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

by Louis Cozolino

Freud argued that in order to understand who and what we are, we need to understand the primal unconscious elements of experience. He called this the id—the primitive and uncivilized life energy that we share with our reptilian and mammalian ancestors.

MacLean suggested that our three brains don’t necessarily communicate or work well together because of their differing “mentalities” and the fact that only the neomammalian brain is capable of consciousness and verbal communication (MacLean, 1990). This is a fundamental issue that connects evolution, neuroscience, and psychotherapy.

This conservation of our evolutionary history alongside our modern neural networks confronts the therapist with the challenge of simultaneously treating a human, a horse, and a crocodile (Hampden-Turner, 1981).

Thus, much of our most important emotional and interpersonal learning occurs during our early years when our primitive brains are in control. The result is that a great deal of learning takes place before we have the necessary cortical systems for explicit memory, problem solving, or perspective. Consequently, many of our most important socioemotional learning experiences are organized and controlled by reflexes, behaviors, and emotions outside of our awareness and distorted by our immature brains. To a great extent, psychotherapy owes its existence to these artifacts of evolution and development.

The slow development of the cerebral cortex maximizes the influence of experience in building the brain. That so much of the brain is shaped after birth is both good and bad news.

The brain is then sculpted in ways that assist the child in surviving childhood but may be maladaptive later in life. It is in these instances that a therapist attempts to restructure neural architecture in the service of more adaptive behavior, cognition, and emotion. Building the human brain is vastly complex. Rebuilding it is a difficult and fascinating challenge.

The early interpersonal environment may be imprinted in the human brain by shaping the child’s neural networks and establishing the biochemical set points in circuitry dedicated to memory, emotion, safety, and survival. Later, these structures and processes come to serve as the infrastructure for social and intellectual skills, affect regulation, and the sense of self.

At the heart of the interface of neuroscience and psychotherapy is the fact that human experience is mediated via two interacting processes. The first is the expression of our evolutionary past via the organization, development, and functioning of the nervous system—a process resulting in billions of neurons organizing into neural networks, each with its own timetable and requirements for growth. The second is the contemporary shaping of our neural architecture within the context of relationships. The human brain is a “social organ of adaptation” stimulated to grow through positive and negative interactions with others. The quality and nature of our relationships become encoded within the neural infrastructure of our brains. It is through this translation of experience into neurobiological structures that nature and nurture become one.

We now assume that when psychotherapy results in symptom reduction or experiential change, the brain has, in some way, been altered (Kandel, 1998).

When we talk of the frontal cortex, amygdala, or hippocampus, we are literally talking about large numbers of individual neurons organized to perform a set of functions. The neurons within these systems need to be able to organize and reorganize in such a way as to allow us to learn, remember, and act as we adjust to different situations. Because each neuron is limited to either firing or not firing, the diverse capabilities of the nervous system come from the complex interaction of individual neuronal signals. A simplistic analogy is an old-fashioned billboard consisting of rows and columns of thousands of light bulbs. Although each individual bulb is limited to being either on or off, the pattern created by these lights can spell out words, form images, and through precise timing, create the illusion of movement. In a similar fashion, patterns of neural firing come to represent specific information within the brain and throughout the nervous system.

When we talk of building and rebuilding the brain, neurons are our basic building blocks and neural networks are the structures that we build and sculpt.

Experience results in the expression of certain genes which trigger the synthesis of proteins that build neural structures. Through genetic transcription, existing neurons grow different kinds of receptors, expand their dendritic structures, and adjust their biochemistry.

Interestingly, brain regions dedicated to certain skills can actually hijack cells in adjacent neural areas to serve their needs to develop skills like playing an instrument or learning Braille (Elbert, Pantev, Wienbruch, Rockstroh, & Taub, 1995).

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.

Affect regulation, especially the modulation and inhibition of anxiety and fear, allows for continued cortical processing in the face of strong emotions, allowing for ongoing cognitive flexibility, learning, and neural integration.

As affect is repeatedly brought into the therapeutic relationship and successfully managed, the client gradually internalizes these skills by sculpting the neural structures necessary for autoregulation. As in childhood, the repeated cycle of attunement, rupture of the attunement, and its reestablishment gradually creates an expectation of reconnection (Lachmann & Beebe, 1996). The learned expectation of relief in the future enhances the ability to tolerate more intense affect in the midst of the stressful moment.

As a therapist, one of my primary goals is to shift my clients’ experience of anxiety from an unconscious trigger for avoidance to a conscious cue for curiosity and exploration.

During our first few years, we have the repeated experiences of going from a comfortable, regulated state to a state of dysregulation. We become frightened, cold, wet, and hungry, and show our displeasure with facial expressions, bodily postures, vocalization, and crying. In the presence of good-enough parenting, our signals are attended to, the source of our displeasure diagnosed, and we are helped back into a regulated state. Across thousands of these temporal-emotional experiences, we go from regulation to dysregulation to reregulation. These experiences shape secure attachment and the expectation of positive outcomes. The summation of these experiences, stored throughout our nervous system, becomes the sensory-motion-emotional background of our experience.

In the absence of adequate assistance in regulating affect or making sense of emotions, the brain organizes a variety of defensive coping strategies. These defenses vary in the degree to which they distort reality in order to achieve their goal of reducing anxiety. This distortion is accomplished in circuits of unconscious memory that control anxiety and fear (Critchley et al., 2000). The neural connections that result in defenses shape our lives by selecting what we approach and avoid, what our attention is drawn to, and the assumptions we use to organize our experiences. Our cortex then provides us with rationalizations and beliefs about our behaviors that help keep our coping strategies and defenses in place, possibly for a lifetime. These neural and psychic structures can lead to either psychological and physical health, or illness and disability.

propose here that all forms of therapy, regardless of theoretical orientation, will be successful to the degree to which they foster appropriate neuroplasticity. Further, I also propose that neural plasticity, growth, and integration in psychotherapy are enhanced by: The establishment of a safe and trusting relationship. Mild to moderate levels of stress. Activating both emotion and cognition. The co-construction of new personal narratives.

Through the activation of multiple cognitive and emotional networks, previously dissociated functions are integrated and gradually brought under the control of cortical executive functions. Narratives co-constructed with therapists provide a new template for thoughts, behaviors, and ongoing integration.

Despite their differences, psychodynamic forms of therapy share theoretical assumptions such as the existence of the unconscious, the power of early childhood experiences, and the existence of defenses that distort reality in order to reduce anxiety and enhance coping.

When this regression occurs, family members try—consciously and unconsciously—to shape the family in a manner that reduces their own anxiety. The alcoholic needs the problem to go unmentioned, while the family needs to put on a good front to the outside world. Dysfunctional family patterns such as this one sacrifice the growth and well-being of one or more members (often the children) to reduce the overall level of anxiety in the family. The cognitive, emotional, and social world of an alcoholic family is shaped by the avoidance of feelings, thoughts, and activities that expose their shameful secret to conscious awareness and the outside world. The development of the children becomes distorted by the adaptations necessary for their survival within the pathological system. Unfortunately, the roles and rules of the family designed to decrease anxiety maintain the pathologies of some and create new pathologies in others.

Over time, the dysfunction becomes embedded in the personality and neural architecture of everyone in the family and they collude to maintain the system, because they now all require the status quo in order to feel safe. These experiences become embedded into their neural architecture and are carried forward into adult relationships.

First, given that the human brain is a social organ, safe and supportive relationships are the optimal environment for social and emotional learning. Empathic attunement with the therapist provides the context of nurturance in which growth and development occur. By activating processes involved in secure attachment, empathic attunement likely creates an optimal biochemical environment for neural plasticity.