotions and on the therapist’s designed to effect changes in a client’s emotions and becoming an adoptive attachment figure for the way of viewing the world and what has happened to client. The therapist relates to the client so as to him or her. For several decades, especially after the foster the development of a secure attachment. The cognitive force in psychotherapy, the major focus belief is that what heals a client who has negative in therapy was designed to help clients think about attachment experiences is the relationship with the their irrational ideas, their negative emotions. therapist. Therapists now understand the biology of Schore (2003) has used right-brain to right- emotions and feelings (Schore, 2003). From brain- brain therapy to describe a therapist’s dealing with based studies, they have uncovered what feelings deep emotional issues—especially early-attachment are located in what parts of the brain, as well as issues. According to him,distribute the right hemisphere what neural substrates continue to support such of the brain stores the 3 Rs, rationality, regula- feelings. The left hemisphere primarily engages tion of affect, and resilience—factors that become in logical thinking, whereas the right hemisphere the foundation orof a person’s sometimes lifelong deals with one’s emotions. exploration, learning, and growth. Neural patterns Neuroscience provides a framework for right- of these 3 Rs are created by the time a child is 18 brain to right-brain therapy. It points out that what- months old, and they remain fairly unchanged ever we turn our attention to will cause a neuron to well into a person’s early adulthood (Schore, 2003). fire. When the therapeutic relationship becomes a Using research from neuroscience, Schore (2003) point of a client’s and a therapist’s focal attention, has asserted that the experiences that we have with brain change within the client becomes possible. post,early significant caregivers are important because When the therapist and client are engaged in they establish subsequent behavioral patterns. moment-to-moment relational-emotional experi- From these early experiences, we learn that our ence, this process will help the client’s brain to build needs and feelings are either important or not—that new implicit and explicit memory patterns regard- we should approach or avoid people and the chal- ing the experience (Siegel, 2010). For instance, lenges of life. the client develops a visual image of his therapist When early attachment experiences are smiling at him with respect, appreciation,copy, and com - repeated over and over again, they cause neurons passion. This relational experience becomes real, is to fire and neural pathways to develop—thereby encoded into implicit memory, and, if repeated a making it more likely that with similar or even new sufficient number of times, replaces the old, disor- experiences these same neurons will fire once again dered patterns ofnot relationships. in the same patterns that strengthen the old neural Right-brain to right-brain therapy refers to circuits and networks of the three Rs—relationality therapy that is attachment based. The therapist (relationship issues), regulation of affect, and resil- uses emotion-focused techniques to activate and ience. That is, the brain stabilizes our experiences rewireDo the early unconscious patterns processed into patterns of neural firing that determine how and stored in the right hemisphere of the brain we respond to future new experiences. when such patterns are unhealthy. In reality, a Essentially, right-brain to right-brain ther- therapist has to use left-brain to right-brain as well apy creates new experiences and installs them

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Copyright ©2016 by SAGE Publications, Inc. This work may not be reproduced or distributed in any form or by any means without express written permission of the publisher. Inner Reflections as new thought and reduce/eliminate old neural pathways: These behavior patterns. are essentially techniques that are designed to How comfortable are you The therapist can make changes in the brain—thought stopping, with the concept of right- use techniques from positive reinforcement for new behavior, and so on—and are already broadly in use. brain to right-brain therapy? the four other forces of psychotherapy to 2. Techniques related to the therapeutic relation- Should therapy be right engage in right-brain ship: This involves the model of compassionate brain to right brain? to right-brain ther- communication (Newberg & Waldman, 2013). apy. Using a psycho- 3. Techniques that involve the integration of the dynamic framework, right and left hemispheres of the brain, the wheel the therapist can use clients’ dreams, which typi- of emotional awareness: This helps clients to cally have deep relational, emotional, and meaning build their attention strength and stimulates content for them, coming from primary processing. neuronal activation and growth to promote The therapist can use the Gestalt technique of the linkages (what Siegel, 2010, called Mindsight empty chair to gain entry to early implicit memory techniques). and later explicit memory. In right-brain to right- 4. Techniques related to the client’s emotional brain therapy, it is important that the therapist state—increasing balance, harmony, and hope. remembers that imagining a thing, for instance, Hope is alwaysdistribute critical. Strengths-based tech- imagining food or a chair or someone loving the niques are also important to lower a client’s client, in one’s visual cortex fires the same neurons defenses and to increase his or her motivation as experiencing it, that is, seeing food or having to orproduce the desired change. someone love one. Using knowledge gathered from the findings on neuroplasticity, the therapist helps Mindsight Techniques the client to rewrite his or her life and to rewire his or her brain. Right-brain therapeutic experiences To develop neural resonance with clients, help clients to rewire the patterns found in the Siegel (2010) suggests that therapists use an exer- inner experiences of the self. cise called the “wheel of awareness” (p. 94), which post,is a metaphor for how a person can become aware of any element in his or her inner or outer worlds. Methods and Techniques The goal is to increase the therapist’s awareness for Neuropsychotherapy of where he or she is with the client at any given There are few established methods and tech- moment during therapy. “The therapist can then niques that have been designed specifically for focus attention (the spokes) on any element of the neuropsychotherapy. Typically,copy, researchers borrow rim. After the therapist reaches a point of inner techniques from the other four forces of psycho- peace (using mindfulness techniques associated therapy. This author asserts that one can glean with the wheel of awareness), he or she can then neuroscientific methods of psychotherapy from work with the client on ‘SNAGging’ the brain— the existing literature. Two such exceptions to stimulating neuronal activation and growth—to this statementnot are Mindsight by Siegel (2010) and promote differentiation and then linkage” (p. 98). Hanson’s HEAL approach to neuropsychotherapy. Therapy techniques for neuropsychotherapy can be HEAL Strategy grouped into the following categories: Do “Taking in the good” is a strategy that helps 1. Techniques related to the brain—techniques clients focus on the positivity in their lives. To designed to increase mirror neurons and neural assist clients with taking in the good in their lives, resonance, create new neural pathways, and Hanson (2013) has developed the acronym HEAL,

CHAPTER 20 NEUROSCIENCE, PSYCHOTHERAPY, AND NEUROPSYCHOTHERAPY 657

Copyright ©2016 by SAGE Publications, Inc. This work may not be reproduced or distributed in any form or by any means without express written permission of the publisher. where H = positive experience, E = enrich it, Eye Movement Desensitization A = absorb, and L = link it with positive and nega- tive experiences. Step 1 activates a positive mental and Reprocessing state in the client, while Steps 2 to 4 help install EMDR is a neurologically based therapy taking in the good in a client’s brain. The therapist approach that Francine Shapiro (1995, 2001) devel- asks the client to notice a positive experience in oped to resolve traumatic events, such as rape, his or her life. For instance, the therapist might ask and negative experiences in combat, as well as the client to think about something for which he other disturbing, unresolved life issues. It is an or she is grateful or to think about a job that was integrative approach that includes elements of performed well. In Step 2, the therapist requests psychodynamic, cognitive-behavioral, interper- that the client stay with that experience for 5 to 10 sonal, experiential, and body-centered therapies. seconds so that positive feeling is felt throughout EMDR psychotherapy is an information-process- the client’s body. As the client thinks about the ing therapy that uses eight phases to address vari- experience and enriches it, neurons begin firing ous mental health problems (see www.emdr.com/ together so that they will wire together. Step 3 general-information/what-is-emdr.html). involves absorbing that experience. In Step 4, the The eight phases of treatment using EMDR client is asked to link the positive and negative are as follows: material. Hanson (2010) states, distribute Phase 1—History-taking sessions: The therapist For example, when you feel included and liked assesses the client’s readiness for EMDR and devel- these days, you could sense this experience making ops a treatmentor plan. The treatment plan deals contact with feelings of loneliness from your past. with recent distressing events, current situations If the negative material hijacks your attention, drop that elicit emotional disturbance, related historical it and focus only on the positive. . . . Whenever you incidents, and the development of specific skills want, let go of all negative material and rest only in and behaviors that will be needed by the client in the positive. (p. 63) future situations. post,Phase 2: The therapist makes sure the client has The pairing of the positive and the negative sufficient methods for handling emotional distress helps uproot the neural pathways that have been and that the client is in a relatively stable emotional wired together because of repeated negative life state. experiences. Phases 3 to 6: A target is identified and processed using EMDR techniques that involve the client identifying the most vivid visual image related to RECENT BRAIN-BASEDcopy, the memory, a negative belief about the self, related emotions, and body sensations. The client identi- THERAPIES: EMDR, fies a positive belief, which is rated, and so is the COHERENCE THERAPY, intensity of the negative emotions. AND BRAINSPOTTINGnot ______Following this, the client is asked to focus on the Although there is no universally recognized theory image, negative thought, and body sensations while at the same time moving his or her eyes back and of neuropsychotherapy, several new brain-based forth, following the therapist’s fingers as they move therapies have emerged that could be included across his or her field of vision for 2 to 30 seconds underDo the neuropsychotherapy paradigm, includ- or more, based on the client’s needs. In addition to ing EMDR, coherence therapy by Bruce Ecker and using eye movements, the therapist can also use colleagues (2012), and brainspotting therapy by auditory tones, tapping, or other types of tactile David Grand (2013). stimulation. The therapist tells the client to notice

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Copyright ©2016 by SAGE Publications, Inc. This work may not be reproduced or distributed in any form or by any means without express written permission of the publisher. whatever happens and then to let his or her mind symptom. Usually, 12 sessions are necessary for the go blank and to notice whatever thought, feeling, client to obtain complete relief from the symptom image, memory, or sensation comes to mind. (Ecker & Hulley, 2006). Ecker et al. (2012) maintain that memory When the client reports no distress related to the reconsolidation is the brain’s only known process targeted memory, the clinician asks him/her to capable of erasing an emotional learning. This think of the preferred belief that was identified theoretical approach guides clients to retrieve at the beginning of the session . . . while simul- taneously engaging in the eye movements. After implicit, emotional learnings into awareness. One several sets, clients generally report increased benefit of coherence therapy is that it does not confidence in this positive belief. (Shapiro, 2001) pathologize a person’s presenting symptoms. They are just implicit memories that need to be reacti- Phase 7—Closure: The therapist requests that the vated and, immediately after the reactivation, taken client keep a journal during the week to document through a process of memory reconsolidation. any related material that may arise and suggests that Ecker and colleagues contend that our knowledge he or she use the self-calming techniques taught of memory reconsolidation will create transfor- during Phase 2. mational change for therapy and could serve as a Phase 8: It involves reevaluation of the prior work unifying framework for psychotherapy integration. and progress. After EMDR therapy, clients have said The authors call fordistribute brain imaging studies to pro- that the emotional distress related to the memory vide empirical evidence for coherence therapy and has been eliminated or greatly reduced. memory reconsolidation.or EMDR has been supported in clinical trials Brainspotting for the treatment of posttraumatic stress dis- order. Because of its positive clinical findings, According to David Grand (2013), brainspot- EMDR is listed as an evidence-supported therapy ting therapy evolved from his work using EMDR by the American Psychiatric Association (2004). in his private practice. It is a focused treatment that In 1995, a professional association—the EMDRpost, works by International Association, independent from Shapiro—was founded, and it established stan- identifying, then processing, and releasing core dards for training and practice. neurophysiological sources of emotional/body pain. It is believed that brainspotting taps into and har- nesses the body’s innate self-scanning capacity to Coherence Therapy process and release focused areas (systems) which are in a maladaptive homeostasis (frozen primitive Coherence therapy iscopy, an experiential system of survival modes). (See https://www/brainspotting psychotherapy that gives memory reconsolidation .pro/page/what-brainspotting) a central role. In fact, the steps of coherence therapy follow closely those outlined for the memory recon- A brainspot is the eye position connected to solidation processnot by brain researchers. The thera- the emotional activation of a traumatic/emotion- peutic process for coherence therapy is experiential ally charged issue within the brain, most likely in rather than analytic (Ecker et al., 2012). The goal of the amygdala, the hippocampus, or the orbito- this form of brain-based therapy is to have the client frontal cortex of the limbic system. A brainspot Doexperience during therapy personal constructs that is “actually a physiological subsystem holding underlie the unwanted symptom and to undergo emotional experience in memory form. When a a natural process of revising or dissolving those brainspot is stimulated, the deep brain reflexively constructs, thereby terminating the existence of the signals the therapist that an area of significance has

CHAPTER 20 NEUROSCIENCE, PSYCHOTHERAPY, AND NEUROPSYCHOTHERAPY 659

Copyright ©2016 by SAGE Publications, Inc. This work may not be reproduced or distributed in any form or by any means without express written permission of the publisher. been located” (see https://www/brainspotting.pro/ published its newest revision of the Diagnostic page/what-brainspotting). Although brainspotting and Statistical Manual of Mental Disorders (fifth typically takes place outside of a client’s awareness, edition, DSM-5), the major manual for diagno- there are a number of reflexive responses that indi- sis in the world, which replaced the DSM-IV-TR cate a brainspot has been located. These reflexive (fourth edition, text revision, 2000). The DSM-5 responses include eye twitches, blinks, pupil dila- is based on the same principles that the American tion, facial tics, yawns, foot moving, and body Psychiatric Association has followed for a number shifting. The brainspot can be accessed and stimu- of editions of this manual. The DSM system has lated by holding the client’s eye position while the limited validity because it is supported by few client is focused on the problem being addressed studies verifying its diagnostic categories. The in therapy. Therapy is directed to activating, locat- DSM system uses consensus by groups of clinicians ing, and process- to establish validity rather than clinical research Inner Reflection ing the brainspot. data. It lacks neurobiological data to support its Oftentimes, clini- diagnostic categories. Of the three brain-based cians use biolateral Just prior to the release of the DSM-5, the therapies discussed in sound CDs because National Institute of Mental Health (NIMH—the this section, for which one biolateral sound world’s largest funding agency for research into would you like to have enhances the brain’s mental health) withdrewdistribute its support from the additional training? processing abilities. manual. Thomas Insel, the director of NIMH, There are more stated that the institute will no longer fund any than 5,000 people research projectsor that rely on DSM criteria and that who have been trained in brainspotting. According the institute will be “re-orienting its research away to the Brainspotting website, from DSM categories” (see NIMH, http://www. nimh.nih.gov). The official statement from NIMH Brainspotting is a “body to body” approach. The (2013) was that the DSM-5 only offers “fumbles distress is activated and located in the body, which and errors” and that “symptom-based diagnosis then leads to the locating of the brainspot based once common in other areas of medicine has been on eye position. As opposed to EMDR where the post,largely replaced in the past half century as we have traumatic memory is the target, in Brainspotting, understood that symptoms alone rarely indicate the the brainspot is the target or “focus or activation best choice of treatment.” point. Everything is aimed at activating, locating, or processing the brainspot. (See https://www/ The NIMH (2013) suggested an approach brainspotting.pro/page/what-brainspotting) based on developments in neuroscience and on brain-based research that was founded on the fol- lowing assumptions: NEUROSCIENCE ANDcopy, THE DSM-5______• A diagnostic approach should be based on the biology, and symptoms must not be limited by Neuroscience and Challenges to the current DSM categories. not • Mental disorders are biological disorders involv- Diagnosing Mental Disorders— ing brain circuits that implicate specific domains the DSM of cognition, emotion, and behavior. • Each level of analysis should be understood The pervasiveness of neuroscience can be seen across a dimension of function. in theDo implicit challenges it is posing for the entire • Mapping the cognitive, brain circuit and genetic diagnosis of mental disorders. For instance, in May features of mental disorders will produce new 2013, the American Psychiatric Association (2013) and better targets for treatment.

660 PART V THE FIFTH FORCE IN PSYCHOTHERAPY

Copyright ©2016 by SAGE Publications, Inc. This work may not be reproduced or distributed in any form or by any means without express written permission of the publisher. RESEARCH AND EVALUATION___ subjects showed lower neural activation in this part of the brain. Citing a number of studies, Blanding Cultural Neuroscience (2010) concluded that cultural interactions pro- duce certain patterns of neurological responsivity and Multiculturalism that are reflected in brain imaging procedures. Cultural neuroscience is an interdisciplin- Moreover, neuroscience has provided some ary field of study that investigates the relation- insight into how one’s race influences perceived ship of culture, biology, brain functioning, and racial group trustworthiness (Stanley et al., 2012). psychology as well as Within the brain, the striatum and amygdala are other social science the regions of the brain involved in trust decisions Inner Reflections areas. Cultural neu- and trustworthiness estimation. The investigators roscience is begin- used BOLD, blood oxygenation level–dependent In your opinion, should ning to challenge the activity, while individuals completed a series of the DSM-5 be discarded or long-held belief that single-shot trust game interactions with real part- simply revised? biological processes ners of varying races. They found that White/ How useful is the DSM-5 that take place in the White and Black/Black groups produced greater for working with clients? brain are the same levels of trust while Black/White groups produced for all people regard- far less trust. Black-versus-Whitedistribute partner combina- less of their culture. tions produced greater activity in the amygdala, the Blanding (2010), however, has reviewed stud- emotional alarm center of our brains. ies that seem to suggest that the results of brain Clearlyor it would seem reasonable to expect imaging results (fMRIs) for American and Indian that culture does have an impact on the brand. The students who listened to classical music varied. verdict is out regarding whether or not individuals The brain imaging results for this group revealed from Western cultures have a brain organization different patterns of neural activation in different pattern that favors the left as opposed to the right parts of the brains of the American students versus hemisphere, whereas just the reverse is held true for their Indian counterparts. individuals from Eastern cultures. Some Eastern An examination of brain imaging resultspost, for cultures emphasize meditation and yoga, practices subjects from Japan and the United States revealed that function to calm the brain and, specifically, the that the fMRI results of persons from the United amygdala. Could the greater emphasis on individu- States reflected significantly higher activation in alism, for instance, explain Western societies’ high the analytical brain regions while the Japanese rate of violent crimes?

CASE ANALYSIScopy,

Justin and Neuropsychotherapy Justin greetednot his counselor with his familiar “Hi Doc, what are we going to do today?” “Didn’t you tell me that we were going to be working on my brain? It’s all messed up, Doc,” Justin laughed. “We can go on to something else.” “I don’t think that your brain is messed up, Justin. You’ve got a good brain. You’re smart; you can draw; you can do a lot of different things with your brain, Justin. What I want us to work on today is increasing your knowledge Doof what is happening in your brain when it is functioning well and what’s happening when it’s not working so well. (Continued)

CHAPTER 20 NEUROSCIENCE, PSYCHOTHERAPY, AND NEUROPSYCHOTHERAPY 661

Copyright ©2016 by SAGE Publications, Inc. This work may not be reproduced or distributed in any form or by any means without express written permission of the publisher. (Continued)

So I brought in two things that I want to share with you. The first thing I want to do is to show you a brief video by Dr. Daniel Siegel on the teenage brain, even though you’re not quite 13 yet. The video is about 7 minutes long, and in it, Dr. Siegel uses his hand in a useful way to think about the brain. He also talks about what goes on in the brain of teenagers, why they make what seems like some crazy choices—doing things that if they had a moment to think about the situation, they might not do. Then the second thing I’d like for us to do is to look at the model of the brain that I have on my desk and maybe engage in an exercise or two, depending on the time that we have left. How does that sound to you? Do you think you would like to do these things today?” “Sure, I’m game. You know, Doc, I don’t mind looking at a video and talking about it.” “Ok. But before we look at the video, I would like to get your thoughts about why there is sometimes friction and conflict between teenagers and their parents and teenagers and other aspects of our society—like school,” the counselor said. “Oh, that’s easy,” Justin replied. “It’s like . . . it’s like they’re always telling us what to do—like do your homework, wash the dishes, stop watching so much TV, get up early enough so that you’re not late for school, and so on and so on. It never stops. It’s like we don’t have a mind of our own. They don’t trust us to do the right thing.” “So you feel as if you are not given an opportunity to make up your own mind aboutdistribute things, that adults don’t trust you to make the right decisions,” the counselor interjected. “Exactly,” Justin said, shaking his head. “I know that my mom doesn’t trust me. I can look at her eyes and see that she is probably thinking, ‘You’re not going where you said you were going.or You tell me anything just to get out of the house.’ And sometimes she’s right. I want to be with my friends. I don’t want to be treated like some kind of a ‘Momma’s boy.’” “Well, Justin, the video raises some of the same issues that you just mentioned. Let’s watch it for 7 minutes and get your reaction to it,” the counselor said. The video showed Dr. Siegel putting his hand in the way to simulate the brain. He described how certain parts of the brain dealt with strong emotions, such as anger and fear. The amygdala was implicated for fear and angry responses to events. The video raised the question aboutpost, why young people sometimes make such poor decisions. The video pointed out that during adolescence, the brain is experiencing a massive and necessary integration of functions that will have a long-term effect, that a young man’s solidarity with his peers was evolutionary insofar as young people banded together because they understood that down the line, they would be living in a world with their friends and peers. The shared experiences that adolescents have with each other enables their generation to become leaders. Adolescents are at the peak of their creative powers and courageousness. Furthermore, Siegel mentioned the four qualities of the adolescent mind: novelty seeking, social engagement, increased emotional intensity, and creative exploration.copy, After viewing the video, Justin said, “Wow, I didn’t know that’s why I do some of the crazy things that I do.” The counselor responded, “What do you mean, Justin? Can you elaborate a little more about ‘why you do the crazy things that you do’?” “Well, things notlike what got me in trouble with the law and got me sent to you. My friends came by my house, and they wanted to go to the mall. I wanted to be with them. I didn’t want to stay at home with my mom. We were going to go out and have some fun. I had no idea that that fun would land me in jail; otherwise, I would have stayed at home.” Do“We were in Walmart, and one of my friends said, ‘Let’s see if we can steal something and get away with it.‘ None of us had any money. At first, I thought that it was crazy. I could see the cop standing near the exit of the store, and I thought, ‘Are you crazy? We could get caught.’”

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Copyright ©2016 by SAGE Publications, Inc. This work may not be reproduced or distributed in any form or by any means without express written permission of the publisher. “Then my friend said, ‘Chick, chick, chick; you’re just chicken, Justin.’ So he stole something. I’m not even sure what he stole; and a store detective told him to put it back. He didn’t, and we all ran out of the store. The cop ran after us, and we were caught and put in jail.” “How are you connecting what happened to you at the mall and the video, Justin?” “Well just like the video said, young people like to be with their friends, and sometimes they will do things in groups that they wouldn’t do if they were by themselves. I wanted my friends to like me. It was exciting that they invited me to go to the mall with them. I felt that I was finally doing something different from what I usually do at home.” Justin sighed, remembering the sequence of events that had landed him in trouble. “Maybe if I hadn’t run,” Justin said. “Maybe I should have told my friend that I was leaving because I didn’t want any part of the stealing. . . . It all happened so fast.” “What you’re saying to me is that if you had been alone, what happened would never have happened. You wanted your friends to like you, and you made the poor choice of sticking with them when you knew that one of them was going to steal something on a dare.” “You’ve got it, Doc. I should have never gone out with them that night. I knew that Darren had been caught stealing at the mall a year ago. Still, I went with them.” “Choices,” the counselor responded. “We all make some bad choices in our lives that we wish we had never made. You can’t undo any of the choices you’ve already made. You have to movedistribute forward, Justin.” “We’re running out of time, and I want to make sure that you get an opportunity to look at the brain model on my desk. Remember, Dr. Siegel spoke about where fear is located in the brain? Well here’s where the amygdala is located, and when it is stimulated in fear or anger, our emotions can getor out of control. This is the part of the brain that Dr. Siegel called our older brain, the reptilian brain. Here, put your hand on the reptilian brain. Sometimes when our emotions are out of control, it’s because the reptilian brain has hijacked the front part of our brain—the prefrontal cortex. The next time you find yourself becoming so angry that you just want to hit someone, say to yourself, ‘I’m not going to let my old brain hijack my thinking.’” Justin said back in his chair and put his hands behind his head, as if he had just received a new insight. “Before, I thought that I couldn’t do anything about my anger. Next time I get real angry, I am going to put my hand on the back of my brain and say, ‘You’re not going topost, hijack me, not today.’”

SUMMARY______functioning, and what happens during the therapy hour when therapists and clients work together A dominant theme throughout this chapter is that to change old, default, and oftentimes destructive the human brain is a socialcopy, brain that depends patterns of behavior. on the quality of its relationships with people and The chapter began with a brief overview of key the surrounding environment. The neuroscience contributors who linked neuroscience and psycho- approach to psychotherapy has a strong environ- therapy. Therapists tend to use two patterns for mental emphasis,not and it is one that encourages a incorporating neuroscientific knowledge into their wellness orientation for helping professionals and practice: (1) they may retain their usual theoretical their clients. framework (psychoanalysis, cognitive-behavioral, Neuroscience has provided scientific explana- social constructivist, etc.) or (2) they may turn to Dotions of therapist and client interventions that were developing a new approach that can best be labeled previously not well understood. Neuroscience is neuropsychotherapy. This chapter first identified clearly the fifth force in psychotherapy because key concepts and terms used in neuropsycho- of its scientific findings regarding the brain, its therapy. The rest of the chapter was dedicated to

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Copyright ©2016 by SAGE Publications, Inc. This work may not be reproduced or distributed in any form or by any means without express written permission of the publisher. providing a framework for neuropsychotherapy demonstrates that the single common denomina- that examined factors such as the therapeutic alli- tor to promote change via talking therapies is the ance, the role of the therapist, right-brain to right- therapist’s use of the basic principles of neuro- brain therapy, and the techniques and methods that anatomy. These key principles are the therapist’s prominent neuroscientists have proposed in their (a) activation of the client’s limbic mirror neuron therapeutic practice. The topic of cultural neuro- system, (b) promotion of safety (down regulation of science was discussed to help practitioners think client distress), (c) enhancement of cortical blood about the relevance of brain science for working flow, (d) strengthening positive neural activation with culturally diverse clients. networks, and (e) encouraging healthy social rela- Mental health specialists are experiencing tionships and interactions with one’s environment. an exciting period after the Decade of the Brain. Research has indicated that the so-called talking therapies are more important than was thought pre- SUPPLEMENTAL AIDS______viously. When therapy is provided in an enriched Discussion Questions environment, new patterns of neural activation can be promoted within clients’ brain functioning. 1. In your opinion, what impact, if any, might pres- Studies have found that the therapeutic alliance, ent and future findings in neuroscience have limbic mirror neuron effect, and therapist facilita- on the social justicedistribute movement in counseling tion of safety and client control are critical to pro- and psychotherapy? Do you believe that neu- mote positive neural change in clients. The process roscience findings might highlight the adverse effects of being routinely exposed to increased of positive brain change in clients via therapy or levels of orfamily violence, poor attachment, and counseling is facilitated by the therapist’s activation lack of social support? of the mirror neuron system, enhancing cortical blood flow to enable good solutions to problems 2. Neuroscience findings are being considered and strengthening new activation of neural pat- in dealing with attention deficit disorders in terns to enhance long-term patterns and reduce children and adolescents. Discuss the pros and risk of relapse into default neural protective pat- post,cons of such research. terns that may be destructive in clients’ lives. 3. Let’s suppose that you have just completed your Neuroscience research on mirror neurons master’s degree in counseling or social work. provides one of the most profound indicators of What neuroscientific principles or intervention the interconnectedness of human beings. We are all techniques would you consider using in your connected together in some way through the mir- new private practice? ror neuron process. The talking therapies provide 4. To what extent do you think the value of neu- a safe environment that encourages the building of copy, roscience for psychotherapy is overstated or healthy new neural pathways in clients. However, understated? these new neural networks are usually fragile. To prevent a client from returning to destructive or 5. If you had to choose only one of the neurosci- negative default neural patterns, therapists must entific approaches to psychotherapy, which one promote sufficientnot neural activation toward new would that be and why? patterns of firing so that the default patterns are changed. The therapist’s interventions are guided Glossary of Key Terms by Hebb’s finding that neurons that fire together sufficientlyDo wire together. (Please note that the terms listed below are para- Studies have found that a variety of talking phrased from Brain Facts: A Primer on the Brain therapies can be effective in promoting neural and Nervous System, on the website for the Society change within clients. Grawe’s (2007) meta-analysis of Neuroscience: http://www.sfn.org.)

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Copyright ©2016 by SAGE Publications, Inc. This work may not be reproduced or distributed in any form or by any means without express written permission of the publisher. acetylcholine A neurotransmitter that is active Tucker and Laura Hulley. It is a system of experi- in the brain, where it regulates memory, and in the ential, empathic psychotherapy that uses memory peripheral nervous system, where it influences the reconsolidation techniques, permitting therapists actions of skeletal and smooth muscle. to consistently promote deep shifts, dispelling clients’ symptoms at their emotional roots often amygdala A structure in the forebrain that is in a small number of sessions. The steps of coher- part of the limbic system and that plays a critical ence therapy correspond closely to the steps of the role in emotional learning, especially within the memory reconsolidation process brain researchers context of fear. have identified. brain The human brain is the most complex organ of the human body. It contains an estimated dopamine A catecholamine neurotransmitter 50 to 100 billion neurons. The scientific study of the that assumes various functions depending on brain and the nervous system is called neurobiol- where it acts. Dopamine is believed to regulate key ogy or neuroscience. The brain is part of the central emotional responses, such as reward, in the brain, nervous system, along with the spinal cord and the and it plays a role in schizophrenia and drug abuse. peripheral nervous system. endorphins Neurotransmitters produced in the brain stem The stem-like part of the base of the brain that have cellular and behavioral effects simi- brain that is connected to the spinal cord. The brain lar to those of morphine.distribute stem controls the flow of messages between the forebrain The largest part of the human brain; it brain and the rest of the body, and it also controls contains the cerebral cortex and basal ganglia. The basic body functions such as breathing, swallow- forebrain isor responsible for the highest intellectual ing, heart rate, blood pressure, consciousness, and functions a human can perform. whether one is awake or sleepy. The brain stem con- sists of the midbrain, pons, and medulla oblongata frontal lobe Contains our cognitive thinking, (MedicineNet.com, http://www.medterms.com/ and this process shapes an individual’s personal- script/main/art.asp?articlekey=2517). ity. The frontal lobe is made up of the anterior portion (prefrontal cortex) and the posterior por- cerebral cortex This is the outermost layer ofpost, the tion, and it is separated from the parietal lobe by cerebral hemispheres of the brain and is primar- the central sulcus. Functions of the frontal lobe ily responsible for all forms of conscious experi- include reasoning, planning, organizing thoughts, ence, including perception, emotion, thought, and behavior, sexual urges, emotions, problem solving, executive planning. and judging. cerebral hemispheres The two specialized halves gamma-amino butyric acid (GABA) An amino of the brain that control copy,different brain functions. acid transmitter in the brain whose major function For instance, in right-handed people, the left hemi- is to inhibit the firing of nerve cells. sphere is specialized for speech, writing, language, and math calculations. The right hemisphere is glutamate An amino acid neurotransmitter that specialized notfor visual face recognition, music per- functions to excite neurons. ception, and spatial abilities. hippocampus A sea horse-shaped brain struc- cognition The process that allows a person to ture that is considered an important part of the gain knowledge of or become aware of objects in limbic system. It is one of the most studied areas Dohis or her environment; the person then uses that of the brain; it functions in learning, memory, and knowledge for comprehension and problem solving. emotion. coherence therapy Formerly known as depth inhibition A synaptic message that prevents a oriented brief therapy, was developed by Bruce neuron from firing.

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Copyright ©2016 by SAGE Publications, Inc. This work may not be reproduced or distributed in any form or by any means without express written permission of the publisher. limbic system A group of structures within the reception, visual-spatial processing, movement, brain (including the amygdala, hippocampus, and color recognition. Disorders of the occipital septum, basal ganglia, etc.) that help regulate lobe can cause visual illusions. the expression of emotion and emotional parietal lobe Responsible for integrating sen- memory. sory information from various parts of the body. long-term memory The last phase of memory; it The optic nerve passes through the parietal lobe allows information to be stored that may last from to the occipital lobe. Functions of the parietal lobe hours to a lifetime. include information processing, movement, spatial orientation, speech, visual perception, pain, and memory consolidation The physical and psy- touch sensation. chological changes that occur when the brain organizes and restructures information to make it serotonin A monoamine neurotransmitter that a permanent part of memory. plays a role in temperature regulation, sensory perception, and the onset of sleep. Neurons using neuron May be defined as the electrically excit- serotonin are located in the brain and in the gut. able cells that process and transmit information by Several antidepressant drugs are targeted to brain electrical-chemical signaling. serotonin systems. neuropsychotherapist A psychotherapist who short-term memory Adistribute phase of memory in is thoroughly grounded in the knowledge of the which a limited amount of information is held for neurobiological workings of the brain and other several seconds or minutes. aspects of human biology and who uses this infor- or mation in working therapeutically with clients. synapse The structural space between neurons in the nervous system. neuropsychotherapy A psychotherapy practice that is informed by neuroscience and that is built temporal lobe There are two temporal lobes, on using a multidisciplinary approach that takes located at about the level of the ears on either side into account the whole individual. of the brain. The temporal lobes are responsible for post,auditory processing and are involved in hearing, neurotransmitter A chemical that is released speech, and memory. from a nerve cell that transmits an impulse from one nerve cell to another. Website Materials occipital lobe The smallest of the four brain lobes. It is located in the rearmost portion of Additional exercises, journals, annotated bibli- the skull and contains the primary visual cortex. ography, and more are available on the open-access Functions of the occipital lobecopy, include visual website at https://study.sagepub.com/jonessmith2e. not Do

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Copyright ©2016 by SAGE Publications, Inc. This work may not be reproduced or distributed in any form or by any means without express written permission of the publisher.