The Neuroscience of Psychotherapy: Healing the Social Brain (Norton Series on Interpersonal Neurobiology)

by Louis Cozolino

Psychotherapy can be thought of as a specific type of enriched environment that promotes social and emotional development, neural integration, and processing complexity. The way the brain changes during therapy will depend upon the neural networks involved in the focus of treatment.

Although psychotherapists do not generally think in “neuroscientific” terms, stimulating neuroplasticity and neural integration is essentially what we do. We

The primary directions of information flow relevant to psychotherapy are top-down (cortical to subcortical and back again) and left-right (across the two halves of the cortex).

Freud focused on the role of overwhelming emotion as the cause of unintegrated neural processing.

In reviewing these different psychotherapeutic modalities, a number of principles emerge that unify the various therapeutic schools. The first is that psychotherapy values openness, honesty, and trust. Each form of psychotherapy creates an individualized experience designed to examine conscious and unconscious beliefs and assumptions, expand awareness and reality testing, and encourage the confrontation of anxiety-provoking experiences. Each perspective explores behavior, emotion, sensation, and cognition in an attempt to increase awareness of previously unconscious or distorted material. The primary focus of psychotherapy appears to be the integration of affect, in all its forms, with conscious awareness, and cognition. Intellectual understanding of a psychological problem in the absence of increased integration with emotion, sensation, and behavior does not result in change.

To “do memory” is essentially to engage in a cultural practice. —Kenneth Gergen

The struggle of man against power is the struggle of memory

against forgetting.

The amygdala is involved with generalization, while the hippocampus is involved with discrimination

theater—an homage to Descartes’s articulation of mind–body dualism—creates the subjective illusion of self as a nonphysical spirit inhabiting the body as opposed to being one with it (Dennett, 1991). This spirit, some religions believe, can leave the

second illusion is that our experience occurs in the present moment and

What we call intuition is likely the result of rapid and unconscious processing that can be so surprising to us that it is often attributed to occult knowledge or psychic powers.

underestimating the role of chance, unconscious influences, and outside forces

Our tendency to explain the behavior of others based

belief perseverance—the tendency to attend to facts supportive of existing beliefs while ignoring others

“people are remarkably reluctant to consider impure motives in a loud moralist” (Nesse & Lloyd, 1992, p. 611) despite the repeated and well-publicized downfall of one moral crusader after another. In fact, the best con artists are often so convincing that their victims refuse to accept that they have been cheated at all.

sense of agency during actions

appear to be involved in coding intentions and calculating the probability of success

The child’s experience of emerging from under the covers into the light of day provides a metaphor for religious enlightenment later in life. The balance provided by the vestibular system may be the model for psychological and emotional stability, and ultimately for leading a more balanced life

Good psychiatry is a blend of science and story. —Jeremy Holmes

Reflexive social language (RSL) is a stream of words that services the maintenance of ongoing social relatedness and communication.

A shift away from logical and orderly left-hemisphere thinking to right-hemisphere-biased processing may allow the mother an increased level of emotional and physiological sensitivity that enhances the intuitive elements of attachment. A shift of brain coherence toward the right hemisphere would explain the decrease in linear semantic processing and memory abilities reported by new mothers and mothers-to-be. Although such a shift might be very useful for attunement with an infant, it could be detrimental to functions best performed by the left, such as finding the right words, remembering appointments, and following logical arguments. Many new mothers report an increasing need during the first year to get out into the world of adults or back to work. This need may parallel a shift back to previous levels of left-right hemisphere balance. As the mother gradually recovers from a deep preoccupation with her infant and again becomes interested in other areas of life, the child is forced to come to terms with some of his or her own limitations.

Respect for the autonomy and separateness of the child motivates the parent to discover the child’s interests, instead of imposing his or her own upon them.

Shame, appearing early in the second year of life, is both a powerful inhibitory emotion and a mechanism of social control. Thus the positive face-to-face interactions that stimulated excitement and exhilaration during the first year come to include expressions of disapproval and anger. Shame is represented physiologically by a rapid transition from a positive to negative affective state and from sympathetic to parasympathetic dominance. This shift is triggered by the expectation of attunement to a positive state, only to receive negative emotions from the caretaker (Schore, 1994). While it may be hard to believe, toddlers expect their parents to be just as excited as they are about covering the floor with milk or plopping their toys in the toilet. Parental reactions of disapproval or anger are, at first, confusing and difficult to comprehend but soon come to shape the biology and psychology of the child.

Behaviorally, people in a shame state look downward, hang their head, and round their shoulders. This same state (submission) is shown by your pet dog when he hunches over, pulls his tail between his legs, and slinks away as you upbraid him for some canine faux

Children left in a shamed state for long periods of time may develop permanently dysregulated autonomic functioning

Slowing down stimulates discomfort, sadness, isolation, and shame, which become background affect throughout life. If manic defenses are chronically employed, they can become a way of life and keep children and adults from constructing inner imaginal experience and a sense of self. Sadly, many children with manic defenses are mistakenly diagnosed with ADHD. They are medicated to help them cope, while the real problem goes unresolved.

linguistic analysis of the coherence of the narrative’s organization and

presentation. Coherence analysis is conducted based on what are called Grice’s maxims and include an examination of both the logic and understandability of the narrative based on the following four principles: Quality: Be truthful, and have evidence for what you say. Quantity: Be succinct, and yet complete. Relevance: Stick to the topic at hand. Manner: Be clear, orderly, and brief.

Mothers and fathers with securely attached children tended to have

second group of parents, associated with avoidantly attached children, demonstrated a lack of recall for childhood events and large

third group of parents, rated as enmeshed or preoccupied, tended

unresolved/disorganized group of parents had highly incoherent narratives disrupted by emotional intrusions and missing or fragmented information.

Not surprisingly, parents’ emotional insight and availability to themselves

availability to their children. The three nonsecure patterns of attachment research all reflect lower levels of psychological and neurological integration. They also correlate with the use of more primitive psychological defenses associated with disconnections among streams of processing within the brain. The lack of recall and black-and-white thinking of the dismissing parent likely reflect blocked and unintegrated neural coherence. This brain organization then results in decreased attention and emotional availability to the child. The enmeshed parent has difficulty with boundaries between self and others, as well as between past memories and present experiences. These internal and interpersonal issues then lead to inconsistent availability and a flood of words that dysregulate the child. Thus the child, who is also anxious and ambivalent, will seek proximity but have a difficult time returning to play because of the unpredictable availability, as well as the confusing and emotionally dysregulating nature of the parent’s messages and emotions. The internalized mother, instead of being a source of security and autonomic regulation, becomes organized as a destabilizing state of mind and body.

fight or flight and splitting (Schore, 1994). The balance of these two

Co-constructed narratives form the core of human groups, from primitive tribes to modern families.

They also help remind me to keep an open mind, and remember that giving up on a child or client is not something I am ever willing or prepared to do.

Their research has thus far revealed three primary ways in which maternal behavior impacts variations in brain structure—learning and plasticity, the ability to cope with stress, and later maternal behavior in adulthood. A mother’s impact on the way her daughter will mother her children serves as a parallel channel of inheritance that is highly sensitive to environmental conditions.

While more maternal attention results in increased growth and enhanced functioning throughout the pups’ brains, separation from mothers proves to have the opposite effects. The same three areas that are upregulated with more maternal attention are all downregulated by her absence. Deprivation of maternal attention increases neural and glial death, while reducing gene expression, impairing their ability to learn. Maternal separation also results in reduced inhibitory (GABA) receptors in the locus coeruleus, increasing adrenaline secretion in reaction to stress while reducing the antianxiety properties of benzodiazepine receptors in the amygdala. Decreased cortisol receptors in the hippocampus also impair the inhibitory feedback to the stress system to shut down cortisol production.

In an exciting twist, it has been found that biological interventions and enriched social and physical environments can reverse the effects of low levels of maternal attention and early deprivation on both HPA activity and behavior (Bredy et al., 2004; Francis et al., 2002; Hood, Dreschel, & Granger, 2003; Szyf et al., 2005; Weaver et al., 2005).

experience early menopause to be available to help nurture their grandchildren and avoid the risks inherent in mating and childbirth, which rise with age for both mother and child (Lee, 2003; Rogers, 1993; Turke, 1997).

The insula begins life on the lateral surfaces of the brain, only to become hidden by the rapid expansion of the frontal and temporal lobes. The insula is sometimes described as the “limbic integration cortex” because of its massive connections to all limbic structures, and its feed-forward links with the frontal, parietal, and temporal lobes

The somatosensory cortex, located along the front of the parietal lobes, processes information about bodily experiences.

In humans, the parietal lobes evolved from the hippocampus and assist it in complex visual-spatial processing. The human hippocampus, along with its adjacent structures (parahippocampal gyrus, dentate gyrus), have come to be specialized in the organization of spatial, sequential, and emotional learning and memory

hyperarousal, intrusion, and avoidance—

These biochemical and neuroanatomical changes are paralleled by such symptomatology as emotional dyscontrol, social withdrawal, and lower levels of adaptive functioning. Together, these and other negative effects of trauma result in compromised functioning in many areas of life. The impact of trauma depends on a complex interaction of the physical and psychological stages of development during which it occurs, the length and degree of the trauma, and the presence of vulnerabilities or past traumas. The impact of chronic trauma becomes woven into the structure of personality and is hidden behind other symptoms, making it difficult to identify, diagnose, and treat.