The Neuropsychotherapist

the neuropsychotherapist

volume 5 issue 12, December 2017 neuropsychotherapist.com From the Editor

n what seems like a flash, I find I am introducing my second issue of The Neuropsy- chotherapist—and, I can confess, I am loving every moment. As I take over the reins of content management, I look forward to receiving your submissions and Richard Hill suggestions for upcoming issues—an article, something short and fascinating, a Managing Editor Ibook review, or perhaps a person who you believe deserves a spotlight. In this issue, we continue to cover the serious problem of PANDAS. Micaela Monteiro-Haig helps us understand the neurobiological details, and she also covers treatments that, among other things, include recommendations for following an anti-inflammatory diet and guidelines for maintaining gut health. Micaela’s view as a naturopath widens our perspective. We have so much to learn about how to recognise and treat this difficult paediatric condition. We will continue our exploration in future issues. Bob Shebib’s article “Neuroscience and Counselling” takes us on a walk through the brain. It is a great introduction for those beginning to learn and an excellent review for others, including myself. I love the way he creates conversations from clinical practice to illustrate the context and application of the neuroscience he describes. And what do we know about smiling? Our neuroscience short-take gives us a surprising research insight that you might not be expecting. Finally, our last Last Word for the year comes from Terry Marks-Tarlow who reflects on time, which is entirely fitting for our year-closing issue. The Neuropsychotherapist is a great fan of Terry’s work on play, art, and creativity. Take some time to search it out. Which leaves me a few lines to wish everyone connected to The Neuropsychotherapist—whether the editorial team, contributor, or reader—a very happy and relaxing end of year break. We hope that you are encouraged and strengthened as you celebrate your personal, cultural and religious traditions, whatever they may be. May you and your families be well and full of good heart, and may the New Year be all that it can be.

Richard Hill 06 16

2 The Neuropsychotherapist Vol 5 Issue 12, December 2017 the neuropsychotherapist™ CONTENTS Volume 5 Issue 12, December 2017 Features UNDERSTANDING PANS & PANDAS: THE 06 INTERPLAY OF IMMUNE SYSTEM AND MENTAL HEALTH Naturopath and expert in how body systems affect mental health Micaela Monteiro-Haig takes a look at a group of autoimmune disorders that have a profound impact on mental wellbeing— paediatric acute-onset neuropsychiatric syndrome (PANS). Micaela Monteiro-Haig

NEUROSCIENCE AND COUNSELLING 16 Bob Shebib, Faculty Emeritus at Douglas College, New Westminster, British Columbia, Canada, is an educator and counsellor with broad experience in child welfare, corrections, mental health, and addictions. This month he gives us a comprehensive overview of neuroscience as it pertains to counselling from his book Choices: Interviewing and Counsel- ling Skills for Canadians (7th Edition) EDITOR IN CHIEF MANAGING EDITOR Bob Shebib Matthew Dahlitz Richard Hill ASSOCIATE EDITOR COPY EDITOR Geoff Hall Tina Pentland Departments ADVISORY BOARD Jack C. Anchin, PhD; Malek Bajbouj, MD; Louis J. Cozolino, PhD; Short Cut...... 04 Todd E. Feinberg, MD; Richard Hill; Stanley Keleman, PhD(hc); The Last Word ...... 62 Jeffrey J. Magnavita, PhD, ABPP; Haley Peckham, PhD; Iain McGil- christ, MD, MRCPsych; Robert A. Moss, PhD, ABN, ABPP; Judith A. Murray, PhD; Georg Northoff, MD, MA, PhD; Pieter J. Rossouw, MClinPsych, PhD, MAPS, CCLIN; Allan N. Schore, PhD; Paul G. Swingle, PhD; David Van Nuys, PhD

ISSN: 2201-9529

The information in this magazine is not intended to be fully systematic or complete, nor does inclusion here imply any endorsement or recommendation by the publisher, or its advisors. We make no war- ranties, express or implied, about the value or utility for any purpose of the information and resources contained herein. This magazine does not presume to give medical or therapeutic advice.

The Neuropsychotherapist™ is a trademark of Dahlitz Media Pty Ltd. This PDF version of The Neuropsychotherapist is best viewed on Adobe Reader. Other PDF readers may not support the Copyright © Dahlitz Media 2017 ACN: 139 064 074 interactivity incorporated in this publication. To download the free reader go to Cover Image: digitalista/Bigstock.com http://get.adobe.com/reader/ www.neuropsychotherapist.com The Neuropsychotherapist 3 short cut No One Expects the Smiling Inquisition!

Smiling has to be a good thing, and broadly speaking, it is, but Aparna Labroo and colleagues have conducted research that shows it rather depends on what you are expecting (Labroo, Mukhopadhyay, & Dong, 2014).

Despite the title above debasing the infamous doing anything meaningful. This proved a strong line from Monty Python, the research examined the correlation. So, if wasting time is a major creator of principle that the more people smile, the happier negative mood, why do people keep going back to they will be. This concept was given weight by the using Facebook? The answer was that many users work of Addelmann and Zajonc (1989) where they committed an “affective forecasting error”, in other showed that smiling, even involuntary lifting of the words, they expected to feel better. mouth by producing smile-like sounds, improved Expectation can be a driver of motivation even mood. However, their work did not show that this when the result proves to be wrong. What is sur- resolved a negative mood—only that it tended to lift prising is that some people will persist with push- a neutral mood. There is also some support for the ing for the expected result regardless of evidence idea that afferently stimulating the seventh cranial to the contrary. Expectations can be a motivation, nerve by smiling (the cranial nerve controls muscles but they can also be the source of disappointment used for facial expressions like smiling) can stimu- and dissatisfaction. The trick is to find something late elements of the social engagement system and to smile about and then smile about it frequently, interpersonal relating (Porges, 2013; Siegel, 2009). without an expectation of anything. But is there a proviso?

Addelmann and Zajonc (1989) found that if smil- - Richard Hill ing was seen as reactive, or a reflection of personal happiness, then smiling was beneficial for well-being. Conversely, if smiling was seen as proactive, Addelman, P. K., & Zajonc, R. B. (1989) Facial ef- and causing happiness, then frequent smiling reference and the experience of emotion. Annual sulted in less well-being. You might interpret that Review of Psychology, 40, 249–280. doi:10.1146/ as showing the need for meaning and relevance annurev.ps.40.020189.001341 for our bodies to respond in more than superficial ways. Smiling to become happy is not an effective Labroo, A. A., Mukhopadhyay, A., & Dong, P. (2014). method; but smiling when you are happy is a tonic Not always the best medicine: Why frequent smil- for you and for those around you. ing can reduce wellbeing. Journal of Experimen- tal Social Psychology, 53, 156–162. doi:10.1016/j. The counterintuitive implication of expecta- jesp.2014.03.001 tion was also found in an interesting study on the emotional consequences of using Facebook by Sa- Porges, S. W. (2013). The Polyvagal Theory. New gioglou and Greitemeyer (2014). The authors were York, NY: Norton. interested in finding out why so many people spent Sagiogiou, C., & Greitemeyer, T. (2014). Facebook’s large amounts of time on Facebook, even though emotional consequences: Why Facebook caus- their research showed that it created negative es decrease in mood and why people still use mood. They first looked at the time spent on Face- it. Computers in Human Behavior, 35, 359–363. book and found that the longer people were active doi:10.1016/j.chb.2014.03.003 on Facebook the more negative their mood was Siegel, D. J. (2012). The Developing Mind (2nd ed). afterwards. They then looked at the relationship of New York, NY: Guilford Press. negative mood to the feeling that the user was not

4 The Neuropsychotherapist Vol 5 Issue 12, December 2017 short cut The Psychotherapist’s Essential Guide to the Brain

The Psychotherapist’s Essential Guide to the Brain is a 147-page, full-colour illustrated guide for psychotherapists describing the most relevant brain science for today’s mental health professionals. Taken from the best of the series published in The Neuropsy- chotherapist, and completely revised, this book represents an easy to read guide for anyone working in the mental health arena.

“This book presents a thorough and clear introduction to the neuroscience that’s essential to today’s psychotherapist. Matt Dahlitz has done so much with The Neuropsychotherapist journal and this book takes a next step. It is an excellent resource. It truly is exactly what it says on the cover and provides engaging discussion on the pathology of oft-encountered disorders and their brain basis together with insights into how awareness of the neuroscience underpinning effective therapy can guide a therapist.” – Amazon UK Reviewer

“Beautifully illustrated and filled with

The Psychotherapist’s Essential Guide to the Brain Dahlitz cutting-edge understanding of the interface the psychotherapist’s of brain, body, mind, mental illness and psychotherapy, I can highly recommend this essential guide to the brain book. I feel I am pretty well-versed in neurobi- Matthew Dahlitz ology and yet this book had much to teach Edited by Geoff Hall me, from the “default mode” in the brain to the complexities of approach and avoidance and the circuits at play in depression and OCD, I feel I have deepened my understand- ings of the neurological underpinnings of mental illness and how to engage these in psychotherapy. For the most part this book still remains the kind of reading that only “brain geeks” can truly love. That being said, brain amateurs who strive to become brain geeks will find the beautiful illustrations and clear explanations very useful guides on their path. ISBN 978-0-9944080-1-3 Dr. Michael Ocana, MD Child and Adolescent Psychiatrist

9 780994 408013 > Available from Amazon.com - Read the preface here www.neuropsychotherapist.com The Neuropsychotherapist 5 integration Understanding PANS & PANDAS

The interplay of immune system & mental health

By Micaela Monteiro-Haig

6 The Neuropsychotherapist Vol 5 Issue 12, December 2017 integration integration nsomnia, out-of-control tantrums, separation anxiety, rage, obsessions, disordered eating, Iparanoia, motor and vocal tics.

As a therapist or parent, have you come across a child exhibiting any of these behaviours and wondered if there was more to it than psychosocial, developmental or family dynamic issues at play? Have you known a child who used to be a great student but is now barely coping with school work because they can’t focus, and has difficulty processing or remembering what they have learnt? Have you been left frustrated at the poor response to treatment? If so, you may have met or know a child who has paediatric acute-onset neuropsychiatric syndrome (PANS) or paediatric autoimmune neuropsychiatric disorder associated with streptococcal disease (PANDAS).

Unfortunately, most children with PANS/PAN- agents such as group A streptococcal, mycoplasma DAS are misdiagnosed as having psychiatric illness, pneumonia, influenza, human herpesvirus 6 (HHV- behaviour problems, or parenting/family dynamic 6), herpes simplex virus (Type 1 and 2), parvovirus concerns. Many go through a number of psychiatric B19, coxsackievirus, Lyme disease, Epstein–Barr medications and therapies with minimal improve- virus, cytomegalovirus and candida (Song, 2017). ment, and many progressively get worse. A diagno- Non-infectious agents include certain metabolic sis of PANS or PANDAS should be considered when- conditions (diabetes, lupus cerebritis), hormonal ever symptoms of OCD, tics, and eating restrictions changes, environmental exposure to heavy metals, start suddenly and are accompanied by other emo- mould toxins, and psychological stressors (O’Hara, tional and behavioural changes, frequent urination, 2015). PANDAS is a subset of infection-triggered motor abnormalities and/or handwriting changes PANS caused by streptococcal infection (Calaprice (Calaprice, Tona, & Murphy, 2017). PANS/ PANDAS et al., 2017). PANS and PANDAS symptoms can vary is also characterised by a relapse and remission pat- and do not necessarily present with an acute and tern—children with PANS/PANDAS seem to have dramatic onset (Song, 2017). Not rare, but rarely di- dramatic ups and downs in their symptoms, and an agnosed due to poor awareness, it is estimated that increased severity of symptoms is often correlated 1 in 100 children are affected by PANDAS/PANS to a return of infection (PANDAS Physicians Net- (Song, 2017). By definition, PANDAS is a paediatric work, 2017). disorder typically first appearing in childhood from PANDAS and PANS describe a subset of paedi- age 3 to puberty; however, it is possible that ado- atric onset obsessive compulsive disorder (OCD). lescents and adults may have immune-mediated PANS may also be a subset of avoidant/restrictive psychiatric disorders such as OCD (Autoimmune food intake disorder (PANDAS Physicians Net- Encephalitis Alliance, 2016). The combination of work, 2017). It is considered a neuroinflammatory autoimmunity and behaviour is a relatively new encephalitis that can have a number of infectious concept linking the brain, behaviour, and neuropsy- and non-infectious triggers (O’Hara, 2015). The syn- chiatric disorders with infections and immune acti- drome is thought to be an immune reaction to vari- vation (Cunningham, 2014).

Kasia Bialasiewicz/Bigstock.com ous physiological stressors that include infectious The bacteria associated with PANDAS are known

www.neuropsychotherapist.com The Neuropsychotherapist 7 integration as group A beta-haemolytic streptococcus (GABHS). Pathophysiology Sites of streptococcal (strep) infection include: the The proposed theory for PANS and PANDAS throat, tonsils, adenoids, skin (eczema, psoriasis), postulates that serum antibodies produced against urinary tract, gastrointestinal tract, and sinuses. In infectious and non-infectious agents cross the addition, rheumatic fever, a disease characterised blood–brain barrier (BBB) and cross-react with neu- by heart and joint inflammation, can also occur af- ronal antigens (Pearlman, Vora, Marquis, Najjar, & ter an untreated strep throat (Cunningham, 2014). Dudley, 2014). These antibodies then elicit injury A child with PANDAS may not necessarily mani- and cause dysregulation to basal ganglia functions fest with a sore, infected throat. At times, the only producing a variety of neurological and psychiat- symptom may be a stomach ache, a rash or recur- ric manifestations (O’Hara, 2015; Pearlman et al., rent impetigo, or a persistent sinus or ear infection 2014). Anti-neuronal antibodies produced include (O’Hara, 2015). Comprehensive testing, with throat, anti-lysoganglioside, anti-tubulin, and anti-dopa- nasal, ear, and perianal swabs, as well as blood anti- mine D1 and D2 receptor antibodies (Cunningham, body titres against strep antibodies, is recommend- 2014). Their effects on the brain include alterations ed, and a viral and bacterial panel is also advisable to the enzyme tyrosine hydroxylase, resulting in (Song, 2017). In PANDAS, GABHS antibodies persist increased synthesis of dopamine (O’Hara, 2015). In for several years after the streptococcal infection addition, dopaminergic and glutamatergic trans- occurs (Nicolini et al., 2015). Although strep anti- mission and regulation are affected due to an in- body titres may not always be elevated, this does crease in receptor sensitivity caused by antibody not exclude a diagnosis of PANDAS (Cooperstock, stimulation (O’Hara, 2015). Increased dopamine Swedo, Pasternack, & Murphy, 2017). and glutamate in the basal ganglia may be respon- Nadezhda1906/Bigstock.com

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sible for the overstimulation and the many psychi- Garvey, Perlmutter, & Swedo, 2000; Kumar, Wil- atric symptoms associated with PANDAS. liams, & Chugani, 2014). The autoimmune pathophysiology of PANS and Neurons connecting to the basal ganglia affect PANDAS may result not only from the adverse ef- motor function, emotion, behaviour, procedural fects of neuronal antibodies but also from the pro- learning, cognition, and sensory issues. Neurologi- motion of inflammatory mediators such as - neu cal and psychiatric manifestations include: OCD, roactive cytokines (Calaprice et al., 2017). A role mood lability, depression, mania, irritability, sleep for inflammatory mediators in psychiatric illness disorders, anxiety (frequently presenting as gener- has been identified in both children and adults alised anxiety or age-inappropriate separation anxi- (Baumeister, Russell, Pariante, & Mondelli, 2014; ety), rage, developmental regression, hypersexu- Mitchell & Goldstein, 2014). In addition to their di- ality, hyperactivity, inattentiveness, oppositional rect action in certain areas of the brain, inflamma- behaviours, obsessive thoughts, checking behav- tory mediators in PANDAS/PANS have also been iours, poor muscle control or coordination, new-on- implicated in a breach of the BBB by inducing capil- set bedwetting, handwriting changes, clumsiness, laries to expand and allowing the tissues to become tics, choreiform movements, cognitive impairment more permeable (Calaprice et al., 2017). When this (e.g., slow processing, poor memory, specific senso- occurs, it makes the BBB vulnerable to the entry ry learning deficits, particularly in maths and tasks of pathogens, permitting neuroactive antibodies involving calculation), sensitivity to light, sounds, to reach neuronal tissue (Calaprice et al, 2017). Of tastes, smells and textures (PANDAS Physicians note, research has demonstrated neuroinflamma- Network, 2017). In addition, the PANS/PANDAS tion within the neurocircuitry and pathophysiol- child may exhibit a fear of vomiting or of being poi- ogy of OCD (Attwells et al., 2017; Giedd, Rapoport, soned or contaminated (O’Hara, 2015). This often Vertolet/Bigstock.com

www.neuropsychotherapist.com The Neuropsychotherapist 9 integration

leads to difficulties with daily activities such as eat- persistent inflammatory cytokine release, will in ing, going to the toilet, going in a car, and dressing. turn affect sleep and mood via disruption to sero- Tics can include uncontrollable movements such as tonin production in the brain (Gruner & Sarris, 2014; eye-blinking, hair twirling, lip smacking or shoulder Savitz et al., 2015). As this neurotransmitter exerts shrugging, or automatic noises such as throat clear- a modulatory effect on dopamine, lower levels of ing, grunting, or saying certain words repeatedly brain serotonin further exacerbate the effects of do- (PANDAS Physicians Network, 2017). pamine dysregulation in neuronal circuits. Contin- The impact of PANDAS/PANS is further exacer- ued disruption in HPA-axis function due to ongoing bated by certain individual vulnerabilities such as infection can eventually lead to underproduction of a family history of autoimmune disease, a com- cortisol and other stress hormones (Gruner & Sar- promised immune system, impaired detoxification ris, 2014). This can result in poor stress tolerance, pathways and pyrrole disorder, to name a few. fatigue, sleep issues, and increased susceptibility to Due to the nature of a long-standing infection, other infections (Gruner & Sarris, 2014). individuals with PANDAS/PANS will often present with other issues that require attention. An over- Treatment active immune system and persistent infection as seen in children with PANDAS/PANS exerts an in- Treatment of PANDAS/PANS requires a multi- creasing strain on the stress response and the hy- pronged approach where a number of modalities are pothalamic-pituitary-adrenal (HPA) axis (Gruner employed in order to address the cause (or causes) & Sarris, 2014; Silverman & Sternberg, 2012). Chil- and resolve symptoms. Comprehensive treatment dren with PANDAS/PANS will often have increased delivered by a team of specialists (including paediat- stress hormone levels further exacerbating the con- ric neurologists and psychiatrists, psychotherapists, dition; increase in the stress hormone cortisol, and occupational therapist and naturopath/nutritionist,

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dependent on the severity of the case) will give the underlying inflammation, modulating the immune PANDAS/PANS child the best chance of remission. system, and supporting the child through the pro- Generally, the clinical management and treatment cess of flare-ups. Additionally, therapies that - sup of PANDAS/PANS will comprise behavioural and port brain and central nervous system function and pharmacological interventions that include antibi- regeneration, modulate the HPA axis, address nu- otic therapy (often for a period of months or years), trient deficiencies (as a consequence of disordered immunomodulatory and/or immunosuppressive eating) and support gut health, as well as other or- therapy, psychotropic medication, cognitive behav- gans and systems affected, are paramount. ioural therapy, and family therapy (Thienemann et Complementary medicine in the treatment of al., 2017). However, as functional medicine practi- PANDAS/PANS has been shown to be helpful, with tioner and paediatrician Elisa Song (2017) has not- a high use among patients (Calaprice et al., 2017). ed, while psychotropic medications may be needed The most frequently used treatments include die- during crises, they are a bandaid solution and are tary modifications (comprising an anti-inflammato- often not effective until the underlying causes are ry diet), supplements that include probiotics to sup- addressed. Most children who undergo treatment port the gut microbiome and gut–brain connection show overall improvement over months and years, (especially important during antibiotic treatment), although relapses may still occur after long periods vitamin D as an immunomodulatory agent, fish oils of remission (Cooperstock et al., 2017). (or other omega-3 fatty acids), turmeric/curcumin, The focus of treatment should be on each indi- vitamin C, melatonin and N-acetylcysteine for re- vidual child and not a protocol, as symptom pres- ducing oxidative stress and inflammation, B vita- entations differ. Within individualized treatment, mins, magnesium, zinc, broccoli sprout powder and however, there is a framework that encompasses glycine to improve detoxification pathways, and dealing with any active infection, addressing the CoQ10, acetyl-carnitine and ribose to address mito- Wavebreak Media Ltd/Bigstock.com

www.neuropsychotherapist.com The Neuropsychotherapist 11 integration

chondrial dysfunction (Calaprice et al., 2017; O’Hara, sociated with streptococcal infection. The American 2015). Further to the above, other interventions in- Journal of Psychiatry, 157, 281–283. doi:10.1176/appi. clude herbal agents with immunomodulatory and/ ajp.157.2.281 or immunosuppressive actions to optimise immune Gruner, T., & Sarris, J. (2014). Stress and fatigue. In J. function and decrease the autoimmune response Sarris & J. Wardle (Eds.), Clinical Naturopathy (pp. (Bradbury & Hartley, 2014). 350–370). Sydney, Australia: Elsevier. The prognosis for a child with PANDAS/PANS Kumar, A., Williams, M. T., & Chugani, H. T. (2015). depends to a great extent on appropriate diagnosis Evaluation of basal ganglia and thalamic inflammation in children with pediatric autoimmune neu- of the disease and early intervention. It is vital that ropsychiatric disorders associated with streptococ- any child exhibiting symptoms of PANDAS/PANS cal infection and Tourette syndrome: A positron be referred for proper and comprehensive testing emission tomographic (PET) study using 11C-[R]- and appropriate treatment. Only then is recovery PK11195. Journal of Child Neurology, 30, 749–756. possible. doi:10.1177/0883073814543303 Mitchell, R. H., & Goldstein, B. I. (2014). Inflammation in children and adolescents with neuropsychiatric References disorders: A systematic review. Journal of the Ameri- Attwells, S., Setiawan, E., Wilson, A. A., Rusjan, P. M., can Academy of Child and Adolescent Psychiatry, 53, Mizrahi, R., Miler, L., . . . Meyer, J. J. H. (2017). Inflam- 274–296. doi:10.1016/j.jaac.2013.11.013 mation in the neurocircuitry of obsessive–compulsive Nicolini, H., López, Y., Genis-Mendoza, A. D., Man- disorder. JAMA Psychiatry, 74, 833–840. doi:10.1001/ rique, V., Lopez-Canovas, L., Niubo, E., . . . Santana, jamapsychiatry.2017.1567 D. (2015). Detection of anti-streptococcal, anti- Autoimmune Encephalitis Alliance (2016). Symptoms. enolase, and anti-neural antibodies in subjects with Retrieved from https://aealliance.org/patient-sup- early-onset psychiatric disorders. Actas Españolas port//symptoms/ de Psiquiatria, 43, 35–41. Retrieved from http://www. Baumeister, D., Russell, A., Pariante, C. M., & Mondelli, actaspsiquiatria.es/repositorio/17/94/ENG/17-94- V. (2014). Inflammatory biomarker profiles of mental ENG-35-41-786949.pdf disorders and their relation to clinical, social and life- O’Hara, N. H., (2015, May). PANDAS–PANS: Autoim- style factors. Social Psychiatry and Psychiatric Epide- mune disorders that impact the brain. Presentation miology, 49, 841–849. doi:10.1007/s00127-014-0887-z at the Mindd Foundation Seminar, Sydney, Australia. Bradbury, J., & Hartley, N. (2014). Autoimmune disease. Retrieved from https://mindd.org/seminar/nancy- In J. Sarris & J. Wardle (Eds.), Clinical Naturopathy hofreuter-ohara/ (pp. 593–628). Sydney, Australia: Elsevier. PANDAS Physicians Network (2017). Seeing your first Calaprice D., Tona J., & Murphy T. (2017). Treatment of child with PANDAS/PANS. Retrieved from https:// pediatric acute-onset neuropsychiatric disorder in a www.pandasppn.org/seeingyourfirstchild/ large survey population. Journal of Child and Adoles- Pearlman, D. M., Vora, H. S., Marquis, B. G., Najjar, S., & cent Psychopharmacology. Advance online publica- Dudley, L. A. (2014). Anti-basal ganglia antibodies in tion. doi:10.1089/cap.2017.0101 primary obsessive-compulsive disorder: Systematic Cooperstock, M. S., Swedo, S. E., Pasternack, M. S., & review and meta-analysis. The British Journal of Psy- Murphy, T. K. (2017). Clinical management of pediat- chiatry, 205, 8–16. doi:10.1192/bjp.bp.113.137018 ric acute-onset neuropsychiatric syndrome: Part III: Savitz, J., Drevets, W. C., Wurfel, B. E., Ford, B. N., Bell- Treatment and prevention of infections. Journal of gowan, P. S. F., Victor, T. A., . . . Dantzer, R. (2015). Child and Adolescent Psychopharmacology, 27, 594– Reduction of kynurenic acid to quinolinic acid ratio in 606. doi:10.1089/cap.2016.0151 both the depressed and remitted phases of major de- Cunningham, M. W. (2014). Rheumatic fever, autoim- pressive disorder. Brain, Behavior, and Immunity, 46, munity, and molecular mimicry: The streptococcal 55–59. doi:10.1016/j.bbi.2015.02.007 connection. International Reviews of Immunology, 33, Silverman, M. N., & Sternberg, E. M. (2012). Gluco- 314–329. doi:10.3109/08830185.2014.917411 corticoid regulation of inflammation and its -func Giedd, J. N., Rapoport, J. L., Garvey, M. A., Perlmutter, tional correlates: From HPA axis to glucocorticoid S., & Swedo, S. E. (2000). MRI assessment of chil- receptor dysfunction. Annals of the New York Acad- dren with obsessive-compulsive disorder or tics as- emy of Sciences, 1261, 55–63. doi:10.1111/j.1749- 6632.2012.06633.x

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Song, E. (2017). Practical insights into PANS. FX Medi- Micaela is a naturopath, nutritionist, herbalist and eat- cine, 87, 18–19. ing psychology coach with a special interest in mental Thienemann, M., Murphy, T., Leckman, J., Shaw, R., health. She has a Bachelor Degree in Health Science- Williams, K., Kapphahn, C., . . . Swedo, S. (2017). Naturopathy with additional studies in mind-body nu- Clinical management of pediatric acute-onset neu- trition, eating psychology and counselling techniques. ropsychiatric syndrome: Part I: Psychiatric and behavioral interventions. Journal of Child and Adoles- cent Psychopharmacology, 27, 566–573. doi:10.1089/ cap.2016.0145 Vertolet/Bigstock.com

www.neuropsychotherapist.com The Neuropsychotherapist 13 I use holistic, evidence-based naturopathic medicine that seeks to educate and assist in healing by incorporating dietary and lifestyle advice, clinical nutritional medicine, western herbal medicine and eating psychology principles such as mind-body nutrition to create a unique treatment plan for each individual.

I offer help with mood disorders (anxiety, depression, post-natal depression, panic at- tacks, pyroluria/Pyrrole disorder, PANS/PANDAS), stress management, sleep issues, fatigue syndromes, female and male hormonal imbalances, thyroid conditions, cognitive issues, immune dysfunction (including food allergies/intolerances, autoimmune conditions), digestive complaints, eating challenges (overeating, binge eating, body image, chronic dieting) and weight management. mybodymindhealth.com.au

Micaela Monteiro-Haig Crown House Publishing

The Practitioner’s Guide to Mirroring Hands A client-responsive therapy that facilitates natural problem solving and mind–body healing Richard Hill and Ernest L. Rossi

This is the first book dedicated to Ernest L. Rossi’s Mirroring Hands therapeutic process. Mirroring Hands is a technique that emerged from Ernest L. Rossi’s studies and experiences with Milton H. Erickson. It has its origins in hypnosis, but Mirroring Hands is an effective process for a wide range of mental health professionals who may not include or intend to include hypnosis in their practice. This book will appeal both to established therapists and to those new to psychotherapy and hypnotherapy and is intended to establish the Mirroring Hands process as a therapy for all practitioners. Rossi himself has described the technique as ‘hypnosis without the hypnosis’. The central focus of the book is the technique: it is a practitioner’s guide. Mirroring Hands seeks to connect the client and the therapist to the natural flow, cycles and self-organising emergence that shift the client toward beneficial change. The authors show how the technique enables clients to unlock their problem solving and mind–body healing capacities and arrive at resolution in ways that many other therapies might not. The 978-178583246-8 overall effect is to create an engaged connection and integration $36.95 with the client’s natural, best self. paperback • ebook December 2017 The process begins with a state of focused attention, which is established by the client keenly observing their hands. The client is invited to look at their hands as though they had never seen them before. This is not to produce a deep hypnotic trance, but to create a mental state that is very different from just engaged conversation. Milton H. Erickson described it as a General Waking Trance. This form of focus and attention is similar to the state created during meditation and mindfulness.

Richard Hill, MA, MEd, MBMSc is acknowledged internationally as an expert in human dynamics, communications, the brain and the mind. He is an international lecturer and keynote speaker on the topics of neuroscience, psychosocial genomics, has developed special training courses for suicide prevention and is the originator of the Curiosity Approach. In addition to lectures to the psychological profession in Australia and the world, Richard has a strong engagement with the coaching and business community Ernest L. Rossi, Ph.D. is a Diplomate in Clinical Psychology and the recipient of three Lifetime Achievement Awards for Outstanding Contributions to the Field of Psychotherapy. He is a Jungian Analyst, the Science Editor of Psychological Perspectives and the author, co-author and editor of more than 50 professional books and more than 170 peer reviewed scientific papers in the areas of neuroscience, psychotherapy, dreams, and therapeutic hypnosis that have been translated into a dozen languages. Rossi is internationally recognized as a polymath, a gifted psychotherapist, and teacher of innovative approaches to facilitating the creative process.

To pre order your copy of the book visit www.crownhousepublishing.com, www.amazon.com or your preferred bookstore. Neuroscience & Counselling

Bob Shebib Sergey Nivens/Bigstock.com Sergey

16 The Neuropsychotherapist Vol 5 Issue 12, December 2017 The Remarkable and Mysterious Brain

On a cold and wet winter morning, Bob overcomes his “excuses” and begins his daily run. As expected, the first few kilometres are gruelling and painful, but midway through the run, something magical is about to happen.

Astonishing electrical and chemical events are unfolding. Aroused by electricity, small molecules awaken and move across tiny gaps in his brain, exciting billions of others that send signals down familiar pathways creating an euphoric feeling that Bob experiences as a “runner’s high,” his reward for persevering.

A vicious dog interrupts the serenity of Bob’s run and begins the chase. Instantly, Bob’s brain assembles its stress and danger response team under the command of the hypothalamus. It signals other parts of the brain and body to release neurotransmitters and hormones, such as adrenaline, glutamate and cortisol to deal with the threatening dog. Responding to energizing signals from the brain, Bob’s heart beat increases to pump more blood to the limbs, his lungs dilate to allow extra oxygen intake, he runs faster, and he escapes to run another day.

Returning to the solitude of the run, in a way that remains a mystery, the greatest miracle of all occurs. Bob‘s mind energizes with self-awareness, freeing him to contemplate his existence, his place in the universe, his future, and his connection with God.

Throughout the run, outside of his conscious awareness, Bob’s brain functions as an active coach and trainer. It organizes and commands a vast team of neurons to make his run possible. It moves his legs, regulates his breathing, monitors his heartbeat, and processes visual signals to produce ul- tra-high definition 3D pictures with stereophonic sound in order to coor- dinate his movement, avoid hazards, maintain equilibrium, and return him safely home.

It’s clear that Bob’s brain, not his legs, deserves the credit for the run.

www.neuropsychotherapist.com The Neuropsychotherapist 17 he brain is a complex, perpetual motion ma- Now, in a new era, with amazing brain imaging tech- chine that controls everything we see, do, niques and extraordinary emphasis on research, the Thear, and think twenty-four hours a day, non- brain is slowly divulging its secrets. stop for our entire lives. Usually, we associate the brain with thinking and making decisions. In reality, Worldwide, brain research has become a prior- its role is far more reaching. It powers amazing elec- ity with work proceeding at an unprecedented rate. trical and chemical interactions involving hundreds For example, the government and The Brain Cana- of different organs and structures within the body da Foundation, a nonprofit public-private partner- and the brain itself. The human brain, with its vast ship formed to support brain research, have invest- network of alive, constantly changing neural con- ed over 200 million dollars in the work of over 700 nections is the ultimate multitasker, simultaneously researchers. Such research is generating a constant managing everything from our heartbeat to our stream of discoveries that informs innovative and dreams, our immune system to our imagination. effective interventions for brain disorders. Although we associate the heart with our feelings, it is actually the brain that is in control of our emo- Serious interest in the brain is no longer confined tions. to professionals. Books, television specials, and popular magazines like National Geographic, Sci- The brain is a ceaseless director, observer, par- entific American, Time, and Discover are publishing ticipant, choreographer, and scriptwriter of our ex- content on the brain for all to read. Libraries and istence. It also relentlessly reinvents itself, literally bookstores now regularly feature displays on the altering its structure and chemistry in response to brain, including a growing body of material on the our experiences. topic of brain health and vitality. Terms like “frontal lobe”, “serotonin”, “dopamine”, “neurotransmit- Most of the work of our brain is done without ter”, and “brain plasticity,” once the jargon of re- requiring our conscious attention. It works silently searchers, academics and doctors, are now part of to make our hearts beat, forge memories, and or- everyday language. Empowerment comes with this chestrate complex chemical and behavioural reac- knowledge. People have access to the knowledge tions to protect us from danger, even before we are that can make them informed consumers of men- consciously aware of any threat. Without our brain, tal health and counselling services. They can take survival is impossible. charge of their brain health by learning strategies for dealing with disorders such as Alzheimer’s. A New Era. We’ve only just begun. With breath- taking speed over the last 20 years, neuroscientists This article can provide only a brief survey of top- have uncovered vast knowledge about the brain and ics that are important for counsellors. Given the its mechanics, but they are still at the early stages of growing importance of neuroscience for counsel- unravelling the mysteries of the most complex and lors, readers should take advantage of opportuni- capable object in the universe. Until recent years it ties for further study available on the web, and in has remained mysterious and little has been known research reports, journals, and books. or understood about how the brain actually works.

BRAIN BYTE: THE NON-STOP BRAIN

At birth, a single brain cell has become 80 billion neural cells eager to define our existence.The brain is an instant super-centre of learning. Two decades later, the brain is still maturing (hopefully) to create a mind with good judgment and impulse control. In every instant, the brain is changing, adapting, and, if necessary, repairing damage. New neurons are created (neurogenesis), and the massive neural highways that control everything are formed, strengthened or pruned. Over a lifetime, experience and reflection give rise to wisdom, a fair trade for the memory and cognitive declines of aging.

18 The Neuropsychotherapist Vol 5 Issue 12, December 2017 BRAIN BYTE: THE AMAZING BRAIN

The brain is 75% water and weighs only 1,400 grams, but it uses 20% of the body’s energy and blood to fuel 80 billion neurons, each of which is connected electrochemically to as many as 40,000 others at a speed of over 400 km per hour. Contrary to popular myth, we use all of our brain, all of the time. Un- like the pictures in the books, the parts of the brain are not colour-coded. The brain is mostly grey, with the same consistency as tofu.

CONVERSATION 1: MIND AND BRAIN

Counsellor: What’s the difference between the mind and the brain?

Teacher: It depends on who you ask. Philosophers, theologians, biologists, and neuroscientists will each have their own definition, and even within their discipline, they will not find consensus.

I’ll give you my opinion. The brain is the physical organ at the top of our heads. The mind is what we are able to do with our brain, our capacity for problem solving and creativity, our consciousness, and our capacity to experience love and joy as well as deep sadness. It also distinguishes us from others by defining our individu- ality and personality.

The greatest marvel of the mind is it allows us reflect on our own existence and find spiritual significance and purpose to life. In the last 35 years, neuroscientists have made remarkable progress in understanding the brain. New research findings are coming at such a rapid rate that vene neuroscientists have trouble keeping up. In the future, we will probably achieve an almost complete description of the structure, chemistry and electrical circuitry of the brain. What about the mind? It’s still a mystery. We know very little.

Counsellor: I wonder if traditional scientific research and analysis are inadequate tools for studying the mind. The mind is concerned with the nature of reality, consciousness, curiosity and spirituality. These mat- ters aren’t part of the physical world that can be studied in the same way. They don’t adhere to the laws of physics. Maybe, because of this we’ll never be able to fully understand the nature of the mind. In fact, I hope this is true. DAntonioGuillem/Bigstock.com

www.neuropsychotherapist.com The Neuropsychotherapist 19 Neuroscience: ling interventions in the context of our clients’ An Emergent Force in Counselling cultural world views. In a multicultural society such as Canada, it a necessary perspec- Over the past 100 years, five key forces (Fig- tive, regardless of the counselling approach ure 1) or approaches have influenced the direction adopted. and philosophy of counselling. Neuroscience is on 5. Social justice recognizes the importance of track to become the sixth force. Each force offers counselling professionals working to help es- counsellors important perspective, knowledge and tablish more equity regarding the distribution guidance. Although some counsellors may strongly of wealth, resources, and opportunity. Social align themselves with a particular approach, most justice accepts that client problems may be recognize the value of drawing on the insights of- the unfortunate outcome of oppression, pov- fered by different theories and models. Wise coun- erty, and marginalization. sellors make informed choices based on individual 6. Neuroscience is the study of the nervous sys- situations and client needs. tem (see Figure 2), which includes the central nervous system (brain and spinal cord) and the peripheral nervous system (nerves outside of the brain and spinal cord). Neuroscience explores the electrical and chemical activity of the brain using a variety of experimental and brain imaging techniques.

Neuroscience explores how the brain controls thinking, behaviour, and emotions, and how the brain reacts to such things as physical or mental illness, trauma, and substance misuse. Neurocoun- Figure 1: Key Forces in Counselling selling, a term not yet in widespread use, is the integration of neuroscience into the practice of counselling. A neuropsychiatrist is a medical doc- Six Key Forces in Counselling tor who specializes in the treatment of neurological injury or disease. A neuropsychologist is a psy- 1. Psychoanalysis focuses on helping clients chologist (usually with a Ph.D.) who deals with the develop understanding and insight regarding psychological problems associated with brain injury the origins of their thoughts, feelings and be- or disease. In Canada, only those with a medical haviour. Heavy emphasis is placed on explor- degree can prescribe medication, but in the United ing the unconscious. States (in some jurisdictions) specially trained psy- 2. Behaviourism looks at human behaviour as chologists can prescribe a limited number of medi- a product of learning and the environment. cations. The emphasis is on behaviour shaped by re- inforcement. Competent counsellors try to understand their clients by considering many variables, including ge- 3. Humanism, with Carl Rogers at the forefront, netics, developmental level, prior learning, relation- is based on the philosophy that people are in- ship and family dynamics, impact of substance mis- nately driven towards growth and fulfillment. use, presence of mental disorders, overall health, Core conditions (empathy, genuineness, and the influence of culture and spiritual beliefs, as well unconditional positive regard) are seen as as systemic issues such poverty, unemployment and “necessary and sufficient” qualities needed oppression. Neuroscience, as an emergent force, by counselors to help clients manage prob- will add yet another dimension for counsellors to lems and emotions. consider. It represents no threat. It won’t negate 4. Multiculturalism involves framing counsel- the long-established and important cornerstones of

20 The Neuropsychotherapist Vol 5 Issue 12, December 2017 effective counselling, such as relationship and the core conditions, especially empathy. In fact, as will Confirmation by neuroscience of what were be explored below, neuroscience has endorsed the largely intuitive practices opens an unprece- validity of these cornerstones. dented way forward for us as therapists to refine our technique, and ourselves, for even greater Why Neuroscience is Important success, while leaving behind those practices for Counsellors revealed to be ineffectual or even detrimental (p.11) Neuroscience endorses counselling. In the future, neuroscience will no doubt contin- A growing body of neuroscience research is pro- ue to offer significant insight and precise guidance viding counsellors with scientific proof of the value of on what works and what doesn’t. Here are some their work, as well as guidance on which counselling examples of notable and relevant neuroscience re- strategies are effective in given situations. McHen- search findings for counsellors: ry, Sikorski, & McHenry (2014) call on counsellors to embrace neuroscience as an important additional • Neuroscience has confirmed the effectiveness tool regardless of their theoretical approach, not- of the mainstays of counselling, listening, em- ing that “all of the main theories of counselling can pathy, and a focus on wellness (Ivey, Ivey, & be supported through the use of brain imaging that Zalaquett, 2010). provides evidence of brain changes in clients” (p. • Counselling aids in the generation of new neu- 12). Neuroscience will add credibility to the field, rons, a process known as neurogenesis (Ivey empowering counsellors with the confidence that et al., 2010). This is important because neuro- comes knowing that their interventions are based genesis aids damaged brains to recover, and it on solid science. As Hill and Dahlitz (2014) note: can slow brain degeneration caused by dementia. • Neuroscience is providing specific guidance on how to promote neurogenesis. It supports the efficacy (effectiveness) of counselling -strat egies that include exercise and diet (Arden, 2015), a strong argument for counsellors to encourage clients to add these lifestyle changes to their action and recovery plans. Similarly, stress management, having positive relationships (including the client/counsellor relationship), spirituality, and mental stimulation increase neurogenesis. • Social interaction stimulates the brain’s reward circuitry and the release of dopamine and oxytocin, neurotransmitters that increase motivation, feelings of well-being (dopamine), and levels of attachment and trust (oxytocin) (Stanford, 2017). This finding reinforces the importance of the counsellor/client relationship, which is strongly linked to counsellor empathy. • The counselling relationship, long recognized as the most important catalyst for client change,

Snapgalleria/Shutterstock Figure 2: The Nervous System creates the fertile conditions for healing the damages created by stress and supporting the www.neuropsychotherapist.com The Neuropsychotherapist 21 growth of new neural pathways fundamental when clients are involved in decision making to wellness and mental health. and have choices, there is increased activity • Mindfulness helps the brain to refocus, de- in the caudate nucleus and other areas of the crease worry, increase working memory, and brain that are involved in motivation. The re- decrease stress. search suggests that clients with choices have • Exercise helps to slow cognitive decline. a greater sense of control, increased motivation, and an overall more positive mood. • Specific interventions such as exposure - ther apy can help to repair the damage caused by trauma to two important parts of the brain, the Addition of a Biological Perspective. Emergent amygdala and the hippocampus (Trouche, Sa- research that reveals the biological basis of many saki et al., 2013). mental disorders is helping to guide the develop- • Problem-solving work and selected computer ment of preventive and interventive strategies. The games enhance cognitive functioning. research is also informing counsellors about how the brain is impacted by crisis, trauma, substance • Most counsellors are aware that confrontation misuse, and social determinants such as poverty. is generally a poor strategy for effecting change (Miller & Rollnick, 2013). Neuroscience tell Since many counsellors have had little or no train- us why. Confrontation arouses the brain’s fight ing in neuroscience, they will need to include this or flight response, as it mobilizes for what is topic in their reading and professional development experienced as an attack. As a result, valuable agenda. Counsellors do not need to become experts energy that might otherwise be harnessed for in neuroscience, but it is imperative that they have change is diverted to defence of the status quo. at least a basic understanding of the brain and the Empathy, on the other hand, offers no such terminology. This will enable them to be active con- threat and, in fact, acts to calm the brain and sumer of neuroscience information. add to the development of the counsellor/client relationship, a major variable associated with Neuroscience provides counsellors with anoth- favourable outcomes in counselling. er rationale for systemic change. Research endors- • Counsellors who use a strengths approach ing the value of counselling interventions is provid- stimulate their client’s prefrontal cortex to ing compelling arguments for increased funding for shift to positive thinking and emotions which counselling preventive and treatment programs. in turn helps to overcome unhelpful and nega- The Centre for Addiction and Mental Health (2017) tive thinking patterns (Ivey, Ivey, Zalaquett & estimated that the total cost of untreated mental Quirk, 2009). illness in Canada is more than 51 billion dollars. Data • Dahlitz (2017) cited research showing that such as this provide an empirical base for counsel-

SUCCESS TIP: EVIDENCE-BASED PRACTICE AND NEUROSCIENCE

Evidence-based best practice (EBP) means that we counsel clients using the best available evidence that what we are doing has a reasonable chance of successfully meeting client needs and goals. Typi- cally, EBP was based on research (outcome and controlled studies), cultural considerations, codes of ethics, and individual client variables, as well as practitioner and colleague experience. Now, neuroscience is providing counsellors with knowledge on how how specific strategies can positively impact the brain and facilitate change or repair of damaged brains. This EBP research provides a strong case in support of an eclectic and customized approach to counselling that allows for change and adaptation based on the individual needs of clients and situations. A “one size fits all” model of counselling may work well in one situation, but fail miserably in another.

22 The Neuropsychotherapist Vol 5 Issue 12, December 2017 lors who are active in lobbying for political and sys- Neuroscience research has made great strides prov- temic change to grossly underfunded mental health ing that there are genetic and biological causes of and addictions system. mental disorders. These findings support the argument that mental disorders ought to be understood Neuroscience can offer guidance on the use of and treated in the same way that biological dis- technology for treatment. Counsellors who are ease or injury is addressed. Stigma will be reduced well versed in neuroscience can inform and refer cli- when people learn and accept that mental illness ents to take advantage of rapidly emerging technol- is not a choice caused by moral weakness. Neuro- ogy. For example, Li, Montaño, Chen, & Gold (2011) science knowledge will help to change thinking so described how virtual reality can be used to rewire that brain-based disorders are viewed no different- the brain to deal with pain management. Techniques ly than any biological disease or injury. Counsellors such as biofeedback can be utilized to supplement can play a major role in communicating this notion more traditional counselling approaches. Another to clients, their families, and the community. promising technological advance is transcranial magnetic stimulation (TMS), which involves the use Neuroscience provides explanations that can of magnetic pulses to stimulate the brain. An effec- be used for psychoeducation. Psychoeducation, tive alternative to medication, this technique has long a mainstay of counselling, involves helping cli- proved very useful in treating depression, including ents and their families learn about the nature of their for those who have not responded to medication. problems, including practical information on how they might address social, psychological, economic, Neuroscience can reduce stigma. Moral and and other issues. Neuroscience explanations can be cultural judgments can inflict shame on those deal- used by counsellors to help clients understand how ing with mental disorders, a reality that often leads their brains are impacted by their life experiences, people to forgo treatment and suffer in silence. trauma, illness, and substance misuse. Most coun- Zinkevych/Bigstock.com

www.neuropsychotherapist.com The Neuropsychotherapist 23 sellors are not experts in neuroscience, so they have Client: How? to be careful that they do not exceed the limits of Counsellor: Some people are helped with medi- their competence in this area. They need to refrain cation, but that’s something for you and your from giving medical advice or offering opinions on doctor to discuss. You’ve told me that it helps to neurological issues in which they are not qualified. avoid situations where you get overwhelmed, and that’s one good coping strategy. It’s the eve- The Internet has made information available to ryday situations and moments that you can’t everyone. As a result, clients have opportunities avoid where you need a solution. Right? (client to become better informed regarding their condi- nods). Generally, avoidance decreases anxiety, tions. There is, however, a real risk that clients, or but increases fear, so the next time you face the even professionals will be misled by false or mis- situation, you will be even more anxious. If you leading information. Sometimes, people will post want, we can work to develop a strategy that will to the Internet based on their beliefs or personal help you take small steps to overcome both fear experience, but their statements may be malicious, and anxiety. You’ll be in charge, and I won’t try to fabricated or simply wrong. An informed client is force you to do anything. empowered, but a misinformed client may delay or suspend treatment based on an unverified opin- In the example above, the next step might in- ion expressed on the Internet. Counsellors can best volve the use of a best-practice counselling strategy support clients by encouraging them to consult with such as systematic desensitization, a technique that reputable sources such as government or national combines relaxation with incremental exposure to user sites. When counsellors have a basic working anxiety provoking situation. (Caution: the use of knowledge of neuroscience and the brain, they are systematic desensitization should be within the in a much better position to help clients access and counsellor’s area of competence.) Clients such as utilize factual and reliable information. the one in the example often report feeling relieved when they finally understand the reasons for their What counsellors can do is help clients acquire a problems and empowered as they learn that their basic understanding of how their problems might problems can be managed. be influenced by the brain. To do so, counsellors need at least a rudimentary appreciation of how Neuroscience provides guidance on medica- the brain works. For example, research has dem- tion. Knowledge of how medications enhance, in- onstrated that excessive anxiety might be due (in hibit, or augment brain and bodily functioning is es- part) to an overactive amygdala (Arden, 2015). This sential for assessment and goal setting with clients. knowledge can form the basis of a simple explana- For example, many psychotropic medications lead tion that can help a client understand and deal with to weight gain, so counsellors can support clients their anxiety. Here’s an example: with wellness initiatives (e.g., diet, exercise). As a result, medication compliance may be improved Counsellor: One of the interesting things they’ve since clients will be less likely to abandon their med- discovered is that when people feel overly anx- ication because of the discouragement associated ious, there’s a part of the brain that’s overactive. with weight gain. However, the good news is, it can be managed.

SUCCESS TIP: NEUROEDUCATION

Counsellors can use neuroscience information to help others to understand behaviour—for example, that children in a classroom who might otherwise be labelled “bad”, “difficult”, or “spoiled” are in fact responding to faulty brain chemistry or behavioural patterns long shaped by repetition

24 The Neuropsychotherapist Vol 5 Issue 12, December 2017 Neuroscience offers hope. Because our brains new tricks. are wired based on past experiences, there is strong pressure to act and think consistent with this wiring. Here’s how a counsellor might explain it to a cli- Put simply, we are creatures of habit, even when our ent: habits of thinking and behaving are problematic, the usual position that brings clients to counselling. Counsellor: In the last 30 years brain researchers However, the good news is that we can change our have discovered that our brains are constantly brains and change their future. changing. Client: So, what’s the big deal. It’s not something Neuroplasticity. Neuroplasticity, one of the most I can control. exciting and relevant discoveries in neuroscience, Counsellor: That’s what everyone believed until refers to the brain’s ability to change itself by form- recently. Now, they’ve learned that there is actu- ing new neural connections in response to learning, ally a lot we can do to help our brains grow and changes in the environment, or as compensation heal. Since your brain is going to change anyway, for injury or disease. Neuroscientists have found you might as well be helping it change for the that not only can the brain change, it is constantly better. And the good news is that we now know changing. (Neuroplasticity will be explored in more how to do it. detail later in this article). Neuroimaging. Modern advances in neuroim- Neuroplasticity concepts can be used by coun- aging have provided facts and information with sellors to convey hope to our clients. They can help enormous implications for counsellors. Research is clients understand that they are not permanently increasingly guiding and informing counsellors how doomed to their current thinking, behaviour or their clients’ brain structure and chemistry might emotions. These concepts can provide guidance respond to different intervention strategies. We are regarding how clients can change or “rewire their well on our way to understanding how specific coun- brains” in ways that reduce or eliminate their cur- selling strategies change the brain to promote posi- rent problems. Neuroplasticity concepts can show tive growth, including neurogenesis, the growth of how tools such as cognitive behavioural counsel- new neurons, something that a short time ago was ling, mindfulness, risk taking, meditation, exercise considered impossible. Clients can change their and diet can be the roots of positive change in our brains. Counselling can support, enhance, and ac- lives. For both counsellors and clients, neuroscience celerate this outcome. provides the science that supports the use of techniques, such as cognitive behavioural therapy, that A look ahead. In the coming decades, neurosci- harness the brain’s amazing neuroplasticity to form ence will continue to have a major impact on our new neural pathways to replace and extinguish un- understanding of mental and physical disorders. helpful and harmful thinking and behavioural pat- Counsellors, social workers, psychologists, child terns. Peckham (2017) offers this perspective: care workers, and other social service providers will need to have at least a basic understanding of the The very definition of neuroplasticity shows us brain and the implications of neuroscience research that acceptance of circumstance does not have for their fields of practice. to be the end of the story. If experiences have shaped us in ways that currently cause distress Academics and researchers in the counselling (both to ourselves and to others in our lives), field will no doubt begin to generate their own re- what experiences could change us to have better search and commentary from a neuroscience per- lives? What experiences might we need? (p.15) spective. Educators will be challenged to integrate neuroscience into professional training programs. Neuroplasticity research confirms that new Research reports in any discipline are often difficult learning is not only possible throughout the lifes- for the average person to understand and absorb. pan, it is also inevitable. Old dogs can, in fact, learn Frequently, this results in a disconnect between the www.neuropsychotherapist.com The Neuropsychotherapist 25 empirical results of science and their application to frontal lobe of the brain plays with respect to per- field practice. Counselling-specific literature utiliz- sonality and other higher order operations. ing neuroscience has the potential to bridge this gap. Brain Imaging Neuroimaging or brain imaging involves the use In the same way that multiculturalism has be- of various tools to explore the structure and func- come a continuing theme in virtually all counsellor tion of the brain. It has evolved considerably since education programs, neuroscience will confirm its the discovery of X-rays by Wilhelm Röntgen at the place as a new force. There is still much to learn, but end of the nineteenth century. Since the 1970s, there is abundant room for optimism that neurosci- technological innovation has produced machines ence discoveries will continue to provide hope for that now provide unprecedented maps and images clients, and guidance to counsellors on how to help of the structure and activity of the brain. people repair damaged brains and slow age-related decline. Neuroscience research will develop greater Although brain imaging techniques cannot be precision regarding how chemical, electrical, and used for psychiatric diagnosis, they are useful for structural abnormalities in the brain lead to brain ruling out physical causes that may lead to psychi- disorders like Alzheimer’s and mental disorders, atric symptoms. In addition, they can show how the such as depression and schizophrenia. Along with brains of people with psychiatric conditions func- this will come new psychotropic medications, cus- tion differently. For example, studies showed that tom designed to restore equilibrium and function to during tasks involving emotions, people with de- wounded brains. The future holds fantastic possi- pression, compared to those without depression, bilities! had activity in a region in the middle of the front of the brain. Another study helped us understand Studying the Brain that people with attention deficit hyperactivity disorder have trouble paying attention because a part Neuroscientists and psychologists can learn of the frontal lobe that helps us focus is less active about the brain in many ways, including through (Sitek,2016). Findings such as this supported the dissection, neuroimaging, studying electrical activ- development of counselling strategies that help ity in the brain, animal studies, and behavioural re- ADHD people stay on task, such as establishing rou- search. They can also learn a great deal by exploring tines and quiet spaces to work where there is not how injury or disease affects normal functioning and too much stimulation. behaviour, or by monitoring the brain as it struggles to heal and recover. For example, if doctors needed MRI – Magnetic Resonance Imaging. This is a to remove a tumour from your brain and this affect- procedure that utilizes magnetic fields and radio ed your vision, they could assume that this part of waves to take three-dimensional structural pictures your brain was involved in vision. Double-blind ex- of the brain and body organs. It aids in the detec- periments are used to study the effects of medication of brain abnormalities, such as tumours, mul- tion on the brain. In a double-blind experiment, one tiple sclerosis, damage from strokes, infections and group is given a placebo, another the medication, accidents. A Functional MRI (fMRI) also utilizes and the results are compared. Neither the subjects magnetic fields, but it measures activity in the brain nor the researcher know which group is receiving while the individual is involved in different activities placebo or medication. or thought. Although fMRI can identify areas of abnormal activity in the brain, this technology has not Frontal lobotomies, which involved destroying a reached the point where it can be confidently used piece of the brain, were often used in the mid-twen- to diagnose mental illness. Future innovations may tieth century before the advent of anti-psychotic make this more feasible and reliable. medication. The results were unpredictable and often horrendously debilitating. The damage from CAT – Computerized Axial Tomography. A CAT lobotomies showed the important role that the scan uses X-rays to detect abnormalities in organs.

26 The Neuropsychotherapist Vol 5 Issue 12, December 2017 CAT scans of the brain can be used to diagnose a which use EEGs to show clients their brains electri- wide range of problems, including strokes, tumours, cal activity, teach clients through trial and error to damage from head trauma, bleeding, skull malfor- control brain wave activity as a way to reduce anxi- mations, and other conditions. ety and stress (Myers & Young, 2012). Research also suggests this strategy may be useful for conditions PET – Positron Emission Tomography. A PET such as migraine, post-traumatic stress disorder scan uses a radioactive dye that is injected into the and ADHD (Attention Deficit Hyperactivity Disor- body to measure blood flow and to detect problems der) (Nordqvist,2017). with the heart, brain, and central nervous system (brain and spinal cord). Emergent Technologies. Diagnostic methods for studying the brain are advancing rapidly with new EEG – Electroencephalography. EEGs pain- techniques such as Magnetoencephalogram (MEG), lessly and without risk measure electrical activity in used to record magnetic fields; functional near- the brain. They are used to assess or rule out condi- infrared spectroscopy (FNIRS), which uses light to tions such as tumours, stroke, head injury, and epi- record changes in brain oxygen levels; diffusion lepsy. Neuroscientists have identified five distinct MRI (DMRI), used to measure water diffusion in the types of electrical brain waves, delta, theta, alpha, brain; event-related optical signal (EROS), used to beta and gamma (Figure 3), which increase or de- assess changes in optical properties in the brain; crease depending on what we are doing or feeling. voxel-based morphometry (VBM), used to measure Techniques such as neurofeedback or biofeedback, anatomical difference in the brain; and many others (Mental Health Daily, 2017). Figure 3. Human Brain Waves Artellia/Shutterstock

www.neuropsychotherapist.com The Neuropsychotherapist 27 BRAIN BYTE: BRAIN WAVE DEPRESSION

Weill Cornell Medicine (2016) reported research utilizing fMRI analysis of over 1000 people with depression. It revealed four distinct subtypes of depression, each with unique patterns of abnormal brain activity. The results helped doctors to determine which patients were more likely to respond to different therapies such as deep brain stimulation, a procedure where electrodes planted in the brain are used to stimulate it.

Neuroplasticity: age to pursue her dreams. Her parents provided An Empowering Discovery her with a rich childhood full of challenging experiences that gave her a chance to develop a wide An exciting and relevant neuroscience finding range of interests and hobbies. As an adult, she is with enormous implications for counsellors and cli- an independent risk taker. ents was the discovery in the 1990s of brain neuroplasticity. As noted earlier, neuroplasticity refers to Clearly, Mildred’s brain is “wired” for success while the brain’s constant changing of neural pathways as Andrea has many neural pathways that, if unchal- a result of new learning, experiences, disease, and lenged, program her for failure. Although Andrea’s injury. Prior to this discovery, it was believed that past has left her ill-equipped for life as an adult, the brain remained relatively unchanged after early with time, patience, effort, and practice, her neu- childhood. It was assumed that we are born with all roplastic brain can be changed. She does not have the neural capacity that we will ever have, and that to be destined to a future defined by the realities brain damage, stress, depression and other life will of her past. Counselling can help her to reprogram result in permanent loss of this neural capacity. her brain. Using cognitive behavioural techniques, she can be helped to recognize problematic think- Peckham (2017) makes this interesting observa- ing and how this negatively impacts her behaviour tion, “nature assumes that the experiences of our and emotions. Then, with the help of a counsellor future will be similar to the experiences of our past she can take steps to reprogram unhelpful thinking (p. 14)”. So, our brain neural pathways form and and automatic responses. strengthen based on our experiences and are programmed to expect more of the same. Unfortu- How to Stimulate Neuroplasticity nately, neural pathways may form that strengthen Neuroscience has demonstrated that brain unhelpful thoughts or behaviour such as self-con- change is continuous. Every day of our lives our demnation, violent actions, or the belief that one brains change in response to every interaction, cannot cope without using alcohol or street drugs. thought, feeling and experience. For better or This reality has profound implications for a person’s worse, the structure and chemistry of the brain in in overall ability to deal with life challenges as the fol- a constant state of flux. The counselling challenge is lowing examples illustrate: to help clients increase the probability that neuroplastic change will be productive and positive. Here Example 1: Andrea grew up in an environment are some things counsellors can do and/or be famil- where she learned that “children should be seen iar with that promote neuroplasticity: and not heard”. On the rare occasions when she expressed feelings or ideas she was berated or • Encourage creativity and new experiences, punished. As an adult, she has difficulty speaking such as learning to play a musical instrument in groups or forming intimate relationships be- or a new language. Pathways in the brain that cause of her constant fear of rejection. She copes are not used are pruned, so the old adage “use by keeping to herself, essentially leading a solitary it or lose it” applies to the brain. life. • Promote client participation in exercise, which has been shown to stimulate the growth of Example 2: Mildred was encouraged from an early neural connections, slow brain decline in

28 The Neuropsychotherapist Vol 5 Issue 12, December 2017 people with dementia, and even stimulate • Help clients deal with the anxiety and stress the growth of new neurons (Budde, Wegner, that happens with change or risk taking. Ex- Soya, Voelcker-Rehage, & McMorris, 2016). cessive stress diverts energy that could oth- • Neuroscience has found that visualizing so- erwise be used for learning and action plans. lutions and success “prewires” the brain Counsellors can assist by helping clients rec- with neural pathways to those desired ends. ognize that change stress is normal and pre- One counselling strategy is the miracle ques- dictable. They can help clients predict and tion, which helps clients fantasize how their manage potential stress points. lives might change if their problems disap- • The counselling relationship itself is a power- peared. Conversely, dwelling on past failures ful ally to change. It can provide clients sup- or imagining future failure reinforces neural port, empathy, and a milieu for emergent pathways supporting failure. Consequently, problem solving. As such, its importance as counsellors should teach their clients how to a motivator and sustainer of the change pro- build and strengthen (through practice) neu- cess should never be underestimated. ral pathways by visualizing success. • Encourage clients to access physical rehabili- • Goal setting stimulates the brain with chal- tation services for brain injuries. For example, lenges. This is particularly important for Can- using repetitive movements helps the brain ada’s aging seniors as a way to slow age-relat- form new neural connections for a movement ed cognitive decline. As they retire from the such as walking that may have been damaged challenges of their jobs, it is important that by injury or illness (Liou, 2010). seniors retain a sense of purpose, so work- • Use cognitive behavioural counselling to ex- ing with them to set SMART goals (Specific/ tinguish unhelpful thinking (negative thought Measurable/Attainable/Realistic/Time Based) patterns) by replacing them with helpful helps to nurture positive brain plasticity. thinking (positive thought patterns), which Blend Images/Bigstock.com

www.neuropsychotherapist.com The Neuropsychotherapist 29 INTERVIEW HELPING CLIENTS HARNESS NEUROPLASTICITY

This brief interview excerpt illustrates a number of important counselling strategies. It introduces the idea that the client’s unhelpful thinking is an outcome of learning, not personal failure or inadequacy. The client has been talking about his fear of taking risks, which has held him back in his career and personal life.

Counsellor: The brain is like a muscle. Exer- A brief introduction helps to normalize the client’s situation cise it and it gets stronger. Sometimes, and it and offers the notion that the client is not the only one with can happen to anyone, we train our minds to this problem. do things that aren’t helpful.

Client: That makes sense. I think I’m pro- The client engages with the concept and relates it to his grammed for failure. Whenever I face a thinking patterns. challenge or new situation I keep thinking, “What’s the point? I can’t do it.” So, I don’t even try.

Counsellor: I’m guessing you’ve been doing “Not yet” lightens the mood – appropriate and timely humour this for a long time is an important part of counselling. However, “not yet” also Client: All my life. conveys the implicit message that what’s been true in the Counsellor: Well, not yet. (client laughs) past does not have to be true in the future. This communi- cates hope for change.

Counsellor: How strong is this belief? Scale The counsellor wants to get a sense of the degree that the of 1 -10? client is committed to his belief. It’s no surprise that he also Client: About an 11! (client chuckles, then shares (nonverbally) his pain. tears up) (pause of 10 seconds)

Counsellor: It hurts to think about it. Counsellor empathy is important when feelings are expressed. Client: A lot.

Counsellor: It’s not easy but what your brain The counsellor conveys hope. The interview continues with has learned can be unlearned. The brain can an example of the strengths approach in practice. The coun- be rewired sellor’s patience during the 10-second pause gave the client a Client: chance challenge his own reaction. This provided the coun- me.” (pause of 10 seconds) See, I’ve done it sellor with an opening to recognize this as an empowering again. My first reaction is, “It won’t work for strength. The counsellor might have picked up on his pessi- Counsellor: Good for you. You’ve already mism with empathy, but there was some value in ignoring the started by recognizing the pattern. That’s an pessimism and suggesting a reframe instead. The client has already declared his “normal” thinking pattern, so there is merit in not getting drawn into this too heavily. important first step. Counsellor: In the last 20 years, a lot of The relationship is now well positioned to further discuss work has been done exploring how the brain the process, then contract to explore change strategies and works. This has given us lots of guidance on action plans. how to change thinking patterns. The principles are quite simple and they work, but they require a lot of persistence and patience to rewire your brain. Client: Can you give me an example?

30 The Neuropsychotherapist Vol 5 Issue 12, December 2017 Counsellor: There are many ways, but here’s The counsellor provides a simple, non-jargonized example one. Research has shown that visualizing of an action plan that can be used to help the client change success can be just as effective in changing the unhelpful thinking patterns. brain as actually doing it. Here’s how it works. You’ll choose a situation you want to change, Letting the client know there will be challenges ahead allows one where you’ve been saying to yourself, “I the client to anticipate and strategize how to handle them. can’t do it.” Then I’ll help you imagine or play This makes it less likely that he will lose motivation when he out the situation where you are successful. faces obstacles. With practice, you’ll actually change your brain by changing the way you think. Repeti- Implicit in the action plan is the neuroscience concept that tion is the key to this wiring. It won’t be easy new learning is enhanced with practice and repetition.

the old pattern with a “12.” – like you said, it’s an “11/10”. So, we’ll fight

Reflections: • Suggest what the counsellor’s next steps might be. • What cognitive behavioural counselling principles are illustrated in the interview? • What are some of the obstacles that the client might encounter? Suggest strategies to handle them.

helps clients accept challenges and risks.. cess to enriching experiences and sports. Marco Learned unhelpful thinking is also a product was physically and sexually abused as a child, of neuroplasticity. then spent over ten years in a long series of foster • Help clients recognize the importance of sleep homes. and the need to deal with problems such as sleep apnea. Research has shown that sleep In rehab, Devin has some advantages. Although boosts neural plasticity and lack of sleep is long dormant, his brain already has neural path- damaging (Gorgoni, M., D’Atri, A., Lauri, G., ways supporting good values and sound judgment, Rossini, P., Ferlazzo, F., De Gennaro, L., 2013). whereas Marco learned that the world is an unsafe place where his physical and emotional needs will Counsellors should be aware of the fact that be unmet. With Devin, a counsellor might strate- early life experiences can play an important part in gize ways to reenergize dormant neural pathways the recovery of individuals who are later impacted that support mental and social coping, such as by by such things as trauma or substance misuse. A encouraging him to recall early memories where he key consideration is whether a client’s neuroplastic felt safe and loved. With Marco, a counsellor needs brain is wired for problem solving, resilience, and to prioritize the development of a trusting relation- healthy living, or not. An example will illustrate: ship with him. The strengths approach philosophy suggests that since Marco, as a result of his expe- Devin and his friend Marco became heavily in- riences, may have developed resilience and capac- volved with drugs in their late teens. Both had a ity, the counsellor should look for ways to recognize five-year-long history of arrests and incarcerations and build on these strengths. This approach will help when they finally entered a Montreal drug rehab counterbalance neural networks programmed with treatment centre in their early twenties. Devin was expectations that he will be abused and rejected. raised in a loving environment, where he had ac- www.neuropsychotherapist.com The Neuropsychotherapist 31 Structure of the Brain the top part of the brain stem (Figure 4). The cerebellum is associated with movement, The brain is composed of three parts: the cere- sensory perception and motor co-ordination, brum, cerebellum, and the brainstem. so it is not surprising that damage to the cerebellum could result in paralysis, tremors, • Cerebrum. The largest part, the cerebrum and problems with motor coordination (body controls higher order functions, including movements), and ataxia (loss of control of emotions, learning and sensory processing. bodily movements). As well, this part of the The cerebrum has two hemispheres (right brain is one of the areas that are adversely and left) and four lobes: frontal, parietal, tem- affected by schizophrenia (Moberget et al., poral, and occipital. Within the lobes, there 2017). It is also believed that the cerebellum is are a large number of parts, each of which has involved in a wide range of disorders, includ- at least one and more often, multiple func- ing ADHD and autism spectrum disorders, as tions. One of the major parts of the cerebrum well as mood and anxiety disorders (Phillips is the limbic system which, because of its crit- et al., 2015). Counsellors can support clients ical role with respect to emotions, is of main seeking psychotherapy treatment for exer- jor interest for counsellors. The limbic system cises that will help them deal with movement includes the thalamus, hypothalamus, amyg- and balance problems in order to reduce the dala, and the hippocampus. risk of injury from falling. For any function controlled by the cerebrum, such as emotion, memory, or decision mak- • Brain Stem. The brain stem connects the ing, there may be a major centre that regu- brain to the spinal cord and provides nerve lates it, but often as not, many other brain pathways for passing sensory information parts play a role. from various sources (e.g., spinal cord and in- • Cerebellum. The cerebellum, sometimes re- ner ear). The brain stem is essential for essen- ferred to as the “little brain” comprises about tial body functions such as breathing, heart 10% of brain volume. It can be found behind control, and sleep cycles. It is responsible for

Figure 4. The cerebellum decade3d/Bigstock.com

32 The Neuropsychotherapist Vol 5 Issue 12, December 2017 BRAIN BYTE: RIGHT- AND LEFT-BRAIN FUNCTIONS

A common belief is that people can be classified as “right-brained” or “left-brained”, suggesting that one part of the brain is used more than the other. However, recent research by the University of Utah (Tatera, 2015) has found no support for this belief and the reality is that both sides of the brain are involved in most functions.

controlling central nervous system functioning, including breathing, consciousness and The thalamus, at the top of the brainstem, acts as blood pressure. Because of the vital role regu- the brain’s switchboard relaying sensory informa- lating bodily functions, damage to it can be tion to the appropriate part of the brain. It also has a life threatening. It has three main parts: mid- part in how we perceive pain and in some aspects of brain, pons, and medulla (Figure 5). motivation, learning, memory, and emotions. The hypothalamus, located between the thalamus and The midbrain (mesencephalon) plays a role in the brainstem, is involved with body functions such sleep, hearing, vision, and the regulation of as thirst, hunger, temperature, sleep, and blood body temperature. It is also associated with pressure. vision, hearing, motor control, sleep/wake, and arousal (alertness). Hemispheres The cerebrum, protected by the eight fused The pons aids in the transmission of mes- bones of the skull, is divided into two hemispheres, sages between the cortex and the cerebel- right and left, each of which has different functions. lum. As well, it is also involved in breathing Generally, the right hemisphere controls the left and sleep. Nerves from the pons play a role in side of the body and the left hemisphere controls biting, chewing, and swallowing. the right side. The right side of the brain is more involved in artistic and creative tasks, while the left- The medulla, responsible for breathing and side of the brain is better at tasks that involve critical regulating blood pressure is essential for sur- thinking, logic and language (See Figure 6). A stroke vival. on the left side of the brain will affect the right side of the body, while a stroke on the right side of the brain will affect the left side of the body. The two hemispheres are connected by the nerve fibres of the corpus callosum, which facilitates communication between the two hemispheres.

White and Grey Matter. The terms “white matter” and “grey matter” are often used to describe brain tissue. Grey matter is composed of cells that help us think. White matter supports connections in the brain, and it supports the transmission and speed of information sharing between Figure 5. The brain stem parts of the brain. Most white Artellia/Shutterstock

www.neuropsychotherapist.com The Neuropsychotherapist 33 thinking. Damaged myelin (Figure 7) is a central feature of multiple sclerosis (MS). Medication and counselling should be utilized to help clients deal with the emotional and psychological effects of demyelination.

Brain Lobes Each of the two hemispheres has four lobes (Fig- ure 8). Although it is common to identify certain responsibilities for each lobe, the reality is that all parts of the parts of the brain are involved and activated during any function through intricate connections that are not fully understood. Neuroscientists are only at the beginning stages of unravelling this complexity.

Kitsana Baitoey/123RF The frontal lobes are often referred to as the executive portion of the brain because of their in- Figure 6. Right- and Left-Brain Functions volvement in higher level thinking. These lobes are enormously important for managing complex matter functions somewhat like the insulation behaviour, including decision making, prediction, on an electric wire. In the central nervous system appropriate behaviour, problem solving, working (brain and spinal cord), the white matter insulation, memory, impulse control, judgment, sexual and so- known as myelin or myelin sheath, protects nerve cial behaviour, and various aspects of personality. cells (Figure 5) Many things can damage the myelin Misuse of substances, stroke, or injury to this part sheath, including multiple sclerosis, stroke, infec- of the brain can cause significant problems or im- tion and excessive use of alcohol. Damage to the pairment in all of these areas. Alcohol, for example, myelin sheath is called demyelination, which can may lead to permanent frontal lobe damage that cause wide-ranging damage, including problems limits an individual’s ability to make rational deci- with emotions, movement, sight, hearing, and sions, including the decision to limit or cease drinking. In addition, alcohol and other substance may lower inhibitions and cause an individual to act irra- tionally in ways that would be otherwise controlled by the frontal lobes (e.g., impulsive behaviour, vio- lence, suicide).

Adolescents, particularly males, are more likely to engage in risky or impulsive behaviour, such as substance misuse, reckless driving, casual sex, and violent behaviour. This is partly explained by the fact that the prefrontal cortex, the front of the frontal lobe, does not fully develop until late adolescence. In addition, peer relationships and strong needs for approval may lead adolescents to increased risk behaviour. Steinberg (2008) uses neuroscience research to argue that this risk taking is inevitable. He also cites research suggesting that preventive edu- cational programs have been largely ineffective. He

BlueRingMedia/Shutterstock Figure 7: Healthy (bottom neuron) and Damaged argues that attention should shift to tactics, such as (top neuron) Myelin

34 The Neuropsychotherapist Vol 5 Issue 12, December 2017 with whom they are familiar. Counsellors can assist by helping people with prosopagnosia to develop recognition strategies, such as using voice, man- nerisms, or clothing for iden- tity clues.

Vision problems such as macular degeneration can cause disorders such as Charles Bonnet Syndrome (CBS), a condition that often causes visual hallucinations among people who have lost their sight or have severely impaired vision. Given Canada’s aging popula- Figure 8: Lobes of the Brain tion, this reality has important implications for counsellors who work with seniors. Consequently, counsellors raising the driving age, greater policing of alcohol who work with this population will want to acquire sales, and increasing access to mental health and specialized skills to assist them to deal with age re- contraceptive services. lated visual problems. Psychoeducation is vital in order to help the client and family understand the Although schizophrenia and other psychotic dis- condition, and to offer reassurance that the person orders are most often associated with the positive with CBS is not losing his or her mind (Bier, 2017). symptoms of hallucinations and delusions, cog- Referral for specialized assessment and treatment nitive impairment (e.g., memory, thinking, judg- will introduce clients to strategies for managing the ment), involving significant problems with frontal condition. This might include eye exercises (Bier, lobe executive functioning, are often far more de- 2017), alterations in lighting that might precipitate bilitating. Early recognition and treatment of psy- or exacerbate the problem (Murphy, 2012, cited in chosis is essential in order to prevent and minimize Bier, 2017), and counselling to deal with any social brain deterioration that results from untreated psy- or psychological condition resulting from CBS. chosis. The temporal lobes process auditory informa- The occipital lobes at the back of the head are tion and have some responsibility for visual memo- responsible for visual processing. When the occipi- ry and speech. Damage to the temporal lobes (e.g., tal lobe is damaged, a person will have trouble cor- trauma, epilepsy) can impact functioning in any or rectly processing what they see. For example, pros- all of these areas and also result in problems with opagnosia, or face blindness, is a disorder in which emotional response and personality changes. Both people cannot recognize faces, even with people Alzheimer’s and Parkinson’s can cause temporal

BRAIN BYTE: WHITE AND GREY MATTER

A University of California, Irvine study (2005) found that men had 6.5 times more grey matter than women, while women had 10 times the amount of white matter. Although general intelligence between the sexes was equal, the results help explain why men tend to be better with precise sciences like math-

Noiel/Shutterstock ematics while women excel with language.

www.neuropsychotherapist.com The Neuropsychotherapist 35 BRAIN BYTE: BROCA’S AND WERNICKE’S AREAS

Broca’s area is located in the left hemisphere of the frontal lobe. It plays a vital role with respect to language and speech. Damage to this part of the brain can result in a speech disorder known as Broca’s Aphasia. Wernicke’s area in the parietal and temporal lobe is essential for understanding speech and finding the right words to express thoughts. People with Wernicke’s Aphasia can speak, but not understand others.

lobe damage involving memory, especially in the responses that encourage clients to share feelings) hippocampus (Goodtherapy, 2017). might be used stimulate and encourage new thinking in the emotional areas of the brain. However, The parietal lobes process body sensations such delving into the emotional area may evoke more as touch, pain, and temperature as well as playing resistance from this client since it is not her usual a role in vision, reading, and solving mathemati- mode of processing. Nevertheless, it may ultimate- cal problems. Left parietal lobe damage can result ly be more useful for the client because it opens up in a number of problems, including “Gerstmann’s new (emotional) perspectives that have not been Syndrome,” characterized by difficulty with writing part of her thinking. The challenge for counsellors (agraphia), mathematics (acalculia), language, and is to balance respect for this client’s natural disposi- left-right confusion. Right parietal lobe damage tion and strength (i.e., logic) with appropriate and may lead to problems with self-care. A stroke in the well-timed encouragement to consider emotions parietal lobe can cause a number of spatial, visual (invitational empathy). Contracting and counsellor and sensory problems. transparency regarding the process and rationale for doing this will be helpful as illustrated in the ex- Brain Lobes and Counselling ample below. Effective counsellors utilize a range of different counselling approaches, which honour individual Counsellor: One of your great strengths is your and situational needs. Different strategies stimulate ability to logically analyze your issues, and this is different parts of the brain. For example, a client important. Not everyone is good at this and you may have great difficulty tracking and understand- are. I’m also aware that we haven’t talked much ing language, but remain quite adept at processing about your feelings. In my experience, I’ve found visual cues that draw on the occipital lobe. Activities emotions play a very important role in problem such as mindfulness and relaxation training activate resolution. Research also confirms this. So, I’m the parietal lobe. All educators know that people wondering if it might be useful for us to spend a learn better by doing, which enhances skill as well bit of time talking about your feelings. What do as memory. Hence the importance of helping cli- you think? [Note: In this example, the counsellor ents set and implement action plans for change. attempts to contract with the client to move the As a rule, the more that counsellors use a variety of interview to the affective (feeling) domain by ap- strategies, the greater the extent that they will be pealing to the client’s strength, logic and reasonable to engage different parts of the brain for un- ing ability]. derstanding and problem-solving process. The Limbic System McHenry et al. (2014) propose that counsellors Although other parts of the brain are involved, tailor their approach depending on which lobe is the limbic system (Figure.9) is often referred to as dominant for a given client. For example, suppose the control centre for our emotions. It’s also in- a client overly intellectualizes his problem with little volved in motivation and memory (Dahlitz & Hall, emotionality. Here, the frontal lobe may be domi- 2016). Because of its central role regarding emo- nant, and he may respond better to approaches tions, it is important for counsellors to have at least a such as CBT that focus on logic and thinking. At basic understanding of this part of the brain, particu- the same time, invitational empathy (counsellor larly the amygdala and hippocampus. 36 The Neuropsychotherapist Vol 5 Issue 12, December 2017 CONVERSATION: MALE AND FEMALE BRAINS

Counsellor: Are there inherent differences between Counsellor: Why are females more likely to be diag- the brains of men and women? nosed with depression? Neuroscientist: The short answer is yes. In an ar- Neuroscientist: Females have a larger, more devel- ticle, psychologist Gregory Jantz, Ph.D. (2014) sum- oped limbic system, which gives them more ability to marized a number of variances. He noted that dif- recognize and process emotions, but this may make ferences in the relative proportion of gray and white them more susceptible to depression. We should also matter in male versus female brains leave women (in consider that they are more likely to seek treatment general) more adept at multi-tasking, while men do for depressive disorders. While we are on the topic, better with highly task-focused work. Although males research has shown that women are more likely to and females have the same brain parts and neu- experience generalized anxiety disorder, panic disor- rotransmitters, the evidence is that they utilize them der, social and other phobias (Eaton, 2012). differently, leading to a tendency for men to be more Counsellor: Are there areas where men are more impulsive. Women utilize more oxytocin, the bond- likely to experience problems? ing chemical. Research supports the conclusion that Neuroscientist: Yes, men are more likely to have men are more interested in technical details and they substance abuse problems, antisocial personality are better at the exact sciences such as mathemat- disorders, ADHD, Tourette’s and they have a higher ics. Women are better with social sciences. But, let’s incidence of dyslexia. It’s often said that women are never forget that these are generalizations. There are more likely to internalize problems whereas men plenty of female scientists who outshine their male externalize with more of a tendency to act out (Eaton, counterparts. Canadian neurologist, Dr. Roberta Bon- 2012). In this sense, anger and aggression in men may actually be a symptom of depression. example. dar, the first Canadian female astronaut, is one great Neuroscientist: I want to stress that we cannot Counsellor: Culture and socialization are also at ignore environmental forces (nurture) when we play here. consider difference between the brains of men and Neuroscientist: Yes indeed. And the number of women. Our brains are shaped by experience, so the women in science is growing. One study (Ontario socialization of men and women must be considered Network of Women in Engineering, 2017) found that when we compare. the number of women in engineering programs in Counsellor: I’m wondering about the counselling Canada, once a male bastion, has grown 68% since implications of what you’ve been saying. It seems 2007. more likely that women would more readily respond Counsellor: We often hear that women are more to counsellors who featured empathic responses feeling-oriented than men. Is this supported by neu- and a greater opportunity to discuss and understand roscience research? their emotions. Action plans could feature cognitive Neuroscientist: With respect to feelings, Jantz behavioural strategies to help them avoid inter- (2014) offered that women have a larger hippocam- nalizing and self-blame, which would help combat pus and they are inclined to be more sensitive to depression. Men might be more responsive to action - before boys or girls are born, their brains devel- ities and actions to overcome depression in order to opedstimulation with different from our hemispheric five major senses. divisions Additionally, of labour. reduceapproaches any behaviour that helped that them is harmful strategize to themselvesspecific activ Female brains are able to draw on verbal centres of others. in both sides of the brain and they are often better Neuroscientist: I agree. As always, exploring indi- communicators who are more expressive, particular- vidual needs and differences through the contracting ly with respect to feelings. In this sense, women are likely to process feelings longer than men, whereas approach is best. In any case, empathy is still an effec- men are more likely to move quickly on to the next tiveprocess and isnecessary essential skill for definingfor working which with counselling men. task. As Baron-Cohen (2005) put it, “women are Counsellor: You’ve alerted me to one very important hard-wired for empathy.” Here again, remember this point. Next time I’m dealing with an angry male cli- is a generalization. No one would argue that the fa- ent, I’m going to explore whether I’m actually dealing mous Dr. Carl Rogers, the founder of person-centred with someone who is depressed. counselling, was not adept at empathy. www.neuropsychotherapist.com The Neuropsychotherapist 37 Figure 9: The Limbic System

The Amygdala and Hippocampus. repairing the hippocampus and calming the amyg- The Amygdala, an often-studied almond shaped dala to make it less reactive (Sapolsky, 2001). There brain part (limbic system, temporal lobe), is in- are a number of strategy choices trained counsel- volved in emotions such as fear and anger. As with lors can teach clients who are dealing with traumat- most brain structures, there is duplication with two ic flashbacks including: amygdalae, one in each hemisphere of the brain. • Breathing and relaxation training to calm The Hippocampus is another critical part of the emotions limbic system. It is responsible for storing memo- • Diversion ries. The hippocampus and the amygdala are con- • Thought-stopping techniques to remind one- nected, and this partnership is responsible for the self that what is occurring is not current real- strong emotions that are connected to memories. ity • Post-traumatic Stress Disorder treatment Trauma and depression can damage the amyg- such as Eye Movement Sensitization and dala and the hippocampus, but counselling can Reprocessing (EMDR), an evidence-based repair or lessen the damage. After trauma, the approach to dealing with trauma based on the amygdala often becomes hypersensitive and it may theory that emotional problems are caused quickly react to even minor stress by activating high by memories that have not been stored prop- intensity stress responses, panic, or even post-trau- erly (Shapiro & Solomon, 2010). matic stress disorder (PTSD). From both trauma and depression, the hippocampus shows reduction in volume which results in increased trouble dis- Consider a client who is afraid of public speaking tinguishing between current and past experiences to the point where even the thought of it sparks his (Bremner, 2006, Wlassoff, 2015). As a result, flash- anxiety. In response, he may use avoidance to cope backs may occur causing an individual to re-experi- with his fear. Avoidance may temporarily reduce ence a past event. Neuroscience research confirms his anxiety, but ultimately it increases both his fear that both medication and counselling contribute to and his anxiety about speaking in public. Exposure Joshua Abbas/123RF

38 The Neuropsychotherapist Vol 5 Issue 12, December 2017 BRAIN BYTE: PSYCHOPATHIC BRAINS

There is evidence that the amygdalae of people diagnosed as psychopaths are smaller, which results in the often-noted lack of fear among this group. They may also have damage to the frontal lobe, which impairs their ability to exercise self-control and good judgment (Scientific American, 2017). counselling, a best practice technique, provides IX. Glossopharyngeal – taste, swallowing a systematic way to reduce both fear and anxiety X. Vagus – heart rate, glands (Trouche, Sasaki, et. al., 2013). Counsellor manage- XI. Spinal accessory – head movement ment and support during the process increases the XII. Hypoglossal – tongue likelihood of success. Counsellors can also help clients become empowered by utilizing progressive Damage to cranial nerves can be caused by dis- relaxation, mindfulness, meditation, exercise, and ease or injury. Some cranial nerve damage can be breathing as tools to reduce anxiety, thereby re- very serious causing loss of senses such as vision training the amygdala. Damage to the hippocam- and hearing. Neuropathic nerve damage adversely pus can be addressed by medication and cognitive affects a person’s ability to feel or move.- Some behavioural counselling (Gradin & Pomi, 2008). times, over an extended period of time, people can recover from cranial nerve damage. Counsellors can The cingulate in the limbic system plays an im- support this recovery by helping clients to make life portant part in the regulation of emotions. Prob- style changes to reduce high blood pressure, in- lems such as post-traumatic stress disorder, schizo- crease physical activity, cease smoking and manage phrenia and anxiety disorders have been found to excessive use of alcohol. (John Hopkins Medicine, be (in part) related to over- or under-activation of 2017). the cingulate (Stevens, Hurley, & Taber, K. H. (2011). Counselling strategies such as the use of cognitive The Endocrine System behavioural therapy are recommended for clients The body’s endocrine system consists of a net- who have difficulty with emotional regulation. The work of glands in the body and brain, which secrete goal here is to help clients learn how to manage hormones into the blood stream. These glands anxiety (relax), and to develop more choices for produce hormones such as insulin, oxytocin, estro- dealing with emotional challenges in their lives. gen, cortisol, somatostatin, and dozens of others that control a wide range of body functions. The Cranial Nerves pea-sized pituitary gland is often referred to as the The brain has twelve pairs of nerves known as body’s “master gland” because of its control over cranial nerves. They perform various functions, in- many other glands such as the thyroid, ovaries, and cluding connecting sense organs such as the nose adrenal glands. Figure 10 presents some of the other or eyes to the brain. Other cranial nerves form con- major glands that counsellors need to understand. nections from glands and organs. Here is a list of the cranial nerves (by convention assigned a Roman Problems such as diabetes occur when the numeral) with their primary function: glands over- or under-produce hormones. For example, adrenalin is a hormone produced by the I. Olfactory – smell renal glands that mobilizes the body to deal with II. Optic – vision fear and threat. When the adrenalin level goes out III. Oculomotor – eye muscle, pupil of balance problems ensue (Figure 11). When the IV. Trochlear – eye movement delicate balance of other hormones is disrupted, V. Trigeminal – facial touch pain, chewing depression, sleep, sexual, anxiety, and weight VI. Abducens – eye movement problems may result. Counsellors who are alert to VII. Facial – taste, facial expression this possibility will want to consider referring their VIII. Vestibulocochlear – hearing, balance clients for medical assessment. www.neuropsychotherapist.com The Neuropsychotherapist 39 Figure 10: Major Glands udaix/Shutterstock

Neurons: The Brain’s Information System The nervous system is dominated by two types of cells, neurons and glia. Generally, neurons transmit information and glia cells support neurons, although recent research has revealed that glia cells are also capable of transmitting information (Dahl- itz, 2017).

There are over 80+ billion nerve cells or neurons in the brain that produce chemicals called neurotransmitters which are the key to brain functioning. Neurons are responsible for transmission of information in the brain and spinal cord. There are three main parts of the neuron (Figure 12): Timonina/Shutterstock Figure 11: Adrenalin 1. The soma (cell body) controls the neuron.

40 The Neuropsychotherapist Vol 5 Issue 12, December 2017 BRAIN BYTE: ENDOCRINE SYSTEM VERSUS NERVOUS SYSTEM

The body’s endocrine and nervous systems control the operation of the body and mind. The central nervous system (CNS) is composed of the brain and spinal cord, and the peripheral nervous system consists of nerves and ganglia outside the CNS. The nervous system uses rapid firing electrical impulses to release neurotransmitters and activate neural pathways. The endocrine system involves glands that secrete hormones into the blood stream. Its actions are slow, but long lasting. In addition to medical intervention, clients with endocrine problems may benefit from lifestyle counselling that focuses on nutrition, exercise, and anxiety management. Counsellors can help clients set goals, develop action plans, and strategize to deal with obstacles that might otherwise sabotage goal attainment. Family and social support system involvement is also an important component of success. Counsellors can play an important role by helping clients find support groups to assist them with chronic (long-term) management of endocrine conditions. Support groups are especially useful for clients who are dealing with conditions such as diabetes that require continuous daily attention and motivation, which can be emotionally taxing.

2. The dendrites receive information from other 13) to another neuron (receptor neuron or postsyn- neurons that are then sent to the cell body. aptic cell). Their release is triggered by chemicals in 3. The axon is covered by myelin (myelin sheath), the body (e.g., sodium and potassium) which create which protects it and aids in the transmission an electrical charge that causes the neuron to fire of electrical signals. These signals are critical (i.e., release the neurotransmitters. Neural path- for activating neurotransmitters, chemicals ways, once activated, allow us to complete all of the which enable one neuron to communicate functions of daily living – thinking, moving, breath- with another. Dendrites on neurons receive ing, for example. and transmit electric signals. If the neurotransmitter causes the receptor neu- Neural transmission. Neurons could not com- ron to fire, it is now activated to signal other neu- municate and the brain could not do its job with- rons to fire. This creates a neural pathway, which out neurotransmitters. The neurotransmitters are may involve hundreds of thousands of neurons in released by one neuron, then they travel across a the brain. Neural transmission ends when the neu- small gap called a synapse or synaptic cleft (Figure rotransmitter returns to the neuron that released it, Figure 12: The Parts of the Neuron joshya/Shutterstock

www.neuropsychotherapist.com The Neuropsychotherapist 41 neural pathways become en- trenched and automatic. Ideally, children grow in a consistent and nurturing environment where neural pathways develop that support healthy self-esteem, empathy for others, and a capacity for appropriate risk taking. Unfortunately, problematic neural pathways such as those that sustain unhelpful thinking (e.g., un- realistic anxiety, self-defeat- ing thought), can form. With every replay of an unhelpful Designua/Shutterstock Figure 13: Synapse thought, the neural pathway becomes stronger and more a process called reuptake. Reuptake is an efficient resistant to change. Practice makes the thought au- process that allows for “recycling” of the neuro- tomatic. transmitter. Some medications temporarily prevent reuptake allowing the neurotransmitter to remain Newton’s famous first law of motion states that active longer. For example, Prozac© prevents the objects at rest tend to stay at rest, and objects in reuptake of serotonin which relieves the symptoms motion tend to stay in motion unless acted on by of depression. some force. This law also seems like an apt description of how the will brain continues to repeat estab- Different neurons have different shapes and func- lished patterns unless something is doe to interrupt tions. Sensory neurons transmit information from it. the sensory organs (skin, eyes, ears). Motor neurons carry information from the brain to the limbs. When There is hope! Problematic neural pathways can a neuron receives a neurotransmitter, it is called a be replaced and neuroscience teaches us how to do receptor neuron or postsynaptic cell. Receptor neu- it. Counsellors, using techniques such as cognitive rons are programmed to accept one specific neuro- behavioural therapy help clients to curb unhelpful transmitter for which it is programmed. Its shape is thinking by replacing unhealthy neural pathways like a lock that can only be open by a key, its assigned neurotransmitter. Figure 14 illustrates types of neuron receptors.

“Neurons that fire together wire together”. This famous phrase was coined by the Cana- dian neuropsychologist Donald Hebb, who observed that learning and repetition creates strong and enduring neural pathways. Neural pathways strengthen with repetitive behaviour, thoughts, or emo-

tions. Subsequently these “wired” Designua/Shutterstock Figure 14: Types of Neuron Receptors

42 The Neuropsychotherapist Vol 5 Issue 12, December 2017 SUCCESS TIP: NEUROPLASTICITY AND CHANGE

This simple truth, long a mainstay of cognitive behavioural counselling, and now confirmed by neuroscience research on brain plasticity, is that the key to change and managing problematic behaviour is practice and repetition of new behaviour to build new or replacement neural pathways. with new pathways that support mental wellness. another (firing). Among the more significant neuro- Since the problematic neural pathways are “wired transmitters are serotonin, dopamine, glutamate, together” considerable repetition with the replace- acetylcholine and GABA. Neurotransmitters are ment thoughts or behaviour will necessary in order further classified according for function as excita- to effect change. Counselling can be the force that tory or inhibitory. changes the fixed momentum of the brain. Coun- sellors can support clients by helping them to un- Abnormally low or high levels of a particular neu- derstand, anticipate, and manage the challenges rotransmitter or breakdowns in the electrical sig- that changes to wired neural pathways entails. nalling that fires neurons are often major causes of physical and psychiatric disorders. For example, Counsellor: If we continue to do, think, or feel faulty electrical signals can lead to epilepsy or cause something, it becomes automatic. Even when the tremors associated with Parkinson’s disease. we know it’s not helpful, we may keep doing it because our brains are programmed to keep us Excitatory neurons. These neurons send neuro- on the same path. When we try to change, our transmitters such as epinephrine and norepineph- brains, out of habit, may sabotage the change rine that stimulate the brain and increase the likeli- and we end up going back to the same old pat- hood that a receptive neuron will fire. tern. Client: So, am I stuck? Glutamate — associated with learning and mem- Counsellor: No! The good news is that change ory. Glutamate abnormalities have been linked is possible, but it takes a plan, patience and prac- to a number of mental disorders, including Alz- tice. As part of this, it will be important to expect heimer’s, autism, obsessive compulsive disorder to feel some anxiety, maybe fear. But, anxiety (OCD), schizophrenia, and depression. (National can be a positive sign that that you are moving Institute of Mental Health, 2015, McGill Univer- forward, making changes. If you agree, we can sity, 2015) Glutamate is the main excitatory, and work together to make this happen. most plentiful neurotransmitter in the brain. Norepinephrine (also called noradrenaline) — Major Neurotransmitters an excitatory neurotransmitter that activates Neuroscientists have identified over 100 differ- and mobilizes the body’s stress response. Abnor- ent neurotransmitters. Some neurotransmitters mally levels of norepinephrine can lead to physi- such as dopamine, serotonin and norepinephrine cal and psychological problems (see Figure 15) also act as hormones, released by the endocrine system into the blood stream, whereas neurotrans- Dopamine — involved in many functions, includ- mitters are released from one neuron of the brain to ing movement, attention and problem solving. It

BRAIN BYTE: ENDORPHINS

Endorphins (endogenous morphine) pituitary gland and the hypothalamus interact with opioid receptors (neurons) in the brain to produce pleasure and reduce pain. Exercise, chocolate, and sex are known to release endorphins. www.neuropsychotherapist.com The Neuropsychotherapist 43 Figure 15: Norepinephrine Figure 16: Dopamine

is most often associated with mood and it is re- temperature, pain, appetite, and sleep. Lower leased when we are involved in activities that we levels of serotonin are believed to be associated find pleasurable. Subsequently, this motivates with depression, impulsiveness, and aggression. us to repeat actions which release dopamine. A (It should be noted that there is some controversy deficit in dopamine can result in Parkinson’s dis- about whether depression is in fact a result of low ease. As well, there is evidence that dopamine serotonin levels and some neuroscientists such as abnormalities may be a factor in schizophrenia or Arden (2015) argue that the actual causation is attention deficit hyperactivity disorder (National much more complicated.) Excessive serotonin can Institute of Mental Health, 2015). However, it is lead to a potentially fatal and very dangerous likely that other neurotransmitters and causa- condition known as serotonin syndrome (Mayo tive factors are also involved when a person has Clinic, 2017a) with symptoms of high fever, ir- schizophrenia (Brisch, Saniotis, et al., 2014). Fig- regular heartbeat, and seizures. This may occur if ure 16 illustrates the impact of excess and defi- clients take too much medication or if they take cient dopamine. their medication with other medicines or illegal drugs. Figure 17 depicts the impact of excess or Inhibitory neurons. These neurons send neuro- deficient serotonin. transmitters such as serotonin and GABA) calm the brain and decrease or inhibit other neurons from fir- Anti-depressant medications such as Prozac can ing. rapidly increase serotonin levels, however, counsellors should be aware that it may take weeks Serotonin— a major inhibitory neurotransmitter for medications to impact depression (Andrews, that is found mostly in the gastrointestinal tract Bharwani, Fox, & Thomson Jr, (2015). Counsel- and the brain stem. It helps regulate mood, body lors can remind clients of this fact and encourage

BRAIN BYTE: DOPAMINE

Addictive drugs create an enormous surge of dopamine in the brain creating an elevated level of pleasure (drug high or rush). In turn, this increases the drive (motivation) to continue to use drugs in order to

recapture the rush from the drug. Timonina/Shutterstock

44 The Neuropsychotherapist Vol 5 Issue 12, December 2017 been able to hang in there. That’s a real strength.

Acetylcholine — linked to central nervous system functions, including wakefulness, attentive- ness, anger, aggression, sexuality, and thirst. It also plays a role in Alzheimer’s. (McGill Univer- sity, 2015) (Note: sometimes acetylcholine acts as an excitatory neurotransmitter while at other times, it functions as an inhibitory neurotransmitter. This depends on the type of receptor neuron that absorbs it.)

GABA (gamma-aminobutyric acid) — plays a role in controlling fear and anxiety, motor control and vision. Adequate levels of GABA are critical for relaxation. Abnormalities can cause anxiety, disturbances in mood, sleep, epilepsy, and pain (WebMd, 2015). It is the main inhibitory neuro- Figure 17: Serotonin transmitter in the brain.

them not to abandon treatment prematurely Mirror Neurons. These are neurons that fire in before the medication has had a chance to take response to another person’s actions or words in effect. In the following example the counsellor, the same way as those of the other person. Mirror while careful not to give medical advice, supports neurons are active when we watch a hockey game, the client’s relationship with the doctor, provides attend a movie, and especially when we witness or general guidance regarding medication compli- hear the emotions of others. When a client expresses ance, and acknowledges the strengths of the cli- emotions, mirror neurons in the counsellor may re- ent. act with the same emotions. This phenomenon has powerful implications. For one thing, it may leave Client: The doctor put me on an anti-depressant counsellors vulnerable to vicarious trauma from the a few weeks ago, but it’s not working. I haven’t cumulative impact of working with clients who have given up, but I’m wondering if it’s worth the ef- been traumatized. It also presents counsellors with fort. opportunities for empathy if they pay close atten- Counsellor: What did the doctor tell you about tion to their own emotional responses. For exam- the meds. ple, if a counsellor is feeling lost and confused as he Client: Lots! But, I don’t remember any of it. listens to his client, he could use this observation to inquire whether his client is feeling the same. Counsellor: Did she say anything about how long it might take for the medication to work? Counsellor: I’d like to know how you might be Client: Now that you mention it, she did say it feeling right now. I’m feeling a bit lost and I won- might take a while. der if that’s also happening for you. Counsellor: Sure. Sometimes these meds can Client: Oh good! It’s not just me. I’m totally take a month or longer to kick in. And some- muddled. times, you might need a higher dose, or even a Counsellor: Okay, what do we need to do to get different drug. So, you need to be…. back on track? Client: Patient? Counsellor: Also, street drugs may interfere, Although our own mirror neurons might be one so it’s important to let your doctor know if you Timonina/Shutterstock cue that aids in the experience and expression of are using. By the way, I’m impressed that you’ve empathy, they are only one part of a very complex www.neuropsychotherapist.com The Neuropsychotherapist 45 system of empathic perception. Counsellors need rons, or protecting the neuron (myelination). to remember that their own prior learning, experience, culture, and their present mood impact the Reward Pathway receptivity and accuracy of their mirror neuron re- The reward pathway (or pleasure pathway) is a actions. Siegel (2012) presents an example that un- pathway in the brain that reinforces or rewards ac- derscores the importance of tentativeness when tivities with dopamine that it finds pleasurable. The interpreting client behaviour or inferring emotions: reward pathway involves ventral tegmental area, the nucleus accumbens, the prefrontal cortex, the If you are from New York City and I raise my hand hippocampus, and the amygdala. in front of you, you may imagine that I am hailing a cab. If you are currently a student, you may im- Pleasurable sensory experiences (e.g., food, sex, agine that I am intending to ask a question. If you positive relationships) cause the reward pathway in have been abused, you may feel that I am going the brain to release dopamine, which creates feel- to hit you (p. 166.) ing of well-being. Dopamine also acts as a reinforc- er, which increases the probability (motivation) that Glial Cells the individual will repeat the experience that gen- In the brain, glia cells or glia, which are far more erated the reward. Many prescribed medications plentiful than neurons, provide essential support such as opiate-based pain killers and most street to neurons. Without them, neurons would be un- drugs, such as heroin, cocaine and methampheta- able to do their work. There are five main types of mine also activate the pleasure pathway. They do so glial cells with the exotic names, Astrocyte, Micro- in dramatic ways that flood the brain with massive glia, Oligodendroglia, Ependymal, Satellite and amounts of dopamine, which causes disruption and Schwann. Each of them have specialized functions damage to the normally balanced reward pathway. such as carrying nutrients, disposing of dead neu- This damage reduces the person’s capacity to expe-

46 The Neuropsychotherapist Vol 5 Issue 12, December 2017 SUCCESS TIP: INTERGENERATIONAL TRAUMA AND EPIGENETICS

There is support for the conclusion that the epigenetic impact of historical trauma such as that experienced by Aboriginals in the Residential Schools may well have accumulated over generations, negatively impacting the collective health of the whole community (Bombay, Matheson, & Anisman, 2014). This finding can help clients and counsellors understand the long-term impact of trauma experienced within their family and Nation.

rience pleasure for normal activities, and the drug fine the outcome of their lives. Change is possible. becomes the only way to feel okay. As a result, the Using techniques, they learn in counselling, clients drive to use the drugs increases, and it may become have the ability to influence whether genes activate. the dominant force in the person’s life. Continued use of the drug leads to tolerance and every increasing levels of it are required to achieve the desired Brain Problems effect, or even to feel “normal”. The brain has undeniable remarkable ability and capacity, yet it is very fragile. Although protected Epigenetics somewhat by the skull, it is vulnerable to injury as Genes, which we inherit from our parents, con- well as disease. Sometimes, recovery is possible tain the code or instructions that define us, includ- and the brain has the capacity to reprogram itself ing the colour of our eyes, how we look and our sus- to compensate for damage. Sometimes, damage ceptibility to certain diseases. Epigenetics is the is irreversible and degenerative as with Alzheimer’s study of how certain genes can be activated or de- for which there is not yet a cure. There are over activated by life experiences such as nutrition, en- 400 different neurological diseases and disorders vironment, poverty, and especially trauma. Studies (Brainfact.org, 2017). The following subsections have shown that epigenetic gene changes from life will explore common and significant disorders of experience may trigger depression, schizophrenia, the brain. alcohol abuse, anxiety and many others in those already predisposed genetically to these conditions Mental Disorders (Albert, 2010; Ptak, & Petronis, 2010). For example, The Diagnostic and Statistical Manual of Men- a review by Radhakrishnan, Wilkinson, & D’Souza tal Disorders (DSM-5) describes and classifies hun- (2014) revealed how marijuana can trigger psycho- dreds of different disorders arranged in develop- sis in some individuals who are predisposed to it. mental sequence. Of significance to counsellors is the fact that- epi genetic gene changes caused by experience can be Meningitis passed down to future generations. Meningitis is a viral inflammation of the lining of the spinal cord or brain. Spread by close contact Further research will no doubt reveal more spe- with others, it is an extremely serious condition that cific information regarding how and when intergen- requires immediate medical attention. erational genetic change occurs, and this will offer guidance regarding customized counselling inter- Encephalitis ventions to prevent (ideally) or address problems. Encephalitis is an inflammation of the brain. It is What we already know is that a range of counsel- usually caused by viral infection. Symptoms might ling interventions, including the counselling rela- include fever, headache, and sometimes confu- tionship itself, diet, exercise, sleep, and providing sion or seizures caused by the inflammation. Some safe environments for those affected by trauma can people experience personality changes, memory lessen the effects of adverse epigenetic experiences loss, and hallucinations (Health Link BC, 2017). It is (Dahlitz, 2016). Epigenetics offers the empowering treated with antiviral medication and recovery can idea that our clients’ genetic codes do not fully de- take months. darrenmbaker/Bigstock.com

www.neuropsychotherapist.com The Neuropsychotherapist 47 Brain tumours ment, as well cognitive and emotional decline. Ap- Brain tumours can be benign (non-cancerous) or proximately 1 in every 1000 Canadians has Hun- malignant (malignant). They are treated in a variety tington’s, and children who have a parent with the of ways, including surgery, chemotherapy, and ra- disorder have a 50% chance of developing the dis- diation. ease (Huntington Society of Canada, 2017). There is now a test to determine if an individual will develop Amyotrophic lateral sclerosis (ALS or Lou Huntington’s Disease. Counsellors may have a role Gehrig’s disease) supporting people who are trying to decide wheth- ALS is a progressive, fatal disorder in which the er to take the test. brain’s motor neurons that carry signals from the brain to the body break down and lose their abil- Multiple sclerosis (MS) ity to communicate with muscles. There are about MS is an autoimmune disease in which myelin, 3000 Canadians living with ALS (ALS Society of a cover protecting nerves, is damaged resulting in Canada, 2017). disruption of nerve impulses. Symptoms are unpredictable and vary widely. They may include fatigue, Cerebral palsy muscle weakness, vision or mood problems. Sig- Cerebral palsy (CP) is a disorder resulting from nificantly, for reasons not yet known, Canada has brain damage before or during birth that affects one the world’s highest rate of MS, with 1 in 340 body and muscle movement. CP affects 1 of every Canadians living with the disease (Multiple Sclero- 500 people in Canada (Cerebral Palsy Association sis Society of Canada, 2017). Counsellors can assist of British Columbia, 2017). Symptoms vary widely clients with MS deal with the social, emotional and from person to person with some only mildly af- financial effects of the disease. Family counselling fected while others require constant care. can provide a safe venue for people to deal with the often difficult emotional and relationship issues -as Epilepsy sociated with the disease. Epilepsy is a non-contagious brain disorder where Parkinson’s disease nerve cells in the brain cause a person to have seizures, although not all seizures involve convulsions. Parkinson’s is a progressive brain disorder caused In Canada, about 0.6 percent of people have epi- by the brain’s deteriorating inability to produce do- lepsy (Epilepsy Canada, 2017). It may be caused by pamine, a neurotransmitter critical to movement such things as tumours, infection, or injury to the and the regulation of emotions. Most people are brain. It is usually treated with anticonvulsant medi- familiar with the tremors caused by Parkinson’s, cation. One additional challenge for people with ep- but symptoms can also include fatigue, movement ilepsy is dealing with the stigma and discrimination problems, sleep disturbance, cognitive decline, and that often accompanies the disease. mood problems, especially depression. L-dopa, which the brain converts to dopamine, is the most Huntington disease common medication. Parkinson’s, affecting over 100,000 Canadians (mostly seniors), is the second Huntington disease (HD) is an inherited brain dis- most common neurodegenerative disorder after order which causes the brain cells to die, leading to Alzheimer’s (Parkinson Canada, 2017). a gradual, eventually fatal inability to control move-

SUCCESS TIP: WHAT TO DO IF SOMEONE IS HAVING A SEIZURE

Stay calm. Don’t try to restrain the person or put anything in their mouth – she will not swallow her tongue. Make sure the area around them is safe by moving hazards such sharp objects or items that could injure. Cushion the person’s head. After the seizure stops, position the person on their side.

48 The Neuropsychotherapist Vol 5 Issue 12, December 2017 Tourette syndrome disease characterized by problems associated with Tourette syndrome (TS) is a neurological disorder memory and thinking (Alzheimers.net, 2017). Of characterized by repetitive vocalizations and invol- particular significance is the fact that up to 50% of untary tics. It was named for Dr. Georges Gilles de persons with dementia, including Alzheimer’s, are la Tourette, a French neurologist who diagnosed clinically depressed, but adult depression does not the condition in 1885. Tics can include eye blinking, increase the likelihood of dementia (Singh-Manoux, lip-licking, shoulder shrugging, and head jerking. It Dugravot, Abell, et al., 2017). might involve involuntary hopping, jumping or spin- ning, as well as meaningless vocalizations (Tourette Alzheimer’s disease, the most common form of Canada, 2017). The Canadian Psychological Asso- dementia, was first described by Dr. Alois Alzheimer ciation (2017) suggests that the prevalence of Tou- in 1906. It is an irreversible, fatal disorder that re- rette’s is about 0.005 percent of the population and sults in behavioural and emotional decline, as well is more likely to affect males. as brain shrinkage (especially in the hippocampus), deterioration, and cell death. Post-mortem micro- Medication and specially designed behavioural scopic analysis of the brain tissue of people with Alz- and cognitive counselling techniques are used to heimer’s show abnormal protein clusters (plaques) treat Tourette’s. Deep stimulation and transcranial and twisted strands of other proteins called tangles magnetic stimulation (TMS) are also being explored (see Figure 18). Plaques and tangles will be very as potential treatment options (Tourette Canada, prevalent in areas of the brain related to learning 2017). and memory. This helps explain the reasons for some of the common symptoms of dementias such Dementia as Alzheimer’s (see Figure 19). Most people have heard of the terms dementia and Alzheimer’s and often they are used inter- Alzheimer’s disease mostly affects people over changeably, but there are differences. Dementia, 65 years old, with the risk increasing with age, but now known as neurocognitive disorder in DSM-5 is early onset can occur in people as young as 40 (Graff- a general term that includes a large number of dis- Radford, 2017). Canada’s rapidly aging population orders such as Alzheimer’s disease, Huntington’s means that there will be a dramatic increase in the disease, Parkinson’s disease and Creutzfeldt-Jakob number of Canadians who are dealing with this dis-

Designua/Shutterstock Figure 18: Cell Deterioration with Alzheimer’s Disease

www.neuropsychotherapist.com The Neuropsychotherapist 49 Late – severe impairment with profound inability to communicate, recognize family and friends, or care for themselves. Continuous care is required. End of Life – symptoms progress further and 24 hours per day care is necessary.

Counselling People with Dementia and Alzhei- mer’s Disease

• Empathy. Counsellors should be aware that an Alzheimer’s diagnosis is a terrifying experience, not only for the patient, but also for everyone in their lives. Patients and caregivers may be reluctant to share their feelings with each other, but be quite willing to open up to a non-judgmental counsellor who is Figure 19: Symptoms of Dementia willing to listen as they share powerful emotions. In this regard, counsellor empathy is an important part of helping people deal with ease. The Alzheimer’s Association of Canada (2017) the emotional impact of the disease. estimates that there are currently about 565,000 Canadians with Alzheimer’s, but this number will • Hope. Alzheimer’s is a progressive disease, grow to 937,000 in the next 15 years. In addition to meaning that the symptoms worsen with the enormous costs (currently estimated by Alzhei- time. The Alzheimer’s Society of Canada mer’s Association at 10.1 billion dollars a year), this (2017) notes that although some dementias disease will increasingly require professional coun- are reversible, Alzheimer’s is not. Counsellors sellors who are well versed in its presentation to need to avoid conveying false hope that “eve- provide support services to patients and caregivers. rything is going to be all right.” On the other hand, hope and optimism can be built on the The Alzheimer’s Society of Canada (2017) identi- knowledge that some of the symptoms can be fies four stages to the disease: managed with medication and counselling. People diagnosed with it can lead meaning- Early – mild symptoms and problems with mem- ful lives for many years. Enormous brain re- ory, communication, mood and behaviour. At this search is now underway to find ways to diag- stage people are generally able to cope, perhaps nose, prevent and cure this complex disease. with some assistance. Although a cure has still evaded researchers, new medications and insights about the dis- Middle – worsening of symptoms. People may ease give reasons to be hopeful that a cure require assistance with daily living tasks. Clearly, and treatment will be found. this puts steadily increasing demands on caregivers, so they may also need considerable support. • Structure. Establishing routines and famili- arity can help to calm people with dementia

BRAIN BYTE: SUNDOWNING

As many as 20%–45% of people with dementia experience “sundowning” or late day confusion, characterized by a deterioration in their condition in late afternoon and evening. Counsellors and caregivers can watch for and manage triggers such as low or fading light, fatigue, depression and sleep disturbance (WebMD, 2017). Sticking to routines, minimizing stress, dietary management, and exercise can help reduce frequency and symptoms (Roth, 2017). arka38/Shutterstock

50 The Neuropsychotherapist Vol 5 Issue 12, December 2017 SUCCESS TIP: DEMENTIA

Put emphasis on what clients can do and what they can be supported to do rather than on what they can’t do or are incapable of doing. Be creative!

CONVERSATION: COUNSELLING PEOPLE WITH DEMENTIA

Student: I’ve just found out that my training counsellors can help those with vision problems placement will be in a centre that deals with clients to access audio books. Anxiety can be reduced by who have dementia. What are the important things promoting such things as consistent routines and for counsellors to remember when working with reminders for those with short-term memory loss. people who have dementia. Putting out familiar objects (e.g., pictures and Counsellor: For one thing, it is important to re- memorabilia) can serve as comforting reminders. member that symptoms can range from very mild Counsellors can help caregivers understand the im- to severe. Consequently, no single recipe for coun- portance of keeping living quarters organized and, selling is possible, and interventions must be cus- if useful, putting signs on doors such as the bath- tomized to individual needs and capacities, just as room to reduce confusion. they are for clients without dementia. Even those Student: What about specific interviewing and with significant impairment may retain some cog- counselling skills? nitive capacity and strengths. For example, clients Counsellor: Here again, there is no one size fits with advanced dementia may still be able to ex- all answer. But generally, counsellors should speak in press themselves with music or art. So, put priority a slow, calm, reassuring manner. Because of cogni- on finding and using strengths, including areas of tive decline, counsellors need to allow time for their the brain that have not been damaged. clients to answer. Counsellors need to be comfort- Student: What else? able with silence and the onus is on them to adjust Counsellor: Although many dementias, espe- pace to meet their clients’ needs. When short-term cially Alzheimer’s, have no cure, some of the com- memory loss is an issue, frequent simple repetitions monly co-existing conditions such as anxiety and and summaries may help. Targeted, short answer depression can be addressed medically and with or questions are preferable to those that require counselling. As much as possible, keep clients in- extended or complex responses. It is also impor- volved in decision making and planning. This helps tant for counsellors to remember the tremendous them retain a sense of control and purpose. Since strain that caregivers often face. Discuss with them boredom is a major cause of depression among the importance of self-care. And that also applies to seniors, including those with dementia, help them you too! There is a lot more information out there. find meaningful and stimulating recreational activ- I’d suggest the local Alzheimer’s Society as a good ity that can help combat depression. For example, place to start.

BRAIN BYTE: IS IT NORMAL OR DEMENTIA?

About 40% of people over 65 will have some memory loss – this “age associated memory loss” is normal and not a sign of dementia. Dementia is characterized by more severe memory loss such not being able to recall the names of family members or recent conversations and events (Alzheimer’s Society of Canada, 2017). www.neuropsychotherapist.com The Neuropsychotherapist 51 who are anxious and dealing with an increasingly forgetful mind. Counsellors can review their client’s pre-dementia routines with their families with the goal of retaining as much of this as possible, even if the client is now in in- stitutional care. • Empowerment. Based on individual capacities, counsellors can look for ways to help clients regain or retain control and power over their lives. Many counselling strategies might be adapted, including involvement in decision making; respect for choices such as where and how clients wish to live their lives; and the identification of activities and tasks that give clients a sense of purpose. • Support for Caregivers. Taking care of someone with dementia requires relentless dedication and personal sacrifice. Counsellors can contract to offer caregivers assistance such as information and guidance about dementia and its stages; education on strategies for communicating and dealing with the challenges presented by the person with de- Figure 20: Stroke Warning Signs mentia; links to support groups; assistance to access respite care;, and personal counselling to deal with their emotions and the difficult decisions caregivers must make such as mov- 2. Hemorrhagic stroke occurs when conditions ing their loved one to a care facility. such as high blood pressure cause arteries in the brain to burst. Stroke 3. Transient ischemic attack (TIA) or mini stroke occurs when a clot blocks an artery. Al- A stroke occurs when blood flow to the brain is though they may not cause damage, TIAs are blocked. Some of the major warning signs of stroke a warning sign that should be taken seriously. are depicted in Figure 20. Although a stroke can occur at any age, nearly three-quarters happen to peo- The effects of a stroke can vary greatly from mild ple over age 65 (The Internet Stroke Center, 2017). to catastrophic. The Cleveland Clinic (2017) reports that a stroke in the right side of the brain can lead There are three major types of strokes: to symptoms such as attention and perception difficulties, trouble processing information, poor judg- 1. Ischemic stroke occurs when a plaque causes ment and communication problems, as well as at- a blockage or clot in the brain. tention and memory problems.Left-brain strokes

SUCCESS TIP: FAST STROKE SIGNS

Face – is it drooping Arms – can you raise both arms Speech – is it slurred Time to call 911 (Heart and Stroke Foundation of Canada, 2017) Irina Strelnikova/Shutterstock/Shutterstock Irina

52 The Neuropsychotherapist Vol 5 Issue 12, December 2017 SUCCESS TIP: INTERVIEWING SKILLS (STROKE AND APHASIA)

Clients who have had a stroke may need more time to process information, so they should not be pressured to respond quickly. Interrupting a silence may deny clients the opportunity to express their thoughts and emotions. Speak normally and keep words and comments simple at a level the client can understand. It may also be helpful to use closed questions to get specific information as well as summaries and paraphrases to confirm understanding. Visual cues and gestures can activate other areas of the brain that are not damaged.

may result in paralysis on the right side, and commu- to deal with the aftermath of a stroke, and family nication problems such as slurred speech, Broca’s counselling. There are a number of risk factors for Aphasia (difficulty with speech, understanding, and stroke which counselling can appropriately address, language) and Wernicke’s Aphasia (difficulty find- including smoking, weight control, sedentary life- ing words and/or using nonsensical words). People style, and heavy drinking. with aphasia have difficulty with language and communication, but their difficulty is not a measure of Counsellors can refer or encourage clients to use their intelligence. services such as physiotherapy, occupational therapy and neurotherapy. Neurotherapy centres, avail- A variety of medications are used to treat and/or able in most major cities in Canada, can customize prevent stroke, including blood thinners, cholester- brain treatment to specific areas of the brain that ol lowering medications, clot busters, blood pres- have been damaged by stroke. sure and cholesterol lowering medications (Heart and Stroke Foundation of Canada, 2017). As well, Traumatic Brain Injury (TBI) and Acquired Brain medications to treat anxiety and depression, which Injuries (ABI) Hackett & Pickles (2014) found occur in 33% or more Traumatic Brain Injury (TBIs) and Acquired Brain of stroke patients, may be used. Injuries (ABIs) include head trauma (from whiplash, falling, or blows to the head), as well as damage Counsellors may be involved in a variety of caused by sports injuries, disease (e.g., heart at- ways, including lifestyle stroke prevention, cogni- tack, seizure, tumours, and infections), poisoning tive behavioural and problem-solving counselling and drug abuse (Brain Injury Canada, 2017). The fre- rocketclips/Bigstock.com

www.neuropsychotherapist.com The Neuropsychotherapist 53 quency of brain injury in Canada is rising, with over injury, but recovery can be maximized through rep- 160,000 Canadians sustaining brain injuries every etition of rehabilitation exercises to enhance brain year, about 50% of which are the result of motor ve- plasticity. Counsellors can help by assisting clients hicle accidents and falls (Brain Injury Canada, 2017). to access local rehabilitation professionals, and by providing supportive counselling to sustain client One common type of brain injury is a concus- motivation during what might be a long period of sion, which can cause symptoms such as loss of recovery requiring patience and continued effort. consciousness, headache, dizziness and confusion and mood changes. Usually, with rest, a concussion Brain and spinal cord injury are potentially cata- will heal, but sometimes medical intervention is re- strophic events with the potential to cause paralysis quired to deal with more serious symptoms such as as well as impact consciousness. The Mayo Clinic internal bleeding. (2017b) describes five different states of consciousness: Canada’s aging seniors are one group at risk of abuse by a family member or caregiver, usually an • Coma – a state of unconsciousness that may adult child. Counsellors should consider the possi- be temporary or permanent. bility that TBI could be the result of abuse. Sensi- • Vegetative state – person is unaware of what tive and non-judgmental interviewing can be used is happening but they may retain some re- to provide an opportunity for the person to disclose sponses (open eyes, sounds, respond to re- abuse. Although there is no legal “duty to report” flexes). abuse of adults, counsellors have a professional • Minimally conscious state – severed altered responsibility to look for ways to ensure that their consciousness, but some awareness of sur- client has a safety plan, with options, including po- roundings. lice intervention, transition homes, family counselling, and anger management for the abuser. Where • Locked-in syndrome – person is aware, un- abuse of a child is suspected, Canadian laws re- able to respond, but may be able to commu- quire that this be reported to the appropriate child nicate with eye movement. welfare authorities. Further in-depth interviewing • Brain death – no activity in the brain and should be suspended and deferred to the responsi- brainstem. ble child welfare specialist. TBI can precipitate a wide range of social and psy- After injury or stroke the brain does not regen- chological problems. Since affected individuals may erate damaged tissue. However, the brain’s re- not be able to work in their chosen profession, em- markable plasticity may enable it to reorganize ployment-counselling professionals can work with (reprogram) neural pathways to allow partial or full them to secure retraining or income replacement. recovery over a period of time. It is analogous to a They can also help clients deal with the emotional road detour. When a part of the brain is unable to loss (grief) associated with an unplanned interrup- continue its work because of injury, it is capable tion in their work, which may result in “depression, of rewiring itself to move the work to a different, anxiety, relationship strain, failed attempts at return- healthy area. Recovery outcome is impacted by ing to work, substance use, loss of self-esteem, and many factors, including age and the nature of the PTSD related to a TBI” (Maucieri, 2012) Since family

SUCCESS TIP: BRAIN HEALTH

The positive impact on brain health of factors such as exercise, diet, social relationships, reduction of substance use, including smoking, housing, sleep, reduction of stress, positive thinking, employment, engaging in stimulating brain activity (reading, education, games), and spirituality have been well docu- mented in the literature. All of them are valid choices for contracting in a comprehensive counselling plan.

54 The Neuropsychotherapist Vol 5 Issue 12, December 2017 members are directly impacted by a loved one’s TBI, thoughts on the pros and cons of taking the they may need to be considered or included in any genetic test to determine if you will develop counselling intervention. the disease. Summary 5. What are your strongest neural pathways? • The brain is a complex organ that controls all What events or experiences made them the functions of the body, including what we strong? Which are helpful to you in leading do, see, hear, and think. your life? Which are problematic? • Neuroscience as a new force in counselling 6. Do you think biology and neuroscience will joins psychoanalysis, behaviourism, human- be able to explain the “mind?” ism, multiculturalism, and social justice. • There are diverse ways to study the brain, in- SKILL PRACTICE cluding dissection, animal studies, the impact of injury or disease, and neuroimaging. 1. Change your neural patterns by visualizing • Neuroplasticity refers to the brain’s continu- (imagining) change. Identify a situation in ous changing of neural pathways as a result of your life where you would like to change how experience and learning. you think, behave or act. Set a specific goal. Now close your eyes and visualize the ideal • A range of counselling strategies can be used result. Use thought stopping to manage un- to enhance neuroplasticity. helpful thinking. Option: Work with a partner • The brain is composed of three parts: the cer- who can assist you with prompts that help ebrum, cerebellum, and the brainstem. you visualize – e.g., “Where are you?” “Who • Eighty billion nerve cells or neurons produce else is present?” Imagine that you are to…. neurons, which are the key to brain function- (situational details). Now, imagine yourself ing and communication. saying “You are feeling… “ (add positive emo- • Neurons communicate with neurotransmit- tion consistent with success). ters such as dopamine and serotonin. 2. Suggest how a counsellor might deal with a • Learning and experience create neural path- client, recently diagnosed with Alzheimer’s ways which may involve hundreds of thou- at the early stages who remarks, “My life is sands of neurons. over.” • There are over 400 named neurological disor- 3. What unique issues might arise for a client ders and diseases, including dementias such age 40 who develops early onset Alzheimer’s? as Alzheimer’s disease. 4. Your client is a 75-year-old man living with his wife, age 68. They have been happily married EXERCISES for over 40 years. Three years ago, she was diagnosed with Alzheimer’s and the disease has SELF-AWARENESS progressed rapidly. She has reached a point 1. How might your genetics be affected by your where she can no longer be left alone. Often, life experiences? she has trouble recognizing family and friends and, on occasion, even her husband. He is in 2. Think about how you might react if you or a good health and determined to keep his wife member of your family was diagnosed with at home. However, he admits that the bur- Alzheimer’s. Reflect on the overall impact for den of her care is becoming overwhelming. you, your friends and your community. Develop a plan for supporting him in the com- 3. Make a list of things you could do to “exer- ing months. cise” your mind. 5. Talk to your circle of family and friends. Ask 4. Imagine that you are an individual whose par- them, “What words and phrases do you think ent has Huntington’s Disease. Share your of when you hear the word Alzheimer’s?” www.neuropsychotherapist.com The Neuropsychotherapist 55 perfected. Now ask them, “What would you say, feel, and think if someone close to you said they 2. Describe how neuroplasticity can be used had Alzheimer’s?”. Share your answers in a to explain cognitive behavioural counselling group discussion with classmates. concepts. 6. You client has recently experienced a stroke. 3. Dispute the common myth that we only use He says, “My life is over.” Suggest counselling part of our brain. priorities for working with this client. 4. How can we best help our clients utilize infor- 7. Your client is a woman, age 28, who has been mation on the Internet? diagnosed with multiple sclerosis. In recent 5. If the brains of psychopaths are damaged, to months, her symptoms have become more what extent should they be held accountable pronounced and she is having difficulty caring for their behaviour. for her twin boys, age 6. She also reports that this is putting a severe strain on her 10-year marriage to her high school sweetheart. As her counsellor, how might you assist her to WEBLINKS deal with her challenges. Note: There are many national, international, 8. Your client is a 20-year-old man who has re- and local agencies that have been formed to provide cently been diagnosed with epilepsy. He re- information and support to people who are dealing ports that he feels ashamed and embarrassed with brain-related problems. They are excellent re- by his condition. Suggest a simple, non-jar- sources for clients, families and professionals. Here gonized response to help him deal with his are some examples: feelings. Use neuroscience concepts. 9. A third-grade teacher is adamant that her http://www.alzheimer.ca/ nine-year-old student diagnosed with ADHD http://www.heartandstroke.ca/ is just “being bad.” Suggest a neuroscience response to the teacher. https://braininjurycanada.ca/ www.epilepsy.ca/ CONCEPTS Link to initiatives and research from Brain Cana- 1. Scientists are a very early stage using tech- da, a national nonprofit agency that supports inno- nology to “read the mind.” Suggest ethical vative brain research projects - http://braincanada. issues that might arise if this technology is ca/

This has been an excerpt from Choices: Interviewing and Counselling Skills for Canadians, 7th Edition by Bob Shebib, reproduced with the permission of the publisher, Pearson Canada.

About the Author Bob Shebib, Faculty Emeritus, Douglas College, New Westminster, British Columbia, Canada, is an educator and counsellor with broad experience in child welfare, corrections, mental health, and addictions. As well, his professional work has included projects in China and Africa. He is the author of a number of textbooks including the best seller, Choices: Interviewing & Counselling Skills for Canadians, 6th edition , 2017, (Pearson). Currently, he is the Executive Director of Choices Consulting where he offers customized training to the counselling and human services community. Contact him at: [email protected].

56 The Neuropsychotherapist Vol 5 Issue 12, December 2017 A site with up-to-date current research, informa- Brisch, R., Saniotis, A., Wolf, R., Bielau, H., Bernstein, tion, data, and links to resources on Alzheimer’s dis- H.-G., Steiner, J., … Gos, T. (2014). The role of dopa- ease - http://www.alz.org/research/overview.asp/ mine in schizophrenia from a neurobiological and evolutionary perspective: Old fashioned, but still References in vogue. Frontiers in Psychiatry, 5, 47. http://doi. org/10.3389/fpsyt.2014.00047 Albert, P. R. (2010). Epigenetics in mental illness: Henning Budde, Mirko Wegner, Hideaki Soya, Hope or hype? Journal of Psychiatry & Neurosci- Claudia Voelcker-Rehage, and Terry McMorris, ence: JPN, 35(6), 366–368. http://doi.org/10.1503/ “Neuroscience of Exercise: Neuroplasticity and jpn.100148 Its Behavioral Consequences,” Neural Plastic- Alzheimers.net. 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58 The Neuropsychotherapist Vol 5 Issue 12, December 2017 digm for understanding and treating mental Steinberg, L. (2008). A Social Neuroscience Per- health issues. Retrieved September 25, 2017 from spective on Adolescent Risk-Taking. Develop- http://www.neuropsychotherapist.com neuro- mental Review: DR, 28(1), 78–106. http://doi. plasticity-a-new-paradigm-for-understanding- org/10.1016/j.dr.2007.08.002 and-treating-mental-health-issues/ Stevens, F. L., Hurley, R. A., & Taber, K. H. (2011). Phillips, J. R., Hewedi, D. H., Eissa, A. M., & Mousta- Anterior cingulate cortex: unique role in cogni- fa, A. A. (2015). The cerebellum and psychiatric tion and emotion. The Journal of Neuropsychiatry disorders. Frontiers in Public Health, 3, 66. http:// and Clinical Neurosciences, 23(2), 121-125. doi: doi.org/10.3389/fpubh.2015.00066 10.1176/appi.neuropsych.23.2.121 Ptak, C., & Petronis, A. (2010). Epigenetic approaches Tatera, K., (2015), Left brained vs right brained? to psychiatric disorders. Dialogues in Clinical Neuro- Myth debunked. Retrieved November 13, 2017 science, 12(1), 25–35. from http://thescienceexplorer.com/brain-and- Roth, E., (2017) 7 tips for reducing sundowning. Re- body/left-brained-vs-right-brained-myth-de- trieved September 10, 2017 from http://www. bunked webmd.com/alzheimers/guide/manage-sun- The Centre for Addiction and Mental Health. (2017). downing#1 Mental illness and addiction: facts and statistics. Radhakrishnan, R., Wilkinson, S. T., & D’Souza, D. Accessed August 1, 2017 from http://www.camh. C. (2014). Gone to pot – A review of the associa- ca/en/hospital/about_camh/newsroom/for_re- tion between cannabis and [Psychosis. Frontiers porters/Pages/addictionmentalhealthstatistics. in Psychiatry, 5(54). http://doi.org/10.3389/fp- aspx syt.2014.00054 The Cleveland Clinic. (2017). Stroke and the brain. Sapolsky, R. M. (2001). Depression, antidepres- Accessed September 5, 2017 from https:// sants, and the shrinking hippocampus. Proceed- my.clevelandclinic.org/health/articles/stroke- ings of the National Academy of Sciences of the and-the-brain. United States of America, 98(22), 12320–12322. Tourette Canada. (2017). Deep brain stimulation, http://doi.org/10.1073/pnas.231475998 Part One: How does it work? Retrieved Novem- Scientific American. (2017). Can you make socio- ber 13, 2017 from https://tourette.ca/deep-brain- path through brain injury or other types of trauma? stimulation-part-one-how-does-it-work. Retrieved October 13, 2017 from www.scienti- University of California, Irvine. (2005, January 22). ficamerican.com/article/can-you-make-socio- Intelligence in Men and Women Is a Gray and path-through-brain-injury-trauma White Matter. ScienceDaily. Retrieved Septem- Shapiro, F. and Solomon, R. M. (2010). Eye move- ber 21, 2017 from www.sciencedaily.com/releas- ment desensitization and reprocessing. Corsini es/2005/01/050121100142.htm Encyclopedia of Psychology. 1–3. WebMD. (2017). How to manage sundowning. Re- Siegel, D.J. (2012). The developing mind: How rela- trieved September 30, 2017 from http://www. tionships and the brain interact to shape who we webmd.com/alzheimers/guide/manage-sun- are (2nd ed.). New York, NY: Guilford Press. downing#1 Singh-Manoux, A., Dugravot, A., Fournier, A., Abell, Weill Cornell Medicine. “Neuroimaging categorizes J., Ebmeier, K., Kivimäki, M., & Sabia, S. (2017). four depression subtypes.” ScienceDaily. Science- trajectories of depressive symptoms before di- Daily, 8 December 2016. . JAMA Psychiatry, 74(7), 712-718. doi:10.1001/ja- Wlassoff, V. (2017). How does post-traumatic stress mapsychiatry.2017.0660 disorder change the brain. Retrieved July 31, 2017 Sitek, K.(2016) Can computers use brain scans from http://brainblogger.com/2015/01/24/how- to diagnose psychiatric disorders. Retrieved does-post-traumatic-stress-disorder-change- July 1, 2017 from http://sitn.hms.harvard.edu/ the-brain/ flash/2016/can-computers-use-brain-scans-to- diagnose-psychiatric-disorders www.neuropsychotherapist.com The Neuropsychotherapist 59 Choices

Now with Brain Bytes: connections to neuroscience research.

Choices is both an introductory textbook for students in counselling training programs and a practice reference for professionals in social work, youth justice, child and youth counselling, addictions and psychology.

A current best seller in Canada, Choices combines theory, practice examples with sample interviews, and challenging self-awareness exercises in a comprehensive, yet readable format. It’s aimed at professionals aspiring to gain a wide range of skills based on supported theory and evidence-based best practices.

Although framed in the Canadian ethical and cultural context, the content of the book is designed to appeal to a broad international audience of professionals.

COMING JANUARY 2019. Choices: Interviewing and Counselling Skills for Canadians, 7th Edition

This edition will contain the new Chapter 11: Counselling and Neuroscience, as seen in this edition of The Neuropsychotherapist.

For training seminars or customized workshops, contact author Bob Shebib at: [email protected]

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60 The Neuropsychotherapist Vol 5 Issue 12, December 2017 The Neuropsychotherapist is the quintessential publication bridging the gap between science and the practice of psychotherapy for mental health professionals everywhere

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www.neuropsychotherapist.com The Neuropsychotherapist 61 the last word the last word Terry Marks-Tarlow

On Time

Endings of all sorts, whether of sessions, days, or decades, are a natural time for reflection. As the end of 2017 approaches, I find myself pondering the nature of time broadly. How it etches itself into this stage of my family’s life. How it courses through the feel of my daily existence. How it marks the beat of my professional life. As a longtime student of neurobiology, I remain fascinated by Benjamin Libet’s research on mind time versus brain time. In a series of experiments, he demonstrated that certain areas of the brain activate a split second before other areas of the brain signal conscious awareness of an act of volition, such as raising a finger. From this perspective, it appears we are literally moved by the power of our unconscious minds. Libet came to his own radical conclusion— that free will is a mere illusion, a story constructed by one part of our brain and planted into another part of our brain after the fact, giving us the illusion of being in charge. Doesn’t Libet’s idea seem a lot like McGilchrist’s, The Master and his Emissary premise, or Gazzaniga’s left- brain “interpreter” that easily lies to conform to evidence available in the present context? I regularly write about nonlinear dynamics and the idea of fractal time, which can be understood in multiple ways. All are nonlinear, and all take Einstein’s ideas about relativity to another level. Not only does space expand, contract, and bend according to gravitational pull, but so does time expand, contract, and bend according to perspective. Einstein’s quote about the relativity of time is well-known: “Put your hand on a hot stove for a minute, and it seems like an hour. Sit with a pretty girl for an hour, and it seems like a minute. That’s relativity.” A fractal perspective on time is also observer-dependent. Consider how each creature on the planet operates on its own, unique timescale. The U.S. National Park Service reports that a hummingbird’s heart can beat as fast as 1,260 beats per minute; and when at rest they take about 250 breaths per minute (https://www.nps.gov/cham/learn/nature/hummingbirds.htm). The Giant Hummingbird beats its wings 10 - 15 times per second, but the fastest recorded rate is the Amethyst Woodstar at about 80 wingbeats per second. Now put yourself in the perspective of a hummingbird for a moment - surely, it is a fast-paced life! Not only does a vast range of timescales exist between different animal species, but a similarly vast range of timescales - called circadian (daily) and ultradian (shorter than daily) rhythms - also exists within humans. Our bodies pulse to many different rhythms and cycles: our sleep/wake cycle entrains to the circadian 24-hour path of the earth around the sun; our digestive systems take approximately 6 to 8 hours for food to pass through the stomach and small intestine; our hearts beat approximately 60 to 100 times per minute; our lungs take in an average of 12 to 20 breaths per minute; and our brains operate on the fastest timescale of all, with the average neuron firing 200 times per second. Subcortical areas of the brain operate on faster timescales than cortical ones, which is why we can find ourselves running from danger before even knowing what we are running away from. I love the image of every human as a fractal flower, with multiply enfolded timescales— where molecules operate on their own timescales within cells and within organs, all as enfolded into larger systems and circuits, each with their own timescale. In this way, every human enjoys a multiplicity of self-states and a multiplicity of temporal scales as well. When it comes to the interpersonal level of clinical practice, time may be one of the most

62 The Neuropsychotherapist Vol 5 Issue 12, December 2017 the last word

important, yet underemphasized, dimensions. While clinical theory inhabits an abstract, timeless realm, clinical practice inhabits the embodied concrete zone of lived time. Clinicians deal with time constantly, and effective clinicians have an intuitive sense that timing is everything. A session of psychotherapy is useless if the patient doesn’t feel open and ready to do the inner work; a great interpretation goes nowhere if it is not timed properly; and a deep supervision paradoxically can backfire if the supervisor’s insights don’t translate into proper timing for the patient. Timing is a therapeutic skill that allows us to fall in and out of sync with the relational rhythms of our patients. Interpersonal timing—whether with friends, family, or patients—has its developmental origins in the cerebellum, where it is combined with the right brain’s pre- verbal, affective, relational foundation. Timing relates to the patterns of attunement (and misattunement) between infants and their caregivers at the start of life. The most secure, organized attachments are exquisitely timed, with periods of engagement and disengage- ment either beautifully in sync or, when out of sync, able to orchestrate a well-timed repair. In contrast, disorganized relationships are often poorly timed: when one person is vulnerable and open to contact, the other is shut down, angry, or withdrawn; and then the pattern often reverses. Simultaneity and mutuality remain forever beyond reach. Because it serves as the nonverbal ground for healing and growth, timing is a fundamental dimension of psychotherapy. Timing separates the science of clinical theory from the art of clinical practice. It governs our clinical intuition, as it unfolds dynamically from minute to minute, thumping out the collective heartbeat of the patient/therapist dyad. Timing provides the music under the words of psychotherapy. It determines turn-taking and the dance of who leads and who follows in the therapeutic relationship, and regulates how our words become encased, punctuated, and surrounded by silences. It paces our shuttle between inner and out- er realms, self and other, past and future. From a purely subjective perspective, how we hold and mark time contributes to the ongoing feel of a session. Does the clinical hour fly by in a second or drag out interminably? Either extreme depends on whether we are caught up in flow states with our patients or struggling to remain present. For me, despite frequent 10 to 12 hour clinical days, my eyes only rarely defer to the clock. Time drags most when I and the patient are locked defensively in discon- nection from one another. By contrast, timeless sessions are the most fully intersubjective ones, where the relationship feels like it has taken off and taken on a life of its own that is unforeseeable, emergent, and spontaneous. Most recently, I ponder the clinical time that undergirds the arc of a session. Well-formed sessions have temporal contours that fit perfectly into the clinical hour. They start slowly, build to a crescendo, and then wind down in time for a clean sense of closure to whatever has happened emotionally and relationally. A patient may have shared intense emotion, but then re-composes in enough time to leave relatively secure. The most “beautiful” temporal arcs wrap around in Ouroboros fashion to end up where they started. The Ouroboros, a snake that swallows its own tail, is the archetypal symbol for self-renewal and re-creation. In more contemporary parlance, the ouroboros represents feedback, where the end product serves the beginning for another round, or iteration, of a process. During psychotherapy, when a session’s arc includes this sort of “ouroboric” twist, I become filled with awe and a magical sense that the very fabric of the universe is attuning, if not conspiring, to help us orchestrate meaning within psychotherapy. On this celestial note, I bid farewell to you, as well as to the year of 2017. May 2018 bring Find Terry at each and every being peace, joy, and productivity - not to mention fantastic timing! markstarlow.com the neuropsychotherapist www.neuropsychotherapist.com The Neuropsychotherapist 63