TheNeuroscienceofPsychotherapy

SecondEdition

TheNeuroscienceofPsychotherapyHealingtheSocialBrain

•SecondEdition•

LouisCozolino

ForewordbyDanielJ.Siegel

W.WNorton&CompanyNewYork•London

Unlessotherwisenoted,figureswerecreatedbytheauthor.

Copyright©2010,2002byLouisJ.Cozolino

Allrightsreserved

Forinformationaboutpermissiontoreproduceselectionsfromthisbook,writeto:Permissions,W.W.Norton&Company,Inc.500FifthAvenue,NewYork,NY10110

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Cozolino,LouisJ.

Theneuroscienceofpsychotherapy:healingthesocialbrain/LouisJ.Cozolino.—2nded.p.cm.Includesbibliographicalreferences.ISBN978-0-393-70642-0(hardcover)1.Psychotherapy.2.Neurosciences.3.Brain—Research.I.Title.RC480.5.C6452010616.89'14—dc22

2009043708

ISBN:978-0-393-70657-4

W.W.Norton&Company,Inc.,500FifthAvenue,NewYork,N.Y.10110www.wwnorton.com

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Thisbookisdedicatedtomyfamily:mymother’scourage,myfather’sdetermination,and

thememoryofmygrandparents.Togethertheysomehowinstilledwithinmethebeliefthatallthingsarepossible.

Contents

Foreword

PrefacetotheSecondEdition

PartI.NeuroscienceandPsychotherapy:AnOverview

1.TheEntangledHistoriesofNeurologyandPsychology

2.BuildingandRebuildingtheBrain:PsychotherapyandNeuroscience

3.NeuralIntegrationinDifferentModelsofPsychotherapy

PartII.HowtheBrainWorks:TheLegacyofEvolution

4.TheHumanNervousSystem:FromNeuronstoNeuralNetworks

5.MultipleMemorySystemsinPsychotherapy

6.Laterality:OneBrainorTwo?

PartIII.TheOrganizationofExperienceandtheHealthyBrain

7.TheExecutiveBrain

8.ConsciousnessandReality

9.FromNeuralNetworkstoNarratives:TheQuestforMultilevelIntegration

PartIV.TheSocialBrain

10.TheSocialBrain

11.BuildingtheSocialBrain:ShapingAttachmentSchemas

12.TheNeurobiologyofAttachment

PartV.TheDisorganizationofExperience

13.TheAnxiousandFearfulBrain

14.TraumaandNeuralNetworkDissociation

15.TheSelfinExile:NarcissismandPathologicalCaretaking

PartVI.TheReorganizationofExperience

16.TheEvolutionaryNecessityofPsychotherapy

17.TeachingOldDogsNewTricks:StimulatingNeuralPlasticity

18.ThePsychotherapistasNeuroscientist

Credits

References

Foreword

LouisCozolino’scontributionstotheNortonSeriesonInterpersonalNeurobiologyhavebeeninstrumentalinmovingthisnewinterdisciplinaryfieldforward.ThefirsteditionofTheNeuroscienceofPsychotherapyinauguratedtheseries,whichnowincludes16titles.Withthissecondedition,Louhasextendedanddeepenedinterpersonalneurobiology’sbasicviewthatintegrationisattheheartofwell-being.Ilovedthefirsteditionandhavelearnedatremendousamountfromreadingthisexcitingandextremelyaccessibleupdatededition.Readersnewtointerpersonalneurobiology(IN)willfindthisawonderfulplacetostarttheirjourney,asLoudeftlybringsthelatestincutting-edgesciencetogetherwiththehealingartofpsychotherapy.ThosefamiliarwiththefieldwillfindthisawelcomeadditiontotheirINlibraryoftextswrittenwiththeclinicianinmind.

AsthefoundingeditoroftheINseries,Ihavebeenproudtooverseethepublicationofthesebooksthatexplorevariousdimensionsofpsychotherapyandscience.Thougheachoftheindividualauthorsofandcontributorsmaynotarticulatetheirworkwiththesamevocabulary,theircontributionshavealladdedtotheresearchandclinicalsynthesisthatformsaneducationalfoundationforINasamultidisciplinaryandsyntheticwayofknowingaboutwhatitmeanstobehuman.Oursisacomplexspecies:Wehaveinheritedanervoussystemwhoseevolutionhasleftuswithmanymechanismsnotsuitedtomodernlife.Andwelivewithinrelationshipsthathaveshapedandcontinuetoshapehowoursocialbrainsareconstructedwithinfamilies,communities,andsociety.Culturalevolutioncontinuestomoldoursynapticarchitecture,influencinghowweexperienceourinner,subjectivelivesandlearntocommunicatewithoneanother.

Thiscomplexitycouldeasilymakeusascliniciansmoveawayfromsciencetoapproachhealingfromanintuitivewayofknowingalone.MyhopeinfoundingthefieldofINhasbeenthatwewouldbeabletoseetheforestforthetrees,sotospeak,andnotgetdistractedbydetails,withalloftheirfascinatingandnuancedcomplexities,butratherbecomeenrichedbyallofthiscutting-edgeunfoldingofnewknowledgeandideas.But,thiscertainlyisachallenge.Inthebusylivesofclinicians(andjustplaineverydaylife),thetremendousamountsofdataemergingfromever-expandingfieldsofsciencecanbedaunting.WhatwearetryingtodowiththeINseriesistoprovideaforumforthoseworkingatthecreativeboundarybetweenthechaosofoverwhelmingknowledgeandtheorderofanintellectualframework.LouCozolinoridesthatedgelikeamastersurfer,bringingtogetheremergingfindingsfromneurosciencewiththebeautyandpowerofhealingrelationships.It’samagnificentadventure,andyouwillneedtotakeadeepbreathandholdonashetakesyoualongwithhimthroughthevariousdimensionsofsciencetoseepsychotherapyfromnewandhelpfulvantagepoints.

Aframeworkthatcanbehelpfulinthisimportantquestviewsclinicalworkasinvolvingatriangleofwell-beingcomprisingthethreepointsofMind,Brain,andRelationships.Thisisavisualmetaphordepictingthemostfoundationaldimensionsofourhumanlives,theessenceofoursubjectiveandourobjectivelives.Thisisatrianglerevealingtheflowofenergyandinformation.Relationshipsarehowwe

shareenergyandinformationwithoneanother.Thebrainisheretheextendednervoussystemdistributedthroughouttheentirebody,whichisamechanismthroughwhichenergyandinformationflows.Andthemind,inpart,ishowthatflowisregulated—howweseeandshapeenergyandinformationasitmovesthroughourbodiesandthroughourrelationships.

Psychotherapyentailsshapingtheseelementsofourtriangletowardwell-being.FromtheINperspective,healthisachievedbypromotingintegrationinourlives:Ourmindscometomonitorandmodifyourinternalandinterpersonalworldstowardthelinkageofdifferentiatedelements.Themindisaprocessthatisbothembodiedandrelational.Inthisviewwecanuseourmindstocultivateintegration,whichpromotesharmony;thelackofintegrationleadstochaosorrigidity.FromtheINstandpoint,wecansee,forexample,thevariouspsychiatricsymptomsandsyndromesasrevealingthechaosandrigiditythatemergefromimpairmentstointegration.Clinicalassessmentcandetectwhenchaosandrigidityarepresentandidentifytheneuralorinterpersonaldomainsinwhichintegrationislacking.Focusingontheneedtoenhancedifferentiationandpromotelinkage,anINclinicianisofferedtheframeworkwithwhichtoevaluate,soheorshecanthencreateatreatmentplanbasedonthecentralityofintegrationinthecultivationofwell-being.Beyondjusteliminatingsymptoms,thisviewdefineshealthandofferspracticalstepstopromotetheintegrationattheheartoflivingaharmonious,creative,andmeaningfullife.

Providinguswitharichandvariedtapestrythatweavesup-to-datesciencewithhisdecadesoffabulousworkasaclinicianandmastereducatorinthefieldofmentalhealth,ProfessorCozolinoisourguideinthiseye-openingexplorationofintegrationandthepathwaytowardhealth.Bothourpatients’andourownlivescangreatlybenefitfromthisfruitfuljourneyofdiscovery.Welcometotheworldofintegrationandinterdisciplinarythinking!

DanielJ.Siegel,MDFoundingEditor,TheNortonSeriesonInterpersonalNeurobiology

PrefacetotheSecondEdition

IthasbeenextremelygratifyingtowitnessthefirsteditionofTheNeuroscienceofPsychotherapyplayaroleinintroducinganewgenerationoftherapiststothecomplexandfascinatingworldofthebrain.Overtheyears,thisbookhascreatedmanyopportunitiesformetointeractwithstudents,teachers,andtherapistswhoarecuriousaboutthebiologicalbasisofhumanbehavior.Theirenthusiasticfeedbackhasstrengthenedmybeliefintherelevanceofneurosciencetoclinicalpracticeandmydedicationtotheintegrationofmindandbrain.

Thereareanumberofreasonsforthisnewedition.ThefirstisthatI’vediscoveredthetruthofthesaying“writingistheprocessofrewritingwhatyouhavealreadyrewritten,”anurgethat,forme,didn’tdiminishwiththepublicationofthefirstedition.Second,theenergyandenthusiasmgeneratedbyneuroscienceinthe1990shascontinuedtobuildmomentumandbearfruit.Newtechnologieshavebroadenedourwindowtoneuralfunctioning;empiricaldiscoverieshaveledusintonewareasofexploration;andincreasinglysophisticatedtheorieshavefueledourimaginations.Finally,thefindingsrelevanttopsychotherapyandmentalhealthfromallthisnewresearchcontinuedtoaccrueandcalledouttobeincludedinTheNeuroscienceofPsychotherapy.

Thissecondeditioncontainsafewnewchaptersthatfocusonattachment,epigenetics,andtheconstructionofconsciousness.Thereisalsoadiscussionofsomeoftheevolutionaryshortcomingsofthehumanbrainthatmakeussosusceptibletopsychologicaldistress.Youwillnoticethatthissecondeditionembodiesashiftinperspectivetowardsocialneuroscience,andtherecognitionthatthehumanbrainisasocialorgan.Reflectingthisshiftisthechangeinthebook’ssubtitlefromBuildingandRebuildingtheHumanBraintoHealingtheSocialBrain:Lessmechanisticandgrandioseperhaps,andalsomorehuman.Ihopeyouenjoythefruitsofthislaboroflove.

IwanttothankLaurenHarb,TehniatMirza,VanessaStreiff,DeniseDuval,andNazaninMoalifortheirassistanceinthepreparationofthismanuscript.ThanksalsotoAndreaCostellaandDeborahMalmudforbeinghighlycompetentandcompassionaterocksatthecenterofthestorm.Andfinally,thankstomyfamily,friends,clients,students,andcolleaguesfortheircaring,support,energy,andlove.

LouisCozolinoLosAngeles,September2009

TheNeuroscienceofPsychotherapy

SecondEdition

PARTI.

NeuroscienceandPsychotherapy:AnOverview

Chapter1

TheEntangledHistoriesofNeurologyandPsychology

Wemustrecollectthatallofourprovisionalideasinpsychologywillpresumablyonedaybebasedonanorganicsubstructure.

—SigmundFreud

Howdoesthebraingiverisetothemind?Wheredothebrainandmindmeet,andbywhatmeansdotheyinteractwithoneanother?Thesearedifficultquestions—sodifficult,infact,thatthecommonreactionistofocusoneitherthemindorthebrainandactasiftheotherisirrelevant(Blass&Carmeli,2007;Pulver,2003).Theproblemwiththisapproachisthebarrieritcreatestounderstandingthatthehumanexperienceofbrainandmindisessentiallyaunifiedprocess(Cobb,1944).Neurologyandpsychologyaresimultaneouslypushedapartbyacademicandintellectualpoliticswhilebeingdrawntogetherbytheircommonpsychobiologicalfoundation.Theentangledhistoriesofneurologyandpsychologyreflectthepushandpullofthesepowerfulopposingforces(Ellenberger,1970;Sulloway,1979).

Freudstartedoutasarebel,aneurologistcuriousaboutthemind.Isuspecthewasfrustratedwiththemind–brainpartisanshipofmedicalschool,andlongedtoworkwithotherswhosharedhisinterests.Attheageof29,Freudwonatravelingfellowshiptospendthefallandwinterof1885attheSalpêtrièreHospitalontheleftbankofParis.ThechoiceoftheSalpêtrièrewasbasedonthereputationofProfessorJean-MartinCharcot,amanconsideredanexpertonbothmindandbrain.InCharcot,Freudsoughtateacherwhowaswellestablished,confident,andunafraidoftheno-man’s-landbetweenmindandbrain.OnecanimagineFreud’sexcitementashewalkedthestreetsofParisonhiswaytomeetthegreatman,apossiblekindredspirit.

Charcotspecializedinpatientssufferingfromwhatwasthencalledhysteria.Thesepatientshadsymptoms,suchasseizuresorparalysis,thatmimickedneurologicalillnessesbutwerewithoutapparentphysicalcause.Aclassicexampleisaconditioncalledgloveanesthesia,inwhichfeelingislostinoneorbothhandsbeginningatthewrist.Inthesepatients,thehandsappeartotakeonsymbolicsignificance;perhapstheyhavebeenusedtocommitsometabooactthattriggeredoverwhelmingguiltorfear.Itwasbelievedthataconflictwithinthemindwasconvertedintoabodilysymptom.

The1880swerealsoatimewhentheabilityofthesubconsciousmindtocontrolbehavior(asdemonstratedthroughhypnosis)burstintopopularawareness.Charcotusedhypnosisduringclinicaldemonstrationstoillustratehisemergingtheoriesaboutmind–bodyinteractions.ThemonthsFreudspentatSalpêtrièrewithCharcothadaprofoundeffectonhim.Hecametobelievethathiddenmentalprocessesdoindeedexertpowerfuleffectsonconsciousness,andthathystericalsymptomsresultnotfrommalingeringorfeigningillness,butfromthepoweroftheunconsciousmindembeddedwithintheneuralstructuresofthebrain.Hysteria,fromthisperspective,reflectedthecapacityoftraumaticexperiencetoreorganizethebrainanddisruptconsciousexperience.Dissociativesplitsbetweenconsciousnessand

behaviordemonstratedtoFreudthatthebrainiscapableofmultiplelevelsofconsciousandunconsciousawareness.Inthedecadestocome,hewouldexploretheuseoflanguage,emotion,andthetherapeuticrelationshiptoreconnectthem.FreudreturnedtoViennainFebruary1886,andopenedhisownclinicalpractice2monthslater.Despitehisentryintothemedicalestablishment,hecontinuedhisrebellionlaterthatyearwiththepresentationofapaperontheexistenceofhysteriainmales.Deeplyfascinatedbytheunconscious,Freudremaineditsmostardentexploreruntilhisdeathin1939.

IntheyearsfollowinghisresidencyatSalpêtrière,FreudexpandedonCharcot’sthinkinginmanysignificantways.Heplacedtheunconsciousinadevelopmentalcontextbytracingthegenesisofhystericalsymptomstochildhoodexperiences.Hecametobelievethathystericalpatientssufferedfromtheunconsciousemotionalaftereffectsofrepressedchildhoodmemories.Furthermore,Freudconnectedthedevelopmentoftheindividualtotheevolutionofthespecies.Influencedbytheancientideathatwecontainwithinusthebiologicalhistoryofourprimitiveancestors,heincludedtheimportanceofinstinctualdrivessuchassexuality,rage,andenvyinhisdevelopmentaltheories.Freudbelievedthatbeneathourcivilizedexteriors,thereexistswithinusamoreprimitivebeing,accountingformanyofthecontradictionsofmodern“civilized”behavior.

Freudarguedthatinordertounderstandwhoandwhatweare,weneedtounderstandtheprimalunconsciouselementsofexperience.Hecalledthistheid—theprimitiveanduncivilizedlifeenergythatwesharewithourreptilianandmammalianancestors.ThisconceptwasmetwithunderstandablehostilitybyFreud’srepressedandrationalcontemporaries.Atthattime,physicianswerepillarsofEuropeanculture,highlyinvestedintheirsuperiorityovertheanimalkingdomandsteadfastintheirrightandobligationtosubjugatethe“primitive”peopleoftheworld.Needlesstosay,linkingcivilizedhumanstoanimals(tosaynothingofhisideathatchildrenhavesexualdesires)madeFreudandhistheoriesscandalousinrespectablecircles.

Freud’sAbandonedProject

Theseeminglyirreconcilabledichotomiesandparadoxesthatformerlyprevailedwithrespecttomindvs.matter…becomereconciledina…unifyingviewofmind,brain,andmaninnature.

—RogerSperry

Inthelate1800s,thedoorstothemicroscopicworldofthenervoussystemopenedforthefirsttime.Technicalimprovementsinthemicroscopeandnewlydevelopedstainingtechniquesledtothediscoveryofbothneuronsandthesynapsesthroughwhichtheycommunicate.Theexistenceofsynapsesrevealedthatthenervoussystemisnotasinglestructure,butinsteadismadeupofcountlessindividualprocessingunits.Furthermore,thathumanssharedtheseneuronswithallotherlivingcreaturessupportedtheDarwinianideaofourcommonancestrywithotheranimals.Aroundthissametime,theworkofWernickeandBrocashowedthatspecificareasofthebrainwereresponsiblefordifferentaspectsoflanguage.Thedualneuroanatomicalnotionsofsynaptictransmissionandthelocalizationofspecificfunctionstodifferentareasofthebrainprovidedrichtheoreticalsoilfornewwaysofunderstandingthebrain.

InspiredbyDarwin,Charcot,andtheopeningofthemicroscopicneuralworldtoinvestigation,FreudwroteTheProjectforaScientificPsychology(Freud,1968).InTheProject,hepostulatedthatwhatwewitnessofconsciousandunconsciousbehaviorisorganizedbyandstoredwithinthebrain’sneuralarchitecture.Aspartofthiswork,hedrewsimplesketchesofinterconnectingneuronstorepresenthumanimpulses,behaviors,andpsychologicaldefenses.Thesesketchesdepictedtheinteractionsamong

drives,theorgansofthesenses,andmechanismsofinhibition.Accordingtohiscolleagues,Freudbecameobsessedwiththeideaofconstructinganeurobiologicalmodelofthemind(Schore,1997b).Despitehisenthusiasm,Freudrealizedthathisdreamforpsychologytobebasedinanunderstandingofthenervoussystemwasfaraheadofitstime,andatoddswithprevailingreligiousbeliefsandmedicaldogma.Fortheseandotherreasons,hesuppressedthepublicationofTheProjectuntilhisdeath.

PerhapsFreudkepttheProjecttohimselfbecausehefearedthatitwouldberelegatedtothesamesortofobscurityasthecaseofPhineasGage.Gage,a19th-centuryrailroadforeman,hadametalbarpasscompletelythroughhisheadasaresultofanaccident,causingthedestructionofthemiddleportionsofhisfrontalcortex.Thisparticularareaofthebrainhassincebeenshowntobeinvolvedwithjudgment,planning,andemotionalcontrol.AlthoughGagehadnospecificmotororlanguagedeficits,thosewhoknewhimsaidthat“GagewasnolongerGage”(Benson,1994).Hisemotionality,relationshipabilities,andthequalityofhisexperiencewerealldramaticallyaltered.BecauseGage’ssymptomsinvolvedhispersonalityandemotions,thepublicationreportinghiscasereceivedlittleattentionformostofthe20thcentury.Notonlywasitoutsidetherealmofbehaviorsthatneurologistsfeltcomfortableaddressing,buttherewasalsoabiasagainstrelatinghumanpersonalitytoneurobiologicalmechanisms(Damasio,1994).

Freud,theneurologist,becameallbutforgottenashispsychologicaltheoriesmovedfurtherandfurtherfromtheirbiologicalroots.Hechoseinsteadtoutilizethemorepalatableandaccessiblemetaphorsofliteratureandanthropologytoprovidetheprimaryvocabularyforpsychoanalysis.Unfortunately,Freud’sshiftfromthebraintometaphorsofmindopenedpsychoanalysistoallsortsofcriticismthroughoutthe20thcentury.MetaphorssuchastheOedipalandElectracomplexeswereseenascontrivedfictions,shieldingthemfromscientificevaluation.PerhapsFreudanticipatedthatinthefuture,psychoanalysiswouldeventuallybeintegratedwithitsneurobiologicalsubstrates.Thiswouldonlyhappenwhenthetimewasrightforasynthesisbasedinanequalpartnershipofbothsciences(Pribram&Gill,1976).

Thetimeforsuchanintegrationhasarrived,andrespectforpsychologicalprocesseshavetakenastrongenoughholdwithinboththescientificcommunityandgeneralculturethatwecanavoidareductionofthemindtobasicbiochemicalprocesses.Onthecontrary,anappreciationforthestructuresandfunctioningofthebrainbynonneurologistshasbecomethenorm.Itisinthisspiritthatweturnourattentiontowaysofthinkingaboutthebrainthatenhanceourunderstandingofhumanexperience.Webeginwithamodelofthebrainthatprovidesabridgebetweenthefieldsofneuroscience,evolution,andtheoriginsoftheunconscious.

TheTriuneBrain

Hewhojoyfullymarchesinrankandfile…hasbeengivenalargebrainbymistake,sinceforhimthespinalcordwouldsuffice.

—AlbertEinstein

Inthe1970s,theneuroscientistPaulMacLeanpresentedatheorythatemphasizedtheconservationofmoreprimitiveevolutionarystructureswithinthemodernhumanbrain(MacLean,1990;Taylor,1999).MacLeancalledhisideathetriunebrain.VerymuchinlinewiththetheoriesofDarwinandFreud,itprovidesanevolutionaryexplanationthatmayaccountforsomeofthecontradictionsanddiscontinuitiesofhumanconsciousnessandbehavior.

MacLeandescribedthehumanbrainasathree-partsystemthatembodiesourevolutionaryconnectiontobothreptilesandlowermammals.Thinkofitasabrainwithinabrainwithinabrain,with

eachsuccessivelayerdevotedtoincreasinglycomplexfunctionsandabilities.Atthecoreisthereptilianbrain,relativelyunchangedthroughevolutionaryhistory,responsibleforactivation,arousal,homeostasis,andreproductivedrives.Thepaleomammalianbrain(orlimbicsystem),whichiscentraltolearning,memory,andemotion,wrapsaroundthereptilianbrain.Thehighestlayer,theneomammalianbrainorcerebralcortex,organizesconsciousthought,problemsolving,andself-awareness(MacLean,1985).

MacLeansuggestedthatourthreebrainsdon’tnecessarilycommunicateorworkwelltogetherbecauseoftheirdiffering“mentalities”andthefactthatonlytheneomammalianbrainiscapableofconsciousnessandverbalcommunication(MacLean,1990).Thisisafundamentalissuethatconnectsevolution,neuroscience,andpsychotherapy.WhatCharcotandFreudcalleddissociationandhysteriacouldwellhavebeentheresultofinadequateintegrationandcoordinationamongthesedifferent,cohabitingbrains.MacLean’sdescriptionofthenonverbalreptilianandpaleomammalianbrainsunconsciouslyinfluencingprocessingintheneomammalianbrainroughlyparallelsFreud’sdistinctionoftheconsciousandtheunconsciousminds.

Themodelofthetriunebrainservesthevaluablefunctionofprovidingaconnectivemetaphoramongtheartifactsofevolution,thecontemporarynervoussystem,andsomeoftheinherentdifficultiesintheorganizationofhumanexperience.Thisconservationofourevolutionaryhistoryalongsideourmodernneuralnetworksconfrontsthetherapistwiththechallengeofsimultaneouslytreatingahuman,ahorse,andacrocodile(Hampden-Turner,1981).

Ah,IfOnlyItWereSoSimple!

Thelargebrain,likelargegovernment,maynotbeabletodosimplethingsinsimpleways.—DonaldHebb

AsuperficialreadingofMacLean’sworkmightleadustotheideathateachlayerofthetriunebrainevolvedindependentlyandsequentially,andthattheyallcooperateinahierarchicalfashionlikeamilitarychainofcommand.Thisisclearlynotthecase.Inreality,thereptilianandpaleomammalianbrainshavecontinuedtoevolvealongsidetheneomammalianbrain.Earlierstructuresarenotconserved“asis”frompastgenerations,butalsoundergoaprocessofexaptation—themodificationofearlierevolvingbrainstructuresfornewapplicationsinnetworksdedicatedtoalternativeormorecomplexfunctions(Cacioppo&Berntson,2004).Thus,allthreelayerscontinuetoevolvealongwiththeemergenceofevermorecomplexverticalandhorizontalneuralnetworks.Thisconservationandmodificationofneuralnetworkshasledtoanamazinglycomplexbraincapableofavastarrayoffunctionsfrommonitoringrespirationtoperformingmathematicalcomputations.Thismakesunderstandingfunctionalneuroanatomyfromastudyofthecontemporarybrainquiteachallenge.

Anexamplefromspaceexplorationmayproveusefulinunderstandingtheneuroanatomist’sdilemma.WhenApollo13approachedthemoon,difficultieswiththeairsupplysystemleftthecrewwithjustafewhoursofoxygen(Lovell&Kluger,1994).Inthefaceofthiscrisis,scientistsonearthremovednonessentialcomponentsfromamockspacecraftandconstructedanewairsupplysystem.Piecesofupholstery,plasticbags,ducttape,andelectricalwiringwereusedininnovativewaystoservenewfunctions.TheinstructionsonhowtobuildthismakeshiftdevicewerethenconveyedtotheApollo13crew.Thisscenarioismuchclosertothecraftingofthemodernbrainthanimagininganengineersittingdownwithablanksheetofpaper.Anengineerofthefuturepresentedwiththisbootstrappedairpurificationsystemwouldhaveadifficulttimefiguringoutwhatitisandwhyitwasbuiltthewayitwas.AlthoughthereareobviousdifferencesbetweentheApollo13scenarioandnaturalselection,bothare

examplesofapragmaticadaptationwithexistingmaterialstoanenvironmentalcrisis.Themultiplerolesplayedbythecerebellumofferaprimeexampleofbothneuralconservationand

exaptation.Thecerebellumisaprimitivebrainstructure.Atitscoreisthevermis,centrallyinvolvedinbalance.Infish,thevermishelpsthemtoswimupright.Inhumans,itcoordinatesvestibularfunctioningandhelpsustositupandwalkwithoutfalling.Duringevolution,asourbrainsandbodiesbecamemorecomplex,thecerebellumexpandedtocoordinategrossandthenfinemotormovements—alogicaldevelopmentforastructureinitiallyatthecoreoftheabilitytoswim.Inaninterestingandsurprisingtwist,thelater-evolvingportionsofthecerebellarlobesareinvolvedintheorganizationandcoordinationoflanguage,memory,andreasoning(Schmahmann,1997).Itappearsthatthecerebellum’sabilitytoprocess,sequence,andorganizevastamountsofsensory-motorinformationwasutilizedbytheevolvingbrainaspartoftheneuralinfrastructureofhighercorticalprocesses.

Justasbalanceandmotorbehaviorrequireconstantmonitoringofpostureandtheinhibitionofunnecessaryanddistractingmovements,so,intheirownways,doattention,concentration,memory,andlanguage.Thesametimingmechanismsinvolvedinlocomotionseemtohavebeenconservedforsequentialprocessinginthoughtandlanguage.Althoughthecerebellumisconsideredaprimitivebrainstructure,itsevolutioninvolvedverticalnetworkingwithmostofthecortex,suggestingthattheverticalnetworksthatconnectthehorizontallayersofthetriunebrainmayserveascluestoitsevolutionaryhistory(Alexander,DeLong,&Strick,1986;Cummings,1993).

Inadditiontohorizontalandverticalnetworks,evolutionhasalsoselectedforincreasingdifferentiationbetweentheleftandrighthemispheres.Certainareasofthebrainhavebecomespecializedforspecificskills,suchaslanguageandspatialabilities.Stillotherareas,suchasthoseintheprefrontalcortex,servetoorganizeandcontroltheactivityofmultipleotherregions.Keepinmindthatthebrainsofmenandwomenalsohavemanydifferencesandthatthebrainchangesaswegrowupandgrowolder(Cozolino,2008).Manyofthesedifferencesareespeciallyimportanttotheprocessesofattachmentandaffectregulationsocentraltopsychotherapy.

Neuralnetworksrelevanttopsychotherapyexistthroughoutthebrain—someareevolutionarilyprimitive,othersdevelopingmorerecently.Somearefullyfunctionalfrombirth,whileotherstakedecadestomature.Thisiswhyanunderstandingofbothevolutionanddevelopmentisvitalincapturingthefullpictureofhumanexperience.

TheInterpersonalSculptingoftheSocialBrain

Itisdifficulttogivechildrenasenseofsecurityunlessyouhaveityourself.Ifyouhaveit,theycatchiffromyou.

—WilliamMenninger

Thetheorythatontogenyrecapitulatesphylogenyreferstotheconceptthattheevolutionofthespeciesisrecreatedinthegestationanddevelopmentofeachindividual.TouseMacLean’sterms,wepassthroughthereptilianandpaleomammalianstagesbeforewedevelopintoafullyhumanbeing.Althoughthetheoryofrecapitulationisinmostwaysincorrect(Gould,1977),someinterestingparallelsexistbetweenourevolutionaryhistoryandtheprocessofhumandevelopment.

Atbirth,thereptilianbrainisfullyfunctionalandthepaleomammalianbrainisprimedandreadytobeorganizedbyearlyexperiences.Thecortex,ontheotherhand,continuestoslowlygrowintothethirddecadeandmaturesthroughoutlife.Thus,muchofourmostimportantemotionalandinterpersonallearningoccursduringourearlyyearswhenourprimitivebrainsareincontrol.Theresultisthatagreat

dealoflearningtakesplacebeforewehavethenecessarycorticalsystemsforexplicitmemory,problemsolving,orperspective.Consequently,manyofourmostimportantsocioemotionallearningexperiencesareorganizedandcontrolledbyreflexes,behaviors,andemotionsoutsideofourawarenessanddistortedbyourimmaturebrains.Toagreatextent,psychotherapyowesitsexistencetotheseartifactsofevolutionanddevelopment.

Theslowdevelopmentofthecerebralcortexmaximizestheinfluenceofexperienceinbuildingthebrain.Thatsomuchofthebrainisshapedafterbirthisbothgoodandbadnews.Thegoodnewsisthattheindividualbrainisbuilttosurviveinaparticularenvironment.Culture,language,climate,nutrition,andparentsshapeeachofourbrainsinauniqueway.Ingoodtimesandwithgood-enoughparents,thisearlybrainbuildingwillservethechildwellthroughoutlife.Thebadnewscomesintoplaywhenfactorsarenotsofavorable,suchasintimesofwarorinthecaseofparentalpsychopathologyorseparation(Benes,Taylor,&Cunningham,2000).Thebrainisthensculptedinwaysthatassistthechildinsurvivingchildhoodbutmaybemaladaptivelaterinlife.Itisintheseinstancesthatatherapistattemptstorestructureneuralarchitectureintheserviceofmoreadaptivebehavior,cognition,andemotion.Buildingthehumanbrainisvastlycomplex.Rebuildingitisadifficultandfascinatingchallenge.

Aportionofthebraincalledtheanteriorcingulate—centrallyinvolvedwithmaternalbehavior,nursing,andplay—appearsintheevolutionofearlymammals(MacLean,1985).Beforethis,animalshadtobepreparedtosurviveontheirownatbirth.Goodexamplesarenewbornseaturtlesthathatchfromtheireggshighonabeachandmakeamadinstinctualdashtowardtheocean.Withtheevolutionofmaternalcare,childrenareallowedtodevelopmoreslowlywithinasupportive,scaffoldingenvironment.Inthecourseofevolution,primateshaveexperiencedincreasinglylongerperiodsofmaternaldependence.Thisluxuryallowsfortheevolutionanddevelopmentofmorecomplexbrains,aswellasanincreasingimpactofparentingandearlyexperiencesonhowthebrainisbuilt.

KonradLorenz(1991)foundthatgeeseimprint(bondtoattachmentfigures)duringalimitedperiodoftimesoonafterbirth.IfbabygeesesawLorenzfirst,theywouldfollowhimasifheweretheirmother.Lorenzalsofoundthatwhenthesegeesereachedsexualmaturity2yearslater,theywould“fallinlove”withthekindsofgeesetheyhadbeenexposedtoduringtheirimprintingperiod.Heevennotedthatababygoose,whichoriginallyimprintedonhim,fellinlovewithahumangirlfromthenexttownwhenhereachedsexualmaturityandwouldflytheretoseeher.TheseearlyexperiencesseemedtobepermanentlyetchedintothebrainsofLorenz’sgeese.

Thisprincipleofimprintingcanbeseeninhumansinthemoreflexibleandcomplexformofattachmentschema.Theearlyinterpersonalenvironmentmaybeimprintedinthehumanbrainbyshapingthechild’sneuralnetworksandestablishingthebiochemicalsetpointsincircuitrydedicatedtomemory,emotion,safety,andsurvival.Later,thesestructuresandprocessescometoserveastheinfrastructureforsocialandintellectualskills,affectregulation,andthesenseofself.

Prolongeddependenceinchildhoodhasallowedforthedevelopmentofaneocortexsocomplexthatwehavebecomecapableofspokenandwrittenlanguage,self-consciousness,andtheconstructionofbothprivateandsocialselves.Althoughtheseabilitiescreatetremendouspossibilities,brainpowerdoeshaveitsdownside.Wearenowalsocapableofbecominganxiousaboutthingsthatwillneverhappen,depressedbyimaginedslights,andsaddenedbypotentiallosses.Ourimaginationscansimultaneouslycreateexcitingnewworlds,aswellasthefearsthatpreventusfromlivinginthem.Itisobviousthatdespitetheevolutionofconsciousnessandrationality,ourprimitiveemotionalbrainsandtheirearlydevelopmentcontinuetoexertagreatdealofinfluenceoverus.

Summary

AlthoughFreudbeganhiscareerattemptingtocreateabrain-basedpsychology,thetheoriesandtechnologyavailabletohimdidnotallowhimtocarryoutthisproject.Variouswaysofthinkingaboutthebrain(likeMacLean’s),althoughlimited,providemodelsthatbridgethegapbetweenpsychologyandneurology.Evolution’slegacyisacomplexbrain,vulnerabletoavarietyoffactorsthatcandisruptthegrowthandintegrationofimportantneuralnetworks.Thefieldofpsychotherapyhasemergedbecauseofthebrain’svulnerabilitytothesedevelopmentalandenvironmentalrisks.Buthowcanpsychotherapistssynthesizeandincorporateboththemindandthebrainintoourwork?Thefollowingchapterpresentsamodelofneuralnetworks,howtheydevelop,andhowweattempttoalterthemduringtreatment.Itisfromthisperspectivethatwewillthenexaminetherelevanceofthenervoussystemtoourwork.

Chapter2

BuildingandRebuildingtheBrain:PsychotherapyandNeuroscience

Iknowofnomoreencouragingfactthantheunquestionableabilityofmantoelevatehislifebyaconsciousendeavor.

—HenryDavidThoreau

Althoughpsychotherapyoriginallyemergedfromneurology,differencesinlanguageandworldviewhavelimitedcollaborationamongthetwofieldsformostofthe20thcentury.Whilepsychotherapistsdevelopedarichmetaphoriclanguageofmind,neurologistsbuiltadetaileddatabaseofbrain–behaviorrelationships.Asweapproachedthe21stcentury,neurosciencebeganprovidinguswithtoolstoexplorewhathappensinthebrainduringearlydevelopment,andlaterinpsychotherapy.AreturntoFreud’sProjectofabiologicalpsychologyisfinallyathand.

Attheheartoftheinterfaceofneuroscienceandpsychotherapyisthefactthathumanexperienceismediatedviatwointeractingprocesses.Thefirstistheexpressionofourevolutionarypastviatheorganization,development,andfunctioningofthenervoussystem—aprocessresultinginbillionsofneuronsorganizingintoneuralnetworks,eachwithitsowntimetableandrequirementsforgrowth.Thesecondisthecontemporaryshapingofourneuralarchitecturewithinthecontextofrelationships.Thehumanbrainisa“socialorganofadaptation”stimulatedtogrowthroughpositiveandnegativeinteractionswithothers.Thequalityandnatureofourrelationshipsbecomeencodedwithintheneuralinfrastructureofourbrains.Itisthroughthistranslationofexperienceintoneurobiologicalstructuresthatnatureandnurturebecomeone.

Attheheartofpsychotherapyisanunderstandingoftheinterwovenforcesofnatureandnurture,whatgoesrightandwrongintheirdevelopmentalunfolding,andhowtoreinstatehealthyneuralfunctioning.Whenoneormoreneuralnetworksnecessaryforoptimalfunctioningremainunderdeveloped,underregulated,orunderintegratedwithothers,weexperiencethecomplaintsandsymptomsforwhichpeopleseektherapy.Wenowassumethatwhenpsychotherapyresultsinsymptomreductionorexperientialchange,thebrainhas,insomeway,beenaltered(Kandel,1998).

Howdoespsychotherapychangethebrain?Howismemorystoredandhowcanthequalityofexperiencechange?Beforewecanaddressthesequestionswehavetofirstgetanideaofhowthebrainisorganizedandhowitperformssomeofitsmanyfunctions.Wewilldiscussthebuildingandrebuildingofneuralnetworks,theroleofenrichedenvironments,andthepartplayedbystressinchangingthebrain.Wewillalsoexplorethecentralroleofthetherapeuticrelationshipinthischangeprocess,aswellastheimportanceoftheexpressionofemotionandthetherapeuticuseoflanguage.

NeuralNetworks

Aforestofthesetreesisaspectacletoomuchforonemantosee.—DavidDouglas

Sofarwehaveusedthetermneuralnetworksinageneralway;Iwouldlikenowtogetabitmorespecific.Neuronsarethemicroscopicprocessingunitsthatmakeupallpartsofthenervoussystem.Whenwetalkofthefrontalcortex,amygdala,orhippocampus,weareliterallytalkingaboutlargenumbersofindividualneuronsorganizedtoperformasetoffunctions.Theneuronswithinthesesystemsneedtobeabletoorganizeandreorganizeinsuchawayastoallowustolearn,remember,andactasweadjusttodifferentsituations.Becauseeachneuronislimitedtoeitherfiringornotfiring,thediversecapabilitiesofthenervoussystemcomefromthecomplexinteractionofindividualneuronalsignals.Asimplisticanalogyisanold-fashionedbillboardconsistingofrowsandcolumnsofthousandsoflightbulbs.Althougheachindividualbulbislimitedtobeingeitheronoroff,thepatterncreatedbytheselightscanspelloutwords,formimages,andthroughprecisetiming,createtheillusionofmovement.Inasimilarfashion,patternsofneuralfiringcometorepresentspecificinformationwithinthebrainandthroughoutthenervoussystem.

FIGURE2.1TheFeedforwardNeuralNetwork

Adepictionofsixteenneuronsinasimplefeedforwardcircuit

Toaccomplishthecomplexityrequiredforbehavior,neuronsorganizeintoneuralnetworks.Aneuralnetworkcanrangefromjustafewneuronsinasimpleanimaltotrillionsofneuralinterconnections

inbrainssuchasourown.Neuralnetworksencodeandorganizeallofourbehaviorsfrombasicreflexes,suchaspullingourhandawayfromahotstove,toourabilitytosimultaneouslycomprehendthevisual,emotional,andpoliticalsignificanceofPicasso’sGuernica.Neuralnetworkscaninterconnectwithmultipleothernetworks,allowingforinteractionandintegration.Becausewewillbereferringtoneuralnetworksthroughoutthechapterstocome,itisimportanttokeepagoodvisualimageinourmindsasweproceed.

FIGURE2.2TheFeedforwardandFeedbackNeuralNetwork

Aslightlymorecomplexmodelinwhichinformationisfedbackwardsandeachneuroncancommunicatewithallofitsneighbors.

Figures2.1and2.2depictsimpleneuralnetworks,witheachcirclerepresentinganindividualneuron.StartingwithFigure2.1,youwillnoticethattheflowofinformationmovesfromlefttorightacrossthefourcolumnsofneurons.Ontheleft,someoftheinputneuronsarefiringinresponsetosomestimulus(1=firing/0=nonfiring).Inturn,theirfiringstimulatestheactivationofsomesetofneuronswithinthehiddenlayersofprocessing,whichleadstothefiringofasetofoutputneurons,whichresultsinaparticularexperienceorbehavioralreaction.Figure2.2representsasteptowardamoreaccuratemodel,withinformationflowinginbothdirectionsandanincreasedlevelofinteractionamongneurons.Eachoftheconnectionswillhaveeitheranexcitatoryorinhibitoryeffectonotherneurons.Thismosaicoffiringpatterns,thenetwork’sinstantiation,willdeterminewhichsetofoutputneuronsfire.Makingthingsslightlymorecomplicated,insteadof16neuronstherearemillions,eachofwhichcanbeconnectedtothousandsofothers.

Instantiationsaresculptedbyexperienceandencodeallofourabilities,emotions,andexperiencesintooneormoreformsofmemory.Itistheconsistencyofthesefiringpatternsthatresultsinorganized

patternsofbehaviorandexperience.Oncetheseneuralpatternsareestablished,newlearningmodifiestherelationshipofneuronswithinthesenetworks.Atothertimes,newlearningmayoccurwhenweshapeoneneuralnetworktoinhibittheactivationofanother.Whenwetalkofbuildingandrebuildingthebrain,neuronsareourbasicbuildingblocksandneuralnetworksarethestructuresthatwebuildandsculpt.

Learningwithinneuralnetworksoccursasaresultoftrialanderror.Feed-forwardandfeedbackinformationloopsformcomplexpatternsofexcitationandinhibitionamongneuronswithinthehiddenlayers.Thisprocesseventuallyleadstoconsistentandadaptiveoutput.Thisisdemonstratedinasoon-to-betoddler,whorepeatedlytestsandrefinesherbalance,legstrength,andcoordinationwitheachnewattempttowalk.Herbraindriveshertokeeptryingwhilerecordinghersuccessesandfailureswithinneuralnetworksresponsibleforbalance,motorcoordination,andvisualtracking.Inthissameway,neuralnetworksorganizebehaviors,emotions,thoughts,andsensationsthatareshapedthroughoutlife.

Irememberbeingsurprisedtofindatableofrandomnumbersinanappendixofmycollegestatisticstextbook.Atfirst,Ithoughtthistobeawasteofpaper,assumingthatanyonecouldgeneraterandomnumbersontheirown.WhenIsharedmythoughtswiththeprofessor,heassuredmethatmuchresearchhadgoneintodemonstratingthatweareincapableofgeneratingrandomnumbers.Hesaidthatashardaswemighttry,wecannotavoidgeneratingspecificpatternsofnumbers.Thisfinallymakessensetomebasedonneuralnetworkorganization:Weareunabletoengageinrandomactionsbecauseourbehaviorsareguidedbypatternsestablishedthroughpreviouslearningtowhichweautomaticallyreturn.Andwhilenotbeingabletogeneraterandomnumbersisoflittleconsequencetousinourday-to-daylives,thetendencytomakethesamemistakesagainandagainiscauseforagreatdealofhumansuffering.ThistendencytorepeatpatternsofthoughtandbehavioriswhatledthepsychoanalystWilhelmReichtosaythatpeopletendtoremainsickbecausetheycontinuetofindthesamewrongsolutionstotheproblemstheyhopetochange.

NeuralNetworkGrowthandIntegration

Plasticitythen,inthewidesenseoftheword,meansthepossessionofastructureweakenoughtoyieldtoaninfluence,butstrongenoughnottoyieldallatonce.

—WilliamJames

Thegrowthandconnectivityofneuronsisthebasicmechanismofalllearningandadaptation.Learningcanbereflectedinneuralchangesinanumberofways,includingchangesintheconnectivitybetweenexistingneurons,theexpansionofexistingneurons,andthegrowthofnewneurons.Allofthesechangesareexpressionsofplasticity,ortheabilityofthenervoussystemtochangeinresponsetoexperience.Althoughthefirsttwoformsofplasticityhavebeenrecognizedinhumansfordecades,thebirthofnewneurons(neurogenesis)wasonlyrecentlydiscoveredinregionsinvolvedwithongoinglearning,suchasthehippocampus,theamygdala,andthefrontalandtemporallobes(Erikssonetal.,1998;Gould,Reeves,Graziano,&Gross,1999;Gould,Tanapat,Hastings,&Shors,1999;Gross,2000).

Existingneuronsgrowthoughtheexpansionandbranchingofthedendritestheyprojecttootherneuronsinreactiontonewexperiencesandlearning(Purves&Voyvodic,1987).Thisprocessisreflectedintheconnectivityamongneuronsinoursimpleschematicdiagrams.Neuronsinterconnecttoformneuralnetworks,andneuralnetworks,inturn,integratewithoneanothertoperformincreasinglycomplextasks.Forexample,networksthatparticipateinlanguage,emotion,andmemoryneedtobecomeintegratedinorderforustorecallandtellanemotionallymeaningfulstorywiththeappropriatewords,correctdetails,andproperaffect.

Associationareaswithinthecortexservetherolesofbridging,coordinating,anddirectingthemultipleneuralcircuitstowhichtheyareconnected.Althoughtheactualmechanismsofthisintegrationarenotyetknown,theyarelikelytoincludesomecombinationofcommunicationbetweenlocalneuronalcircuitsandtheinteractionsamongfunctionalbrainsystems(Trojan&Pokorny,1999).Changesinthesynchronyofactivationofmultipleneuralnetworksmayalsoplayaroleinthecoordinationoftheiractivityandtheemergenceofconsciousawareness(Crick,1994;Konig&Engel,1995).

GeneticInheritanceandGeneExpression

Evolutionconsistsofthegradualtransformationoforganismsfromoneconditionofexistencetoanother.

—ErnstMayr

Nowthatmostofsciencehasgottenbeyondthebasicdebateofnatureversusnurture,wecanacknowledgethatthegrowthandorganizationofthebrainreflectsacomplexyetsubtleblendingofgeneticandenvironmentalinfluences.Towardthisend,itismuchmorehelpfultothinkofgenesintermsofservingbothatemplateandatranscriptionfunction(Kandel,1998).Astemplates,genesprovidetheorganizationoftheuniformstructuresofthebrain,whicharegenerallyunaffectedbyenvironmentalinfluences,exceptincasesofprenatalgeneticabnormalities.Thesestructuresandfunctions,suchasthegenerallayoutofthenervoussystemandbasicreflexes,areinheritedviaourDNAandsharedbyallhealthymembersofourspecies.Thisistheaspectofgeneticinheritancetraditionallythoughtofas“nature.”

Ontheotherhand,theexpressionofmanygenesdependsonexperiencesthattriggertheirtranscription(Black,1998).Transcriptiongeneticscontrolsthemoresubtleaspectsofthebrain’sorganization,suchasthespecificsculptingoflaterdevelopingneuralnetworksandthelevelsofspecificneurotransmittersavailabletodifferentbrainsystems.Infact,themajorityofourcortexisaddedafterbirthinanexperience-dependentfashionthroughthistranscriptionalprocess.Nurture,therefore,influencesbraindevelopmentviatheselectiveactivationofgenesthatshapetheexperience-dependentaspectsofdevelopment.Howdoesthishappen?

Experienceresultsintheexpressionofcertaingeneswhichtriggerthesynthesisofproteinsthatbuildneuralstructures.Throughgenetictranscription,existingneuronsgrowdifferentkindsofreceptors,expandtheirdendriticstructures,andadjusttheirbiochemistry.Forexample,althoughidenticaltwinsraisedinthesamehouseholdmayhaveidenticalgenesforschizophrenia,onlyonemaydeveloptheillness.Thisisbelievedtobetheresultoftheexpressionofdifferentgenesbasedontheuniqueinteractionsbetweeneachchildandhisorherenvironment.Thetranscriptionfunctionofgenesallowsforongoingneuralplasticitythroughoutlifeandprovidesthebasisforenrichedexperiences(likepsychotherapy)tobenefitboththeadolescentandadultbrain.Inalaterchapterwewillexplorethelinksbetweenmaternalnurturanceandtheearlybuildingofthebrainthatresultindifferentlevelsoflearning,emotionalregulation,andattachmentbehavior.

TheRoleofEnrichedEnvironments

ItisalwayswithexcitementthatIwakeupinthemorning….It’smypartner.—JonasSalk

Thebrainisnotastaticorgan;itcontinuallychangesinresponsetoenvironmentalchallenges.Becauseofthis,theneuralarchitectureofthebraincomestoembodytheenvironmentthatshapesit.Youcouldalsothinkofourneuralarchitectureasatangibleexpressionofourlearninghistory.Theearlyresearchonneuralplasticitybeganbyexploringtheimpactofdifferenttypesofenvironmentsonbraindevelopment.Inthesestudiesdoneprimarilywithrats,enrichedenvironmentstooktheformofmorediverse,complex,colorful,andstimulatinghabitats,whileimpoverishedenvironmentswererelativelyemptymonochromaticenclosures.Itwasfoundthatanimalsraisedinenrichedenvironmentshadmoreneurons,moresynapticconnectionsamongneurons,agreaternumberofbloodcapillaries,andmoremitochondriaactivity(Diamond,Krech,&Rosenweig,1964;Kempermann,Kuhn,&Gage,1997,1998;Kolb&Whishaw,1998;Sirevaag&Greenough,1988).Thesefindingsdemonstratethatabrainwhichischallengedcomestobemorecomplex,active,androbust.Subsequentresearchwithhumanshasyieldedsimilarresultsforindividualswithmoreeducationandmorecomplexandchallengingoccupations.

Forhumans,enrichedenvironmentsincludethekindsofchallengingeducationalandexperientialopportunitiesthatencourageustolearnnewskillsandexpandourknowledge.Higherlevelsofeducation,practicingskills,andcontinuedengagementinmentalactivitiesallcorrelatewithmoreneuronsandneuralconnections(Jacobs&Scheibel,1993;Jacobs,Schall,&Scheibel,1993).Higherlevelsofeducationandreadingabilityhavealsobeenshowntocorrelatewithadiminishedimpactofdementialaterinlife(Schmand,Smit,Geerlings,&Lindeboom,1997).Interestingly,brainregionsdedicatedtocertainskillscanactuallyhijackcellsinadjacentneuralareastoservetheirneedstodevelopskillslikeplayinganinstrumentorlearningBraille(Elbert,Pantev,Wienbruch,Rockstroh,&Taub,1995).Thereisnodoubtthatthehumanbraingrowsinresponsetochallengeandnewlearning.

Psychotherapycanbethoughtofasaspecifictypeofenrichedenvironmentthatpromotessocialandemotionaldevelopment,neuralintegration,andprocessingcomplexity.Thewaythebrainchangesduringtherapywilldependupontheneuralnetworksinvolvedinthefocusoftreatment.

LearningandStress

Everystressleavesanindeliblescar,andtheorganismpaysforitssurvivalafterastressfulsituationbybecomingalittleolder.

—HansSelye

Mildtomoderatestress(MMS)activatesneuralgrowthhormonessupportiveofnewlearning(Cowan&Kandel,2001;Gould,McEwen,Tanapat,Galea,&Fuchs,1997;Jablonska,Gierdalski,Kossut,&Skangiel-Kramska,1999;Myers,Churchill,Muja,&Garraghty,2000;Pham,Soderstrom,Henriksson,&Mohammed,1997;Zhu&Waite,1998).Thus,MMSmaybeutilizedtoenlistnaturallyoccurringneurobiologicalprocessesintheserviceofnewlearning.Althoughweusethetermstressinanimalresearch,humansalsodemonstratearousalintheformofcuriosity,enthusiasm,andpleasure.Humanscanalsobemotivatedtolearnnewskillsandtakeonnewchallengestorelievediscomfortandstress.Thesemotivationalstateshaveallbeenrecognizedfortheirroleinsuccessfuloutcomesfrompsychotherapy.

Dissociationisacommonresultofthehighlevelsofstressassociatedwithtraumaticexperiences.Characterizedbyadisconnectionamongthoughts,behaviors,sensations,andemotions,dissociationdemonstratesthatthecoordinationandintegrationofthesefunctionsisanactiveneurobiologicalprocess.Becauseallofthesefunctionsareseamlesslyandunconsciouslyinterwovenduringnormalstatesofawareness,itiseasytooverlookthefactthattheirintegrationisacentralcomponentofmentalhealth.

Thepowerofmildtomoderatelevelsofstresstotriggerneuralplasticityisakeyelementinthe

successofpsychotherapyoranylearningsituation.Asopposedtotraumaticexperiences,thecontrolledexposuretostressduringtherapyenhancesnewlearningandincreasesneuralintegration.Astherapists,weintuitivelyworktoregulatestressandintegrateneuralnetworks,aprocessthatisessentiallytheoppositeofthedissociationobservedinreactiontotrauma.Healthyfunctioningrequiresproperdevelopmentandfunctioningofneuralnetworksorganizingconsciousawareness,behavior,emotion,andsensation.

Asinearlydevelopment,therepeatedexposuretostressinthesupportiveinterpersonalcontextofpsychotherapyresultsintheabilitytotolerateincreasinglevelsofarousal.Thisprocessreflectsthebuildingandintegrationofcorticalcircuitsandtheirincreasingabilitytoinhibitandregulatesubcorticalactivation.Affectregulation,especiallythemodulationandinhibitionofanxietyandfear,allowsforcontinuedcorticalprocessinginthefaceofstrongemotions,allowingforongoingcognitiveflexibility,learning,andneuralintegration.

Inthisprocessthetherapistplaysessentiallythesameroleasaparent,providingandmodelingtheregulatoryfunctionsofthesocialbrain.Asaffectisrepeatedlybroughtintothetherapeuticrelationshipandsuccessfullymanaged,theclientgraduallyinternalizestheseskillsbysculptingtheneuralstructuresnecessaryforautoregulation.Asinchildhood,therepeatedcycleofattunement,ruptureoftheattunement,anditsreestablishmentgraduallycreatesanexpectationofreconnection(Lachmann&Beebe,1996).Thelearnedexpectationofreliefinthefutureenhancestheabilitytotoleratemoreintenseaffectinthemidstofthestressfulmoment.

Asatherapist,oneofmyprimarygoalsistoshiftmyclients’experienceofanxietyfromanunconscioustriggerforavoidancetoaconsciouscueforcuriosityandexploration.Oneofmypatientsdescribeditmetaphoricallyasusinganxietyasacompasstohelpguidehimtoandthroughhisunconsciousfears.Becomingawareofanxietyisthenfollowedwithanexplorationandeventualunderstandingofwhatweareafraidofandwhy.Thenextstepistomovetowardtheanxietywithanunderstandingofitsmeaningandsignificance.Inthisway,anxietybecomeswovenintoaconsciousnarrativewiththepossibilityofwritinganewoutcometoourstory.Thisprocessreflectstheintegrationofcorticallinguisticprocessingwithconditionedsubcorticalarousalintheserviceofinhibiting,regulating,andmodifyingmaladaptivereactions.

Aswewillseelaterwhendiscussingthebuildingofthesocialbrain,biologicalandenvironmentalfactorsduringchildhoodcanresultinlongperiodsofdysregulation.Earlydeprivationorchronicstressincreasethechancesofdamagetothebrain,deficitsinmemoryandrealitytesting,andtheprolongedutilizationofprimitivedefenses(Brown,Henning,&Wellman,2005;Radleyetal.,2006;Sapolsky,1985).Withincreasednurturanceandsupport,stresshormonelevelsdecrease;physicalcomfortandsoothingtalkwithcaretakershelpsthebraintointegrateexperience.

EmotionalToleranceandAffectRegulation

Fewthingsarebroughttoasuccessfulissuebyimpetuousdesire,butmostbycalmandprudentforethought.

—Thucydides

Althoughweusuallythinkofthecortexasagiantharddrivecapableofstoringhugeamountsofdata,anotherprimaryroleofthecortexisinhibition.Takeforexamplethegraspingreflexweareallbornwith.Thispowerfulgripallowedourancestorstoholdontotheirmothersastheymovedthroughtreesandoverland.Duringtheearlymonthsoflifethisgraspingreflexissooninhibitedbydescendingcorticalcircuitry.

Theinhibitionofthisandotherreflexesallowforacorticaltakeoverofthesefunctionsduringdevelopment.Sowesacrificethegraspingreflexforthefingerdexteritynecessarytomanipulatedigits,write,andusetools.Laterinlifeifwehavethemisfortuneofsuccumbingtodementia,thisandotherearlyreflexesbegintoreappearasourcortexgraduallylosesitsinhibitoryability.Inasimilarfashion,ourprefrontalcortexisshapedbyexperiencetoinhibitandcontrolsubcorticalfunctionalactivation,whicheventuallyresultsinourabilitytoregulateouremotions.Earlyattachmentrelationshipsestablishtheexperiencesthatshapetheseneuralnetworksandallowustoregulateouremotionalexperience.

Assistancewithexperiencingincreasinglevelsofpositiveandnegativeaffectisavitalcomponentofbothparentingandpsychotherapy.Thegraduallyincreasingtoleranceforstressbuildsourbrains,expandsneuralorganizationofemotionalandcognitiveintegration,andcreatesnetworksofdescendingcontroltohelpinhibitandregulateaffect(Schore,1994).Emergingfromchildhoodwithanabilitytoexperiencearangeofemotionsandtoleratestressservesbothasameansofbraingrowthandcontinueddevelopmentthroughoutlife.

Duringourfirstfewyears,wehavetherepeatedexperiencesofgoingfromacomfortable,regulatedstatetoastateofdysregulation.Webecomefrightened,cold,wet,andhungry,andshowourdispleasurewithfacialexpressions,bodilypostures,vocalization,andcrying.Inthepresenceofgood-enoughparenting,oursignalsareattendedto,thesourceofourdispleasurediagnosed,andwearehelpedbackintoaregulatedstate.Acrossthousandsofthesetemporal-emotionalexperiences,wegofromregulationtodysregulationtoreregulation.Theseexperiencesshapesecureattachmentandtheexpectationofpositiveoutcomes.Thesummationoftheseexperiences,storedthroughoutournervoussystem,becomesthesensory-motion-emotionalbackgroundofourexperience.

Intheabsenceofadequateassistanceinregulatingaffectormakingsenseofemotions,thebrainorganizesavarietyofdefensivecopingstrategies.Thesedefensesvaryinthedegreetowhichtheydistortrealityinordertoachievetheirgoalofreducinganxiety.Thisdistortionisaccomplishedincircuitsofunconsciousmemorythatcontrolanxietyandfear(Critchleyetal.,2000).Theneuralconnectionsthatresultindefensesshapeourlivesbyselectingwhatweapproachandavoid,whatourattentionisdrawnto,andtheassumptionsweusetoorganizeourexperiences.Ourcortexthenprovidesuswithrationalizationsandbeliefsaboutourbehaviorsthathelpkeepourcopingstrategiesanddefensesinplace,possiblyforalifetime.Theseneuralandpsychicstructurescanleadtoeitherpsychologicalandphysicalhealth,orillnessanddisability.

PsychopathologyandNeuralNetworkIntegration

Inastructureascomplexasthehumanbrainamultitudeofthingscangowrong.Thewonderisthatformostpeoplethebrainfunctionseffectively.

—SeymourKety

Ifeverythingweexperienceisrepresentedbyinstantiationswithinneuralnetworks,thenbydefinition,psychopathologyofallkinds—fromthemildestneuroticsymptomstothemostseverepsychosis—mustalsoberepresentedwithinandamongneuralnetworks.Inlinewiththistheory,psychopathologywouldbeareflectionofsuboptimaldevelopment,integration,andcoordinationofneuralnetworks.Patternsofdysregulationofbrainactivationfoundindisorderssuchasdepressionandobsessive-compulsivedisordersupportthetheoryofabrain-basedexplanationforthesymptomsofpsychopathology.Difficultiesinearlycaretaking,geneticandbiologicalvulnerabilities,ortraumaatanytimeduringlife

canresultinthelackofintegrationamongnetworks.Unresolvedtraumacancauseongoinginformationprocessingdeficitsthatdisruptintegratedneuralprocessing.Forexample,dissociativesymptomsfollowingtrauma—reflectingthedisconnectionamongnetworksofbehavior,emotion,sensation,andcognition—predictthelaterdevelopmentofposttraumaticstressdisorder(Koopman,Classen,&Spiegel,1994;McFarlane&Yehuda,1996).Childrenvictimizedbypsychological,physical,andsexualabusehaveagreaterprobabilityofdemonstratingelectrophysiologicalabnormalitiesinexecutiveregionsofthebrainvitaltoneuralnetworkintegration(Itoetal.,1993;Teicheretal.,1997).

Ingeneral,psychologicalintegrationsuggeststhattheconsciouscognitivefunctionsoftheexecutivebrainhaveaccesstoinformationacrossnetworksofsensation,behavior,andemotion.Aprimaryfocusofneuralintegrationintraditionaltalkpsychotherapyisbetweennetworksofaffectandcognition.Dissociationbetweenthetwooccurswhenhighlevelsofstressinhibitordisruptthebrain’sintegrativeabilitiesamongtheleftandrightcerebralhemispheresaswellasamongthecortexandlimbicregions.Theintegrationoftheleftandrighthemispherescanbedisruptedwhilethecircuitsofthereptilianandpaleomammalianbrainscanbeunlinkedfromtheconsciousneomammaliancortex.

Thisunlinkingmaynotbeanevolutionaryaccident.Asvaluableaslanguagecanbeforhumans,evolutionappearstohaveselectedfortheshutdownoflanguage(andadecreaseincognitiveprocessing)whenconfrontedwiththreat.Theresultingdisruptionofinformationprocessingmaybethemostcommoncauseofneuralnetworkdissociation.Corticalnetworksresponsibleformemory,language,andexecutivecontrol(initsmanyforms)becomeinhibitedandunderperformduringtimesofoverwhelmingstress.Theverywaythatthebrainhasevolvedtosuccessfullycopewithimmediatethreatappearstohavecreatedavulnerabilitytolongertermpsychologicaldistress:Enterpsychotherapy.

Applyingthismodel,psychotherapyisameansofcreatingorrestoringcoordinationamongvariousneuralnetworks.Researchhasdemonstratedthatsuccessfulpsychotherapycorrelateswithchangesinactivationinareasofthebrainhypothesizedtobeinvolvedindisorderssuchasobsessivecompulsivedisorderanddepression(Baxteretal.,1992;Brody,Saxena,Mandelkern,etal.,2001;Brody,Saxena,Schwartz,etal.,1998;Schwartz,Stoessel,Baxter,Martin,&Phelps,1996).Thereturntonormallevelsofactivationandhomeostaticbalanceresultsinreestablishingpositivereciprocalcontrolamongrelevantneuralstructuresandnetworks.

PsychotherapyandNeuralNetworkIntegration

Theonlythingthey(neuralconnections)cando…istodeepenoldpathsortomakenewones.

—WilliamJames

Abasicassumptionofbothneuroscienceandpsychotherapyisthatoptimalfunctioningandmentalhealtharerelatedtoincreasinglyadvancedlevelsofgrowth,integration,andcomplexity.Onaneurologicallevel,thisequatestotheintegrationandcommunicationofneuralnetworksdedicatedtoemotion,cognition,sensation,andbehaviorandaproperbalancebetweenexcitationandinhibition.Onanexperientiallevel,integrationistheabilitytolivelife—loveandwork—whileemployingaminimumofdefensiveness.Growthandintegrationareoptimizedbyapositiveearlyenvironment,includingstage-appropriatechallenges,support,andparentswhoarecapableandwillingtoputfeelingsintowords.Thesefactorsleadtopositiveaffectregulation,biologicalhomeostasis,andaquietinternalmilieuallowingfortheconsolidationoftheexperienceofsubjectivityandapositivesenseofself.

Fromtheperspectiveofneuroscience,psychotherapycanbeunderstoodasaspecifickindof

enrichedenvironmentdesignedtoenhancethegrowthofneuronsandtheintegrationofneuralnetworks.Thetherapeuticenvironmentisindividuallytailoredtofitthesymptomsandneedsofeachclient.Iproposeherethatallformsoftherapy,regardlessoftheoreticalorientation,willbesuccessfultothedegreetowhichtheyfosterappropriateneuroplasticity.Further,Ialsoproposethatneuralplasticity,growth,andintegrationinpsychotherapyareenhancedby:

1. Theestablishmentofasafeandtrustingrelationship.2. Mildtomoderatelevelsofstress.3. Activatingbothemotionandcognition.4. Theco-constructionofnewpersonalnarratives.

Althoughpsychotherapistsdonotgenerallythinkin“neuroscientific”terms,stimulatingneuroplasticityandneuralintegrationisessentiallywhatwedo.Weprovideinformationtoclientsaboutourunderstandingoftheirdifficultiesintheformofpsychoeducation,interpretations,orrealitytesting.Weencourageclientstoengageinbehaviors,expressfeelings,andbecomeconsciousofaspectsofthemselvesofwhichtheymaybeunaware.Wedarethemtotakerisks.Weguidethembackandforthbetweenthoughtsandfeelings,tryingtohelpthemestablishnewconnectionsbetweenthetwo.Wehelpclientsaltertheirdescriptionofthemselvesandtheworld,incorporatingnewawarenessandencouragingbetterdecisionmaking.Withsuccessfultreatment,themethodsbeingusedareinternalizedsothatclientscangainindependencefromtherapyandwedothisallinthecontextofawarm,supportive,committed,andconsistentrelationship.Thesesamefactorsareatplayacrosspsychodynamic,systems,andcognitive-behavioralapproachestotreatment.

Thebroadcontextinwhichtheseprocessescansuccessfullyoccurisoneofincreasinglevelsofaffecttoleranceandregulationandthedevelopmentofintegrativenarrativesthatemergefromtheclient–therapistrelationship.Inthecontextofempathicattunementwithinasafeandstructuredenvironment,clientsareencouragedtotoleratetheanxietyoffearedexperiences,memories,andthoughts.Inthisprocess,neuralnetworksthatarenormallyinhibitedbecomeactivatedandavailableforinclusionintoconsciousprocessing(Siegel,1995).Interpretationsinpsychodynamictherapy,exposureinbehavioraltherapies,orexperimentsindifferentiationfromasystemsperspectiveallfocusonthisgoal.Throughtheactivationofmultiplecognitiveandemotionalnetworks,previouslydissociatedfunctionsareintegratedandgraduallybroughtunderthecontrolofcorticalexecutivefunctions.Narrativesco-constructedwiththerapistsprovideanewtemplateforthoughts,behaviors,andongoingintegration.

PathwaysofIntegration

Itistheharmonyofthediverseparts,theirsymmetry,theirhappybalance;inaworditisallthatintroducesorder,allthatgivesunity.

—HenriPoincaré

Giventhatinformationflowssimultaneouslyinmultipledirectionsthroughmanyneuralnetworks,optimalneuralintegrationlikelyinvolvesmaximizingtheflowandflexibilityofenergythroughneuralnetworks(Pribram,1991).Usingthismodel,psychopathologycanbecausedbydifficultiesnotjustinaspecificregionofthebrain,butalsointheinteractionsamongparticipatingsystems(Mayberg,1997;Maybergetal.,1999).Numerousprocessingnetworkscombineaffect,sensation,behavior,andconsciousawareness

intoanintegrated,functional,andbalancedwhole—theneuralsubstrateforwhatFreudcalledtheego.Theegoisessentiallyshorthandforhowtheorganizationoftheselfcomestobeexpressedindimensionssuchaspersonality,affectregulation,copingstyles,andself-image.

Theprimarydirectionsofinformationflowrelevanttopsychotherapyaretop-down(corticaltosubcorticalandbackagain)andleft-right(acrossthetwohalvesofthecortex).Keepinmindthattheseinformationloopsneedtocommunicatewitheachotheraswellaswithmanyotherprocessingsystems.Top-downorbottom-upintegrationwouldincludeMacLean’slinkupamongthethreelevelsofthetriunebrainandtheunificationofthebody,emotion,andconsciousawareness.Thisiscalledtop-downbecausethesecircuitsformloopsthatgofromthetopofourheaddownintothedepthsofthebrainandbackupagain.Top-downintegrationincludestheabilityofthecortextoprocess,inhibit,andorganizethereflexes,impulses,andemotionsgeneratedbythebrainstemandlimbicsystem(Alexanderetal.,1986;Cummings,1993).Frontallobedisordersoftenresultinadisinhibitionofimpulsesandmovementsnormallyunderitscontrolsuchasobsessive-compulsiveandattentiondeficitdisorders.WithinthiscategoryIincludewhathasbeenreferredtoasdorsal-ventralintegration,connectingcorticalwithlimbicprocessing(Panksepp,1998;Tucker,Luu,&Pribram,1995).

Left-rightorright-leftintegrationinvolvesabilitiesthatrequiretheinputofboththeleftandrightcerebralcortexandlateralizedlimbicregionsforoptimalfunctioning.Forexample,adequatelanguageproductionrequiresanintegrationofthegrammaticalfunctionsoftheleftandtheemotionalfunctionsoftheright.Left-rightintegrationallowsustoputfeelingsintowords,considerfeelingsinconsciousawareness,andbalancethepositiveandnegativeaffectivebiasesoftheleftandrighthemispheres(Silberman&Weingartner,1986).Abalanceamongtheleftandrightprefrontalcorticesisalsonecessaryfortheproperbalanceofaffectandemotion.Alexithymia(theinabilitytoputwordstofeelings)andsomatizationdisorder(theconversionofemotionalconflictsintobodilyillness)mayreflectleft-rightdissociation(Hoppe&Bogen,1977).Thereisalsoevidencethatdepressionandmaniacorrelatewithdysregulationofthebalanceofactivationbetweentheleftandrightprefrontalcortices(Baxteretal.,1985;Field,Healy,Goldstein,Perry,&Bendell,1988).

Therighthemisphereismorehighlyconnectedwiththebodyandthemoreprimitiveandemotionalaspectsoffunctioning.Thelefthemisphereismorecloselyidentifiedwithcorticalfunctioning,whereastherightismoredenselyconnectedwithlimbicandbrainstemfunctions(Shapiro,Jamner,&Spence,1997).Forexample,statesofstress,anxiety,andfearresultinincreasedactivationintherightcortexandsubcorticalstructures(Rauchetal.,1996;Wittling,1997).Thisbiasisalsorelevanttotheorganizationofsocialemotionalattachmentpatterns,transference,andaffectregulation(Minagawa-Kawaietal.,2008).Muchoftheintegrationoftop-downandleft-rightsystemsismediatedthroughinteractionsamongregionsofthefrontalcortex,ourprimaryexecutivesystem.

Duetotheinterconnectivitybetweenleft-rightandtop-downneuralnetworks,examiningintegrationfromeithertheverticalorhorizontaldimensionaloneisoverlysimplistic.Studiesofmetabolicactivityinspecificareasofthebraininpathologicalstatesrevealdifferencesinbothcorticalandsubcorticalstructuresonbothsidesofthebrain.Thisresearchsuggeststhatrestoringneuralintegrationrequiresthesimultaneousreregulationofnetworksonbothverticalandhorizontalplanes.Itisalsoimportanttorememberthatalthoughwearediscussingbrainfunctioningfromtheperspectiveofneuralnetworks,anequallymeaningfuldiscussioncouldfocusontheimpactofpharmacologicalagentsonthemodulationandhomeostaticbalanceofthesesamenetworks(Coplan&Lydiard,1998).Thisperspectivehelpsustounderstandwhybothpsychotherapyandmedicationcanresultinshiftsofneuralactivityandsymptomreductionandwhytogethertheymayworkbetterthaneitheronealone(Andreasen,2001).

Neuralnetworkintegrationcanalsobeaccomplishedthroughtheactivationofconsciouslanguageproduction(topandleft)withmoreprimitive,emotional,andunconsciousprocesses(downandright)thathavebeendissociatedduetostressortrauma.Dependingontheirtheoreticalorientation,therapists

facilitatetheprocessofnetworkintegrationbysupplyingchallengesofallkinds.Ananalystmayuseinterpretationstoenhanceawarenessofinhibited,repressed,ordissociatedthoughtsandemotions.Acognitive-behavioraltherapistwillexposeaclienttoafearedstimuluscombinedwithrelaxationtraining,allowingnormallyinhibitedcorticalcircuitrytointegratewiththesubcorticalcircuitrythatcontrolsfear.Researchacrossallformsofpsychotherapysupportsthehypothesisthatpositiveoutcomesarerelatedtoutilizingbothsupportandchallengeinthecombinedengagementofthoughtandaffect(Orlinsky&Howard,1986).Boththequalityoftheinterpersonalconnectionandcreatingtheproperlearningenvironmentappearessential.

PsychotherapyandParenting

Parentsarelikeshuttlesonaloom.Theyjointhethreadsofthepastwiththreadsofthefutureandleavetheirownbrightpatternsastheygo.

—FredRogers

Wehavetalkedalittleabouttheparallelsbetweenpositiveparentingandsuccessfulpsychotherapy;thesesimilaritiesreflectthecommonalityoftheconditionsrequiredforbuildingandrebuildingthebrain.Mutualeyegazeandescalatingpositiveemotionalinteractionsbetweenparentandchildstimulatethegrowthandorganizationofthebrain.Inthefuture,wemaydiscoverscientificevidencethattheinterpersonalexperienceofpsychotherapyimpactstheneurobiologicalenvironmentofthebraininwaysthatstimulateneuralplasticityandneurogenesis.Althoughthevariousschoolsoftherapytendtoaccentuatetheirdifferences,thetherapeuticrelationshipitselfmaybethemostpowerfulcurativeagent.

Thewarmth,acceptance,andunconditionalpositiveregarddemonstratedbyCarlRogers’sworkembodiesthebroadinterpersonalenvironmentfortheinitialgrowthofthebrainandcontinueddevelopmentlaterinlife(Rogers,1942).HavingspentabriefperiodoftimewithDr.Rogersasastudent,Icanattesttothepowerofhisinterpersonalstyleandtherapeutictechnique.Iamsureheleftmany,includingmyself,withthefantasyofbeingavailableforadoption.

Primarygoalsofparentingincludeprovidingachildwiththecapacityforself-soothingandtheabilitytoformpositiverelationships.Thisallowsthechildtofacethechallengesoflifeandbenefitfromhealinglifeexperiences.Thesuccessfulmasteryofchallengesthroughoutlifeleadstotakingonevenmorecomplexchallengesthatwillpromoteincreasinglyhigherlevelsofneuralnetworkdevelopmentandintegration.Wheninternalorexternalfactorspreventanindividualfromapproachingchallengingandstressfulsituations,neuralsystemswilltendtoremainunderdevelopedorunintegrated.

Inareviewofhundredsofstudiesexaminingtheoutcomeofpsychotherapy,OrlinskyandHoward(1986)lookedforthosefactorsthatseemedtorelatetosuccess.Theyfoundthatthequalityoftheemotionalconnectionbetweenpatientandtherapistwasfarmoreimportantthanthetherapist’stheoreticalorientation.Patientswhoaremotivatedtochangeandareabletoworkcollaborativelywiththeirtherapistsalsodobetter.Therapists’professionalexperiencewaspositivelyrelatedtosuccess,asweretheuseofinterpretation,afocusontransference,andtheexpressionofemotion.Thecontinualinvolvementofbothcognitiveandemotionalprocessingduringtreatmentseemsessentialforpositivechange.

Psychotherapy,likeparenting,isneithermechanicalnorgeneric.Eachtherapist–clientpaircreatesauniquerelationshipresultinginaparticularoutcome.Theimportanceoftheunconsciousprocessesofbothparentandtherapistishighlightedbytheiractiveparticipationintheco-constructionofnewnarrativesoftheirchildrenandpatients.Aswewillseeinresearchonattachment,eachparent’s

unconsciousplaysaroleinthecreationofthechild’sbrain,justasthetherapist’sunconsciouscontributestothecontextandoutcomeoftherapy.Thisunderscorestheimportanceofpropertrainingandadequatepersonaltherapyfortherapists,whowillbeputtingtheirimprintonthehearts,minds,andbrainsoftheirclients.

Summary

Inthischapterwehaveexploredsomeinitialconceptsintheintegrationofpsychotherapyandneurosciencebasedoncommonprincipleswithinbothfields.Wehaveequatedpsychologicalhealthwithoptimalneuralnetworkgrowthandintegration.Boththebrainandtheselfarebuiltinastepwisemannerbyexperience.Thenervoussystemismadeupofmillionsofneuronswhilehumanexperienceisconstructedwithincountlessmomentsoflearning.Thepsychologicaldifficultiesforwhichpatientsseekpsychotherapyareafunctionofinadequategrowthandintegrationwithinandbetweenthesesamenetworks.Theaspectsofdevelopmentthatfosterpositivebraindevelopmentandthoseintherapythatpromotepositivechangeareemotionalattunement,affectregulation,andtheco-constructionofnarratives.

Inthefollowingchapter,weturnourattentiontomajormodelsofpsychotherapyinusetoday.Byexaminingtheirtheoriesandtechniques,wewillseehowtheyhavebeenshapedbyunderlyingprinciplesrelatedtothegrowthandintegrationofneuralnetworks.Itismybeliefthatthedevelopmentofpsychotherapyhasalwaysbeenimplicitlyguidedbytheprinciplesofneuroscience.Allformsoftherapyaresuccessfultothedegreetowhichtheyhavefoundawaytotapintoprocessesthatbuildandmodifyneuralstructureswithinthebrain.

Chapter3

NeuralIntegrationinDifferentModelsofPsychotherapy

Thetechniquesofbehaviortherapyandpsychotherapyhavereliedontheprinciplesofbrainplasticity,generallywithoutrealizingit,fornearlyonehundredyears.

—NancyAndreasen

Likeotherscientificdiscoveries,psychotherapydevelopedfromacombinationoftrial-and-errorlearning,theintuitionofitsfounder,andplainluck.Eachschoolofpsychotherapyoffersanexplanationofmentalhealthandillnessaswellaswhyitsstrategiesandtechniquesareeffective.Fortunately,theeffectivenessofaninterventiondoesnotdependontheaccuracyofthetheoryusedtosupportit.Forexample,therewasatimewhenpsychoanalystsattributedthesuccessofelectroshocktherapytotheneedofadepressedpersontobepunished.Thetreatmentworkedandstillworksdespitethelackofasolidunderstandingofitsmechanismsofaction.

Althougheachapproachtopsychotherapyisexperiencedasafundamentaltruthbyitsdisciples,allmodesoftherapyareactuallyheuristics.Heuristicsareinterpretationsofexperienceorwaysofunderstandingphenomena.Thevalueofaheuristicliesinitsabilitytoorganize,explain,andpredictwhatweobserve.Neuroscienceisanotherheuristic,onethatweareusinginthepresentdiscussiontoexplainthemechanismsofactionofpsychotherapy;inotherwordshowandwhyitworks.Itismybeliefthatneuroscienceisahelpfulheuristicthatwillleadustoafullerunderstandingoftheprocessofpsychotherapyandmayalsoserveasarationalmeansofselecting,combining,andevaluatingtreatmentmodalities.

Inthischapterweexamine,inbroadstrokes,someoftheprimaryapproachestopsychotherapy.Theseoverviewsarepresentedinordertoprovideacontextinwhichtounderstandandorganizetheneuroscientificconceptsinthecomingchapters.Intakingasampleofgeneraltheoreticalapproachestopsychotherapy,wewilllookforcommonelementsamongthem,andhowtheseelementsmayrelatetoneuralnetworkdevelopmentandchange.Remember,fromtheperspectiveofneuroscience,psychotherapistsareinthebrain-rebuildingbusiness.

PsychoanalyticandPsychodynamicTherapies

Beingentirelyhonestwithoneselfisagoodexercise.—SigmundFreud

Freud’spsychoanalysis,theoriginalformofpsychodynamictherapy,hasspunoffcountlessvariantsinits

century-longexistence.Egopsychology,self-psychology,andschoolsofthoughtconnectedtonamessuchasKlein,Kernberg,andKohuthaveallattractedconsiderablefollowings.Despitetheirdifferences,psychodynamicformsoftherapysharetheoreticalassumptionssuchastheexistenceoftheunconscious,thepowerofearlychildhoodexperiences,andtheexistenceofdefensesthatdistortrealityinordertoreduceanxietyandenhancecoping.

TheexplorationoftheunconsciousanditsconnectiontoourevolutionarypastmaybeFreud’sgreatestlegacy.HeremainedtruetoCharcotbyexploringthemultiplelevelsofhumanawarenessanddesignedmanytechniquestobringtheunconsciousintoconsciousawareness.Thepoweroftrauma,especiallyduringchildhood,anditsabilitytoshapetheorganizationofthemindwerealsoexaminedingreatdetail.Freudtheorizedthatearlyattachmentandrelationaldifficulties,neglect,ortraumaresultindevelopmentalarrestsor“fixations”thatdelayorderailtheadult’spotentialtoloveandwork.Fromthestandpointofneurobiology,mostofFreud’sworkaddressedthediscontinuitiesanddissociationsbetweennetworksofconsciousandunconsciousprocessing.Freudfocusedontheroleofoverwhelmingemotionasthecauseofunintegratedneuralprocessing.

Freud’spsychicselfcontainstheprimitivedrives(id),thedemandsofcivilizationtoconformforthebenefitofthegroup(superego),andthosepartsoftheself(ego)thatattempttonegotiatethenaturallyoccurringconflictsbetweenthetwo.Initsroleasadiplomatinthefightbetweenidandsuperego,theegoutilizesmanyelaboratedefensestocopewithreality.Egostrength,orourabilitytonavigaterealitywithaminimumofdefensiveness,reflectstheintegrationofneuralnetworksofemotionandthought,andthedevelopmentofmaturedefenses.Themoreprimitiveorimmaturethedefensemechanism,themorerealityisdistortedandthemorefunctionalimpairmentoccurs.Sublimation,forexample,enablesustoconvertunacceptableimpulsesintoconstructiveandprosocialgoals.Maturedefenses,likesublimationorhumor,allowustoassuagestrongfeelings,keepincontactwithothers,andremainattunedtoasharedsocialreality.

Lessmaturedefenses,suchasdenialanddissociation,resultingreaterdistortionofrealityanddifficultiesinbothworkandrelationships.Defensesareofteninvisibletotheirownersbecausetheyareorganizedbyhiddenlayersofneuralprocessingthatareinaccessibletoconsciousawareness.WhatFreudcalleddefensescanbeseenaswaysinwhichneuralnetworkshaveadaptedtocopewithemotionalstress.Peopleseektreatmentwhentheirdefensemechanismscannotadequatelycopewithrepressedemotions,orwhensymptomsbecomeintolerable.

Despiteaconsciousawarenessthatsomethingmaybewrong,thehiddenlayersofneuralprocessingcontinuetoorganizetheworldbasedonthepriorexperiencesthatshapedthem.Aswewillseeinlaterchapters,theneuralcircuitryinvolvedwithfearhasatenaciousmemoryandcaninvisiblyinfluenceconsciousawarenessforalifetime.Partofpsychodynamictherapyisanexplorationanduncoveringofthisunconsciousorganizationofexperience.Freud’sprojectivehypothesisdescribedtheprocessbywhichourbrainscreateandorganizetheworldaroundus.Astheclarityofasituationdecreases,thebrainnaturallygeneratesstructureandprojectsitontotheworld.Thewayweorganizeandunderstandambiguousstimuligivesuscluesaboutthearchitectureofthehiddenlayersofneuralprocessing(howourunconsciousorganizestheworld).FromtheprojectivehypothesiscametheinventionofprojectivetestssuchasRorschach’sinkblots,freeassociation,andanemphasisontheimportanceofdreamsasthe“royalroadtotheunconscious.”

Aspartoftheprojectivehypothesis,psychodynamictherapistsoftenprovideminimalinformationaboutthemselves,allowingtheclienttoprojectontothemimplicit(unconscious)memoriesfrompastrelationships.Thisformofprojection,transference,resultsintheclientplacingexpectationsandemotionsfromearlierrelationshipsonthetherapist,whichallowsthemtobeexperiencedandworkedthroughfirsthand.Itisthroughthistransferencethatearlyrelationshipsforwhichwehavenoconsciousrecollectionarebroughtfullyintotherapy.Freudfeltthattheevocationandresolutionofthetransference

wasacorecomponentofasuccessfulanalysis.InFreud’swords,onlytransferencerenders“theinvaluableserviceofmakingthepatient’sburiedandforgottenloveemotionsactualandmanifest”(Freud,1975,Chapter7).

Resistancerepresentsaspectsofimplicitmemorypresentedbytheclientthatitisuptothetherapisttodecipher.Earlyexperiencesofrejection,criticism,orneglectfromparentsresultinshame,whichcanevolveintoachild’snegativeself-image.Theresultantself-criticism(superego)manifestsindisrespectforanyonewhoshowsthechildloveorrespect.AnexampleofthisisexpressedintheGrouchoMarxline,“I’dneverjoinaclubthatwouldhavemeasamember.”Intherapy,thismaymanifestasastrongdistrustofthetherapist’sintentionsorhisorherabilitytobeofhelp.

Interpretationsareoneofthepsychodynamictherapist’smostimportanttools.Sometimescalledthe“therapist’sscalpel,”interpretationsattempttomaketheunconsciousconscious.Basedonobservationsofalllevelsoftheclient’sbehavior,thetherapistattemptstobringtheprocessingofthehiddenlayerstotheclient’sattention.Repeatedandskillfulattentiontounconsciousmaterialviainterpretations,confrontations,andclarificationsresultsinagraduallyexpandingawarenessofunconsciousprocessesandtheintegrationofdissociatedtop-downandright-leftprocessingnetworks.

Accurate,successfulinterpretationsaresometimesaccompaniedbyfeelingsofdisorganization,anger,ordepression.Thisisbecausewhendefensesaremadeconsciousandareexposedforwhattheyare,theylosetheireffectiveness,leadingtoadisinhibitionoftheemotionsthattheyhavebeensuccessfullydefendingagainst.Inotherwords,thenetworkscontainingthenegativeemotionsbecomedisinhibitedandactivated.Forexample,ifintellectualizationisbeingusedtoavoidtheshameanddepressionrelatedtoearlycriticism,recognitionofthedefensewillbringthesefeelingsandrelatedmemoriestoawareness.

Emotionsplayacentralroleinthesuccessofpsychodynamictherapies.Theneuralnetworksthatorganizeemotionsareoftenshapedtoguideusawayfromthoughtsandfeelingsforwhichwewerepunishedorabandoned.Unconsciousanxietysignalscontinuetoshapeourbehavior,leadingustoremainontried-and-truepathsandavoidsituationsthattriggerourunrememberedpast.Anemphasisontheevocationofemotionandcognitionisanimportantcontributionofpsychoanalysisandreflectsfundamentalunderlyingneurobiologicalprocessesofhealthandillness.

Acrosspsychodynamicformsoftherapy,consciousawarenessisexpanded,emotionsareexplored,andtheexpressionofrepressedorinhibitedemotionsisencouraged.Feelings,thoughts,andbehaviorsarerepeatedlyjuxtaposed,combined,andrecombinedintheprocessofworkingthrough.Theassumptionsandnarrativesfromthepastareeditedbasedonnewinformation,andthoseaboutthepresentandfuturearereevaluated.Theoverallgoaliscombiningemotionwithconsciousawarenessandrewritingthestoryoftheself.Theseprocesses,whensuccessful,enhancethegrowth,integration,andflexibilityofneuralnetworksandhumanexperience.

RogerianorClient-CenteredTherapy

ThecuriousparadoxisthatwhenIacceptmyselfjustasIam,thenIcanchange.—CarlRogers

Againstthedominantbackgroundofpsychoanalysis,CarlRogers(1942)emergedwithaformoftherapyhereferredtoas“client-centered.”Instarkcontrasttoatheory-basedanalysisofthepatient,Rogersemphasizedcreatingarelationshipthatmaximizedtheindividual’sopportunityforself-discovery.Rogers’sapproachgainedrapidacceptanceinthenonmedicalcommunityandbythe1960scametobethe

dominantformofcounseling(Gilliland&James,1998).Whendifferentapproachestotherapyarecomparedforeffectiveness,thegeneralagreementisthat

theperceivedqualityoftheclient–therapistrelationshiphasthehighestcorrelationwithreportedtreatmentsuccess.Somehavegoneasfarassayingthatthecurativeelementisthetherapeuticrelationshipitself,ratherthananyspecifictechniques.ThiswouldcertainlyhavebeenRogers’sbelief,forhebelievedthatthecurativeaspectsoftherapywerethetherapist’swarmth,acceptance,genuineness,andunconditionalpositiveregard.Hisemphasisoninterpersonalcongruenceforeshadowedthefocusonemotionalresonanceandempathicattunementinlater-emergingformsofpsychotherapysuchasobjectrelationsandintersubjectivity(Kohut,1984;Stolorow&Atwood,1979).

Overthelastcentury,thetherapistattributessuggestedbyRogersandwhatwehavecometothinkofasthebestpossibleattitudesforoptimalparentinghavebecomeessentiallyidentical.Rogerianprinciplesleadtoaminimizedneedfordefensivenessandshamewhilemaximizingexpressiveness,exploration,andrisktaking.Rogerswaslikelydescribingthebestinterpersonalenvironmentforbraingrowthduringdevelopmentandneuralplasticityinpsychotherapywhenhestatedthatclient-centeredtherapy“aimsdirectlytowardthegreaterindependenceandintegrationoftheindividualratherthanhopingthatsuchresultswillaccrueifthecounselorassistsinsolvingtheproblem.Theindividualandnottheproblemisthefocus.Theaimisnottosolveoneparticularproblem,buttoassisttheindividualtogrow,sothathecancopewiththepresentproblemandlaterproblemsinabetter-integratedfashion”(Rogers,1942,Chapter2).

Duringmytraininginclient-centeredtherapy,IwasstruckbythepowerofRogers’sapproach.Ifounditimmenselydifficulttomaintainhissupportivestance,andoftenstruggledtokeepmyselffromdirectingmyclients,givingadvice,andpushingthemtochange.Tomyastonishment,IfoundthatprovidingclientswithasupportiverelationshipledtoinsightsontheirpartthatmirroredtheinterpretationsIstruggledtosuppress.Clientsoftenexpressedamixtureofsadnessandappreciationwhentheyrealizedhowmuchtheylongedtobelistenedtowithoutfearofjudgmentandshame.

Whatmightbegoingoninthebrainofaclientinclient-centeredtherapy?IntheRogerianinterpersonalcontext,aclientwouldmostlikelyexperiencethewidestrangeofemotionswithintheegoscaffoldingofanempathicother.Theactivationofneuralnetworksofemotionmakesfeelingsandemotionalmemoriesavailableforreorganization.Rogers’snondirectivemethodactivatesclients’executivenetworksandtheirself-reflectiveabilities.Supportiverephrasingandclarificationofwhatclientssaymayalsoenhanceexecutivefunctioning.Thissimultaneousactivationofcognitionandemotion,enhancedperspective,andtheemotionalregulationofferedbytherelationshipmayprovideanoptimalenvironmentforneuralchange.Clients,scaffoldedbythetherapist’ssupportandstimulatedbyhisorherwords,canthenworktorewritetheirstories.

Weknowthatsocialinteractionsearlyinliferesultinthestimulationofbothneurotransmittersandneuralgrowthhormonesthatparticipateintheactivebuildingofthebrain.Byrecreatingapositiveparentingrelationship,itislikelythattheempathicconnectednesspromotedbyRogersactuallystimulatesbiochemicalchangesinthebraincapableofenhancingnewlearning.Forexample,studieswithbirdshavedemonstratedthattheabilitytolearntheirsongsisenhancedwhenexposedtolivesingingbirdsversustaperecordingsofthesamesongs(Baptista&Petrinovich,1986).Otherbirdsareactuallyunabletolearnfromtaperecordingsandrequirepositivesocialinteractionsandnurturanceinordertolearn(Eales,1985).Wewillseelaterhowmaternalcontactandnurturanceinratsprotectthebrainfromthedamagingeffectsofstress(Meaney,Aitken,Viau,Sharma,&Sarrieau,1989;Plotsky&Meaney,1993).

Studiessuchasthesedemonstratethatsocialrelationshipshavethepowertostimulatetheneuralplasticityrequiredfornewlearning.Theinterpersonalandemotionalaspectsofthetherapeuticrelationship,referredtoasanonspecificfactorinthepsychotherapyoutcomeliterature,maybetheprimarymechanismoftherapeuticaction.Aswewillseeinalaterchapter,thesenonspecificfactorsare,

infact,quitespecific,asearlymaternalcarehasbeenlinkedtoincreasedneuralplasticity,emotionalregulation,andattachmentbehavior.Inotherwords,thosewhoarenurturedbestsurvivebestwithinapositiveandsafeenvironment.Unfortunately,thesocialisolationcreatedbycertainpsychologicaldefensesreinforcestherigidityofneuralorganizationastheclientavoidstheinterpersonalcontextsrequiredtopromotehealing.Intheseinstances,thetherapeuticrelationshipmayserveasabridgetoonceagainconnectwithothers.

CognitiveTherapies

It’snotwhathappenstoyou,buthowyoureacttoitthatmatters.—Epictetus

Cognitivetherapieshighlightthecentralityofaperson’sthoughts,appraisals,andbeliefsinguidinghisorherfeelingsandactions.Theyemphasizethatnegativethoughts,skewedappraisals,anderroneousbeliefscancreatepsychologicalproblems.Cognitivetherapyfocusesontheidentificationandmodificationofdysfunctionalthoughtswiththeultimategoalofimprovedaffectregulation(Beck,Rush,Shaw,&Emery,1979;Ellis,1962).Theprimarytargetsofcognitive-behavioraltherapyhavebeendepression,anxiety,obsessive-compulsivedisorder,phobias,andpanicdisorders.

Depressedpatientstendtoevaluatetheirworldinabsoluteterms,takedetailsoutofcontext,andexperienceneutralcommentsandeventsasnegative.Commondepressivethoughtsincludetheexpectationoffailuredespitemanypastsuccesses,andthoughtsthatoneisalonedespitebeingsurroundedbyfriendsandfamily.Incognitivetherapy,thepatientiseducatedaboutthesecommondistortionsandencouragedtoengageinrealitytestingandself-talkdesignedtocounteractnegativereflexivestatements.

Inanxietydisorders,fearcomestoorganizeandcontrolthepatients’lives.Highlevelsofanxietyinhibitanddistortrationalcognitiveprocessing.Cognitiveinterventionswiththesepatientsoftenincludeeducatingthemaboutthephysiologicalsymptomsofanxietysuchasaracingheart,shortnessofbreath,andsweatypalms.Thesepatientsaretaughtthatfeelingsofdreadaresecondarytoautonomicsymptomsandshouldnotbetakenasseriouslyastheyfeel.Afocusonunderstandingnormalbiologicalprocessesusuallyredirectstheclientawayfromcatastrophicattributionsthatservetoincreaseanxiety.

WithclientssufferingwithphobiasorPTSD,psychoeducationiscombinedwithexposureandresponseprevention,inwhichtheclientfacesthefearedstimulus(e.g.,venturingoutsideorthinkingaboutanegativeevent)withoutbeingallowedtoretreatbacktothesafetyofhomeorastateofdenial.Exposureisusuallysystematic,gradual,andpairedwithrelaxationtrainingusedtoaidinthedownregulationofphysiologicalarousal.Thisprocesscombinesincreasedcorticalprocessing(thought)withsubcorticalactivation(emotion)toallowforintegrationwithcorticalcircuitryinordertopermithabituation,inhibition,andeventualextinctionviadescendingcorticalnetworks.

Howdoesthistranslateintowhatisgoingoninthebrainduringcognitivetherapy?Researchhasdemonstratedthatdisordersofanxietyanddepressioncorrelatewithchangesinmetabolicbalanceamongdifferentbrainregions.Forexample,symptomsofdepressioncorrelatewithactivationimbalancewithintheprefrontalcortex—lowerlevelsofactivationintheleftandhigherlevelsintheright(Baxteretal.,1985;Fieldetal.,1988).Thissupportsthehypothesisthatmentalhealthcorrelateswiththeproperhomeostaticbalancebetweenneuralnetworks.Symptomsofobsessive-compulsivedisordercorrelatewithchangesinactivationinthemedial(middle)portionsofthefrontalcortexandasubcorticalstructurecalledthecaudatenucleus(Rauchetal.,1994).Posttraumaticflashbacksandstatesofhigharousalcorrelatewithhigherlevelsofactivationinright-sidedlimbicandmedialfrontalstructures.Importantly,

higharousalalsocorrelateswithdecreasedmetabolismintheexpressivelanguagecentersofthelefthemisphere(Rauchetal.,1996).

Ofallthedifferenttypesoftherapy,specificlinkshavebeenfoundbetweensuccessfulcognitive-behavioraltherapyandchangesinbrainfunctioning.Asdescribedinthelastchapter,changesinbrainfunctioningandsymptomatologyinbothobsessive-compulsivedisorderanddepressionhavebeenfoundaftersuccessfulpsychotherapy(Baxteretal.,1992;Brody,Saxena,Mandelkern,etal.,2001;Brody,Saxena,Schwartz,etal.,1998;Schwartzetal.,1996).Thesefindingsstronglysuggestthattherapistscanutilizecognitiontoaltertherelationshipamongneuralnetworksinawaythatimpactstheirbalanceofactivationandinhibition.Instrivingtoactivatecorticalprocessingthroughconsciouscontrolofthoughtsandfeelings,thesetherapiesenhanceleftcorticalprocessing,inhibitingandregulatingrighthemisphericbalanceandsubcorticalactivation.Thereestablishmentofhemisphericandtop-downregulationallowsforincreasesinpositiveattitudesandasenseofsafetythatcounteractthedepressingandfrighteningeffectsofrighthemisphereandsubcortical(amygdala)dominance(Ochsner&Gross,2008).

Althoughcognitive-behavioraltherapyiscarriedoutinaninterpersonalcontextofcollaborationandsupport,itplacesfarlessemphasisonthetherapeuticrelationshipthandoRogerianandpsychodynamicapproaches.Theinherentwisdomofthisapproachwithdepressedandanxiouspatientsliesinthefactthatdisordersofaffectneedactivationofcorticalexecutivestructures.Giventhatemotionsarecontagious,adeeperemotionalconnectionmightresultinthetherapistattuningtodysregulatedstatesandsharinginthepatient’sdepressed,anxious,andpanickyfeelings.Whileemotionalattunementwiththesefeelingsishelpful,ithasbeenmyexperiencethataftertheworkingrelationshipisestablished,challengingthoughtsandencouragingnewbehaviorscanoftenbefarmorebeneficialtothetherapeuticprocessthanempathyalone.Thestructuredaspectofcognitive-behavioraltherapymayprotectboththerapistandpatientfromthepowerofnegativeaffect.

SystemicFamilyTherapy

Wemustnotallowotherpeople’slimitedperceptionstodefineus.—VirginiaSatir

Thereisincreasingevidencethatneuralnetworksthroughoutthebrainarestimulatedtogrowandorganizebyinteractionwiththesocialenvironment.Earlyrelationshipsbecomeencodedinnetworksofsensory,motor,andemotionallearningtoformwhatdynamictherapistscallinnerobjects.Theseinnerobjectshavethepowertosoothe,arouse,anddysregulate,dependingonthequalityofourattachmentexperienceswithsignificantothers.Theseunconsciousmemoriesorganizeourinnerworldswhenwearewithothersandwhenwearealone.Thus,weconstantlyexperienceourselvesinthecontextofothers.

Thisisonereasonsystemstherapistsquestionthevalidityofdiagnosingandtreatingpeopleinisolation.Theybelievethatinourday-to-dayexperiencewesimultaneouslyexistintworealities:ourpresentfamiliesandourmultigenerationalfamilyhistories.Thisperspectiveisespeciallyrelevantwhenworkingwithchildrenwhohaveyettoformclearegoboundariesbetweenthemselvesandtheirfamily.Someadultpatientswhohavenotsuccessfullyindividuatedalsodemonstrateunclearboundariesbetweentheirownthoughtsandfeelingsandthoseoffamilymembers.Regardlessofage,however,thebasicprinciplesarethesame.

MurrayBowen,aprimecontributortosystemsthinking,presentedamodelthatiscompatiblewithanexplorationoftheunderlyingneuroscienceofpsychotherapy.Hisperspectiveisbasedontherecognitionthatafamilyprovidesbothemotionalregulationandaplatformfordifferentiation.Hedefines

differentiationasthedevelopmentofautonomy—abalancebetweentherecognitionoftheneedsofselfandothers.Differentiationinvolvestheregulationofanxietyandabalanceofintegrationofaffectandcognition.Bowenwouldsaythatanxietyistheenemyofdifferentiation.Thatis,themorefrightenedpeopleare,themorelikelytheyaretodissociateandthemoredependentandprimitivetheybecomeintheirinteractionwithothers(Bowen,1978).

Whenthisregressionoccurs,familymemberstry—consciouslyandunconsciously—toshapethefamilyinamannerthatreducestheirownanxiety.Thealcoholicneedstheproblemtogounmentioned,whilethefamilyneedstoputonagoodfronttotheoutsideworld.Dysfunctionalfamilypatternssuchasthisonesacrificethegrowthandwell-beingofoneormoremembers(oftenthechildren)toreducetheoveralllevelofanxietyinthefamily.Thecognitive,emotional,andsocialworldofanalcoholicfamilyisshapedbytheavoidanceoffeelings,thoughts,andactivitiesthatexposetheirshamefulsecrettoconsciousawarenessandtheoutsideworld.Thedevelopmentofthechildrenbecomesdistortedbytheadaptationsnecessaryfortheirsurvivalwithinthepathologicalsystem.Unfortunately,therolesandrulesofthefamilydesignedtodecreaseanxietymaintainthepathologiesofsomeandcreatenewpathologiesinothers.

Overtime,thedysfunctionbecomesembeddedinthepersonalityandneuralarchitectureofeveryoneinthefamilyandtheycolludetomaintainthesystem,becausetheynowallrequirethestatusquoinordertofeelsafe.Theseexperiencesbecomeembeddedintotheirneuralarchitectureandarecarriedforwardintoadultrelationships.Asaresult,manyofusre-createthedysfunctionfromourfamilyoforigininourchoiceofpartnersandhowweshapethefamilieswebuildasadults.Eachfamily’sproblemsaredeterminedbythemultigenerational,unconsciousshapingofbothneuralstructureandbehavior.Thefunctioningofbrainsandfamilydynamicsreflectshowtheyhavebeenorganized.Thedysfunctionalbrain,likethedysfunctionalfamily,isshapedbytheavoidanceofthoughtsandfeelings,resultinginthedissociationofneuralsystemsofaffect,cognition,sensation,andbehavior,aswellasalackofhumandifferentiation.

Asinotherformsofpsychotherapy,thegoalofsystemstherapyistointegrateandbalancethevariouscorticalandsubcortical,leftandrighthemisphereprocessingnetworks.Thisprocessrequiresadecreaseinanxietyfromhightolowormoderatelevels.Highlevelsofaffectblockthinking,whereasmoderatelevelsenhanceneuroplasticprocesses,whichinturnsupportcognitionandemotion.Inessence,Bowenishighlightingthatthesimultaneousactivationofcognitionandemotionleadstoneuralintegration.Increaseddifferentiationofindividualswithinafamilywilldecreasetheoverallrigidityofthesystem.Thisprocessalsoallowsfamilymemberstobecomemoreresponsivetotheneedsofothersandlessreactivetotheirowninnerconflicts.

Thefirststepinsystemstherapyistoeducatethefamilyabouttheseconceptsandtoexplorethehistoryofbothsidesofthefamilythroughthepastfewgenerations.Inthecontextofsystemstheoryandfamilyhistory,theproblemsbroughtintoreliefoftenbecomemoreunderstandable.Uncoveringfamilysecretsandrealitytestingaroundthemythsandprojectionsofeachfamilymemberallowforcorticalprocessingofprimitiveandunconsciousdefenses.Theprocessoffamilytherapyinvolvesaseriesofexperimentswithincreasinglyhigherlevelsofdifferentiation.Communicationskills,assertivenesstraining,andexercisesinnewformsofcooperationcanallincreasecorticalinvolvementwithpreviouslyreflexiveorregressiveemotionsandbehaviors.Oftenthepersonwiththesymptomsneedstotakemoreresponsibility,whilepathologicalcaretakersmustlearntoacceptnurturance.Eachmemberofthefamilyneedstoachieveabalancebetweenautonomyandinterdependence.Ultimately,psychological,interpersonal,andneuralintegrationaredifferentlevelsandmanifestationsofthesameprocess.

ReichianandGestaltTherapy

Iamnotinthisworldtoliveuptootherpeople’sexpectations,nordoIfeelthattheworldmustliveuptomine.

—FritzPerls

WilhelmReich,oneofFreud’searlydisciples,feltthatmemoryandpersonalityareshapedandstorednotjustinthebrainbutthroughouttheentirebody.Becauseofthis,Reichnotonlypaidcarefulattentiontohisclients’musculature,posture,andbreathing,butalsoencouragedthemtoexpressthemselvesphysicallyduringanalysis.Bybeatingtheirfists,stompingtheirfeet,andusingexaggeratedbreathingtechniques,theyattemptedtoreleasenormallyinhibitedemotions.Reichhighlightedtheimportanceofthetherapist’sinterpretationofthenonverbalmessagesofthebody,makingthemavailableforconsciousconsideration.HistheoriesledtothedevelopmentofRolfing(whichusesdeepbodymassagetoevokeandprocessmemories)andGestalttherapy(whichfocusesondrawingattentiontononverbalaspectsofcommunicationandincreasedself-awareness).

Reich(1945)believedthatthemajorfocusofpsychotherapyshouldbetheanalysisofthecharacter,somethinghesawassimilartoFreud’snotionofego.WhileFreudfocusedonverbalcommunication,Reich’smajorcontributionwastodrawmoreattentiontothenonverbalandemotionalaspectsofthetherapeuticinteraction.Hecontendedthattheproblemspeoplebringtotherapyareembeddedintheircharacterarmor,shapedduringdevelopmentasanadaptationagainstrealorimagineddanger.Characterarmorformsasaresultofmisattunement,neglect,ortraumaatthehandsofcaretakers.Thisarmorispreverbalandorganizesduringthefirstyearsoflife.AccordingtoReich,earlydefensestakeshapeatalllevelsofthenervoussystem,becomeencodedinourentirebeing,andare,liketheairwebreathe,utterlyinvisibletous.ThedefensesidentifiedbyReichreflectemotionalmemoriesfromearlypreverbalexperiencesthatarestoredinsensory,motor,andemotionalnetworksofearlymemory.Becausecharacterarmorisinvisibletoitsowner,thetherapist’sjobistomaketheclientawareofitsexistence,expression,andmeaning.

GestalttherapyisauniqueexpressionofReichiantheorythatisparticularlyrelevanttothenotionofneuralintegration.Gestalt,aGermanwordmeaning“whole,”reflectstheorientationofbringingtogetheranawarenessofconsciousandunconsciousprocesses;inotherwords,seeingthewholepicture.Gestalttherapy’scharismaticfounder,FritzPerls,usedthetermsafeemergencyfortheexperiencethatpsychotherapistsstrivetocreateintreatment(Perls,Hefferline,&Goodman,1951).Asafeemergencyisachallengeforgrowthandintegrationinthecontextofguidanceandsupport.Itisalsoawonderfulwaytodescribeanimportantaspectofgoodparenting.Therapistscreatethisemergencybyexposingclientstounintegratedanddysregulatingthoughtsandfeelingswhileofferingthemthetoolsandnurturancewithwhichtointegratetheirexperiences.Safetyisprovidedintheformofasupportiveandcollaborativetherapeuticrelationship,ofteninthecontextofagroup.Theemergencyiscreatedbyanunmaskingofdefenses,makingunacceptableneedsandemotionsconscious,andbybringingintoawarenessdissociatedelementsofconsciousness.

Thestoriesapatienttellsabouthisorherproblemsareoftenseen,intheGestaltcontext,asself-deceptions.Theyservetokeepfromawarenessthosefeelingsthatarerelevanttohealingbutlessacceptable.Unconsciousgestures,facialexpressions,andmovementsarefirstbroughttoawareness,thenexaggerated,andfinallygivenavoicewiththepurposeofunderstandingandintegratingexperience.Thetherapistpointsoutcontradictions,suchasmakingpositivestatementswhileshakingthehead“no,”orsmilingwhiletalkingaboutapainfulexperience.Thesecontradictionsareexploredasindicationsofinternalconflictstobebroughtintoawareness.Again,thefocusisonbringingtoconscious(cortical)awarenesstheautomatic,nonverbal,andunconsciousprocessesprimarilyorganizedinrighthemisphereandsubcorticalneuralnetworks.

Gestalttherapyemphasizestheidentificationandexplorationofprojection,identifyingitasan

avenuefordiscoveringaspectsoftheselfthathavebeendifficultorimpossibletoaccept.Inthepopular“emptychair”technique,patientsalternatelyplaytheroleofdifferentpartsofthemselvestofullyarticulatethedifferentsidesofinnerconflicts.TheGestalttherapistbelievesthatmaximizingawarenessofallaspectsoftheself—includingcognition,emotion,behavior,andsensation—willresultinincreasedmaturationandpsychologicalhealth.Thisprocessdependsontheintegrationoftheneuralnetworksresponsibleforeachofthesefunctions.

CommonFactors

Myworkasapsychoanalystistohelppatientsrecovertheirlostwholenessandtostrengthenthepsychesoitcanresistfuturedismemberment.

—C.G.Jung

Inreviewingthesedifferentpsychotherapeuticmodalities,anumberofprinciplesemergethatunifythevarioustherapeuticschools.Thefirstisthatpsychotherapyvaluesopenness,honesty,andtrust.Eachformofpsychotherapycreatesanindividualizedexperiencedesignedtoexamineconsciousandunconsciousbeliefsandassumptions,expandawarenessandrealitytesting,andencouragetheconfrontationofanxiety-provokingexperiences.Eachperspectiveexploresbehavior,emotion,sensation,andcognitioninanattempttoincreaseawarenessofpreviouslyunconsciousordistortedmaterial.Theprimaryfocusofpsychotherapyappearstobetheintegrationofaffect,inallitsforms,withconsciousawareness,andcognition.

Intellectualunderstandingofapsychologicalproblemintheabsenceofincreasedintegrationwithemotion,sensation,andbehaviordoesnotresultinchange.Allformsoftreatmentrecognizetheneedforstress,fromthesubtledisruptionofdefensescreatedbythecompassionofCarlRogerstotheexposuretofearedstimuliinexposuretherapies.Thereisarecognitionthattheevocationofemotioncoupledwithconsciousawarenessismostlikelytoresultinsymptomreductionandpersonalgrowth.Whetheritiscalledsymptomrelief,differentiation,egostrength,orawareness,allformsoftherapyaretargetingdissociatedneuralnetworksforintegration.

Whentheoriesofneuroscienceandpsychotherapyareconsideredsidebyside,anumberofworkinghypothesesemerge.First,giventhatthehumanbrainisasocialorgan,safeandsupportiverelationshipsaretheoptimalenvironmentforsocialandemotionallearning.Empathicattunementwiththetherapistprovidesthecontextofnurturanceinwhichgrowthanddevelopmentoccur.Byactivatingprocessesinvolvedinsecureattachment,empathicattunementlikelycreatesanoptimalbiochemicalenvironmentforneuralplasticity.

Second,weappeartoexperienceoptimaldevelopmentandintegrationinthecontextofamildtomoderatelevelofarousalorwhatwemightcalloptimalstress.Suboptimalaffectregulationduringdevelopmentcanresultinsymptoms,maladaptivedefenses,andpsychopathology.Optimalstresswillcreatethemostfavorableneurobiologicalenvironmentforneuralplasticityandintegration.Althoughstressappearsimportantaspartoftheactivationofcircuitsinvolvedwithemotion,statesofmildtomoderatearousalseemidealforconsolidationandintegration.Instatesofhigharousal,sympatheticactivationinhibitsoptimalcorticalprocessinganddisruptsintegrationfunctions.Theebbandflowofemotionoverthecourseoftherapyreflectstheunderlyingneuralrhythmsofgrowthandchange.

Psychodynamictherapiesalternateconfrontationsandinterpretationswithasupportiveandsoothinginterpersonalenvironment(Weiner,1998).Thesystematicdesensitizationofcognitive-behavioraltherapypairsexposuretofearedstimuliwithpsychoeducationandrelaxationtraininginthepresenceofacoach

andally(Wolpe,1958).Bowen’sfamilysystemsapproachfocusesonpairinganxietyreductionwithexperimentsinincreasinglevelsofindependentanddifferentiatedbehavior(Bowen,1978).Allformsofsuccessfultherapystrivetocreatesafeemergenciesinoneformoranother.

Athirdhypothesisisthattheinvolvementofaffectandcognitionappearsnecessaryinthetherapeuticprocessinordertocreatethecontextforintegrationofneuralcircuitswithahighvulnerabilitytodissociation.Ithasbeensaidthat,inpsychotherapy,“understandingistheboobyprize.”Itisahollowvictorytoendupwithapsychologicalexplanationforproblemsthatremainunchanged.Ontheotherhand,catharsiswithoutcognitiondoesnotresultinintegrationeither.Theabilitytotolerateandregulateaffectcreatesthenecessaryconditionforthebrain’scontinuedgrowththroughoutlife.Increasedintegrationparallelsanincreasedabilitytoexperienceandtoleratethoughtsandemotionspreviouslyinhibited,dissociated,ordefendedagainst.Affectregulationmaybethemostimportantresultofthepsychotherapeuticprocessacrossorientations,becauseitallowsforareconnectionwiththenaturallyoccurringsalubriousexperiencesinlife.

Repeatedsimultaneousactivationofnetworksrequiringintegrationwithoneanothermostlikelyaidsintheirintegration.Repetitiveplayinchildrenandthephrase“workingthrough”intherapybestreflectthisprocess.Thisconceptparallelstheprinciplefromneurosciencethat“neuronsthatfiretogether,wiretogether”(Hebb,1949;Shatz,1990).Thesimultaneousactivationofneuralcircuitsallowsthemtostimulatethedevelopmentofconnectionswithinassociationareastocoordinateandintegratetheirfunctioning.

Fourth,theco-constructionofnarrativesbetweenparentandchildortherapistandclientprovidesabroadmatrixsupportingtheintegrationofmultipleneuralnetworks.Autobiographicalmemorycreatesstoriesoftheselfcapableofsupportingaffectregulationinthepresentandthemaintenanceofhomeostaticfunctionsintothefuture.Memory,inthisform,maymaximizeneuralnetworkintegrationasitorganizesvastamountsofinformationacrossmultipleprocessingtracks.Thus,languageisanimportanttoolinbothneurologicalandpsychologicaldevelopment.

SamandJessica

Thedeepestprincipleinhumannatureisthecravingtobeappreciated.—WilliamJames

Beinghumanmeancommunicatingwithothers.Humanshavemanychannelsofcommunication,includingtouch,eyecontact,toneofvoice,andwords.Throughourinteractionswehavethepowertoimpactoneanotherateverylevel.Oneofmymostpowerfulexperiencesofthetruthofthisfactdidnottakeplaceinaseminarorconsultingroom,butratheratthehomeofafriend.Ihadvolunteeredtowatchhistwoyoungchildrenforafewhourswhileheransomeerrands.IhadknownJessicaandSam,4and6yearsold,alltheirlives.Iwassomeoneonanouterringoftheiruniverse,anattractivecombinationoffamiliarandnew,andcompletelyunpreparedforwhatwasabouttohappen.Theminutetheirfatherleft,theyshiftedfromlowtomediumtohighgearandIfoundmyselfinthemidstofafrenzyofexcitement.

Toysbeganflyingoutofclosetsandstoragecontainers;gameswerebegunandtossedaside;videoswerestarted,stopped,andreplaced—asuccessionofIndianprinces,mermaids,lionkings,ladies,andtramps.Afterwhatfeltlikehours,Iglancedatmywatchtofindonly15minuteshadpassed!Fourmorehoursatthispace?Iwasn’tsureIcouldsurvive.IkepttryingtorefocusSamandJessica’sactivity,tonoavail.Atonepoint,aswedashedfrombedroomtodentolivingroom,Isanktothefloorinthehall,andproppedmyselfupagainstthewall.WhentheyrealizedthatIwasn’trightbehindthem,theyranbackto

findme.Theystoodpanting,oneoneithersideofme,wonderingwhatnewgameIhadconcocted.My

suggestionthatwesitandtalkforawhilepassedunnoticed.Afterafewseconds,Samlookedathissisterandyelled,“ShowLouhowyouburpyourdolly!”BothletoutascreamandJessicasoonreturnedwithanadorablesquishydoll.AsIreachedforthedolltoholdandadmireit,Jessicathrewthedollonthefloorfacefirstanddroveherfistsintoitsback.AsJessicaandSamtookturnscrushingthedollintothecarpet,Iwatchedinhorror,completelyidentifyingwiththedoll.Ihadtoholdbackmyurgetosavethepoorthingfromherviciousattackers.

IquicklyremindedmyselfthatIwasfeelingsorryforaballofcottonandthatIshouldturnmyattentionbacktothechildren.IalsorealizedthatrescuingthedollwouldbescoldingSamandJessicafortheirbehavior,whichIdidnotwanttodo.Istruggledtomakesenseofwhatwashappeningandaskedmyselfiftheremightbesomesymbolicmessageinthewaytheyweretreatingthisdoll.JessicaandSamhadexperiencedagreatdealofstressintheirbrieflivesintheformsofseverephysicalillness,surgery,drugaddictioninthefamily,andanunderstandablyoverwhelmedsupportsystem.ThefranticactivityIwaswitnessingmayhavereflectedtheaccumulatedanxietyfromalltheyhadgonethrough,mixedwithnormalchildhoodexuberance.Buthowmightknowingthisbehelpfultothesetwobeautifulchildren?

AsIreflectedonthesethingsIwashitbythenotionthatperhapsthedollrepresentedbothSamandJessica.Thisdollneededtobeburped.Itneededthehelpofanadulttoalleviateitsdiscomfortandregainasenseofcomfortandequilibrium.PerhapsSamandJessicawereshowingmethatwhentheyneededtobecomforted,theyweremetwithmorepain,or,attheveryleast,insufficientunderstandingandwarmth.Mighttheirbehaviorbeamessage?“Please,weneednurturanceandhealing!”Theirworldseemedchaoticandunsafe,awhirlwind;thesewerethesamefeelingstheyhadcreatedwithinmeduringthelasthalfhour.Wastheirbehavioraformofcommunication?

Theyhadeachtakenanumberofturns“burping”thedollandIsuspectedthattheirattentionwouldsoonturntome.Whattodoorsay?Ididn’twanttoburpthebabytheirway,andmythoughtsaboutwhatwashappeningwouldbemeaningless.Icouldfeelmyanxietygrowingwhenfinally,theybothturnedtomeandcriedinunison:“Yourturn!”Ihesitated.Thechantof“Burpthebaby,burpthebaby”begantorise.Ilookedatbothofthemandsaid,“Iknowanotherwaytoburpababy.Here’showmymomburpedme.”Acheerwentup.IsuspecttheyassumedthatIwasgoingtosetthedollonfireorputitinthemicrowave.

Igentlypickedupthedollandbroughtittomyleftshoulder.Rubbingitsbackinacircularmotionusingmyrighthand,lookingdownatitwithtenderness,Iquietlysaid,“Thiswillmakeyoufeelbetter,littleone.”Asilencefelloverthehallway.IlookeduptofindJessicaandSamtransfixed,asifhypnotized.Theireyesfollowedtheslowcirclesofmyhand,headstiltedlikepuppies.Theirbodiesrelaxed,theirhandslimpattheirsides,calmforthefirsttime.

Afterfollowingthemovementofmyhandforabout30seconds,Jessicalookedupatmeandsoftlyasked,“CanIhaveaturn?”“Ofcourseyoucan,”Itoldher.AtfirstIthoughtshemeantthatshewantedaturnburpingthebaby.Butthencarefully,almostrespectfully,shetookthedollfrommeandplaceditonthefloorwithitsbackagainstthewall.Shesteppedovertome,climbedovermycrossedlegsandputherheadonmyshoulderwherethedoll’sheadhadbeen.Sheturnedtomeandalmostinaudiblysaid,“I’mreadynow.”AsIrubbedJessica’sback,Ifelthergrowingmoreandmorelimpasshemeltedintomyshoulderandchest.IhalfexpectedSamtotearheroff,climbonhimself,andturnitintoawrestlingmatch.WhenIlookedovertohim,Icouldseethathewasinthesamepostureandstateofmindhehadbeeninwatchingmeburpthedoll.Heeventuallylookedupatmeandasked,“CanIhaveaturn?”BeforeIcouldanswer,Jessicaliftedherheadslightlyandtoldhim,“Inaminute.”

Afterawhile,shegaveupherspotonmyshoulderandSamhadhisturnbeing“burped.”Itfeltwonderfultoholdtheminthiswayandgivethemsomethingtheyseemedtoneedsobadly.Afterafew

turnsforeachofthem,wewentintotheden,curleduponthesofa,oneofthemundereachofmyarms,andwatchedamovie.Actually,Iwatchedthemovie—theydozedoffafteronlyafewminutes.Whilemyeyesfollowedthefreneticanimationonthescreen,mybreathingpacedtheirsandIsharedthepeacetheyseemedtobefeeling.

Imarveledathowtheymanagedtocommunicatetheirpainandconfusionbycreatingthesesamefeelingsinme.Emotionistrulycontagiousandapowerfulsourceofhumanconnection.Byhavingthemsettheinitialpaceofourplay,ItoldthemIrespectedtheirwayofcoping.Throughtheuseofthedoll,theycommunicatedthatwhentheyneededsoothingtheiranxietywasoftenmetwithmoreofthesame.WhenIburpedtheirdollinacaringandlovingway,IshowedthemthatIwascapableofsoothingthemiftheywerefeelingbad.Byaskingmetoburpthem,theytoldmeIwastrusted.Infallingasleep,theysaid,“Wefeelsafeandweknowyouwillwatchoveruswhilewerest.”Whilenoneofthiswasspoken,thecommunicationwasclear.

OurinteractionswiththedollchangedSamandJessica’sstateofmindandbodyaswellasmyown.Ibelievethatitnotonlyimpactedtheirattitudesandbehaviorsthatafternoon,butmayhavealsochangedtheirbrainsinsomesmallbutperhapspermanentway.Icouldseethisreflectedintheirfacesandhearitinthetoneoftheirvoices;somethingfundamentalhadchangedthataffectedtheirentirebeings.Iprovidedthemwithametaphorthroughwhichtheycouldreorganizetheirexperience,havetheirneedsmet,andregulatetheiremotions.Together,thethreeofusco-constructedanewnarrativeforthemtouseasawayofsoothingthemselvesandeachother.

Werethisprocesstoberepeatedenoughtimes,theirbrainscouldreorganizearoundthismetaphorofnurturanceandholdingandenhancecommunicationbetweennetworksofcognitiveandemotionalprocessing.PerhapsSamandJessicacouldinternalizeamodelofself-holdingandnurturancethatwouldhelpthemnavigatefuturechallenges.Thiskindofinteractionisattheheartofallformsofpsychotherapy,regardlessofphilosophyortechnique.Allformsoftherapyhavetheirownversionsofintegrativemetaphors,servingtoreorganizeneuralnetworksandalterhumanexperience,hopefully,forthebetter.

Summary

Inthischapterwehavediscussedsomeofthebasicprinciplesconnectingthehistoricalandconceptualconnectionsbetweenpsychotherapyandneuroscience.Fourcommonfactorsrelatedtothenatureofsocialrelationships,optimalstress,theactivationofaffectandcognition,andtheco-constructionofnarrativesemergefromthereview.Inthechapterstocome,wewillexplorethecomponentsandorganizingprinciplesofthenervoussystem.Thesebasicconceptswillhelpusunderstandtheneuralmechanismsofthebuildingandrebuildingofthebrain.

PartII.

HowtheBrainWorks:TheLegacyofEvolution

Chapter4

TheHumanNervousSystem:FromNeuronstoNeuralNetworks

Allfunctionsofmindreflectfunctionsofbrain.—EricKandel

Studyingthehumanbrainisadauntingtask.Infact,thehumanbrainissovastlycomplexthatitwouldtaketensofthousandsofpagestodojusticetowhatisknownaboutitsstructureandfunction.Buthowmuchdowereallyneedtoknowaboutthebraintohelpusinourworkastherapists?Mybeliefisthatabasicunderstandingofthenervoussystem,withoutgettinglostinthedetails,wouldbeveryhelpful.Withthisasourgoal,wewillmovethroughathumbnailsketchofthebasicstructures,functions,anddevelopmentofthenervoussystem.Keepinmindthatthisisaskewedlookatthehumannervoussystembiasedtowardthosestructures,processes,andtheoriesthatwillberelevanttothechapterstocome.

Neurons

Itisimpossible,inprinciple,toexplainanypatternbyinvokingasinglequantity.—GregoryBateson

Thebasicunitofthenervoussystemistheneuron,whichreceivesandtransmitssignalsviachemicaltransmissionandelectricalimpulses.Thereareanestimated100billionneuronsinthebrain,withbetween10and100,000synapticconnectionseach,creatinglimitlessnetworkingpossibilities(Nolte,2008;Post&Weiss,1997).Neuronshavefiberscalledaxonscoveredwithmyelin,aninsulatorthatenhancestheefficiencyofcommunication.Becauseneuronsmyelinateastheydevelop,onewayofmeasuringthematurityofaneuralnetworkistomeasureitsdegreeofmyelinization.Multiplesclerosis—adiseasethatbreaksdownmyelin—resultsinadecreaseintheefficiencyofneuralcommunication,negativelyimpactingcognition,affect,andmovement(Hurley,Taber,Zhang,&Hayman,1999).Thewhitematterofthebrainiswhitebecausemyeliniswhite(oratleastlightincolor).Graymatterconsistsprimarilyofneuralcellbodies.

Whenaneuronfires,informationiscarriedviaanelectricalchargethattravelsdownthelengthofitsaxon.Neuronscommunicatewithoneanotheracrosssynapses(thespacesbetweenneurons)viachemicalmessengerscalledneurotransmitters.Thecombinationofthesetwocomplementaryprocessescreatesthebrain’selectrochemicalsystem.Manyneuronsdevelopelaboratebranches,calleddendrites,whichformsynapticconnectionswiththousandsofdendritesfromotherneurons.Therelationshipsformedamongthesedendritesorganizethecomplexnetworkingofthenervoussystem.

Glia

Complex,statisticallyimprobablethingsarebytheirnaturemoredifficulttoexplainthansimple,statisticallyprobablethings.

—RichardDawkins

Althoughthefocusofneuroscienceresearchisusuallyonneurons,theymakeuponlyhalfthevolumeofthecerebralcortex.Theotherhalfofourbrainismadeupofapproximatelyonetrillioncellsknownasglia.Onereasonweknowsomuchmoreaboutneuronsisthattheyareapproximately10timeslargerthanglialcells.Ithaslongbeenknownthatgliaplayanimportantsupportiveroleintheconstruction,organization,andmaintenanceofneuralsystems.Morerecently,ithasbecomeapparentthattheyarealsoinvolvedinneuralnetworkcommunicationandplasticity(Allen&Barres,2005;Pfrieger&Barres,1996;Sontheimer,1995;Vernadakis,1996).Neuralplasticityreferstotheabilityofneuronstochangethewaytheyareshapedandrelatetooneanotherasthebrainadaptstotheenvironmentthroughtime.

Astrocytes,themostabundantkindofglia,havebeenshowntoparticipateintheregulationofsynaptictransmissionandtobeinvolvedinthecoordinationandsynchronizationofsynapticactivity(Fellin,Pascual,&Haydon,2006;Newman,1982).Therenowappearstobeglialaswellasneuraltransmission.Thereisalsothedistinctpossibilitythatastrocytesbothshapeandmodulatesynapses(Halassa,Fellin,&Hayden,2007).Throughevolution,theratioofglialcellstoneuronshassteadilyincreased,leadingsometobelievethatourexpandingcognitivesophisticationis,inpart,relatedtotheparticipationofastrocytesininformationprocessing(Nedergaard,Ransom,&Goldman,2003;Oberheim,Wang,Goldman,&Nedergaard,2006).WewillrevisitthisinalaterchapterwhenwediscussEinstein’sglialcellsandhisexceptionalimaginalabilities.

Neurogenesis

Whatweteachtodayispartbiologyandparthistory…butwedon’talwaysknowwhereoneendsandtheotherbegins.

—J.T.Bonner

Neurogenesis,thebirthofnewneuronsviacelldivision,occursinthelowerregionsoftheventricles,thefluid-filledcavitieswithinourbrains.Somefishandamphibians,whichdemonstrateongoingneurogenesis,possessnervoussystemsthatcontinuetogrowinsizethroughoutlife(Fine,1989).Duringevolution,itappearsthatprimatesmayhavetradedmuchoftheircapacityforneurogenesistocontinuebuildingexistingneuralnetworksinordertoretainpastlearninganddevelopexpertknowledge.Inotherwords,ifinsteadofbeingreplaced,neuronsareretainedandcontinuallymodifiedthroughthebranchingoftheirdendritesinreactiontonewexperience,morerefinedlearningmayresult(Purves&Voyvodic,1987).Neuronsdonotappeartohavealifespan,butdieoffeitherasafunctionofnormalapoptosisorbecausetheirbiochemicalenvironmentbecomesinhospitable.Highlevelsofcortisol,alackofbloodflow,orthebuildupofharmfulfreeradicalscanallleadtoneuronaldeath.

Thetraditionalwisdomconcerningneurogenesisinvertebrates,andespeciallyprimates,hasbeenthatnewneuronsarenolongercreatedafterearlydevelopment(Michel&Moore,1995;Rakic,1985).Despiteconsiderableevidencetothecontrary,thisdogmaheldswaythroughmostofthe20thcentury.However,researchcontinuestodemonstratethatnewneuronsareformedinthebrainsofadultbirds(Nottebohm,1981),treeshrews(Gouldetal.,1997),primates(Gould,Reeves,Fallah,etal.,1999),and

humans(Gould,Reeves,Graziano,etal.,1999).Further,neurogenesisisregulatedbyenvironmentalfactorsandexperiencessuchasstressandsocialinteractions(Fowler,Liu,Ouimet,&Wang,2002).

Humanshavemaintainedtheabilitytocreateneuronsinareasinvolvedwithnewlearning,suchasthehippocampus,theamygdala,andthecerebralcortex(Erikssonetal.,1998;Gould,2007;Gross,2000).Theimportanceofthesediscoveriesandtheabandonmentoftheolddogmacannotbeunderestimated.Nobel-prize-winningneuroscientistEricKandelreferredtoNottebohm’sdiscoveryofseasonalneurogenesisinbirdsashavingresultedinoneofthegreatparadigmshiftsinmodernbiology(Specter,2001).

NeuralSystems

IbelieveinGod,onlyIspellitNature.—FrankLloydWright

Asthebraindevelopsandmatures,neuronsorganizeinmoreandmorecomplexneuralnetworkstailoredtocarryoutthenumerousfunctionsofthenervoussystem.Thetwomostbasicdivisionsofthenervoussystemarethecentralnervoussystem(CNS)andtheperipheralnervoussystem(PNS).TheCNSincludesthebrainandspinalcord,whereasthePNSiscomprisedoftheautonomicnervoussystemandthesomaticnervoussystem.TheautonomicandsomaticnervoussystemsareinvolvedinthecommunicationbetweentheCNSandthesenseorgans,glands,andthebody(includingtheheart,intestines,andlungs).

Theautonomicnervoussystemhastwobranches,calledthesympatheticandparasympatheticnervoussystems.Thesympatheticsystemcontrolstheactivationofthenervoussysteminresponsetoathreatorotherformofmotivation.Theparasympatheticsystembalancesthesympatheticsystembyfosteringconservationofbodilyenergy,immunologicalfunctions,andrepairofdamagedsystems.Athirdsystemreferredtoasthesmartvagusoperatesinparalleltotheparasympatheticbranchoftheautonomicnervoussystemandisdedicatedtofine-tuningbodilyreactions,especiallyinsocialsituations(Porges,2007).Thesethreesystemswillbeofparticularinterestinlaterchapters,whenwediscussattachmentandtheeffectsofstressandtrauma.

AlthoughMacLean’sformulationofthetriunebrainisseenastoosimplisticbymostneuroscientists,manystillrecognizethetripartitedivisionofthebrainintothecerebralcortex,thelimbicsystem,andthebrainstem.Eachlayeristhoughtofashavingdifferentresponsibilities.Thebrainstem—theinnercoreofthebrain—overseesthebody’sinternalmilieubyregulatingtemperature,heartrate,andbasicreflexessuchasbloodflowandrespiration.Thestructureandfunctionsofthebrainstemwereshapedduringourgenetichistoryandarefullyformedandfunctionalatbirth.Thereflexesweseeinthenewbornwhograspshermother,sucklesherbreast,andknowstoholdherbreathwhenputunderwateraregeneticmemoriesretainedfromourtree-dwellingancestors.

Theouterlayerofthebrain,thecerebralcortex,isfirstorganizedby,andthencomestoorganize,ourexperiencesandhowweinteractwiththeworld.Aswegrow,thecortexallowsustoformideasandmentalrepresentationsofourselves,otherpeople,andtheenvironment.Distinctfromthebrainstem,thecortexisexperiencedependent,whichmeansthatitisshapedthroughcountlessinteractionswithoursocialandphysicalworlds.Inthiswaywegrowtoadapttotheparticularnicheintowhichweareborn.

Thetwohalvesofthecerebralcortexhavegraduallydifferentiatedduringprimateevolutiontothepointwhereeachhasdevelopedareasofspecialization,referredtoaslateraldominanceorspecialization.Languageisthebest-understoodexampleoflateralspecialization.Thetwocerebral

hemispherescommunicatewitheachotherprimarilyviathecorpuscallosum,whichconsistsoflongneuralfibersthatconnectthetwo.Althoughthecorpuscallosumisthelargestandmostefficientmodeofcommunicationbetweenthehemispheresinadults,thereareanumberofsmallercorticalandsubcorticalinterconnectionsbetweenthetwohalvesofthebrain(Myers&Sperry,1985;Sergent,1986,1990).

Thecortexhasbeensubdividedbyneuroanatomistsintofourlobes:frontal,temporal,parietal,andoccipital(Figure4.1).Eachisrepresentedonbothsidesofthebrainandspecializesincertainfunctions:theoccipitalcortexcomprisestheareasforvisualprocessing;thetemporalcortexforauditoryprocessing,receptivelanguage,andmemoryfunctions;theparietalcortexforlinkingthesenseswithmotorabilitiesandthecreationoftheexperienceofasenseofourbodyinspace;andthefrontalcortexformotorbehavior,expressivelanguage,executivefunctioning,abstractreasoning,anddirectedattention.Thetermprefrontalcortexisoftenusedtorefertotheforemostportionofthefrontallobe.Twoadditionalcorticallobes,thecingulateandinsulacortices,aregainingincreasingrecognitionasdistinctandimportantareasofthecortical-subcorticalinterface.Theyareinvolvedintheintegrationofinnerandouterexperience,linkingtherestofthecortexwithsomaticandemotionalexperience.

Betweenthebrainstemandthecortexliesaregionreferredtoasthelimbicsystem,whichisinvolvedwithlearning,motivation,memory,andemotion.Becausethisbookfocusesondevelopmentandpsychotherapy,youwillnoticerepeatedreferencestotwolimbicstructures.Thefirstistheamygdala,akeycomponentinneuralnetworksinvolvedinattachmentaswellastheappraisalandexpressionofemotionthroughoutlife(Cheng,Knight,Smith,&Helmstetter,2006;Phelps,2006;Strange&Dolan,2004).Theotheristhehippocampus,whichorganizesexplicitmemoryandthecontextualmodulationofemotionincollaborationwiththecerebralcortex(Ji&Maren,2007).

NeurotransmittersandNeuromodulators

Brainsexistbecausethedistributionofresourcesnecessaryforsurvivalandthehazardsthatthreatensurvivalvaryinspaceandtime.

—JohnAllman

Recallthat,withinthenervoussystem,neuronscommunicatewitheachotherviachemicalmessengerscalledneurotransmitters.Differentneuralnetworkstendtoutilizedifferentsetsofneurotransmitters,whichiswhycertainpsychotropicmedicationsimpactdifferentsymptoms.Chemicalsthatserveasneurotransmittersincludemonoamines,neuropeptides,andaminoacids.Neuromodulators(e.g.,thehormonestestosterone,estrogen,cortisol,andothersteroids)regulatetheeffectsoftheneurotransmittersonreceptorneurons.Aminoacidsarethesimplestandmostprevalentneuromodulators.Glutamateisthemajorexcitatoryaminoacidinthebrainandcentraltoneuralplasticityandnewlearning(Cowan&Kandel,2001;Malenka&Siegelbaum,2001).Interactionswithoneofitsprimaryreceptors,N-methyl-D-aspartate(NMDA),regulateslong-termpotentiationandlong-termdepression,therebyshapingtherelationshipbetweenneurons(Liuetal.,2004;Masseyetal.,2004;Zhaoetal.,2005).

Themonoamines—includingdopamine,norepinephrine,andserotonin—playamajorroleintheregulationofcognitiveandemotionalprocessing(Ansorge,Zhou,Lira,Hen,&Gingrich,2004).Allthreeareproducedindifferentareasofthebrainstemandarecarriedupwardviaascendingneuralnetworkstothecortex.Dopamine,producedinthesubstantianigraandotherareasofthebrainstem,isakeyneurotransmitterinmotoractivityandrewardreinforcement.Toomuchdopaminecanresultinmood

changes,increasedmotorbehavior,anddisturbedfrontallobefunctioning,which,inturn,cancausedepression,memoryimpairment,andapathy.Parkinson’sdiseaseresultsfromdamagetothesubstantianigraandaconsequentlossofdopamine.Manybelievethatschizophreniaiscausedbytoomuchdopamine,whichoverloadssensoryprocessingcapabilitiesandcreateshallucinationsanddelusions.

Norepinephrine,producedinthelocuscoeruleusandotherbrainregions,isakeycomponentoftheemergencysystemofthebrainandisespeciallyrelevantforunderstandingstressandtrauma.Highlevelsresultinanxiety,vigilance,symptomsofpanic,andafight-flightresponse.Norepinephrinealsoservestoenhancememoryforstressfulandtraumaticevents.Serotonin,generatedintheraphenucleus,isdistributedwidelythroughoutthebrainandplaysaroleinarousal,thesleep–wakecycle,andthemediationofmoodandemotion(Fisheretal.,2006).PopularantidepressantmedicationssuchasProzacandPaxilcausehigherlevelsofavailableserotonininthesynapsesandhigherlevelsofneurogenesis(Encinas,Vaahtokari,&Enikolopov,2006).

Thegroupofneurotransmittersknownasneuropeptidesincludesendorphins,enkephalins,oxytocin,vasopressin,andneuropeptide-Y.Thesecompoundsworktogetherwithneuromodulatorstoregulatepain,pleasure,andrewardsystems.Theendorphinstendtomodulatetheactivityofmonoamines,makingthemhighlyrelevantforunderstandingpsychiatricillnesses.Endogenousendorphins(endorphinsproducedbythebody)serveasananalgesicinstatesofphysicalpain.Theyarealsoinvolvedwithdissociationandself-abusivebehavior,aswewilldiscussinalaterchapterontrauma.Therelationshipbetweenthemonoaminesandneuropeptidesisvitallyimportanttothegrowthandorganizationofthebrain.

Glucocorticoids/Cortisol

We’relousyatrecognizingwhenournormalcopingmechanismsaren’tworking.Ourresponseisusuallytodoitfivetimesmore,insteadofthinking;maybeit’stimetotrysomethingnew.

—RobertSapolsky

Cortisol,themostimportantglucocorticoid,isoftenreferredtoasthe“stresshormone.”Itisproducedintheadrenalglandsinresponsetoawidevarietyofeverydaychallenges.Thetermglucocorticoidcomesfromthefactthatitwasfirstrecognizedforitsroleinglucosemetabolism.Withfurtherstudy,however,manymorefunctionsofcortisolwereuncovered.Glucocorticoidreceptors(GRs)arefoundinalmostallofthetissuesofourbodies.Atnormallevelsandovershortperiods,cortisolenhancesmemory,mobilizesenergy,andhelpstorestorehomeostasisafterstressfulsituations.Glucocorticoidsstimulategluconeogenesisandthebreakdownoflipidsandproteinstomakeenergyavailabletousforemergencies.Ifwehavetofightorflee,wearegoingtoneedenergy.

Cortisolevolvedtobeusefulforperiodsofbriefstresswhich,whenresolved,allowGRstosignaltheadrenalglandstoshutdownproduction.Prolongedcortisolrelease,ontheotherhand,canweakentheimmunesystembypreventingT-Cellproliferation.Infact,thesyntheticformofcortisoliscalledhydrocortisoneandisusedtotreatinflammationandallergiesbyinhibitingnaturalimmunologicalresponses.Sustainedhighlevelsofcortisoldisruptproteinsynthesis,haltneuralgrowth,anddisturbthesodium-potassiumbalancetothepointofneuraldeath.Earlyandprolongedstresshasbeencorrelatedwithmemorydeficits,problemswithaffectregulation,andreductionofvolumeinbrainregionsincludingthehippocampusandamygdala(Buchanan,Tranel,&Adolphs,2006).

Itisbelievedthatsustainedhighlevelsofglucocorticoidsearlyinlifecanhaveanegativeimpactonbraindevelopmentandmakeachildmorevulnerabletosubsequentstress.Ithasbeenshownthatmaternal

behaviorinratsstimulatesthedevelopmentofGRsinthebrainsoftheirpups.GreaterdensityofGRsinthebrainresultsinenhancedfeedbacktotheadrenalglands,whichservestoshutdowncortisolproduction.Thisisoneoftheunderlyingneurobiologicalcorrelatesassociatingmaternalattentionwithresilienceandpositivecopinglaterinlife.Theproductionandavailabilityoftheseneurochemicalsshapeallofourexperience,frombondingandaffectregulationtocognitiveprocessingandoursenseofwell-being.Regulationoftheseneurochemicalstocontrolpsychiatricsymptomatologyisthefocusofthefieldofpsychopharmacology(Gitlin,2007;Stahl,2008).

GeneticsandEpigenetics

Iamconvincedthatitwillnotbelongbeforethewholeworldacknowledgestheresultsofmywork.

—GregorMendel

AttheforefrontofthescienceofgeneticsisAbbotGregorMendel,who,inthegardenofhisancientabbey,discoveredmanyoftheprinciplesofinheritancethatstillholdtrue.Itturnsoutthathisdiscoverieswithpeaplantsapplytoanimalsandhumansbecausetheunderlyingmechanismsofheredityaresimilarforallcomplexlifeforms.Asyouprobablyremember,hisfindingsincludeddominantandrecessivegenesandtheprinciplesofsegregationandindependentassortment.

Withthebenefitsofmoderntechnology,Mendel’sobservationsofthenaturalworldwerelaterunderstoodtobetheeffectsoftemplategenetics,orthewayinwhichgenesandchromosomescombinetopassalongtraitsfromonegenerationtothenext.Wenowknowthatourgeneticinformationiscodedinfouraminoacidbases(adenine,thymine,guanine,andcytosine)thatflowfromDNAtomessengerRNA(mRNA)toprotein.Althoughthisunderstandingwasahugeleapforwardinourknowledgeoftheunderlyingprocessesofgenetictransmission,itaccountsforonlyabout2%ofgeneticexpression.Thescientifictermfortheother98%ofgeneticmaterialwas“junk,”oncethoughttobeaccumulateddebrisofnaturalselection.Itturnsout,however,thatsomeofthisjunkplaysanimportantroleinguidingintronsandexons,whichhelpdeterminewhetherspecificelementsofthegeneticcodegetexpressedorliedormant.

BiologistC.H.Waddingtoncoinedthetermepigeneticsbycombiningthewordsgeneticsandepi,Greekforoverorabove.Epigenesisdescribesthetransformationofcellsfromtheiroriginalundifferentiatedstateduringembryonicdevelopmentintoaspecifictypeofcell.Thus,epigeneticsisthestudyofhowourgenotypeisorchestratedintoourphenotype.Understandingtheelementsofepigeneticsmayhelpusgraspwhyidenticaltwinswiththesamegenesmaydifferinphenotype,thatis,whyonebecomesschizophrenicandtheotherdoesnot.

Thisgetsusbacktotheoldnature-nurturedebateandthequestion:Whatdoweinherit,andwhatdowelearnfromexperience?Ourbestguessisthatalmosteverythinginvolvesaninteractionbetweenthetwo.Whileweinheritatemplateofgeneticmaterial(genotype),whatgetsexpressed(phenotype)isguidedbynoncodedgeneticinformationthatisexperiencedependent.Experiencecanincludeanythingfromtoxicexposuretoagoodeducation;highlevelsofsustainedstresstoawarmandlovingenvironment;feasttofamine.Thus,manymoregenesareinvolvedwiththeregulationofwhatisexpressedthanwiththedirectsynthesisofprotein.Sowhiletemplategeneticsmayguidetheearlyformationofthebrainduringgestation,theregulationofgeneexpressiondirectsitslong-termdevelopmentinreactiontoongoingadaptationtothesocialandphysicalworlds.EpigeneticsisatermusedtodescribethischangeinthephenotypicexpressionofgenesintheabsenceofachangeintheDNA

template.Anexampleofthisprocessofparticularrelevancetoemotionaldevelopmentandpsychotherapyis

theimpactofearlystressontheadultbrain.Meaneyandhiscolleagues(1991)believethatearlyenvironmentalprogrammingofneuralsystemshasaprofoundandlong-lastingeffectonthehypothalamic-pituitary-adrenal(HPA)axis,whichregulatesanindividual’sresponsivitytostress.Researchwithratshasdemonstratedthatthestressofearlymaternaldeprivationdownregulatesthedegreeofneurogenesisandtheresponsetostressduringadulthood(Mirescu,Peters,&Gould,2004;Karten,Olariu,&Cameron,2005).Justasimportantforus,theseprocessesarereversiblelaterinlife.Astherapists,weattempttoreprogramtheseneuralsystemsviaasupportiverelationshipandthetechniqueswebringtobearduringtreatment.Inotherwords,weareusingepigeneticstochangethebraininwaysthatenhancementalandphysicalwell-being.

ViewsoftheBrain

Whenconsideringtheabilitiesandcomplexitiesofthebrain,oneisstruckbytheincredibleefficiencyandsplendorexpressedingrayandwhitematter.

—JulianPaulKeenan

Throughoutmostofthehistoryofneurology,thehumanbrainwasonlyexaminedafterinjuryordeath.Thelocationofbraindamageduringautopsywaslinkedtothenatureandseverityofthepatient’sclinicalsymptomsduringlife.Braindevelopmentwasstudiedbyexaminingandcomparingthebrainsofhumansandanimalsatdifferentages.Thesebrainswerecomparedforsize;thenumberofneurons,synapses,anddendrites;thedegreeofmyelinization;andotheraspectsofneuralmaturation.

Newertechniquesallowustoexaminebrainstructureinlivingsubjects.Throughtheuseofcomputerizedtomography(CT)andmagneticresonanceimaging(MRI),weareabletoseetwo-andthree-dimensionalpicturesofthelivingbrain.Bothofthesetechniquesprovideaseriesofcross-sectionalimagesofthebrainthroughitsmanylayers.CTscansdothisviamultipleX-rays.MRIscansutilizeradiowavesandamagneticfieldtostudythemagneticresonanceofhydrogenmoleculesinthewaterpresentindifferentbrainstructures.Indeterminingbrain–behaviorrelationships,thesemeasuresneedtobeevaluatedonthebasisofwhethertheyarecausesorcorrelatesofthedisorderbeingstudied(Davidson,1999).Intheirpresentpracticalapplications,radiologistslearntoreadtheseimagesforthepresenceandlocationsoftumorsorlesionsinordertoassistsurgeonsintheirwork.Thesescanshavebecomeanindispensabletoolinneurology.

Thefunctioningofthebraincanalsobemeasuredinmanyways.Clinicalandmentalstatusexams,testsofstrengthandreflexes,andneuropsychologicalassessmentallrequireapatienttoperformphysicalormentaloperationsthataretiedtoknownneurobiologicalsystems.Theseclinicaltestsaresupplementedbyanumberoflaboratoryteststhatmeasuredifferentaspectsofbrainfunctioning.Theelectroencephalograph(EEG)measurespatternsofelectricalactivitythroughoutthecortex.Therearecharacteristicbrainwavepatternsindifferentstatesofarousalandstagesofsleep.Epilepsyorthepresenceoftumorswilldemonstratecharacteristicalterationsofnormalelectricalfunctioning,allowingEEGstobeusedasdiagnostictools.EEGscanalsobeusedtomeasurebraindevelopment,becauseneuralnetworkorganizationischaracterizedbythereplacementoflocalerraticdischargeswithmorewidespreadandconstantwavepatterns(Barryetal.,2004;Field&Diego,2008b;Forbesetal.,2008).

Themostexcitingnewtoolsinneurosciencearethevariousbrainscanningtechniquesprovidinguswithawindowtothebraininaction.Positronemissiontomography,singlephotonemission

tomography,andfunctionalmagneticresonanceimagingmeasurechangesinbloodflow,oxygenmetabolism,andglucoseutilization,whichtellusabouttherelativeactivityofdifferentregionsofthebrain.Usingthesetechniques,neuroscientistscannowexplorecomplexactivation–deactivationpatternsofbrainactivityinsubjectsperformingawiderangeofcognitive,emotional,andbehavioraltasks(Drevets,1998).Mostofthesenewerscanningtechniquesarestillsomewhatexperimental,andmethodologicalstandardsregardingtheiruseandinterpretationcontinuetoevolve.Thesemethods,andthoseyettobedeveloped,willvastlyenhanceourunderstandingofthebrain.Astheygrowincreasinglymoreaccurateandspecific,sotoowillourknowledgeofneuralnetworkfunctioning.

BrainDevelopmentandNeuralPlasticity

Swiftlythebrainbecomesanenchantedloom,wheremillionsofflashingshuttlesweaveadissolvingpattern—alwaysameaningfulpattern—thoughneveranabidingone

—SirCharlesSherrington

Experiencesculptsthebrainthroughselectiveexcitationofneuronsandtheresultantshapingofneuralnetworks.Paradoxically,thenumberofneuronsdecreaseswithagewhilethesizeofthebrainincreases.Thesurvivingneuronscontinuetogrowfromwhatlooklikesmallsproutsintomicroscopicoaktrees.Thisprocessofgrowthandconnectivityissometimesreferredtoasarborization.

Inorderforaneurontosurviveandgrow,itmustwirewithotherneuronsinincreasinglycomplexinterconnections.Justaswesurviveandthrivethroughourrelationshipswithothers,neuronssurviveandgrowasafunctionofhow“wellconnected”theyare.ThroughwhatappearstobeacompetitiveprocessreferredtoasneuralDarwinism,cellsstruggleforconnectivitywithothercellsinthecreationofneuralnetworks(Edelman,1987).Cellsconnectandlearningoccursthroughchangesofsynapticstrengthbetweenneuronsinresponsetostimulation.Repeatedfiringoftwoadjacentneuronsresultsinmetabolicchangesinbothcells,whichprovidesanincreasedefficiencyintheirjointactivation.Inthisprocess,calledlong-termpotentiation(LTP)orHebbianlearning,excitationbetweencellsisprolonged,allowingthemtobecomesynchronizedintheirfiringpatternsandjointeffectiveness(Hebb,1949).LTPisbelievedtobeafundamentalprincipleofneuroplasticlearning.UnderlyingLTPistheconstantreachingoutofsmallportionsofthedendritesinanattempttoconnectwithadjacentneurons.Whentheseconnectionsaremade,neuronssynthesizenewproteintobuildmorepermanentbridgesbetweenthem.

ThroughLTP,cellassembliesorganizeintofunctionalneuralnetworksthatarestimulatedthroughtrial-and-errorlearning.Thisisonlyonesmallpieceofavastlycomplexsetofinteractionsinvolvingtheconnection,timing,andorganizationoffiringwithinandbetweenbillionsofinterconnectedneuronsintheCNS(Malekna&Siegelbaum,2001).Earlyindevelopment,thereisaninitialoverproductionofneuronsthatgraduallydecreasesthroughtheprocessofpruning,orapoptosis.NeuralDarwinismappliestoboththesurvivalofneuronsandthesynapticconnectionsamongthem.Synapsesthatareformedmaybesubsequentlyeliminatediftheybecomeinactivatedorinefficient(Purves&Lichtman,1980).Infact,eliminationofsynapticconnectionsinthecortexcontinuesshapingneuralcircuitrythroughadolescenceandintoadulthood(Cozolino,2008;Huttenlocher,1994).

Incontrasttothebrainstemandlimbicsystem,thecortexisimmatureatbirthandcontinuestodevelopthroughoutadulthood.Becauseofthisdevelopmentaltiming,brainstemreflexesorganizemuchoftheinfant’searlybehaviorsandthebehaviorofanewbornisdominatedbysubcorticalactivity.Theneonatewillorienttothemother’ssmell,seekthenipple,gazeintohereyes,andgraspherhair.AgoodexampleofabrainstemreflexistheMororeflex,bywhichtheinfantreachesoutwithopenhandsand

legsextended,puttingtheinfantintoapositionconducivetograspingandholding(Eliot,1999).Thechild’seyesreflexivelyorienttothemother’seyesandfaceandababy’sfirstsmilesarecontrolledbybrainstemreflexestoattractcaretakers.Infact,childrenbornwithageneticmalformationthatresultsinhavingonlyabrainstemarestillabletosmile(Herschkowitz,Kegan,&Zilles,1997).Thesereflexesenhancephysicalsurvivalandjumpstarttheattachmentprocessbyconnectingparentandchild,whileenhancingtheirbond.

Asanyonewhohasbeenpregnantcantellyou,babiesbegintoengageinspontaneousactivityofthearmsandhandswellbeforebirth.Whilethebabyispracticingusingitsarmsandlegs,parents-to-begrowincreasinglyexcitedasthesesignsofactivitygrowinfrequencyandstrength.Afterbirth,newbornscontinuetomoveallpartsoftheirbodies,allowingthemtodiscovertheirhandsandfeetastheypassinfrontoftheirfaces.Althoughthesemovementsmaylookrandom,theyarethebrain’sbestguessatwhichmovementswilleventuallybeneeded.Thesereflexivemovementsjumpstarttheorganizationofmotornetworkstobuildtheskillsthechildwillneedlateron(Katz&Shatz,1996).

Throughmonthsandyearsoftrial-and-errorlearning,thesebestguessesbecomeshapedintopurposefulandintentionalbehaviorsthatarereflectedintheorganizationofunderlyingneuralnetworks(Shatz,1990).Assensorysystemsdevelop,theyprovideincreasinglypreciseinputtoguideneuralnetworkformationformorecomplexpatternsofbehavior.Aspositiveandnegativevaluesareconnectedwithcertainperceptionsandmovements—suchastheappearanceofthemotherandreachingouttoher—emotionalnetworkswillintegratewithsensoryandmotorsystems.Inthedevelopmentoftheseandothersystems,wefindthesequentialactivationofreflexiveandspontaneousprocessesprimingneuraldevelopment,whichcomestobeshapedbyongoingexperience.

CorticalInhibitionandConsciousControl

Hewhoconquersothersisstrong;hewhoconquershimselfismighty.—Lao-Tzu

Thegradualattenuationofneonatalreflexesandspontaneousbehaviorcorrespondswithrisinglevelsofcorticalactivityandinvolvementinbehavior.Asthecortexdevelops,vastnumbersoftop-downneuralnetworksconnectitwithsubcorticalareas.Thesetop-downnetworksprovidethepathwaysforinhibitingreflexesandbringingthebodyandemotionsunderincreasingcorticalcontrol.Anexampleofthisisthedevelopmentofthefinemotormovementsbetweenthethumbandforefingerthatarerequiredtoholdaspoon.Primitivegraspingreflexesallowonlyforthespoontobeheldinatightfist,renderingituselessasatool.Thedevelopingcortexenablesthegraspingreflextobeinhibited,whilecorticalnetworksdedicatedtofingersensitivityandhand–eyecoordinationmature.Thus,avitalaspectofthedevelopmentofthecortexisinhibitory—firstofreflexes,laterofspontaneousmovementsandevenlaterofemotionsandinappropriatesocialbehavior.

Onlythroughrepeatedtrial-and-errorlearningareearlyclumsymovementsslowlyshapedintofunctionalskills.Childrenandtheirbrainsintuitivelyknowthisandwillresistbeingheldbackorhelpedtoomuch.Whenweattempttohelp,achild’simpatientprotestof“Letmedoit!”reflectsinstinctualwisdomoftheimportanceoftrial-and-errorlearninginthegrowthofneuralnetworks.Thismakesformanyyearsofmessesandboo-boos.Anothergoodexampleoftheprocessofbrainmaturationisourabilitytoswim.Thenewborn’sbrainstemreflextoholditsbreathandpaddlewhendroppedintowaterislost(inhibitedbyhigherbraincircuitry)justweeksafterbirth.Theskillsinvolvedwithswimmingneedtoberelearnedascorticallyorganizedskillsinyearstocome.Motornetworksneedtobetaughtbody

movements,asbreathingbecomestimedandsynchronizedwitheachstroke.Corticalinhibitionanddescendingcontrolarealsocentraltoaffectregulation.Therapidlychanging

andoverwhelmingemotionsdisplayedbyveryyoungchildrenreflectthislackofcontrol.Asthemiddleportionsofthefrontalcortexexpandandextendtheirfibersdownintothelimbicsystemandbrainstem,childrengraduallygainincreasingcapacitytoregulatetheiremotionsandfindwaystogainsoothing,firstthroughothers,andeventuallybythemselves.Whenthesesystemsaredamagedordevelopmentallydelayed,wewitnesssymptomsrelatedtodeficitsinattention,emotionalregulation,andimpulsecontrol.

Weseethechangesinmotorcontrolandpostureasachildmovesfrombeingabletosituprightwithouthelpatabout6months,tocrawlingatabout9months,andthentowalkingwithouthelpbyabout1year.At2years,achildwillwalkupanddownstairs;by3shecanpeddleatricycle.Astheseskillsareshaped,sotooarethebrainsystemsdedicatedtobalance,motorcontrol,visual–spatialcoordination,learning,andmotivationthatcontrolthem.Thegrowth,development,andintegrationofneuralnetworkscontinuetobesculptedbyenvironmentaldemands.Inturn,neuronalsculptingisreflectedinincreasinglycomplexpatternsofbehaviorandinnerexperience.

SensitivePeriods

Theprincipalactivitiesofbrainsaremakingchangesinthemselves.—MarvinL.Minsky

Thebraincontinuestogrowaslongaswecontinuetolearn,essentiallyuntilthedaywedie.Earlybraindevelopmentishighlightedbyperiodsofexuberantneuralgrowthandconnectivitycalledsensitiveperiodstriggeredbytheinteractionofgenesandexperience.Thesesensitiveperiodsaretimesofrapidlearningduringwhichthousandsofsynapticconnectionsaremadeeachsecond(Greenough,1987;tenCate,1989).Thetimingofsensitiveperiodsvariesacrossneuralsystems,whichiswhydifferentabilitiesappearatdifferentages.

Themostwidelyrecognizedsensitiveperiodisthedevelopmentoflanguage.At24months,anaveragechildunderstandsandusesabout50words;thisincreasesto1,000wordsby36months(Dunbar,1996).Theextentofneuralgrowthandlearningduringsensitiveperiodsresultsinearlyexperiencehavingadisproportionateimpactonourbrains,minds,andexperiences.Aswelearnofthebrain’sabilitytocreatenewneuronsandretainplasticitythroughoutlife,theimportanceofsensitiveperiodstakesonnewmeaning.Thequestionfortherapistsis:Howamenablearetheseestablishedstructurestomodification?Thisisatopicwewillcomebacktoagainandagaininlaterchapters.

Thegrowthofneuronsandthedevelopmentofincreasinglycomplexneuralnetworksrequirelargeamountsofenergy.Patternsofincreasingglucosemetabolismduringthefirstyearoflifeproceedinphylogenicorder,meaningthatthedevelopmentofmoreprimitivebrainstructuresprecedesthosewhichevolvelater(Chugani,1998;Chugani&Phelps,1991).Earlysensitiveperiodsaccountforthehigherlevelofmetabolisminthebrainsofinfantscomparedtoadults.Evernoticehowwarmababy’sheadis?Ithasbeenestimatedthatinrats’brains,250,000synapticconnectionsareformedeverysecondduringthefirstmonthafterbirth(Schuz,1978).Justimaginewhatthenumbermustbeforhumans.

Networksdedicatedtoindividualsensesdevelopbeforetheassociationareasthatconnectthemtooneanother(Chugani,Phelps,&Mazziotta,1987).Thegrowthandcoordinationofthedifferentsensesparallelwhatwealsowitnessinsuchbehavioralchangesashand–eyecoordinationandtheabilitytoinhibitincorrectmovements(Bell&Fox,1992;Fischer,1987).Asthecerebralcortexmatures,achildat8monthsisabletodistinguishfacesandcomparethemtohisorhermemoryofotherfaces.Itisaround

thisperiodthatstrangeranxietyandseparationanxietydevelop.Asthebrainmatures,wewitnessincreasingcorticalactivationandtheestablishmentofmoreefficientneuralcircuitryfiringinincreasinglysynchronouspatterns.

Althoughboththeleftandrightcerebralhemispheresaredevelopingatveryhighratesduringtheearlyyearsoflife,therighthemisphereappearstohavearelativelyhigherrateofactivityandgrowthduringtheearliestyears(Chironetal.,1997).Duringthistime,vitallearningintheareasofattachment,emotionalregulation,andself-esteemareorganizedinneuralnetworksbiasedtowardtherighthemisphere.Somewherearoundage3,thispatternofasymmetricalgrowthshiftstothelefthemisphere.

Summary

Thematurationandsculptingofsomuchofthecortexafterbirthallowsforhighlyspecificenvironmentaladaptations.Thecaretakerrelationshipistheprimarymeansbywhichphysicalandculturalenvironmentsaretranslatedtoinfants.Itiswithinthecontextofthesecloserelationshipsthatnetworksdedicatedtofeelingsofsafetyanddanger,attachment,andthecoresenseofselfareshaped.Thefirstfewyearsoflifeappeartobeaparticularlysensitiveperiodfortheformationofthesenetworks.Itmaybepreciselybecausethereissomuchneuralgrowthandorganizationduringsensitiveperiodsthatearlyinterpersonalexperiencesmaybefarmoreinfluentialthanarethoseoccurringlater.Thefactthattheyarepreconsciousandnonverbalmakesthemdifficulttodiscoverandmoreresistanttochange.Becausetheseneuralnetworksaresculptedduringearlyinteractions,weemergeintoself-awarenesspreprogrammedbyunconsciouslyorganizedhiddenlayersofneuralprocessing.Thestructureoftheseneuralnetworksorganizescorestructuresofourexperienceofself.

Chapter5

MultipleMemorySystemsinPsychotherapy

To“domemory”isessentiallytoengageinaculturalpractice.—KennethGergen

Theprocessofpsychotherapyistotallydependentuponmemory.Fromwhatweknowofclients’pastandcurrentlives,totheirabilitytobringthelessonsoftherapyintopractice,everythingdependsontheirabilitytolearnandremember.Yet,despiteitscentralroleinourwork,themajorityofclinicalpsychologists,psychiatrists,familytherapists,andsocialworkersreceivelittleornotraininginthehowsandwhysofmemory.Inthischapterweexplorevariousaspectsofmemoryandtheirroleinbothmentalillnessesandpsychotherapy.

Psychotherapistshavetraditionallydividedmemoryintothebroadcategoriesofconscious,preconscious,andunconscious.Consciousmemoryisexpressedinrecollectionsofthepast,thecontentofprevioustherapysessions,andreportsofcurrentday-to-daylife.Thepreconsciouscontainsmemoriesthatarenotthefocusofcurrentattentionbutwhichcaneasilybebroughtintoconsciousawarenesswithaminimumofdifficulty.Unconsciousmemoryunavailabletoconsciousconsiderationcanmanifestinbehaviors,attitudes,andfeelingsaswellasinmorecomplexformssuchasdefenses,self-esteem,andtransference.Muchofthetrainingofpsychodynamictherapistsistheidentificationanddecipheringofunconsciousmemoryintoaformthatisaccessibletothepatient.

Freudbelievedthatafundamentalgoaloftherapyistomaketheunconsciousconscious.Fromtheperspectiveofrebuildingthebrain,thisgoalcanbedescribedasincreasingtheinterconnectionandintegrationofneuralnetworksdedicatedtounconsciousandconsciousmemory.Thisprocessmakesunderstandingtheevolution,development,andfunctioningofthevarioussystemsofmemorycrucialtoconceptualizingandtreatingpsychologicaldistressandmentalillnesses.Italsoaidsinexplainingtoclientssomeoftheparadoxesandconfusiontheyexperiencebasedonthevarietyofwaystheirbrainsprocessinformation.

ResistancetoTherapyorMemoryDeficit?

Oursenseofworth,ofwell-being,evenoursanitydependsuponourremembering.But,alas,oursenseofworth,ourwell-being,oursanityalsodependuponourforgetting.

—JoyceAppleby

Foralmostayear,ItreatedawomannamedSophiawhohadexperiencedrepeatedtraumasandchronic

stressdatingbacktoearlychildhood.Amongthemanyissuesshebroughttotreatmentwerefamilyconflict,earlysexualabuse,andcurrentrelationshipproblems.OneofSophia’slong-standingcomplaintswasseverememorydifficulties,especiallywhenitcametorememberingnames,dates,andappointments.Inhighschoolherteacherstoldhershewasstupidbecauseshewasunabletorecallwhatwassaidinclassfromonedaytothenext.Sophiawassoembarrassedbyherinabilitytoremembernamesthatsheavoidedpartiesandallbutessentialworkgatherings.Ontheotherhand,hermemoryforemotionallyladenexperienceswaslikeasteeltrap,continuallyevokingfearandsadness.Sophiawasconvincedthatthepartofherbrainresponsibleforrememberingshamewasverydifferentfromtheonethatrecallednames.

Sophiahadgonetomanytherapiststhroughoutheradultlife,repeatedlymissedappointments,andhadbeentoldshewasresistanttotreatment.Sophiafoundthisveryfrustratingbuthadnoexplanationofherown.Basedonherhistory,thesetherapistsassumedthatherproblemswithmemorywerecausedbydenial,avoidance,orrepression,andencouragedhertofaceherfears.Whileeachtherapistofferedtheirowninterpretationofherdefensivenesstotreatment,nonerangtrue,andsheusuallyterminatedtherapyafterjustafewsessions.Certainthatitwasherfault,Sophia’streatmentfailuresledhertofeelincreasinglyhopelessabouteverfindingthehelpsheneeded.Theannoyanceand“criticism”shereceivedfromtherapistsalsoincreasedherfeelingsofshame.Althoughshefearedourworktogetherwouldmeetthesamefate,shewaswillingtogivetherapyonemoretry.

Afterlearningherhistory,Isharedabitofneurosciencetohelpherbetterconceptualizeherissueswithmemory.Myminilecturefocusedonthedestructiveroleofearlyandprolongedstressonthedevelopmentandwell-beingofthehippocampusandassociatedneuralnetworksresponsibleforexplicitmemory.Isuggestedthatwebeginourworkbystudyingmemorytogetherandexploringpragmaticwaystoimproveit.Alongthewayweexperimentedwiththeuseofmemoryaidsfromthefieldofcognitiverehabilitation.Daytimers,watcheswithalarms,andpersonaldigitalassistants(PDAs)allproveduseful.(Thedevelopmentofsmartphonesnowallowsustocarryallofthesefunctionsinonedevice,arealboontomanypatients.)

Forthefirst2months,SophiaandIscheduledtelephonecontacteveryotherdayforafewminutes.Duringthesecontacts,weexercisedhermemory,checkedonthevariousstrategieswehadsetupduringourprevioussession,andreinforcedhersuccesses.Initially,Sophianeededhelplearningtoremembertouseherstrategiesthathelpedherremember.Utilizinghermemoryaidsandcheckingthemonaregularbasisgraduallybecameautomaticevenif,inthemoment,shewouldforgetwhyshewascheckingherbookorcallingme.

After6weeks,Sophiawasconsistentlyabletorememberappointments.Thissuccessstimulatedconfidenceinherselfandintherapy.Shebegantoseethathermemoryproblemsinnowaymeantshewasstupidorharboreddeeppsychologicalproblems.Onthecontrary,herself-respectincreasedasourdiscussionshelpedhertorealizehowmuchshehadaccomplishedinherlifedespitehertraumatichistoryandstruggleswithmemory.Oncememory-relatedissueswerenolongeranimpedimenttomaintainingconsistentcontact,weshiftedthefocusoftreatmenttotheimpactofherlifeexperiencesonherrelationshipsandcareer.Theinitialfocusoftherapy,usingaformulationfromneuroscienceandcognitiverehabilitation,turnedouttobeanecessaryfirststepinasustainedandsuccessfultherapeuticrelationship.Fromthispoint,thetherapywascharacterizedbyamoretraditionalpsychodynamicapproachwithregularmemorycheckupsandadjustmentstoherstrategies.

Manypsychologicaldisordersmanifestavarietyofmemorydeficits.Anydisorderthatresultsinsubstantialarousalandtriggersthesecretionofthestresshormonecortisolcandamageneuralnetworksofexplicitmemory.Infact,mostpsychiatricdisordersrevealhighratesofcortisolandsmallerhippocampi,bothofwhicharecorrelatedwithmemorydisturbances.Inadditiontoproblemswithremembering,someillnessesservetodistortbothlearningandmemory.Depression,forexample,results

inanegativebiasintherecollectionandinterpretationofpast,present,andfutureevents(Beck,1976).Italsoleadsustoselectivelyscantheenvironment,whichreinforcesnegativeperceptions.Depressionconvincinglydemonstratestheinfluenceofemotionalstatesintheorganizationofconsciousmemory,sometimescalledstate-dependentmemory.Clientsreportthatiftheywakeupdepressed,everythinglooksworsethanitdidthedaybefore,eventhoughtheyknow,intellectually,thatnothinghaschanged.

Therapid(andunconscious)networksofemotionshapeourunderstandingoftheworldmicrosecondsbeforewebecomeawareofourperception.Throughsimilarmechanisms,ourpastexperiencescreateourexpectationsforthefuture.Implicit,unconsciousmemories,createdindysfunctionalsituationsyearsbefore,canrepeatedlyleadustore-createunsuccessfulbutfamiliarpatternsofthought,emotion,andbehavior.Thus,ourperceptionoftheworldisacreationbasedonpastexperience.

MultipleMemorySystems

Memory…isthediarythatweallcarryaboutwithus.—OscarWilde

Researchandclinicalexperiencesupporttheexistenceofmultiplememorysystems,eachwithitsowndomainsoflearning,neuralarchitecture,anddevelopmentaltimetable(Tulving,1985).Learningwithinallsystemsofmemoryisdependentontheprocessoflong-termpotentiationintheHebbiansynapseswehavealreadydiscussed,aswellasthedendriticremodelingandchangesintherelationshipsbetweenneurons(Hebb,1949;Kandel,1998).Thetwobroadestcategoriesofmemoryareexplicitandimplicit.Theconceptsofexplicitandimplicitmemory,althoughsimilarinsomewaystoFreud’sconceptoftheconsciousandunconscious,donotdirectlyoverlap.

Explicitmemorydescribesconsciouslearningandmemory,includingsemantic,sensory,andmotorforms.Thesememorysystemsallowustorecitethealphabet,recognizethesmellofcoconut,orplaytennis.Someofthesememoryabilitiesremainjustbeneaththelevelofconsciousnessuntilweturnourattentiontothem.Implicitmemoryisreflectedinunconsciouspatternsoflearningstoredinhiddenlayersofneuralprocessing,largelyinaccessibletoconsciousawareness.Thiscategoryextendsfromrepressedtraumatoridingabicycle,togettinganuneasyfeelingwhenwesmellafoodthatoncemadeussick.Explicitmemoryisthetipofourexperientialiceberg;implicitmemoryisthevaststructurebelowthesurface.

Manyofourdailyexperiencesmakeitclearthatwehavemultiplesystemsofexplicitandimplicitmemory.Forexample,movingyourfingersoverthekeypadofanimaginaryphonesometimeshelpsyourecallaphonenumber.Thisprocessdemonstratesthatimplicitsystemsofmotorandvisualmemorycanaidintheexplicitrecallofnumbers.Anotherexampleisaphenomenoncommonamongolderadults,inwhichtheyhavedifficultylearningnewinformationbuteasilyrecallstoriesfromtheiryouth.Thismaybebecausethenetworksinvolvedinthestorageoflong-termexplicitmemoryaredistributedthroughoutthecortexandaremoreresistanttotheeffectsofagingthanthoseresponsibleforshort-andmedium-termmemory(Schacter,1996).

Thinkingbacktothetriunebrain,eachtierisinvolvedwithdifferentaspectsofmemoryfunctioning.Thereptilianbraincontainsinstinctualmemories,thelessonsofpastgenerations(geneticmemory)thatcontrolreflexes,andinnerbodilyfunctions.Thepaleomammalianbrain(limbicsystem)contributestoemotionalmemoryandconditionedlearning—amixtureofprimitiveimpulsesandsurvivalprogramssculptedbyexperiences.ThesetwosystemsarenonverbalandcompriseaspectsoftheFreudian

unconscious.Theneomammalianbrain,althoughlargelyunconsciousinitsprocessing,containsnetworksresponsibleforexplicitverbalmemorybiasedtowardthelefthemisphere.

Becauseoftheorderinwhichtheydevelop,implicitandexplicitmemory(detailedinTable5.1)arereferredtoasearlyandlatememory.Systemsofimplicitmemoryareactiveevenbeforebirth,asdemonstratedinthenewborn’sinstinctstoorienttothesoundofhermother’svoice(deCasper&Fifer,1980).Duringthefirstmonthsoflife,basicsensorymemoriescombinetogetherwithbodilyandemotionalassociations(Stern,1985).Thesenetworksallowforthesightofone’sfathertobepairedwithraisedarms,asmile,andagoodfeeling.Somatic,sensory,motor,andemotionalexperienceshelpsculptneuralnetworksduringthefirstfewyearsintoasenseofaphysicalself.

TABLE5.1MultipleMemorySystems

Anumberofthebasicdistinctionsbetweenimplicitandexplicitsystemsofmemory

IMPLICIT EXPLICITEarlyDeveloping LateDevelopingHighlyFunctionalatBirth MatureslaterwithHippocampusand

CortexSubcortical/AmygdalaBias Cortical/HippocampalBias

Nondeclarative DeclarativeEmotional OrganizedbyLanguageVisceral/Sensory-Motor VisualImagesContextFree OrganizedwithinEpisodesandNarrativesProceduralLearning ConsciousOrganizationofExperienceBehaviorPatternsandManual ConstructionofNarrativeSelf

Thedevelopmentofconsciousmemoryparallelsthematurationofthehippocampusandhigher

corticalstructuresoverthefirstyearsoflife(Fuster,1996;Jacobs,vanPraag,&Gage,2000;LeDoux,1996;McCarthy,1995).Childhoodamnesiaortheabsenceofexplicitmemoryfromearlylifelikelyresultsfromthismaturationaldelayandotherdevelopmentalchangesinhowourbrainsprocessinformation.Intheabsenceofexplicitmemory,however,welearnhowtowalkandtalk,whethertheworldissafeordangerous,andhowtoattachtoothers.Thesevitalearlylessons,storedinnetworksthroughoutourbrain,lacksourceattribution;thatis,wedonotrememberhowwelearnedthem.Althoughmanyofusthinkwehaveexplicitmemoriesfromthefirstyearsoflife,thesearemostlikelyconstructedlaterandattributedtoanearliertimeinourlife.

Explicitmemorycanbesensoryandlinguistic,asweassociateandremembersights,sounds,andsmellswithwordsandorganizetheminconsciousmemory.Formostofus,wordsandvisualimagesarethekeystoconsciousmemory.Differenttypesofsemanticmemoryincludeepisodic,narrative,andautobiographical,whichcanallbeorganizedsequentially.Autobiographicalmemorymaintainstheperspectiveofthenarratoratthecenterofthestory.Storiesabouttheselfcombineepisodic,semantic,andemotionalmemorywiththeself-awarenessneededformax-imalneuralnetworkintegration(Cabeza

&St.Jacques,2007).Thisformofmemoryisespeciallyimportantfortheformationandmaintenanceofemotionalregulation,self-identity,andthetransmissionofculture.

Overall,thedevelopmentofthedifferentsystemsofmemoryreflectstheearlyprimacyofimplicitmemoryforlearninginsensory,motor,andemotionalnetworks.Theseearly-formingneuralnetworksdependonthemoreprimitivebrainstructuressuchastheamygdala,thalamus,andmiddleportionsofthefrontalcortex(Figure5.1).Asthecortexandthehippocampuscontinuetodevelopoverthefirstfewyearsoflife,thereisagradualmaturationofthenetworksofexplicitmemory.Thesesystemsprovideforconscious,contextualizedlearningandmemorythatbecomesmoreconsistentandstableovertime.

Thevarioussystemsofmemoryaredistributedthroughoutthebrainandwhereaparticularmemoryisstoreddependsonthetypeofmemoryandhowitisencoded(McCarthy,1995).Agoodexampleofthedistributionofmemorycomesfromanexperimentmeasuringcerebralbloodflowwhilesubjectswereaskedtonamepicturesofeitheranimalsorhandtools(Martin,Wiggs,Ungerleider,&Haxby,1996).NamingbothanimalsandtoolsresultedinincreasedactivityinthetemporallobesandBroca’sarea.Thismakessense,becausethetemporallobesareknowntobeimportantfortheorganizationofmemorywhereasBroca’sareaorganizesverbalexpression.Morespecifically,namingtoolsactivatedareasintheleftmotorcortexinvolvedinthehandmovementsthatwouldbeusedtocontrolthem(Martinetal.,1996).Thissuggeststhatpartofour“toolmemory”isstoredinneuralnetworksthatutilizethem.Whilethereisoverlapofactivationduringpicturenaming,thenatureofthevisualimagetriggersbrainareasrelevanttowhatisdepicted.Thus,memoryisaformofinternalenactmentofwhateverisbeingrecalled.

Theportionofthevisualsystemactivatedbypicturesofanimalsisanareainvolvedwithveryearlystagesofvisualprocessing.Thismaybeareflectionofhowevolutionhasshapedtheprimitiveareasofourvisualbrainstorecognizeandreactquicklytothreatsfrompossiblepredators(animalschosenforthisstudyhappenedtobeabearandanape,bothevolutionarilyrelevantbasedontheirpotentialdangertous).Researchhasconsistentlydemonstratedthattheoccipitallobebecomesactivatedwhensomethingisseenand,later,imagined.Inthecaseoftheimaginedmemory,theprefrontalareaalsobecomesactivated,reflectingitsroleinprocessingtheinstructions,stayingontask,andaccessingimagination.Howneuralnetworksintheprefrontalcortexknowhowtodothisisasyetunknown(Ungerleider,1995).

Althoughthesestudiesfocusprimarilyoncorticalactivity,psychotherapyofteninvolvestheretrievalofsubcorticalemotionalmemories.Emotionalmemoriesrelyonsubcorticalstructuressuchastheamygdalaandhippocampus:bothcentraltoupcomingdiscussionsofpsychopathologyandtheimpactofchildhoodexperiences,stress,andtraumaonadultfunctioning.

AmygdaloidMemoryNetworks

Nothingfixesathingsointenselyinmemoryasthewishtoforgetit.—MicheldeMontaigne

Theamygdala,thecentralhuboffearprocessing,islocatedwithinthelimbicsystemandbeneaththetemporallobesoneachsideofthebrain.Itisfullydevelopedbytheeighthmonthofgestation,sothatevenbeforebirth,wearecapableofexperiencingintensephysiologicalstatesoffear.Duringthefirstfewyearsoflifewearedependentoncaretakersforexternalmodulationoftheamygdalauntilweareabletoregulateitourselves.Insomewaystheamygdalaisourfirstcortex,playingasignificantroleinthenetworksinvolvedinemotionallearning(Brodal,1992).Portionsoftheamygdala(thebasolateralareas)haveevolvedintandemwiththeexpansionofthecerebralcortexinhumansalongwithourabilitiestoassesstheenvironment(Stephan&Andy,1977).

Theamygdala’sneuralconnectivitysupportsitsparticipationintheintegrationofthedifferentsenseswithinhumans,withaspecialemphasisonvision(vanHoesen,1981).Itfunctionsasanorganofappraisalfordanger,safety,andfamiliarityinapproach-avoidancesituations(Berntsonetal.,2007;Elliott,Agnew,&Deakin,2008;Sarter&Markowitsch,1985).Inassociationwithmedialareasofthefrontalcortex,itconnectsemotionalvaluetotheobjectofthesensesbasedonbothinstinctsandlearninghistory,andtranslatestheseappraisalsintobodilystates(Davis,1992;LeDoux,1986).Itisacentralneuralplayerinassociatingconsciousandunconsciousindicationsofdangerwithpreparationforasurvivalresponse(Ohman,Carlsson,Lundqvist,&Ingvar,2007).Mostimportantforpsychotherapyisthatitplaysa“behindthescreens”roleincreatingemotionalbiasinconsciousprocessingbyspinningourexperienceinwaysthatmakeus,forexample,seetheglassashalfemptyorhalffull(Kukoljaetal.,2008).

Twocircuitsofsensoryinputreachtheamygdalaintheadultbrain.Thefirstcomesdirectlyfromthethalamusandtheotherfirstloopsthroughthecortexandhippocampusbeforereachingtheamygdala(LeDoux,1994).Thefirstsystemservesrapidresponsesduringsurvivaldecisionsbasedonaminimumofinformation.Theslowersecondsystemaddscorticalprocessing(contextandinhibition)toappraiseongoingperceptionsandbehaviors.Theamygdala’sdirectneuralconnectivitywiththehypothalamus,limbic-motorcircuits,andmanybrainstemnucleiallowsittotriggerarapidsurvivalresponse.Theemotionalpowerofphobiasandflashbacksisgreatlyenhancedbytheactivationofintensesomaticarousalprovidedbythisdirectconnectivity.

Thus,theamygdalaisoneofthekeycomponentsofaffectivememory,notjustininfancybutthroughoutlife(Chavez,McGaugh,&Weinberger,2009;Ross,Homan,&Buck,1994).Inafullydevelopedbrain,theamygdalaalsoenhanceshippocampalprocessingofemotionalmemorybystimulatingthereleaseofnorepinephrineandglucocorticoidsviaotherbrainstructures(McGaugh,2004;McGaughetal.,1993).Throughthesechemicalmessages,thehippocampusisalertedtotheimportanceofrememberingwhatisbeingexperienced—akeycomponentofnewlearning.Theactivationofthesympatheticnervoussystemaltersthechemicalenvironmentwithinandbetweenneurons,enhancingLTPandneuralplasticity.Wewillreturntothistopicingreaterdetailinlaterchapters,whenwediscusstheimpactofstressandtraumaonthebrain.

TheAmygdalaandUnusualExperiences

The“uncanny”elementsweknowfromexperienceariseeitherwhenrepressedchildhoodcomplexesarerevivedbysomeimpression,orwhenprimitivebeliefsthathavebeen“surmounted”appeartobeonceagainconfirmed.

—SigmundFreud

Giventheamygdala’searlydevelopmentanditsuniqueroleinlearningandmemory,abnormalitiesofamygdalafunctioningmaybeinvolvedinsomeunusualhumanexperiences.Electricalstimulationoftheamygdalahasbeenshowntoresultinawidevarietyofbodilysensations,feelingsofanxiety,déjàvu,andmemory-likehallucinations(Chapman,Walter,Markham,Rand,&Crandall,1967;Halgren,Walter,Cherlow,&Crandall,1978;Penfield&Perot,1963;Weingarten,Cherlow,&Holmgren,1977).Becauseofitslowseizurethreshold,subtleseizureactivitymaytriggertheamygdalatoactivatenormallyinhibitedsensoryandemotionalmemoriesthatthenbreakthroughintoconsciousawareness(Sarter&Markowitsch,1985).Theseprimitivememoriesmayalsobecometriggeredbysensorycuesofpastfearsandaccountforposttraumaticintrusions(vanderKolk&Greenberg,1987).Individualsunderstressmay

beparticularlyvulnerabletotheintrusionofpowerfulbutconsciousmemories,evenfromveryearlychildhood(Cozolino,1997).

Primaryprocessthinkinganddreamlikeexperiencesaremorelikelytomergewithconsciousawarenessinsituationsofdecreasingcontextualcues,asinnear-sleepstatesorconditionsofsensorydeprivation(Schacter,1976).Decreasingcontextualcueslessentheabilityofthecorticohippocampalsystemstoutilizepastlearningtomakesenseofpresentexperienceandinhibitamygdalainputtoconsciousawareness.Thismayaccountforthesuccessofprojectivetestingintappingintounconsciousprocessing.Inattemptingtomakesenseofambiguoussituations,subcorticalcircuitsaremorelikelytoguideconsciousawareness.

Individualswithtemporallobeepilepsy(TLE)oftenexperienceextremereligiosity,suggestingthatstimulationoftheamygdalacaninfuseeverydayexperiencewithasenseofdeepsignificance.Inotherwords,itsabilitytoinformtherestofthebrainthatweareexperiencingsomethinghighlysignificantcanbeappliedinaninappropriatemannerleadingtooddanddelusionalthinking.Thecentralnucleusoftheamygdalaalsohasahighdensityofopioidreceptors,whicharebiochemicalmechanismsofbondingandattachmentbehavior(Goodman,Snyder,Kuhar,&Young,1980;Herman&Panksepp,1978;Kalin,Shelton,&Lynn,1995;Kalin,Shelton,&Snowdon,1993)thatarealsoimplicatedinalterationsofconsciousness.ThissuggeststhatunregulatedactivationoftheamygdalamaybeaneurobiologicaltriggerforthereligiouspreoccupationsoccurringinsomeindividualswithTLE.Thefactthathypergraphia(writingalot)canalsobeasymptomofTLEhasledmanytospeculatethatsomereligioustextshavebeendrivenbyunusualamygdalaactivationstimulatedbyseizureactivity.

HippocampalMemoryNetworks

Amemoryiswhatisleftwhensomethinghappensanddoesnotcompletelyunhappen.—EdwarddeBono

Thehippocampi,shapedlikeseahorsesoneithersideofthehumanbrain,areessentialstructuresfortheencodingandstorageofexplicitmemoryandlearning(Zola-Morgan&Squire,1990)andplayacentralroleintheorganizationofspatialandtemporalinformation(Edelman,1989;Kalischetal.,2006;O’Keefe&Nadel,1978;Selden,Everitt,Jarrard,&Robbins,1991;Sherry,Jacobs,&Gaulin,1992).Thehippocampusalsoparticipatesinourabilitytocomparedifferentmemoriesandmakeinferencesfrompreviouslearninginnewsituations(Eichenbaum,1992).Ifdamaged,itcanpreventnewlearningfromoccurring,condemningthevictimtoforgettingeverythingafewsecondsafteritisexperienced(Squire,1987).

Thehippocampusisnotedforitslatematuration,withthemyelinationofcortical-hippocampalcircuitscontinuingintoearlyadulthood(Benes,1989;Geuze,Vermetten,&Bramner,2005).Thelatedevelopmentofthehippocampusanditsconnectivitywiththecortexreflectsbothitsdelayedfunctionalavailabilityandprolongedsensitivitytodevelopmentaldisruptionandtraumaticinsult.Itremainsparticularlyvulnerabletohypoxia(lackofoxygen)throughoutlife.Mountainclimbersanddeepseadiverswhomayexperienceperiodsofdecreasedoxygenavailabilityhavebeenshowntohavehippocampaldamageandshort-termmemorydeficits.Gradualatrophyofthehippocampusappearstobeanaturalcomponentofaging,alongwithacorrespondingdecreaseinexplicitmemoryabilities(Gartside,Leitch,McQuade,&Swarbrick,2003;Golombetal.,1993).

Researchsuggeststhatsustainedstressresultsinexcessiveexposureofthehippocampustoglucocorticoids(cortisol),releasedinresponsetoacutestress(Sapolsky,1987).Prolongedhighlevelsof

glucocorticoidscanresultindendriticdegeneration,celldeath,increasedvulnerabilitytofutureneurologicalinsult,andinhibitedhippocampalfunctioning(Kim&Diamond,2002;Watanabe,Gould,&McEwen,1992).Patientssufferingfrompost-traumaticstressdisorder(PTSD)secondarytochildhoodtraumaorcombatexposure,prolongeddepression,temporallobeepilepsy(deLanerolle,Kim,Robbins,&Spencer,1989),andschizophrenia(Falkai&Bogerts,1986;Nelson,Saykin,Flashman,&Riordan,1998)havealsobeenshowntohavehippocampalcellloss.Decreasesinhippocampalvolumehavebeenshowntocorrelatewithdeficitsofencodingshort-termintolong-termmemoryandanincreasedvulnerabilitytopsychologicaltrauma(Bremner,Scott,etal.,1993;Gilbertsonetal.,2002).Giventhatchronicstresscorrelateswithdecreasedhippocampalvolume,andthatsomanypatientsinpsychotherapyhaveexperiencedchronicstress,itislogicaltoassumethatmanypatients(likeSophia)havedifficultyinthosefunctionswhichdependuponthehippocampus.

Amygdaloid-HippocampalInteraction

Thestruggleofmanagainstpoweristhestruggleofmemoryagainstforgetting.—MilanKundera

Therelationshipbetweentheamygdalaandhippocampusisextremelyimportanttohumanexperienceandcontributessignificantlytotop-downandleft-rightintegration.Theparticipationoftheamygdalaisbiasedtowardbothrightanddownsystems,whereasthehippocampusplaysalargeroleinleftandtopprocessing.Putanotherway,theamygdalahasacentralroleintheemotionalandsomaticorganizationofexperience,whereasthehippocampusisvitalforconscious,logical,andcooperativesocialfunctioning(Tsooryetal.,2008).Theirrelationshipwillimpactaffectregulation,realitytesting,restingstatesofarousalandanxiety,andourabilitytolearnemotionalandmoreneutralinformation.Thelevelandqualityofthefunctionalconnectivityoftheamygdalaandhippocampuswillbeimpactedbytemperament,lifestress,andepigeneticfactors(Canlietal.,2006).

DouglasandPribram(1966)suggestedthattheamygdalaandhippocampusplayoppositerolesinanattention-directingprocess.Byaccentuatingsmalldifferencesamonginputs,theamygdalaheightensawarenessofspecificaspectsoftheenvironment(attention)whereasthehippocampusinhibitsresponses,attention,andstimulusinput(habituation)(Douglas,1967;Kimble,1968;Marr,1971).Theamygdalaisinvolvedwithgeneralization,whilethehippocampusisinvolvedwithdiscrimination(Sherry&Schacter,1987).Inotherwords,theamygdalawillmakeusjumpatthesightofaspider,whilethehippocampuswillhelpustorememberthatthisparticularspiderisnotpoisonous,soweshouldn’tworry.Theirproperbalancewillalsoallowustostayclosetoothersevenwhentheycauseusupset.

Wecanimmediatelyseetherelevanceofthesetwosystemstopsychotherapy.Theamygdaloidmemorysystem,organizingearlyshameexperience,makesthepatientwithborderlinepersonalitydisorderreacttotheperceptionofabandonmentwhenlittleornoneexistsinreality.Therapywiththispatientwouldutilizethehippocampal-corticalsystemstotesttherealityoftheseamygdala-triggeredcuesforabandonmentinordertoinhibitinappropriatereactions.Thisrealitytestinghelpsustodistinguishrealabandonmentfrominnocenttriggerssuchassomeoneshowingupafewminuteslateforanappointmentandinhibitinappropriateemotionalreactions.Remember,forayoungprimate,abandonmentmeansdeath.Thecatastrophicreactionofborderlinepatientstoabandonmentisaresultofthefactthat,tothem,itisexperiencedaslifethreatening.

Flashbacks,memoriesfromtraumaticexperiences,likelyresideinamygdaloid-drivenmemorynetworks.PTSDvictimsdescribeflashbacksaspowerfulandmultisensory,oftentriggeredbystress,and

experiencedasiftheywereoccurringinthepresent(Gloor,1978;LeDoux,Romanski,&Xagoraris,1989;vanderKolk&Greenberg,1987).Theseflashbacksalsohavethecharacteristicofbeingstereotypedandrepetitive(vanderKolk,Blitz,Burr,Sherry,&Hartmann,1984),suggestingthattheyarenotsubjecttotheassimilatingandcontextualizingpropertiesofthecortexandhippocampus.Amodelofdualmemoryprocessing,parallelingtheamygdala/hippocampaldistinctionmadehere,hasbeenpreviouslyproposedasunderlyingmechanismsinbothPTSD(Brewin,Dalgleish,&Joseph,1996)andthereemergenceofpastfearsandphobias(Jacobs&Nadel,1985).

Giventhereciprocalnatureofamygdaloidandhippocampalcircuits,impairmentofthehippocampusshouldleadtoanincreasedinfluenceoftheamygdalaindirectingmemory,emotion,andbehavior.Thisimbalancetowardtheamygdalawouldalsodisruptaffectregulation.Depressedpatientsareoverwhelmedbytheirnegativefeelingsandunabletoengageinadequaterealitytesting.Indeed,Shelineandhercolleaguesnotedbothdecreasedhippocampalandamygdaloidvolumeindepressedpatients(Sheline,Wang,Gado,Csernansky,&Vannier,1996;Sheline,Gado,&Price,1998).Dysregulationofhippocampal-amygdaloidcircuitsarelikelyinvolvedindepressivesymptomatologyanddisturbedrealitytesting(Pittenger&Duman,2008).Researchwithratshasfoundthatincreasedlevelsofserotoninleadstoenhancedneurogenesisinthehippocampus(Jacobsetal.,2000).ThissuggeststhatProzacandPaxilmaybeeffectiveintreatingdepressionbecausetheyboosthippocampalvolumeanditsabilitytomoderateamygdalaactivation.

TheIntrusionofEarlyImplicitMemoryIntoAdultConsciousness

Allourknowledgehasitsoriginsinourperceptions.—LeonardodaVinci

Earlymemoriesstoredincircuitsoftheamygdalaandrighthemispherecanintrudeintoadultconsciousnessinavarietyofways.Theybecomeespeciallyrelevanttopsychotherapywhentheyaretheresultoftraumaandimpactourabilitytoloveandwork.Childrenwhosufferearlyabusemayentertheirschool-ageyearsagitated,aggressive,anddestructive.Theymayengageinfights,propertydamage,settingfires,orhurtinganimals,resultingincriticism,punishment,andsocialexclusion.Althoughthesebehaviorsareexpressionsoftheirmemoriesofabuse,othersreactwithcriticismandretaliation.Thisfeedback,incombinationwiththeemotionaldamagesfromtheirabuse,evolvesintoanever-deepeningnegativeself-image.

Intheabsenceofanexplicitmemoryoftheirearlytrauma,thesechildren’sbehaviorisnotexperiencedbythemasareactiontoanegativepastevent,butasanaffirmationoftheirinnerfeelingsofessentialbadness.Becausetheseexperiencesdatebacktotheformationofpreverbalsensory,motor,andaffectivememorysystems,victimsoftenreportfeeling“eviltothecore.”Thisiscommoninchildrenwhogrowupincultsorwithhighlyauthoritarianorabusiveparents.Thekidsofsoldiers,policeofficers,andministersappeartobeatparticularriskfortheinternalizationofanegativeself-image.Childrenofparentswithobsessive-compulsivedisordercanalsofindtheyholdanextremelynegativeviewofthemselves.WhileapersonwithOCDneedsorder,cleanliness,andcontrol,anewbornbringsjusttheoppositeintotheirlife.Thechild’searlyimplicitmemoriesarelikelytobecenteredaroundbeingasourceofannoyance,anxiety,anddisgusttotheirparents.

Theformationofattachmentschema(akeyformofimplicitmemory)guidesandshapesrelationshipsthroughoutlife.Giventhatsomanyclientscometotherapywithrelationshipdifficulties,thisimplicitmemorysystemmaybeoneofthemostimportanttoexploreinpsychotherapy.Thesesame

networksofsocialmemorygiverisetothephenomenonoftransference,aprocessthatbringstheseearlyunconsciousmemoriesintotheconsultingroomastheyareplayedoutbetweenclientandtherapist.Enactmentsinpsychotherapy,involvingtheinterplaybetweenunconsciouselementswithinthepatientandthetherapist,alsoactivatetheseimplicitmemories.

Wehaveallexperiencedhavingourbuttonspushedbysomeone;manyofthese“buttons”aretheemotionaltracesofpersonalexperiences,storedinimplicitsystemsofmemory.Overreactingtosomethingimpliesthatthedifferencebetweenanappropriatereactionandhowweactuallyreactisattributabletoasensitivitybasedonourlearninghistory.Themostcommondistortionsbasedontheinputofearlymemoryareinthedirectionofshame,aprimarysocializingaffectstartingatabout12months(Schore,1994).Individualswhoare“shamebased”(Bradshaw,1990)canfindcriticism,rejection,andabandonmentinnearlyeveryinteraction,resultinginalifeofchronicanxiety,astruggleforperfection,exhaustion,anddepression.

Silenceisanambiguousstimulusthatactivatessystemsofimplicitmemory.Silencemaybegolden,butintherapyitevokesavarietyofimplicitmemories.Thereactionofclientstothesilenceteachesussomethingoftheiremotionalhistory.Duringperiodsofsilence,manyclientsassumethatthetherapististhinkingcriticalthoughts.Theyimaginethetherapistthinkstheyareboring,stupid,awasteoftime,orabadclient.Thesefeelingsusuallymirrorthosebasedinproblematicrelationshipswithoneorbothparents.Furthermore,thesefeelingsaredeepseatedandtenacious,oftentakingmanyyearstomakeconscious,examine,andmodify.Ontheotherhand,someclientsfindsilencetobeaformofacceptanceandarelieffromthepressuresofbeingarticulateandcommunicative.Thesestarkdifferencesinclientreactionstothesimilarsituationsareconvincingevidenceoftheworkingsofimplicitmemoryandtheireffectsonconsciousexperience.

Asimilarphenomenonoccursinindividualswhobecomeuncomfortablewhentheytrytorelaxwithoutanydistractions.Theemotions,images,andthoughtsthatemergeinconditionsoflowstimulation(ortheabsenceofdistraction)mayholdcluestotheworkingsofourbrainsandtheaftereffectsofearlylearning.Defensestoescapenegativefeelingscometorequireconstantactionanddistractiontokeepusfrombecomingfrightenedoroverwhelmed.

TheMalleabilityofMemory

Theonlyparadiseisparadiselost.—MarcelProust

Thefalsememorydebateofyearspasthighlightedmanyshortcomingsintheknowledgeoftherapistswhenitcametounderstandingtheworkingsofmemory.Highlypublicizedlegalcasesofrepressedmemoryandcliniciancontributiontotheco-constructionoffalsememorieshaveresultedinincreasedunderstandingandtrainingfocusedontheprocessesofmemory.Mosttherapistsarenowawareofthevulnerabilityofconsciousmemorytosuggestion,distortion,andfabricationfrombothclientandtherapist(Loftus,1988;Paz-Alonso&Goodman,2008).

Researchhasdemonstratedthatmemorycanbeimplantedinexperimentalsituationswherethesubjectsoonbecomescertainthatthefalsememorieshaveactuallyoccurred(Ceci&Bruch,1993;Loftus,Milo,&Paddock,1995).Atherapist’sbeliefthatherclienthasbeenabusedmayinfluencethatpatienttounconsciouslyfabricateamemorythattheyboththencometobelieveistrue.Thisprocessisacleardemonstrationofboththemalleabilityofmemoryandthepowerofco-constructednarrativeinshapingexperience(Alberini,2005;Anderson,Wais,&Gabrieli,2006;Dudai,2006;Nielson,Yee,&Erickson,

2005).Giventhatmemoryisencodedamongneuronsandwithinneuralnetworks,themalleabilityof

memoryisanobservablemanifestationoftheplasticityoftheseneuralsystems.Thismalleabilityiscertainlyastumblingblocktoourjusticesystem,whichreliessoheavilyoneyewitnesstestimony.ThehundredsofconvictionsthathavebeenoverthrownbynewDNAmethodsattesttotheinadequacyofourpresentstandardsofeye-witnessevidence.Butfromtheperspectiveofpsychotherapy,thisplasticityprovidesanavenuetothealterationofdestructivememories.Revisitingandevaluatingchildhoodexperiencesfromanadultperspectiveoftenleadstorewritinghistoryinacreativeandpositiveway.Theintroductionofnewinformationorscenariostopastexperiencescanalterthenatureofmemoriesandmodifyaffectivereactions.

TheMagicTricycle

Thegreatestweaponagainststressisourabilitytochooseonethoughtoveranother.—WilliamJames

Sheldonwasamaninhislate60swhocametotherapyforhelpwithhismanyanxietiesandfears.Asachild,hisparentshadhiddenhimfromtheNazisinastorageroombehindthehomeoffamilyfriends.Oneday,afterfindingoutthatsheandSheldon’sfatherwouldsoonbetakentotheconcentrationcamps,Sheldon’smothertoldhimtobeagoodboy,saidgoodbye,andleft.Whilethefamilyfriendswerekindtohim,hespenthisdaysalonewithfewtoys,hissmalltricycle,andsomescrapsoffood.Describingthesedays,Sheldonrecalledalternatingstatesofterrorandboredom,duringwhichhewouldeithersitandrockorridehistricyclearoundinslowtightcircles.Theslightestnoisewouldstartlehimandhefearedthateachpassingsirenmightbethepolicecomingforhim.Eachday,exhaustedbyfear,hewouldeventuallyfallasleep.

Theinterveningdecadeshadnotdiminishedtheimpactofhisexperiencesduringthewar;60yearslater,hestillfoundhimselfreflexivelyrockingorwalkinginsmallslowcircleswhenhebecamefrightened.Hislifefeltlikeonelong,fear-filledday.Inrepeatedlyrecallingtheseexperiencesintreatment,hesometimesmentionedhowhewishedhecouldhaveleftthehousewherehewashiddenandtraveleddownthenarrowstreetstohisgrandmother’shouse.Sheldonrememberedlongafternoonshespenttherebeforethewar,listeningtostoriesofherchildhoodonherfather’sfarm.Hisgrandmotherandhisparentsperishedinthewar,andheneversawthemagain.

Oneday,Iaskedhimforpermissiontochangehismemoriesjustabit.Afterafewquizzicallooksheagreedtoclosehiseyesandtellmetheentirestoryagain,atwhichpointIwouldinterrupthimandmakesomesuggestions.Ashecametothepartofthestorywhereherodearoundincircles,Iaskedhim,“Whatwouldyoudoifthiswasamagictricycleanditcouldtakeyouthroughwallswithoutgettinghurt?”IfeltSheldonhadsufficientegostrengthtoallowhimtosimultaneouslyengageintherole-playwhilestayingfullyintouchwithpresentreality.

Aftersomehesitation,Sheldonsaid,“Iwouldriderightthroughthehouseandoutontothesidewalk.”

“Fine,”Isaid.“Let’sgo!”Sheldonhadbeenprimedforourimaginarytherapyplaybecausehehadspentmanyenjoyablehoursofstorytelling,cuddling,andlaughingwithhisgrandchildren.Ifeltthatanimaginativetasklikethiswasnotonlyaccessibletohimbutwouldalsoservethepurposeofbridgingthepositiveaffectfromhisgrandchildrentohislonelyandfrightenedexperiencesasachild.Imagininghewasmakingupthestoryforhisgrandchildrenmightalsohelphimcopewiththeembarrassmentofdoing

thiswithanotheradult.Aftersomemildhesitation,hepedaledthroughthehouse.Ashegotclosetothedoor,however,he

said,“They’llseemeandkillme.”“Whatifthemagictricyclehasthepowertomakeyouinvisible?”Iasked.“Ithinkthat’lldo,”saidSheldon,andhepedaledthroughthefrontofthehouseandoutontothe

sidewalk.Oncehegotoutofthehouse,heknewwhattodo.Hedescribedthestreettomeashepedaledtowardhisgrandmother’shouse.Thestorekeepers,theneighbors,thepark,hisrabbi,evensomeofhisyoungfriendswereallaliveinhismemories.Sureenough,whenhefinallygottohisgrandmother’shouseshewashomeand,asalways,happytoseehim.Hetoldhisgrandmotherabouthisinvisibletricycleandhowscaredhewasinhishidingplace.Hewentontotellheroftheendofthewar,histravels,andraisinghisfamily.Finally,almostlikeaprayer,Sheldontoldherhow,manyyearsfromnow,shewouldhavethemostbeautifulgreat-great-grandchildrenlivinginfreedom,redeeminghersuffering.

Overthenextfewmonths,wheneverSheldonexperiencedhischildhoodfearsandanxieties,wewouldrevisithisstoryandmodifydifferentdetails.Thesechangesseemedtogrowmoredetailedandmorevividinhismind.Hisimaginationgavehimthepowertomastermanyofhispastfears.Becausememoryismodifiedeachtimeitisremembered,Sheldon’sbrainwasabletograduallycontaminatehispainfulchildhoodwithhispresentsafetyandjoy(Bruner,1990).Heevenbegantotellhisgrandchildrenstoriesaboutalittleboywithamagictricyclewhoaccomplishedgreatthingswithhiscourageandwit.Sheldonwasaveryspecialmanwhowasabletotakeadvantageofthemalleabilityofmemorytomakehisinnerworldasaferplace.Nothinghadchangedabouthischildhoodexceptthatnow,whenherememberedhishidingplace,healsorememberedhismagictricycle.

AnimportantpartofrestructuringmemoryissomethingFreudcalledNachtraglichkeit,whichmeanstheabilitytoreconceptualizeamemorybasedonevolvingmaturity.Thisprocessrequiresbeingabletoholdthememoryinmindwithoutbeingemotionallyoverwhelmedandsimultaneouslybringingitintothepresent,picturingitasitwouldlookfromtheperspectiveofwhoweareandwhatweknowtoday.BothFreud’sideaandSheldon’sexperienceshighlightthefactthatmemoryisanevolvingprocessthatissubjecttopositiveinfluence.

Theconstructionandreconstructionofautobiographicalnarrativesrequiresthatthesemanticprocessingofthelefthemisphereintegratewiththeemotionalnetworksintheright.Storytellingalsoinvokesparticipationofthebodyaswegestureandactouttheeventswearedescribing.Assuch,narrativesareavaluabletoolintheorganizationandintegrationofneuralnetworkspronetodissociation.Becausewecanwriteandrewriteourownstories,newonesholdthepotentialfornovelwaysofexperiencing.Ineditingournarratives,wechangetheorganizationandnatureofourmemoriesand,hence,reorganizeourbrains.Thisisacentralendeavorinmanyformsofpsychotherapy.

Summary

Asaboyintheearly1960s,IrememberbeingfascinatedbynewsstoriesofJapanesesoldiersattackingtouristsontinyislandsintheSouthPacific.DuringWorldWarII,theJapanesenavyleftsoldiersonmanyislandsthroughoutthePacificbutneverretrievedthemattheendofthewar.Decadeslater,pleasurecraftswouldinnocentlylandontheseislandsonlytobeattackedbysoldierswhothoughtthewarwasstillbeingfought.TheyhaddutifullykeptgunsoiledandremainedvigilantfordecadesinanticipationofanAmericanattack.Iwasawedbytheirloyaltyandsaddenedbythethoughtoftheyearstheyspentfightingawarthatnolongerexisted.

Likethesesoldiers,earlyamygdala-basedmemorysystemsretainstruggles,stress,andtraumafromatimebeforeconsciousmemory.Wemaygrowandmoveontonewlives,yetourimplicitmemory

systemsretainoldfears.Whileremainingvigilantforsignsofattackforearlyattachmentpain,approachingintimacycansetoffallofthedangersignals.Therapistsaretrainedtobeamygdalawhispererswholandonthesebeaches,attemptingtoconvincetheloyalsoldierswithinimplicitsystemsofmemorythatthewarisover.

Chapter6

Laterality:OneBrainorTwo?

Thoughthebrainisenclosedinasingleskull,itisactuallymadeoftwoseparatelumps…whicharedesignedtodisagreewitheachother.

—JonahLehrer

Wenowswitchourfocusfromthemultipleanddiversesystemsofmemorytoanotherrealmofneuralcomplexity—corticallaterality.Asyouknow,thehumancerebralcortexisdividedintorightandlefthemispheres,eachcontrollingtheoppositesideofthebody.Thetermlateralityreferstothespecializationofcertaintaskstoonesideofthebrainortheother,andisreflectedinhowthehemispheresdifferintheirorganization,processingstrategies,andneuralconnectivity.Keepinmindalsothatlateralityshowsvariabilityamongindividuals,andleft-andright-handedpeople,aswellasmalesandfemales.

Althoughmostneuralprocessingrequiresthecontributionofbothhemispheres,therearesituationswhenthehemispheresnotonlythinkdifferentlybutalsocompetewithoneanother.Thisstrugglefordominanceandcontrolmaybeonecauseofourpsychologicalstruggles,givingnewmeaningtowhywesometimesfeel“besideourselves”or“oftwominds.”Bytheendofthischapter,youmaybeleftwonderingwhetherweinfacthaveonebrainortwo.

JohnHughlingsJackson,theeminent19th-centuryneurologist,believedthattheleftsideofthebrainwas,formostpeople,the“leading”side.ThisseemedlogicalgivenBroca’sfindingthatthelefthemispherewasresponsibleforourabilitytousesemanticlanguage.Jacksonlatersuggestedthattherighthemispherewastheleadingsideofthebraininvisual-spatialabilities.

Overtheyears,ithasbecomeclearthatdividingthebrainintotwodiscretehalvesisnotthebestapproach.Giventhatmostneuralsystemsintegratecircuitryfromtheleftandrightsidesofthebrain,researchattemptingtolocalizefunctionsinonehemisphereortheotheroftenresultsin“untidy”findings(Christman,1994).Whenwespeakoffunctionsoftherightorleftbrain,wearemoreaccuratelyreferringtofunctionsthatareeitherrepresentedmorefullyorperformedmoreefficientlyinonehemispherethantheother.Overthepast40years,muchhasbeenwrittenabouttheartisticrightbrainandthelogicalleft.Althoughthisviewmaybeappealingtotheimagination,itisfartoosimplistic.Assigningspecificfunctionstoparticularareasofthebrainneedstobedonewithbothcautionandtherecognitionthatourknowledgeisstillevolving.

EvolutionandDevelopment

Ascientifictruthdoesnottriumphbyconvincingitsopponentsandmakingthemseethe

light,butratherbecauseitsopponentseventuallydieandanewgenerationgrowsupthatisfamiliarwithit.

—MaxPlanck

Lateralspecializationisanevolutionarychoice,anddoesnotexistinallanimals.Manybirdsandfish,forexample,haveidenticalhemispheres.Theseanimalsareabletosleeponehemisphereatatime,allowingthemtokeepswimmingorflyingtoavoidpredators,continuefeeding,orrestduringlongmigrations.Althoughredundanthemispheresprovidecertainbenefits,suchasabackupsystemincaseofinjury,hemisphericspecializationvianaturalselectionpromotesneuralcomplexity.Throughhumanevolution,therightandleftcerebralhemisphereshavebecomeincreasinglydissimilar(Geschwind&Galaburda,1985).Lateraldominanceappearstohavebeendelegateddependingonthefunctionaldomaininquestion(Cutting,1992;Goldberg&Costa,1981;Semmes,1968).Forexample,areasoftheleftandrightcorticeshavebecomespecializedintheorganizationoftheconsciouslinguisticselfintheleftandthephysicalemotionalselfintheright.

Duringthefirst2yearsoflife,therighthemispherehasagrowthspurtthatparallelstherapiddevelopmentofsensorimotor,emotional,andrelationalcapabilities(Casey,Galvan,etal.,2005;Chironetal.,1997;Thatcher,Walker,&Giudice,1987).Thechildlearnshand–eyecoordination,crawling,andwalkingwhilebecomingattachedtocaretakers.Anorganizedsenseofthebodyinspaceandtheembodiedselfforminsubcorticalandcorticalnetworksinvolvingthethalamus,cerebellum,andparietalcortex.Atthesametime,middleportionsoftheprefrontalcortexarematuringandintegratingwithsubcorticalstructurestoestablishthebasicstructuresofemotionalregulationandattachment.Duringthisperiod,thedevelopmentofthelefthemisphereisslowedabitandreservedforlater-developingfunctions(Gould,1977).

Inthemiddleofthesecondyear,agrowthspurtoccursinthelefthemisphereandanexplosioninlanguageandlocomotionlauncheschildrenintothebroaderphysicalandsocialworlds.Inthefrontallobes,thereisashiftofdevelopmenttothedorsolateralareas,linkingbacktoothercorticalregions,thatsculptsthelanguagenetwork(Tucker,1992)whileconnectingthemovementsofhandsandeyestovisualstimuliandwords.Thecorpuscallosumbeginstodevelopattheendofthefirstyear,issignificantlydevelopedbyage4,andcontinuestomaturepasttheageof10.Becauseofthisslowmaturation,thetwohemispheresatfirstfunctionrelativelyautonomously,graduallygaininginterconnectionandcoordinationthroughchildhood(Galin,Johnstone,Nakell,&Herron,1979).

Agreatdealofwhatisknownaboutthefunctionsofthedifferenthemisphereshasbeentheresultofthesplit-brainresearchofSperryandhiscolleagues(Sperry,Gazzaniga,&Bogen,1969).Split-brainpatientsareindividualssufferingfrommedication-resistantepilepsy,whohavetheircorpuscallosumsurgicallyseveredtolimitseizurestoonesideofthebrain.Presentinginformationseparatelytoeachoftheirhemisphereshasrevealeddivisionsofawarenessandspecializationinarangeofcognitiveandemotionaltasks,therebyexpandingourknowledgeofcorticallaterality(LeDoux,Wilson,&Gazzaniga,1977;Rossetal.,1994;Sperry,1968).

LateralAsymmetry

Allorgansofananimalformasinglesystem…andnomodificationcanappearinonepartwithoutbringingaboutcorrespondingmodificationsinalltherest.

—GeorgeCuvier

Theearliestformoflanguagewasmostlikelyhandgestures,whichmayexplainwhyhandednessandlanguagefunctionsaresocloselylinkedinthebrain.Mostofusareright-handed(controlledbytheleftbrain)andhavesemanticlanguagelateralizedinthelefthemisphere.Neuralnetworksforbothspokenandsignlanguagearelocatedinthelefthemisphereformostadults,anddamagetothelefthemisphereusuallyresultsinlanguagedisturbancessuchasaphasia(Corina,Vaid,&Bellugi,1992).Inleft-handedorambidextrousindividuals,lateralizationoflanguageissomewhatlessclear.Asthesemanticfunctionsofthecortexexpandedduringevolutionandlanguagebecamemoredescriptiveanduseful,wordsgraduallyreplacedgesturesinimportance.Ourpresentuseofhandgesturestoaugmentspokenlanguagemaybetraythisevolutionarypath.Ourtendencytousehandgesturesevenwhentalkingonthetelephonesuggeststhattheynotonlyplayaroleincommunicationbutalsoinorganizingandsupportingourthinking.

Thelefthemisphereappearstobemoreinvolvedinconsciouscopingandproblemsolvingthantheright.Thisismostlikelyafunctionofitslanguageskillsandprosocialorientation.Thelefthemispherefunctionsbestwithinthemiddlerangeofaffectandisbiasedtowardpositiveemotionsandapproachbehaviors(Silberman&Weingartner,1986).Strongaffect,especiallyanxietyandterror,resultinhighlevelsofrighthemisphereactivationandappearstoinhibitthelefthemisphereandlanguage—hence,theexperienceofstagefrightandspeechlessterror.

IthasbeensuggestedthatWernicke’sareainthelefttemporallobe,knowntobecentrallyinvolvedinlanguagecomprehension,actsasaprobabilitycalculatorforotherformsofbehavioraswellaslanguage(Bischoff-Grethe,Proper,Mao,Daniels,&Berns,2000).Giventherapiditywithwhichweprocessspeech,Wernicke’sareamayprocesswhatisheardbasedasmuchonwhatitexpectstohearaswhatisactuallysaid.Thiswouldcertainlyhelptoexplainwhyhumancommunicationcanbesoproblematicandmisunderstandingssocommon.Broca’sareamayhavesimilarpredictivefunctions,whichallowustospeakfasterthanwethinkandeven,attimes,besurprisedbywhatwehearourselvessaying(Nishitanietal.,2004).Infact,WilliamJames,oneofthefathersofAmericanpsychology,saidthatheneededtohearhimselftalktoknowwhatwasonhismind.

Formostindividuals,therighthemisphereprocessesinformationinaholisticfashionandisdenselyconnectedtothelimbicsystemsandtheviscera(Nebes,1971).Thelefthemisphere,ontheotherhand,processesinformationinalinear,sequentialmannerandhaslessconnectionwiththebody.Therighthemisphereisheavilywiredtothelimbicsystemandismoredirectlyinvolvedintheregulationoftheendocrineandautonomicnervoussystemsthantheleft(Wittling&Pfluger,1990).Italsocontainscenterswithintheparietallobesthatmightcontainarepresentationoftheentirebody.

Therighthemisphereisgenerallyresponsibleforbothappraisingthesafetyanddangerofothersandorganizingasenseofthecorporealandemotionalself(Devinsky,2000).Appraisalsimplymeansattachingapositiveornegativeassociationtoastimulus,whileemotionistheconsciousmanifestationofthisappraisalprocess(Fischer,Shaver,&Carnochan,1990;Fox,1991).Thevastmajorityofappraisaloccursatanunconsciouslevel.Thisiswhytherighthemisphereismoreoftenassociatedwiththeunconsciousmind,thatis,whatguidesourthoughtsandbehavioroutsideofourawareness.

Thebiasagainstleft-handednessacrossmanyculturesmayreflectanintuitiveunderstandingofthelefthand’s(rightbrain’s)relationshiptothedark,primitiveaspectsofournature.Thesebiaseslikelydatebackintoprehistory,whenthelefthemispheremayhaveexertedlessinhibitorycontrolovertheright.ThinkabouttheFrenchwordgaucheandtheItaliansinestreforleftandalltheirtastelessandevilconnotations.Byofferingtherighthandingreeting,earlyhumansmayhavebeenmorelikelytobehaveinacivilizedmanner,andlesslikelytoactoutselfishorviolentimpulses.AnexaminationofcavedrawingsinSouthernEuropesuggeststhatthebiastowardright-handednesshasexistedforatleastthelast5,000years(Coren&Porac,1977).

Althoughthelefthemispheregenerallyproducessemanticlanguage,itisunclearwhetherithasanyadvantageinlanguagecomprehension.Therighthemispheremay,infact,bebetteratcomprehendingthe

emotionalaspectsoflanguagesuchasthetoneofvoiceortheattitudewithwhichwordsaresaid(Searleman,1977).Emotionsingeneral,theabilitytoevaluateemotionalfacialexpressions,andvisual-spatialandmusicalabilitiesareprimarilyright-hemisphereprocesses(Ahernetal.,1991).Damagetotherighthemisphereresultsnotonlyinanimpairmentofourabilitytoassessfacialgestures,butalsotocomprehendothernonverbalaspectsofcommunicationsuchashandgesturesandtoneofvoice(Blonder,Bowers,&Heilman,1991).

LateralityandEmotion

Whenangry,counttofour;whenveryangry,swear.—MarkTwain

Evidencesuggestiveofarelationshipbetweenlateralityandemotionalitywasfirstobservedincasesofdamagetotheprefrontalcortex.Patientswithdamagetothelefthemisphereappearedtobefarmorelikelytohaveadepressivereactionthanthosewithdamagetotheright(Gainotti,1972;Goldstein,1939;Sackheimetal.,1982).Itwaslaterfoundthattheclosertheselesionsweretotheprefrontalregions,themoreseverethesymptomsofdepression(Robinsonetal.,1984).Rightbrain-damagedpatientswerealsofoundtodescribeexperienceswithlessemotionalintensitythanleftbrain-damagedpatientsornormalcontrols(Borodetal.,1998).

Imagingstudieshaveshownthatpeoplewithoutbraindamagewhosufferfromdepressionhavelowerlevelsofglucosemetabolismandcerebralbloodflowintheleftprefrontalcortex(Galynkeretal.,1998;Kalia,2005;Mathewetal.,1980).Inaddition,peopleexperiencingmaniaintheabsenceofbraindamagedemonstratedecreasedrightprefrontalactivity(Al-Mousawietal.,1996).Thesestudiesexpandtheassociationbetweenlateralityandemotiontothegeneralpopulation.AnexaminationofTable6.1revealsthatthelefthemisphereisbiasedtowardpositiveaffect,safety,andpositivesocialapproach,aswellasangerandaggressiondirectedtowardothers.Overall,theleftsideofthebrainappearstobeinchargeofthesuccessfulnavigationofthesocialworld.

TABLE6.1LateralityandEmotion

Increasedlefthemisphereactivationoccursinresponseto:

Happystimuli1

Positivepictures2

Positiveaffectinresponsetopositivefilms3

Approach-relateddispositionaltendencies4

Morepositivedisposition5

Smilingandfacialexpressionsofenjoyment6

Reportedwell-being7

Infantsmilinginresponsetomotherapproach8

Traitanger9

Stateanger10

Stateaggression11

Increasedrighthemisphereactivationoccursinresponseto:

Facialexpressionsofdisgust12

Tastesassociatedwithdisgust13

Negativepictures14

Avoidancebehavior15

Negativeaffectinresponsetonegativefilms16

Threat-relatedvigilance17

Strangerapproach18

Maternalseparation19

Theintimateassociationbetweenemotionandcognitionhasbeendemonstratedinmanylateralitystudies.Forexample,sadfacesareratedasrelativelysadderwhenpresentedtotheleftvisualfieldcomparedtotheright(Sackheimetal.,1988).Negativestimuliareconsciouslyperceivedmostoftenwhenpresentedtotherighthemisphere(Smith&Bulman-Fleming,2004).Researchhasshownthatanesthesiaofthelefthemisphereresultsingreaterexpressionsofnegativeemotionsandlessprosocialexplanationsofexperience(Dimond&Farrington,1977;Rossetal.,1994).Orientingeyegazetotheleft(stimulatingtherighthemisphere)resultsindecreasedoptimism,whiletheoppositeistruewithrightwardeyegaze(Drake,1984;Thayer&Cohen,1985).Righthemisphere-biasedneuralprocessingcorrelateswithlowself-esteem(Persinger&Makarec,1991).

Higherlevelsofleftprefrontalactivationhavebeenassociatedwitharesilientaffectivestyle,fasterrecoveryfollowingnegativeevents,andlowerlevelsofthestresshormonecortisol(Davidson,2004;Jacksonetal.,2003;Kalin,Larson,Shelton,&Davidson,1998).Whilethereappearstobeanoverallbiasofpositiveleft/negativeright,thepictureismorecomplicated.Thehemispheresarealsolateralizedforsocial/privateandapproach/avoidance(left/right)behavior.Thesepatternsofleft/rightactivationsuggestthathealthandhappinessmaybeassociatedwithgenerallateralbalanceaswellastheabilitytobeaggressiveandexpressangerbiasedtowardtheleftandgriefandshamebiasedtowardtheright.

TheIntegrationoftheBodyintheRightHemisphere

Thebodyneverlies.—MarthaGraham

Theparietallobes,locatedaboveourearstowardthetopofourheads,areatthecrossroadsofneuralnetworksresponsibleforvision,hearing,andsensation.Theyserveasahigh-levelassociationareaforthecoordinationandintegrationofthesefunctions.Theanterior(front)portionoftheparietallobes

organizestactileperception,whiletheposterior(back)portioninterconnectsthesensestoorganizesensory-motorwithconceptualevents(Joseph,1996).Accordingly,cellsintheparietallobesrespondtohandposition,eyemovement,words,motivationalrelevance,bodyposition,andotherfactorsrelevanttotheintegrationofexperience.

Thepurposeoftheassociationofallofthesehigh-orderprocessingnetworksistoprovideacoordinatedandintegratedawarenessofone’sownbodyanditsrelationtotheexternalenvironment(Ropper&Brown,2005).Thismakessenseinthattheparietallobesevolvedfromthehippocampus,which,inlowermammals,servesasacognitivemapforexternalspace(O’Keefe&Nadel,1978).Partofthejoboftheparietallobesistoorganizeanintegrativemapofourbodiesinspace,whichisavailableforconsciousreflection.Thus,damagetotheparietallobes,especiallyontherightside,resultsinavarietyofdisruptionsinourexperienceoftheselfandtheworldaroundus.

Althoughthelefthemisphereseemstocontainanetworktomonitorattentionontherightsideofthebody,therighthemisphereofright-handershasaspecializedabilitytodirectattentionbilaterallytoboththerightandleftsidesof“extrapersonalspace”(Mesulam,1981).Hemi-neglect,orthedenialoftheexistenceoftheleftsideofthebody,canresultfromlesionstotherightparietallobe.Whenneglectissevere,thepatientbehavesasifthelefthalfoftheworldhasceasedtoexist.Patientswithhemi-neglectwilldressandputmakeuponlyontherightsideoftheirbodieswhiledenyingownershipoftheirleftarmorleg.Askedtodrawthefaceofaclock,theymayputall12numbersontherightsideorsimplystopat6o’clock.

Thephenomenonofhemi-neglecthasalsobeenshowntoexistinimaginaryspace.BisiachandLuzzatti(1978)examinedtwopatientswithrightparietalinjuriesandleft-sidedneglectwhowereaskedtodescribethePiazzadelDuomoinMilan.Thepiazzawasveryfamiliartobothpatients.Butwhenaskedtoimaginethepiazzafromoneend,theycouldrecallanddescribethedetailsontheirimaginedrightsideandnottheirleft.Later,theywereaskedtoreimaginethepiazzafromtheotherend.Lookingbacktowheretheypreviouslypicturedthemselvessitting,theywerenowabletoaccuratelydescribewhatwasontherightsidebutnotontheleft.Inotherwords,oncetheyimaginedturningaround180degrees,theynowhadaccesstomemoriesthattheywereunabletorememberjustashortwhileearlier.Further,theinformationtheyprovidedpreviouslywasnolongeraccessible.Thisremarkabledemonstrationsuggestsneuralnetworksthatorganizeandattendtothebodyinspacearealsoutilizedinimagination.

Inlaterresearch,Bisiachandhiscolleagues(Bisiach,Rusconi,&Vallar,1991;Cappa,Sterzi,Vallar,&Bisiach,1987;Vallar,Sterzi,Bottini,Cappa,&Rusconi,1990)foundthatvestibularstimulationviacoldwaterirrigationoftheleftear(thecalorictest)inpatientswithrightparietallobelesionsresultedintemporaryremissionoftheirlefthemi-neglect.Puttingcoldwaterintotheleftinnerearstimulatedareaswithintherighttemporallobeandcausedthepatientstoorienttowardtheleft(Friberg,Olsen,Roland,Paulsen,&Lassen,1985).Althoughthemechanismofactionisnotcertain,onepossibleexplanationcouldbethatactivationoftherighttemporalloberesultedinareintegrationofrightandlefthemisphericattentionalprocesses,bringingtheworldtemporarilyintoanorganizedwhole(Rubens,1985).Thistheoryissupportedbythefactthatbeingshownfearfulfacesalsoappearstoovercometheattentionalneglectofthesepatients(Tamiettoetal.,2007).Thesurvivalvalueofthesefacesmaysurpassahigherthresholdestablishedinthehemi-neglectphenomenon.

TheLanguageNetworkandtheLeftHemisphereInterpreter

Allmenarefrauds.Theonlydifferencebetweenthemisthatsomeadmitit.Imyselfdenyit.—H.L.Mencken

Thelefthemispherelanguagenetworkreliesontheconvergenceofauditory,visual,andsensoryinformationfromthetemporal,occipital,andparietallobes.Wernicke’sareainthetemporallobereceivesinputfromtheprimaryauditoryareaandorganizesitintomeaningfulbitsofinformation.Theconvergencezoneconnectssounds,sights,andtouch,sothatcross-modalconnectionscanbemade,allowingustonamethingswetouchandhearwithoutvisualcues.Itisalsonecessaryforthedevelopmentofsignlanguage,wherewordstaketheformofgestures.ThissophisticatedandhighlyprocessedinformationprojectsforwardtoBroca’sareawhereexpressivespeechisorganized.

Neuralnetworkslinkinglanguageareastotherestofthefrontallobesallowbothspokenandinternallanguagetoguidebehaviorandregulateaffect.Althoughthesemanticaspectsoflanguageareusuallylateralizedtothelefthemisphere,therightcontributestheemotionalandprosodicelementofspeech.Theintegrativepropertiesoflanguagemaybeunequaledbyanyotherfunctionofthebrain.Creatingandrecallingastoryrequirestheconvergenceofmultisensoryemotional,temporal,andmemorycapabilitiesthatbridgeallvectorsofneuralnetworks.Inthisway,languageintegrates,organizes,andregulatesthebrain,andisthereforeusedtogreatbenefitineverydaystorytellingaswellasinpsychotherapy.

Consistentfindingsacrossavarietyofsettingshaveledtoageneralacceptancethattheverbalneocortexorganizesconsciousexperienceandembodiesthesocialselfasarbiterofrules,expectations,andsocialpresentation(Nasrallah,1985;Rossetal.,1994).Workingwithsplit-brainpatients,Gazzanigaandhiscolleaguesfoundthatthelefthemispherecouldcreateanexplanationofexperiencewhenrighthemisphereinformationwasunavailable(Gazzaniga,LeDoux,&Wilson,1977).Gazzaniga(1989)laterdevelopedtheconceptofthelefthemisphereinterpreterthatsynthesizesavailableinformationandgeneratesacoherentnarrativefortheconscioussocialself.

Thestrategyoffillingingapsinexperienceandmemory,andmakingaguessatanexplanation,parallelsconfabulatoryprocessesseeninpatientswithpsychosis,dementia,andotherformsofbraindamage.Confabulationappearstobeareflexivefunctionofthelefthemisphereinterpreterasitattemptstomakesenseofnonsense,organizeexperience,andpresenttheselfinthebestpossiblelight.ThisphenomenonislikelyrelatedtoFreudiandefensemechanismsthatdistortrealityinordertoreduceanxiety.

AgoodexampleofthiskindofconfabulatorybehaviorwasdemonstratedbyS.M.,a77-year-oldsufferingfromparietalandtemporallobeatrophyinherrighthemisphere.Onedayhersonsawherusingsignlanguageinfrontofthemirrorinherbedroom(Feinberg&Shapiro,1989).Whenaskedwhatshewasdoing,thepatienttoldhimthatshewascommunicatingwiththe“otherS.M.”ShewentontotellhimthattherewasanotherS.M.whowasidenticaltoherinappearance,age,background,andeducationwhowasalwaysinthemirror.SheandtheotherS.M.hadgonetothesameschool,butdidnotknoweachotherfromthattime.TheotherS.M.alsohadasonwiththesamenamewholookedjustlikehim.

S.M.andherdoublewereidenticalineveryrespect,exceptthattheotherS.M.hadatendencytotalktoomuchanddidnotcommunicateaswellasshedidinsignlanguage.Ifhersonortheexaminerappearedbehindherinthemirror,shewouldcorrectlylabelthatperson’smirrorreflection.Thus,thephenomenonofadoublewasonlyevidentforherownimage.Whenitwaspointedoutthatthiswasherownimageinthemirror,shewouldreply,“Ohsure,that’swhatyouthink”(Feinberg&Shapiro,1989,Chapter3).WhileS.M.’scomprehensionandidentificationofherselfandtheworldhadbeendisruptedbyherrighthemispherelesion,herlefthemisphereinterpreterremainedintact.Itissomewhatcomicaltothinkthatsheexperiencedherreflectioninthemirrorastalkingtoomuchandbeinglessskilledthanherselfinsignlanguage.Perhapsthelefthemisphereinterpretermayexplainwhyweareallaboveaverageinourownminds.

Thisconfabulatoryandpositiveself-biasofS.M.versusherreflectionisaperfectexampleofthelefthemisphereinterpreteratwork.Italsoreflectsthebrain’sbasicinstincttoengageinexplanatory

behaviorforthingsitcannotunderstand.Someversionoftheinterpreterconcepthaspreviouslybeenusedtoexplainthedevelopmentofparanormalbeliefs(Cozolino,1997),schizophrenicdelusions(Maher,1974),andreligiousbeliefs(Gazzaniga,1995).Theconceptisespeciallyrelevanttopsychotherapy,becausetheconstructionofrealityisatworkintheworldviewsofpatientswithcharacterdisorders,thedefensemechanismsofneurotics,andtheday-to-dayrealityofhealthyindividuals.Thelefthemisphereinterpreterisaninternalpressagentfortheself,puttingapositivespinonwhatisexperiencedandhowitispresentedtoothers.Iftheinterpreterisnotdoingitsjobadequately,asinthecaseoflefthemispheredamageordecreasedactivationoftheleftfrontalcortex,wecanbecomerealistic,pessimistic,anddepressed.

CommunicationandCoordinationBetweentheHemispheres

Isthebrain,whichisnotablydoubleinstructure,adoubleorgan,“seemingparted,butyetaunioninpartition”?

—H.Maudsley

Asourleftandrighthemispheresdifferentiatedduringevolution,eachcametogaindominanceforspecificfunctionsafterfailedexperimentswithtranscorticaldemocracy(Levy,Trevarthan,&Sperry,1972).Atthesametime,theblendingofthestrengthsofeachhemisphereallowsforthemaximumintegrationofourcognitiveandemotionalfunctioning.Whenweareawake,therighthemisphereconstantlyprovidesinformationtotheleft.Nasrallah(1985)suggestedthatthisinputrelatestointuition,feelings,fantasy,andvisualimages.Themomentarybubblingupoffeelingsorimages,whicharethenquicklylost,mayreflectoneaspectoftheintrusionofrighthemisphereprocessingintolefthemispherecontrol.Thefiltrationofrighthemisphericprocessesmaybenecessarytoallowustoremainfocusedonthetasksinwhichweareengaged,althoughitmaynotnecessarilyregister,understand,orallowtheinformationintoconsciousness.

Whathappenswhenthehemispheresfindthemselvesdisconnectedfromoneanother?JasonandPajurkova(1992)reportedacaseofa41-year-oldright-handedmanwhosuffereddamagetothefrontportionofhiscorpuscallosumandthemedialportionofhisfrontalcortex.Themostsalientaspectofhisbehaviorafterhisinjurywasthatthetwosidesofhisbodyseemedtobeinconflictwithoneanother.Duringneuropsychologicaltesting,thepatient’srighthandwouldattempttoperformataskbuttheleftwouldmoveinanddisruptwhathadbeenaccomplished.Whenhewouldtrytogodownasetofstairs,hisrightfootwouldleadbutthenhislefthandwouldgrabthedoorjambandrefusetolethimmoveforward.Hefoundhimselfunabletodothingsthatrequiredthecooperationofbothhands.

Thepatientsaid,“Myleftfootandmylefthandwanttodotheoppositeofwhatmyrightonedoesallthetime”(Jason&Pajurkova,Chapter13).Onanotheroccasionhestated,“Mylefthanddoesn’tgowhereIwantitto”(Chapter13).Ineachsituation,therighthandandside(controlledbythelefthemisphere)attemptedtocarryouttheconsciouswillofthepatient.Buttheleftside(controlledbytherighthemisphere)wouldhavenopartofit.Theauthorsreportedthatitseemedasiftherighthemispherewasactinglikeaspitefulsibling,competingforattentionandcontrol(Jason&Pajurkova,1992).Althoughthisconflictualbehaviordecreasedovertime,itwasstillevident6monthsaftertheinjury.Similarleft–rightconflicts,usuallyresolvinginthefirstfewweeksaftersurgery,havealsobeenreportedinsplit-brainpatients.

Itisclearinthesecasesthatthelefthemisphereisexperiencedastheconsciousself(ego)whilethebehavioroftherighthemisphereisexperiencedasaforcefromoutsidetheself(ego-alien).The

experienceandbehaviorofsuchpatientssuggestsnotonlyalternatewaysofprocessinginformationineachhemisphere,butalsotwoseparatewills.Theunconsciousandoppositionalqualityofthebehaviorofthisclient’srighthemispheresuggeststhatthelefthandmayhavebeenactingoutunconsciousemotionalreactions.

Right-LeftIntegrationandPsychopathology

Weuseourbrainstoolittleandwhenwedo,itisonlytomakeexcusesforourreflexesandinstincts.

—MartinFischer

Ipostulatedearlierthatneuralnetworkintegrationshouldcorrelatewithmentalhealth,whiledissociationorimbalanceamongneuralnetworksshouldcorrelatewithmentalillness.Ifthisistrue,wecanassumethatintegrationbetweentherightandlefthemispheresisoneelementofoptimalbrainfunctioning.Itturnsoutthatanxiety,affectivedisorders,psychosis,alexithymia,andpsychosomaticconditionshaveallbeenlinkedtodeficitsintheintegrationandbalanceamongthecerebralhemispheres.

AnxietyandDepression

Anxietyislove’sgreatestkiller…—AnaïsNin

Asmentionedearlier,eachhemispherehasanemotionalbias,andsoitappearsthattheproperbalanceofright-leftactivationallowsustoexperienceahealthymixofpositiveandnegativeemotionalexperiences,aswellastoregulateandmanageanxiety(Silberman&Weingartner,1986).Thelefthemispherehasabiastowardpositiveaffect,prosocialbehavior,andassertiveness,allofwhichhelpustoconnectwithothersandfindsafetyinthegroup,whiletherighthemisphere’sbiastowardsuspiciousnessandnegativitykeepsusvigilantandalerttodanger.

Frontallobeactivation,whenbiasedtowardtherighthemisphere,correlateswiththesignsandsymptomsofdepression(Nikolaenko,Egorov,&Freiman,1997).Thesamephenomenonholdstrueforanxiety.Primateswithextremerightfrontalactivityaremorefearfulanddefensive,andhavehigherlevelsofstresshormones,thandothosewithactivitybiasedtowardthelefthemisphere(Kalinetal.,1998).Adultswithahistoryofchildhoodtraumademonstrateasignificantlygreatershifttorighthemisphericprocessingwhenaskedtothinkaboutunpleasantmemories(Schiffer,Teicher,&Papanicolaou,1995).Activationofmanystructuresoftherighthemisphereisalsoevidentduringposttraumaticflashbacks(Rauchetal.,1996).

Ifanxietyanddepressionare,inpart,theresultofabiastowardrighthemisphereprocessing,thenanyformofsuccessfultreatmentwillenhancearebalancingofthesesystems.Cognitivetherapiesforbothanxietyanddepressionutilizerationalthoughtthatmayworkbyactivatinglefthemisphereprocessestoregainlateralbalance.Symptomaticreliefcanalsobeachievedbyadownregulationoftherighthemisphereprocessesthroughrelaxationtraining.

Anunfortunateartifactoftheevolutionoflateralitymaybethattherighthemisphereisbiasedtowardnegativeemotionswhilealsohavingprimarycontroloveremotionalself-awareness(Keenanetal.,1999).Inaddition,becausethereissomuchearly,unconsciousrighthemisphereemotionallearning,

earlynegativeexperienceshavealong-lastingyethiddenimpactonourself-esteem,attitudes,andpersonalities.Theseaspectsoflateralitymaycreateabiastowardshame,guilt,andpessimismwhilepossiblyexplainingtheneurobiologicalmechanismunderlyingNietzsche’sstatementthat“Manistheonlyanimalwhohastobeencouragedtolive.”

AlexithymiaandPsychosomaticIllness

Itispreciselybecauseachild’sfeelingsaresostrongthattheycannotberepressedwithoutseriousconsequences.

—AliceMiller

Alexithymia—theinabilitytoconsciouslyexperienceanddescribefeelings—ischaracterizedbydeficitsintheawarenessandintegrationofrighthemispherefunctions.Thesepatientsarenotpronetodepressionormaniabutinsteadhaveapovertyofemotionalexpressionandexperience.Theyareabletorecognizethatothershavefeelings,butreportbeingunabletolocateanywithinthemselves.

Fromapsychodynamicperspective,thesepatientsseemtrappedinsecondaryprocessthinking,disconnectedfromtheirinnerphysicalandemotionalworlds.Patientswithalexithymiaaredescribedashavingaconcreteorstimulus-boundcognitivestyle,restrictedimagination,andalackofmemoryfordreams(Bagby&Taylor,1997).Theyhavedifficultybenefitingfromtraditionalmodesoftalktherapybecauseoftheirinabilitytobringemotionsintothesession,ortouseimaginationorrole-playingtoexpandtheirthinkingaboutthemselves.Althoughtheneurologicalcorrelatesofthisdisorderarestillunknown,alexithymiahasbeendescribedasa“bidirectionalinterhemispherictransferdeficit”(Taylor,2000).Theresultantfailureoftheintegrationofaffectandcognitionleavestheconsciousselfofthelefthemispherewithlittleinputfromtheemotional,intuitive,andimaginativeright.

Patientswithotherpsychiatricdisordersrevealpatternssimilartothosewithalexithymia.Hoppe(1977)foundthatpatientswithpsychosomaticdisordershavecharacteristicssimilartothosewithalexithymiasuchasimpoverisheddreams,apaucityofsymbolicthinking,andtroubleputtingfeelingsintowords.SimilardifficultieswerealsofoundinHolocaustsurvivors,split-brainpatients,andindividualswithtraumaticbraininjuries.HoppeandBogen(1977)hypothesizedthatproblemsduringdevelopmentorunderlyinggeneticprocessescouldleadhemispherestoorganizeandfunctionautonomously.Thetheoryofsuchan“interhemispherictransferdeficit”wassupportedbyresearchwithpatientssufferingfromPTSDandalexithymiawhowerefoundtohavedeficitsintransferringsensorimotorinformationbetweenhemispheres(Zeitlin,Lane,O’Leary,&Schrift,1989).

Psychosis

Realityismerelyanillusion,albeitaverypersistentone.—AlbertEinstein

Whereasnormalstatesofawarenessarecomprisedofanintegrationandbalanceofrightandlefthemisphereprocessing,psychosismaybearesultoftheintrusionofrighthemispherefunctioningintoconsciousawareness.Hyperactivationoftherighthemisphere,oradecreaseintheinhibitorycapacitiesoftheleft,maydiminishtheabilitytofilterprimaryprocessinputfromtherighthemisphere.Thisshiftinright-leftbiasmayoccurformanyreasons,includingchangesinlevelsofimportantneurochemicalssuch

asdopamine,neuroanatomicalabnormalities,orchangingactivationinsubcorticalbrainareassuchasthethalamus.Schizophrenicpatientsandtheircloserelativesdemonstratereducedlefthemispherevolumesinthehippocampusandtheamygdala,whichhasbeenshowntocorrelatewiththoughtdisorder(Seidmanetal.,1999;Shentonetal.,1992).

Auditoryhallucinations,orhearingoneormorevoicestalking,areacoresymptomofschizophrenia.Infact,thetermschizophreniameanssplitmind.Theseaberrant,intrusive,andego-dystonicexperiencesmayreflectrighthemispherelanguage(relatedtoprimaryprocessthinkingand/orimplicitmemories)breakingintolefthemisphereawareness.Thesevoices,oftenheardassinglewordswithstrongemotionalvalue,areexperiencedascomingfromoutsidetheself.Forexample,patientsreporthearingprofanitiesorcriticalwords(jerk,idiot)aspeoplewalkbythemonthestreet.Commandhallucinationstohurtoneselforothersortoengageindangerousbehaviorshavethesamequalities.Schizophrenicpatientsappeartoopenlystrugglewithshamefulaspectsoftheirinnerworld(likelystoredintherighthemisphere)thattherestofusarebetterabletoinhibit,repress,anddeny.

Inpsychosis,primaryprocessthinkingbreaksintonormalstatesofawarenesstocreatewhatarediagnosedasdeficitsinrealitytestingandthoughtdisorders.Patientsdescribethisasafeelingofdreamingwhileawakeandstrugglingtomakesenseofthesimultaneoussuperimpositionofprimaryandsecondaryprocessexperiences.Thisattempttomakesenseoutofnonsensefiresupthelefthemisphereinterpreter,leadingtotheelaborationofbizarredelusions(Maher,1974).Althoughahemisphericmodelofpsychosisisstillspeculative,testsoflateraldominance(measuredbyalisteningtask)haveshownthatdecreasedlateraldominanceinthesepatientscorrelateswithmoreseverepsychoticsymptoms(Wexler&Heninger,1979).

Inspiredbybothmodernscienceandancienttexts,theneuropsychologistJulianJaynes(1976)developedatheoryoftheevolutionofhumanconsciousnessbasedontheincreasingabilityofthelefthemispheretoinhibitinputfromtheright.Jaynesarguedthatpriorto1000B.C.,thetwohalvesofthehumanbrainactedindependently;therighthemisphereunconsciouslycontrolledthebody,whiletheleftwitnessedanddescribedthesocialenvironmentandactionsofthebody.Thismodeloflateralitymayhavereflectedanintermediateevolutionarystagebetweenhavingtwomodesofconsciousawarenessandourcurrentbiastowardrighthemisphereinhibition.

Jaynessuggestedthatwhenourforebearswereinsituationsofextremestress,suchascombat,therighthemisphereprovidedauditorycommandstotheleft,whichwereexperiencedascomingfromoutsidetheself.Thiscouldreflectaninternalizedauditorymemoryofthetriballeadersandwarriors,commandssimilartothosereportedbymodern-dayschizophrenics.Withtheexpansionofthecorpuscallosumandincreasingdominanceofthelefthemisphere,amoreunifiedsenseofselfgroundedinthelefthemispherehasbecomedominantandabletoinhibittheseinnervoices.Jaynesfeltthatpsychoticsymptomsseeninpatientsinmoderntimesmaybetheresultofabreakdownofthelefthemisphere’scapacitytoinhibitthesemessagesfromtheright.

LateralityandPsychotherapy

Happinessisnotamatterofintensitybutofbalance,order,rhythmandharmony.—ThomasMerton

Theproperbalanceandintegrationoftherightandlefthemispheresdoesnotappeartobeagiveninthecourseofdevelopment.Istronglysuspectthatleft-rightintegrationisanexperience-dependentprocessthatreliesonadequateassistancewithaffectregulationthroughsecureattachment.Itisalsodependenton

theco-constructionofnarrativeswhereamodelispresentedfortherecognitionandlabelingoffeelings,aswellasintegratingthemintoexperience.Psychotherapycanserveasameanstoreintegratethepatient’sdisconnectedhemispheresthroughrealitytesting,emotionalexpression,andputtingwordstofeelingsinthecontextofacaringrelationship.

Examplesfrompsychiatryandneurologystronglysuggestthatpsychologicalhealthisrelatedtotheproperbalanceofactivation,inhibition,andintegrationofsystemsbiasedtowardtheleftandrighthemispheres.Geneticandneuroanatomicalfactorscancombinewithearlyneglectortraumatointerferewiththedevelopmentofoptimalneuralnetworkintegrationandregulation.ThesimilaritybetweenhemisphericspecializationandFreud’snotionoftheconsciousandunconsciousmindhasnotbeenlostonpsychotherapists.RighthemispherefunctionsaresimilartoFreud’smodeloftheunconsciousinthattheydevelopfirstandareemotional,nonverbal,andsensorimotor(Galin,1974).Thisnonlinearmodeofprocessingallowstherighthemispheretocontainmultipleoverlappingrealities,similartoFreud’sprimaryprocessthinkingmostclearlydemonstratedindreams.ThelinearprocessingofconsciousthoughtinthelefthemisphereparallelsFreud’sconceptofsecondaryprocess,whichisboundbytime,reality,andsocialconstraints.

Whenpatientscometotherapy,thelefthemisphereinterpretertellsitsstory.Butsomethingisusuallywrong:thestorydoesnotfullyaccountforwhatishappeningintheirlives.Thenarrativesthatorganizetheiridentitiesinadequatelyaccountfortheirexperiences,feelings,andbehaviors.Therighthemispherealsospeaksviafacialexpressions,bodylanguage,emotions,andattitudes.Thus,welistentobothstoriesforthecongruencebetweentheverbalnarrative,andnonverbalandemotionalcommunication.Inthisprocess,weanalyzetheintegrationandcoherenceofleft-rightandtop-downneuralnetworks.Aprimarytoolacrossallmodelsoftherapyiseditingandexpandingtheself-narrativeofthelefthemispheretoincludethesilentwisdomoftheright.

Hopefully,thetherapistwillbebetterintegratedthantheclientinatherapeuticrelationship.Thiswillallowthetherapisttoreacttowhatissaidwithemotion,resonatewiththeclient’semotions,andthensharethoughtsaboutthoseemotionswiththeclient.Thus,thetherapist’sabilitytotraversethecolossalbridgebetweenhisorherownrightandlefthemispheresservesasamodelandguidefortheclient.

Anotherwayofdescribingtherapyfromtheperspectiveoflateralityisthatweteachclientsamethodbywhichtheycanlearntoattendtoandtranslaterighthemisphereprocessingintolefthemispherelanguage.Weteachthemaboutthelimitationsanddistortionsoftheirownconsciousbeliefspresentedbytheirlefthemisphereinterpreter.Manyclientsneedtobesuspiciousoftheideasthattheirlefthemispheresofferthem.Thisiswhyrealitytestingissoimportantfortreatmentsuccess.Itisthetherapist’sjobtohearwhatisnotsaid,resonatewithwhattheclientisunabletoconsciouslyexperience,andcommunicateitbacktohimorherinawaythatwillallowittobecomeintegrated.Thishumanprocessserveshemisphericintegration.

Summary

Theintegrationofdissociatedprocessingsystemsisoftenacentralfocusoftreatment.Gradually,clientscometolearnhowthetherapistgathersandinterpretstheinformationpresentedtothem(Gedo,1991).Thisprocesscloselyparallelswhatisdoneduringpositiveinteractionswithparentsduringchildhood.Ifthemethodtaughtduringchildhoodismaladaptive,itleavesthechild(andlatertheadult)inastateoflimitedself-awarenessandneuralnetworkdissociation.Thelearningoftheseskillsintherapyoccursinthecontextofemotionalandcognitiveintegration,requiringtheparticipationofbothhemispheres,reflectivelanguage,feelings,sensations,andbehaviors.Inthelanguageofneuroscience,weareintegratingdissociatedsystemsofmemoryandprocessingsystemsbyteachingnewstrategiesfor

integratingrationalandemotionalinformation.Theseprocessesaidintheconstructionofamoreinclusiveself-narrative,which,inturn,servesasablueprintforongoingneuralintegration.

PartIII.

TheOrganizationofExperienceandtheHealthyBrain

Chapter7

TheExecutiveBrain

Myownbrainistomethemostunaccountableofmachinery—alwaysbuzzing,humming,soaringroaringdiving,andthenburiedinmud.Andwhy?What’sthispassionfor?

—VirginiaWoolf

Throughcountlessadaptationalchallengesandtheprocessofnaturalselection,wefindourselveswithstaggeringlyintricateandsophisticatedbrains:Ferraris—notFords.Ancientnetworkshavebeenconserved,expanded,andreorganized,whilenewnetworkshaveemergedandcombinedtoperformincreasinglycomplexfunctions.Intheprocess,someexecutivefunctionsremainedwithearlierevolvingnetworks,andsomemoveduptofrontalandprefrontalregions,whilestillotherswereassumedbythemindandthesocialgroup.

Thecontrolofthevastmajorityofourbodilyandmentalfunctionsisonautomaticpilot.Undernormalcircumstances,wepayvirtuallynoattentiontobreathing,walking,talking,andthousandsofothercomplexprocesses.Wecandriveacarsafely(andmindlessly)forhourswhileconversingandlisteningtomusic.Allofthisautomaticityallowsustofocusourconsciousattentiononjustasmallfractionofwhatishappeningatanygivenmoment.

Theexecutivecorticalareasinourprefrontallobesaresomeofthelatestneuralsystemstoevolveandtheslowesttodevelopduringchildhoodandadolescence.Inmanyrespectsthesesystemscontinuetodevelopthroughoutlife,allowingthepotentialforincreasingperspective,compassion,andwisdom.Theexecutivebraincontainsthecontrolmechanismsthatenableustoattendtoaparticularactivity,filteroutdistractions,makedecisions,andactinanorganizedandpurposefulway.Ifthesefunctionsarecarriedoutsuccessfully,wefeelcalmandsafeenoughtoturnourattentioninwardforcontemplation,imagination,andself-awareness.Thesecapabilities,inturn,createthepossibilityforart,religion,philosophy,andotheruniquelyhumanendeavors.

ThinkforamomentofalargecorporationwithaCEOatthetopofitsexecutivehierarchy.Lowerlevelmanagers,whospecializeinparticularareasofoperation,areemployedbythecorporationtocontrolthousandsofdiversefunctions.UtilizingmultiplelowerlevelexecutivesfreestheCEOtomonitormarketforces,keepaneyeonthecompetition,andplanforthefuture.JustasaCEOisfreedfromtheeverydayconcernsofproduction,buildingmaintenance,andbillpaying,theexecutiveareasofthecerebralcortexarefreedfromattentiontobasicbodilyfunctions,well-learnedmotorbehavior,andvisual-spatialorganization.Theexecutivebrainparticipatesinmorebasicfunctionsonlyinsituationsthatarenovelandproblematic.

Althoughtheexecutiveareasofthebrainaretraditionallythoughtofasbeingresponsibleforourrationalabilities,theyactuallycombinesensory,motor,memory,andemotionalinformationtoshapeideas,plans,andactions.Thisbroaderviewofexecutivefunctioninghasbeenguided,inpart,byan

increasingappreciationofthecontributionofemotionandintuitionindecisionmaking(Damasio,1994).Becausesomuchofbrainfunctioningisunconscious,nonverbal,andhiddenfromconsciousobservation,theexecutivebrainisalsostronglyinfluencedbynonconsciousprocesses.Psychotherapycallsontheexecutivebraintoupdateandreorganizetherelationshipamongtheconsciousandunconsciousnetworkstheyoverseeintheserviceofmentalandphysicalhealth.

Forthepurposeofthepresentdiscussion,wewillfocusprimarilyontheexecutivefunctionsofthefrontalandprefrontalcortices.Whatweknowabouttheseareasisbasedonacombinationofprimateandhumanresearch,naturalisticobservations,andclinicalevidencewithhumanpatients.Althoughthefocushereisonthefrontalandprefrontalcortices,wewillreturntotheideaofmultipleexecutiveregionsinalaterdiscussionoftheparietallobes.

TheFrontalandPrefrontalCortices

Thehighestpossiblestageinmoralcultureiswhenwerecognizethatweoughttocontrolourthoughts.

—CharlesDarwin

Thefrontalandprefrontalcorticesaretheprimecandidatesforbehavioralandemotionalexecutivefunctioninginprimatesandhumans.Theirorganizationandconnectivityprovidefortheintegrationofcognitiveandemotionalprocessing(Fuster,1997).Becausetherearenoprimarysensoryareasinthefrontalcortex,theyareentirelydedicatedtotheassociationofinformationthathasalreadybeenhighlyprocessedinotherneuralsystemsthroughoutthebrain(Nauta,1971).Forexample,projectionsfromtheparietalregionscontainintegratedvisual,motor,andvestibularinformation,whereasthosefromthetemporallobehavealreadycombinedsensoryinformationwithsocioemotionalappraisal.

Althoughthehumanfrontallobesinitiallyevolvedtoorganizecomplexmotorbehavior,theexpansionoftheprefrontallobesaddedcapacitiesforplanning,strategy,andworkingmemory.Neuronsandneuralnetworkswithinthefrontalcortexorganizeourbehaviorthroughtime(Fuster,Bonder,&Kroger,2000)bysustainingamemoryforthefuture(Ingvar,1985)thatkeepsinmindtheeventualconsequencesofbehaviorsabouttobeperformed(Dolan,1999;Watanabe,1996).Theabilitytorememberthepastandpredictthefutureisessentialforsurvival.Broca’sarea,intheleftfrontalcortex,forexample,whichcontrolsexpressivespeech,islocatedadjacenttotheareaofthemotorcortexdedicatedtothelipsandtongue.Thisproximityreflectsthecoevolutionandinterdependenceofspokenlanguageandfinemotorcontrol.Becauseoftheevolutionarylinksbetweenmotorbehaviorandcognition,sometheoristsconsidercognitiontobeaderivativeofmotorbehavior(Wilson,1998).Supportforthisideamayexistinthatmuchofoursymbolicandabstractthinkingisorganizedbythevisceral,sensory,andmotormetaphorsthatpermeateourlanguage(Johnson,1987).

Aswehaveseen,networksinbothhemispheresfeedhighlyprocessedsensory-motorinformationforwardtothefrontalcortex.Simultaneously,multiplehierarchicalnetworks,whichloopupanddownthroughthecortex,limbicsystem,andbrainstem,providethefrontalcortexwithsomaticandemotionalinformation(Alexanderetal.,1986).Theconvergenceofallofthesenetworkswithinthefrontalandprefrontallobesallowsthemtosynthesizediverseinformationandcoordinateourattention,emotions,andcognitionwithaction.

Theprefrontalcortexalsoparticipatesinconstructingideasaboutthebeliefs,intentions,andperspectiveofothersinaprocesscalledtheoryofmind(Goel,Grafman,Sadato,&Hallett,1995;Stuss,Gallup,&Alexander,2001).Damagetotheprefrontalcortexinearlychildhoodusuallyresultsindeficits

inthedevelopmentoftheoryofmind,includinglearningsocialroles,perspectivetaking,andempathicabilities(Dolan,1999).Damageinthesameareaslaterinlifecanalsoresultindeficitsintheseabilities,sometimesreferredtoaspseudopsychopathy(Meyers,Berman,Scheibel,&Hayman,1992).Becauseempathyrequiresconceptualunderstanding,emotionalattunement,andtheabilitytoregulateone’sownaffect,damagetoanyareaoftheprefrontalcortexmayimpairdifferentaspectsofempathicbehavior(Eslinger,1998).Empathicthinkingrequiresbothcognitiveflexibilityandaffectregulationinordertopullbackfromtheenvironment,putourcurrentneedsasideforthemoment,andimaginethefeelingsofothers.

Theactofmurderistheultimateexpressionofalackofempathy.Asagroup,peoplewhohavecommittedmurderdemonstratesignificantlylowerglucosemetabolisminbothdorsalandorbitalportionsofthefrontalareas.Thisfindingexistsintheabsenceofindicationsofbraindamageordecreasedmetabolisminotherareasofthebrain(Raineetal.,1994).Althoughantisocialbehaviorisacomplexphenomenon,correlationsexistbetweendeficitsinaffectregulation,impulsecontrol,andtheinabilitytorelatetotheexperienceofothers.

Theclassicexampleofdamagetotheorbitomedialprefrontalcortex(ompfc)isthecaseofPhineasGage(Harlow,1868;Damasio,1994).Mr.Gagewasayoungandwell-respectedNewHampshirerailroadforemanwhowasknownforhismaturityand“well-balanced”mind.Anaccidentonthejobsentaninch-and-a-quarter-wideironbarupthroughhishead,obliteratingmuchofhisompfc.Althoughfreeofany“neurobehavioral”deficitsfromtheaccident(suchasaphasia,paralysis,orsensoryloss),hisworkmatesreportedthatGagewas“nolongerGage.”Aftertheaccidenthewasunabletocontrolhisemotions,sustaingoal-orientedbehavior,oradheretosocialconventions.Hewentfrombeingayoungmanwithapromisingfuturetoanaimlessandunsuccessfuldrifter.

TheCortexandInhibition

Whataman’smindcancreate,man’scharactercancontrol.—ThomasA.Edison

Whenwethinkofthehumancerebralcortex,wemaythinkoftheaccomplishmentsofmusic,art,andculture—productsofcorticalandespeciallyprefrontalevolution.Althoughwefocusonthesevisibleandimpressiveproductsofthehumanbrain,thehiddenroleofthecortexininhibitingitselfandotherbrainstructuresisavitalaspectofthebrain’scapabilities.Considerthisexample:wearebornwithabroadarrayofprimitivebrainstemreflexesconservedfromourprimateancestors.Oneoftheseisthegraspingreflex,whichallowsustopickupinfantsbyputtingourindexfingersintheirpalmsandlifting.Forthefirstfewmonthsoflifeinfantscanholdtheirownweight,afterwhichtheyarenolongerabletoholdon.

Itisbelievedthatthisgraspingreflexisaholdoverfromatimewhennewbornmonkeyshadtoholdontotheirmothers’furtofreethemothers’handstotraversebranchesandgatherfood.Soalthoughthisbehaviorisnolongerrequiredforsurvivalbyhumans,ithasbeenconservedwithinourgeneticblueprint.Theonlypossibleroleitmayplayforusistoenhancetheexperienceofbondingbetweennewbornandparent.Manyparentsarecaptivatedandenthralledbythefactthattheirinfantgraspsthemandholdsonsostrongly.Overthefirstfewmonthsoflifethisreflexgraduallydiminishesasdescendingfibersfromthecerebralcortexconnectwiththebrainstemregionsthattriggerthem.Butwhydoesthecortexmakethisinhibitoryprocesssuchanearlypriority?Afterallthereissomuchtolearn.Themostlikelyreasonisthatbeforethecorticalmotorareascanbegintoshapethedexterityofthehandsandfingers,theyneedtobereleasedfromthecontrolofthisprimitivereflex.Inotherwords,beforewecanmoveeachofourfingers

independentlyandincoordinationwitheachother,theyneedtobefreefromthetendencytoacttogetherforasinglepurpose.

Nowfastforwardtolaterinlife,whenthissamechildis60,70,or80yearsold.Herchildrennoticethatsheseemsforgetfulandbecomesdisorganizedfromtimetotime,andwonderiftheremaybesomethingwrong.Thefamilydoctorrefershertoaneurologistwhoperformsaseriesofclinicaltests.Inoneofthesetests,thedoctoraskshertoholdherarmsoutstraightinfrontofherwithherhandsopenandpalmsfacingdown.Extendinghisarmsunderherswithhispalmsup,thedoctorslideshisfingersunderherarmsfromtheelbowsuptowardsherhands.Ashereachesherwrists,hecurlshisfingersslightlyandholdsthemrigid.Asthedoctor’sfingersslideunderthepalmsandthenthefingersheislookingtoseeifthetouchofhishandtriggersherfingerstocurlinwardandgrasphisown.Iftheydo,hewilltryitagainaftertellinghernottograsphisfingers.Ifithappensagain,itislikelythatthetouchofhishandistriggeringthesamebrainstemgraspingreflexthatsheshowedearlyinlife.Whyisthisclinicallysignificant?

Itturnsoutthatthereflexesinthenewborndonotdissolve,butratherremainembeddedwithinthebrainstemthroughoutlife,andarecontinuallyinhibitedbydescendingfibersfromthecortex.Withdiseaseslikedementia,theneuronsinthecortexgraduallydieoffandthecortexbecomesincreasinglycompromised.Sowhatthedoctorislookingforaresignsofcompromiseofcorticalinhibitoryfunctioningsuggestiveofapotentialstroke,tumor,ortheonsetofdementia.Earlyreflexesthatreemergeafterdamagetothebraininadulthoodarereferredtoascorticalreleasesigns(Chuganietal.,1987).

Thisinhibitorycorticalfunctionisnotlimitedtoprimitivereflexes;itisinplaywhenweareabletokeepourselvesfromreactingingamesofSimonSayswhenSimondoesn’tsay,orholdourtonguesinemotionalsituationswheresayingsomethingwouldonlymakethingsworse.Amajorneurobiologicalcomponentofsecureattachmentisthebuildingofdescendingfibersfromorbitalandmedialregionsoftheprefrontalcortexdowntotheamygdalaandotherlimbicstructures,whichallowthechildtofirstuseparentsasemotionalscaffoldingfortheregulationoffear,andlatertobeabletoregulateherownfearthroughself-talk,memoryofpositiveoutcomes,andproactiveproblemsolving(Ghashghaei,Hilgetag,&Barbas,2007).

ThePrefrontalCortex

Oneofthemostremarkableaspectsofananimal’sbehavioristheabilitytomodifythatbehaviorbylearning,anabilitythatreachesitshighestforminhumanbeings.

—EricKandel

Theprefrontalcortexisgenerallydividedintotwodivisions;thefirstconsistsoftheorbitalandmedialregions(ompfc)andthesecondcomprisesthedorsalandlateralareas(dlpfc).Althoughphysicallycontiguous,theorbitomedialanddorsolateralprefrontalareasdifferintheirconnectivity,neuralarchitecture,biochemistry,andfunction(Wilson,O’Scalaidhe,&Goldman-Rakic,1993).Researchwithprimateshasdemonstratedthatalthoughbothareasplayaroleininhibitionandcontrol,thedlpfcisinvolvedwhenthedecisionisattentional,andtheompfcwhenitinvolvesemotionalinformation.

Theompfc,firsttoevolveandfirsttodevelopduringchildhood,sitsattheapexofthelimbicsystemandisrichlyconnectedwithsubcorticalnetworksoflearning,memory,andemotion(Barbas,1995).Theseconnections,andtheirbiastowardtherighthemisphere,areassociatedwiththeextremesofemotionalprocessing.Liketherightandlefthemisphereswithwhichtheyarelinked,theompfcanddlpfccandemonstratevariousdegreesofintegrationanddissociation.

TABLE7.1FunctionsofthePrefrontalLobes

OrbitalandMedialRegions

Attachment1

Socialcognition2

Thinkingaboutasimilarother3

Self-referentialmentalactivity4

Appreciatinghumor5

Encodingnewinformation6

Sensory-visceral-motorlinkage7

Estimatingrewardvalueandmagnitude8

Sensitivitytofutureconsequences9

Achievinggoals10

Stimulus-independentthought11

Inhibitorycontrolinemotionalprocessing12

Decisionsbasedonaffectiveinformation13

DorsalandLateralRegions

Cognitivecontrol14

Directingattention15

Organizingtemporalexperience16

Organizingworkingmemory17

Organizingepisodicmemory(right)18

Voluntarysuppressionofsadness19

Learningmotorsequences20

Decisionsbasedoncomplexinformation21

Thinkingaboutadissimilarother22

Theintegrationofemotionandcognition23

Thecognitiveandemotionalintelligencesinwhichtheyspecializehavedifferentdevelopmentaltimetablesandlearningcontexts.Orbitalandmedialprefrontalareasbegintoorganizeemotionaldevelopmentinthecontextofinterpersonalrelationships—fromthefirstmomentsoflife.Duringthefirst18monthsoflife,theompfcsharesasensitiveperiodofdevelopmentwiththerighthemisphere.

Dorsolateralareasexhibitaninitiallagandthenagrowthspurtwiththedevelopmentoflanguageandtheexplorationofourphysicalandconceptualworlds.

Ourprefrontalcortexhastwooverarchingandinterwovenareasoffunction,theregulationofaffectandattachmentsontheonehand,andthesynthesisandcoordinationofcognitiveandmotorprocessesontheother.Althoughthesetwotasksseemquitedifferent,eachisdependentupontheother.Abstractthinkingandproblemsolvingareparticularlydependentonadequateemotionalregulation,which,inturn,canbeaccomplishedbyusingrationalthoughtandproblemsolving.Theprefrontalcortexalsoappearsnecessaryformetacognition—ourabilitytoobserveourstreamofconsciousness,revisitmemories,andthinkaboutourthinking,whichdependsupontheintegrationofaffectandcognition.

Wecanobserveanarrayoffunctionsinwhichtheprefrontallobesparticipatebyexaminingthekindsofproblemsthatemergewhentheyareinjured(seeTable7.2).Wecanalsoseethatdifferentregionsoftheprefrontalcortexspecializeindifferentfunctions.Withmosttraumaticbraininjuries,liketheonesufferedbyLuis,whomyouwillsoonhearabout,alloftheseareasarenegativelyimpacted.Ontheotherhand,morelocalizedlesionsmayresultinsomeofthesesymptomsandnotothers.Eachpsychiatricillness,too,hasitscharacteristicprofileofcognitivedistortions,difficultieswithemotionalregulation,anddeficitsofself-awarenessandself-monitoringreflectiveofdifferentpatternsoffrontallobeinvolvement.

Problemsolving—whichrequiresemotionalregulation,sustainedattention,andcognitiveflexibility—isacentralexecutivefunctionthatcanbecomeimpairedwithfrontalcompromise.Somepatientsgetstuckinaparticularwayofthinking(perseveration),whileothershavedifficultyutilizingabstractconcepts(concretethinking).Theymayhavedifficultyinrememberingtheoutcomeofpastbehaviorsandrepeatedlyapplythesameunsuccessfulsolutionstonewproblems.Patientswithfrontaldeficitsoftenhaveadifficulttimemonitoringsocialinteractions,suchaskeepingthelistener’sperspectiveinmindandabidingbysocialrules.

TABLE7.2ManifestationsofPrefrontalCompromise

OrbitalandMedialRegions DorsalandLateralRegions

SocialandEmotionalDisinhibition LossofExecutiveFunctionTactlessnessorsillyattitude ForgetfulnessDecreasedsocialconcern DistractibilitySexualexhibitionismandlewdconversation

Decreasedmemoryforthefuture

Grandiosity DecreasedanticipationFlarewithangerandirritability PoorplanningabilityRestlessness Deteriorationofworkquality

Apathy LossofAbstractAttitudeDecreasedattention ConcretenessLossofinitiative StimulusboundLackofspontaneity LossofaestheticsenseIndifference Perseveration

Depression Setstuckness

Luis

Theveryessenceofinstinctisthatit’sfollowedindependentlyofreason.—CharlesDarwin

Luiswasinaseriousautoaccidentafewdaysafterhis20thbirthday.Heandhisparentscameintoseemeafterhisneurologistsuggestedtheyallmightbenefitfromfamilytherapy.Atthetimeoftheirfirstappointment,Iopenedthedoortofindeightpeoplepackedtightlyintomysmallwaitingroom.AsLuis,hisparents,andfiveyoungersiblingsfiledintomyoffice,InoticedthescarsandindentationsacrossLuis’sforeheadandimaginedthedamagebeneaththem.Iknewfromtalkingwithhisneurologistthathehadsustainedsevereinjuriestohisprefrontalcortexandthathehadbecomeimpulsive,irritable,andoccasionallyviolent.Luisnowpossessedlimitedinhibitorycapacity,reasoningabilities,andalmostnoabilitytobeguidedbysocialexpectations.

Afterweallsettledinmyoffice,IturnedtothefatherandaskedhowIcouldhelphimhelphisfamily.Heimmediatelybecametearful,shookhisheadslowlyfromsidetoside,andrubbedhishandstogether.“Hedrivestoofast,”hesaidquietly.“Idon’t!”exclaimedLuis.“Exceptforthatonetime!”Everyoneinthefamilylookedawayandappearedembarrassed.Itwasimmediatelyclearthattalkingbacktohisfatherwaspartoftheproblem.Althoughhehadalwaysbeensomewhatimpulsive,hisparentsclaimedthathewasfarworsethanbeforetheaccident.IsuspectedthatnomatterhowimpulsiveLuismighthavebeenbeforetheaccident,thisdisrespectfulbehaviorwasnew.ThiseffectofLuis’saccidentwasapparentjustafewsecondsintothesession.

Asthefamilydiscussedtheirsituation,IfoundoutthatLuis’sparentshadmovedtotheUnitedStatesfromMexicoshortlybeforehisbirth,andhadadaptedwelltotheirnewhome.Despitetheirsuccessfulacculturation,theyremainedtruetotraditionalMexicanvaluesofloyaltytothefamilyandrespectforelders.Inthiscontext,Luis’sreflexiveandloudcontradictionofhisfatherwasasourceofshameforeveryoneexceptLuis.Hisinjuryhaddamagedthenetworksthatallowedhimtomonitorandcontrolhisownbehaviorandtakeintoaccounttheexpectationsofothers.Ayearaftertheaccidenthereturnedtohisautorepairjobbutwasunabletofocusonhisworkorgetalongwithcoworkersandcustomers.Thedescendingnetworksofcorticalinhibitionhadbeencompromisedthroughthelossofsomanyprefrontalneurons.

Luisdidn’trememberanythingabouthisaccidentand,infact,hadnomemoryfortheweeksbeforeoraftertheevent.Hereadthepolicereportstodiscoverthathehadlostcontrolofhiscarwhilestreetracingandcrashedintoapole.Hisinjurieswerecompoundedbythefactthathewasnotwearingaseatbeltandhadinstalledasteelsteeringwheelwithoutanairbag.Wasthisthefoolishnessofadolescenceorevidencereflectinghislackofjudgmentpriortotheaccident?Hismotherreportedthathespentmostofhistimeathomewithher,andthathisbehaviorwaserraticandsometimesfrightening.Attimeshewouldcryfornoreason,yellatherandtheothers,andjumpinhercarandraceoff.Afewtimes,hewentintoarageandthrewfurniturearoundthehouse.HehadalsomadesexualstatementsandcursedusingJesus’snameduringtheholidays,upsettingeveryoneinthefamily.FamilymemberswereconfusedandtornbetweentheirloyaltytoLuisandtheirdisgustwithhisbehavior.

Automobile,industrial,andrecreationalaccidents,aswellascommunityanddomesticviolence,allcontributetotheincreasingnumberofpeoplewhoexperiencetraumaticbraininjury.Becausethefrontalareasarelocateddirectlybehindtheforehead,theyarealsomostlikelytobedamagedinfightsand

accidents.Althoughpatientswithheadinjuriescomefromallwalksoflife,youngmalesaredisproportionatelyrepresented.Theiryouthfulimpulsivity,risktaking,andlackofjudgment,alldependentonprefrontalandfrontallobefunctioning,makethemmorevulnerabletodamagingtheseveryregions.Themassivereorganizationofprefrontalbrainareasalongwithbiochemicalandhormonalchangesduringadolescencelikelycontributetothesedangerousbehaviors(Spear,2000).Manyoftheseyoungmenmayhavealreadyhadfrontaldeficitsorslowedfrontaldevelopmentpriortotheiraccidents,amplifyingmoretypicaladolescentrisktaking.Inthisway,frontalinjuriesoftencompoundpreexistingdeficitsofimpulsecontrolandjudgment,complicatingtreatmentandrecovery.

TreatmentwithLuisandhisfamilywasmultifaceted.IbeganbyeducatingtheentirefamilyaboutthebrainandLuis’sparticularinjuries.Thespecificinformationwaslessimportantthanlabelinghisbehaviorsassymptomsofhisinjury.Itargetedinparticularhiscursingandsexualstatements,whichwere,intheirminds,connectedtohischaracterandspiritualhealth.Bysharingcasestudiesofotherswiththem,IwasabletoshowthatLuis’ssymptomswerepartofapatternofpathologicaldisinhibitionrelatedtohisbraindamageandnottheresultofmorallapsesorbadparenting.

MorespecificinterventionsincludedenrollingLuisinanoccupationaltherapyprogramtohelphimdeveloptheinstrumentalandinterpersonalskillsneededtoobtainandmaintainemployment.Astheoldestson,itwasimportantforhimandtherestofthefamilythathebeproductiveandregainasenseofself-worth.Oneofmygoalswastoreducehisresistancetotakingmedicationthatwouldhelphimwithhisanxietyanddepressioncausedbyhischangedcircumstances.IalsoworkedwithLuisandhisfamilytodevelopskillsrelatedtostressreductionandangermanagement.Weturnedtheseexercisesintofamilyrole-playinggamesthatalleviatedtensionandallowedeveryonetoparticipateinhelpingLuis.

Overtime,Luiswasabletoapplyhisknowledgeofcarstoapart-timejobinanautopartsstore.Hisoccupationaltherapisthelpedhimestablishroutinesthatallowedhimtosuccessfullyusethecomputer.Antidepressantsprovedhelpfulwithbothhismoodandirritability,andtherole-playinggamesbecamewovenintothefamily’severydayinteractions.Alloftheseimprovementsmadetheoccasionaloutburstsmoretolerableandmoreeasilyseenaspartofhisillness.Luiswassoveryfortunatetohavetheunquestioningloveandsupportofastrongandinvolvedfamily.

TheOrbitomedialPrefrontalCortex

Opinionisultimatelydeterminedbythefeelings,andnotbytheintellect.—HerbertSpencer

Tuckedunderandbetweenthelobesofthefrontalcortexandsittingdirectlyabovetheeyes,theompfcisdenselyconnectedtotheanteriorcingulate,amygdala,andotherstructuresofthebasalforebrain(Heimeretal.,2008;Zahm,2006).Thesenetworksareofspecialinteresttopsychotherapistsbecausetheybothgenerateandregulateemotionandattachment(Kernetal.,2008;Levesqueetal.,2004;Rogersetal.,2004;Wageretal.,2008;Waltonetal.,2003).Theanteriorcingulate—involvedwithattention,reward-basedlearning,andautonomicarousal—firstappearedduringevolutioninanimalsdemonstratingmaternalbehavior,nursing,andplay(Devinsky,Morrell,&Vogt,1995;MacLean,1985;Shima&Tanji,1998).Consequently,damagetoeithertheompfcortheanteriorcingulateresultsindeficitsofmaternalbehavior,emotionalfunctioning,andempathy.Asdescribedearlier,disordersofemotionalcontrolarealsoseenwithdamagetotheseregions,includinginappropriatesocialbehavior,impulsiveness,sexualdisinhibition,andincreasedmotoractivity(Price,Daffner,Stowe,&Mesulam,1990).

Theompfcisvitalforappraisal—interpretingcomplexsocialeventsandlinkingthemwiththeir

emotionalvalueviaconnectionstotheamygdalaandothersubcorticalstructures.Agoodexampleofthisistheabilityoftheompfctomodulatetheamygdala’sreactiontofearfulfacesbasedonthecontextinwhichthefacesarepresented(Hariri,Bookheimer,&Mazziotta,2000).Sowhiletheamygdalawillalertustothesightofanangryface,theompfcwillincludeinformationaboutadditionalenvironmentalvariablesandinformationbasedonpastlearning.Iftheompfcrecognizesthefaceasthatofafearedpredator,thefight-or-flightresponsewillbeactivated.Iftheompfcaddsthatitisthefaceofadistressedbaby,wemayapproachthechildtofindoutwhatiswrongandifthereissomethingwecandotohelp.Damagetoeithertheamygdalaorompfcatanytimeduringlifecanresultinaninabilitytoorganizevitalsocialinformationinausefulmanner,resultingindeficitsincommunicationandconnection.

Researchhasdemonstratedthattheompfcalsocalculatesthemagnitudeofrewardorpunishmentvalueofourbehaviorsuchasapproachinganotherforhelpandwinningorlosingmoneywhilegambling.Estimatingrewardvalueisajointoperationbetweentheompfcandtheamygdala(Dolan,2007;Gottfried,O’Doherty,&Dolan,2003).Muchofthisanalysisoccursoutofconsciousawarenessandiscommonlycalledintuition.Thoseofuswhoaregoodat“reading”peopleorgamblingmightjustbeawareofhavingafeelingaboutaparticulardecision.Inactuality,basalforebrainandsomatosensoryareasworktogethertoappraisehugeamountsofinformationthatprovideuswiththisfeelingaboutwhattodoevenifitissometimescontrarytoourconsciouslogic(Damasio,1994).

TheDorsolateralPrefrontalCortex

Twothingscontrolmen’snature,instinctandexperience.—BlaisePascal

Thedorsalandlateralregionsoftheprefrontalcortex(dlpfc)integrateinformationfromthesenses,thebody,andmemorytoorganizeandguidebehavior.Thedlpfcperformsavarietyoffunctions,includingdirectingattention,organizingworkingmemory,learningmotorsequences,andorganizingtemporalexperience(Fuster,2004).Thedlpfcisthelatestdevelopingregionofthecortexandcontinuestomatureintothethirddecadeoflife.Thisgradualmaturationofneuralnetworksisvitaltoattentionandjudgment.Itcanbetrackedbylookingattheincreasingcomplexityofschoolcurriculaandlaterthroughtheslowdeclineofautomobileinsuranceratesfromtheteensintothe30s.Theroleofthedlpfcininteractingandcopingwiththeenvironmentishighlightedbythereducedspontaneityandflattenedaffectseenwhentheyaredamaged.

Acomponentoftheintegrationoftop-down,cortical,andlimbicprocessingoccursinthecommunicationbetweentheompfcandthedlpfc.Thebiasoftheseregionstowardtherightandlefthemispheresrespectivelyallowsthemtoalsosupporttheintegrationoftheleftandrightcerebralcortices.Inaddition,thedorsalandlateralareasofthefrontalcortexevolvedtonetworkwiththehippocampuswhilethemedialregionsbecamedenselyinterwovenwiththeamygdala.Thus,thecommunicationamongprefrontalregionsprovidespathwaysofintegrationforthehippocampalandamygdaloidmemorysystemsdescribedearlier.

Emotionandhighercognitioncanbeintegrated,i.e.,atsomepointofprocessing,functionalspecializationislost,andemotionandcognitionconjointlyandequallycontributetothecontrolofthoughtandbehavior.(Grayetal.,2002,p.4115)

Likeatennisdoublesteam,theompfcandthedlpfcdependononeanother’sperformancefor

optimalfunctioning.Iftheompfcisnotdoinganadequatejobregulatingamygdalaactivation,heightenedlevelsofautonomicarousalwillinterferewithdlpfc-directedcognitiveprocesses(Dolcos&McCarthy,2006).Thisiswhywemayhavedifficultiesincomprehendingandsolvingeventhemostbasicproblemswhenwearefrightenedordistraught.Ontheotherhand,ifthedlpfcisnotproperlyprocessingandmanagingenvironmentaldemands,theresultantanxietywillovertaxandeventuallydisruptemotionalregulation.Inessence,bothinnerandouterworldsneedtobebalancedandadequatelyregulatedforoptimalfunctioning.

Attention-Deficit/HyperactivityDisorder

Thinkingisthemomentarydismissalofirrelevancies.—BuckminsterFuller

Jimmy,anelfin8-year-old,wasreferredtometoassesswhetherornothehadattention-deficit/hyperactivitydisorder(ADHD).Beforemeetinghim,Ireadnotesfromhisparents,teachers,andsoccercoachthatdescribedhisbehavior.Allagreedhewasmoredistractedandenergeticthanotherchildrenhisage.HiscoachnotedJimmy’sinabilitytostayfocusedonthegame;oneteacherdescribedhimasabundleofenergy;hisfatherwrote,inbigletters,“Exhausting!”Jimmy’srestlessnessandimpulsivitymadeitdifficultforotherkidstointeractwithhim,andhismotherfelthewasbecomingisolatedashispeerssoughtcalmercompany.

IwalkedintothetestingroomtofindJimmy’smotherslumpedinachairwithherfaceinherhands.ShedidnotreactwhenIenteredtheroomandIwonderedifshemightbecrying.Iscannedtheroom,lookedbehindthechairandsmallsofa,butcouldnotseeJimmyanywhere.BeforeIcouldspeak,Jimmyshouted,“I’muphere!!”Startled,Ilookedupandsawhimperchedontopofasix-footstorageunit.Isawhismothermomentarilypickupherhead,rollhereyes,andloweritbackdownintoherhands.Shewasn’tcrying,justoverwhelmed.Itwasclearthatwhilemakingadiagnosismightnotbedifficult,gettingthroughtheassessmentprocesswouldrequirestaminaandpatience.

JimmydidhaveADHD,withthesamesymptomshisfatherhadwhenhewasaboy.ADHDdoessometimesruninfamilies.Apparently,hisfatherstillsufferedfrommanysymptomsofdistractibilityandrestlessnessthatcreateddifficultiesinhisworkandrelationships.Aftermanyfailedcareerattempts,hefoundconsiderablesuccessinrealestate.Theconstantmovementandtransientrelationshipsutilizedhisenergyandpersonality,whilehischoiceofabusinesspartner—whoexcelledathandlingthedetailsofhissales—protectedhimfromhisdeficitsinattention.Beingastablehusbandandfather,however,provedmoreproblematic.

ThetreatmentforJimmyincludedbehavioraltherapytohelpwithhisattentionandsocialskills,martialartsclasses,andstimulantmedications.Theseandotherinterventionsweredesignedtoboostfrontalfunctioningthroughbiochemicalandbehavioralinterventions(socialskillsandteachinghimtostopandthink),andbygivinghimconstructiveavenuesthroughwhichtochannelhisconsiderableenergy.IndividualslikeJimmywhosufferfromADHDarecharacterizedbyaninabilitytosustainattentionandinhibitextraneousimpulses,thoughts,andbehaviors.Theseindividualscanbeeasilylostindaydreamsorbeinconstantmotion.Theyarealsoindangerofleapingbeforetheylook.Infact,Jimmyhadbeeninjuredayearearlierwhenheracedintoaneighbor’sbackyardandjumpedintothepoolbeforenoticingithadbeendrainedforrepair.

SinceSatterfieldandDawson(1971)firstpointedtoadysfunctionoffrontal-limbiccircuitry,ADHDhasbeenunderstoodtobeadisorderofexecutivecontrol.Thecommonexplanationfrom

psychiatriststoparentsisthattheirchildrenhavealaginfrontallobedevelopmentthatresultsinadisinhibitionofimpulsesfromlowerinthebrainanddifficultieswithtaskswhichrequiresustainedattention.Theyarealsotoldthatthereisagoodchancetheirchildwill“growoutofit”asthefrontallobesmature.Inthemeantime,stimulantmedicationswillturbochargetheselaggingfrontalregions,allowingformorefunctionalbehavior.Whilethisisagoodanecdotalexplanation,theunderlyingmechanismsandtheetiologyofADHDarelikelymuchmorecomplicated.

FunctionalimagingresearchcomparingADHDtonon-ADHDsubjectsrevealsavarietyofpatternsofhigherandlowerlevelsofactivationthroughoutthebrain.Andlikemostpsychiatricdisorders,ADHDisheterogeneousandemergesfromaspectrumofgenetic,biological,andinterpersonalfactors(Sunetal.,2005).Itislikelythattheexplanationsofthecausesandtreatmentsofthedisorderliewithinhierarchicalnetworksbetweentheattentionalandinhibitorycircuitryofthefrontalandparietalcortex,andsubcorticalnetworksinthestriatumandcerebellumthattriggerandorganizemotorbehavior.Itisunwise,however,tonecessarilypositthesedeficitsinthefrontallobebecausecomplexbehaviorsrelyonfar-reachingcircuitrythatcandemonstratesimilardysfunctionsregardlessofwhereinthenetworktheproblemsexist(Seidman,Valera&Makris,2005;Willcuttetal.,2005).

Stimulantmedications(suchasRitalin)maybeworkingonthefrontallobes,thestriatum(Vaidyaetal.,1998),thecerebellum(Andersonetal.,2002),ormoresystemicallybyboostinggenerallevelsofdopamineandnorepinephrine(Arnsten,2000;Arnsten&Li,2005).Allwecanbesureofisthatitisrebalancingthishierarchicalcircuitryinawaythatdecreasesmotoragitationwhileenhancingattention.Becausethebrainworksininteractivenetworks,thesafestworkinghypothesisatthispointisthatthereisaprobleminthehierarchicalneuralnetworksthatbothactivateandregulatebehaviorandattention(Durstonetal.,2003;Leeetal.,2005;Rubiaetal.,1999).

ThinkofplayingagameofSimonSays.SimonSaystestsourabilitiestorespondtothecommandwhilemonitoringandinhibitingourbehaviorbasedonwhetherornotSimonsays.Thewinnerwillbesomeonewithwelldeveloped,balanced,andintegratedbottom-upnetworksofmotorresponsesandtop-downnetworksofinhibitorycontrol.Whenwehearacommandintheabsenceofthewords,“Simonsays,”wefeelourbodyreactandthetensionofinhibitionasweexertcontroltostopourselves.Thepopularityofthisgamewithsmallchildrenreflectsthedevelopmentofthesesystemsaswellasawaytoexercisevoluntarycontroloverimpulses.WhenindividualswithADHDengageintaskssimilartoSimonSays,theyshowalowerlevelofactivityintheusualcorticalareasdedicatedtoinhibitionandinsteadrelyonamorediffuseandlesseffectivegroupofneuralstructuresascompensatorymechanisms(Durstonetal.,2003;Schulzetal.,2004;Zangetal.,2005).

ChildrenwithADHDhavedifficultiesinorganizingtheirbehaviorwhentheyareconfrontedwithsituationsthatrequirethemtoinhibitmotorresponsesandsustainattentiontoaddressingcomplextasks.Thus,theyhavedifficultiesinlearning,whichrequiresattendingtoandrecallingverbalmaterial,complexproblemsolving,andplanning.Theyrequiremuchmoremotivationtomaintainattention,andsotheyoftenexcelatvideogames,whichcapturetheirattentionandforwhichtheirabilitytoshiftattentionservesthemwell.

OurunderstandingofthebrainsofindividualswithADHDisstilllimited,andavarietyoffindingshaveemergedfromresearchusingvariousimagingtechniques(Bush,Valera,&Seidman,2005).Table7.3listssomeofthestudiesthatpointtoanarrayofdifferencesbetweenADHDandnon-ADHDindividualsusingdifferentmeasurementmethods.ThebestguessatthispointisthatindividualsdiagnosedwithADHDlikelyreflectanumberofsubgroupswithdifferenttypesofbraininvolvement.Theysufferfromanumberofdifferentprocessesreflectedinthesize,shape,andfunctionoftheirbrains.Theusualcorticalsystemsofattentionalcontrolandinhibitionappearcompromisedwhileothernetworksattempttocompensate.Subcorticalstructuresinvolvedinmotormovementsarealsoaffectedinwaysthatresultingreaterbutlessorganizedimpactonexperienceandbehavior.

TABLE7.3Attention-Deficit/HyperactivityDisorder

FunctionalMagneticResonanceImaging(fMRI)DecreasedActivationInParietalattentionalsystems1Anterior-midcingulatecortex2Supplementalmotorarea3Rightmiddleprefrontalcortex4Rightinferiorfrontalcortex,leftsensorimotorcortexandbilateralcerebellumlobesandvermis5

IncreasedActivationInLefttemporalgyrus6Basalganglia,insula,cerebellum7

Rightanteriorcingulatecortex8

RegionalCerebralBloodFlow(rCBF)HypoperfusionorDecreasedActivationWhitematterregionsofthefrontallobesandcaudatenuclei9

HyperperfusionorIncreasedActivationRightstriatumandsomatosensoryarea10

BrainMorphology

Smallercerebralandcerebellarvolume11Smallerrightprefrontalandcaudatevolume12Reductionofleftcorticalconvolutionalcomplexityinboys13Corticalthinninginadultsinrightparietal,dorsolateral,andanteriorcingulateareas—allinvolvedwith

attentionalcontrol14Lossofcerebellarvolume15Decreasedfrontalandcerebellarwhitematterdensity16

Lastly,IwanttomentionaphenomenonIhavewitnessedrepeatedlyovertheyears—childrenwhoarediagnosedwithADHDandtreatedwithmedicationbutarebetterdescribedasusingamanicdefensetocopewithoverwhelminganxiety.Anassessmentofthepsychologicalstateofthehousehold—parentalrelationship,parentalpsychopathology,emotionalcontextofsiblingsandextendedfamily,externalstressors,andsoon,canallgoalongwayinsortingoutaproperdiagnosis.Chronicstressnegativelyimpactsfrontallobefunctioningandcanresultinmemoryimpairment,poorimpulsecontrol,anddeficitsofattention(Birnbaumetal.,1999).

Summary

Executivefunctioningisacomplexevolutionaryaccomplishmentthatwearestillintheprocessofunderstanding.Manyregionsacrosstheprefrontalregionsandthroughoutthecortexcontributetoourabilitiestofocus,organizeourthoughts,regulateouremotions,andcreatetheexperienceofself.Headinjury,ADHD,andotherpsychiatricillnessesprovideselectiveinsightintotheresultsofdysregulationorlossofneuralnetworkscentraltoexecutiveprocessing.Asourknowledgeofneuralnetworksexpands,perhapswegainagreaterunderstandingofhowthemindemergesfromthewetwareofthebrain.

Chapter8

ConsciousnessandReality

Peopleareaccustomedtolookattheheavensandtowonderwhathappensthere.Itwouldbebetteriftheywouldlookwithinthemselves…

—KotzkerRebbe

Attheheartofpsychotherapyaretwointerwovenprocesses;thefirstisthewayinwhichourbrainsandmindsconstructreality,whilethesecondisourabilitytomodifytheseconstructionstosupportmentalhealthandwell-being.Inotherwords,whyarewesovulnerabletoconstructingdistortedrealities,andhowcanwelearntocounterbalancethesedistortions?Peoplecometotherapybecauseoneormoreaspectsoftheirlivesarenothowtheywouldlikethemtobe.Mostoftenourclientsknowwhattheyshouldbedoingdifferentlybutcannotbringthemselvestomakechanges.Theycomeinwithafeelingthatsomethingwithinthemisholdingthemback.Theanswerstotheirquestionscanusuallybefoundinthearchitectureofthehiddenlayersofneuralprocessing—thosenetworkswithinthebrainthatconstructourreality,guideourexperience,andshapeouridentity.

Priortomytrainingasaclinicalpsychologist,IspentmanyyearsstudyingthebeliefsandpracticesofEasternreligions.OneofthefirstthingsIdiscoveredwasthatBuddhismislessakintoWesternreligioustraditionsthantotheanalyticintrospectionofWilliamJamesortheselfanalysisofSigmundFreud.AtthecoreofBuddhistteachingsisthebeliefthattheexperienceofworldandselfareillusions(Maya)andthatourmindsandsensesfoolusintoattributingsignificancetothingsthatare,inthemselves,devoidofmeaning.Inotherwords,“reality”isaconstructionofthemindwhichwetaketobeanexternaltruth.So,attheheartofbothdynamicpsychotherapyandBuddhismisthefundamentalbeliefthatourconsciousexperienceisacreativefictionsubjecttodistortion.

Althoughcontroversial,thewayinwhichthebraingeneratesconsciousness,includingitsmanydistortions,mayhavebeensubjecttothepressuresofnaturalselection.Thatis,ourcreativefictionsmaybesculptedtoenhancesurvivalratherthantomaximizeperceptualaccuracy.Whilethewayinwhichourbrainsconstructconsciousnessandrealitymayhavesomesurvivaladvantages,weturnourfocusheretothoseaspectswhichimpairourrelationshipsandlimitself-insight.Youwillsoonseethatthetake-homemessagefrompsychoanalysis,Buddhism,andneuroscienceistobeaskepticalconsumeroftheofferingsofyourmind.

BewareofMaya

Wedon’tseethingsastheyare;weseethingsasweare.—AnaïsNin

Let’sbeginbytakingalookatsomeoftheillusionsofconsciousnessthroughwhichweconstructreality.Thefirstisthatourconsciousawarenesscomestogetheratsomespecificlocationwithinourheadsandispresentedtousonascreen.ThisCartesiantheater—anhomagetoDescartes’sarticulationofmind–bodydualism—createsthesubjectiveillusionofselfasanonphysicalspiritinhabitingthebodyasopposedtobeingonewithit(Dennett,1991).Thisspirit,somereligionsbelieve,canleavethebodyupondeath,gotoheaven,oroccupyanewbodyinthenextlife.

Asecondillusionisthatourexperienceoccursinthepresentmomentandthatconsciousthoughtanddecisionmakingprecedefeelingsandactions.Infact,ourbrainsreacttointernalandexternalstimuliinaslittleas50milliseconds,yetittakesmorethan500millisecondsforconsciousawarenesstooccur.Duringthishalf-second,hiddenlayersofneuralprocessingshapeandorganizethesestimuli,triggerrelatednetworks,andselectanappropriatepresentationforconsciousawareness(Panksepp,1998).Althoughwetendtothinkofourbrainsasprocessinginformationfromtheenvironment,thevastmajorityoftheinputtothecerebralcortexcomesfromwhatisalreadyinsidethebrain.Andbecauseoursensesareshapedbyexperience,theyarealsosilentcontributorstotheconstructionofreality(Gibson,1966).

TheprojectionontothescreenofourCartesiantheaterisactuallygeneratedwithinthehiddenlayersofourneuralarchitecturepriortoconsciousawareness.Thisleadsustoassumethattheworldofourexperienceandtheobjectiveworldareoneandthesame.Wealsotendtobelievethatwehaveallthenecessaryinformationweneedtomakechoices.Intruth,weoftenhavelittleornoaccesstotheinformationorlogicuponwhichwebaseourdecisions.Inaddition,wepossessapowerfulreflextoconfabulateintheabsenceofknowledge(Bechara,Damasio,Tranel,&Damasio,1997;Lewicki,Hill,&Czyzewska1992).Whatwecallintuitionislikelytheresultofrapidandunconsciousprocessingthatcanbesosurprisingtousthatitisoftenattributedtooccultknowledgeorpsychicpowers.

Athirdillusion,whichreliesonthefirsttwo,isthatourthoughtsandbehaviorsareunderconsciouscontrol(Bargh&Chartrand,1999;Langer,1978).Thishubrisleadsustoconsistentlyoverestimatetheauthoritywehaveoveranoutcome,whileunderestimatingtheroleofchance,unconsciousinfluences,andoutsideforces(Taylor&Brown,1988).Soalthoughwemayfeelasifweareatthewheelofourlives,itmightbemoreaccuratetosaythatmostofusaretryingtosteerourliveswiththerearviewmirror.

TheillusionsoftheCartesiantheatre,livinginthepresentmoment,andbeingintotalcontrolofouractionscanbesuccessfullyexposedoncognitiveandneurologicalgrounds.Yettheubiquityofmanyperceptualandcognitivedistortionsineverydayhumaninteraction,providesconvincingevidencefortheexistenceofnonconsciousprocessing(Levy,1997).Andunlikebothersomepsychologicalsymptoms,theseillusionsanddistortionsareinvisiblywovenintothewarpandwoofofourperception,memory,andcharacter(Reich,1945).

Bydefinition,hiddenlayersofneuralprocessingcannotbedirectlyobserved.Likeblackholes,wearemadeawareoftheirexistencebytheireffectsuponthevisibleworld.Hiddenlayerscanmakethesamesituationasourceofpleasureordread,acceptanceorrejection,prideorshame.Theywillhighlightsomeaspectsofexperiencewhilediminishingothers,orientustocertainaspectsoftheenvironment,andcompletelyblockawarenessofothers.Ourhiddenlayerstranslatepastexperienceintoananticipatedfuture,convertingpasttraumaintoaself-fulfillingprophecyoffuturesuffering(Brothers,1997;Freyd,1987;Ingvar,1985).Thiscarryoverofpastlearningintothepresentwhereitmaybeirrelevantordestructiveiscertainlyoneofthecontemporaryhumanbrain’smajordesignflaws.

PerceptualBiasesandSelf-Deception

Themosterroneousstoriesarethosewethinkweknowbest—andthereforeneverscrutinizeorquestion.

—StephenJayGould

Theconsistencyofmanyperceptualandcognitivebiasesacrossindividualsreflectsoursharedneuralorganizationandfunctioning.Someofthesebiasesaretheresultofnaturallimitstoourperspectiveandjudgment,whileothersmayhaveevolvedtohelpuscopewithlivinginanuncertainanddangerousworld.Althoughmanyofourperceptualbiasesappeartoserveus,theycanalsoleadtothekindsofproblemsthatoftenbecomethefocusofpsychotherapy.

Socialpsychologistshaveidentifiedanumberofconsistenterrorsinhumanjudgmentthatcanbeespeciallydamagingtorelationshipsamongindividuals,groups,andnations.Ourtendencytoexplainthebehaviorofothersbasedonaspectsoftheircharacter,whileexplainingourownbehaviorsasaresultofexternalfactors,isreferredtoasthefundamentalattributionerror(Heider,1958).Inotherwords,othersflunktestsbecausetheyarenotsmartenoughoraretoolazytostudy;wefailbecausethetestwasn’tfairorbecausetheprofessorwasn’tverygood.Anextensionofthisattributionalbiasleadstoaphenomenoncalledblamingthevictim,whereindividualsvictimizedbycrimeorpovertyarebelievedtohavedonesomethingtocreatetheirmisfortune(Ryan,1971).

Whileindividualperspectivesarelimitedandincomplete,thisdoesnotstopusfromassumingthatwepossessthetrueviewoftheworld.Thisegocentricbiasleadsustoreflexivelybelievethatanyonewhoseestheworlddifferentlyfromourselvesismisguidedordull-witted.Unfortunately,italsoleadsmortalenemiestobothbelievethatGodisontheirside.Whileanegocentricbiasisreflexiveandself-evident,maintainingabalancedperspectiverequiressustainedmindfuleffort.

Anotherbiasorganizedwithinourhiddenlayersiscalledbeliefperseverance—thetendencytoattendtofactssupportiveofexistingbeliefswhileignoringothers(Lord,Ross,&Lepper,1979).Thehiddenlayersareconservative,holdingontothoughts,feelings,andbehaviorsthathavebeenassociatedwithpastsurvival(Janoff-Bulman,1992).Thus,wescanforexamplesthatprovepreexistingbeliefsandignoreoneswhichcontradictthem.Thistendencyislikelydrivenbythetenacityoffearmemoriesstoredwithintheamygdalaandourdesiretoavoidthepossibilityofdangerintheunknown.Thismayexplainwhyprejudicescontinuetopersistinthefaceofconflictingevidence.

Onereasonthatourabilitiesofself-deceptionmayhavebeenselectedduringevolutionisbecausetheyaidinthedeceptionofothers.Themorewebelieveourowndeceptions,thelesslikelywearetogiveawayourrealthoughtsandintentionsvianonverbalsignals.Infact,itrequiresconsiderablemorebrainpowertoliethantotellthetruth,andevenmoretoconvinceothersthatwearebeinghonestwiththemwhenwearelying(Ganisetal.,2003).Goodpokerplayersraisetheskillofsocialdeceptiontoanartbykeepingapokerfacewhilelearningthe“tells”oftheiropponents.Actionsandbeliefsthataretheoppositeofourtruedesirescanbequiteeffectiveindeceivingothers.Ithasalsobeennotedthat“peopleareremarkablyreluctanttoconsiderimpuremotivesinaloudmoralist”(Nesse&Lloyd,1992,p.611)despitetherepeatedandwell-publicizeddownfallofonemoralcrusaderafteranother.Infact,thebestconartistsareoftensoconvincingthattheirvictimsrefusetoacceptthattheyhavebeencheatedatall.

Thedistortionsofthepsychodynamicunconscious—reflectedindefensemechanismssuchasreactionformation,denial,humor,andintellectualization—arethoughttokeepthoughtsandfeelingsoutofconsciousawarenesstohelpusregulatenegativeemotions.Defensemechanismsmayenhancesurvivalbyreducingshame,minimizinganxiety,anddecreasingawarenessofdepressinganddemoralizingrealities.Somedefensesalsosupportsocialcooperationandleadustoeitheroverlookorputapositivespinonthebadbehavioroffamilyandfriends.Freudrecognizedthatwecanseetheworkingsofdefensemechanismsandotheraspectsoftheunconsciousinthewaythatweorganizeandunderstandambiguousstimuli.Inaconditionofreducedexternalstructure,ourhiddenlayersorganizetheworld,makepredictions,andhighlightcertainthoughtsandfeelingswhileignoringothers.YoumayrememberthatFreudreferredtothisphenomenonastheprojectivehypothesis.

Therapistsemploytheprojectivehypothesistoexplorethearchitectureoftheirclients’unconscious.Sometrytoremainasneutralaspossibletoallowclientstoprojectfeelingsandthoughtsontotheminaprocessreferredtoastransference.Inasimilarmanner,projectivetestsliketheRorschachpresentambiguousstimulitoevokeidiosyncraticperceptionsofthematerial.Finally,becauseoftheiruninhibitednature,Freudwasimpressedwiththevalueofdreamsinprovidinguswithinsightintohiddenlayers,callingthem“theroyalroadtotheunconscious.”

Mostformsofpsychotherapyattempttoshinethelightofconsciousawarenessonbeliefperseveranceandattributionbiases,andunderminetheconservativenatureofthehiddenlayers.Othersengageinadeepexplorationofthedynamicunconscious,defenses,andprimitiveemotionalstates.Byencouragingclientstobeopentonewideas,exploretheconnectionswithintheirhiddenlayers,andtakeresponsibilityforpositivechange,wechallengethemtoreorganizetheneuralnetworksoftheirhiddenlayers.

SearchingfortheStillPoint

Menaredisturbednotbythings,butbytheviewwhichtheytakeofthem.—Epictetus

Bynowitisclearthatourbrainsareinthebusinessofconstructingratherthanconveyingreality.ThisperspectiveisinsharpcontrasttothemodernWesternnotionofthebrainasacombinationcamera,taperecorder,andcomputer.Ifourelectronicequipmentreallydidfunctionlikeourbrains,wewouldreplacethematthefirstopportunity.ButI’msureyouwouldagreethat,imperfectastheyare,wewouldtakeourbrainsoveramachineanyday.Fewofuswouldwanttosacrificefeelingsoflove,inspiration,andpassionforthesakeofaccuracyorefficiency.

Oncewewakeuptohowourbrainswork,whatdowedo?Howcanweovercomeoratleastcopewithourdistortions,impulses,andunconsciousdrivesinconstructiveandhealthyways?Fortunately,ourbrainscontainstructuresandnetworksthatallowustocounteractsomeofthemoreproblematicworkingsofourhiddenneurallayers.Let’sbeginanexplorationoftheevolutionofconsciousnesswithicecream.

I’mapersonwhohasbeenonadietallmylifewithlimitedsuccess.Icoulddowellallday—eatproperlyandexercise—butatnight,Iwouldseemtohavenoself-control.Iwouldgointoeachdayfeelingbadaboutthenightbeforeandvowtodobetter,onlytofailagain.YearsintotherapyImentionedthisinasessionandwasgiventhefollowingsuggestion:“Payattentiontoyourthoughts,feelings,andfantasiesduringthetransitionfromdoingwelltoyourlossofcontrol.”Itturnedoutthat,dependingontheday,Ifeltexhausted,stressed,lonely,ordissatisfiedwithonethingoranotherontheseevenings.WhenmytherapistaskedwhatIdidwiththesenegativeandpainfulfeelings,Iwasstumped.Ididn’trememberdoinganythingwiththem—theyseemedtojustdissolve.AsIstruggledtomakesenseofthisprocess,Irecalledavividmemory.

Iwasayoungboyof5or6standinginmygrandmother’skitchenandhadjustexpressedbeingupsetaboutsomething.Icouldfeelmyunhappinessexpressedinthemusclesofmyfaceandrecallmygrandmother’sfacemirroringmine.Withoutsayingawordshepivotedaround,openedthefreezer,tookoutalargeboxofNeapolitanicecream(chocolate,vanilla,andstrawberryinthreeneatrows),toreoffthecardboardtabholdingthelidclosed,buriedaspoonintheicecream,andhandedmetheentirebox.AlsowithoutawordIwenttothesofa,laydown,putthequartoficecreamonmychestandbeganeating.Infacttherewerenowordsatall.TherewasnomemoryofdiscussinghowIfelt.WhateverbadfeelingsImayhavebeenhavingquicklydissolvedinahazeofglucose.

Thesimilarityofthismemorytomyexperienceinmyadultlifewasstriking.Myhiddenlayershadlearnedapattern—feeltired,sad,stressed,ordisappointed;getlotsofcalories;watchTV;andthefeelingspass.Theseearlymemorieswereencodedinhiddenlayersandguidedmybehaviorwhentriggeredbysimilarstatesofmind.Beingthefirstgrandchildinanextendedfamilythathadexperiencedagreatdealofsadnessandloss,Irealizeinretrospectthatnoonecouldcopewithmysadness.Iwasthehopeforabetterfuturewheretherewouldbenopain.Havingnolanguagewithwhichtoprocessmyfeelings,Icouldonlydealwiththemthroughactions.AslongasIcontinuedtoactthisprocessoutwithoutawarenessofwhatwashappening,itcontinuedinastereotypedmannermuchlikeaposttraumaticflashback.

Whatisitthatallowsustobecomeself-aware,generateexplanations,andmodifylong-standingwaysofbeing?Howdoweexpandconsciousawarenessinwaysthatallowustochange?Obviously,somethinghastochangeinthewayourbrainsprocessinformationwhenwebenefitfrompsychotherapy.Let’sexploretwocentralregionsinvolvedinawarenessandchange—theprefrontalandparietalcortices.

Becausebehavioriseasilyobservable,neurologistshavetraditionallyfocusedonthemanifestresultsofbraininjurysuchasdeficitsinlanguage,motorbehavior,andmemory.Atthesametime,therehasbeensignificantconfusionandmisunderstandingwhenitcomestochangesinsubjectiveexperience.Ihaveworkedwithmanyclientswhoperformwithinnormativerangesonobjectivetestsofmemoryandintellect,butcomplainthattheirinnerworldsarenolongerthesame.Someusethemetaphorofahouseandsaythatsomeroomsarenolongeraccessibletothem.Othershavedescribedblackboardstheycouldusetoworkoutproblemsthathavebeenlost.Thesesubtleandelusiveaspectsofhumanexperiencehavereceivedlittleattentionfromneurologists.Whatisevenmoredifficultforclientsistoperformwellonobjectivetestsofmemoryandproblemsolving,andbetoldthattheyhavefullyrecovered,wheninfacttheyknowbetter.Theiruseofthree-dimensionalmetaphorslikehousesandblackboardstodescribeinnerexperiencemaybetelling.Isthehouseasanarchetypefortheself(asCarlJungsuggested)morethanmyth?

Howdoesthebrainachieveconsciousawareness?Whereistheseatofconsciousness?Theanswertobothofthesequestionsisthatwedon’tyetknow.Atthispoint,wemustbesatisfiedwithdiscoveringpiecesofthiscomplexpuzzleofconsciousnessthatwillbeassembledsometimeinthefuture.Becauseexecutiveproblemsoftenariseafterdamagetotheprefrontalareas,itisgenerallyassumedthatconsciousnessandself-awarenessresidewithintheseregions,butthekeytounderstandingconsciousnessextendsbeyondthefrontallobes.Wecanbesomewhatconfidentthatconsciousnessemergesfromthecoordinationofmanyprocessesthroughoutthebrainandthattheprefrontallobesaremajorplayers.Iwouldsuggestthatanothermajorcontributortoourconsciousexperienceisourparietallobes.Letmeexplainwhy.

TheParietalLobes

Thesoulneverthinkswithoutamentalpicture.—Aristotle

Youmayrememberthattheparietallobesevolvedfromthehippocampuswhich,inlowermammalsandhumans,organizesaninternalthree-dimensionalmapoftheexternalenvironment(Joseph,1996;O’Keefe&Nadel,1978).Thisisespeciallyusefulinnavigatingahabitatforforaging,storing,andretrievingfood.Thehippocampiofmotherratsactuallyincreaseinsizewhentheyhavebabies,inpreparationforhavingmoremouthstofeed.ThehippocampiofcabdriversinLondonarelargerthanthoseofotherLondoners,

becauseoftheirneedforadetailedinnermapofalargeandcomplicatedcity(Maguire,Woollett,&Spiers,2006).Itseemsthattheparietallobesdevelopedaparallelcapacityforconstructingandnavigatingamapofinternal,imaginalspace.

Curiously,somestudiesofprimatebrainevolutionsuggestthatexpansionoftheparietalandnotthefrontallobesismostcharacteristicofthetransitiontothehumanbrain(vonBonin,1963).Couldthefactthatwedon’tthinkoftheparietallobesasacomponentoftheexecutivebrainreflectaculturalbiasofequatingindividualswiththeirexternalbehaviorratherthanthequalityoftheirinnerexperiences?Theparietallobes’interconnectionswiththerestofthecortexallowedfortheintegrationofworkingvisualmemory,attentionalcapacities,andbodilyawarenessnecessaryfortheseimaginalabilities.Thissuggeststhatourself-awarenesswaslikelybuiltinastepwisemannerduringevolutionthroughaseriesofoverlapping“maps”—firstofthephysicalenvironment,thenofselfinenvironment,andlaterofselfasenvironment.Thus,thegrowthofimaginalabilitiesallowedustocreateanincreasinglysophisticatedinnertopography.

Thelowerpartsoftheparietallobesdevelopthroughthefirstdecadeoflifeinparallelwithourincreasingabilitiesinreading,calculations,workingmemory,andthree-dimensionalmanipulation(Joseph,1996;Klingberg,Forssberg,&Westerberg,2002;Luna,2004).Cellsintheseinferiorparietalregionsrespondtohandposition,eyemovement,words,motivationalrelevance,bodyposition,andmanyothercomponentsoftheintegrationofphysicalexperienceinspace.Leftparietaldamagedisruptsmathematicalabilitieswhiledamagetotherightparietalloberesultsindisturbancesofbodyimageandtheneglectoftheleftsideofthebody.Despitethesefloridanddebilitatingsymptoms,patientsareeitheroblivioustoordenythesignificanceoftheirdeficits,whichsuggeststhattheparietallobesserveanexecutiveroleintheorganizationofself-awareness.Damagetotheparietallobesdisruptstheexperienceoflocation,self-organization,andidentity—inotherwords,whoandwhereweare(seeTable8.1).

TABLE8.1ManifestationsofParietalCompromise

LeftParietalCompromiseResultsInGerstmannsyndrome,whichincludesthefollowingsymptoms:Right-leftconfusionDigitalagnosia(inabilitytonamethefingersonbothhands)Agraphia(inabilitytowrite)

Acalculia(inabilitytocalculate)1

ThesymptomsofGerstmannsyndromearelinkedthroughaunitarydeficitinspatialorientationofbody—sides,fingers,andnumbers2

RightParietalCompromiseResultsinDeficitsOfMentalimageryandmovementrepresentations3Visual-spatialawareness4Visual-spatialproblemsolving5Temporalawarenessandtemporalorder6

Spatialperception7Somatosensoryexperience8Detectingapparentmotion9

Theanalysisofsoundmovement10Spatial-temporalabnormalities11Contralateralneglectofthebodyandexternalspace12Denialofhemiparalysisandneglect13

Theposteriorparietalregionsweavetogethersensoryinformationaboutourphysicalenvironmentwithnetworksoforganizedmotoricactionsandintentionswhich(alongwiththefrontallobes)creategoal-directedactionplans(Anderson,Snyder,Bradley,&Xing,1997;Colby&Goldberg,1999;Medendorp,Goltz,Crawford,&Vilis,2005).Incombinationwithepisodicandworkingmemory,thiswouldprovideaworkspacefordecisionmakingaboutwhetherornottoperformanaction—shouldIeattheicecreamorissomethingelsegoingonthatIshouldpayattentionto?Utilizingtheseabilities,afrontal-parietalnetworkcouldsupporttheintegrationofperceptionandactionovertime(Quintana&Fuster,1999).

Parietalactivationoccursduringawidevarietyofcognitivetasks,suggestingthathigh-levelassociationareasinvolvedinthecoordinationofsensoryandmotorprocessingunderliewhatweexperienceasabstract(nonphysical)processes(Culham&Kanwisher,2001;Jonidesetal.,1998).Itislikelythatevolutionhasusedthesecorevisual-spatialnetworkstoserveasaninfrastructureforlanguageandhighercognitiveprocesses(Klingbergetal.,2002;Piazzaetal.,2004;Simonetal.,2002).Theparietallobesparticipateinourconsciousawarenessofvisualexperience,voluntaryactions,andasenseofagencyduringactions(Chaminade&Decety,2002;Decetyetal.,2002;Rees,Kreiman,Koch,2002;Siriguetal.,2003).Themultimodalrepresentationofspaceintheposteriorparietalareasintegratesourgoal-directedbehaviorandattentionwithhighercognitivefunctions(Andersenetal.,1997;Bondaetal.,1996;Corbetta&Shulman,2002;Culham&Kanwisher,2001).

Likethefrontallobes,areasoftheparietallobesbecomeactivatedbynoveltyandappeartobeinvolvedincodingintentionsandcalculatingtheprobabilityofsuccess(Platt&Glimcher,1999;Snyder,Batista,&Andersen,1997;Walsh,Ashbridge,&Cowey,1998).Thesefindingspointtothefactthattheparietallobesarefarmorethansensory-motorassociationareas,butareinvolvedinthedeploymentofattention,understandingtheenvironment,andconstructingtheexperienceofself(seeTable8.2).

Themedialparietalareacanbeconceptualizedasthecentralstructureforself-representation,self-monitoring,andastateofrestingconsciousness(Louetal.,2004).Damageatthejunctionoftheparietalandtemporallobescorrelateswithout-of-bodyexperiencesandavarietyofotherdisturbancesofidentityandself(Blanke&Arzy,2005).Thereisalsoevidencetosuggestthattheparietallobesparticipateinthecreationofinternalrepresentationsoftheactionsofotherswithinus(Shmuelof&Zohary,2006).Inotherwords,weinternalizeothersbycreatingrepresentationsoftheminourimaginations.Thisallowsustobothlearnfromothersandcarrythemwithuswhentheyareabsent.Theseinnerobjects,asdescribedinpsychoanalysis,likelyserveastheinfrastructureoftheconstructionandmaintenanceofourexperienceofself(Macraeetal.,2004;Tanji&Hoshi,2001).

TABLE8.2FunctionsoftheParietalLobes

Hemisphere FunctionRight Analysisofsoundmovement1

Generalcomparisonofamounts2

Attention3

Self-facerecognition4

Left Verbalmanipulationofnumbers5

Mathematics6

Multiplication7

Motorattention8

BilateralFindingsVisual-spatialworkspace9

Visual-spatialproblemsolving10

Visualmotion11

Constructionofasensory-motorrepresentationoftheinternalworldinrelationtothebody12

Internalrepresentationofthestateofthebody13

Verbalworkingmemory14

Retrievalfromepisodicmemory15

Sequenceandorderingofinformationinworkingmemory16

Controllingattentiontosalienteventandmaintainingattentionacrosstime17

Preparationforpointingtoanobject18

Grasping19

Movementofthree-dimensionalobjects20

Asenseof“numerosity”definedasnonsymbolicapproximationsofquantities(l)21

Processingofabstractknowledge22

Perspectivetaking(r)23Processingofsocialinformation(r)24

Takingathird-personperspective(r)25

(l)lefthemisphere(r)righthemisphere

Somesortoffrontal-parietalnetworkappearstobeessentialtoourexperienceofself.Neuralfibersconnectingthemiddleportionsofthesetwoareasappeartoserveageneralintegrativefunctionoflinkingrightandlefthemispheres,limbicandcorticalstructures,aswellasanteriorandposteriorregionsofthecortex(Louetal.,2004).Frontal-parietalnetworksworktogethertoanalyzethecontextandlocationofspecificvariables,worktointerruptongoingbehavior,anddirectattentiontonewtargets(Corbetta&

Shulman,2002;Peersetal.,2005).Frontal-parietalcircuitsarealsoinvolvedinthesustainedfocusandupdatingofinformationinworkingmemory(Edinetal.,2007;Sausengetal.,2005).Theymaytogethergiverisetoaglobalworkspaceorcentralrepresentationallowingforconsciousworkingmemoryandself-reflection(Baars,2002;Cornette,Dupont,Salmon,&Orban,2001;Taylor,2001).

Thefrontal-parietalnetworkmaybeprimarilyresponsiblefortheconstructionoftheexperienceofself(Lou,Nowak,&Kajer,2005).Aproperlyfunctioningfrontal-parietalnetworkallowsforthesuccessfulnegotiationofourmoment-to-momentsurvivalandtheabilitytoturnourattentiontoinnerexperience.Acompromisedorpoorlydevelopedprefrontalcortexcanensnareusin“anoisyandtemporallyconstrainedstate,lockingthepatientintotheimmediatespaceandtimewithlittleabilitytoescape”(Knight&Grabowecky,1995,p.1368).Withouttheabilitytoreflectonandsometimescancelreflexivemotorandemotionalresponses,thereislittlefreedom(Schall,2001).Asimilarphenomenoncanoccurwithanxiety,asinobsessive-compulsivedisorder.Whenthemedialfrontallobesareincapableofadequateaffectregulation,victimsbecome“stuck”totheenvironmentor“stimulusbound”andunabletooverridereflexivereactions(Brownetal.,1994).

ConstructingaSelf

Inevercametoanyofmydiscoveriesthroughtheprocessofrationalthinking.—AlbertEinstein

Creatingaquietinternalworldallowsforprivatethought,self-reflection,andtravelingthroughtimeviaepisodicmemory.Quietmomentscanthenserveasthegroundsformentalization,creativity,andconsolidatingtheself(Winnicott,1958).Victimsoffrontalbraininjurylosethisabilityandareconstantlydistractedbysensoryandemotionalexperience,areunabletomaintainfocus,andsufferdeficitsofimagination.Theseindividualsbecometrappedintime,unabletodisengagefromtheconstantstreamofsensations,emotions,anddemandsoftheirinnerandouterworlds.Althoughtheyretainconsciousness,forthem,attention,concentration,affectregulation,andmotivationbecomeproblematic,whilehigherlevelmetacognitiveprocessesbecomeimpossible.

Winnicott(1962)suggestedthattheegoandone’ssenseofselfconsolidateduringtheperiodsofquiescencewhenchildrenfeelsafeandcalminthepresenceoftheirparents.Good-enoughparentingscaffoldsthechild,allowinghimorhertogo“inside”andrestinimaginationandtheexperienceofself(Stern,1985).Thismayserveasanimportantmechanismofthetransmissionofneuralorganizationfromparenttochild.Itisraretofindachildwhoisabletobestillandcenteredandfeelsafeinthepresenceofchaoticadults.Webelievethatearlycaretakingbuildsandshapesthecortexanditsrelationshipswiththelimbicsystem,whichsupportsemotionalregulation,imagination,andcopingskills.Tothiswenowmustaddthedevelopmentoftheparietallobesintheconstructionofinternalspace.

AsachildIhadanimaginaryretreat.Iwouldclosemyeyesandpicturethebackofmygrandmother’scloset,alwayspiledhighwithshoeboxes.Behindtheseboxeswasahiddendoorjustlargeenoughforme(butnotanadult)tosqueezethrough.Oncethroughthedoor,therewasaflightofstairsleadinguptoalargeroomresemblingamedievallaboratory,thekindwitharesidentsorcerer.Thiswasasafeplaceforme—quietandprivate—whereIcouldimagineotherworlds,reflectonlife,andfantasizeaboutthefuture.Theevolutionandexpansionoftheparietallobeswerelikelyessentialtotheemergenceofthiskindofimaginalself.

Onestudyhasshownthatwhenexperiencedmeditatorsengageinmeditation,thefrontallobesbecomelessactivewhiletheparietallobesbecomemoreactive,reflectiveperhapsofashiftfromouter

toinnerattention(Newbergetal.,2001).Otherstudieshaveshownashifttolefthemisphereactivationandstrongerimmuneresponsewithmeditation(Davidson,Kabat-Zinn,etal.,2003).Interestingly,inferiorregionsoftherightparietallobebecomeactivatedwhenwewitnessothersbeingstill.ThismayexplainhowmeditatingoninanimateobjectsorstatuesofatranquilBuddhamayhelpusfeelcenteredwithinourselves(Federspieletal.,2005).Thismayalsobeapartofinternalizingcalmparentsasamodelforself-reflection.

Johnson(1987)assertsthattheexperienceofourbodiesprovidestheinternalbasisformeaningandreasoningwithoursenseofnumbers,quantity,andspacegrowingoutofbodilyexperience.Thebrain’sabilitytotakeourphysicalexperienceanduseitmetaphoricallyisthebasisofimagination.Forexample,jumpingdownaslidemayserveasasensory-motormetaphorforfallinginlove.Thechild’sexperienceofemergingfromunderthecoversintothelightofdayprovidesametaphorforreligiousenlightenmentlaterinlife.Thebalanceprovidedbythevestibularsystemmaybethemodelforpsychologicalandemotionalstability,andultimatelyforleadingamorebalancedlife(Frick,1982).Physicalmetaphorsprovideacontextualgroundingintimeandspacethathelpsusgraspourexperienceandmayserveasaninfrastructureofhighercognitiveprocesses.

AlbertEinstein,whodidpoorlyinmathduringhisformaleducation,wentontosolvesomeoftheuniverse’smostcomplexmysteries.Heintuitedrelationshipsbetweentime,matter,andenergy,whichcontributedtothedevelopmentofatomicenergyandbroughtusastepclosertounderstandingtheworkingsoftheuniverse.Iremembermyseventhgrademathteacherpraisinguswiththephrase“LittleEinstein.”Asyoucanimagine,manyneuroscientistswereinterestedinhavingalookatEinstein’sbraintoseeifandhowitdifferedfromyoursandmine.Incomparisonto91otherbrains,Einstein’swasdifferentonlyinthesizeoftheinferiorparietallobe(Witelson,Kigar,&Harvey,1999).AsubsequentexaminationofthesameregionrevealedlowerratiosofneuronstoglialcellswhencomparedtootherareasofEinstein’sbrainaswellastothebrainsofotherpeople(Diamondetal.,1966;Diamond,Scheibel,Murphy,&Harvey,1985).Itishighlylikelythatthisenhancedneural-glialrelationshipenhancedneuronalactivityandledtosuperiorvisual-spatialabilities(Nedergaardetal.,2003;Oberheimetal.,2006;Taber&Hurley,2008).

TheseneuroanatomicalfindingsareespeciallyinterestinginlightofEinstein’sreporteduseofmentalimagerytosolvecomplexconceptualproblems.Einsteindescribedtranslatingnumericalequationsintoimagesthathewouldmanipulateinimagination,comeupwithsolutions,andtranslatebackintoequations.Thisabilitytoconceptualizeandmanipulatethree-dimensionalobjectsinimaginationappearstoseparateusfromotherprimatesandmaybeauniquelyhumanevolutionaryaccomplishment(Orbanetal.,2006;Vanduffeletal.,2002).Basedonhisdescriptionofhisproblem-solvingstrategiesandthefindingsconcerninghisbrain,itispossiblethatEinstein’sunusualparietallobesmayhavebeencentraltohisgenius.

Einstein’sdifficultyinnavigatingthesimpledemandsofday-to-daylifewasnotorious,makinghimthearchetypicalabsent-mindedprofessor.Interestingly,onestudyhasshownthatthevolumesofthefrontalandparietallobesdemonstratesignificantnegativecorrelation(Allen,Damasio,&Grabowski,2002).Beingabsent-mindedmayhavebeenthepricehepaidforanoverdevelopedparietallobe.Researchsuggeststhatinnerimaginalspaceenhancesthepossibilityforcreativeproblemsolving,empathy,andcompassion.PerhapsthisisoneofthereasonsthatEinsteinturnedhisattentiontoworldpeaceandotherhumanitarianconcernslaterinlife.

TheExecutiveBraininPsychotherapy

Allofourfinaldecisionsaremadeinastateofmindthatisnotgoingtolast.

—MarcelProust

Asstatedearlier,thebrainisanorganofadaptation,aprocessthatcontinuesforaslongaswelive.Giventheirroleashigh-levelassociationareassculptedbyongoingexperience,thefrontalandparietallobeslikelyretainagreatdegreeofneuralplasticity.Thisplasticityandtheirjointrolesinthesynthesisofphysical,social,andemotionalinformationmaketheseregionsprimarytargetsofpsychotherapy.Inlinewiththis,psychotherapyrequiresthatwestepawayfromreflexivebehaviorandtheimmediatedemandsoftheenvironmenttoreflectuponourexperiencesinsophisticatedways.Actingininsteadofactingoutprovidesuswiththeinterpersonalandintrapsychicspacetotryonnewtruths.Considermyclient,Sandy,whofoundherselftrappedinamysteriouscycleofchangingattitudesandmoods.

Sandycametotherapyinhermid-40swiththeusualconcernsaboutrelationships,family,andcareer.Althoughhermoodwasgenerallyupbeatandpositive,sheoccasionallycametosessionsfeelingirritable,deflated,andhopeless,leadingmetothinkthatshemightbesufferingfrombipolardisorder.WhenImentionedherfluctuatingmoods,shewasdistressedthattheywerenoticeabletoothers.Shetoldmethatshehaddiscountedtheirimportancebecausetheydidn’tseemtorelatetoeventsinherlife,“justhormonesIguess.”

OnceSandybegantofocusherattentiononthesemoods,shereaffirmedthattheyseemedtocomeoutofnowhereanddisappearjustasmysteriously.Whenshewasdown,shefeltlikeafraud,andplannedtoquitherjobandleaveherhusband.“WhenIfeelthisway,”shesaid,“Ijustlosethewilltolive.”Onfurtherreflectionsherealizedthatthesemoodstateshadbeenpartofherlifeforaslongasshecouldremember—recallinginstancesasfarbackaselementaryschool.

Wemonitoredanddiscussedherexperiencesthroughanumberofmoodcyclesandengagedinconsiderablespeculationabouttheirorigin.Herfatherwaspronetomoodinessandshehadamaternalauntwhohada“nervousbreakdown”decadesearlier,whichmadeusconsiderageneticinheritanceormodelingbehaviorsthatshesawasachild.Sandystruggledtofindthoughts,feelings,oreventsinherlifethatwouldprecipitatethemanddiscoveredthattheydidnotcoincidewithanythingrelatedtoherwork,family,menstrualcycle,exercise,ordiet.Allseriousmedicalconditionswereruledout,heronlyphysicalcomplaintbeingherallergiesandfrequentsinusinfections.Ontheoutsidechancetherewassomerelationshipbetweenheruseofantihistaminesandhermoodchanges,wecreatedamoodchartthatincludedheruseofmedication.

Althoughwedidnotfindanyconnectionbetweenmoodandmedication,itdidturnoutthatsheconsistentlylostherwilltoliveadayortwobeforesufferingasinusinfection.Hermoodwouldthenimproveshortlyaftertheonsetofherrespiratorysymptomsandheadaches.Oncewemadethisconnection,wewaitedforthenextdipinmoodtoseeifitwouldagainbefollowedbyasinusinfection.Sureenough,thesamepatternemerged.Althoughwestilldidnotknowwhataffectedhermood,thetimingdidsuggestthatitwasrelatedtothecycleofherallergiesandsinusinfections.Uptothispoint,ourworktogetherdependeduponSandy’sabilitytoreflectonherexperiences,analyzeherreactionstosituations,andthinkaboutherthinking.NowitwastimetodevelopSandy’smemoryforthefuture,andcreatesomeexperimentsfocusedonalternativeplansandactions.

Wedecidedtoanticipatehernextdipinmoodwithanewplan.Weagreedthatshewouldstopevaluatingherlifeondaysthatshelostherwilltolive.Shewasnotallowedtothinkaboutleavingherhusbandorherjob,orassessherworthasaperson.Instead,themooddipwouldbeacueforhertogotothehealthfoodstore,buyvitaminCandzinctablets,andrearrangeherscheduletoreducestress.Shealsomadeanappointmentwithanewallergist.Inessence,herassignmentwastorememberthefutureinthepresent.Sandyhadtoremainmindfulofthepossibilitythatwhatsheexperiencedasnegativeemotionswasreallyaresultofbiologicalchangesrelatedtoaphysicalillnessandnotacollapseofcharacterorimpendingglobalcatastrophe.Weworkedondevelopingasafeinternalplaceforhertoretreattoatthese

times,whereshecouldsootheandcomfortherselfandfocusonhealing.Overtime,theassociationbetweensinusinfectionsandmoodchangesheldup—wehadcreateda

newnarrativewithfarmoreexplanatorypowerthantheoneitreplaced.Forsomeunknownreason,Sandy’sbiochemistryreactedtoinfectionwithasharpdropinmood,mostlikelyrelatedtodropsinserotoninanddopamine.Thepsychologicaldepressionexperiencedasaresultofthesechangesledhertoreinterpret,inanegativeway,thevalueofallaspectsofherexistence.Howshedealtwiththesefeelingswasneitherpleasantnoradaptive.Bybeingmindfulofthisprocessandusingherfrontalandparietalexecutivefunctionstoassociateexperienceswithnewmeanings,shewasabletoengageindifferentbehaviorsandcreateabetteroutcome.Wehadconvertedwhatusuallyledtoanexistentialcrisisintoatriggerforenhancedself-awareness,self-care,andmedicalmanagement.

Sandyneededtolearnhowtopayattentiontoherfeelings,reflectonthemwithpastexperiencesinmind,andfollowanewplanofactioncontrarytooldreflexivepatterns.TheseimportantfrontalfunctionsallowedSandytoescapefromautomaticanddetrimentalbehaviors.Shewasabletomodifystimulus-responseconnectionsbyescapingthepresentmomentbothintherapyandtheninherday-to-daylife,firstimaginingandthenexecutinganewscenario.AsSandylearnedtounderstandthefunctioningandfluctuationsofherbrain,shewasabletoutilizeexecutivefunctionsandanimaginalselftogaininsight,perspective,andchangedysfunctionalpatternsofbehavior.

Summary

Theexplorationofhumanconsciousnessisavastnewfrontierforneurosciencewheretheremayalwaysbemorequestionsthananswers.Weknowconsciousnessexists;wejusthavenoideaofhowitemergesfromthefunctioningofthebrain.Aninherentchallengetothisexplorationwillalwaysbetheconflictofinterestinvolvedwhensomethingisstudyingitselfwithallthebiasanddistortionthatinterfereswithobjectiveobservation.Thereisnoeasywayaroundthis.

Chapter9

FromNeuralNetworkstoNarratives:TheQuestforMultilevelIntegration

Thereisnogreateragonythanbearinganuntoldstoryinsideyou.—MayaAngelou

Itappearsthatnaturehasretainedafundamentalstrategyofconnectingthings—betheyneurons,neuralnetworks,orindividualpeople—intomorecomplexorganizations.Aswezoomintolookatgroupsofneuronsandzoomouttolookatgroupsofpeople,thesamebasicprinciplesofconnectivityandhomeostaticbalanceappeartoholdtrue.Aswelearnaboutthenecessarysynergisticconnectivityofneuralnetworks,wearealsocomingtounderstandtherelationshipbetweennetworkimbalanceandmentaldistress.FromextremePTSDtoeverydayneurosis,weallexhibitapatternofintegrationanddissociationreflectiveofouradaptationalhistoryandthehealthofourbrains.Attheleveloftheexperienceofself,networksdedicatedtosensation,perception,andemotionseamlesslyintegrateintotheemergenceofconsciousexperience(Damasio,1994;Pessoa,2008;Foxetal.,2005).Let’stakealookattheimpactofasomewhatsimplebreakdownofneuralnetworkintegrationontheexperienceofself.

Afewyearsago,ayoungmaninhislateteenscameinforatherapysession.ThepreviousSeptember,Craighadlefthometoattendhisfirstyearofcollege,butbymid-December,somethinghadgonehaywire.HisparentswerecalledbythedeanandtoldthatCraighadnotbeengoingtoclassesforweeks.Theywerealsoinformedbytheresidentadvisorthat5daysearlier,Craighadlockedhimselfinhisroom,thrownallofhisandhisroommate’spossessionsoutofthewindow,andwaslisteningtothesamesong24hoursaday.Hisparentsracedtocampustofindhiminthemiddleofanacutepsychoticepisode.

CraighadbeenreleasedfromthehospitalwhereIworkedjustafewweeksearlieranditwasgoodtoseehimonceagainindependentandactive.Ashewalkedacrossmyoffice,Icouldseehismovementswereslowedbythemedicationsthatwerekeepinghishallucinationsatbay.IhadseenCraiginindividualandgrouptherapyforapproximatelyamonth.Hissymptomshadslowlyclearedandhewasreleasedtohisparents’careaweekearlier.Thiswashisfirstsessionsincebeingdischarged.Afterhesettledin,Iaskedhimhowthingshadbeengoingsinceheleftthehospital.Slowly,andinasoftvoice,hetoldmethatlifewasprettygoodandthatheenjoyedplayinghisguitarandworkingonsomenewsongs.Hewasn’tfeelingparanoidorhearingvoiceslikehehadbeenweeksago,hissleepandappetitewereokay,andhefeltlikehewasreadytoreturntoschool.“There’sonlyoneproblem,Doc.Idon’tfeelcomfortableathomebecausemyparentsandbrotherhavebeenreplacedbydoubles.”

“Doubles?”Iaskedhim.“Whatdoyoumean,doubles?”Craigstartedbysayingthathehadgottenastrangefeelingabouthisparentsandbrotherwhenthey

cametovisithiminthehospital,buthefiguredhewasoffbecauseofthemedication.Butoncehegothome,hediscoveredthereasonforhisstrangefeelings.“AfterawhileIrealizedthatthey’vebeen

replacedbydoubles!”Igavehimmybestquizzicaltherapistexpressionandaskedwhatmadehimthinktheyweredoubles.

Craigdescribedhowtheywereexcellentcopiesandwellpreparedtotrickhim.Heaskedthemscoresofquestionshethoughtonlyhisparentsandbrothercouldanswerand,sureenough,theygotthemright.“Whoeverisdoingthistomeisgood!”hesaidwithnervousadmiration.WhenIaskedhimagainhowhecouldbesosuretheywerereplacements,herepliedwithannoyance,“Don’tyouthinkIwouldknowmyownparents?”

Thissyndromeofsuspectingimpostors,calledCapgrassyndrome,canoccuralonebutusuallyappearsintandemwithsomeotherbraindysfunctionsuchasschizophrenia,temporallobeepilepsy,orheadinjury(Serieux&Capgras,1909).AlthoughtheneurobiologyofCapgrassyndromeisnotdefinitivelyunderstood,therehasbeenongoingspeculationthatitisadisconnectionsyndromethatsomehowseparatesnetworksofperception,emotion,andconsciousanalysis(Alexander,Stuss,&Benson,1979;Merrin&Silberfarb,1979).AnEEGstudyfound“abundantandsevereEEGabnormalities”in21Capgraspatientsintheareaofthetemporallobes.Thisledtheauthorstosuggestthatthedelusionofimpostorsmaybecausedbya“dysrhythmia”ofbrainwavesinnetworksresponsibleformatchingfaceswithemotionalfamiliarity(Christodoulou&Malliara-Loulakaki,1981).

Capgrassyndromedoesnotaffecttheneuralnetworksresponsibleforrecognizingfamiliarfaces.Craigcouldseethatthesepeoplehetookforimposterswerephysicallyidenticaltohisparentsandbrother.ButCraig’sexperiencewasthattheynolongerfeltlikehisparents—theemotional“glow”ofrecognitionoflovedandfamiliarpeoplewasmissing(Hirsten&Ramachandran,1997).Wecanhypothesizethatadisconnectionorlackofcoherenceoccurrsbetweenthecircuitsofthetemporallobesresponsibleforfacerecognitionandtheompfc-amygdalaaxis,whichwouldaddtheemotionalreactionofseeingalovedone.Withthisconnectionsomehowdisrupted,Craig’sstillintactlefthemisphereexplanatorycircuitrycreatedadelusionofimposters;anexplanationthatislogicalifyouaccepttheexperientialpremise.ThepeopleinCraig’shomelookedandactedlikehisfamily,butwithouttheusualinputfromtheemotionalcircuitryresponsibleforthefeelingoffamiliarity,hislefthemisphereinterpreterconcludedthattheymustbeimposters.

Mostofushavefeltthefiringofthesefamiliaritycircuitsinanexaggeratedformwhenweunexpectedlyrunintoafriendinanunusualplace.Ourshockofrecognitionleadstotheinevitable,“OhmyGod,whatareyoudoinghere?”Craigwasexperiencingwhatamountstotheoppositeofthisexperience.Heexpectedtohavethefeelingofrecognitionbutdidn’t.Thisisprobablywhathewasreferringtowhenhesaid,“Don’tyouthinkIwouldknowmyownparents?”Capgrassyndromemaywellbetheoppositeofadéjàvuexperience,wheresomethingwhichisactuallynewispairedwithafeelingoffamiliarity.Déjàvuislikelyarandomfiringoffamiliaritycircuitsinanunfamiliarsetting.Thefactthatstrongdéjàvuexperiencesareoftenreportedbypatientswithtemporallobeepilepsysuggeststhattheirout-of-controlelectricalfiringisactivatingtheamygdala,whichisdeepwithinthetemporallobes.

Thedelusionofimpostorsgeneratedbythelefthemisphereinterpretermaybesimilartotheattributionsmadeaboutdéjàvuexperiencessuchaspastlives,clairvoyance,andotherparanormalbeliefs.Thisverynormalimpulsetomakesenseofnonsenseisalsoseeninschizophrenics,whoattempttocreatealogicalexplanationfortheirbizarresensoryexperiences(Maher,1974).Inthefaceofexperiencingthoughtsbeinginsertedintheirheads,patientsaskthemselves,“Whowouldhavethetechnologytodosuchathing?”

WhenIworkedinBoston,patientspointedthefingeratMIT,whilethepeopleItreatedinLosAngelessuspectedCalTech.Delusionalbeliefscanbecomequitecentraltoaclient’slifeaswellastenaciousanddifficulttodislodge.Forexample,whenthreepatients,eachofwhombelievedtheywereChrist,werehousedtogether,eachcametobelievethattheothertwoweredelusional(Rokeach,1964).

PathwaysofIntegration

Allorgansofananimalformasinglesystem…andnomodificationcanappearinonepartwithoutbringingaboutcorrespondingmodificationsinalltherest.

—GeorgeCuvier

Thelongandcircuitouspathofbrainevolutionhasnotprovideduswithabrainthatissimpleinfunctionorstraightforwardindesign.Wehavealreadyseenhowthebrainconsistsofdifferentmemorysystems,twohemisphereswithdifferentprocessingcapabilities,andmultipleexecutivesystemscontrollingdifferentskillsandabilities.Wehavealsoexploredhow,whenthesesystemsgetoutofsync,psychotherapyattemptstoreconnectandbalancethem.

Althoughwearejustbeginningtounderstandfunctionsandthecomplexitiesofourneuralpathways,someconsistentfindingsarebeginningtoemerge.Aswediscussedinanearlierchapter,thetwomainpathwaystoconsideraretop-downandleft-right.Itisalsoimportanttoalwayskeepinmindthattheyarenotindependentofoneanotherbecausetopandleftareashavedevelopedcertainspecialconnections,ashavethebottom(subcortical)andtherighthemisphere.Anotherimportantpointtokeepinmindisthatthesetop-downandleft-rightsystemsinvolvemultiplestructuresalongtheway,eachwithitsownuniquecontributionandpotentialroleinnetworkfunctioning.Weshouldalsoaddtwomorespecificpathways,therelationshipsbetweenregionswithinthefrontallobes(theompfcandthedlpfc),andbetweenthehippocampusandamygdala.Thesesystemsalsohaveparticularassociationswithbothtop-downandleft-rightintegration.

Let’sreviewthegeneralmapofthebrain’spathwaysofintegration.InTable9.1,noticethealignmentofthesefourpathways.Top-down,lefthemisphere,dlpfc,andthehippocampusarealignedontheleftbecausetheytendtobeconnectedmoreheavilywithoneanotherthanwiththoseinthecolumnontheright.Theyalsotendtobeinvolvedwithconscious,rational,andlanguage-basedfunctions.Bottom-upprocessing,therighthemisphere,theompfc,andtheamygdalaappeartohavemoredenseconnectivityamongthemselvesandaremorelikelytobeinvolvedwithunconscious,somatic,andemotionalfunctions.So,forexample,Capgrassyndromemayreflectadisconnectionofbottom-upemotionalprocessinginvolvingtheamygdalaandrighthemispherefromthetop-downandlefthemispherecognitiveanalysisofsensoryexperience.

TABLE9.1PathwaysofIntegration

Top(cortical) Bottom(subcortical)

Lefthemisphere Righthemisphere

dlpfc ompfcHippocampus Amygdala

Thereispresentlyagreatdealofresearchfocusedonbreakingdownthesefunctionalnetworksinto

finerandmoreprecisedistinctionsandgeneratingmodelsofprocessingpathsandorganizationalpatterns.Separatingtherolesofeachregionofthebrainineachhemisphereisalsounderexploration,asisthemappingofpatternsofactivation(instantiations)fordifferentsymptomsanddiagnosticgroups(Dougherty

etal.,2004).Aswithallofthisresearch,wehavetokeepinmindthatage,gender,andlifeexperiencesallplayaroleinhowthesenetworksorganizeandfunctionineachindividual.Forourpresentpurposes,Ihavechosentofocusonthesegeneralcategoriesbecauseoftheirobviousapplicabilitytopsychotherapyandmentalhealth.

Top-Down–Bottom-Up

Thecomplexityofthenervoussystemissogreat,itsvariousassociationsystemsandcellmassessonumerous,complexandchallenging,thatunderstandingwillforeverliebeyondourmostcommittedefforts.

—RamonyCajal

Althoughtherearemanyverticalcircuitsthatcutacrossthehorizontalstrataofthebrain,importanttop-downnetworksforpsychotherapistsarethoseconnectingtheompfcandamygdala.Theompfcandtheamygdalaareconnectedbydensebidirectionalnetworksthatfeedphysiologicalandemotionalinformationupwardtothecortexwhileallowingtheompfctomodulatetheoutputoftheamygdalatotheautonomicnervoussystem(Ghashghaei&Barbas,2002;Ghashghaeietal.,2007;Haririetal.,2000,2003).Thinkoftheamygdalaasaprimitivestructuredesignedtolinkimmediatethreatwitharapidsurvivalresponse.Thinkoftheompfcashavingtheabilitytogatherandupdateinformationanduseittopredictpotentialoutcomesandshapebehavior(Dolan,2007;Rosenkranz,Moore,&Grace,2003).Perhapsagoodanalogyisasquadofsoldierstrainedtofightandsurvive(amygdalaandanatomicnervoussystem)andageneralwhoisanexpertstrategistwhocontinuestokeepaneyeontheentirebattlefield,updatehisstrategy,andadjustlong-rangegoals(ompfc).

Inthenormallyfunctioningbrain,thebalanceofompfc–amygdalaactivationreflectsadynamicmoment-to-momentbalanceoffocusedattentionandemotionalarousal(Simpson,Drevets,etal.,2001;Simpson,Snyder,etal.,2001).Whenfacedwithapsychosocialstress,weseeelevatedcortisollevelsalongwithincreasedactivationintheamygdalaandlowerlevelsofactivationintheompfc(Kernetal.,2008).Higherlevelsofompfcactivityarebelievedtoreflectaninhibitionofaffectiveprocessesandanenhancedfocusontheoutsideworld,whileadecreasesuggestsashiftingofattentiontointernalprocesses.Asnegativeaffectdecreases,sodoesamygdalaactivation,whileactivationintheompfcincreases(Urryetal.,2006).Itisnowbelievedthateachofushasauniquehomeostaticbalanceofthiscircuitrywhichshapesouremotionalregulationandaffectivestyle(Davidson,2002).

Let’sthinkaboutwhathappensinthehumanbrainduringpublicspeaking.Formostindividuals,gettingupinfrontofagrouptospeakresultsinincreasedcorticalactivation.Thismakessensebecauseweneedourcortextoprocessthecognitivedemandsofgivingatalk.Butwhensociallyphobicindividualsgetuptospeak,thereisadecreaseincorticalactivityandanincreaseinamygdalafiringalongwithbodilysymptomsofanxietyandpanic(Tillforsetal.,2001).Thismayhelpusunderstandthephenomenonofstagefright,wherepeopleeitherforgettheirlinesorfinditimpossibletospeakwhenfacedwithanaudience.Highlevelsofcortisol,dopamine,andbottom-upinhibitionfromtheamygdalacanalltaketheprefrontalcortex“off-line”duringstress(Arnsten&Goldman-Rakic,1998;Bishop,Duncan&Lawrence,2004).This“amygdalahijack,”asitiscalledintheself-helpliterature,isthetakeoverofexecutivefunctioningbytheamygdalaandothersubcorticalsystems(Goleman,2006).

Thebalanceandintegrationoftheompfcandamygdalaareinfluencedbyeverythingincludingpasttrauma,currentstress,andserotoninlevels(Hariri,Drabant,&Weinberger,2006;Heinzetal.,2005).Whenpeoplesufferfromsymptomsofdepressionoranxiety,thereisageneraldecreaseincortical

activationandanincreaseinanteriorregionsofthecingulateandinsula(Kennedyetal.,2007;Maybergetal.,1999).Thisbalancereversesasmoodlightenswithorwithouttreatment(Kennedyetal.,2001).Ithasalsobeenfoundthatpretreatmentmetabolismintheseandotherregionspredictsresponsetoantidepressantmedication(Davidson,Irwin,etal.,2003;Pizzagallietal.,2001;Saxenaetal.,2003;Whalenetal.,2008;Wuetal.,1999).

Aswesawearlier,sadnessanddepressionalsoreflectaleft-rightimbalance.Left-biasedprefrontalactivationdownregulatesnegativeaffectinnondepressedindividualswhiledepressedindividualsshowbilateralfrontalactivation(Johnstoneetal.,2007).Thesefindingshighlightthefactthatthemodulationofmoodislikelytooccursimultaneouslyonmultipleplanesofhomeostaticbalance—top-down,left-right,andsoon.Thus,ashiftawayfromdepressionmayreflectadualregulatoryshiftfromrightanddowntotopandleftactivation.Keepinmindthatconflictingresultshavealsobeenfound,soourunderstandingoftheseprocessesisstilljustdeveloping(Holthoffetal.,2004).

Withinthisbroadtop-downsystemtherearelikelynumeroussubsystemsinvolvedinemotionalregulation.Differentstudieshavedemonstratedavarietyofactivationpatternsinbroadtop-downnetworksintasksofaffectregulationandthevoluntarysuppressionofemotions(Anderson&Green,2001;Beauregard,Lévesque,&Bourgouin,2001;Phanetal.,2005).Forexample,thecoordinationofactivitybetweentheamygdalaandtheanteriorcingulatehasbeenshowntobecorrelatedwithtraitanxietyandasusceptibilitytodepression(Pezawasetal.,2005).Suppressingcigarettecravingcorrelateswithincreasedactivationinthecingulatecortexandaninhibitionofsensoryandmotorregionsassubjectsrespondtosmoking-relatedstimuluscues(Brodyetal.,2007).

Theanteriorcingulate,amygdala,andinsulaaremodulatedbytheprocessingofinternalsomaticexperienceduringbiofeedbacktrainingwhiletheanteriorinsulaisinvolvedwiththeinteractionbetweentheaccuracyandsensitivityofthefeedback(Critchleyetal.,2002).Thismaybethesamecircuitryactivatedduringtherapyasweintegrateconsciousawarenesswithsomatic,emotional,andmemoryprocessing.Simultaneoustop-downandleft-rightinhibitionislikelyresponsibleforwhatFreudcalledrepression.Asprefrontalandanteriorcingulateregionsareinhibitingconsciousrecallofexplicitmemories,leftfrontalnetworkscanbesimultaneouslyinhibitingnegativesomaticandemotionalmemoriesstoredinright-biasedsystems(Anderson&Green,2001).Theresultwouldbealackofconsciousrecallofathreateningexperienceandadissociationofexperiencefromconsciousawareness.

LeftHemisphere–RightHemisphere

Theinterpretivemechanismofthelefthemisphereis…constantlylookingfororderandreason,evenwhenthereisnone—whichleadsitcontinuallytomakemistakes.

—MichaelGazzaniga

Aswesawinanearlierchapter,left-rightintegrationisrequiredforproperlanguagefunctioning,bodilyawareness,emotionalregulation,andmanyotheressentialhumanprocesses.Aswewillsoondiscuss,theemergenceofstorytellingandnarrativestructureasuniversalaspectsofhumanculturemayhaveemerged,inpart,toassistintheintegrationandcoordinationofthetwoverydifferentbrains.

Agreaterleft-hemisphereadvantageinverbalprocessinghasbeenshowntobeapredictorofamorefavorableoutcomeincognitive-behavioraltherapy(Bruderetal.,1997).Thissuggeststhatthoseindividualswithmoreleft-lateralizedlanguageabilitiesmayalsohavestrongerinhibitorycapacitiesoveremotionalexperiencestoredintheright.Ithasbeenshownthatgoodreadershavelessinterhemisphericconnectivityandarebetteratprocessingrapidlychangingsensoryinput(Doughertyetal.,2007).For

sometasks,lessintegrationandcooperationareanadvantage,especiallywhenspeedorfocusofattentionarefactors.Havingtheinputofbothhemispheresmaybequiteadaptivewhenwearesolvingcomplexsocialandemotionalproblems,butislikelytoslowusdownandmakeusstumbleifweneedtoengageinfastandautomaticbehavior(Cozolino,2008).

Aformoftreatmentusedtoreadjustright-leftbalanceistranscranialmagneticstimulation(TMS).TMSisanoninvasive,painlesstechniqueforthestimulationandinhibitionofneuralfiring.Acoilofwiresisplacedonthescalpthatgeneratesamagneticfieldstrongenoughtopenetratetheskull.Thismagneticfieldistransformedintocurrentflowinthebrainthattemporarilyexcitesorinhibitsselectareas,whichcanbeappliedeitherasasinglepulseorrepetitively(rTMS).Dependingonitsfrequency,iteitherincreasesordecreasescorticalexcitability—fastrTMSincreasesactivationwhileslowrTMSdecreasesit(Daskalakis,Christensen,Fitzgerald,&Chen,2002).

Inseveralstudies,patientswithtreatment-resistantdepressionexperiencedsymptomaticimprovementafteraseriesoffastrTMStreatmentsappliedtotheleftprefrontalcortex(Pascual-Leoneetal.,1996;Georgeetal.,1997;Figieletal.,1998;Tenebacketal.,1999;Triggsetal.,1999).Theserepeatedmagneticpulsestothelefthemispheremayhaveincreasedactivityandshiftedthebalanceofmoodinamorepositivedirection.SlowrTMSappliedtotherightprefrontalcortexresultedinsimilarimprovementsindepressivesymptoms(Kleinetal.,1999;Menkesetal.,1999).SlowerfrequencyrTMStotherightprefrontalcortexwasthoughttoinhibitrightfrontalfunctioningandhavelessadversesideeffects(Schutter,2009).

StudiesofrTMSanddepressionleadustotheconclusionthatthetechnique’sabilitytobothstimulatethelefthemisphereandinhibittherighthemispheremayproveequallyusefulindepressedpatients.Currentviewstakethepositionthatrestoringthebalancebetweenleftandrightprefrontalcortexactivityismoreimportantintreatingdepressionthanestablishingclearincreasesinleft-sidedactivity.IfrTMScanhaveapositiveeffectondepressivesymptoms,mightitworkinthereversemannerformania?Studiesinthisareaarelessextensive,butfindingsdosuggestsomeeffectivenessofrTMSinthetreatmentofmaniawhenitisappliedathighfrequencytotherightprefrontalcortex(Belmaker&Grisaru,1999;Grisaruetal.,1998;Michael&Erfurth,2002;Sabaetal.,2004).TheprocedurehasbeenapprovedbyHealthCanadaforclinicalusebutnotintheUnitedStates,whereitsapplicationislimitedtoclinicalresearch.

Dlpfc–Ompfc

ModernPsychologytakescompletelyforgrantedthatbehaviorandneuralfunctionareperfectlycorrelated,thatoneiscompletelycausedbytheother….Itisquiteconceivablethatsomedaythisassumptionwillhavetoberejected.

—DonaldHebb

Asawhole,theprefrontalcortexsculptsexperienceandbehaviorthroughacomplexarrayofinhibitoryandexcitatoryactivities(Knight,Staines,Swick,&Chao,1999).Youwillrecallthattheprefrontalcortexisdividedintofourregionsandthatthedorsalandlateralregionstendtoengageincoordinatedactivityasdotheorbitalandmedialareas.Becauseoftheseconnectionstheyareoftenreferredtoasthedlpfcandompfc.Thelocationofprefrontalactivationvariesdependingontheemotionalsalienceofthetask;themoreemotionalthetask,themoreompfcactivation—themorecognitivelydemandingatask,themorethedlpfctakescenterstage(Goel&Dolan,2003;Northoffetal.,2004;Schaeferetal.,2002).Asthecognitivedemandsofataskincrease,thereisadecreaseinactivationnotonlyintheompfc,butalsoin

theamygdalaandanteriorcingulate,whicharecloselylinkedtotheompfc(Pochonetal.,2002;Rushworth&Behrens,2008).Thisislikelythereasonwhyengagingincognitivetasks,likewordormathproblems,oftenreducesanxiety.

Thedlpfcexertscontroloverneuralprocessingbasedonhigherorderrules(environmentalcontext,prediction,etc.)whiletheompfcdoesthesamefromtheperspectiveoflowerorderrules(impulse,drives,emotions,etc.).Fromthiswegetthesensethattop-downandbottom-upprocessingisinterwovenwiththebalanceofactivationbetweenthedlpfcandompfc,respectively.Interestingly,whenpeoplemakedecisionscongruentwithimplicitracialandgenderbiases,theompfcandamygdalabecomemoreactive,whilethedlpfcshowsmoreactivitywhenweexpressbeliefsthatareincongruentwithprejudice(Knutson,Mah,Manly,&Grafman,2007).Thisreflectswhatwealreadyknow—moreprimitiveimpulsesdriveprejudicewhileeducationandexpandedperspectiveallowustogobeyondourreflexivelimitations.

Experiencingtheworldfromafirst-personperspectiveandtasksofself-regulationactivateompfcregionswhilesituation-focusedregulationactivatesdlpfcsystems(Ochsneretal.,2004).Theompfcbecomesinvolvedindiversetasksthatrequiredifferingkindsanddegreesofself-referentialknowledge(Ochsneretal.,2005).Withintheompfc,thedecodingofthementalstatesofothersbasedonobservablecuessuchasfacialexpressionsmayrelyontherightompfcwhilereasoningabouttheirmentalstatesmaybelateralizedtotheleftompfc(Sabbagh,2004).Whenweconsiderthetypesofissuesbroughtintopsychotherapy,itislikelythatweareworkingtobuild,integrate,andbalancetheompfcanddlpfc.

Considerwhatwedowhenweassistclientsinshiftingfromtheirownperspectivetolookingatasituationfromanotherpointofview,tothinkingaboutthesituationonceagainfromamoreobjectiveperspective.Wearecallingupontheompfcanddlpfcindifferentwaysasweattempttoguidethemtoamoreholisticperspectiveofalifesituation.Thisprocessmostlikelyenhancesthegrowthofompfcanddlpfcsystems,whilebuildingnewbrainnetworkstobridgethetwoforhigherlevelawareness.Optimalfunctioningnecessitatescoordination,flexibility,andcomplementaritybetweenthesemodesoffunctioning.Whentheompfcanddlpfcareinproperbalance,theycreatethepossibilityoftruecognitive-emotionalintegration(Grayetal.,2002).Insituationsofstressandtraumatheompfcanddlpfcarecapableofeithermutualdissociationorinhibition(Roberts&Wallis,2000).Aninabilityoftheompfctomodulatestresswillresultinadecreaseofactivationinthedlpfcduringacognitivememorytaskandcauseaperformancedeficit(Dolcos&McCarthy,2006;Drevets&Raichle,1998).Buildingstrongconnectionsbetweenompfc-dlpfccircuitscreatesresiliencetostressandahedgeagainstresortingtodissociation,aswellasgreateraffecttoleranceandegostrength.

Hippocampus–Amygdala

Emotionshavetaughtmankindtoreason.—MarquisDeVauvenargues

Thehippocampusandamygdalabothplaycentralrolesinlearningandmemory.Theamygdala(inconnectionwiththeompfc)organizesemotionalexperienceand(inmoderatestatesofarousal)signalsthehippocampusaboutwhatisimportanttolearn.Ontheotherhand,thehippocampus(alongwiththedlpfc)participatesinthecognitiveevaluationofsituationsthatwillinformtheamygdalawhentorampuporbackdownonitsemotionalreaction.Inotherwords,IcanseethatthedogiswagginghistailsoperhapsIdon’tneedtobeasafraidofbeingbitten.Sincetheactivationofemotionandthecognitiveanalysisofexperiencearebothnecessaryfornormalfunctioning,theproperregulatorybalanceofthehippocampus

andamygdalaisvital.Thehippocampusisnecessaryforformingnewexplicitmemorieswhiletheamygdalaorganizes

highlystressfulandtraumaticlearning.Atlowlevelsofarousal,amygdalaactivationsupportshippocampallearningbyboostingthebiochemicalaspectsofneuralplasticity.Athigherlevelsofarousal,theamygdalastimulatesHPAactivation,whichinterruptshippocampallearningwhilesupportingfear-basedamygdalalearning(Kim,Koo,Lee,&Han,2005;Kim,Lee,Han,&Packard,2001).Inessence,duringstatesofhigharousal,hippocampalandamygdalanetworksbecomedissociated,resultinginadisconnectionbetweenvisceral-emotional(amygdala)anddeclarative-conscious(hippocampal)processing(Williamsetal.,2001).Thus,optimallearningrequiresabalanceofamygdalaandhippocampalparticipation.

Manypeople,perhapseventhemajorityofclientsinpsychotherapy,donotcomefortreatmentofamajorpsychiatricillness.Mostclientswhoaresomewhat“lessill”havesofarnotbeenincludedinextensive(andexpensive)outcomeresearchthatincludesbrainimagingstudies.Manypeopleseekpsychotherapysimplybecause,astheyoftensaythemselves,lifehassomehowgottenoutofbalance.Thismaymeanthattheirfearsandworrieshavetakencontroloftheirlivesandlimitedtheirabilitytofunctionorfindhappinessintheworld.Othersfindthemselvesdevoidofemotionandwithoutempathyforothers,leadingthemtoseektherapytosavetheirmarriagesandrelationshipswiththeirchildren.Manyhavethesensethattheyarenotlivinguptotheirpotentialorgetintheirownwaywhenitcomestoworldlysuccessandemotionalsatisfaction.

Theseclientsareoftenreferredtoasthe“worriedwell,”implyingthattheyshouldsomehowgetoverthemselvesandgetonwithlife.Mysenseisthatthisgroupofpatients,inwhichIwouldincludemyself,alsosuffervariousversionsofahomeostaticimbalance.Anexaggeratedrelianceonintellectualdefenses,overemotionality,oranegativeattachmentexperiencecanbecomeestablishedasself-perpetuatingpatternsthatleadtosocialisolationandunderperformance.Allofthesesuboptimallifestylesaremostlikelyreflectedinbiasedpatternsofneuralactivation,whichbecomethefocusofpsychotherapy.Whilepsychotherapyisarelativelyrecentandculture-specificdevelopmentinhumanhistory,talkingtooneanother,seekingoutadvice,andexchangingstorieslikelygobacktothefirsthumans.Thus,thetalkingcureexistswithinamatrixofbeingswhosharethegiftofgab.Isuggesttoyouthattheevolutionofthebrainandthedevelopmentofnarrativeshavegonehandinhand.

FromNeuralNetworkstoNarratives

[Words]leavefingermarksbehindonthebrain,whichinthetwinklingofaneyebecomethefootprintsofhistory.

—FranzKafka

Theevolutionofthehumanbrainisinextricablyinterwovenwiththeexpansionofcultureandtheemergenceoflanguage.Thus,itisnocoincidencethathumanbeingsarestorytellers.Throughcountlessgenerations,humanshavegatheredtolistentostoriesofthehunt,theexploitsoftheirancestors,andmoralitytalesofgoodandevil.Ithaslongbeensupposedthatthesestoriessupportthetransmissionofculturewhilepromotingpsychologicalandemotionalstability.Storiesconnectustoothers,propupouroftenfragileidentities,andkeepourbrainsregulated.Thus,Ibelievethatboththeurgetotellataleandourvulnerabilitytobeingcaptivatedbyonearedeeplywovenintothestructuresofourbrains.

Narrativesperformanarrayofimportantfunctionsincluding:

GroundingourexperienceinalinearsequentialframeworkRememberingsequencesofeventsandstepsinproblemsolvingServingasblueprintsforemotion,behavior,andidentityKeepinggoalsinmindandestablishingsequencesofgoalattainmentProvidingforaffectregulationwhenunderstressAllowingacontextformovementtoself-definition.

Formostofhumanhistory,oralcommunicationandverbalmemorywerethemediumandrepositoryofouraccumulatedknowledge.Theongoingvalueofstoriestoeachofusishighlightedintoday’sworldbytheenergyweinvestintelevision,movies,magazines,andeverydaygossip.Thedriveofolderfolkstorepeatedlytellthesamestoriesismatchedbythedesireofyoungchildrentohearthemagainandagain.Thisinter-lockingconduitofcultureacrossgenerationscarriesmemories,ideas,andidealsthroughtime.Theimportanceofnarrativesinhumanevolutionisfurtherunderscoredbythefactthatourabilitytorememberandrecallstoriesisessentiallylimitless.Infact,theastonishingabilitiesofmemoryexpertsrelyonplacingdiscretepiecesofinformationintonarrativesthatexpandthecapacityofworkingmemorytothelimitsoftheirimagination.

Althoughstoriesmayappearimpreciseandunscientific(Oatley,1992),theyserveaspowerfultoolsforhigh-levelneuralnetworkintegration(Rossi,1993).Thecombinationofalinearstorylineandvisualimagerywoventogetherwithverbalandnonverbalexpressionsofemotionactivatesandutilizesdedicatedcircuitryofbothleftandrighthemispheres,corticalandsubcorticalnetworks,thevariousregionsofthefrontallobes,andthehippocampusandtheamygdala.Thecooperativeandinteractiveactivationinvolvedinstoriesmaybepreciselywhatisrequiredforsculptingandmaintainingneuralnetworkintegrationwhileallowingustocombineoursensations,feelings,andbehaviorswithconsciousawareness.Further,storieslinkindividualsintofamilies,tribes,andnationsandintoagroupmindlinkingeachindividualbrain.Itislikelythatourbrainshavebeenabletobecomeascomplexastheyarepreciselybecauseofthepowerofnarrativesandthegrouptosupportneuralintegration.

Muchofneuralintegrationtakesplaceintheassociationareasofthefrontal,temporal,andparietallobes,whichservetocoordinate,regulate,anddirectmultipleneuralcircuits.Theyareourconsciousswitchboardoperators,abletouselanguageandstoriestolinkthefunctioningofsystemsthroughoutthebrainandbody.Aninclusivenarrativestructureprovidestheexecutivebrainwiththebesttemplateandstrategyfortheoversightandcoordinationofthefunctionsofmind.Astorywelltold,containingconflictsandresolutions,gesturesandexpressions,andthoughtsflavoredwithemotion,connectspeopleandintegratesneuralnetworks.

AStoryWellTold

Man’smind,oncestretchedbyanewidea,neverregainsitsoriginaldimensions.—OliverWendellHolmes

Haveyouhaveeverwatchedthefacesofsmallchildrenastheylistentoagiftedstoryteller?Youcanseetheunfoldingdramareflectedintheireyes,ontheirfaces,andthroughouttheirbodies.Listenerswillexperiencearangeofdrasticallyshiftingemotions,beabsorbedineverydetail,andevenshoutoutwarningstocharactersindanger.Narrativesallowustoplaceourselveswithinalternatepointsofviewandincreaseourunderstandingoftheexperienceofourselvesandothers.Wecanescapeourbodiesinimaginationtootherpossibleselves,waysofbeing,andworldsthathaveyettobecreated.

Throughstorieswehavetheopportunitytoponderourselvesinanobjectivewayacrossaninfinitenumberofcontexts.Inlifeandintherapy,wecanusestoriestoimagineourproblemshappeningtosomeoneelseorviewourselvesatadistance(externalization).Wecanshareversionsofpossibleselvesandreceiveinputfromothers.Finally,wecanexperimentwithnewemotions,actions,andlanguagetoeditthescriptsofourlives(Etchison&Kleist,2000).Ourabilitytoeditnarrativessummonsustotryonnewwaysofbeing.(RecallthecaseofSheldonandhismagictricycle.)

Whatmakesforagoodstory?WhycanIsitthroughPrettyWomanorAFewGoodMenoverandoveragain,eventhoughIknowexactlyhowtheyend?Ifyoutakeascreenwritingclassyoulearnthatthereisaformulaforsuccessfulnarrativestructure.Everystoryneedsahero,aprotagonistwithwhomwecanidentify.Theprotagonistisfacinganexternalchallengeandpossessesaninnerwoundthatcauseshimpersistentpain.ForbothRichardGereandTomCruise,thispaincamefromtheiremotionalestrangementfromtheirfathers.Atfirsttheheroeitheravoidsthechallengeorfails,leadinghimtoquestionhisabilitytosucceedorevenhisdesiretochange.Thechallengeconfrontingtheheroisatfirstresisted,thenrejected,andeventuallyaccepted.Duringthejourney,theheroleavesbehindolddefinitionsofselfandtravelsintounchartedterritory.Someinnertransformationtakesplacethatallowshimtofacehisdemons,succeedinhisworldlychallenge,andsolidifyhisidentity.RichardGereacceptsJuliaRobertsandTomCruisefacesdownJackNicholson.

ThisisessentiallytheuniversalMythoftheHero,describingthetransitionfromadolescencetoadulthood(Campbell,1949).Redemption—awordcommonlyusedforthistransition—canhappenatanyage.Theadolescentstrugglingtoattainadultstatus,theemotionallyshut-downScroogefacedwithhishistoryofloss,oraclienttryingtomakesenseofearlydeprivationhave,attheircore,awoundthatneedshealing.Myexplanationwouldbethatwhatweshareincommon—brain,culture,language,andthefightforgrowthandsurvival—aretheunderlyingmotivesoftheheroicnarrative.Anotherwayofsayingthisisthatwhatweshareinourcommonstruggleforsurvivalandmeaningisdeeperandmorepowerfulthanthosethingswhichmakeusappeardifferent.

NarrativesandEmotionalRegulation

Goodpsychiatryisablendofscienceandstory.—JeremyHolmes

Asthelanguageareasofthelefthemisphereentertheirsensitiveperiodduringthemiddleofthesecondyearoflife,grammaticallanguageintheleftintegrateswiththeinterpersonalandprosodicelementsofcommunicationalreadywelldevelopedintheright.Asthecorticallanguagecentersmature,wordsarejoinedtogethertomakesentencesandcanbeusedtoexpressincreasinglycomplexideasflavoredwithemotion.Asthefrontalcortexcontinuestoexpandandconnectwithmoreneuralnetworks,memoryimprovesandasenseoftimeslowlyemergesandautobiographicalmemorybeginstoconnecttheselfwithplacesandevents,withinandacrosstime.Theemergingnarrativesbegintoorganizethenascentsenseofselfandbecomethebedrockofoursenseofselfininterpersonalandphysicalspace.

Asourexperienceofselfandthestorieswetellaboutourselvesbecomeinterwoven,self-identitybecomesthecenterofnarrativegravity(Dennett,1991).Aschildrenwearetoldbyothers,andgraduallybegintotellothers,whoweare,whatisimportanttous,andwhatwearecapableof.Theseself-storiesareshapedbycultureandco-constructedwithparentsandpeers.Andalthoughitdoessometimesseemthatchildrenarelittlescientistsdiscoveringtheworld,whatweoftenmissisthattheyareprimarilyengagedindiscoveringwhattherestofusalreadyknow,especiallyaboutthem(Newman,1982).This

servesthecontinuityofculturefromonegenerationtothenextaswereflexivelystrivetorecreateourselves.

Theroleoflanguageandnarrativesinneuralintegration,memoryformation,andself-identitymakesthemapowerfultoolinthecreationandmaintenanceoftheself(Bruner,1990).Storiesarepowerfulorganizingforcesthatservetoperpetuatebothhealthyandunhealthyformsofself-identity.Thereisevidencethatpositiveself-narrativesaidinemotionalsecuritywhileminimizingtheneedforelaboratepsychologicaldefenses(Fonagy,Steele,Steele,Moran,&Higgitt,1991).Inthesameway,anxiousandtraumatizedparentspassalongtheirnegativeexperiencesinthestoriestheytell.Therecognitionofthenegativepowerofpersonalnarrationscontainingnegativeself-statementsstimulatedthedevelopmentofrationalandcognitive-basedtherapies(Ellis,1962).Let’slookattheroleofapositivenarrativeforayoungboy.

Seven-year-oldTrevorwasbroughttoseemebecausehisparentswereconcernedthathemighthave“somethingtroublinghim.”Hewasveryclosetohisgrandfatherwhohadpassedaway6monthsearlier,buthedidn’tseemtohaveareactiontothisloss.Whilehisparentsfelttheyhaddoneeverythingtheycouldtoencouragehimtotalkabouthisfeelings,hedidn’thavethatmuchtosay.Trevorseemedtobeanormalkidwithinterestsinscience,videogames,andcomputers.Ashebecamecomfortable,wehungout,played,andtalkedaboutallkindsofthings.Duringoursecondsession,hementionedthathelikeddoingpuzzles,soIpurchasedafewandbroughtthemtotheoffice.

Beforeoursession,Ispreadoneofthepuzzlesoutonmydesk.Iputtogetherafewpiecestogivehimajumpstartandhadtoquellmyowncompulsiveimpulsetokeepgoing.Hewasexcitedwhenhenoticeditandaskedifhecouldhelpmeworkonit.“Certainly,”Isaid,andwesatdowntoasessionofpuzzling.Itdidn’ttakelongformetorealizethathewashavingdifficultyandIwonderedifIhadchosenonethatwastoodifficultforhim.ThelastthingIwantedtodowastogivehimafailureexperience.

Ioffhandedlysuggestedthatwedidn’thavetoworkonthepuzzleifhewouldprefertodosomethingelse.“Maybethisoneistoohardforus,”Isaid.“No,”hereplied,“don’tgiveup.We’llgetit.”Impressedbyhisdetermination,wecontinuedtomovepiecesaroundinsearchofcolorsandpatterns.Everyonceinawhile,IwouldleaveapieceinfrontofhimthatIknewwouldfitwithsomethinghewasholding.Ibecamemoreandmoreamazedathispatienceanddedication.Manyboyshisagewouldmoveontosomethingelseorjustclearthetablewiththeswipeofanarm.

Afterawhile,IheardTrevormumblingunderhisbreath.Hewasrepeatingsomethingoverandoverlikeasongormantra.Ileanedover,slowlyputtingmyearcloserandclosertohimsoIcouldmakeouthiswords.FinallyIcouldhear,“IthinkIcan,IthinkIcan.”Hewaschantingthethemeof“TheLittleEngineThatCould.”Hewasthelittletrainthatkeptonkeepingon.Iimmediatelyfeltmyeyeswellupandhadtoresisttheurgetohughim.Sureenough,heslowlygotthehangofitandmadelotsofprogress.

IlaterfoundoutfromhisparentsthattheLittleEnginewashisfavoritestoryandonehisgrandfatherlovedtotellhim.Theytoldmehewantedtohearitexactlythesamewayeachtimeandiftheymadeamistakeonanywordhewouldstopandcorrectthem.ItwasclearthatthisLittleEnginewasakindofherotohim,andheuseditwhenhewasstressedbyachallengingsituationtoregulatehisanxietyandkeephimselfmovingahead.Partofthisheroicstorywaslikelythememoryofalovinggrandfatherwhomhecarriedinsideofhim.TheLittleEnginebecameawayforustoshareabouthisgrandfather.Trevorwasshowingmethepowerofastorytosootheandinspire.IcametorealizethathisgrandfatherhaddoneawonderfuljobofbecomingpartofTrevor’sexperienceofhimselfandpreparinghimforhisdeath.IlearnedthatTrevor’slosswascomplicatedbecause,inmanyways,hestillhadhisgrandfatherwithhim.IbelievethatTrevor’sabilitytousenarrativeinthiswayandhisinternalizationofhisgrandfather’slovebodewellforhishealing.

Toservetheirimportantroleinemotionalregulation,narrativesneedtohaveabriefsummaryorhookthatcanbeheldinmindinthepresentmoment.Thissummary,whichcanbeaword,aphrase,a

visualimage,orevenagesture,caninstantaneouslyevokethebeginning,middle,andendofthenarrative,andespeciallyitsmessage.InTrevor’scase,itwasthephrase“IthinkIcan.”Thisdecreasedhisanxiety,enhancedhisproblemsolving,andallowedhimtodiscoverhistruecompetence.

Puttingfeelingsintowords(affectlabeling)haslongservedapositivefunctionformanyindividualssufferingfromstressortrauma.Labelingemotionscorrelateswithdecreasedamygdalaresponseandanincreaseinrightprefrontalactivation(Haririetal.,2000).Ithasalsobeenfoundthatamygdala–rightfrontalactivationareinverselycorrelatedandthatthishomeostaticbalanceismediatedbytheompfc(Liebermanetal.,2007).Thissuggeststhatthelabelingprocessmayrequireboththelateralandmedialprefrontalregionsinorderforcognitiveprocessestohaveamodulatoryimpactonouremotionalactivation(Johnstoneetal.,2007).Thenarrative,whichsimultaneouslyactivatesanarrayofnetworks,enhancesmetabolicactivityandneuralbalance.

Theperceptionofcontrolhasbeenshowntoreduceemotionalarousalandstress.Itislikelythatcognitiveprocessesinvolvedinpredictionandcontrolactivatefrontalfunctioninganddownregulateamygdalaactivation.Inotherwords,thinkingwehavesomecontrolputsusinastateofmindthatpreparesustothinkandactivatesprefrontalfunctioning,whichreducesouremotionality.Asaself-fulfillingprophecy,believingyouareanefficaciouspersonstimulatesfrontalactivation,makingyouamoreefficaciousperson(Maieretal.,2006).

Evenwritingaboutyourexperiencessupportstop-downmodulationofemotionandbodilyresponses.Inalargeseriesofstudies,JamesPennebaker(1997)andothershaveinstructedsubjectstojournalaboutemotionalissuesofpersonalimportance,especiallyexperiencesrelatedtoclosepersonalrelationships.Thesestudieshaverevealedincreasedwell-beingincludingareductioninphysicalsymptoms,physicianvisits,andworkabsenteeism(Pennebaker&Beall,1986;Pennebaker,Kiecolt-Glaser,&Glaser,1988).ThissortofjournalinghasalsobeenfoundtocorrelatewithgreaterT-helperresponse,naturalkillercellactivity,andhepatitisBantibodylevelsaswellaslowerheartrateandskinconductancelevels(Christensenetal.,1996;Petrieetal.,1995;Petrie,Booth,&Pennebaker,1998).Journalingaboutemotionalissueslikelyincreasesprefrontalactivation,downregulatingthenegativeemotionalactivationoftheamygdala(Dolcos&McCarthy,2006).Ourabilitytotametheamygdala(andtheHPAaxis)inthiswayresultsinacascadeofpositivephysiological,behavioral,andemotionaleffects.

LevelsofLanguageandSelf-Awareness

Thelessmenthink,themoretheytalk.—BarondeMontesquieu

Languageisnotoneentityusedforasinglepurpose.Duringtheevolutionofculture,typesandusesoflanguageexpandedalongwiththesophisticationofthebrain.Throughself-reflection,mostofusbecomeawarethatweseemtoshiftbackandforthamongdifferentperspectives,emotionalstates,andwaysofusinglanguage.Introspectionprovidesuswithawindowtoshiftsinstatesofmindthatreflecttheactivationandintegrationofdifferentneuralnetworks.Iamawareofatleastthreelevelsoflanguageprocessingthattakeplacewithinmyclientsandmyselfduringtheseshiftingstatesofmind;areflexivesociallanguage,aninternaldialogue,andalanguageofself-reflection.

Reflexivesociallanguage(RSL)isastreamofwordsthatservicesthemaintenanceofongoingsocialrelatednessandcommunication.Primarilyafunctionoflefthemisphereprocessing,RSLmirrorsactivitywithintheinterpersonalworldandisdesignedtogreasethesocialwheels.Verbalreflexes,

clichés,andoverlearnedreactionsinsocialsituationsprovidealoosebutmeaningfulwebofconnections.Mostofusexperiencethiswheneverweautomaticallysaysomethingpositivetoavoidconflict,ortellpeoplewearefineregardlessofwhat’stroublingus.ThenaturalclichésofRSLareasautomatictousaswalkingandbreathing.Thisleveloflanguageservesthesamepurposeasgroominginmosttypesofprimates.

InadditiontoRSL,wearealsoawareoftheconversationsweseemtocarryonwithourselvesinsideourheads.Thisinternaldialogueoftendepartsincontentandtonefromwhatweexpresstoothers.AndwhileRSLisdrivenbysocialcooperation,internaldialogueisshapedbypersonalemotionsandisusuallyexperiencedasaconversationbetweentwoaspectsoftheself.Internaldialoguemayhaveevolvedonaseparatetrackfromsociallanguagetoallowforprivatethoughtaswellasdeceivingothers.Itmayalsobeoneoftheprimarywaysinwhichrighthemisphereprocessingparticipatesinconsciousawareness.RSLandinternaldialoguearelikeoverlearnedmotorskillsthatservetomaintainpreexistingattitudes,behaviors,andfeelings.LikeRSL,internaldialogueisprimarilyreflexiveandbasedonsemanticroutinesandhabitsreflectingourlearninghistory.Wehearinourheadsthesupportiveorcriticalvoicesourparentsimplantedearlyinlife.SowhileRSLkeepsusinlinewiththegroup,internaldialoguekeepsusinlinebasedonearlyprogramming.

WhenwefindourselvesreflectingonRSLandinternaldialogue,anewleveloflanguageseemstoemerge,oneofself-reflection.Inthisstateofmind,ourthoughtsandwordsfocusonthereflexivethoughts,feelings,andbehaviorsweusuallyengagein.Thisthirdleveloflanguageislessamechanismofsocialcontrolthanavehicleofthoughtfulconsiderationandpotentialchange.Itemploysexecutivefunctionandservestodevelopatheoryofourownmind.Muchoftherapyconsistsofuncoveringandexploringreflexivesociallanguageandinternaldialogue,bothofwhichreflectunconsciousaspectsoftheself.Inthisprocesswedevelopthelanguageofself-reflection,learningthatwearenotonlyoursocialreflexesplusthevoicesthathauntusbutarealsotheonethatcanobserve,listen,andjudgewhatwehearthesevoicessay.

Asthelanguageofself-awarenessisexpandedandreinforced,welearnwearecapableofevaluatingandchoosingwhethertofollowtheexpectationsofothersandthemandatesofourchildhoods.Thelanguageofself-reflection,whencontrastedwithRSLandinternaldialogue,mostlikelyreflectsahigherlevelofintegration.Inthislanguage,cognitionisblendedwithaffectsothattherecanbefeelingsaboutthoughtsandthoughtsaboutfeelings.Ataverydeeplevel,thislanguageleadsustomeditation,wherewelearntoquietourthoughtsandmovebeyondwords.

Therapyattemptstocreatethismetacognitivevantagepointfromwhichtheshiftingstatesofmindthatemergeduringday-to-daylifecanbethoughtabout.Thisisaccomplishedbyinterweavingthenarrativesofclientandtherapistandhopefullyleadingtheminamorehealthfuldirection.Youbeginbymakingclientsawareofoneormoreofthenarrativearcsoftheirlifestoryandthenhelpthemunderstandthatchangeispossibleandofferingalternativestorylines.Astheeditingprocessproceeds,newnarrativearcsemerge,asdopossibilitiestoexperimentwithnewwaysofthinking,feeling,andacting.Theimportanceoftheunconsciousprocessesofbothparentandtherapistishighlightedbytheiractiveparticipationintheco-constructionofthenewnarrativesoftheirchildrenandpatients.Thisunderscorestheimportanceofthepropertrainingandadequatepersonaltherapyfortherapistswhowillbeputtingtheirimprintonthehearts,minds,andbrainsoftheirclients.

Inessence,therapistshopetoteachtheirclientsthattheyaremorethantheirpresentstorybutcanalsobeeditorsandauthorsofnewstories.Whenweevolvedthecapacitytoexamineournarratives(metacognition)andseethemasoneoptionamongmany,wealsogainedtheabilitytoeditandmodifyourlives(White,2001).Thenarrativeprocessallowsustoseparatestoryfromself.Itisliketakingoffyourshirttopatchatearandthenputtingitbackon.Thisallowsustohavetheexperienceofaselfthatisseparatefromourbehaviors,feelings,actions,andproblems.Thefactthatsomeonecansay,“I’mnot

myselftoday,”impliesthecapacityforself-reflectionandcomparisonbetweenacurrentstateofmindandoureverydayself-narrative.Theabilitytotakeotherperspectivesalsoenhancesourempathyforothers.

Abbey

Donotdwellinthepast,donotdreamofthefuture,concentratethemindonthepresentmoment.

—Buddha

Likemostthings,ournarrativesarebothgoodandbad.Unexamined,theykeepusinnegativepatterns.Seenandunderstood,theyprovideameansofchange.Thus,unravelingalloftheconsciousandunconsciousmaterialthatsupportsanarrativearccantakeconsiderabletimeandbringmanychallenges.Hereisanexample.

Abbey,anextremelybrightandcharismaticwoman,cametomyofficewithtearsinhereyesandasmileonherface.Evenbeforeshesatdown,Abbeylaunchedintoadescriptionofallthepositiveeventsthathadhappenedtoherandherfamilyoverthelastweek.Seeingthepaininhereyesandtherigidityofherbody,myfacemusthavereflectedthesadnessIwasfeeling.MyexpressionseemedtomakeAbbeyavoidmyeyesandspeakevenfaster.Fromtimetotime,Iwouldattempttobreakinandaskherwhatshewasfeeling.

Abbeyignoredmyquestions,talkingataneverfasterpace.Sheremindedmeofhow,asachild,Iwouldcovermyearsandhumwhenmymotherwasabouttosay,“Bedtime!”IsoonrealizedthatallIcoulddowassit,listen,andwait.Isatacrossfromherandtriedtoremaintruetomyfeelings,allowingthemtoshowinmyeyesandfacialexpressions.Eventuallyherspeechslowedandshebecamequietandhungherhead.Herfeelingsseemedtohavefinallycaughtupwithher,theimpulsivestreamofreflexivesociallanguagefinallycomingtoahalt.

Iwasconsideringwhattosaywhenshespoke:“Icaughtmyselfblabbingon.”ItwasgoodtoseethatAbbeycouldemployherlanguageofself-reflectionandshareherobservationswithme.Iaskedherwhatshehadbeenthinkingaboutwhilesittinginsilence.Abbeyreplied,“IwasthinkingofwhatanidiotIamandhowImustboreyouwithendlessprattleaboutmystupidlife.”Nowshewassharingthecontentofherinternaldialogue,likelyprogrammedearlyinlife.Sheseemeddeflated,depressed,andashamedofherself.Asareactionagainstherownshame,sheattacked.“Whatastupidjobyouhave,sittinginthisofficeeveryday,listeningtopeople’sproblems.Whydon’tyougetoutofhereandgetalife?”Abbeysoonloweredherfaceintoherhandsandbegantosob.Icouldseethatnotonlywasshesharingwithmethevoicesinherheadandherfearsanddoubts,butshewasalsoprojectingontomeheranger,confusion,andfrustration.Herinternaldialoguewashurtingherandshewantedmetoknowhowshefelt.Isaid,“Beingcriticizedcanbereallypainful.”SheinstantlyknewIwastalkingaboutthevictimizationbyherinnervoicesnow,andbyherparentsasachild.

Whenshespokeagain,shetoldmeoftheemptinessshefeltfromthelossofherhusbandafewmonthsearlier(untilthispointshehaddenieditshavingmuchimpactonher).Ithadbecomecleartoheroverthelastfewminutesthatshehadbeencopingwithhersadnessbyburyingherselfinaflurryofwords,socialactivities,andtakingcareofothers.Afterafewminutesofsilenceanddeepsighs,Abbeybegantotalkabouthowmuchshemissedhishugs,goodadvice,andthefeelingofsafetyofhavinghimaround.Abbeywasnowspeakinginthelanguageofself-reflection.Shewasabletomournthedeathofherhusbandinthisstateofmind.

Whenclientsshifttothelanguageofself-reflection,thechangesintheirtone,manner,andmoodare

palpable.Iimagineatthismomentthatclientshavetheclearestperspectiveontheirthoughts,behaviors,andfeelings.Theyspeakmoreslowlybecausetheorganizationofsentencestakestimewhentheynolongerrelyonclichésandsemantichabits.Emotionsbubbleupandclientsfeelsafeenoughtoexpresstheminaprocessthatenhancesaffectregulation.ThisiswhenIfeelmostconfidentaboutaclient’sabilitytojoinmeasacollaboratorinthetherapeuticprocess.Thesestatesareusuallyfleetingandoftennotsupportedbyfamily,friends,ortheday-to-daydemandsofmodernlife.Therapysometimesneedstobecomesomewhatsubversiveandconspiratorialasclientandtherapistattempttoworkagainstalltheforcesofhabitandsocialmomentumthatkeepusconsistentlyunhealthy.Ithasbeensaidthatthechallengeofincreasedself-awarenessisrememberingwearemorethanourreflexesanddefenses(Ouspensky,1954).

Summary

Thefocusonintegrationexistsateachlevelofnature’scomplexityfromneuronstonarrativestonations.Assystemsbecomemorecomplex,ittakesmoresophisticatedmechanismsandincreasingamountsofenergytosupporttheircontinuinginterconnectionandhomeostaticbalance.Inthischapterwehaveexploredtheaxesofneuralintegrationaswellasthenarrativesthathelpuscoordinatethegovernmentofsystemsthatcompriseourbrainsandconstructourconsciousexperience.Althoughpsychotherapydealsinstories,itturnsoutthattheyemergedfrombrainevolutiontoservethepurposesofincreasingcomplexity,coordination,andconnectivitybetweenus.Thisisoneofthemanyconnectionsbetweeninterpersonalrelationshipsandbrainfunctioningthatmakepsychotherapyaneuroscientificintervention.

PartIV.

TheSocialBrain

Chapter10

TheSocialBrain

Ourbrainsandbodiesaredesignedtofunctioninaggregates,notinisolation.—JohnCacioppo

Usingevolutionasanorganizingprinciple,webeginwiththeassumptionthatourhighlysocialbrainshavebeenshapedbynaturalselectionbecausebandingtogetheringroupsenhancessurvival.Themoretightlyinterwovenweareasagroup,themoreeyes,ears,hands,andbrainswehaveavailabletous.Weknowthattheexpansionofthecortexinprimatescorrespondstoincreasinglylargesocialgroupsandthedevelopmentoflanguage,problem-solving,andabstractabilities.Ourlargerandmorecomplexbrainsnotonlyallowforagreatervarietyofresponsestochallengingsituationsandacrossdiverseenvironments,butalsoprocessthevastamountofsocialinformationneededtosupportcommunicationandgroupcoordination.

Increasinglysophisticatedsocialgroupsallowedfortaskspecializationsuchashunting,gathering,andprolongedanddedicatedcaretaking.Caretakingspecialization,inturn,allowedforlongerpostnataldevelopmentandbrainsbuiltnotbygeneticpreprogrammingbutbylivedexperience.So,whilemanyanimalsneedtobeimmediatelyprepareduponbirthtotakeonthechallengesofsurvival,humaninfantshavetheluxuryofyearsoftotaldependencyastheylearnthecomplexitiesofthegroup.Withtheexpandingsizeofprimategroups,thegrooming,grunts,andhandgesturesadequateinsmallgroupsweregraduallyshapedintospokenlanguage.Associalgroupsgrewevenlarger,morecorticalgeographywasneededtoprocessincreasinglycomplicatedsocialinformation.Thiscoevolutionofrelationships,language,andbrainallowedforthedevelopmentofhigherlevelsofsymbolicandabstractfunctioning.Inotherwords,earlycaretakingandintimaterelationshipsareafundamentalbuildingblockintheevolutionofthehumanbrain.

Despitethefactthatourbrainsaresocialorgans,Westernsciencestudieseachindividualasasingle,isolatedorganismratherthanoneembeddedwithinthehumancommunity.ThiswayofthinkingleadsusintheWesttosearchfortechnicalandabstractanswerstohumanproblemsinsteadoflookingatday-to-dayhumaninteractions.Take,forexample,howphysiciansrespondedtothehighmortalityrateamongchildreninorphanagesduringthelastcentury.Assumingthatmicroorganismsweretoblame,theyseparatedchildrenfromoneanotherandorderedtheirhandlingtobekepttoaminimumtoreducetheriskofcontamination.Despitethesemandates,thechildrencontinuedtodieatalarmingrates,leadingstafftofilloutadmissionsformsanddeathcertificatesduringintakeforthesakeofefficiency.Itwasnotuntilchildrenwereheldandplayedwithbyconsistentcaretakersandallowedtointeractwithoneanotherthattheirsurvivalrateimproved(Blum,2002).

Thenotionofthebrainasasocialorganemergedinneuroscienceduringthe1970sasanimalresearchersslowlybegantoappreciatethatneuroanatomy,neurochemistry,andsocialrelationshipsare

inextricablyinterwoven.ThenotionthatprimatespossessneuralnetworksspecificallydedicatedtosocialcognitionwasinitiallyproposedbyKlingandStecklis(1976),whofoundthatdamagetocertainbrainstructuresinprimatesresultedinaberrationsofsocialbehaviorandadeclineingroupstatus.Sincethen,scientistshavebeenexploringthevariedneuralterrainactivatedduringsocialinteractions.Subsequentresearchintheexpandingfieldofneurosciencehasuncoveredmultiplesensory,motor,cognitive,andemotionalprocessingstreamsthatcontributetointerpersonalintelligence(Karmiloff-Smithetal.,1995).

Manyofthesefindingshaveledtothegrowingrealizationthatthelessonslearnedduringacenturyofdynamicpsychotherapymayhaveimportantneuroscientificimplications.Themostbasicisthatwearebornintorelationshipsandcometoourindividualidentitywhilerestinguponsocialconnectivity.Anotheristhatsocialinteractionsaffecteverythingfromourbiologytoourintellectualabilities.Neuroscienceresearchersareslowlycomingtotherealizationthatthescopeoftheirscientificobservationneedstoexpandtoincluderelationships.

Neuroscientistsalreadypossesstheperfectmodelforunderstandinginterdependency—theindividualneuron.Weknowthatneithertheindividualneuronnorthesinglehumanbeingexistinnature.Withoutmutuallystimulatinginteractions,peopleandneuronswitheranddie.Inneurons,thisprocessiscalledapoptosis,whileinhumans,itiscalledanacliticdepression.Frombirthuntildeath,eachofusneedsotherswhoseekusout,showinterestindiscoveringwhoweare,andhelpustofeelcaredforandsafe.Relationshipsareournaturalhabitat,whiletheisolatedbrainisanabstractconcept.Thus,understandingthebrainrequiresknowledgeofthepersonembeddedwithinacommunityofothers.Therapists,teachers,andparentsintuitivelygraspthisprofoundrealityjustaslaboratoryscientistsoftendonot.Wearenowinapositiontohelpresearchscientistsknowwheretolookastheyexplorehowthebraingrows,learns,andchangesthroughoutlife.

TheSocialSynapse

Lifeisthecontinuousadjustmentofinternalrelationstoexternalrelations.—HerbertSpencer

Aswediscussedearlier,individualneuronsareseparatedbysmallgapscalledsynapses.Thesesynapsesareinhabitedbyavarietyofchemicalsubstancesengagedincomplexinteractionsthatresultinneuraltransmission.Thisactivitystimulatesneuronstosurviveandmodifythemselvesandeachother.Overvastexpansesofevolutionarytime,synaptictransmissionhasgrownincreasinglyintricatetomeettheneedsofamorecomplexbrain.Aparallelprocesshasalsobeenoccurringintheevolutionofthesocialsynapse.

Thesocialsynapseisthespacebetweenus.Itisalsothemediumthroughwhichwearelinkedtogetherintolargerorganismssuchasfamilies,tribes,andsocieties.Whenwesmile,wave,andsayhello,thesebehaviorsaresentthroughthespacebetweenusviasights,sounds,odors,andwords.Theseelectricalandmechanicalmessagesreceivedbyoursensesareconvertedintoelectrochemicalimpulseswithinourbrains.Thesesignalsstimulatenewbehaviors,which,inturn,transmitmessagesbackacrossthesocialsynapse.Fromthemomentweareborn,ourverysurvivaldependsuponconnectingtothosearoundusthroughtouch,smell,sights,andsounds.Ifweareabletoconnectwithnurturantotherswhosebrainsareprimedtoacceptusasanextensionofthemselves,thenwecanbond,attach,andsurvive.

Thebandofcommunicationacrossthesocialsynapseisextremelybroadandincludesunconsciousmessagessentviaposture,facialexpression,eyegaze,pupildilation,andevenblushing.Aswegrowincreasinglyinterdependent,ourinnerexperiencebecomesmorevisiblethroughtheseandothermeansof

communication,inordertoenhancethestrengthofourattachments(Cozolino,2006).Contactwithothersacrossthesocialsynapsestimulatesneuralactivation,whichinfluencestheinternalenvironmentofourneurons.Thisactivationinturntriggersthegrowthofnewneuronsaswellasthetranscriptionofprotein,whichbuildsneuronsastheyexpand,connect,andorganizeintofunctionalnetworks.Abasicassumptionisthatlovingconnectionsandsecureattachmentsbuildhealthyandresilientbrains,whileneglectfulandinsecureattachmentscanresultinbrainsvulnerabletostress,dysregulation,andillness.

Earlybondingexperiencesnotonlystrengthenthenetworksofthesocialbrain,theyalsopromotethebuildingofthebrainasawholebystimulatingmetabolicarousal.Physicalandemotionalinteractionsbetweenmotherandchildresultinacascadeofbiochemicalprocesses,enhancingthegrowthandconnectivityofneuralnetworksthroughoutthebrain(Schore,1994).Face-to-faceinteractionsactivatethechild’ssympatheticnervoussystemandincreaseoxygenconsumptionandenergymetabolism.Higherlevelsofactivationcorrelatewithincreasedproductionandavailabilityofnorepinephrine,endorphins,anddopamine,enhancingthechild’spleasureduringpositiveconnections(Schore,1997a).Thevitalimportanceoftheseearlyinteractionstothebuildingoftheentirebrainmayhelptoexplainthedeathofinstitutionalizedchildrendeprivedofinteractionandlove(Spitz,1946).

Youmayrememberfromanearlierchapterthatasensitiveperiodisawindowoftimewhenexuberantgrowthandconnectivityoccurinspecificneuralnetworks.Theonsetandconclusionoftheseperiodsaregeneticallyandenvironmentallytriggered,andcorrespondwiththerapiddevelopmentofskillsandabilitiesorganizedbyeachnetwork.Thus,earlyexperienceshaveadisproportionatelypowerfulroleinsculptingthenetworksofattachmentandaffectregulationduetothestrengthoflearningduringthesesensitiveperiods(Ainsworth,Blehar,Waters,&Wall,1978).Justaspositiveexperiencesequipuswithfeelingsofself-assuranceandoptimism,suboptimalbondingexperiencesbecomestoredwithinimplicitmemory,carriedintoadulthood,andbecomewovenintoouradultrelationships.Nowherearetheseorganizingprinciplesmoreevidentthaninpsychotherapy.

AttunementandReciprocity

Mirrorneuronsshowhowstronganddeeplyrootedisthebondthattiesustoothers.—G.RizzolattiandC.Sinigaglia

Attunementandreciprocityareaspectsoftheattachmentprocessthatreflectmutualawareness,turntaking,andemotionalresonance.Mother–infantemotionalattunementduringthefirstyearispredictiveofthetoddler’sself-controlat2years,evenwhentemperament,IQ,andmaternalstylearecontrolledfor(Feldman,Greenbaum,&Yirimiya,1999).Amother’sabilitytoresonatewithherinfant’sinternalstatesandtranslateherfeelingsintowordswilleventuallyleadtothechild’sabilitytoassociatefeelingswithwords.Asthechildgrows,thepairingoffeelingswithwordsenhancestheintegrationofverticalandhorizontalnetworksdedicatedtolanguageandemotions.Earlyemotionalregulation,establishedviamother–infantsynchrony,contributestotheorganizationandintegrationofneuralnetworksandtheeventualdevelopmentofself-regulationinthechild.

Stage-appropriateattunementmaximizesthepossibilityofneuralgrowth,networkcoherence,andsecureattachment.Thecombinedsenseofsafety,freedomfromanxiety,andexcitementgeneratedviaattunementprovidestheaffectivebackgroundfortheexperienceofvitalityandspontaneousexpression.Forthenewborn,attunementmaybecommunicatedviastrokingandcuddling;fora4-year-old,itmeanshelpinghimorherlearntosharewithasibling.A16-year-old,ontheotherhand,mayneedassistancewithcreatingandstayingfocusedongoalsforthefuture,whilea30-year-oldwillbenefitfromfinancial

adviceandsomefreebabysitting.Thissafeemotionalbackgroundcreatedbyproperattunement,reciprocity,andlovingkindnessparallelsanoptimaleducationalandpsychotherapeuticrelationship.

Thebuildingofthesocialbrainduringthefirst2yearsisdrivenbytheattunementbetweentherighthemispheresoftheparentandthechild(Schore,2000).Itisthroughthisconnectionacrossthesocialsynapsethattheunconsciousofthemotheristransferredtotheunconsciousofthechild.Theright-hemisphere-biasedcircuitsofthesocialbraincomeonlineatbirthandappeartohavetheirsensitiveperiodsduringthefirst2yearsoflife(Chironetal.,1997).Themotherseemstoregresstoastateofpreoccupationwithherinfantinthelastmonthsofpregnancy,andcontinuesinthisstateforanumberofmonthsaftergivingbirth(Winnicott,1963).Thismaternalpreoccupationinvolvesanincreasedsensitivitytothevisceralandemotionalexperienceofthechildinordertoattunetohisorherprimitivemeansofcommunication.Themother’spurposefulregressionallowshertolendhercapacitytotranslatebodilystatesintowordsandactionsthataresoothingtotheinfant.

Jump-startingAttachment

Amotherunderstandswhatachilddoesnotsay.—Jewishproverb

Evenbeforebirth,mothersandchildrenengageincomplexandreciprocalinteractions.Communicationoccursthroughsound,movement,andtouch,whiletheirsharedbiochemicalenvironmentinformsthechildabouthisorhermother’sstateofmindandbody.Priortotheformationofcorticallyorganizedsocialneuralnetworks,wepossessanumberofprimitivereflexivebehaviorsthatjump-startandstimulatethedevelopmentofthemoresophisticatedformsofattachmentbehaviortocome.Thesereflexesreachacrossthesocialsynapseandallowustobecomequicklyintegratedwithourparents.Theprocessoftransmittingthecommunicationstyleofthemother,family,andculturebeginsimmediatelyatbirth.

Withinthefirsthoursafterbirth,newbornsopentheirmouthsandstickouttheirtonguesinimitationofadults,andafter36hourstheyareabletodiscriminateamonghappy,sad,andsurprisedfacialexpressions(Field,Woodson,Greenberg,&Cohen,1982).Seeinghappyfacescausesnewbornstowidentheirlips,whilesadfaceselicitpouting,andsurprisedexpressionsresultinwide-openmouthmovement.Infantslookprimarilyatthemouthforhappyandsadfaces,whereastheyalternatebetweentheeyesandmouthinresponsetoexpressionsofsurprise,suggestingtheyarecapableofselectingdifferentvisualtargetsbasedonthetypesofinformationpresentedtothem(Fieldetal.,1982).

Over20involuntaryreflexeshavebeenidentifiedinthenewborn.Some—liketherootingandsuckingreflexes—helptheinfantobtainnurturance,whilethepalmargrasp(automatichandgrasp)andtheMororeflex(reachingoutofthearms)helpthechildholdontothecaretaker.Theseearlyreflexes,controlledbythebrainstem,aregraduallyinhibitedbythecortexandreplacedbyconscious,flexible,voluntarybehavior.Reflexessuchastheseincreasethenewborn’schancesofsurvivalbyenhancinghisorherphysicalandemotionalconnectiontomotherandfather.Theoldimageoftheinfantasapassiverecipientofstimulationhasbeenreplacedwithaviewoftheinfantasacompetentparticipantinthesocialenvironment.

Oneofmyclientstoldmeofhisfirstinteractionwithhisson:“Afewsecondsafterhewasborn,thenursehandedhimtomeandtoldmetoputhiminasmallbedunderaheatlamp.Idutifullycrossedthedeliveryroomandgentlyplacedhimunderthelamp.Thelightwasverybrightandhesquintedhard,makinghisfacelooklikeabunchofwrinkles.Iputmyhandoverhisfacetoshieldhiseyesandheinstinctivelyreachedupandtookmythumbinhislefthandandmypinkyinhisrightandpulledmyhand

ontohischeek.Hewasnowabout90secondsoldandhadbecomemyson.Ifelttheglowofprideabouthowcleverhewas,whilesimultaneouslyfeelingasurgeofprotectiveness.Thiswasobviouslyaveryintelligentchildwithabrightfuture.”Inthisway,reflexesprovidethedualfunctionofcreatingphysicalconnectionandensuringtheemotionalinvestmentoftheadultsuponwhomtheinfantrelies.

Althoughspecificwordsaremeaningless,thetoneandprosodyoftheparents’voicesholdcenterstage.Evenstrangerswillinstinctivelyraisethepitchoftheirvoicewhentalkingwithbabiestomatchtheirhearingabilities.Amotherreflexivelyholdsherbabyagainstherbodyafterbirth,maximizingskincontactandhelpingtheinfant’shypothalamusestablishasetpointfortemperatureregulation.Theinfantandmothergazeintoeachother’seyes,linkingtheirheartsandbrains,whilenursingestablishesthelifelongrelationshipbetweennutritionalandemotionalnurturance(foodequalslove).

Thewarmandhappyfeelingsassociatedwithholding,touching,andnursing,thepainofseparationandthejoyofreunion,areallstimulatedthroughavarietyofprimitiveneurochemicalsthatsupportbondingandattachment.Throughthisbiochemicalcascade,mother–childinteractionsstimulatethesecretionofoxytocin,prolactin,endorphins,anddopamine,resultinginwarm,positive,andrewardingfeelings.Thesebiochemicalprocesses,inturn,stimulateneuralactivationandthestructuralmaturationofthebrainwhileshapingattachmentcircuitry(Fisher,2004;Panksepp,1998).

Thesecretionofendogenousendorphinsresultsinfeelingsofwell-beingandelation.Itactuallydoesfeelbetterwhenalovedonekissesyourboo-boobecauseendorphinsarealsonaturalanalgesics.Theseopiatesarestronglyreinforcingandservetoshapeourpreferencesfromearlyinlife(Kehoe&Blass,1989).Researchwithprimatessuggeststhattheactivationoftheopioidsystemsofmotherandchildpropelsandregulatestheattachmentprocess.Whenparent–childprimatepairsengageintouchingandgroomingbehavior,endorphinlevelsincreaseinboth(Keverne,Martens,&Tuite,1989).Duringseparation,theadministrationofnonsedatingmorphinehasthesamesoothingeffectontheinfantasdoesthereappearanceofthemother.Whennaltrexone(adrugthatblockstheeffectsofendogenousopioids)wasadministeredtoinfantprimates,rodents,anddogs,proximityseekingincreased(Kalinetal.,1995;Knowles,Conner,&Panksepp,1989;Panksepp,Nelson,&Siviy,1994).

Reflexivelyorientingtheheadtothesoundofthemother’svoiceincreasesthepossibilityofeyecontactwhiletheinstincttoseekcirclesandcomplexfiguresdirectsthebaby’sattentiontowardthemother’seyesandface.Prolongedmutualgazingstimulatesmetabolicactivityandneuralgrowth,whilereflexivesmilingevokespositivefeelingsandexpressionsincaretakers,furtherstimulatingtheinfant’sbrain.

Closeexaminationofthebidirectionalprotoconversationbetweenamotherandherbabydemonstratesthatinfantshavefarmoreinfluenceontheirmothersthanpreviouslythought(Bateson,1979).Ababydoesnotsimplyreacttoitsmother,butinsteadlearnshowtoaffectherfeelingsandbehaviors.Bothmotherandinfantadjusttoeachother’sgestures,behaviors,andsoundsinasortoflyricalsonganddance(Trevarthen,1993).Itisthroughthislanguageofintersubjectivitythatchildrenlearnfromtheirmothersaboutthefundamentalsafetyordangerousnessoftheworld.Protoconversationoverthefirstyearoflifeservesastheinterpersonalandemotionalscaffoldingintowhichsemanticlanguageandnarrativeswillgraduallyemerge.Thegrowthspurtoftherighthemisphereprovidestheneuralsubstrateforthedevelopmentoftheemotionalcomponentsoflanguage.

TheImportanceofEyes

Thereisaroadfromtheeyetoheartthatdoesnotgothroughtheintellect.—G.K.Chesterton

Theeyesareaprimarypointoforientationforinfants.Theyplayasignificantroleinbondingandsocialcommunication.Throughouttheanimalkingdom,eyesplayacrucialroleindeterminingthesafetyordangerposedbyothers.Gazeaversion(visualcutoff)isanimportantsocialbehaviorthatindicatesdominancehierarchyinbothprimatesandhumans.Directeyegazeisathreatsignalinprimates(DeWaal,1989),andtherecognitionthatwearebeinglookedatresultsinincreasedheartrateandamygdalaactivation(Nichols&Champness,1971;Wada,1961).Whatmustitbelikeforprimatestrappedinzooswhohavehundredsofhumanprimatesfilingbyandstaringatthemeachday?RobertDeNiro’s“Areyoulookin’atme?”monologueinTaxiDriverisadramaticexampleoftherelationshipbetweeneyegaze,threat,anddominance.

Learningthelanguageofeyesprovidesuswithvaluableinformationaboutourenvironmentandwhatmightbeonthemindsofothers.Wereflexivelylookupwhenweseeotherpeopledoingso;inthesesituations,theeyesserveasasourceofsocialcommunicationaboutpossiblethreatsinourenvironment.Elaborateneuralcircuitshaveevolvedtomonitorthedirectionofeyegazeofpotentiallydangerousothersinordertoanticipatetheirnextmove.Ontheotherendofthespectrum,theconnectionamongtheeyes,thevisualsystem,andemotioncanbeeasilywitnessedinthedelightachildtakesinagameofpeek-a-boo.Thankstotheneurochemistryofbonding,thesmilesandlaughterelicitedfromachildduringpeek-a-booarejustasaddictingforadults.Thereisasurgeofgoodfeelingsinbothchildrenandcaretakerswitheachreappearanceoftheeyes.Similarly,considerthewaytwopeopleinlovecanstareendlesslyintoeachother’seyes,constantlyrechargingfeelingsofhappiness.

Duringinfancy,mutualgazebetweencaretakerandchildisaprimarymechanismforpromotingbraingrowthandorganization.Intheirexplorationoftheenvironment,toddlersregularlycheckbacktoseetheexpressionontheirparent’sface.Iftheparentlookscalm,thechildwillfeelconfidenttoexplorefurther.Afrightenedlookfromtheparentmayresultinthechildseekingproximityanddecreasingexploration.Thisuseoftheeyesandfacialexpressionstoencourageorinhibittoddleractivitiesisreferredtoassocialreferencing(Gunnar&Stone,1984).

Intherapy,thewayapatientexperiencesyourgaze(ascaringorthreatening)isanaspectoftransferencethatmayprovideimportantcuestoearlybondingexperiences.Anidenticalexpressionwill,forsomepatients,leadtoarequestthatthetherapistnotstareatthem,whileitwillmakeothersfeelattendedtoandcaredfor.Althoughsomepatientsprefertoliedownandlookawayfromthetherapist,otherswanttokeepaneyeonyou.Thesereactionsreflecttheeyes’abilitytoelicitemotionsfromthepatient’sinterpersonalhistorystoredwithinnetworksofimplicitmemory.Thus,exploringtheclients’reactiontoyourgazemayyieldvaluableinformation.

RecognizingFacesandReadingFacialExpressions

Laughteristhesunthatdriveswinterfromthehumanface.—VictorHugo

Avitalfunctionofthesocialbrainistorecognizefacesandassignavaluetothem;inotherwords,aretheyfamiliarorstrange,friendorfoe—shouldIstayorshouldIgo?Thisinvolvesbothdeterminingidentity(whoisthis?)andusingfacialexpressionstoguesstheotherperson’semotionalstateandintentions(whataretheyupto?).Thefirstpartofthisprocessinvolvesthecomplextaskofrecognizingafacefromallpossibleangles,ananalysisthatiseasyforachildbutcontinuestoeludethefastestcomputers.Althoughtherecognitionoffacesinvolvesbothhemispheres,itisafunctionmostsuitedtothevisual-spatialmechanismsandholisticprocessingstrategiesoftherighthemisphere.

Researchwithprimateshasdemonstratedthataparticularregionofthetemporalcortexcontainscellsthatareresponsivetofaces,theiridentity,andvariousfacialexpressions(Perrettetal.,1984).Neuronsactivatedspecificallybyfaceshavealsobeendetectedintheamygdalaconnectingthereadingofothers’facestoourownautonomicreactions,emotions,andbehaviors(Leonard,Rolls,Wilson,&Baylis,1985;Perrett,Rolls,&Caan,1982).Thetemporalcortexcontributesitsabilitiesforcomplexrecognitiontasks(i.e.,thecountlesscombinationsoffacialfeatures),whiletheamygdalaandtheompfcaddtheemotionalelementstoprocessingsocialinformation.Togethertheygiveustheabilitytoapproachfriendlyfacesandmakeuswaryofpotentialenemies.

Ourtemporallobescontainneuronsdedicatedtofacesthatareessentialtoourabilitytorelatetoothers.Besidesbeingabletorecognizefacesandthebehaviorsofothers,weneedtoexperienceotherpeopleasbeingdifferentfrominanimateobjects.YouareprobablyfamiliarwithautismandAspergersyndrome;bothdisordersarecharacterizedbyprofounddeficitsintheabilitytorelatetoothers.Ininteractingwithindividualssufferingfromthesedisorders,Ihavebeenleftwiththefeelingthat,tothem,Iamnodifferentfromanyotherobjectintheroom.Notsurprisingly,researchhasdemonstratedthatindividualswithautismprocessfacesinanareaoftherighttemporallobenormallyusedtoprocessobjects(Schultzetal.,2000).Thisfindingreflectsoneofthemanyneuroanatomicalmechanismsunderlyingprofounddisordersofrelationship.

MirrorNeurons

Behavioristhemirrorinwhicheveryoneshowstheirimage.—JohannWolfgangvonGoethe

Anotherwayinwhichwelinkupacrossthesocialsynapseiswiththehelpofwhatarecalledmirrorneurons.Letmefirstdescribehowtheywerediscovered.Usingmicrosensors,neuroscientistsareabletorecordthefiringofsingleneuronsinmonkeys’brains.Thisrecordingcantakeplacewhiletheyareaware,alert,andinteractingwithothermonkeys.Throughsuchmethods,neuronswerediscoveredinthepremotorareasofthefrontalcortexthatfirewhenanotherprimateortheexperimenterisobservedengaginginaspecificbehavior,suchasgraspinganobjectwithahand(Jeannerod,Arbib,Rizzolatti,&Sakata,1995).Someoftheseneuronsaresospecificthattheyonlyfirewhenanobjectisgraspedinacertainwaybyparticularfingers(Rizzolatti&Arbib,1998).Whatisevenmoreinterestingisthattheseveryneuronsfirewhenthemonkeyitselfperformsthesameaction(Gallese,Fadiga,Fogassi,&Rizzolatti,1996).

Theseneuronshavebeendubbedmirrorneuronsbecausetheyfirebothinresponsetoanobservationofahighlyspecificrelationshipbetweenanactorandsomeobjectandwhentheactionisperformedbytheobserver.Thus,mirrorneuronsservetoconnectourvisualandmotorsystemswithfrontalsystemsresponsibleforgoal-directedbehavior.Forobviousreasons,thesamesortofstudiesarenotpossibleinhealthyhumansubjects.However,noninvasivescanningtechnologieshavebeenusedtoextendthesefindingstohumanbrains.Onesuchstudydemonstratedthatareasinourbrainanalogoustothosecontainingmirrorneuronsinprimatesareactivatedduringboththeobservationandtheexecutionofhandactions(Nishitani&Hari,2000).SupportfortherelationshipbetweentheseareasinthemonkeyandBroca’sareainhumanscomesfrompositronemissiontomographystudiesshowingactivationinBroca’sareaduringtheactiveorimaginedcarryingoutofhandmovements(Bonda,Petrides,Frey,&Evans,1994;Decety,1994;Grafton,Arbib,Fadiga,&Rizzolatti,1996).

Thefactthatmirrorneuronsfirewhenthesameactionisobservedorperformedleadstosome

interestinghypothesesabouttheirroleinlearningandcommunication.Ithasalwaysbeenknownthatbothhumansandprimatescanlearnbyobservation.Becausemirrorneuronsactivateforbothobservationandaction,theymaybethemechanismforone-triallearning.Also,becausetheseneuronshavebeenfoundinBroca’sareainhumans,mirrorneuronsmaybeinvolvedintheimitation,learning,andexpressionoflanguage(Galleseetal.,1996).Sharedactionsandturntakingmayhavebeenthegenesisofprotoconversationandsemanticlanguage.Somelanguagelearningmaybejump-startedbythesemirrorneuronswithinBroca’sarea,asthesoundsandlipmovementsofcaretakersareimitated.Thealternationofmirroringandturntakingseeninmother–infantinteractionsmaybeacontemporaryreflectionoftheearlyevolutionoflanguage(Iacoboni,2008;Rizzolatti&Sinigaglia,2008).

Themostinterestingapplicationofmirrorneuronstopsychotherapyisthatthefacialexpressions,gestures,andpostureofanotherwillactivatecircuitsintheobserversimilartothosewhichunderlieempathy.Seeingasadchildcrymakesusreflexivelyfrown,tiltourheads,say“aawwhhhh,”andfeelsadtoo.Watchinganathletewalkoffthefieldwithhisheadheldhighandchestpushedoutcanleadustofeelenergizedandproud.Intheseandotherways,mirrorneuronsmaybridgethegapbetweensenderandreceiver,helpingusunderstandoneanotherandenhancethepossibilityofempathicattunement(Wolf,Gales,Shane,&Shane,2000).Theinternalemotionalassociationslinkedtomirrorcircuitryareactivatedviaoutwardlyexpressedgestures,posture,tone,andotherpragmaticaspectsofcommunication.Thus,ourinternalemotionalstate—generatedviaautomaticmirroringprocesses—canbecomeourintuitive“theory”oftheinternalstateoftheother.Thesestructuresareatthecoreofourabilitytodevelopintimaterelationships,beattunedtooneanother,andaidourchildreninshapingahealthyandbalancedsenseofself.

WinnicottandtheEmergenceofthePerson

Manypatientsneedustobeabletogivethemacapacitytouseus.—DonaldWinnicott

DonaldWinnicott,anEnglishpediatricianandpsychoanalyst,developedsomebasicprinciplesthatprovideahelpfulwayofthinkingaboutthesocialprocesseswhichshapetheseneuralstructures.Hisworkwithmothersandchildrenledhimtocointermssuchasgood-enoughmothering,holdingenvironment,andtransitionalobject,whichhavebecomepartofthebasiclexiconofchilddevelopment.Hisideashavebeenhighlyinfluentialbothbecauseoftheirrelevancetoeverydayexperienceandtheirfreedomfromobscurejargon.

Winnicottdescribedthecoreofmotheringasprovidingafacilitatingandholdingenvironment,whichrequiresboththemother’sempathicabilitiesandrespectfortheautonomyofthechild.Amother’sdevotiontoherchildallowshertoofferanexpandingscaffoldingthatconstantlyadaptstoherchild’schangingneedsandabilities.Winnicottdefinedtheearlyandintensefocusonthebabyasprimarymaternalpreoccupation,andunderstoodittoincludethemother’sabsorptionintoandattunementtotheexperienceswithherbaby’sprimitivedevelopmentalstate.Inthisprocess,sheutilizesthebiochemistryofattachmentandthecircuitsofthesocialbraintobridgethesocialsynapsebetweenherselfandherchild.Thegood-enoughmother,inWinnicott’sthinking,isamotherwhodoesanadequatejobinthisdifficult,complex,andconstantlyshiftingprocessofadaptation(Winnicott,1962).

Winnicottbelievedthattotalkofaninfantseparatefromitsmotherwasatheoreticalabstraction.Whatactuallyexistsisasymbioticinfant–motherdyadwithinwhichthechildisnurturedanditssocialbrainisformed,andfromwhichtheinfanteventuallyemergesasanindividualpsychologicalbeing.

Becauseaninternalizedmotherandtherepresentationofthemother–infantdyadremainasorganizingprinciplesofthesocialbrain,theycontinuetoimpactusthroughoutourlives.Inthisway,anadolescentoradultwithgood-enoughmotheringisneverreallyalone.

AcentralcomponentofdevelopmentfromWinnicott’sperspectivedependsonthemother’sabilitytomirrorherchild.Mirroringistheprocessbywhichamotherattunestoherchild’sinnerworldandgivesformtohisorherformlessfantasies,thoughts,andneeds.Mirroringservesthepurposeoftakingthedisorganizedprocesseswithinthechild,namingthem,andmakingthemapartoftherelationship.Thechildthenlearnsabouthisorherinnerworldthroughtherelationship.Althoughmanydecadesbeforetheirdiscovery,Winnicottwasdescribingaprocessthatreliesonmirrorneuronstosupportthisdeepattunementbetweenmotherandchild.

ItisnotuncommonforwomeninthethirdtrimesteroftheirpregnancyorinthefirstmonthsaftergivingbirthtoreportthattheyfeeltheyhavelostIQpoints.Althoughthesechangesareoftenattributedtotheeffectsofhormonesandsleepdeprivation,theymayalsoberelatedtoashiftinbiastotherighthemisphere.Ashiftawayfromlogicalandorderlyleft-hemispherethinkingtoright-hemisphere-biasedprocessingmayallowthemotheranincreasedlevelofemotionalandphysiologicalsensitivitythatenhancestheintuitiveelementsofattachment.Ashiftofbraincoherencetowardtherighthemispherewouldexplainthedecreaseinlinearsemanticprocessingandmemoryabilitiesreportedbynewmothersandmothers-to-be.Althoughsuchashiftmightbeveryusefulforattunementwithaninfant,itcouldbedetrimentaltofunctionsbestperformedbytheleft,suchasfindingtherightwords,rememberingappointments,andfollowinglogicalarguments.Manynewmothersreportanincreasingneedduringthefirstyeartogetoutintotheworldofadultsorbacktowork.Thisneedmayparallelashiftbacktopreviouslevelsofleft-righthemispherebalance.

Asthemothergraduallyrecoversfromadeeppreoccupationwithherinfantandagainbecomesinterestedinotherareasoflife,thechildisforcedtocometotermswithsomeofhisorherownlimitations.Inanappropriatelyattunedparent,agraduatedfailureofadaptationwillparalleltheinfant’sincreasingabilities,frustrationtolerance,andaffectregulation.Winnicottusedthetermimpingementtodescribetheimpactonthechildofmaternalmisattunements.Thesecantaketheformofnotappropriatelyanticipatingthechild’sneeds,interferingwiththeneedforquietandcalm,andevenunderestimatinghisorherabilities.Parentshavetofailtoadaptindifferentwaysinorderfortheirchildrentofacethechallengesnecessaryforadequatedevelopment.

Minorimpingementsarechallengesthatcreatemoderateandmanageablelevelsofstresswhichthechildisabletocopewithandmaster.Theseexperienceslikelypromoteandmayevenmaximizebraingrowthandneuralnetworkintegration.Majorimpingementsoverwhelmthechild’sabilitytocopeandintegrateexperienceinacohesivemanner,resultingindissociatednetworkingandfunctionaldisabilities.Gradualminorimpingementsforcetheinfanttogrow,whereasmajorimpingementscanresultinderailmentofpositiveadaptationandthesolidificationofdefensemechanisms.Minorimpingementsarelearning-enhancingexperiences,whereasmajorimpingementsresultindecreasedneuralintegrationandhamperthechild’sdevelopment.

OneofWinnicott’smostclinicallyusefulconceptshasbeentheideaofthedevelopmentofatrueandfalseself.Secureattachmentsandasenseofasafeworldcreatethecontextforthedevelopmentofthetrueself,whichrepresentsthoseaspectsoftheselfthatdevelopinthecontextofmanageable(minor)impingements,support,encouragement,andpropermeaningbythecaretaker.Respectfortheautonomyandseparatenessofthechildmotivatestheparenttodiscoverthechild’sinterests,insteadofimposinghisorherownuponthem.Thetrueselfreflectsourabilitytotoleratenegativefeelingsandintegratethemintoconsciousawarenessandtoseekoutwhatfeelsrightforusinouractivities,ourselves,andourrelationshipswithothers.Winnicott’strueselfisobviouslyoneinwhichneuralnetworkdevelopmenthasbeenmaximized,affectiswellregulated,andemotionsandcognitionarewellintegrated.Thetrueself

reflectsanopenandongoingdialogueamongtheheart,themind,andthebody.WhatWinnicottcalledafalseselfresultsfrommajorimpingementsforwhichthechildis

unprepared.Prolongedimpingementscanresultinchronicemotionaldysregulation.Forexample,neglect,abuse,orcontinuousstatesofshamecanoverwhelmthechild’snaturaldevelopmentandleadtothedominanceofemotionaldefenses.Thesestressfulrelationshipswillalsoinhibitneurogenesisandproperbraindevelopment(Stranahan,Kahlil,&Gould,2006).Whenself-involvedorpathologicalparentsusechildrenfortheirownemotionalneeds,thechildcanbecomecompulsivelyattunedtotheparents,creatingafalseselfdesignedtoregulatetheparents’needs.Withoutappropriateassistanceindevelopinghisorherself-reflectivecapacity,suchchildrenlivethroughreflexivesocialbehaviorandneverlearnthattheyhavefeelingsandneedsoftheirownthatshouldbeexpressedandnurtured.Winnicottunderstoodtherapymostgenerallyasaprocessofcontrolledregressiontoachildhoodstatewiththepurposeofsucceedingindevelopingatrueselfinthepresentwhichwasthwartedinearlylife(St.Clair,1986).

Shame

Everyword,facialexpression,gesture,oractiononthepartofaparentgivesthechildsomemessageaboutself-worth.Itissadthatsomanyparentsdon’trealizewhatmessagestheyaresending.

—VirginiaSatir

Duringthefirstyearoflife,healthyparent–childinteractionsareprimarilypositive,affectionate,andplayful.Duetotheirlimitedmobility,infantsstayincloseproximitytocaretakers,whoprovidefortheirmanybodilyandemotionalneeds.Astheinfanttransformsintoatoddler,aparent’srolecomestoincludeprotectingthechildfromdangersuchasfallingdownstairs,beingbittenbystraydogs,ordrinkingfabricsoftener.Theemergenceofnormal,incessantexploratorybehaviorintoddlersisdrivenbythebrain’sintenseneedforstimulationandgrowth.Duetothetoddler’sincreasingmotorcoordinationandexploratorydrive,parentsfindthemselvesprotectivelysaying“no”beginningatabout18–24months(Rothbart,Taylor,&Tucker,1989).Affectionandattunement,experiencedasunconditionalduringthefirstyear,cometobetiedtolimitsetting,control,andearlyattemptsatdiscipline.

Shame,appearingearlyinthesecondyearoflife,isbothapowerfulinhibitoryemotionandamechanismofsocialcontrol.Thusthepositiveface-to-faceinteractionsthatstimulatedexcitementandexhilarationduringthefirstyearcometoincludeexpressionsofdisapprovalandanger.Shameisrepresentedphysiologicallybyarapidtransitionfromapositivetonegativeaffectivestateandfromsympathetictoparasympatheticdominance.Thisshiftistriggeredbytheexpectationofattunementtoapositivestate,onlytoreceivenegativeemotionsfromthecaretaker(Schore,1994).Whileitmaybehardtobelieve,toddlersexpecttheirparentstobejustasexcitedastheyareaboutcoveringthefloorwithmilkorploppingtheirtoysinthetoilet.Parentalreactionsofdisapprovalorangerare,atfirst,confusinganddifficulttocomprehendbutsooncometoshapethebiologyandpsychologyofthechild.

Behaviorally,peopleinashamestatelookdownward,hangtheirhead,androundtheirshoulders.Thissamestate(submission)isshownbyyourpetdogwhenhehunchesover,pullshistailbetweenhislegs,andslinksawayasyouupbraidhimforsomecaninefauxpas.Similarly,thispostureinhumansreflectssocialexclusion,loss,andhelplessness.Duringearlysocializingexperiences,shameistheemotionalreflectionofalostattunementwiththecaretaker,drawingitspowerfromthechild’sprimalneedtostayconnectedforsurvival.Prolongedandrepeatedshamestatesresultinphysiological

dysregulationandnegativelyimpactaffectregulation,attachment,andthedevelopmentofnetworksofthesocialbrain(Schore,1994).

Thereturnfromastateofshametoattunementresultsinarebalancingofautonomicfunctioning,supportsaffectregulation,andcontributestothegradualdevelopmentofself-regulation.Repeatedandrapidreturnfromshametoattunedstatesalsoconsolidatesintoanexpectationofpositiveoutcomesduringdifficultsocialinteractions.Theserepairsarestoredasvisceral,sensory,motor,andemotionalmemories,makingtheinternalizationofpositiveparentingafull-bodyexperience.Thus,thecontinualexperienceofattunement,misattunement,andreattunementcreatesakindofbodymemorywhichbecomesanexpectationofapositiveoutcomeforrelationshipsandlife.Childrenleftinashamedstateforlongperiodsoftimemaydeveloppermanentlydysregulatedautonomicfunctioningalongwithdepression,hopelessness,anddespair.Asthechildgraduatesintoincreasinglycomplexpeergrouprelations,thesesamephysiologicalprocessesareconnectedtopopularity,socialstatus,anddominancewithingroupsatschoolandontheplayground.

Becauseshameisapowerful,preverbal,andphysiologicallybasedorganizingprinciple,theoveruseofshameintheprocessofparentingcanpredisposechildrentodevelopmentalpsychopathologyrelatedtoaffectregulationandidentity(Schore,1994;Schore&Schore,2008).Aspartofhistherapeuticprograms,JohnBradshaw(1990)refersto“innerchildwork”asaddressingthelong-standingpoweroftheseearlyshameexperiences,whichhecalls“toxicshame.”Shameneedstobedifferentiatedfromthelater-occurringphenomenonofguilt.Guiltisamorecomplex,language-based,andlessvisceralreactionthatexistsinabroaderpsychosocialcontext.Guiltisrelatedtounacceptablebehaviors,whereasshameisanemotionabouttheselfthatisinternalizedbeforetheabilitytodistinguishbetweenone’sbehaviorandone’sselfispossible.Ifguiltis“Ididsomethingbad,”thenshameis“Iambad.”Weseethisoften,inindividualswhospendtheirlivestakingcareofothersanddoinggooddeedsinanattempttomakeupforsome“sin”thattheycannotrecall.

TheConsolidationoftheSelf

Neverbeafraidtositawhileandthink.—LorraineHansberry

InWinnicott’sview,toomanyimpingementspreventtheinfantfromexperiencingwhathecalledformlessquiescence:thosemomentsofsafetyandcalmthatteachthechildtheworldcanbeasafeplace.Itisinthesequietmomentsthattheexperienceofselfisconsolidated,neuralnetworksintegrate,andfantasyandrealityaregentlycombined.Inessence,good-enoughparentingresultsinthebeliefinabenignworldwhereoneissafetobuildaninternalexperienceofself(Winnicott,1958).Thus,Winnicottfeltthatamajorachievementofearlyattachmentwasthecapacitytobealone,anabilitylearnedbybeingaloneinthepresenceofacompetentcaretaker.Theseexperiencescreateenoughsecuritytoallowfeelingsinthechildtospontaneouslybubbleupwiththeconfidencethattheywillbemanageableandunderstandable.Inthisstateofmind,theneedtoemploydefensestocopewithexternalthreatandinneremotionsisataminimum.Atthesametime,parietal-frontalsystemsinvolvedinimaginationandthecreationofaninnersenseofselfbecomeactivated.

Themanicdefensesweoftenseeinourclientsresultfromthelackofthecapacitytobealone.Impulsivebehaviorsandthoughts,disconnectedfromself-reflectiveprocesses,servetoinhibitemotionsbecausetotheseindividuals,tofeelistofeelbad(Miller,Alvarez,&Miller,1990).Slowingdownstimulatesdiscomfort,sadness,isolation,andshame,whichbecomebackgroundaffectthroughoutlife.If

manicdefensesarechronicallyemployed,theycanbecomeawayoflifeandkeepchildrenandadultsfromconstructinginnerimaginalexperienceandasenseofself.Sadly,manychildrenwithmanicdefensesaremistakenlydiagnosedwithADHD.Theyaremedicatedtohelpthemcope,whiletherealproblemgoesunresolved.

Peoplewithmanicdefensesoftenmasktheirinabilitytobealonebystirringupaconstantwhirlwindofactivities,socialinteractions,andphonecalls.Despitetheiroutwardsuccess,andtheirnarcissisticandgrandioseattitudes,theyoftenhavegreatdifficultiesinrelationshipsandreportfeelingsofdespairandemptiness.Explorationoftheirhistoriesusuallypointstopatternsofinsecureattachmentsinwhichachievementservedasthecurrencyforacceptance.Constantlyescalatinglevelsofactivityarereinforcedbypraisefromothersandtheavoidanceofthenegativefeelingsthatbubbleupwhenthepatientsarequietoralone.Thesepeopleoftenhaveahardtimerelaxingortakingavacationbecausethelackofdistractionsleavesthemopentotheintrusionofuncomfortablefeelingsforwhichtheyhavenoeffectivecopingskills.

Theinabilitytobealoneisseenmostclearlyinindividualswithborderlinepersonalitydisorder,whohaveacatastrophicreactiontorealorimaginedabandonment.Forthesepeople,separationisexperiencedasathreattotheirverysurvivalinmuchthesamewayasaninfantreactstotheabsenceorlossofaparent.Theircatastrophicreactioninadulthoodislikelytheactivationofanimplicitmemoryofoverwhelmingabandonmentfearsfromatimebeforeobjectconstancyorself-regulation.Itisasifthechildwithinthesepatientsisinaholdingpattern,awaitingproperparenting.Theextremelyemotionallife-and-deathreactionsinborderlinepatientsmaybeourbestwindowtothechaoticandoftenfrighteningemotionalworldofearlychildhood.

Summary

Thebrainisasocialorganconnectedtootherbrainsviathesocialsynapse.Primitivereflexesjump-starttheattachmentprocessandaregraduallyreplacedbyvoluntarybehaviors.Themotivationtostayconnectedisdrivenbybiochemicalsystemswesharewithourprimitiveancestors.Whiletherearemultiplechannelsofcommunicationbetweenus,visionisanimportantlinkacrossthesocialsynapseandtheexpressivefaceafocalpointofsocialinformation.TheoriesofpsychologicaldevelopmentbyWinnicott,Freudandothersprovideuswithmodelsforthedevelopmentofmindembeddedinthesemorebasicneurobiologicalprocesses.Thedevelopmentofasenseofselfrequiresperiodsoffreedomfromexternalthreatandinnerturmoil.Italsorequiresthedevelopmentoffrontal-parietalsystemsresponsibleforinnerimaginalspace.Childrenconstantlybuffetedbyexternalchaoscanremaintrappedina“selfless”statewheretheyarewitnesstointernalimpulsesandexternalbehaviorswithlittleornoabilitytoeitherunderstandorcontrolwhattheyaredoing.

Chapter11

BuildingtheSocialBrain:ShapingAttachmentSchemas

Experienceisabiochemicalintervention.—JasonSeidel

WhileWinnicottobservedandworkedwithmother–infantpairsinhisconsultingoffice,JohnBowlbywasperformingnaturalisticobservationsofprimatesinthewildandchildreninorphanages.Hewasespeciallyinterestedinmother–childbonds,theimportanceofexploratorybehavior,andtheimpactofseparationandlossonhealthydevelopment.Hisexperiencesledhimtodeveloptheconceptsofattachmentfigures,proximityseeking,andasecurebase(Bowlby,1969).Bowlby’sobservationsandthesubsequentscientificfindingsinattachmentresearchareeasilyintegratedwithWinnicott’stheoriesofbondingandattachment.

Bowlby’swork,whichhighlightedtheimportanceofspecificcaretakerstoachild’ssenseofsecurity,resultedinamajorshiftinthecareofinstitutionalizedchildren.Toencouragebonding,childrenwhohadpreviouslybeencaredforbywhomeverwasavailable,werenowassignedconsistentcaretakers.Inaddition,thischangeinattitudechangedtheroleofnursesandcaretakersfromonlycustodiansofsmallbabiesintoemotionalattachmentfigures.Inessence,theyweretoldthatbecomingattachedshouldnotbeavoided.Subsequently,MaryAinsworthandherstudentMaryMaindevelopedresearchmethodstotestBowlby’stheories.Decadesofattachmentresearchfollowed,providinguswithsomefascinatingtoolstostudythesculptingofthesocialbrainduringchildhood,aswellasthelong-termimpactofearlyexperienceslaterinlife.

Bowlbysuggestedthatearlyinteractionscreateattachmentschemasthatpredictsubsequentreactionstoothers.Schemasareimplicitmemoriesthatorganizewithinnetworksofthesocialbrain,basedonexperiencesofsafetyanddangerwithcaretakersduringearlysensitiveperiods.Asecureattachmentschemaenhancestheformationofabiochemicalenvironmentinthebrainconducivetoregulation,growth,andoptimalimmunologicalfunctioning.Insecureanddisorganizedattachmentschemashavetheoppositeeffect,andcorrelatewithhigherfrequenciesofphysicalandemotionalillness.

Bowlbybelievedattachmentschemastobeasummationofthousandsofexperienceswithcaretakersthatbecomeunconscious,reflexivepredictionsofthebehaviorsofothers.Attachmentschemasbecomeactivatedinsubsequentrelationshipsandleadustoeitherseekoravoidproximity.Theyalsodeterminewhetherwecanutilizeintimaterelationshipsforphysiologicalandemotionalhomeostasis.Theseimplicitmemoriesareobligatory;thatis,theyareautomaticallyactivatedevenbeforewebecomeconsciousofthepeoplewithwhomweareabouttointeract.Theyshapeourfirstimpressions,ourreactiontophysicalintimacy,andwhetherwefeelrelationshipsareworthhaving.Theytriggerrapidandunconsciousmoment-to-momentapproach-avoidancedecisionsininterpersonalsituations.Attachmentschemasareespeciallyapparentunderstressbecauseoftheircentralroleinaffectregulation.Attachmentismediated

bytheregulationoftheautonomicnervoussystembythesocialbrain,andacascadeofbiochemicalprocessesthatcreateapproachandavoidancereactionsaswellaspositiveandnegativeemotions.Schemasshapeourconsciousexperienceofothersbyactivatingrapidandautomaticevaluationshundredsofmillisecondsbeforeourperceptionsofothersreachconsciousness.

EmpiricalresearchintoattachmentschemasbeganwithAinsworth’snaturalisticin-homeobservationsofmothersinteractingwiththeirchildren(Ainsworthetal.,1978).Thesemotherswerefoundtofallintothreecategories:availableandeffective(freeautonomous),dismissingandrejecting(dismissing),andanxiousandinconsistentintheirattentiveness(enmeshed/ambivalent).Thebeliefwasthatthesedifferentcaretakingstyleswouldcreatedifferingcopingandinterpersonalstylesintheirchildren.Sothenextstepwastodeterminewhetherthechildrenofmothersineachcategorydisplayeddifferencesintheirattachmentbehaviors,especiallywhenstressedorfrightened.

Themethoddevelopedtostudythechildren’sattachmentbehavioriscalledtheinfantstrangesituation(ISS).TheISSconsistsofplacinganinfantanditsmotherinaroom,thenhavingastrangerjointhem.Afteraperiodoftime,themotherexitstheroom,leavingthechildalonewiththestranger.Anotherbriefperiodfollows,andthenthemotherreturns.Children’sreunionbehavior,orhowtheyrespondtothereturnoftheirmother,isratedtodeterminetheirattachmentstyle.ThissituationwaschosenbecauseofBowlby’sobservationthatbeingleftalonewithanunknownotherevokesdistresscallsinyoungprimates.Theattachmentschemaofthechild,ortheexpectationofbeingsoothedbythemother,shouldbearousedbythestressofthesituationandreflectedinhisorherreunionbehavior.Doesthechildseekcomfortfromthemotherorignoreher?Thisresearchwasbegunwithanumberofquestions:Doesthechildhaveahardtimebeingcomforted?Doesthechildsoonfeelsafeandreturntoplay,orisheorsheanxious,clingy,orwithdrawn?TheseandotherbehaviorsarethefocusoftheISSscoringsystemandarethoughttoreflectthechild’sexperienceandexpectationofthemother’ssoothingcapacity.

Fourcategoriesoftheinfants’reactionstotheirmothers’returnhavebeenderivedfromtheISS:secure,avoidant,anxious-ambivalent,anddisorganized.Furthermore,arelationshipwasfoundbetweenISScategoriesandthematernalbehaviororiginallyderivedfromin-homeobservations.Thegeneralfindingswereasfollows:childrenratedassecurelyattachedsoughtproximitywiththemotheruponherreturn,werequicklysoothed,andsoonreturnedtoexploratoryorplaybehavior.Thesechildren,comprisingapproximately70%ofthesample,seemedtoexpectthattheirmotherswouldbeattentive,helpful,andencouragingoftheircontinuedautonomy.Securelyattachedchildrenappearedtohaveinternalizedtheirmothersasasourceofcomfort,usingthemtofeelsafe.Thesemotherswereseenaseffectiveintheirinteractionswiththeirchildrenandhadbecome“abackgroundcontextforseekingstimulationelsewhere”(Stern,1995,Chapter6).

Avoidantlyattachedchildrentendedtoignoretheirmotherswhentheyreturnedtotheroom.Theywouldglanceovertothemotherasshecamein,orshuncontactaltogether.Thesechildrentendedtohavedismissingandrejectingmothersandappearedtolackanexpectationthatshewouldbeasourceofsoothingandsafety.Avoidantlyattachedchildrenbehavedasthoughitwaseasiertoregulatetheirownemotionsthanseekcomfortfromtheirmothers,whosemisattunementordismissalmightwellcompoundtheirstress.

Childrenratedasanxious-ambivalentsoughtproximitybutweredifficulttosootheandslowtoreturntoplay.Anxious-ambivalentchildren,whooftenhadenmeshedorinconsistentlyavailablemothers,mayhavetheirstressworsenedbytheirmothers’distress.Theirslowreturntoplayandemotionalregulationmaybeareflectionoftheirmothers’anxietyandlackofinternalizedsafety.Thesechildrentendedtoclingmoreandexploretheirenvironmentless.

Finally,therewasagroupofchildrenwhoengagedinchaoticandevenself-injuriousbehaviors.Onreunionwiththeirmothers,theydemonstratedoddbehaviorsuchasturningincirclesorfallingtotheground.Theywouldfreezeinplaceorbeovercomebytrancelikeexpressions.Duringlaterresearch,

thesechildrenwereincludedinafourthcategorycalleddisorganizedattachment.Thesechaoticbehaviorsweredemonstratedinconjunctionwithsecure,avoidant,andanxious-ambivalentbehaviorsandwereoftenpresentinchildrenwhosemotherssufferedfromunresolvedgriefortrauma.Parentsofchildreninthiscategorydemonstratefrightenedandfrighteningbehaviortotheirchildren,inducinganalarmstateinthechild.Inthisbiologicalparadox,thechild’sbrainhasaninnatedrivetomovetowardthemother.However,sincetheparentisalsoasourceofalarm,thechildisfacedwithanapproach-avoidanceconflict.Theresultinginnerturmoildysregulatesthechildtothepointthathisorheradaptationandcopingskills—evenmotorabilities—appeartobecomedisorganized.Thefearandchaosofthemothers’internalworldscanbeobservedintheirchildren’sbehavior.

Thetransmissionoftraumafromparenttochildisbothpowerfulandinsidious.Atraumatizedmotherwhocreatesalarmingexperiencesforherchildleavesthechildnochoicebuttostaywithanddependonthesourceofthealarm.Thechild’ssafehavenisreplacedwithrepetitivetraumabyproxyandemotionaldysregulation(Olsson&Phelps,2007).Thisprocesscreatesanewgenerationofvictims.InresearchwithHolocaustsurvivors,indicationsofparentaltraumawerefoundtobereflectedinthebiochemistryoftheirnontraumatizedchildren(Yehudaetal.,2000;Yehuda&Siever,1997).Furthercompoundingthechild’sdysregulatingenvironment,thetrauma-relatedbehaviorsofvictimswillleadthemtobeavoidedbyotherchildreninnormalsocialinteractions.Itisnotsurprisingthatchildrenwithavoidantanddisorganizedattachmentschemaarealsoshowntohavehigherlevelsofstresshormonesandotherbiologicalmarkersoftraumaandsustainedstress(Spangler&Grossman,1993).

ParentsTalkofTheirChildhoods

AFreudianslipiswhenyousayonethingbutmeanyourmother.—Unknown

Therelationshipsdiscoveredbetweenattachmentschemasandparentingstyleraisedthequestionofwhetheraparent’searlyattachmentexperiencesinfluencedparentingstyledecadeslater.Whileitwasassumedthattheparentingstylesofadultsaresomehowshapedbychildhoodexperiences,therewasnoempiricalsupportforthistransferfromonegenerationtothenext.Becauseimplicitmemoryisinaccessibletoourconsciousmind,andexplicitmemoriesofchildhoodareshapedbysomanyemotionalfactors,ameasurewasneededthatcouldbypasstheusualdistortionsofmemoryandallofourdefensemechanisms.AnextremelyinterestingresearchtoolthatappearstohavesucceededinthistaskistheAdultAttachmentInterview(AAI)(Main&Goldwyn,1998).

TheAAIconsistsofaseriesofopen-endedquestionsaboutchildhoodrelationshipsandearlyexperiencessuchasthese:

I’dlikeyoutotrytodescribeyourrelationshipwithyourparentsasayoungchild…ifyoucouldstartfromasfarbackasyoucanremember.Chooseadjectivesthatreflectyourrelationshipwithyourmother,father,andsoon.Whichofyourparentsdidyoufeelclosesttoandwhy?

AlthoughtheAAIgathersinformationaboutwhatindividualsrememberoftheirchildhood,italsoprovidesthedataforalinguisticanalysisofthecoherenceofthenarrative’sorganizationandpresentation.CoherenceanalysisisconductedbasedonwhatarecalledGrice’smaximsandincludean

examinationofboththelogicandunderstandabilityofthenarrativebasedonthefollowingfourprinciples:

1. Quality:Betruthful,andhaveevidenceforwhatyousay.2. Quantity:Besuccinct,andyetcomplete.3. Relevance:Sticktothetopicathand.4. Manner:Beclear,orderly,andbrief.

Scoringtakesintoaccounttheintegrationofemotionalandexperientialmaterials,gapsinmemoryandinformation,andtheoverallqualityofthepresentation(Hesse,1999).

TheAAIbypassesthelefthemisphereinterpreterbyexaminingthequalityofthebrain’ssynthesisofthevariouscognitiveandemotionalcomponentsofexplicitandimplicitmemory.Siegel(1999)proposedthatthecoherenceoftheAAInarrativeparallelsthelevelofneuralintegrationattainedduringchildhood,providingawindowtoearlyattachmentexperiencesandemotionalregulation.Inessence,theAAIgetsathowindividualsputfeelingsintowords,resolvetraumaticexperiences,andintegratethevariousnetworksofinformationprocessingacrossemotion,sensation,andbehaviorinmakingsenseoftheirlives.Itdoesallofthiswhilesimultaneouslybypassingtheproblemsinherentinself-reportmeasuresaboutthepast.

FourcategoriesemergefromtheAAIthatappeartocorrespondtothefindingsofthein-homeobservationsandtheinfantstrangesituation.Mothersandfatherswithsecurelyattachedchildrentendedtohavemoredetailedmemories,aswellasarealisticandbalancedperspectiveoftheirparentsandchildhood.AdheringwelltoGrice’smaxims,theywereabletodescribetheseexperiencesinacoherentnarrativethatwasunderstandableandbelievabletothelistener(Main,1993).Thisgroup,calledautonomous,demonstratedanintegrationofcognitiveandemotionalmemories,hadprocessedtheirnegativeexperiences,andwasthereforemorefullyavailabletotheirchildren.

Thesecondgroupofparents,associatedwithavoidantlyattachedchildren,demonstratedalackofrecallforchildhoodeventsandlargegapsinmemoryfortheirchildhood.Thislackofrecallisbelievedtoreflectadisruptionoftheintegrationofcognitiveandemotionalelementsofautobiographicalmemory.Thiscouldbeduetotrauma,chronicstress,oralackofassistanceinlearningtoregulateaffectfromtheirownparentsearlyinlife.Theyalsodemonstratedanoveralldismissingattitudetowardtheimportanceoftheirearlyrelationships,justastheyweredismissiveoftheirownchildrennow.Thenarrativesoftheseparentswereincoherentbothduetomissinginformationandatendencytoeitheridealizeorcondemntheirparents.Theygavetheimpressionthattheyweredefendingagainstfullyacknowledgingtheirhistoriesthroughdenialandrepression.

Athirdgroupofparents,ratedasenmeshedorpreoccupied,tendedtohaveanxious-ambivalentlyattachedchildren.Theirnarrativescontainedexcessive,poorlyorganizedverbaloutputthatlackedboundariesbetweenthepastandpresent.Theyappearedpreoccupied,pressured,andhaddifficultykeepingtheperspectiveofthelistenerinmind.

Last,theunresolved/disorganizedgroupofparentshadhighlyincoherentnarrativesdisruptedbyemotionalintrusionsandmissingorfragmentedinformation.Theirnarrativesnotonlyreflectedthedisorganizationofverbalandemotionalexpression,butalsothedevastatingimpactearlystresshadonthedevelopmentandintegrationoftheirneuralnetworks.Thecontentoftheirnarrativesconfirmedchaoticandfrighteningchildhoodexperienceswhichwecanassumeweredevastatingtotheintegrationandhomeostaticbalanceofbothbodyandbrain.SeeTable11.1forasummaryofattachmentfindings.

TABLE11.1SummaryofAttachmentFindings

In-HomeObservationsofMothers

InfantStrangeSituationInterview AdultAttachment

FreeautonomousEmotionallyavailablePerceptiveandeffective

SecureInfantseeksproximityEasilysoothed/returnstoplay

AutonomousDetailedmemoryBalancedperspectiveNarrativecoherency

DismissingDistantandrejecting

AvoidantInfantdoesnotseekproximityInfantdoesnotappearupset

DismissingDismissing/denialIdealizingLackofrecall

Enmeshed-ambivalentInconsistentavailability

Anxious-ambivalentInfantseeksproximityNoteasilysoothedNotquicktoreturntoplay

Enmeshed-preoccupiedLotsofoutputIntrusions,pressured,preoccupiedIdealizingorenraged

DisorganizedDisorientingFrighteningorfrightened

DisorganizedChaoticSelf-injurious

Unresolved/disorganizedDisorientedConflictualbehaviorUnresolvedlossTraumatichistory

Thepoweroftherelationshipbetweenparentandchildattachmentpatternswasdemonstratedby

FonagyandhiscolleagueswhentheyadministeredAAIstoexpectantfirst-timeparents(Fonagy,Steele,&Steele,1991a).Overayearlater,whenthechildrenreachedtheirfirstbirthday,theirattachmentpatternswereassessedusingtheISS.In75%ofthesecases,thechild’sattachmentpatternwaspredictedbythecoherenceoftheparent’snarrativeandattachmentstylemanymonthsbeforebirth.Parentsofinfantswhocametobesecurelyattachedwereabletoprovideafluidnarrativewithexamplesofinteractions,hadfewmemorygaps,andpresentedlittleidealizationofthepast.Theseparentsdidnotseemtohavesignificantdefensivedistortions,wereabletoexpressnegativefeelingswithoutbeingoverwhelmed,andlistenerstendedtobelievewhattheyweresaying.Itisnotabigstretchtoseethattheseparentswerebestabletoprovidethekindofgood-enoughsocialenvironmentprovidingabalancebetweensafetyandchallenge,attunementandautonomy.

Wenowhavesomeevidencethatparents’capabilitiesforattachmenttoaninfantbegintotakeshapeintheirownchildhoods.Theirskillasparentswilldependontheirempathicabilities,emotionalmaturity,andneuralintegration:inessence,howtheywereparentedaschildren.Asachild,ayounggirlmaybegintoimaginesomedayhavingchildrenofherown.Theshapingofhervirtualchildrenwillbeinfluencedbybothherfulfilledandunfulfilledneeds.Theempathyandcareeachparentreceivedaswellastheassistancetheyexperiencedinarticulatingandunderstandingtheirinnerworldswillinfluencefutureparentingabilities.Amother’schildhoodcandeterminewhethersheispreparedtoemotionallyprovideforhernewbornorifshewillunknowinglyrequireherchildtogivehertheattentionshefailedtoreceivewhenshewasyoung(Miller,1981).

Becauseattachmentschemasarepartofimplicitmemory,thislevelofcaretakingoccurs

automaticallyandconnectsourunconsciouschildhoodexperiencesacrossthegenerations.Inthisway,aparent’sunconsciousisachild’sfirstreality.Interestingly,negativeeventsinchildhoodarenotnecessarilypredictiveofaninsecureordisorganizedattachmentschemaorfutureparentingstyle.Workingthrough,processing,andintegratingearlyexperiences,andconstructingcoherentnarratives,aremoreaccuratepredictorsofaparent’sabilitytobeasafehavenforhisorherchildren.Thisearnedautonomy,throughthehealingofchildhoodwounds,appearstointerruptthetransmissionofnegativeattachmentpatternsfromonegenerationtothenext.

Theinferencethatparentswhoareratedasautonomoushavehigherlevelsofneuralintegrationisbasedonthefactthattheyareabletoaccessandconnectcognitiveandemotionalfunctioninginaconstructiveandusefulmanner.Theydonotappeartobesufferingtheeffectsofunresolvedtraumaordissociativedefensesandhaveattainedahighdegreeofaffectregulation,asdemonstratedbytheirabilitytomeetthedemandsofparentingwithongoinggrace.Theyareabletorememberandmakesenseoftheirownchildhoodsandareavailabletotheirchildrenbothverballyandemotionally.Theirchildrendevelopattachmentschemasthatmakethemsecureintheexpectationthattheirparentsareasafehavenandwillsootheandassistthemwhenthreatsarise.Notsurprisingly,parents’emotionalinsightandavailabilitytothemselvesappearstoparalleltheiremotionalavailabilitytotheirchildren.

Thethreenonsecurepatternsofattachmentresearchallreflectlowerlevelsofpsychologicalandneurologicalintegration.Theyalsocorrelatewiththeuseofmoreprimitivepsychologicaldefensesassociatedwithdisconnectionsamongstreamsofprocessingwithinthebrain.Thelackofrecallandblack-and-whitethinkingofthedismissingparentlikelyreflectblockedandunintegratedneuralcoherence.Thisbrainorganizationthenresultsindecreasedattentionandemotionalavailabilitytothechild.Theenmeshedparenthasdifficultywithboundariesbetweenselfandothers,aswellasbetweenpastmemoriesandpresentexperiences.Theseinternalandinterpersonalissuesthenleadtoinconsistentavailabilityandafloodofwordsthatdysregulatethechild.Thusthechild,whoisalsoanxiousandambivalent,willseekproximitybuthaveadifficulttimereturningtoplaybecauseoftheunpredictableavailability,aswellastheconfusingandemotionallydysregulatingnatureoftheparent’smessagesandemotions.Theinternalizedmother,insteadofbeingasourceofsecurityandautonomicregulation,becomesorganizedasadestabilizingstateofmindandbody.

Maternalandpaternalinstincts—infactallcaretakingbehaviors—areactsofnurturancethatdependuponthesuccessfulinhibitionofcompetitiveandaggressiveimpulses.Toooften,however,thatinhibitionisincompleteandsomeofusareunabletobegood-enoughparents.Whenaparentabuses,neglects,orabandonsachild,theparentiscommunicatingtothechildthatheislessfit.Consequently,thechild’sbrainmaybecomeshapedinwaysthatdonotsupporthislong-termsurvival.Nonlovingbehaviorsignalstothechildthattheworldisadangerousplaceandtellshimtonotexplore,discover,ortakechances.Whenchildrenaretraumatized,abused,orneglected,theyaretaughtthattheyarenotamongthechosen.Theygrowtohavethoughts,statesofmind,emotions,andimmunologicalfunctioningthatareinconsistentwithwell-being,successfulprocreation,andlong-termsurvival.Withallduerespecttotheoldadage,wecouldalsosaythatwhatdoesn’tkillusmakesusweaker.

Thetragedyofthisliesinthefactthatearlyexperienceshavesuchadisproportionatelypowerfulimpactonthedevelopmentoftheinfrastructureofthebrain.Ashighlyadaptivesocialorgans,ourbrainsarejustascapableofadjustingtounhealthyenvironmentsandpathologicalcaretakersastheyaretogood-enoughparents.Whileourbrainsbecomeshapedtosurviveearlytraumaticenvironments,manyoftheseadaptationsmayimpedehealthandwell-beinglaterinlife.Negativeinterpersonalexperiencesearlyinlifeareaprimarysourceofthesymptomsforwhichpeopleseekreliefinpsychotherapy.

Secureattachmentsrepresenttheoptimalbalanceofsympatheticandparasympatheticarousal,whereastheirimbalancecorrelateswithinsecureattachmentpatternssuchasfightorflightandsplitting(Schore,1994).Thebalanceofthesetwosystemsbecomesestablishedearlyinlifeandtranslatesinto

enduringpatternsofarousal,reactivitytostress,andpossiblevulnerabilitytoadolescentandadultpsychopathology.Poorattachmentpatternsleadtolong-lastingemotionalandphysicalover-orunderarousalthroughoutthebodyandthebrain.

Secureandinsecureattachmentschemasarequitedifferent.Securelyattachedchildrendonotproduceanadrenocorticalresponsetostress,suggestingthatsecureattachmentservesasasuccessfulcopingstrategy.Ontheotherhand,thosewithinsecureattachmentschemasdoshowastressreaction,demonstratingthatinsecureattachmentisbetterdescribedbyamodelofarousalratherthanofsuccessfulcoping(Izardetal.,1991;Nachmias,Gunnar,Mangelsdorf,Parritz,&Buss,1996;Spangler&Grossman,1993;Spangler&Schieche,1998).Inotherwords,thebehaviorofinsecurelyattachedindividualsisanexpressionofthestateoftheirautonomicarousalinresponsetofear.

NarrativeCo-construction

Thewisemanmustrememberthatwhileheisadescendantofthepast,heisaparentofthefuture.

—HerbertSpencer

Parent–childtalk,inthecontextofemotionalattunement,providesthegroundfortheco-constructionofnarratives.Thesenarratives,intime,becomethemassofourinnerexperienceandtheparametersofourpersonalandsocialidentities.Whenverbalinteractionsincludereferencestosensations,feelings,behaviors,andknowledge,theyprovideamediumthroughwhichthechild’sbrainisabletointegratethevariousaspectsofitsexperienceinacoherentmanner.Theorganizationofautobiographicalmemorythatincludesinputfrommultipleneuralnetworksenhancesself-awarenessandincreasestheabilitytosolveproblems,copewithstress,andregulateaffect.Thisintegrativeprocessiswhatpsychotherapyattemptstoestablishwhenitisabsent.

Co-constructednarrativesformthecoreofhumangroups,fromprimitivetribestomodernfamilies.Thecombinedparticipationofcaretakersandchildreninnarratingsharedexperiencesorganizesmemories,embedsthemwithinasocialcontext,andassistsinlinkingfeelings,actions,andotherstotheself.Thecreationandrepetitionofstorieshelpchildrentodevelopandpracticerecallabilitiesandhavetheirmemoriesshapedinrelationships(Nelson,1993).Thismutualshapingofmemorybetweenchildandcaretakercanservebothpositiveandnegativeends.Positiveoutcomesincludeteachingtheimportanceofaccuracyofmemory,impartingofculturalvalues,andshapingthechild’sviewofherselfbasedonherroleinthestory.Negativeoutcomesincludethetransferofthecaretakers’fearsandanxietiesintothechild’snarrativessothattheybecomecentralthemesintheexperienceofthechild(Ochs&Capps,2001).

Whencaretakersareunabletotoleratecertainemotions,theywillbeexcludedfromtheirnarrativesorshapedintodistortedbutmoreacceptableforms.Thenarrativesoftheirchildrenwillcometoreflecttheseeditorialchoices.Attheextreme,parentscanbesooverwhelmedbytheemotionsrelatedtounresolvedtraumathattheirnarrativesbecomedisjointedandincoherent.Ontheotherhand,narrativesthatstruggletointegratefrighteningexperienceswithwordscanserveasthecontextforhealingbysimultaneouslycreatingcorticalactivationandincreasingdescendingcontroloversubcorticallytriggeredemotions.Parentalnarratives,bothcoherentandincoherent,becometheblueprintnotonlyforthechild’snarratives,butfortheorganizationandintegrationoftheirneuralcircuitry.Asitturnsout,thereappearstobearelationshipamongthecomplexityofachild’snarratives,self-talk,andthesecurityofthechild’sattachment.

Mainandhercolleagues(Main,Kaplan,&Cassidy,1985)studiedagroupof6-year-oldchildrenwho,at1year,wereassessedintheinfantstrangesituation.Theydiscoveredthatsecurelyattachedchildrenengagedinself-talkduringtoddlerhoodandspontaneousself-reflectiveremarksatage6.Theyalsotendedtomakecommentsabouttheirthinkingprocessandtheirabilitytorememberthingsabouttheirhistory.Theseprocessesofmind,whichinsecurelyattachedchildrenoftenlack,reflecttheutilizationofnarrativesinthedevelopmentofselfandself-identity.Theyalsopointtoamoresophisticatedabilitytometacognize(thinkaboutthinking),thatrepresentsahighlevelofneurolinguisticself-regulation.Whatwearewitnessingappearstobetheinternalizationoftheirparents’self-regulatorymechanisms.Asyoumightexpect,childabusecorrelateswithlesssecureattachmentpatternsinchildrenandadecreasedabilitytotalk(orthink)abouttheirinternalstates(Beeghly&Cicchetti,1994).

Fonagy,Steele,Steele,Moran,etal.(1991)studiedtherelationshipbetweeninfantsecurityandreflectiveself-functioninginmothersandfathers.Theyfoundastrongcorrelationbetweenmeasuresofself-reflectionandnarrativecoherence.Infact,whenreflectiveself-functionwascontrolledforinthestatisticalanalysis,coherencenolongerrelatedtoinfantsecurity.Thissuggeststhattherelationshipbetweencoherenceandreflectiveself-functioningispowerful,andthattheabilitytoreflectontheselfplaysanimportantroleintheintegrationofmultipleprocessingnetworksofmemory,affectregulation,andorganization.Indiscussingtheseresults,theresearcherssuggested,“Thecaregiverwhomanifeststhiscapacityatitsmaximumwillbethemostlikelytobeabletorespectthechild’svulnerableemergingpsychologicalworldandreducetoaminimumtheoccasionsonwhichthechildneedstomakerecoursetoprimitivedefensivebehaviorcharacteristicofinsecureattachment”(Chapter11).

Whentheparents’inabilitytoverbalizeinternalandexternalexperiencesleavesthechildinsilence,thechilddoesnotdevelopacapacitytounderstandandmanagehisorherowninnerandouterworld.Theabilityoflanguagetointegrateneuralstructuresandorganizeexperienceataconsciouslevelisleftunutilized.Whenchildrenwithnonhealingparentsexperiencetraumaearlyinlife,thestressofeachnewdevelopmentalchallengeismultiplied.Inthesameway,language,incombinationwithemotionalattunement,isacentraltoolinthetherapeuticprocess,creatingtheopportunityforneuralgrowthandneuralnetworkintegration.

Achildwhoisabletoachievethisabilitywiththehelpofsomeoneotherthantheprimarycaretaker,maybeabletoearnahigherlevelofintegrationandsecuritythanwouldbepredictedbyhisorherparents’ratingontheAdultAttachmentInterview.Thismaycomefromothersignificantpeopleinthechild’senvironmentwhoareabletoattunetothechild’sworldandassistinthechild’sarticulationofhisorheremotionallife.Thismightexplainsomeoftheearnedautonomyseeninparentswithnegativechildhoodexperiencesbutwithcoherentnarrativesandtheabilitytoprovideasafehavenfortheirchildren.Earnedautonomyisconvincingevidencethatearlynegativeexperiencescanberein-tegratedandrepairedlaterinlife.Personalgrowthhastheabilitytohealbecausethesocialbrainremainsplastic.

Attachmentpatternsformedinchildhoodcanberelativelystableintoadulthoodandhavebeenshowntoimpactromanticlove,interpersonalattitudes,andpsychiatricsymptoms(Brennan&Shaver,1995;Hazan&Shaver,1990).Adultchildrenofanxiousparentsrepeatedlyreturntothemthroughoutlife,stillseekingcomfortandasafehaven.Manyofthesechildrenbecomeparentstotheirparents,takingcareofthepeopletheywishwouldandcouldcareforthem.Theycontinuetoreturntoanemptywell;eachtimethebucketisloweredthereisthehopethatitwillcontainthenurturancetheyneed.Eachreturningemptybucketreinforcestheirlackofsafety.

ChildTherapists

Treatpeopleasiftheywerewhattheyoughttobeandyouhelpthemtobecomewhatthey

arecapableofbeing.—Goethe

Aquestionthatcommonlyarisesamongtherapists,adoptiveparents,andmentalhealthlegislatorsis,“Whenisittoolate?”Atwhatagedothenegativeeffectsofearlyabuse,trauma,andneglectbecomepermanent?Gettingtotheheartoftheissue,thetruequestionbecomes:Whoisworthseeingasaclient,adoptingasachild,orinvestingpublicfundsinforrehabilitation?Inmymind,thesearemoralratherthanscientificquestions.Ihavebecomeveryskepticalof“experts”whothinktheyhavefoundanswerstoanyissueinneuroscience.Mybiasistotrustinplasticityandourowningenuitytodiscovernewsolutionstotheseproblems.Hereisastudythatmaygiveussomeguidanceasweconsidertheseissues.

Totesttheimpactofmaternaldeprivation,HarryHarlowisolatednewbornmonkeysnotonlyfromtheirmothers,butfromanyandallcontactwithothermonkeys.Beyondminimalcontactrelatedtotakingcareoftheirbasicneeds,theseyoungmonkeyswereleftaloneinacagewithafewtoysandlittleelse.Picturesoftheseisolatemonkeysareheartbreaking—theyhuddleincorners,rock,bitethemselves,andstaycurledupinafetalposition.Itisasiftheyaretrappedinanautistichellwaitingtobebornintothesocialworld.

Whentheseisolatedmonkeysarethenintroducedintoastandardmonkeycolonyat6monthsofage,theyareunderstandablyterrified.Theydon’tseemtounderstandwhatisgoingon,retreatfromcuriousothers,anddotheirbesttoavoidinteraction.Atfirstitwastemptingtothinkofthis6-monthperiodasacutoffpointforattachmentplasticity.Perhapsattachmentcircuitryhadgonethroughahard-wiredcriticalperiodand,by6months,itwastoolatetolearnhowtobesocial.Butaswitheveryconclusioninneuroscience,thereneedstobecaution.

HarlowandSuomi(1971)wonderediftherapycouldhelptheseisolatemonkeysovercometheirfearandallowthemtojointhesocialworldofthecolony.Buthowdoyoudotherapywithamonkey?WouldyouchooseGestalt,cognitive-behavioral,orpsychoanalytictreatment?Ultimatelywhatwaschosenwasacombinationofplayandattachmenttherapy.The“therapists”chosenforthejobwerenormal3-month-oldmonkeys,whowereselectedbecausetheyweresmaller,cravedplayfulcontact,werelessaggressive,andprobablylessthreateningthansame-agedpeers.

Therapyconsistedofthree2-hoursessionsperweekfor4weeks—atotalof24hoursof“treatment.”Whenthe“therapists”arrivedforthesession,theisolateswereterrifiedandretreated.Thetherapistsapproached,touched,andclimbedontheirolderclients.Theisolatestriedtoretreatwhiletheiranxietyandself-stimulatingbehaviorincreased.Againthetherapistsengaged,touched,climbedon,andgotinthefaceoftheirclients.Apparently,whenitcomestoplayandsocialengagement,a3-month-oldmonkeywon’ttakenoforananswer.Asthesessionscontinueditwasreportedthattheisolatesgraduallycametohabituateandaccepttheirtherapists’interventions.Theseinteractionsinterruptedautistic,self-stimulatingbehavior,andtheclientseventuallybegantoinitiatephysicalcontactandinteractwiththeiryoungertherapists.Therapywassosuccessfulthattheauthorsstated,“By1yearofage,theisolateswerescarcelydistinguishablefromthenormaltherapistsintermsoffrequenciesofexploratory,locomotive,andplaybehavior”(p.1537).

Afteracourseoftreatment,whentheseformerisolateswereintroducedtothecolony,theydidmuchbetter,andwereabletofindarolewithinthegroupandsocialhierarchy.Weretheyimpaired?Mostlikely,earlydeprivationhadalong-lastingimpact,butitappearedtotheresearchersthattheyhadattainedafunctionalsocialrecovery.TheseresultssurprisedHarlowandSuomibecauseoftheirpriorassumptionsaboutcriticalperiods.Theyalsohelpremindmetokeepanopenmind,andrememberthatgivinguponachildorclientisnotsomethingIameverwillingorpreparedtodo.

Summary

Neurosciencesuggeststhatanimportantaspectofloveistheabsenceoffear.Iftherapistsandadoptiveparentscancreateanenvironmentthatminimizesfearandmaximizesthepositiveneurochemistryofattachmentthroughhumancompassion,attachmentcircuitrycanbestimulatedtogrowinwayswhicharenotonlyhealing,butthatallowvictimsofabuseandneglecttoriskformingabondwithanother.

Becausetheprocessofattachmentis,atheart,awayinwhichsocialanimalsinitiallyregulatefear,andlatertheiraffectivelives,modifyinginsecureattachment,firstandforemost,requirestheestablishmentofasafeandsecurerelationship.Therapistsworkdiligentlytoestablishthistypeofrelationshipforeachclientandtocreateanexperiencesimilartowhatthe3-month-oldmonkeyswereabletogivetheirseniorisolates:theexperienceofsocialconnectionintheabsenceofthreatorrejection.

Thereareprobablythousandsofstudiessupportingwhatweallintuitivelyknow—childhoodexperienceaffectsemotionalandphysicalhealthlaterinlife.Whilethereareplentyofpsychologicalandsocialtheoriesthatattempttoexplainthisrelationship,wearebeginningtoputtogetherthebiologicalmechanismsofactionofthesefindings.Thegeneralquestionis,howdoearlysocialexperiencesshapeourneurobiologyinwaysthatcaninfluenceusdecadeslater?

Chapter12

TheNeurobiologyofAttachment

Offspringinherit,alongwiththeirparents’genes,theirparents,theirpeers,andtheplacestheyinhabit.

—LeonEisenberg

Reflectedinthearchitectureofeachofourbrainsisthecomingtogetherofourevolutionaryhistory,thegenerationsprecedingourbirth,andouruniquerelationshipwithourparents(Eisenberg,1995).Hundredsofstudieshavedemonstratedthewaysinwhichearlyexperienceiscorrelatedwithphysicalandemotionalhealthlaterinlife.Researchinpsychoanalysis,epidemiology,developmentalpsychology,andpsychiatryhaveallsupportedwhatwethinkofascommonsense:Agoodchildhoodisbetterthanabadone;positiveparentalattentionisimportant;andlessstressearlyinlifeisagoodthing.Ofcourse,eachfieldexplainsthesefindingsfromitsowntheoreticalmodelandtendstoseeotherperspectivesassecondary.

Recentresearchinmolecularbiologyoffersusagroundbreakingviewintotheunderlyingmechanismoftheeffectsofearlyexperienceongeneticexpression,thatis,howearlyexperiencetriggersgeneexpressiontoguideourbrainsontoparticularadaptationaltrajectories.Incontrasttothecorrelationsfoundinotherfieldsofstudy,thisnewworkexplorescausalbiologicallinksbetweenmaternalbehaviorandthebuildingofthebrainsofchildren.

Whenwethinkabouthavinganinternalizedmother,ourthoughtsusuallystraytoimagesofakindsmile,awarmhug,feelingsafe,andbeingloved.Dependingontheculture,youmayrememberyourmomservingThanksgivingdinner,stirringtomatosauce,orfryingchicken.Thoseofuswhoarelessfortunatemayhaveimagesofragefulbehavior,endlesscriticism,oramotherpassedoutonthecouchafteralongdayofdrinking.Theseconsciousautobiographicalmemoriesarebutonelayerofaninternalizedmother.Anotherlevel,deeperandjustasmeaningful,ishowtheseearlyexperiencesshapedtheneurobiologicalprocessesofourbrains.

Inthischapterweclimbupanddowntheevolutionaryladderfromhumanstoratsandbackagaintohumans.Itturnsoutthatwehavelearnedagreatdealbyexploringhowthebehaviorofmamaratsinfluencesthebrainsoftheirpups.Theconservationofstructuresandfunctionsduringevolutionprovidesuswithagoodanimalmodeloftheeffectsofmaternalbehavioronthebrain.Althoughthisresearchhasyettobedonewithhumans,thebehavioralandneurobiologicalparallelsbetweenratsandhumansarestriking,makingratsveryhelpfulinunderstandingtheinterpersonalaspectsofneurobiology.Wealsoexplorenetworksofthehumanbrainthatrelyonsimilarshapingduringearlyexperience,aswellassomeotherwaysinwhichepigeneticsfactorsmayimpacteverythingfromthetimingofmenopausetohumanlongevity.Inplaces,thischapterisheavyonthescience,sobepreparedtoreadcertainsectionsoverafewtimes.Ihaveputmostofthespecificdataintablestoactasanoverviewandguidetoparticular

studiesforthosewhowishtodofollow-upreading.

TheEvolutionofComplexity

Whotakesthechildbythehandtakesthemotherbytheheart.—Germanproverb

Let’ssetthestagetolookatthesestudieswiththeassumptionthatoursocialbrainshavebeenshapedbynaturalselectionbecausebeingsocialenhancessurvival.Ourbestguessisthatlargerandmorecomplexbrainsallowformorediverseresponsesinchallengingsituationsandacrossdiverseenvironments.Ourbrainsallowustofashionclothing,buildhouseswithheatingsystems,andcreatesophisticatedfarmingtechniquesthatallowustoexpandourhabitatsandsourcesoffood.Butdoesthisexplainwhywehaverelationships?

Weknowthattheexpansionofthecortexinprimatescorrelateswithincreasinglylargesocialgroups.Thebenefitoflivinginatribeisnotjustinthesafetyofnumbers,butalsointheabilityofgroupstohavetaskspecializationsuchashunting,gathering,andcaretaking.So,whilemanyfishandreptilesneedtobebornimmediatelypreparedtotakeonthechallengesofsurvival,humaninfantshaveyearsoftotaldependencyduringwhichtheirbrainscangrowandadapttoveryspecificenvironments.Thislargerwindowoftimeforadult–childinteractionsallowsforincreasinglysophisticatedpostnatalbraindevelopmentandincreasedinvestmentineachchild(Kaplan&Robson,2002).Thisexpandedsocialinvestmentenhancesthechild’schancesofsurvival,whichinturnincreasesthechancesofourgenessurvivingintothenextgeneration(Allen,Bruss,&Damasio,2005;Charnov&Berrigan,1993).Thus,thedevelopmentofthebrain,grouporganization,caretaking,andsocialcommunicationco-evolvedinamutuallyinterdependentmanner.

Therearemanyinterestingtheoriesabouthowhumansevolvedtobethecomplexsocialcreaturesweare.Thebigstoryprobablygoessomethinglikethis:

Largergroupsizeenhancedtheprobabilityofsurvival,butrequiredbiggerandmorecomplexbrainstoprocesssocialinformation,andsolargerbrainswereselected.Morecomplexbrainsrequirelongerperiodsofdevelopmentandresultinprolongedperiodsofchilddependency.Longerperiodsofdependencyrequiremoreattentionanddedicationtonurturance,caretakingspecialization,andsocialstructuresthatcansupportthisspecialization.Asthesizeofprimategroupsexpanded,grooming,grunts,andhandgesturesbecameinadequateandweregraduallyshapedintospokenlanguage.Complexsocialstructuresencouragedthedevelopmentofmoresophisticatedcommunication,leadingtothedevelopmentoforalandwrittenlanguage.Associalgroupsgrewinsizeandlanguagebecamemorecomplex,alargercortexwasneededtoprocessincreasinglycomplexinformation.Languageandcultureprovideourexpandingbrainstheabilitytorecordandaccumulatehistoryandinformation,anddeveloptechnology.Theaccomplishmentsofcultureallowforevengreatergroupsizeandmoresophisticatedbrains.

Itisverylikelythatsomeversionofthisevolutionarynarrativeshapedthecontemporaryhumanbrain.Butdespitesomeremarkableadvances,wehavecontinuedtobegovernedbythebasicbiologicalprinciplesofhomeostasis,fundamentalapproach-avoidancechoices,andflowsofelectricalandchemicalinformationthroughoutourbrainsandbodies.Likeeverylivingsystem,fromasingleneurontocomplexecosystems,thebraindependsoninteractionwithotherbrainsforitssurvival.Becauseincreasingcomplexityrequiresgreaterinterdependency,ourbrainshavecometoexistmoreandmoreprofoundlywithinamatrixofotherbrains.

Atbirth,thehumanbrainisdependentoncaretakersforitssurvivalandgrowth.Theprolongedandsophisticatedparentingthathasevolvedinprimatesscaffoldsanincreasingamountofpostnatalgrowthanddevelopment.Thisallowseachhumanbraintobeauniqueblendingofnatureandnurtureasitbuildsitsstructuresthroughinteractionsandmoldingitselftoitsenvironment.Parents’nonverbalcommunicationsandpatternsofrespondingtotheinfant’sbasicneedsalsoshapethebaby’sperceptionsoftheworldanditssenseofself.Becausethefirstfewyearsoflifeareaperiodofexuberantbraindevelopment,earlyexperiencehasadisproportionateimpactonthedevelopmentofneuralsystems.

Genesfirstservetoorganizethebrainandtriggersensitiveperiods,whileexperienceorchestratesgenetictranscriptionintheongoingadaptiveshapingofneuralsystems,sothatexperiencebecomestheactualhardwareofourbrains.Thisstructure,inturn,organizesotherbrains,allowingexperiencestobepassedthroughagroupandcarriedforwardacrossgenerations.Whilebeingembeddedinagroupcomeswithmanychallenges,italsocomeswithanabilitytointeractivelyregulateeachother’sinternalstatesandassistinneuralintegration.

EnvironmentalProgramming

Thegroupconsistingofmother,father,andchildisthemaineducationalagencyofmankind.—MartinLutherKingJr.

Thetransductionofbondingexperiencesintoneurobiologicalstructureisafascinatingareaofstudy.Itcarriesdeepimplicationsforhowrelationshipsthroughoutlifeimpactourexperienceandtherebyshapeourbrains.MichaelMeaneyandhiscolleagueshavebeenstudyingthisquestioningreatdepthformanyyears.Theirworkhastakenadvantageofnaturallyoccurringvariationinthematernalbehaviorofmotherrats(dams)toexploretheimpactoftheirministrationsonthebrainsoftheirpups.Motherratslick,nurse,andretrievetheirpupswhentheyrolloutofthenest.Thesethreebehaviorsareeasilyobservedandcountedbywillingundergraduates,andcorrelatedwithbehavioralandbiologicalvariablesinthebrainsofbothmothersandchildren.

TheworkofMeaneyandothershasprovideduswithampleevidencethatmotherratspassontheirgenesthroughDNAandshapegeneticexpressionthroughtheirbehavior.Environmentalprogrammingisatermusedtodescribethisorchestrationofepigeneticfactorsduringdevelopment(Fishetal.,2004;Meaney&Szyf,2005;Sapolsky,2004).Thus,twomechanismsofinheritanceexist:slowchangesacrossmanygenerationsthroughmutationandnaturalselection,andrapidchangesingeneticexpressionduringeachgeneration(Clovisetal.,2005;Cameronetal.,2005;Meaney&Szyf,2005;Zhang,Parent,Weaver,&Meaney,2004).Theirresearchhasthusfarrevealedthreeprimarywaysinwhichmaternalbehaviorimpactsvariationsinbrainstructure—learningandplasticity,theabilitytocopewithstress,andlatermaternalbehaviorinadulthood.Amother’simpactonthewayherdaughterwillmotherherchildrenservesasaparallelchannelofinheritancethatishighlysensitivetoenvironmentalconditions.

Geneticexpressionisprogrammedbyexperiencethroughthealterationofthechromatinstructure

andthemethylationofDNA(Szyf,Weaver,&Meaney,2007).Ineffect,thegenomeislikeakeyboardwhiletheseprocessesselectthenotestobeplayed.MethylationisaprocessbywhichamethylgroupisaddedtoDNA.ThishasbeenshowntobeareversiblebutstablemodificationtoDNAthatispassedalongtodaughtercellsandcanleadtolong-termgenesilencing.Lowlicking/groomingmotheringresultsinincreasedglucocorticoidreceptormethylation,decreasedglucocorticoidreceptor(GR)expression,andanincreasedstressresponse.Licking/groomingdecreasesmethylation,increasesGRexpressionanddownregulatesthestressresponse(Weaveretal.,2007).Soasweshowaffectionandkindnesstoourchildren,wemaybebuildingmoreresilientbrains,anexpressionofgeneticvariationthatwouldlikelyhavemadeLamarcksmile.

Threedifferentresearchmethodshavebeenemployedtostudytheeffectsofmaternalbehaviorongeneticexpression.Inthefirstmodel,theamountofattentionismeasuredandthebehaviorsandbrainsofpupsinhigh-andlow-attentiongroupsarecompared.Thesecondexaminestheeffectsofperiodsofmaternaldeprivation,whilethethirduseshandlingofthepupsbyhumanresearchersastheexperimentalmanipulation.Becauseithasbeenfoundthathumanhandlingstimulatesmorematernalattention,thefirstandthirdcategoriesmayturnouttobeoneandthesame(Garoflosetal.,2008).

Levelsofmaternalattentionhavebeenshowntoeitherstimulateorsilencegeneexpressioninthedomainsofneuralgrowthandplasticity,modulationofhypothalamic-pituitary-adrenal(HPA)activity,andprogrammingoffuturematernalbehavior(Szyf,McGowan,&Meaney,2008).Neuralgrowthisstimulatedviatheactivationofbrain-derivedneurotrophicfactor(BDNF),cFos,andmessengerRNAexpressioninavarietyofbrainareas,processestiedtothebiochemistryofneuroplasticityandlearning.Stressreactivityiscontrolledvialevelsofbenzodiazepine,oxytocin,andglucocorticoidreceptorsinmanyregionsofthebrain.Higherlevelsofmaternalattentionresultinmoreofthesereceptorsbeingformed,allowingforthedampeningoffearandanxietyandanincreaseinexploratorybehavior.Maternalbehaviorisgovernedbythegrowthandactivationofmedialopticareas(therats’versionofourompfc)aswellastheregulationofoxytocinandestrogenreceptors(Neumann,2008).SeeTable12.1forsomeofthespecificfindingsineachareaofstudy.

Inessence,ratswhoreceivemorematernalattentionhavebrainsthataremorerobust,resilient,andnurturingofothers.Theyareabletolearnfasterandmaintainmemorieslonger.Theyarelessreactivetostressandarethusabletousetheirabilitiestolearnathigherlevelsofarousalandacrossmoredifficultsituations.Theywillalsosufferlessfromthedamagingeffectsofcortisolbydownregulatingitsoonerafterastressresponse.Andfinally,femalesgrowingupwithmoreattentivemotherspassthesepositivefeaturesontotheirchildren.Themechanismsfortheassociationinhumansbetweenearlysecureattachmentandhealthiermindsandbodiesislikelysimilarbutfarmorecomplex.

TABLE12.1TheImpactofMaternalAttention

MaternalAction StudyFindings

NeuralGrowthandPlasticityLicking Increasedsynapticdensity,longerdendriticbranching,andincreasedneuronalsurvival1

Licking Increasedneuronalsurvivalinthehippocampus2

Licking Fosexpressioninthehippocampusandparietalandoccipitalcortex3

Licking/nursing IncreasedNMDAandBDNFexpressionandincreasedcholinergicinnervationofthehippocampus4

ModulationofHPAActivityLicking IncreasedmedialPFCdopamineinresponsetostressandincreasedstartleinhibition5

Licking/nursingDecreasedfearreactivity6

Licking/nursingIncreasedepigeneticexpressionofglucocorticoidreceptorgenepromoterinthehippocampus7

Licking/nursing IncreasedmRNAexpressioninmedialprefrontalcortex,hippocampus,andthebasolateralandcentralregionsoftheamygdala8

Licking/nursingIncreasedlevelsofbenzodiazepinereceptorsinthelateral,central,andbasolateralregionsoftheamygdalaandthelocuscoeruleusaswellasincreasedlevelsofalpha2adrenoreceptordensityanddecreasedCHRreceptordensityinthelocuscoeruleus9

ModulationofFutureMaternalBehavior

Nursingcall Enhancedmetabolicactivationinprecentralmedialcortex,anteriorcingulatecortex,andlateralthalamus10

Licking ElevatedlevelsofestrogenmRNAandmorematernalbehaviorlaterinlife11

Licking/nursing Increasedlevelsofoxytocinandestrogenreceptorsinmedialpreopticareas(andincreasedmaternalbehaviorwhentheyhavetheirownpups)12

Licking Lesssexualbehaviorinfemalesandlesslikelytobecomepregnantaftergivingbirth13

MaternalattentionstimulatestheexpressionofBDNF,themostabundantneurotrophinsinthebrain.

Amongitsmanyfunctions,BDNFmodulatesglutamate-sensitiveNMDAreceptorswhich,inturn,regulatebothlong-termpotentiation,long-termdepression,andneuroplasticity(Alonsoetal.,2002;Bekinschteinetal.,2008;Monfils,Cowansage,&LeDoux,2007).WhilecortisolinhibitstheproductionofBDNF(andnewlearning),higherlevelsofBDNFappeartobothbufferthehippocampusfromstressandencourageongoingplasticity(Penceaetal.,2001;Radeckietal.,2005;Schaaf,deKloet,&Vregendenhil,2000).AndbecausetheproductionofBDNF(andotherneurotrophins)areunderepigeneticcontrol,physical,emotional,andinterpersonalexperienceallinfluencetheirproductionandavailability(Bertonetal.,2006;Branchietal.,2004;Branchi,Francia,&Alleva,2006).

Manyresearchershavefoundcorrelationsbetweenhippocampalvolumeandsymptomsofdepression.Whilemoststressfulillnessescorrelatewithreductionsinhippocampalvolume,thereisspeculationthatdepressionmaybearesultratherthanacauseofhippocampalreduction.Inotherwords,thesymptomsofdepressionareanexperientialexpressionofashutdownofneuroplasticity.Thus,ifourneuronsbecomedepressed,sodowe.Sincedepressionisoftenanaturalconsequenceofprolongedstress,onemechanismofactionlinkingthetwomaybethecatabolicimpactofhighlevelsofcortisolontheneuronswithinthehippocampus.ItissuspectedthatantidepressantSSRIsandphysicalactivityworktoreversethenegativeimpactofcortisolinthehippocampusbytriggeringBDNFsynthesis(Fernandesetal.,2008;Russo-Neustadtetal.,2000;Warner-Schmidt&Duman,2006).DirectadministrationofBDNFhasalsobeenshowntohavelong-lastingantidepressanteffects(Hoshaw,Malberg,&Lucki,2005).

Whilemorematernalattentionresultsinincreasedgrowthandenhancedfunctioningthroughoutthepups’brains,separationfrommothersprovestohavetheoppositeeffects.Thesamethreeareasthatareupregulatedwithmorematernalattentionarealldownregulatedbyherabsence.Deprivationofmaternalattentionincreasesneuralandglialdeath,whilereducinggeneexpression,impairingtheirabilitytolearn.

Maternalseparationalsoresultsinreducedinhibitory(GABA)receptorsinthelocuscoeruleus,increasingadrenalinesecretioninreactiontostresswhilereducingtheantianxietypropertiesofbenzodiazepinereceptorsintheamygdala.Decreasedcortisolreceptorsinthehippocampusalsoimpairtheinhibitoryfeedbacktothestresssystemtoshutdowncortisolproduction.SeeTable12.2forthespecificstudiesfromwhichthisinformationistaken.Soagainweseeresultsthatparallelfindingswithhumansubjectswhereearlymaternaldeprivationthroughseparationordepressionresultsindecreasedbrainfunctioning,higherlevelsofanxiety,anddifficultywithsubsequentattachment(Brennanetal.,2008;Tyrkaetal,2008).

TABLE12.2TheImpactofMaternalSeparation

NeuralGrowthandPlasticityIncreasedneuronalandglialdeath1Decreasedneurotrophinlevelsinventralhippocampus2Decreasedglialdensity3

ModulationofHPAActivityReducedGABAreceptorsinthelocuscoeruleusDecreasedGABAreceptormaturityReducedbenzodiazepinereceptorsinthecentralandlateralamygdalaandincreasedmRNAexpressionin

theamygdala4Increasedanxiety,fearfulness,andresponsetostress5IncreasedLTPandLTDinamygdalo-hippocampalsynapses6Decreasedexploratorybehavior,avoidanceofnovelty,andgreatervulnerabilitytoaddiction7Reducedgeneexpression8Greatercortisolsecretioninresponsetomildstressandincreasedstartleresponseandstartle-induced

sounds9Reducedsomaticanalgesiaandincreasedcolonicmotilitymimickingirritablebowelsyndromein

humans10Upregulationofglutamatereceptors11

ModulationofFutureMaternalBehaviorDecreasedsynapticdensityinthemedialprefrontalcortexDecreasedcellsurvivalinmaternalneuralnetworks12DecreasedactivationintheBednucleusofthestriaterminalisandnucleusaccumbens13

Theevidencefromthehandlingstudiesisessentiallythesameasforhighlyattentivemothersinneuralhealthandthemodulationofanxiety,supportingtheideathattheymaybothrepresenttheeffectsofgreateramountsofmaternalattention.Moreglucocorticoidreceptors,lowercortisollevels,andgreaterbrainactivityreflectabraingearedtowardlessanxiety,helplessness,andfear.Inturn,thesepupsaremoreresilient,engageinmorecomplexexploratorybehavior,andarebetterlearnersthantheir

nonhandledsiblings.Similarresultshavealsobeendiscoveredinparrotsandpigs(seeTable12.3).

TABLE12.3TheImpactofHumanHandlingonRats,Pigs,andParrots

ModulationofHPAActivity

RatpupsIncreasedconcentrationsofglucocorticoidreceptorsinthehippocampusandfrontallobes1Increasedglucocorticoidreceptorbindingcapacityinthehippocampus2Increasedcorticotrophin-releasingfactormRNAandgreaterCRFlevels3Decreasedinhibitoryavoidanceandincreasedobjectrecognition4Lowerlevelsofstressinreactiontoapredatoryodor5Increasedneurotrophin-3expressionandneuronalactivationinhippocampusandparietallobes6Lowcortisolsecretioninresponsetostress/highexploratorybehavior7Protectionagainstage-relatedneuroendocrineandbehavioraldeclinewithage8Decreasedhelplessnessbehaviors9

BabypigsLowerbasalandfreeplasmalevelsofcortisol10

AmazonparrotsDecreasedserumcortisollevelsinresponsetostress11

Theseandotherstudiessupportthebeliefthatthereactionofthebraintomaternalattentionisnotanabstracttheorybutawell-documentedphenomenon.Theconsistencyofbehavioral,emotional,andbiologicalfindingsacrossspeciesistoopowerfultobediscounted.Infact,over900geneshavebeendiscoveredthataredifferentiallyexpressedbasedontheamountofmaternalbehavior(Ramponetal.,2000;Weaveretal.,2006).Andthereisnoreasontobelievethatthematernalcontrolofepigeneticexpressionhasnotbeenconservedinprimatesandhumans.

Rhesusmonkeysdeprivedofmaternalcontactdemonstratereducedtranscriptionalefficiencyofserotoninanditsreceptorsinthebrain(Bennettetal.,2002).Wedoknowthatlowlevelsofcaringmaternalbehaviorinhumanscorrelatewithmorefearfulbehavior,lesspositivejointattention,andright-biasedfrontalactivation,allofwhicharerelatedtohigherlevelsofstressandarousal(Hane&Fox,2006).Self-esteemandlocusofcontrolhavebeenfoundtocorrelatewithhippocampalvolume,whichweknowistiedtocortisolregulation(Pruessneretal.,2005).Inmymind,theparallelsaswellasthetendencyforevolutiontoconservesuchmechanismsformastrongcaseforthetheorythatwhatMeaneyandhiscolleaguesarefindinginratsisatworkinhumans.

Inanexcitingtwist,ithasbeenfoundthatbiologicalinterventionsandenrichedsocialandphysicalenvironmentscanreversetheeffectsoflowlevelsofmaternalattentionandearlydeprivationonbothHPAactivityandbehavior(Bredyetal.,2004;Francisetal.,2002;Hood,Dreschel,&Granger,2003;Szyfetal.,2005;Weaveretal.,2005).Unfortunately,chronicstressortraumainadolescenceand

adulthoodcanalsoreversethepositiveeffectsofhigherlevelsofattentionearlierinlife,shapingabrainthatresemblesonethatwasdeprivedofearlymaternalattention(Ladd,Thrivikraman,Hout,&Plotsky,etal.,2005).Thesestudiesallsupportthenotionthatourbrainsarecapableofcontinualadaptationinbothpositiveandnegativedirectionsandthatsuccessfulpsychotherapy,onethatestablishesanurturingrelationship,maywellbecapableoftriggeringgeneticexpressioninwaysthatcandecreasestress,improvelearning,andestablishabridgetonewandhealthierrelationships.

Keepinmindthattheamountofattentionthatamotherratshowsherpupsexistsinabroadadaptationalcontext.Highlystressedmothersdemonstratelowerratesoflickingandgrooming,whichprepareherpup’sbrainsforlivinginastressfulenvironment.Inotherwords,underadverseconditions,maternalbehaviordecreases,whichprogramsheroffspringforenhancedreactivitytostress.Thislikelyincreasestheprobabilityofsurvivalwhilesimultaneouslyelevatingtheriskofphysicalandemotionalpathologylaterinlife(Diorio&Meaney,2007).Theimpactofneonatalhandlingisalsodifferentformaleandfemalepups,reflectingtheirdivergentadaptationalrolesandcontributionstothesurvivaloftheirspecies(Park,Hoang,Belluzzi,&Leslie,2003;Plojetal.,2001;Stamatakisetal.,2008).Allofthissuggeststhatthelevelofmaternalbehaviorisinterwovenintoamatrixofadaptationchoicesthatvarybasedonexternalfactors.Thefactthatprocessesthataresetinmotionearlyinlifecanbemodifiedbysubsequentexperiencedemonstratestheabilitytoadapttoachangingenvironment.

Thisworkwithratshasestablishedguidelinesforfutureexplorationintoenvironmentalprogramminginhumans.Thereareobviouslimitationstoresearchwithhumansthatrequiresphysicalexaminationofthebrain.Wewillhavetorelyonsamplesofopportunityandutilizecarefulmethodologicalcontrolstobecertainofthequalityofresults.OnesuchstudycomparedthebrainsofsuicidevictimswithnormalcontrolsandfoundlowermRNAlevelsofBDNFandtrkBinthesuicidevictims,bothofwhichareinvolvedinneuronalhealthandplasticity.Thesedataraisethepossibilitythatearlyenvironmentalprogrammingmayhavemadethemsusceptibletodepressionandsuicide(Dwivedietal.,2003).AmorerecentstudycomparedthebrainsofsuicidevictimswithandwithouthistoriesofchildabuseandfoundthatthosewithhistoriesofearlyabusedemonstrateddecreasedlevelsofglucocorticoidreceptormRNA,receptorexpression,andgrowthfactortranscriptionwhencomparedtothosewithoutabuse(McGowanetal.,2009).Thesestudiesarehighlysupportiveofourabilitytoapplyanimalresearchtohumans.

AttachmentandtheHumanBrain

WhatIdoandwhatIdreamincludethee,asthewinemusttasteofitsowngrapes.—ElizabethBarretBrowning

Itturnsoutthatgeneexpressioninresponsetoclosecontactisatwowaystreet.Givingbirthandexposuretochildrenchangesthebrainsofparentsandcaretakersinwaysthatsupportbonding,attachment,andnurturance.Aprimarydiscoveryinmotherratshasbeentheremodelingandexpansionofthehippocampusinpreparationforlocating,storing,andretrievinggreateramountsoffood(Pawluski&Galea,2006).Contactwithherpupscausesincreasedgrowthinthemedialpreopticarea,basolateralamygdala,andparietalandprefrontalcortexasthebrainexpandstoincorporatethesenewbeingsintotheself-experienceofthemother(Fleming&Korsmit,1996;Kinsleyetal.,2006;Lonsteinetal.,1998).Evenvirginratswhoaregivenpupstocareforexperienceincreaseddendriticgrowthandneuronalexcitationinsuperopticareas(Modney,Yang&Hatton,1990;Modney&Hatton,1994;Salm,Modney,&Hatton,1988).Thus,justasinchildren,interpersonalcontactchangesthebrainsofparents.

Ithasbeenshownthatwhenhumanmothersheartheirinfantscry,thereisanincreaseinactivityintheirrightmedialprefrontalcortexandanteriorcingulate—regionsknowntomediatematernalresponse(Lorberbaumetal.,1999).Watchingavideooftheirowninfantwillstimulateactivityintherightanteriortemporalpole,leftamygdala,andbothrightandleftompfc(Minagawa-Kawaietal.,2008;Nitschkeetal.,2004;Ranoteetal.,2004).

Itislikelythatjustasmaternalattentiontriggersepigeneticfactorsinchildren,caringforchildrenmayalsochangegeneticexpressionintheircaretakers.Thegrandmothergenehypothesissuggeststhathumanwomenexperienceearlymenopausetobeavailabletohelpnurturetheirgrandchildrenandavoidtherisksinherentinmatingandchildbirth,whichrisewithageforbothmotherandchild(Lee,2003;Rogers,1993;Turke,1997).Inessence,thegrandmothergenehypothesissuggeststhatearlymenopausehasbeenshapedbynaturalselectiontoenhancethesurvivalrateofawoman’schildren’schildren.

Sear,Mace,andMcGregor(2000)studiedtriballifeinruralGambiawherefamiliesliveatthelevelofsubsistenceanddependupononeanotherforbasicsurvival.Theirlifestyleislikelysimilartothesocialandenvironmentalcontextofmostofourevolutionaryhistory.Theresultsoftheirresearchshowthatnutritionalstatus,height,andtheprobabilityofsurvivaloftheiryoungweresignificantlycorrelatedwiththepresenceofpostmenopausalmaternalgrandmothers.Ontheotherhand,thepresenceoffathers,paternalgrandmothers,orothermalekinhadanegligibleimpactoneitherthenutritionalstatusorsurvivalratesofoffspring.Similarfindingshavebeenobtainedinstudiesofhunter-gathererpopulationsofTanzania,premodernJapan,Canada,andFinland,andcontemporaryurbanpopulationsintheUnitedStates(Hawkes,O’Connell,&Jones,1997;Lahdenperäetal.,2004;Popeetal.,1993).

Besidesthetimingofmenopause,isitpossiblethatwomenlivelongerbecausetheyaretraditionallyinvolvedincaringfortheiryoung?Thatis,isthereahealthbenefitinvolvedintakingcareofchildrenbecauseoftheneurobiologicalprocessesitstimulatesinourbrainsandbodies?Someinterestingevidencethatmaysupportaconnectionbetweenchildcareandlongevitycomesfromlookingatparentingresponsibilitiesacrossdifferentspeciesofprimates.Alongevityadvantageforfemalesdoesexistingorillas,orangutans,andhumans,inwhichtheyaretheprimarycaretakers.Ontheotherhand,inspeciessuchastheowlandtitimonkey,wherethemaleistheprimarycaretakerofinfants,malestendtosurvivelonger.InGoeldimonkeys,wherecaretakingisshared,thelongevityforbothgendersisequivalent(seeTable12.4).

TABLE12.4ChildCareandLongevityAcrossPrimateSpecies

Primate Female/MaleSurvivalRatio MaleCareChimpanzee 1.418 RareSpidermonkey 1.272 RareOrangutan 1.203 NoneGorilla 1.199 Pair-living,littledirectroleGibbon 1.125 ProtectsandplayswithoffspringHuman 1.052–1.082 Supportseconomically,somecareGoeldimonkey 0.974 BothparentscarryinfantSiamang 0.915 CarriesinfantinsecondyearOwlmonkey 0.869 CarriesinfantfrombirthTitimonkey 0.828 Carriesinfantfrombirth

AdaptedfromAllman,Rosin,Kumar,&Hasenstaub,1998.

Giventheamountofdatasupportingthebeneficialeffectsofsecureattachment,caretaking,human

touch,andsocialsupport,itisplausiblethatnurturing,emotionalattunement,andphysicalcontacthavesalubriouseffectsthatmayprovideprimarycaretakerswithasurvivaladvantage.Itispossiblethatattachmentbonds,caretakingexperiences,andtheneurochemicalsandepigeneticphenomenatheyimpactmaywellenhanceourhealthandsurvival.Perhapscaringforourchildrenandgrandchildrenmaybemoresupportiveofhealthandlongevitythancholesterolmedicationandtreadmills.

Interestingly,womenwhogivebirthaftertheageof40arealmostfourtimesmorelikelytolivetobe100yearsold(Perls,Alpert,&Fretts,1997).Whilethisisusuallyexplainedintermsoftheprotectivenatureofbirth-relatedhormones,theirenhancedlongevitymaybepartofbroaderbiologicalandpsychologicalprocessesinvolvedinintensecaretaking(King&Elder,1997).Itisagoodbetthattakingcareofachildtellsthebrainandbodytotriggerepigeneticandbiochemicalprocessesthatenhancehealthandslowdownaging.

TheHumanSocialBrain

Itisgoodtorubandpolishourbrainsagainstthoseofothers.—Montaigne

Wehaveseenagreatdealofevidenceoftheimpactofearlynurturanceontheshapingofthesocialbrainanditsemotionalcircuitry.Sowhenourearlyrelationshipsarefrightening,abusive,ornonexistent,ourbrainsdutifullyadapttotherealitiesofourunfortunatesituations.However,thereisreasontobelievethatthesecircuitsretainexperience-dependentplasticitythroughoutlife,especiallyincloserelationships(Bowlby,1988;Davidson,2000).Experience-dependentplasticityhasbeenfoundinmanyareasofthebrain,includingtheprefrontalcortexandhippocampus(Kolb&Gibb,2002;Maletic-Savatic,Malinow,&Svoboda,1999).Thesestructures,centraltolearningandmemory,arealsokeyinshapingattachmentschema.Further,researchisemergingthatinthetransitionfromdatingtomarriage,thereisabroadtendencytomovefrominsecureanddisorganizedattachmentschematoincreasinglysecurepatterns(Crowell,Treboux,&Waters,2002).Ontheotherhand,socialstressinhibitscellproliferationandneuralplasticity,whilesocialsupport,compassion,andkindnesssupportpositiveneuralgrowth(Czéhetal.,2007;Davidson,Jackson,&Kalin,2000).

Whileratspossessthebasicmechanismsofbondingandmaternalbehavior,ourbrainshavemoreelaborateandsophisticatedmechanismsforattachment.Infact,thehumanbrainiscriss-crossedwithneuralnetworksdedicatedtoreceiving,processing,andcommunicatingmessagesacrossthesocialsynapse.Thedifferenceinhumansisthattheenvironmentalprogrammingoftheseexperience-dependentcircuitsisfarmorelengthyandcomplex.Networksofourcomplexsocialbrainsincludebrainregions,neuralsystems,andregulatorynetworkslistedinTable12.5.Thesearethesamecircuitsthattherapistsattempttoinfluenceinreshapingthebraininwayswhichleadtomorepositiveadaptationlaterinlife.Theideathatpsychotherapyisakindofreparentingmaybemorethanametaphor;itmaybepreciselywhatweareattemptingtoaccomplishattheleveloftheepigenome.Thisresearchestablishesattention,care,andnurturanceasawaytoinfluencetheverystructureofourbrainandplacespsychotherapyattheheartofbiologicalinterventions.ItisoddtothinkthatCarlRogersmaysomedayfindaplacenexttoCrickandWatsoninthepantheonofbiologists.

Nowlet’sshiftourattentiontothestructuresofthehumanbrainthatorganizeattachment,affectregulation,andthemodulationofstress.Foramorein-depthexplorationofthesocialbrain,seeTheNeuroscienceofHumanRelationships(Cozolino,2006).Keepinmindthat,justasinrats,thesesystemsarealsobuiltbytheattachmentstheycometocontrol.Thus,ourlearninghistorycomestobereflectedinthearchitectureofourneuralsystems.

TABLE12.5StructuresandSystemsoftheSocialBrain

CorticalandSubcorticalStructuresOrbitalandmedialprefrontalcortices(ompfc)

Cingulatecortexandspindle(VonEconomo)cellsInsulacortex

SomatosensorycortexAmygdala,hippocampus

Hypothalamus

Sensory,Motor,andAffectiveSystemsFacerecognitionandexpressionreading

Imitation,mirroring,andresonancesystems

RegulatorySystemsAttachment,stressandfearregulation(orbitalmedialprefrontalcortex–amygdalabalance)

Socialengagement(thevagalsystemofautonomicregulation)Socialmotivation(rewardrepresentationandreinforcement)

CorticalandSubcorticalStructures

Theprehistoricalandprimitiveperiodrepresentsthetrueinfancyofthemind.—JamesBaldwin

Theompfc,insula,andcingulatecortices—themostevolutionarilyprimitiveareasofthecortex—lieburiedbeneathandwithinthefoldsofthelaterevolvingcortex.Infact,someneuroanatomistsseethesecontiguousstructuresascomprisingafunctionalsystemcalledthebasalforebrain(Critchley,2005;Heimer&VanHoesen,2006).Theompfcsitsattheapexofthelimbicsystem.Asaconvergencezoneforpolysensory,somatic,andemotionalinformation,itisintheperfectpositiontosynthesizeinformationfrombothourinternalandexternalworlds.Initspositionattheapexofthelimbicsystem,theompfc’sinhibitoryroleinautonomicfunctioninghighlightsitscontributiontotheorganizationofbehaviorandaffectregulation.

Theompfcallowsustotranslatethepunishmentandrewardvaluesofcomplexsocialinformationsuchasfacialexpressions,gestures,andeyecontactintomeaningfulinformation,associateitwithourownemotions,andthusorganizeattachmentschema(O’Dohertyetal.,2001;Tremblay&Schultz,1999;Zald&Kim,2001).Theompfcalsomediatesemotionalresponsesandcoordinatestheactivationand

balanceofthesympatheticandparasympatheticbranchesoftheautonomicnervoussystem(Haririetal.,2000;Price,Carmichael&Drevets,1996).

Thecingulatecortexisaprimitiveassociationareaofvisceral,motor,tactile,autonomic,andemotionalinformationthatbeginstoparticipateinbrainactivityduringthesecondmonthoflife(Kennard,1955).Itfirstappearedduringevolutioninanimalsexhibitingmaternalbehavior,play,andnursing,andwhenmakingsoundsbecameinvolvedwithcommunicationbetweenpredatorandprey,potentialmates,andmotherandchild(MacLean,1985).Thecaretakingandresonancebehaviorsmadepossiblebythecingulatealsoprovideanimportantcomponentoftheneuralinfrastructureforsocialcooperationandempathy(Rillingetal.,2002;Vogt,2005).Destructionoftheanteriorcingulateinmammalsresultsinmutism,alossofmaternalresponses,infantdeathduetoneglect,andemotionalandautonomicinstability(Bush,Luu,&Posner,2000;Bushetal.,2002;Paus,Petrides,Evans,&Meyer,1993).

Theanteriorcingulatecontainsspindle-shapedneuronsthatappeartohaveevolvedinhumansandgreatapestoconnectandregulatedivergentstreamsofinformation(Nimchinskyetal.,1995,1999).Thesecellsmayprovidetheneuralconnectivitynecessarybothforthedevelopmentofself-controlandtheabilitytoengageinsustainedattentiontodifficultproblems(Allmanetal.,2001,2005).Spindlecellsareespeciallyfascinatingbecausetheyemergeafterbirthandareexperience-dependent.Earlyneglect,stress,andtraumamaynegativelyimpactthedevelopmentandorganizationoftheanteriorcingulateandspindlecells,resultinginlifelongcognitivedeficits,andemotionalfunctioningmaybebasedontheconstructionandhealthofthesestructures(Cohenetal.,2006;Ovtscharoff,Helmeke,&Braun,2006).

Theinsulabeginslifeonthelateralsurfacesofthebrain,onlytobecomehiddenbytherapidexpansionofthefrontalandtemporallobes.Theinsulaissometimesdescribedasthe“limbicintegrationcortex”becauseofitsmassiveconnectionstoalllimbicstructures,anditsfeed-forwardlinkswiththefrontal,parietal,andtemporallobes(Augustine,1996).Itprovidesthebrainwithameanstoconnectprimitivebodilystateswiththeexperienceandexpressionofbodilyawareness,emotion,andbehavior(Carretal.,2003;Phanetal.,2002).Intandemwiththeanteriorcingulate,theinsulaallowsustobeawareofwhatishappeninginsideofourbodiesandreflectonouremotionalexperiences(Bechara&Naqvi,2004;Critchleyetal.,2004;Gundel,Lopez-Sala,Ceballos-Baumann,2004).Damagetotherightinsulacanresultinanosognosia,aconditionwhereapatientseemsunawareofandunfazedbysevereparalysisontheleftsideofthebody(Garavan,Ross,&Stein,1999).Recentresearchsuggeststhattheinsulaisinvolvedwithmediatingtheentirerangeofemotionsfromdisgusttolove(Bartels&Zeki,2000;Calderetal.,2003).

Thesomatosensorycortex,locatedalongthefrontoftheparietallobes,processesinformationaboutbodilyexperiences.ItliesjustbehindthecentralgyrusandwrapsdeepwithintheSylvianfissurethatdividestheparietalfromthefrontallobes.Alongwiththeinsulaandanteriorcingulatecortices,itcontainsmultiplerepresentationsofthebodythatprocessandorganizeourexperienceoftouch,temperature,pain,jointposition,andourvisceralstate.Thesedifferentprocessingstreamscombinetocreateourexperienceofourphysicalselves.Italsoparticipatesinwhatwecallintuitionorgutfeelingsbyactivatingimplicitmemoriesrelatedtoourexperiencesandhelpingustomakedecisionsguidedbyfeelings(Damasio,1994).Theexperienceofourownbodiesbecomesthemodelforourunderstandingandempathywithothers(Damasioetal.,2000).

Workinginconcertwiththeompfc,thesubcorticalamygdalaisanothercorecomponentofthesocialbrain.Theamygdalaachievesahighdegreeofmaturitybytheeighthmonthofgestation,allowingittoassociateafearresponsetoastimuluspriortobirth(LaBaretal.,1995;Ulfig,Setzer,&Bohl,2003).Asaprimitiveorganofappraisal,theamygdalacloselymonitorssignalsofsafetyanddangerandmediatesthefight-or-flightresponseviatheautonomicnervoussystem(Davis,1997;Ono,Nishijo,&Uwano,1995;Phelps&Anderson,1997).Theompfccaninhibittheamygdalabasedonconsciousawarenessandfeedbackfromtheenvironment(Beeretal.,2003).Bythesametoken,whenwearefrightenedandour

amygdalaisactivated,itinhibitstheompfcandwehaveadifficulttimebeingrational,logical,andincontrolofourthoughts.Theamygdalaalsoappearstocontributetoourconsciousexperienceofbothemotionalandphysicalpain(Mitra&Sapolsky,2008;Neugebauer,Li,Bird,&Han,2004).Sincethenetworksconnectingtheompfcandtheamygdalaareshapedbyexperience,ourlearninghistoryofwhatissafeanddangerous,includingourattachmentschema,isthoughttobeencodedwithinthissystem.

Thehippocampusissituatedatthejunctionbetweenthecortexandlimbicsystemonbothsidesofthebrain.Inlowermammalsliketherat,thehippocampusisaspecializedspatialmapofforagingterritory.Inhumans,theparietallobesevolvedfromthehippocampusandassistitincomplexvisual-spatialprocessing.Thehumanhippocampus,alongwithitsadjacentstructures(parahippocampalgyrus,dentategyrus),havecometobespecializedintheorganizationofspatial,sequential,andemotionallearningandmemory(Edelman,1989;McGaughetal.,1993;Sherryetal.,1992;Zola-Morgan&Squire,1990).Incontrasttotheamygdala,thehippocampusisalatebloomer,continuingtomatureintoearlyadulthoodalongwiththedlpfcconnectionsuponwhichitrelies(Benes,1989).Ourlackofconsciousmemoryforearlychildhood,knownaschildhoodamnesia,islikelyduetotheslowdevelopmentalcourseofthehippocampus(Fuster,1996;Jacobsetal.,2000;McCarthy,1995).

Thehypothalamusisasmallandancientstructurethatsitsatthecenterofthebrainbelowthethalamusandhalfwaybetweenthecortexandthebrainstem.Ithasextensiveconnectionswiththestructuresofthesocialbrainwithinthefrontallobes,limbicsystem,andbrainstem.Iincludethehypothalamusaspartofthesocialbrainbecauseitiscentrallyinvolvedwiththetranslationofconsciousexperienceintobodilyprocessesandthus,thetransductionofearlyexperienceintothebuildingofthebrainandbody.Itsvariousnucleiorganizemanybodilyfunctionssuchastemperatureregulation,hunger,thirst,andactivitylevel.Thehypothalamusisalsoinvolvedintheregulationofsexualbehaviorandaggression.AstheheadoftheHPAaxis,ittranslatesbrainprocessesintohormonalsecretionsfromtheanteriorpituitary.Amongthehormonesproducedbythepituitary,follicle-stimulatinghormoneandprolactinareinvolvedinreproductionandnursing.Adrenocorticotropichormone,whichissenttotheadrenalglandsviathebloodstream,stimulatestheproductionofcortisol,whichwewillbediscussingindepthlaterasitrelatestocaretakingandearlystress.

Sensory,Motor,andAffectiveSystems

CommonSenseisthatwhichjudgesthethingsgiventoitbyothersenses.—LeonardodaVinci

Itisinthetemporallobesthatoursensesareintegrated,organized,andcombinedwithprimitivedrivesandemotionalsignificanceina“vertical”linkupacrossallthreelevelsofthetriunebrain(Adams,Victor,&Ropper,1997).Forexample,therecognitionoffacesandreadingtheirexpressionsoccursinthetop-downnetworks.Cellsinvolvedinbothreadingandidentifyingfacialexpressionsarelocatedinadjacentareasofthetemporallobes(Desimone,1991;Hasselmo,Rolls,&Baylis,1989).Whenweseefaces,theareasofthebrainthatbecomeactivatedlieinaprocessingstreamdedicatedtotheidentificationofvisualstimuli(Luetal.,1991).Theassociationregionoftheoccipitallobededicatedtotheidentificationoffacesisthefusiformfacearea(Gauthieretal.,2000;Halgrenetal.,1999).Theseareas,inturn,areinterconnectedwithotherclustersofcellsthatareresponsibleforeyegaze,bodyposture,andfacialexpressionasthebrainconstructscomplexperceptionsandsocialjudgmentsfrombasicbuildingblocksofvisualinformation(Jellema,Baker,Wicker,&Perrett,2000).

Regionsintheanterior(front)portionsofthesuperiortemporalsulcus(STS)integrateinformation

aboutvariousaspectsofthesameperson(form,location,andmotion),allowingustoidentifyothersfromdifferentangles,invariousplaces,andwhiletheyareinmotion(Jellema,Maassen,&Perrett,2004;Pelphreyetal.,2003;Vainaetal.,2001).TheSTSalsocontainsmirrorneurons,whichactivateeitherwhenwewitnessothersengaginginbehaviorsorwhenweourselvessubsequentlyengageintheseactions.Bybridgingneuralnetworksdedicatedtoperceptionandmovement,mirrorneuronsconnecttheobservedandtheobserverbylinkingvisualandmotorexperience.Resonancebehaviors(basedonmirrorsystems)arethereflexiveimitationresponseswemakewheninteractingwithothers.Itishypothesizedthatmirrorsystemsandresonancebehaviorsprovideuswithavisceral-emotionalexperienceofwhattheotherisexperiencing,allowingustoknowothersfromtheinsideout.

RegulatorySystems

Wegainourendsonlywiththelawsofnature;wecontrolheronlybyunderstandingherlaws.

—JacobBronowski

Thebody’sregulatorysystemsareinvolvedinthemaintenanceofinternalhomeostaticprocesses,balancingapproachandavoidance,excitationandinhibition,andfightandflightresponses.Theyalsocontrolmetabolism,arousal,andourimmunologicalfunctioning.Itisthroughthesesystemsthatweregulateeachother’sbiologicalandemotionalstates.

TheStress,Fear,andAttachmentSystem

I’mnotafraidofstorms,forI’mlearninghowtosailmyship.—LouisaMayAlcott

TheHPAsystemregulatesthesecretionofhormonesinvolvedwiththebody’sresponsetostressandthreat.Theimmediatereactiontostressisvitalforshort-termsurvival,whiletherapidreturntonormalizationafterthethreathaspassedisessentialforlong-termsurvival.Prolongedstressresultsinsystemdamageandbreakdown.Thelong-termeffectsofnegativeparentingexperiences,failuresofattachment,andearlytraumaaremediatedviatheHPAsystem.Intermsoffear,weturnagaintotheamygdala,asitalertsavarietyofbraincentersthatafight-flightresponseisrequired.Inturn,theactivationofthesympatheticbranchoftheautonomicnervoussystemresultsinsymptomsofanxiety,agitation,andpanic.Theprimedirectiveoftheamygdalaistoprotectusbypairingastimuluswithafearresponse,anditworkssofastthatthispairingcanbecreatedfaraheadofourconsciousperceptionofthreat.Throughoutourlives,butespeciallyduringchildhood,relationshipswithothersregulateourstressandfear.Asecureattachmentindicatesthatwehavelearnedtosuccessfullyutilizeourrelationshipswithotherstoquellourfearsandmodulateourarousal.

TheSocialEngagementSystem

Communicationleadstocommunity,thatis,tounderstanding,intimacyandmutualvaluing.—RolloMay

Thetenthcranialnerve,alsocalledthevagus,isactuallyacomplexcommunicationsystembetweenthebrainandmultiplepointswithinthebodyincludingtheheart,lungs,throat,anddigestivesystem.Itsafferent(sensory)andefferent(motor)fibersallowforrapidcontinuousfeedbackbetweenbrainandbodytopromotehomeostaticregulationandtheoptimalmaintenanceofphysicalhealthandemotionalwell-being(Porges,Doussard-Roosevelt,&Maiti,1994).Thevagalsystemisacentralcomponentoftheautonomicnervoussystem.Intheabsenceofexternalchallenge,thevagusworkstoenhancedigestion,growth,andsocialcommunication.Whenachallengedoesarise,adecreaseinvagalactivationfacilitatessympatheticarousal,highenergyoutput,andthefight-flightresponse.Betweenrestandall-outactivation,thevagusallowsustomaintaincontinuedengagementbymodulatingarousalduringemotionalinterpersonalexchanges.Thevagalsystemaccomplishesthisbymodulatingandfine-tuningsympatheticarousal.

Liketheattachmentsystemdescribedearlier,thedevelopmentofthisengagementsystemandthefine-tuningofthevagalbraketoregulateaffectappeartodependonthequalityofattachmentrelationshipsinearlychildhood.Thisallowsustointernalizewhatwelearnfromexperiencewithcaretakersintomoment-to-momentsomaticregulation.Thevagalsystemalsocontrolstheprimaryfacial,mouth,andthroatmusclesinvolvedincommunication,andlinksthemwithanawarenessandcontrolofinternalstates,coordinatingthecognitiveandemotionalprocessingnecessaryforrelationships.

The“tone”ofthevagusreferstothevagalsystem’sdexterityinregulatingtheheartandothertargetorgans(Porgesetal.,1996).Inadequatedevelopmentofthisexperience-dependentvagaltonecanimpactalllevelsofpsychosocialandcognitivedevelopment(Porgesetal.,1994).Childrenwithpoorvagaltonehavedifficultyinsuppressingemotionsinsituationsdemandingtheirattention,makingitdifficultforthemtoengagewiththeirparents,sustainasharedfocuswithplaymates,andmaintainattentiononimportantmaterialintheclassroom(seeTable12.6formoredetails).

Vagalregulationallowsustobecomeupset,anxious,orangrywithalovedonewithoutwithdrawingorbecomingphysicallyaggressive.Wecanhypothesizethatmanywhoengageindomesticviolence,childabuse,andotherformsofaggressivebehaviormaynothavehadthekindsofearlyattachmentrelationshipsrequiredtobuildanadequatevagalsystem.Thus,goodparentingnotonlyteachesappropriateresponsesinchallenginginterpersonalsituations,butitalsobuildsvagalcircuitryrequiredtostayengaged.

TABLE12.6CorrelatesofVagalTone

HigherVagalToneCorrelatesWith LowerVagalToneCorrelatesWithTheabilitytoself-regulateIrritability IrritabilitySelf-soothingcapacityby3monthsofage Behavioralproblemsat3yearsofageTherangeandcontrolofemotionalstates EmotionaldysregulationMorereliableautonomicresponses Distractibility

Suppressionofheartratevariability Hyper-reactivitytoenvironmentalandvisceralstimulii

Enhancedattentionalcapacityandtheabilitytotakeininformation

Positivesocialengagement WithdrawalIncreasedbehavioralorganization Impulsivity/actingoutConsistentcaretaking/secureattachment Insecureattachment

TheSocialMotivationSystem

Interdependenceisandoughttobeasmuchtheidealofmanasself-sufficiency.Manisasocialbeing.

—MohandasGandhi

NelsonandPanksepp(1998)postulatedtheexistenceofasocialmotivationsystemmodulatedbyoxytocin,vasopressin,endogenousendorphins,andotherneurochemicalsrelatedtoreward,decreasedphysicalpain,andfeelingsofwell-being.Whileconservedfrommoreprimitiveapproach-avoidanceandpainregulationcircuitry,thesocialmotivationsystemextendsintotheamygdala,anteriorcingulate,andorbitalmedialprefrontalcortex.Thesecircuitsandneurochemicalsarethoughttoregulateattachment,pairbonding,empathy,andaltruisticbehavior(Decety&Lamm,2006;Seitz,Nickel,&Azari,2006).Inotherwords,asFisher(1998)suggested,thesocialmotivationsystemcanbedividedintothreecategories:thoseinvolvedinbondingandattachment(regulatedbypeptides,vasopressin,andoxytocin),attraction(regulatedbydopamineandothercatecholamines),andsexdrive(regulatedbyandrogensandestrogens).Theproductionofthesevariousbiochemicalelements,aswellasthecreationoftheirreceptors,areallsubjecttotheinfluencesofexperienceearlyinlife.

Inaddition,thedopaminerewardsystemofthesubcorticalareaknownastheventralstriatumisinvolvedwithmorecomplexanalysisofrewardandsocialmotivation.Theventralstriatumbecomesactivatedwithanexpectationofasocialreward,suchaswhenweanticipatebeinggivencandyorpositiveattention(Kampeetal.,2001;Pagnoni,Zink,Montague,&Berns,2002;Schultzetal.,1992).Forexample,oncethecortexhasdeterminedthatwefindsomeoneattractive,theventralstriatumbecomesactivatedwhentheylookourway,givingthesignalthatthepossibilityforbeingrewardedwithadesirableoutcomehasincreased(Elliott,Friston,&Dolan,2000;Schultz,Dayan,&Montague,1997;Schultz,1998).Theactivationoftheventralstriatumtranslatestheanticipationofrewardintoaphysicalimpulsetoapproach.Inthisway,thosewhomwefindattractiveactuallyexertwhatfeelslikeagravitationalpullonus.

Summary

Recentresearchhasprovideduswithnewwaysofunderstandinghowearlyexperiencebuildsthebrain.Maternalattentionhasbeenlinkedtotheneurobiologyofsystemsrelatedtolearningandmemory,stressregulation,andattachmentbehavior.Althoughthehumanbrainisfarmorecomplexthanthoseoftheanimalsuponwhomthisresearchhasbeenconducted,findingsinhumanresearchacrossabroadarrayofdisciplinesdemonstrateconsistentresultsintheareasoflearning,resilience,andattachment.Theneuralhubsandregulatorynetworksdescribedhereareallbuiltinanexperience-dependentmanner.Thatis,earlyrelationshipsshapethebuildingofneuralcircuitry,whichguideshowweareabletolearn,reacttostress,andattachtoothersinwaysthatparallelthoseseenintheanimalresearchdiscussedearlier.Aswelearnmoreaboutthecomplexitiesofthehumanbrain,wewillunderstandhowrelationshipsbuildthebrain,andhowlovebecomesflesh.

PartV.

TheDisorganizationofExperience

Chapter13

TheAnxiousandFearfulBrain

Fearistheoldestandstrongestemotionofmankind.—H.P.Lovecraft

Allanimalshavebeenshapedbyevolutiontoapproachwhatislifesustainingandavoidwhatisdangerous.Thesuccessofrapidandaccurateapproach-avoidancedecisionsdeterminesifanorganismlivestoreproduceandcarryitsgenesforwardtothenextgeneration.Becausevigilancefordangerisacentralmechanismoftheprocessofnaturalselection,evolutionmaywellfavorananxiousgene(Becketal.,1979).Someanxietiesappeartobehardwired,specifictoprimates,andlinkedtobothourpresentandpastsurvivalneeds.Fearofspiders,snakes,heights,andopenandclosedspacesallharkenbacktothesurvivalofourforest-dwellingancestors.Fromanevolutionaryperspective,ourcomplexneuralsystemshaveallbeensculptedtobetterservetheprimedirectiveofsurvival.

Theneuralcircuitryinvolvedinfearandanxiety,althoughbiasedtowardtherighthemisphere,involvesbothhemispheresandalllevelsofthetriunebrain.Themostprimitivesubcorticalfight-or-flightcircuitry,sharedwithourreptilianancestors,interactswiththemosthighlyevolvedregionsofthecortex.Thisresultsinthecapacitytoexperienceanxietyabouteverythingfromanunexpectedtapontheshouldertoanexistentialcrisis.Theconnectionbetweeneverykindofanxietyandthecorebiologicalmechanismsofphysicalsurvivalsupportsthephilosophicalnotionthatallanxiety,atitscore,maybethefearofdeath(Tillich,1974).

Anxietyandfeararetheconsciousemotionalaspectsofthebody’songoingappraisalofthreat,tellingustobepreparedtotakeaction.Anxietycanbetriggeredbycountlessconsciousorunconsciouscuesandhasthepowertoshapeourbehaviors,thoughts,andfeelings.Atitsmostadaptive,anxietyencouragesustostepbackfromtheedgeofacliff,ortochecktoseeifwesignedourtaxformsbeforesealingtheenvelope.Atitsleastadaptive,anxietysteersusawayfromtakingimportantandappropriaterisks,pushingourselvestoreachpersonalgoals,orengaginginnewandpotentiallybeneficialbehaviors.

Theresponsetostress,orgeneraladaptationsyndrome(Selye,1979),resultsinarangeofphysiologicalchangesdesignedtopreparethebodyforfightorflight.Energyismobilizedthroughincreasedcardiovascularandmusculartone,whereasdigestion,growth,andimmuneresponsesareinhibited.Aspartofthestressresponse,acascadeofbiochemicalchangesoccurinthehypothalamus,pituitary,andadrenalglands(theHPAaxis),aswellasinthesympatheticnervoussystem.Thesebiochemicalsmediatethephysicalandpsychologicalchangesexperiencedduringstress.Increasedlevelsofglucocorticoids,epinephrine,andendogenousopioidsareparticularlyrelevanttoadiscussionofthepsychologicalimpactofstressandtrauma,inthattheyalterattention,cognition,andmemory.Weexperiencetheeffectsofthegeneraladaptationsyndromeinsituationssuchasautomobileaccidents,atcrucialmomentsduringsportingevents,orwhenengaginginpublicspeaking.Thedangerscanbereal,

imagined,orexperiencedvicariouslyaswewatchothersinstressfulordangeroussituations.Withtheexpansionofthecerebralcortexandtheemergenceofimagination,wehavebecome

capableofbeinganxiousaboutsituationswewillneverexperience.Wecannowworryaboutmonsterslivingunderourbedsandtheincinerationoftheearthresultingfromthesun’sexpansion.Becauseourimaginalcapabilitieshaveallowedfortheconstructionoftheself,wecanalsobecomeanxiousaboutpotentialthreatstoourpsychologicalsurvival.Psychotherapistsdealwithawidevarietyofanxietydisordersbasedinthefearofasocialdeath.Theexpectationofrejectionbyanothercanresultinsocialwithdrawal;thefearofforgettingone’slinesinaplaycanresultinstagefright.Systemsofphysicalsurvivalhavebeenconservedintheevolutionofconsciousnessandtheego,tobetriggeredwhenthreatstotheseabstractconstructionsareactivated.

Consciouslyexperiencedanxietyprovidestheopportunitytofaceandworkthroughone’sfears.Thecommonwisdomofgettingbackonthehorsethatthrewyouisadviceclearlyaimedatpreventingtheuseofavoidancetocontrolanxiety.Infact,thereductionofanxietythroughavoidancereinforcesthebehaviorandmakesthefearedstimulusseemalltheworse.Unfortunately,anxietycanbepairedwithallkindsofautomaticandinternalsensations,emotions,andthoughts,whichshapebehavioroutsideofconsciousawareness.Compoundingtheproblem,thelefthemisphereinterpreterprovidesarationalesupportingandreinforcingavoidance:“It’sinhumantoridehorses!”“Whoneedsplanes?”

“Whygooutwhenit’ssocomfortableathome?”Theavoidanceofthoughtsandfeelingsassociatedwithfearedstimulibothreflectsandperpetuatesalackofintegrationamongneuralnetworks.Facingone’sfearsisacorecomponentofallformsofpsychotherapy.

Weseethis,forexample,withadultwomenwhoweresexuallyoremotionallyabusedaschildrenwhosometimescometotherapywithchronicandsevereweightproblems.Theydowellondietsuntiltheybegintobenoticedbymen,associatedinimplicitmemorywiththepainandshameoftheirchildhoodexperiences.Thesenegativeemotionalreactionsleadthemtoreturntobehavioralpatternsassociatedwithanavoidanceofsuchfeelings,suchaseating.Theactofeatingisdoublyreinforcingbecauseitprovidesnurturance,whilegainingbacktheweightservestoprotectagainstsexualadvances.

Thus,whatstartedoutasastraightforwardsurvival-basedalarmsystemhasalsobecomeanuisance.Thisisanotherdownsideofthedesigncompromisesbetweenspeedandaccuracymentionedearlier(Mesulam,1998).Evolutiondesignedabrainthatreactsquicklytoavarietyofsubtleenvironmentalcues.Thesesamecapabilitieshavenegativeconsequenceswhenappliedtoacomplexandlargelynonconsciouspsychologicalenvironment.Anunderstandingoftheneuroscienceofanxietyandfearishelpfulinboththeconceptualizationandtreatmentofmostclinicaldisorders.Inthefollowingpages,wewilllookatthetwoloopsoffearcircuitryoutlinedbyJosephLeDoux,theroleoftheamygdalaintheregulationoffearandanxietyproposedbyMichaelDavis,andRobertSapolsky’sworkonthenegativeimpactoflong-termstress.

FastandSlowFearNetworks

Fearisanemotionindispensibleforsurvival.—HannahArendt

Throughhisresearchwithanimals,LeDoux(1994)demonstratedtheexistenceoftwoseparateyetinterrelatedneuralcircuitswhichregulatefear.Theconservationofthesesystemsduringevolutionallowsustoapplythesefindingstohumanexperience(Phelps,Delgado,Nearing,&LeDoux,2004).Thetwosystems(whichwewillcallfastandslow)eachplayasomewhatdifferentroleinourreactiontodanger.

Thismodelcanbeclinicallyusefulforanxiousandfearfulclientsbyhelpingthemunderstandtheneurobiologicalmechanismsunderlyingtheirunsettlingexperiences.

Thereflexivefastsystemactsimmediately,sendinginformationdirectlyfromthesenseorgans(eyes,ears,skin,nose,tongue)throughthethalamustotheamygdala.AndwhenIsayfast,Imeanfast:Allofthisprocessingcanoccurinonetwelfthofasecond.Theamygdalaevaluatesthesensoryinputandtranslatesitintobodilyresponsesviaitsmanyconnectionswiththeautonomicnervoussystems.Thethalamusmayaidinthisrapidevaluationbymaintainingcruderepresentationsofpotentiallydangerousthingsoftenencounteredintheenvironmentsuchasspiders,snakes,anddangerouspredators(Brosch,Sander,&Scherer,2007).Thesesubcorticalstructuresplayanexecutiveroleinrapidappraisalbecausetheincreasedtimeitwouldtaketoincludethecortexmighthavetoolargeasurvivalcost.

Simultaneously,theslowsystemsendssensoryinformationontothehippocampusandcortexforfurtherevaluation.Thissystemisslowerbecauseitcontainsmoresynapticconnectionsandinvolvesconsciousprocessing.Corticalcircuitsofmemoryandexecutiveprocessingexaminetheinformationmorecarefully,compareittomemoriesofsimilarsituations,anddecidehowtoproceed.Theslowcircuitaidsinfearprocessingbycontextualizingtheinformationintimeandspace.Thisslowsysteminhumans—withitsapexintheprefrontalcortex—hastheadditionaltaskofmakingsenseofthebehavioralandvisceralreactionalreadysetintomotionbythefastsystems.Inthisway,ourconsciousexecutivefunctionsdiscoverthedecisionsthathavealreadybeenmadebyourunconsciousexecutives.Wefindourselvesalreadyscaredwhenweinitiallyperceivewhatisfrighteningus;orecstaticasourlovedonecomesintoview.Figure13.1depictstheneuralcircuitsofthefastandslowfearnetworks.

Thisdualcircuitryhelpsustounderstandwhyweoftenreacttothingsbeforethinkingandthenhavetoapologizelateron.Intherapy,weoftenattempttoutilizetheconsciouslinguisticstructuresoftheslowcircuittomodifyorinhibitdysfunctionalreflexesandemotionalappraisalsofthefastcircuit.Coupledwithrelaxationtechniquesandenhancedawareness,exposuretoafearedstimuluscanservetoenhancetheregulatoryinputoftheslowcorticalcircuitsbybuildingnewneuralconnections.Cognitiveandbehavioralinterventionsthereforeincreasetheabilityofthecortextoinhibittheamygdala.

FIGURE13.1FastandSlowFearCircuits

Adepictionofthetwopathwaysofinformationtotheamygdala—onedirectlyfromthethalamusandtheotherthroughthecortexandhippocampus(adaptedfromLeDoux,J.Emotion,memory,andthe

brain.Copyright©1994byScientificAmerican,Inc.Allrightsreserved.)

Therearemanyexamplesofthesetwosystemsinaction.Iwalkedintomygarageonedaytolookforatoolwhen,outofthecornerofmyeye,Isawasmallbrownobjectnearmyfoot.Thereareplentyoflittlecrittersinmyneighborhoodandtheyoftencrawl,burrow,orflyintomyhouse.Iimmediatelyjumpedback,myheartrateincreased,myeyeswidened,andIbecametense,readytoact.Movingbackward,Iorientedtowardtheshape,sawthatitlookedmorelikeapieceofwoodthanarodent,andbegantorelax.Afterafewseconds,myheartrateandlevelofarousalwerebacktonormal;thepotentialdangerhadpassed.

Analyzingthisexperienceintermsofthetwosystems,myperipheralvisionsawtheobjectandmyamygdalaappraiseditinanovergeneralizedfashiontobeathreat.Myamygdalaactivatedavarietyofsympatheticresponsesincludingstartle,increasedrespiration,andavoidance.Inthesplitsecondwhilemybodywasreacting,Ireflexivelyorientedmyheadtowardtheshape,whichbroughtittothefoveaofmyretina,providingmyhippocampusandcortexwithmoredetailedvisualinformation,allowingthemtoappraiseitmoreaccuratelythanmyskittishamygdala.Isupposethataspecies-specificfearaccountsforsuchastrongreactiontoananimalweighingjustafewounces.Thisexample,trivialasitmaybe,leadstoamoreseriousapplicationofLeDoux’stheorytointerpersonalrelationships.

Asthecoreofoursocialbrain,theamygdalaorganizestheappraisalsofwhatwehavelearnedfromourrelationshiphistory.Ininterpersonalsituations,ouramygdalareflexivelyandunconsciouslyappraisesothersinthecontextofourpastexperiences.Frommomenttomoment,thereflexiveactivationsofourfastsystems(organizedbypastlearning)shapethenatureofourpresentexperience(Baretal.,2006).Thisisapowerfulmechanismbywhichourearlysociallearninginfluencesourexperienceofthepresent.So,bythetimewebecomeconsciousofothers,ourbrainhasalreadymadedecisionsaboutthem.Inthecaseofprejudice,skincolortriggersasetofassumptionsuponwhichweevaluateotherpeople(Olsson,Ebert,Banaji,&Phelps,2005).Attheoppositeextreme,loveatfirstsightisasortofpositiveprejudicetriggeredbyemotionalmemoriesprojectedontoanotherperson.

TheAmygdala’sRoleinAnxietyandFear

Nopassionsoeffectuallyrobsthemindofallitspowersofactingandreasoningasfear.—EdmundBurke

Theamygdalaplaysacentralroleintheactivationoffear.Ithasbeenconservedandexpandedduringevolutioninordertoprocessincreasinglycomplexcognitive,sensory,andemotionalinput.Itscentralroleinappraisalandthetriggeringofthebiochemicalcascadeofthefight-or-flightresponsemakesitvitalforprocessingmemory,emotionalregulation,bonding,andattachment.Electricalstimulationoftheamygdala’scentralnucleusresultsintheexperienceoffear,whereasdestructionoftheamygdalawilleliminatefearreactionsaltogether(Carvey,1998).Infact,thedestructionoftheamygdalainanimalsresultsinaninabilitytoacquireaconditionedfearresponse.

Althoughwearegeneticallyprogrammedtobecomeanxiousaboutthingslikesnakesorabandonment,fearcanbelearnedbypairinganythought,feeling,orsensationwithanoxiousstimulus,suchasaloudnoiseoranelectricshock(Corcoran&Quirk,2007).Learningtobeanxiouscanoccuratconsciousandunconsciouslevelsrelatedtobothinternalandexternalstimuli.Likethehippocampus,thelateralareasoftheamygdalaarecapableoflong-termpotentiation(LTP)involvedinreinforcingconnectionsamongneurons.RememberthatLTPistheprocessthroughwhichtheassociationamongneuronsbecomesstrengthenedandlearningisestablished.Theamygdalacanlearn,throughoutlife,topairanystimulus(evenphysicalaffectionorpraise)withfear.

Aswesawearlierinourdiscussionofmemory,thehippocampusandamygdalaorganizeinteractingbutdissociablesystemsofmemory.Becharaandcolleagues(1995)reportedthatapatientwithbilateral(leftandright)amygdaladamagewasunabletoacquireaconditionedautonomicresponsetosensorystimuli.Thepatientwas,however,abletoconsciouslyremembertheconditioningsituationbecausehishippocampiwerestillintact.Anotherpatientwithbilateraldamagetothehippocampusshowednoconsciousmemoryfortheconditioningsituationbutdidacquireautonomicandbehavioralconditioning.Theauthorsconcludedthattheamygdalais“indispensable”forcouplingemotionalconditioningwithsensoryinformationwhilethehippocampusisrequiredforconsciousrecollection(Becharaetal.,1995).

Theneuralprojectionsfromtheamygdalatonumerousanatomicaltargetscausethemultiplephysicalexpressionsofanxiety,fear,andpanic.Projectionsfromtheamygdalatothelateralhypothalamusresultinsympatheticactivationresponsibleforincreasedheartrateandbloodpressure.Theamygdala’sstimulationofthetrigeminalfacialmotornerveevencausesthefacialexpressionsoffear(Davis,1992).Theamygdalaisalsoessentialinreadingthefearfulfacialexpressionsofothers(Bairdetal.,1999).AsyoucanseefromFigure13.2,theamygdalaiswellconnected,makingthefearresponseapowerfulwhole-bodyexperience.

FIGURE13.2SomeTargetsoftheAmygdalaintheFearResponse

Someofthemanyanatomicaltargetsoftheamygdalainthefearresponse,andtheirbiologicalandbehavioralcontribution.

Thetriggeringoftheautonomicnervoussystembytheamygdalacausesaracingheart,sweating,andotherphysiologicalsymptomsasthebodypreparesforfightorflight.Intheabsenceofrealexternaldanger,thisisexperienceiscalledapanicattack.Sufferersoftengotoemergencyroomsthinkingtheyarehavingaheartattack.Individualswithpanicdisorderhaveincreasedneuralactivityintheamygdala(Reimanetal.,1989).Psychologically,victimsreportasenseofimpendingdoom,feelingsofunreality,andthethoughtthattheyaregoingcrazy.Panicattacksareoftentriggeredbystressorotherconflictsinthesufferer’slife,butheorsheseldommakestheconnectionbetweentheseeventsandthepanicattacks.Becausetheneuralconnectionsarecontainedwithinhiddenneurallayers,theyareexperiencedas“comingoutoftheblue,”leavingvictimsstrugglingtocomprehendwhatishappeningtothem.

Theamygdala’stendencytowardgeneralizationresultsinpanicbeingtriggeredbyanincreasingnumberofinternalandexternalcues(Douglas&Pribram,1966).Becausepanicattacksareexperiencedasunpredictableandlifethreatening,theyresultinalimitationofactivities.Agoraphobia,orfearofopenspaces,developsasvictimsofpanicattacksassociatefearwithabroadervarietyofsituations.Hopingtoavoidtheseattacks,sufferersrestricttheiractivitiestothepointwheretheyeventuallybecomehousebound.Simultaneously,theamygdalabecomesconditionedtorespondfasterinpeoplewhobecomephobic,creatingaviciouscycleofanxietyandfear(Larsonetal.,2006).Thebehavioroftheseindividualsbecomessoshapedbyfearthattheycometoavoidmostoflife.Ontheotherhand,thoseofuswithaslowerandlessactiveamygdalaexperiencegreaterpsychologicalwell-being(vanReekumetal.,2007).Onegiftofagingisthattheamygdalaalsoappearstobecomelesssensitivetofearaswegrowolder.

Thedevelopmentandconnectivityoftheamygdalahavemanyimplicationsforbothearlychilddevelopmentandpsychotherapy.Withouttheinhibitoryimpactofthelater-developinghippocampal-corticalnetworks,earlyfearexperiencesareunregulated,overwhelmingfull-bodyexperiences.Becausetheamygdalaisoperationalatbirth,theexperienceoffearmaybethestrongestearlyemotion.Partofthepowerofearlyemotionallearningmaybetheintensityoftheseunregulatednegativeaffectsinshapingearlyneuralinfrastructure.Theinfantisverydependentoncaretakerstomodulatethesepowerfulexperiences.Amygdalaandhippocampus-mediatedmemorysystemsaredissociablefromoneanother,

whichmeansthatearlyandtraumaticmemoriescanbestoredwithoutconsciousawarenessorcorticalcontrol.Theywillnotbeconsciouslyremembered,butinsteadwillemergeassensory,motor,andemotionalmemoriesliketraumaticflashbacks.

Anotherlimbicstructurecloselyconnectedtotheamygdalaisthebednucleusofthestriaterminalis(BNST).Liketheamygdala,itisconnectedupwardtotheprefrontalcortex,aswellasdownintotheautonomicnervoussystem.Unliketheamygdala,theBNSTissensitivetoabstractcuesandiscapableoflong-termactivation,suggestiveofbothitslaterevolutionanditsroleinanticipatoryanxiety(Davis,1998;Kalinetal.,2001).ItappearsthatperhapstheamygdalaspecializesinfearwhiletheBNSTevolvedtodealwiththemorecomplextriggersforanxietythatemergedasourbrainsbecamecapableofimaginingmultiplepotentialoutcomes.Interestingly,theBNSTinratsisastructurethatgrowsinresponsetomaternalresponsibilities.Wehavetowonderif,asthebrainbecamespecializedforcaretaking,thescaffoldingweneedtocreatearoundourchildrenpushedtheevolutionofaconstantfocusonpotentialdangers.

TheLocusCoeruleusandNorepinephrine

Worrygivesasmallthingabigshadow.—Swedishproverb

OneimportantdescendingprojectionfromtheamygdalaandBNSTconnectsthemwiththelocuscoeruleus(LC).TheLCisasmallstructurewithextensiveprojectionsthroughoutthebrainstem,midbrain,andcerebralcortex.Itis,infact,connectedwithmorepartsofthebrainthananyotherstructuresofardiscovered(Aston-Jones,Valentino,VanBockstaele,&Meyerson,1994).TheLCisthebrain’sprimarygeneratorofnorepinephrine(NE),whichdrivestheactivityofthesympatheticbranchoftheautonomicnervoussystemresponsibleforthefight-or-flightresponse.OneeffectofNEistoenhancethefiringofneuronsthatarehighlyrelevanttoapresentexperiencebasedonpastlearning(pastfearresponses),whileinhibitingthoseinvolvedinbaselineactivities.

ThismeansthatstimulationoftheLCpreparesusfordangerbyactivatingcircuitsdedicatedtoattentionandpreparationforaction.NEactivationmakesusbecomevigilant,scanfordanger,andmaintainapostureoftensereadiness.Italsoheightensourmemoryfordanger,creatingasortof“printnow”commandforamygdalamemorycircuits(Livingston,1967).Thepathwayscontainingthesetraumaticmemoriesbecomehyperpotentiated,meaningthattheyaremoreeasilytriggeredbylessseveresubsequentstressors.Thisallowsustoberemindedinthefutureofsimilardangers.Duringtimesofloweredhippocampal-corticalinvolvement(e.g.,intoxicationornear-sleepstates),thesestressfultraumaticmemoriesmaybecomedisinhibitedasintrusiveimagesandflashbacks.Translatedintohumanandclinicalterms,thismeansthatsurgesofNEduringperiodsofsafetymayresultinpasttraumaticassociations(anxiety,startle,visualimages,etc.)beingbroughttoawareness,whichovershadowcurrentexperiences.

StimulatingtheLCinanimalsresultsinadisruptionofongoingbehaviorandtriggeringofanorientingreflex,liketheoneIhadtothesmallpieceofwood.ThisisseeninpatientswithPTSDwhorespondtotrauma-relatedcuesdecadesaftertheirtraumaticexperience.LCactivityinprimatesresultsinahighdegreeofvigilancewhileinterruptingsleep,grooming,andeating.Throughaseriesofconnections,thecentralnucleusoftheamygdalastimulatestheLC,which,inturn,isthoughttobeamajorcontrolareaofthesympatheticnervoussystem(Aston-Jonesetal.,1994).AnunderstandingofthebiochemistryandfunctioningoftheLCisanimportantcomponentofanytheoryofcausesofanxietydisorders(Svensson,

1987).

StressandtheHippocampus

Anxietyisathinstreamoffeartricklingthroughthemind.Ifencouraged,itcutsachannelintowhichallotherthoughtsaredrained.

—ArthurSomersRoche

Thehumanbrainiswellequippedtosurvivebriefperiodsofstresswithoutlong-termdamage.Inanoptimalstate,stressfulexperiencescanbequicklyresolvedwithgoodcopingskillsandthehelpofcaringothers.However,peopleoftencometopsychotherapywithlonghistoriesofanxiety,whichcanhaveprofoundeffectsonthebrain.Workingwithratsandvervetmonkeys,Sapolskyandhiscolleaguesdemonstratedthatsustainedstressresultsinhippocampalatrophyandavarietyoffunctionalimpairments(Sapolsky,1990;Sapolsky,Uno,Rebert,&Finch,1990).Hisresearchisparticularlyimportantbecauseitmayhelpexplainsomeofthenegativelong-termeffectsofchildhoodtrauma.

Thebiologicallinkbetweenprolongedstressandhippocampalatrophyappearstobemediatedviathecatabolicinfluenceofstresshormones.Glucocorticoids(GC)suchascortisolaresecretedbytheadrenalglandtopromotethebreakdownofcomplexcompoundssothattheycanbeusedforimmediateenergy.Thefirstofthesehormoneswasfoundtobreakdowncomplexsugars,hencethenameglucocorticoids.Itwaslaterfoundthattheyalsoblockproteinsynthesis,inhibitingbothnewneuralgrowthandtheconstructionofproteinsinvolvedinimmunologicalfunctioning.Overall,long-termlearningandbiologicalwell-beingaresacrificedforthesakeofimmediatesurvival.Thismakesgreatsensewhenstressorsareshort-lived.Butwhenstressischronic,highlevelsofcortisolputusatriskofphysicalillness,learningdysfunctions,andmemorydeficits.AnumberofrolesofcortisolareseeninTable13.1,alongwithitsimpactonthebrainanditsrelationshiptoavarietyofillnesses.

Thefocusonimmediatesurvivalsupersedesalllong-termmaintenance,akintoburningthefurnituretosurvivefreezinginwinter.Thus,thesebiologicalprocessesneedtobereversedassoonaspossibleafterthecrisishaspassedtoallowthebodytorecoverandreturntofunctionsofrestorationandrepair.Itisapparentthatthissystemwasdesignedtocopewithbriefperiodsofstressinemergencysituations;itwasnotdesignedtobemaintainedforweeksoryearsatatime.Thecomplexitiesofcorticalprocessingandanticipatoryanxietyarepoorlymatchedwiththeseprimitivestresssystems.

Prolongedstressmostaffectstwoprocesses.First,itinhibitsproteinproductioninordertomaintainhigherlevelsofmetabolism.Proteinsare,ofcourse,thebuildingblocksoftheimmunologicalsystem(leukocytes,B-cells,T-cells,naturalkillercells,etc.)andthesuppressionofproteinsynthesisalsosuppressesourbody’sabilitytofightoffinfectionandillness.Thisisoneoftheprimaryreasonsforthehighcorrelationsfoundbetweenprolongedstressanddisease.Second,sustainedhigherlevelsofmetabolismcontinuetopumpsodiumintoneurons,eventuallyoverwhelmingthecell’sabilitytotransportitoutagain.Thisresultsindestructionofthecellmembraneandconsequentcelldeath.Thisprocesshasbeenfoundtobeparticularlydamagingtothehippocampus,resultinginavarietyofmemorydeficitsanddepression.LossofvolumeinthehippocampusisrelatedtocumulativeGCexposure(Sapolskyetal.,1990).Sustainedhighlevelsofstresspartlyexplainwhyearlynegativeexperiencesinparentingandattachmenthavealifelongimpactonphysicalhealth,mentalhealth,andlearning.

TABLE13.1StressandtheHippocampus

TheRoleofCortisolBreaksdownfatsandproteinsforimmediateenergyInhibitsinflammatoryprocessesInhibitsproteinsyntheseswithintheimmunesystem(leukocytes,BandT-cells,naturalkillercells,etc.)Suppressesgonadalhormonesthatsupportneuralhealth,growth,andlearning

ChronicHighLevelsofCortisol/GlucocorticoidsResultInDecreasedplasticity1Dendriticdegeneration2Deficitsofremyelination3Celldeath4Inhibitionofneurogenesisandneuralgrowth5

HighLevelsofCortisolCorrelateWith:Impaireddeclarativememoryandspatialreasoning6

CompromisedHippocampiResultInDeficitsofnewlearning7Short-andlong-termmemory8

IndividualsWithSmallerHippocampiIncludeAdultvictimsofearlytrauma9Post-traumaticstressdisorder10Temporallobeepilepsy11Schizophrenia12Cushing’sdisease(hypercortisolism)13

Thehippocampus,richinGCreceptors,playsanegativefeedbackrolewiththeadrenalglandtoinhibitGCproduction.IfthehippocampusdetectstoomanyGCstogether,itsendsamessage(viathehypothalamusorthepituitary)totheadrenalglandtoslowdownGCproduction(Sapolsky,Krey,&McEwen,1984).Themorereceptorswehave,thegreaterourfeedbackabilitiestodecreasecortisolproduction.ProlongedhighlevelsofGCsincreasethevulnerabilityofthehippocampustoanumberofpotentialmetabolicinsults(Sapolsky,1985;Woolley,Gould,&McEwen,1990).Atthispointitisunclearifdecreasedvolumereflectspermanentdamagetothehippocampusorareversibleinhibitionofthegrowthofnewneurons.Ineithercase,lesshippocampalmassmeansfewerGCreceptors,which,inturn,meanslessnegativefeedbacktotheadrenalgland.LossofvolumeinthehippocampusisrelatedtocumulativeGCexposure(Sapolskyetal.,1990).

Earlytraumaresultsinhippocampalimpairment,whichdecreasesourabilitytoinhibittheemotionstriggeredbyamygdaloidmemorysystems.Further,deficitsinrealitytestingandshort-termmemorywillmaketheprocessofintegratingtraumaticexperiencesintoconsciousawarenessmoredifficult.Longerperiodsofrelationshipbuildingandpragmaticinterventionsfocusedonstressreductionandthedevelopmentofcopingskillsmaybenecessaryprerequisitesforsuccessfullong-termtherapywithvictimsofearlystressandtrauma.Thehippocampusisalsoexquisitelysensitivetooxygendeprivation,

sopatientswhohavesufferedmetabolicdisruptions,headtrauma,orseizuresmayhavehippocampalcompromise,aswellasmountainclimbers,divers,orindividualswithheartdisease(Lombroso&Sapolsky,1998;Regard,Oelz,Brugger,&Landis,1989).High-dosecortisoladministrationforautoimmunediseasesmayalsoresultinhippocampaldamage(Sapolsky,1996).Allofthesefactorsshouldbekeptinmindwhentakinghistoriesofpatientswithcognitiveandneurologicalsymptoms.

Impairmentofthehippocampusfromearlychronicstressmaymakethetherapeuticprocessmoredifficultformanyclients.Forexample,Steinandhiscolleagues(Stein,Koverla,Hanna,Torchia,&McClarty,1997)foundthatadultwomenwhohadexperiencedchildhoodabusehadsignificantlyreducedlefthippocampalvolume.Theyalsofoundthattheamountofreductionwassignificantlycorrelatedwithincreaseddissociativesymptoms.Thisrelationshipsuggeststhatthelefthippocampusmayplayaroleinintegratingmemoriesintoacohesivenarrative.Thehippocampusisalsothoughttobeinvolvedintheflexibleincorporationofnewinformationintoexistingstructuresofmemory(Eichenbaum,1992).Ifthisisthecase,earlyabusemayresultindamagetoneuralstructuresrequiredtocreatenewandmorefunctionalnarratives.

Ratsandhumansdifferinanumberofwaysbesideswhiskerlength.Theincreasedsizeofthehumanbrainanditsadditionalprocessingcapacitymakeitpossibleforustoworryaboutmanymorepotentialdangers,bothrealandimagined.Inaddition,ourbrainsallowustocreatecomplexsituationssuchastrafficjamsandoverburdenedschedules,generatingever-increasinglevelsofstress.Stressorssuchasthese,whichareexperiencedasinescapable,tendtohaveagreatersustainedcortisolactivationandnegativeimpactonthebrain.Althoughweliketothinkofchildhoodasatimeofinnocenceandplay,manychildrengrowupinastateofconstantdistress.Wesawthisclearlyintheattachmentresearchwhereadultswithanxiousattachmentpatternsdemonstratedalackofrecallforlongperiodsoftheirchildhoods.Parentalphysicalormentalillness,communityviolence,poverty,andmanyotherfactorscancontributetothis.Prolongedchildhoodstresscanhavelifelongeffectsonfunctioningrelatedtohippocampaldamage,immunologicalsuppression,andotherstress-relatedimpairments.

LearningNottoFear

Courageisactinginspiteoffear.—HowardW.Hunter

Itisanunfortunatetwistofevolutionaryfatethattheamygdalaismaturebeforebirthwhilethesystemsthatinhibitittakeyearstodevelop.Thisleavesusvulnerabletooverwhelmingfearwithlittletonoabilitytoprotectourselves.Ontheotherhand,evolutionhasalsoprovideduswithcaretakerswhoallowustolinkintotheirdevelopedcortexuntilourownisready.Thewaytheyprotectusfromfearandmodulateouranxietybecomesamodeluponwhichourownbraindevelops.Thus,weuseproximitytoourparentsasourkeymethodoffearregulation,justascold-bloodedanimalsuselocomotionandchangeoflocationtoregulatetheirinternaltemperature.Ourattachmentschemascometoreflectthesuccessorfailureofhowweandourparentsnavigatethisprocess.Wehaveseenfromtheresearchwithratsthatmaternalattentionresultsinabrainthatisbetterequippedtolearnaswellastodownregulatetheimmediateandlong-termeffectsofstress.Itturnsoutthatindealingwithfear,theabilitytolearnaswellashavingamoreresilientstresssystemarebothimportantforfacinglife’schallenges.

Thehippocampusisconstantlyremodeledtokeepabreastofcurrentenvironmentalchanges.Ontheotherhand,theamygdala’sroleistorememberathreat,generalizeittootherpossiblethreats,andcarryitintothefuture.Becausetheamygdalaexhibitspersistentdendriticmodeling,weareunabletocompletely

forgetpainfulandtraumaticexperiences(Rainnieetal.,2004;Vyas,Bernal,&Chattorji,2003;Vyas,&Chattorji,2004).Thepoweroftheamygdalaanditsstubbornnessinthefaceofthehippocampusleadsustobebiasedtowardanxietyandfear.

Thephenomenonofspontaneousrecoveryofaphobiademonstrateshowthefearwehopedwaslonggonewasstoredinouramygdalaallalong(Vansteenwegenetal.,2005).Gettingpastourfearsandphobiasdoesnotentailforgettingtobeafraid;rather,theextinctionoffearsrepresentsnewlearningorganizedbyourslowsystemsofthecortexandhippocampus.Inotherwords,extinctionlearningrepresentstheformationofnewneuralassociationsthatsomehowkeepthememorystoredintheamygdalafromtriggeringthesympatheticnervoussystem(Milad&Quirk,2002;Rau&Fanselow,2007).

Theabilityoftheprefrontalcortexinmodulatingamygdalaactivityisbelievedtooccurthroughthedevelopmentofdescendinginhibitorycircuitry(Akirav&Maroun,2007;Ochsneretal.,2004).Evidenceforthisincludesthefactthatthiscortical-amygdalanetworkexhibitsareciprocalactivationpatternwheremorecorticalactivationresultsinlessamygdalaactivationandviceversa.Thismaynotonlybewhyourproblem-solvingabilitiescanbeshortedoutbyfear,butalsowhythinkingaboutandbeingpreparedforasituationlessensourfears.Whenwesuccessfullyusecognitivetechniquestodecreaseanxiety,wearelikelybuildingthesedescendingcorticalnetworkstoinhibitamygdalaandautonomicactivation(Schaeferetal.,2002).

Learningnottofear,justlikesecureattachment,appearstobeamajorcontributionoftheompfc(Morgan,Romanski,&LeDoux,1993;Phelpsetal.,2004).Electricalstimulationofthehomologousregioninthecortexofratsresultsinbothamygdalainhibitionandareductionofconditionedfear(Milad,Vidal-Gonzalez,&Quirk,2004;Perez-Jaranay&Vives,1991;Quirk,Likhtik,Pelletier,&Paré,2003).Eventhesizeoftheompfcinhumansispositivelycorrelatedwithourabilitytoinhibitafearfulresponse(Milad,Quinn,etal.,2005).Thus,itappearsthattop-downcontroloftheamygdalaallowsustolearntodiscontinueafearfulresponsetosomethingthatmakesusafraid.InastudybyKim,thosewhoweretaughttointerpretasurprisedfaceasnegativehadgreateramygdalaactivationwhilethosewhowereguidedtoseeitaspositivehadmoreompfcactivation(Kimetal.,2003).Thesestudiessupportthenotionthattheompfcmodulatestheactivationoftheamygdalabasedoncontextualandmotivationalfactors(Kimetal.,2005;Myers&Davis,2007;Ochsneretal.,2002;Phanetal.,2005).Inotherwords,theslowsystemregulatesthefastsystem.

Thesetop-downcircuitsorganize,modulate,anddirectattentioninwaysthatshapeexperienceandreinforcetheexistingemotionalstate(Bishop,2007;Christakou,Robbins,&Everitt,2004).Anxietyisassociatedwithareducedtop-downcontrolofthreatcuesjustasthereisareductionofcontrolovernegativestimuliindepression(Bishopetal.,2004;Brewin&Smart,2005).Inotherwords,anxiouspeopletendtofinddangerwhiledepressedpeoplediscoverthenegativeaspectsoftheirenvironments.Andwhilethoseofuswithmoreattentionalcontrolwillstillhaveabiastoorienttowardthethreat,wewillexertmoretop-downcontrolaswebecomeconsciousofthestimulus(Derryberry&Reed,2002).Onceagain,theslowsystemmodulatesthefastsystem.

Thus,thebalanceofactivationamongtheprefrontalcortexandamygdalaalsoguidesvisualattentionbasedonrelevance,emotion,andmotivation(Gazzaleyetal.,2007;Geday,Kupers,&Gjedde,2007).ThisisoneofthemanynetworksthatmaybecomedysregulatedinPTSD,resultingindisturbancesofsensoryprocessingandmemory,andevencausingvisualhallucinations(Gilboaetal.,2004;Rauch,Shin,&Phelps,2006).DissociatedPTSDpatientshavegreateractivationinneuralnetworksinvolvedintherepresentationofbodilystates,suggestingalackofadequatetop-downmodulationofthesenetworksbyfrontalexecutivesystems(Laniusetal.,2005).Asonewouldexpect,theseverityofPTSDsymptomsispositivelyassociatedwithamygdalaactivationandnegativelycorrelatedwithompfcsizeandresponsivity(Shin,Rauch,&Pitman,2006;Williamsetal.,2006).

AswesawinFigure13.2,thecentralnucleusoftheamygdalaisanoutputregionthatprojectsto

sitesinthemidbrainandhypothalamusresponsibleforgeneratingdifferentaspectsofthefearresponse.Theconnectionsoftheompfctothecentralnucleusoftheamygdalaareparticularlystrong,especiallytoGABAergic(inhibitory)neuronscalledintercalatedcells(Freedman,Insel,&Smith,2000;McDonaldetal.,1999;Royer,Martina,&Paré,1999).Itisnowbelievedthatitiswithinthedescendingnetworksfromtheompfctotheamygdala’scentralnucleusthatextinctionlearningisrememberedandcarriesoutitsinhibitoryinfluences(Gottfried&Dolan,2004;Quirk&Mueller,2008).Becauselearninginthisneuralcircuitconformstowhatisknownabouttheneurobiologyoflearningingeneral,theroleofNMDAreceptors,proteinsynthesis,cortisol,andotherfactorsthatmodulatelearningarelikelyinvolvedinextinctionlearning(Elvander-Tottieetal.,2006;Santinietal.,2004).

Researchshowsthatsubjectsinvolvedinthecognitiveappraisaloffearfulfacesshowbothadecreaseinamygdalaactivationandanincreaseinprefrontalactivation(Haririetal.,2000,2003).Thissameamygdala-prefrontalactivityshiftoccursduringactivationofaplaceboeffect(Wageretal.,2004)andrecoveryfollowingthepresentationofnegativeemotionalmaterial(Jacksonetal.,2003).Individualswhomanagetocontroltheirfeartendtohavemoreactivationinrightfrontalregionsthanthosewhodonot(Johansonetal.,1998).

AdeficitofextinctionlearningcouldbeanalternativedescriptionofPTSD.SuffererswithPTSDshowamygdaladysinhibition,makingthemvulnerabletothehallmarksymptomsofintrusionandarousal(Akirav&Maroun,2007).PatientswithPTSDhavealsobeenshowntohavesmallersubregionswithintheirompfcinregionswhereintercalatedcellsareassumedtoreside(Rauchetal.,2003).AlsothethicknessandactivitylevelsoftheseprefrontalregionsinpatientswithPTSDduringextinctiontrainingcorrelateswiththeirsymptoms,supportingtheassociationbetweentheirsymptomsanddeficitsofcorticallybasedextinctionlearning(Milad,Orr,etal.,2005;Phelpsetal.,2004).

TheRecoveryofFearsandPhobiasUnderStress

Dangersbringfears,andfearsmoredangersbring.—RichardBaxter

JacobsandNadel(1985)proposedtheexistenceoftwosystemsoflearningandmemoryinvolvedinfearsandphobias.ThesetwosystemspredictedandparallelLeDoux’smodeloffastandslowfearcircuitry.Thetaxonsystem(fastsystemoramygdaloidsystem)isresponsiblefortheacquisitionofskillsandrules,andtheconditioningofstimulus-responseconnections.Thissystemiscontextfree,meaningthatitcontainsnoinformationaboutthetimeorlocationinwhichthelearningtookplace.Taxonlearninggeneralizesbroadlyandisprimarilynonconscious.Thisisthesysteminwhichearlylearningoffear,safety,andattachmentisorganizedandstored.Thetaxonsystemisrepresentedinwhatcognitivepsychologistscallimplicitandproceduralmemory.

Thelocalesystem—withthehippocampusandthecortexatitscore—isresponsibleforcognitivemapsnecessaryforexternalcontext,mentalrepresentations,andthepairingofmemorieswiththesituationsinwhichtheywerelearned.Thedevelopmentofthelocalememorysystemparallelsthatofhippocampal-corticalcircuits.Thus,althoughthereisagreatdealoflearningduringinfancy(especiallyinthenetworksofthefearfulandsocialbrains),thereisnosourceattributionorautobiographicalnarrative.

Forexample,amother’sfearfullookwhenstrangersapproachmaycauseherchildtodevelopageneralwarinessoftheworld,butnotrecognizethesourceofthisapprehensioninsimilarsituationslaterinlife.Weentermiddlechildhoodwithneuralnetworksprogrammedbyearlylearning,experiencedas

basicemotionalgivens.Intheabsenceoftrauma,learninginadultsinvolvesabalancedintegrationoftaxonandlocalesystemsthatconnectsensory,motor,andemotionalaspectsofmemorytoitssemanticandautobiographicalcomponents.Forchildrenandtraumatizedadults,thetaxonsystemmayfunctionindependently,resultinginanadaptivedissociationamongvarioussystemsofmemoryandconsciousawareness.

JacobsandNadelcontendedthatstressbothchangestheinnerbiologicalenvironmentactivatingthetaxonsystemandsuppressestheinhibitoryeffectsofthelocalesystem.Thesechangesresultintheemergenceofearlierfearsorfrighteningexperiencesthathadbeensuccessfullyinhibited.Thistheorycertainlyparallelsthevoluminousresearchdemonstratingthecontributionofstresstotheemergenceorworseningofpsychiatricandphysicaldisorders.Theysuggestedthatstressimpairsordowngradesthefunctioningofthelocalesystem,causingustofallbackonthemoreprimitiveorganizationoftaxon(amygdaloid)systems.Fromapsychoanalyticperspective,thisprocessmaybeunderstoodasregressiontomoreprimitiveselfstatesanddefensemechanisms.Thisprocessalsoparallelsthereturnofneonatalreflexes(thecorticalreleasesignspreviouslydiscussedinpatientswithAlzheimer’sdiseaseorotherformsofbraindamage).

Despitetheapparentextinctionofaphobiaorfear,theoriginalmemoryismaintainedandcanbecomereactivatedunderstress.ThisneuralexplanationaddressestheFreudiannotionofsymptomsubstitution,inwhichonefearorsourceofanxietymaybereplacedbyanotheraftersuccessfultreatmentofthefirst.Inotherwords,anewtriggerreactivatesthestillintactunderlyingneuralcircuitry,anotherwayofsayingwhatwecoveredearlier—thatneuronswithintheamygdalaexhibitpersistentdendriticmodeling(Vyasetal.,2003).Becauseofthis,JacobsandNadelsuggestedthatthetherapisttreatingfearsandphobiasmayneedtogeneratestressasapartoftreatmenttoactivateandhaveaccesstotheseamygdalacircuits.Inaddition,treatmentmayneedtobecontinuedwellafterbehavioralmanifestationsareeliminated,aswellasincludestressmanagementtraining.Iftheoveralllevelofstresscanbedecreased,thelikelihoodofreactivatingofprimitivefearcircuitrydecreases.

Successfulpsychotherapyforanxiety,fears,andphobiashasbeenshapedbythenecessityofintegratingfastandslowcircuits,taxonandlocalesystems,andaffectandcognition.Educatingpatientsaboutpanicleadstoincreasedparticipationofthecortexduringanxietystates.Cognitivetherapyisallaboututilizingtheslowlocalesystemstoinhibitandmodulatefasttaxonsystemsthathavebeenshapedinmaladaptiveways.Stressinoculation,orcognitivepreparationforfuturestress,leadstoanincreasingopportunityfordescendinginhibitionoftheamygdaloidcircuitsbythehippocampal-corticalnetworks.Exposure,responseprevention,andrelaxationtrainingresultinthecounterconditioningofunconsciousassociationsstoredinamygdaloidmemorysystems.Thismodelofmemoryappliestoallclinicalsituations,regardlessofthepresenceofpanicoranxietydisorders.

DrowninginaSeaofDoom

Thereisnogreaterhellthantobeaprisoneroffear.—BenJohnson

Tina’scardiologistsuggestedthatsheseeapsychotherapistafterathirdvisittotheemergencyroom.Eachtime,seeminglyoutofnowhere,Tinawouldbecomebreathlessandlightheaded;herheartwouldraceuntilshefeltasifitweregoingtoburstfromherchest.Convincedshewashavingaheartattack,Tinawouldcalltheparamedics.Asshewaitedfortheambulance,Tinareportedfeelinglikeshewasdrowningina“seaofdoom.”Shewouldimagineherteenagedchildrengrowingupwithouther,andvividly

recollectherownmother’sdeathwhenshewasachild.Thesefeelingsandimages,togetherwiththefearofdeath,wouldmakeherevenmorefrightened.Shetoldmethatwaitingfortheambulancefeltlike“aneternity.”

Tina,whowasactuallyinexcellenthealth,wasrepeatedlytoldshewashavingpanicattacks.Ittookthreeoftheseembarrassingepisodestoconvincehertoseektherapy.Shecametomyofficefeelingdefeatedandveryfrightened,asifshewaslosingalifelongbattletostayincontrol.Duringourfirstsession,IlearnedthatTinahadadifficultchildhood,includingabandonmentbyherfather,prolongedfinancialdifficulties,andthedeathofhermotherwhenshewas15.Tinafinishedhighschoolwhilelivingwithanaunt,putherselfthroughcollege,andbecameasuccessfulrealestateagent.A4-yearmarriagehadleftherwithtwochildren,nowintheirteens,toraiseonherown.Tina’sidentitywasthatofasurvivorandhardworkerwhodidnotallowherselftodependonothers.Thepanicattackshadshakenherself-confidenceandcreatedafearofreturningtothechaos,pain,anddependencyofherchildhood.Shehadhopedforamedicalexplanationtoavoidrevisitingherpast.

IbegantreatmentbyeducatingTinaaboutherbody’sfearresponseandwhyitfelttoherlikeshewashavingaheartattack.Herracingheart,lightheadedness,rapidbreathing,andsenseofdangerweretheresultoftheamygdala’smultiplesignalstopreparetofightorrun.Gainingconsciousregulationofheramygdala’salarmcircuitrywasthefirstorderofbusiness.Wediscussedstrategiestowardofftheseattacksbyslowingherbreathingandemployingrelaxationtechniques.Duringsessions,IwouldhaveTinamakeherselfanxious,andthenassistherincalmingdown.Thisprovidedherwithasenseofmasteryinregulatingamygdalaactivation.Understandingwhatwashappeninginherbodyandknowingthatherlifewasnotindangerrelievedsomeofherfear.

Thesecondphaseoftreatmentfocusedonaddressingthelong-standinglifestyleissuesthatkeptherinachronicstateofstress.Weexaminedtheheavyburdenofresponsibilitiesshecarriedandherlackofrelaxationandrecreation.Tina’sfinancialfearsledhertooverbookherworkscheduletothepointofexhaustion.IlearnedthatTinaconstantlycriss-crossedtheLosAngelesfreewaysystem,travelingbetween30,000and40,000mileseachyear.Betweenshowinghomesandshuttlingherchildrenfromschooltotheirvariousactivities,wecalculatedthatshewasfightingtrafficupto6hoursaday,usuallybehindschedule.Shebegantounderstandthepanicattacksasherbody’swayoftellinghertomakesomechangestoreduceherlevelofstress.Regularexercise,decreasinghersalesterritory,andmakingalternativearrangementsforsomeofherchildren’stransportationprovedtobethemosthelpfulsolutionsintheseareas.

Astheseinterventionsbecamemoreroutine,weexploredtheimpactofherchildhoodexperiencesonbothherself-imageandlifestyle.Tinaharboredthefearthatshewoulddielikehermother,leavingherchildrenaloneintheworld.Shetriedtodoeverythingshecouldforthem,andsaveallthemoneytheywouldneedtogotocollege,allthetimethinkingthatshewouldnotbearoundmuchlonger.Herfinancialplanningwasdetailedandovertheyearsshehadfollowedthroughwithitalmosttotheletter.Theproblemwasthatithadoriginallybeencreatedfortwoincomes;nowshewasdoingitonherown.Shecametoseethatherfearofdeathmightbecomeaself-fulfillingprophecy.Tinaalsocametorealizethatherheartwasstillbrokenoverhermother’sdeath,andthatshehadneverallowedherselftogrieveherloss,aluxuryshehadfeltshecouldnotafford.Openingherselftothesefeelingsoflosswasthebeginningofhertherapy.

Summary

Thefearfulbrainhastwointerconnectedsystemsresponsiblefordifferentaspectsoffearprocessing.Thefastortaxonsystem—withtheamygdalaatitscore—makesrapid,reflexive,andunconsciousdecisions

toprovideforimmediatesurvival.Thissystemdevelopsfirstandorganizeslearningrelatedtoattachmentandaffectregulation.Itinvolvessensory,motor,andaffectivememoriestypicalofearlylifeandlatertraumaticmemories.Thesloworlocalesystem,basedinhippocampal-corticalnetworks,contextualizesandmakesconsciouswhatisbeingprocessed.Theslowsystem’sjobistoregulatetheactivityoftheamygdalabymodulatingitsoutputbasedonamorecomplexappraisalofpotentiallydangeroussituations.Thissystemcontextualizesexperienceintimeandspace,andsupportsconsciousawarenessviacorticalconnectivity.

Thesetwosystems,reflectingbothtop-downandleft-rightcircuits,canbecomedissociatedduringprolongedperiodsofstressortrauma.Inpsychotherapy,weattempttoactivatebothfastandslowcircuits,taxonandlocalesystems,andimplicitandexplicitformsofmemorytoinformandeducateeachabouttheother.Whenemotionaltaxonnetworksareinhibited,weusetechniquestotriggerthemsothattheycanbeactivatedandintegratedwithslowlocalecircuits.Whenthesesamenetworksareoutofcontrol,werecruitlocalecircuitstocontextualizethemintimeandspaceandallowthemtobetamedbythedescending,inhibitorycapabilitiesofcorticalprocesses.Theoverallgoalistheactivationandintegrationofbothsystems.

Chapter14

TraumaandNeuralNetworkDissociation

Thebeautyoftheworldhastwoedges,oneoflaughter,oneofanguish,cuttingtheheartasunder.

—VirginiaWoolf

Foreachofusthereisapointatwhichfearcrossesthelineintotrauma,causingseveredisturbancesintheintegrationofcognitive,sensory,andemotionalprocessing.Thepsychologicalandneurobiologicalreactionstotraumaticexperienceslieonacontinuumofseverity.Asageneralrule,theearlier,moresevere,andmoreprolongedthetrauma,themorenegativeandfarreachingitseffects(DeBellis,Baum,etal.,1999;DeBellis,Keshavan,etal.,1999).Unresolvedtraumamayresultinsymptomsofpost-traumaticstressdisorder(PTSD),whichreflectthephysiologicaldysregulationanddissociationofmultipleneuralnetworks.

TheSymptomsofPost-traumaticStressDisorder

Thebestwayoutisalwaysthrough.—RobertFrost

Traumaticexperiencesresultinavarietyofwell-understoodphysiologicalandpsychologicalreactionstothreat,whichcauseanumberofpredictablesymptomstoemerge.Thesesymptomstendtograduallydiminishaftertheresolutionofthetraumaticsituation,aswegathersupportfromothers,andrepeatedlytalkthroughtheexperience.Theseconditionsallowustoregainbothneurobiologicalhomeostasisandasenseofemotionalcontrol.

Talkingthroughthetraumawithsupportiveotherscreatestheneurobiologicalconditionsforthereestablishmentofneuralcoherence.Putanotherway,constructingnarrativesinanemotionallysupportiveenvironmentsupportsthepsychologicalandneurobiologicalintegrationrequiredtoavoiddissociativereactions.Narrativesdrivetheintegrationofcognition,affect,sensation,andbehaviors,whichcanremaindissociatedespeciallywhenearlytrauma,suchaschildsexualabuse,isneverallowedtobediscussed.ThesufferingofHolocaustsurvivorsandcombatveteransisoftenexacerbatedbythepoliticalandsocialdynamicsthatencouragethemtoremainsilentabouttheirhorrifyingexperiences.

WhentraumaissevereorchronicthevictimcandevelopPTSD.PTSDiscausedbythelossoftheregulationoftheneurobiologicalprocessesresponsibleforappraisingandrespondingtothreat.Whenthissystembecomesdysregulated,thebodyreactsasifthepasttraumaiscontinuingtooccur.Thethreemain

symptomclustersofPTSD—hyperarousal,intrusion,andavoidance—reflectthelossofintegrationamongneuralnetworkscontrollingcognition,sensation,affect,andbehavior.

Hyperarousalreflectsastress-induceddysregulationoftheamygdalaandautonomicnervoussystem,resultinginanexaggeratedstartlereflex,agitation,anxiety,andirritability.Thatjumpyfeelingwegetwhenwedrinktoomuchcaffeinegivesusatasteofthisexperience.Chronichyperarousalleadsonetoexperiencetheworldasamoredangerousandhostileplace.Constantagitationandwarinessmakeuslessdesirablecompanionsandcancutusofffromthehealthfuleffectsofrelationships.

Intrusionsoccurwhentraumaticexperiencesbreakintoconsciousawarenessandareexperiencedasiftheyarehappeninginthepresent.Thereisnosenseofdistancefromthetraumaintimeorplace,becausethecorticohippocampalnetworkshavenotbeenabletocontextualizethesomatic,sensory,andemotionalmemorieswithinnetworksofautobiographicalmemory.Intrusionsmaymanifestasflashbacks,resultinginaveteranhittingthegroundinresponsetoacarbackfiring,orarapevictimhavingapanicattackwhilemakinglovetoherhusband.Theseareactivationsofsubcorticalsystemscuedbystimulireminiscentofthetrauma.Youmayrememberfromthechaptersonmemoryandfearthattheamygdalabothcontrolsthisactivationandtendstogeneralizefromtheinitialstimulitoawidevarietyofcues.

Avoidanceistheattempttodefendagainstdangersbylimitingcontactwiththeworld,withdrawingfromothers,andnarrowingtherangeofthoughtsandfeelings.Avoidancecantaketheformofdenialandrepression,and,inmoreextremeinstances,dissociationandamnesia.ThepowerofavoidancewashighlightedbytheresearchofWilliams(1994),whofoundthat38%ofadultwomenwhohadsuffereddocumentedsexualabuseaschildrenhadnomemoryoftheevent.Compulsiveactivitiescanalsoaidinavoidingnegativeaffect,ascanalcoholanddrugabuse,bothsocommoninvictimsoftrauma.Avoidanceenablesshort-termanxietyreductionwhilemaintainingthelackofneuralnetworkintegrationwhichperpetuatestheillness.

Whenexperiencedincombination,thesesymptomsresultinacycleofactivationandnumbing,reflectingthebody’smemoryfor,andcontinuedvictimizationby,thetrauma(vanderKolk,1994).Insteadofservingtomobilizethebodytodealwithnewexternalthreats,traumaticmemoriestriggercontinuingfrighteningemotionalresponses.SomeonesufferingfromPTSDisinacontinualloopofunconsciousself-traumatization,coping,andexhaustion.Whenthesesymptomsareexperiencedonachronicbasis,theycandevastateeveryaspectofthevictim’slife,fromphysicalwell-beingtothequalityofrelationshipstothevictim’sexperienceoftheworld.

Wehaveallheardthesayings“Whatdoesn’tkillyoumakesyoustronger”and“Timehealsallwounds.”Thesebitsofcommonwisdomconjureuppicturesofdifficultandtraumaticexperiencesthat,onceovercome,resultingreaterlevelsofphysicalandemotionalwell-being.Althoughtrialsandtribulationscancertainlybeimportantlearningexperiences,theycanalsocreatepermanentbiological,neurological,andpsychologicalcompromise.Traumaproduceswidespreadhomeostaticdysregulationsthatinterferewithallrealmsofpersonalandinterpersonalfunctioning(Perryetal.,1995).

SupportforthenegativeimpactoftraumacomesfromresearchshowingthatcumulativelifetimetraumaincreasesthelikelihoodofdevelopingPTSD(Yehudaetal.,1995).AhistoryofpreviousassaultsincreasesthechancesofdevelopingPTSDfollowingrape(Resnick,Yehuda,Pitman,&Foy,1995).Likewise,childhoodabusevictimsaremorelikelytodevelopPTSDafteradultcombatexposure(Bremner,Southwick,etal.,1993).Ithasalsobeenfoundthatseverestressreactionsduringcombatmakesubsequentnegativereactionstomildandmoderatestressmoreprobable(Solomon,1990).

TheNeurochemistryofPTSD

GulfWarSyndromeisnotonecause,notoneillness.Itismanycauses,manyillnesses.

—ChristopherShays

Statesofacutestressresultinpredictablepatternsofbiochemicalchangesincludingincreasesinnorepinephrine,dopamine,endorphins,andglucocorticoids,andadecreaseinserotonin.Thesechangesarepartofthebody’smobilizationtoconfrontthreat.Whenstressisprolongedorbecomeschronic,changescontinuetooccurinthebaselineproduction,availability,andhomeostaticregulationoftheseneurochemicals,resultinginlong-termbehavioralandpsychologicalalterations.Eachofthesesubstanceshasitsownroleinthestressresponseandcontributesindifferentwaystothelong-termimpactofPTSD.

Aswehaveseen,increasedlevelsofnorepinephrine(NE)prepareusforfight-or-flightreadinessandreinforcethebiologicalencodingoftraumaticmemory.Higherlong-termlevelsofNEresultinanincreaseinarousal,anxiety,irritability,andaheightenedorunmodulatedstartleresponse(Butleretal.,1990;Ornitz&Pynoos,1989).Besidesbeingstronger,thestartleresponseisalsomoreresistanttohabituationinresponsetosubsequentmilderandnovelstressors(Nisenbaum,Zigmond,Sved,&Abercrombie,1991;Petty,Chae,Kramer,Jordan,&Wilson,1994;vanderKolk,1994).Beingconsistentlystartledincreasesthevictim’sexperienceoftheworldasanunsettlinganddangerousplace,agoodexampleofafeedbackloopbetweenphysiologicalandpsychologicalprocesses.Infact,drugsthatblocktheimpactofNEarebeingusedexperimentallytodetermineiftheymayhelpvictimsofPTSDdecreasetheirphysiologicalresponsetoremindersoftheirtrauma(Brunetetal.,2008).

Highlevelsofdopaminecorrelatewithhypervigilance,paranoia,andperceptualdistortionswhenunderstress.Symptomsofsocialwithdrawalandtheavoidanceofnewandunfamiliarsituations(neophobia)areshapedbythesebiochemicalchanges.Lowerlevelsofserotoninhavebeenfoundintraumatizedhumansandanimalsafterbeingsubjectedtoinescapableshock(Anisman,Zaharia,Meaney,&Merali,1998;Usdin,Kvetnansky,&Kopin,1976).Chronicallylowlevelsofserotoninarecorrelatedwithhigherlevelsofirritability,depression,suicide,arousal,andviolence(Canli&Lesch,2007;Coccaro,Siever,Klar,&Maurer,1989).

Elevatedlevelsofendogenousopioids,whichserveasanalgesicstorelievepaininfight-or-flightsituations,canhaveaprofoundlynegativeimpactoncognition,memory,andrealitytesting.Higheropioidlevelsalsosupportemotionalblunting,dissociation,depersonalization,andderealization,allofwhichprovideasenseofdistancefromthetraumatizedbody(Shilony&Grossman,1993).However,whentheybecomeharmfullyusedasdefenses,theydisruptourabilitytostayengagedinday-to-daylife.

Aswehaveseen,highlevelsofglucocorticoidshaveacataboliceffectonthenervoussystemandarethoughttoberesponsiblefordecreasedhippocampalvolumeandrelatedmemorydeficits(Bremner,Scott,etal.,1993;Nelson&Carver,1998;Watanabe,Gould,&McEwen,1992).ThehippocampiofpatientswithPTSDrelatedtochildhoodphysicalandsexualabusehavebeenshowntobe12%smallerthanthoseofcomparisonsubjects(Bremneretal.,1997).Anotherstudyshowedthatrighthippocampiwere8%smallerinpatientswithcombat-relatedPTSD(Bremneretal.,1995).Glucocorticoidssacrificelong-termconservationandhomeostasisforshort-termsurvival.Chronicallyhighlevelshavenegativeeffectsonbrainstructuresandtheimmunesystem,resultinginhigherratesoflearningdisabilitiesandphysicalillness,whichenhancesvictims’experienceofbeingfragileandvulnerableindividuals.

Thesebiochemicalandneuroanatomicalchangesareparalleledbysuchsymptomatologyasemotionaldyscontrol,socialwithdrawal,andlowerlevelsofadaptivefunctioning.Together,theseandothernegativeeffectsoftraumaresultincompromisedfunctioninginmanyareasoflife.Theimpactoftraumadependsonacomplexinteractionofthephysicalandpsychologicalstagesofdevelopmentduringwhichitoccurs,thelengthanddegreeofthetrauma,andthepresenceofvulnerabilitiesorpasttraumas.Theimpactofchronictraumabecomeswovenintothestructureofpersonalityandishiddenbehindothersymptoms,makingitdifficulttoidentify,diagnose,andtreat.

ExpandingtheDefinitionofTrauma

Tothechild…traumasarenotexperiencedaseventsinlife,butaslifedefining.—ChristopherBollas

Traumaisnotlimitedtosurvivinglife-threateningexperiences,asthestandarddiagnosticmanualappearstosuggest(AmericanPsychiatricAssociation,2000).Forayoungchild,traumamaybeexperiencedintheformofseparationfromparents,lookingintotheeyesofadepressedmother,orlivinginahighlystressfulhousehold(Cogill,Caplan,Alexandra,Robson,&Kumar,1986).Foranadolescent,traumamaycomeintheformofincessantteasingbypeersorcaringforanalcoholicparent.Foranadult,chroniclonelinessorthelossofapetmaybetraumatic.

Thereisincreasingevidencethatstressispossibleevenbeforebirth;anunbornchildmaybecomestressedasaresultofthesharedbiologicalenvironmentwithitsmother.Studiessuggestthatmaternalstressisassociatedwithlowerbirthweight,increasedirritability,hyperactivity,andlearningdisabilitiesinchildren(Gunnar,1992,1998;Zuckerman,Bauchner,Parker,&Cabral,1990).Ratsborntostressedmothersshowmoreclingingtothemotheranddecreasedlocomotionandenvironmentalexploration(Schneider,1992).Prenatalstressmayalsoresultinpermanentalterationsindopamineactivityandcerebrallateralization,makingoffspringmoresusceptibletoanxietyandimpairingtheirfunctioningasadults(Fieldetal.,1988).ChildrenofHolocaustsurvivorshaveanincreasedprevalenceofPTSDdespitesimilarratesofexposuretotraumaticeventsaschildrenofnon-Holocaustsurvivors.Thissuggeststhattheyexperiencedatransferredvulnerabilitythroughinteractionswiththeirtraumatizedparents(Yehuda,1999).

Maternaldepressionmayserveasahighlystressfulortraumaticexperienceforinfantsandchildren.TiffanyFieldandhercolleaguesfoundthatinfantsofdepressedmothersshowneurophysiologicalandbehavioralsignsofdepressionandstress,includinggreaterrightfrontallobeactivation,higherlevelsofNE,lowervagaltone,andhigherheartratesandcortisollevels(Field&Diego,2008b;Field,Diego,&Hernandez-Reif,2006).Justliketheirdepressedmothers,theseinfantsengageinlessinteractivebehaviors(e.g.,orientingtowardandgazingatothers)vitalforhealthydevelopment.Infantsofdepressedmothersbehaveinthiswayevenwithotheradults,makingitdifficultforthemtosuccessfullyinteractwithnondepressedothers(Fieldetal.,1988).

Inanotherstudy,itwasfoundthatdepressedmotherswereangryattheirinfantsmoreoften,disengagedfromthemmoreoften,weremorelikelytopokethem,andspentlesstimeinmatchingemotionalstates(Field,Healy,Goldstein,&Guthertz,1990).Theseresultssuggestthatinfantsaremodelingtheirmother’sbehavior,resonatingwiththeirdepressedmoods,andreactingtothenegativebehaviorsdirectedtowardthem.Althoughwewouldnotconsidertheseinfantstraumatizedinthetraditionalsense,thelossofmaternalpresence,engagement,andvitalitymayallbeexperiencedaslifethreatening.Fortunately,ithasbeenshownthatinterventionswithdepressedmothersandtheirinfantshavepositiveresults.Forexample,remissionofmaternaldepressionandteachingmotherstomassagetheirinfantsonaregularbasisimprovestheinfants’symptomsandthemothers’mood(Field,1997).

Theeffectsofearlyandseveretraumaareextremelywidespread,devastating,anddifficulttotreat.Becauseoftheimportanceofacontextofsafetyandbondingintheearlyconstructionofthebrain,childhoodtraumacompromisescoreneuralnetworks.Itstandstoreasonthatthemostdevastatingtypesoftraumaarethosethatoccuratthehandsofcaretakers.Physicalandsexualabusebyparentsnotonlytraumatizeschildren,butalsodeprivesthemofhealinginteractionsandasafehaven.Thewiderangeofeffectsinvolvedintheadaptationtoearlyunresolvedtraumaresultsincomplexpost-traumaticstressdisorder.

ComplexPost-traumaticStressDisorder

TheotherdayIheardsomeoneknockingonmywindow.I’dratherbedeadthanhearthat.—A10-year-oldkidnappingvictim

ComplexPTSDoccursinthecontextofearly,prolonged,andinescapabletrauma.Itiscalledcomplexbecauseofitsextensiveeffectsonallareasofphysiology,development,andfunctioning(Herman,1992;Navaltaetal.,2004).Theenduringpersonalitytraitsandcopingstrategiesthatemergeinthesesituationstendtodecreasepositiveadaptationandincreaseanindividual’svulnerabilitytofuturetrauma.Thiscanmanifestthroughengagementinabusiverelationships,poorjudgment,oralackofadequateself-protection.Long-termPTSDhasbeenshowntocorrelatewiththepresenceofneurologicalsoftsigns,whichsuggestsubtleneurologicalimpairments(Gurvitsetal.,2000),andmayreflectavulnerabilityto,ortheimpactof,theeffectsoftrauma(Green,1981).

Foranadultundernormalcircumstances,athreattriggersafight-or-flightresponse.Thethreatisdealtwithandtheflight-fightresponsesoonsubsides.Childrenarenotwellequippedtocopewiththreatinthisway.Fightingandfleeingmayactuallybemaladaptivebecausetheirsurvivaldependsonrelyingonthosearoundthem.Whenachildexperiencestraumainflictedbyacaretaker,orcriesforhelpbutnohelparrives,heorshemayshiftfromfearandhyperarousaltopsychologicalandneurologicaldissociation(Perryetal.,1995).Thismayalsobetrueforthosewomenwhoareunabletooutrunoroutfightmaleattackers.Thesymptomsofagitationshownbytraumatizedchildrenareoftenmisdiagnosedasattentiondeficitdisorder,whilethenumbingresponseininfantscanbemisinterpretedasalackofawarenessorsensitivitytopain.

Untilrecently,surgerywasperformedoninfantswithoutanesthesiabecausetheirgraduallackofprotestwasmistakenlyinterpretedasaninsensitivitytopainratherthanlapsingintoastateofshock(Zeltzer,Anderson,&Schecter,1990).Surveyresearchsuggeststhatlessthan25%ofphysiciansperformingcircumcisiononnewbornsuseanyformofanalgesia(Wellington&Rieder,1993),despitephysiologicalindicationsthatneonatesareexperiencingstressandpainduringandaftertheprocedure(Hoyleetal.,1983).Thesepracticesappeartobeaholdoverofbeliefsthatnewbornseitherdon’texperienceordon’trememberpain(Marshall,Stratton,Moore,&Boxerman,1980).Thus,ourlackofappreciationforthepossibilityfortraumaticreactionsinneonatesandchildrenlikelyleadsustomissmanyPTSDreactionsintheyoung.

ResearchwithratshasdemonstratedthatexposuretoinescapableshocksensitizestheirhippocampitosubsequentreleasesofNEunderstress(Pettyetal.,1994).Thissuggeststhatprolongedstressandtraumamaycauseustoreactmorestronglytosubsequentmilderstress.ThismayhelptoexplainthecopingdifficultiesseeninvictimsofPTSDwhenconfrontedwithmildtomoderatestress(Pettyetal.,1994).ThinkbacktoSheldon,whostillsufferedfromanxiety60yearsafterhischildhoodexperiencesduringWorldWarII.

Dissociationallowsthetraumatizedindividualtoescapethetraumaviaanumberofbiologicalandpsychologicalprocesses.Increasedlevelsofendogenousopioidscreateasenseofwell-beingandadecreaseinexplicitprocessingofoverwhelmingtraumaticsituations.Derealizationanddepersonalizationreactionsallowthevictimtoavoidtherealityofhisorhersituation,orwatchitasadetachedobserver.Theseprocessescancreateanexperienceofleavingthebody,travelingtootherworlds,orimmersingoneselfintootherobjectsintheenvironment.Manyvictimsofviolenceandsexualabusereportwatchingthemselvesbeingattackedfromadistance.Hyperarousalanddissociationinchildhoodcreateaninnerbiopsychologicalenvironmentprimedtoestablishboundariesbetweendifferentemotionalstatesandexperiences.Ifitistoopainfultoexperiencetheworldfrominsideone’sbody,evenone’sself-identitycanbecomeorganizedoutsidethephysicalself.

Earlytraumaticexperiencesorganizeneuroanatomicalnetworking,thusimpactingexperienceandadaptationthroughoutdevelopment.Thetendencytodissociateanddisconnectvarioustracksofprocessingcreatesabiastowardunintegratedinformationprocessingacrossconsciousawareness,sensation,affect,andbehavior.Generaldissociativedefensesresultinginanaberrantorganizationofnetworksofmemory,fear,andthesocialbraincontributetodeficitsofaffectregulation,attachment,andexecutivefunctioning(vanderKolketal.,1996).Themalformationoftheseinterdependentsystemsresultsinmanydisordersthatspringfromextremeearlystress.Compulsivedisordersrelatedtoeatingorgambling,somatizationdisordersinwhichemotionsareconvertedintophysicalsymptoms,andborderlinepersonalitydisorderallreflectcomplexadaptationstoearlytrauma(Saxeetal.,1994;vanderKolketal.,1996).

IAmNotCrazy!

Demoralizetheenemyfromwithinbysurprise,terror,sabotage,assassination.—AdolfHitler

Jessewasreferredtomebyherneurologistaftermonthsofextensivemedicalandneurodiagnostictesting.Herteamofdoctorscouldfindnophysicalcauseforthedebilitatingpainsheexperiencedinherheadandupperbody.Shehadtriedalternativeformsoftreatment,suchaschiropracticsandacupuncture,withoutmuchrelief.Jessecametoseemeattheinsistenceofherhusband,andshewasnottheleastbithappyaboutit.Shesatdownwithherarmscrossedandherjawset,glaredatme,andsaid,“Iamnotcrazy!”

Formanyyears,lifehadbeengoingwellforJesse.Shehadasolidmarriageandahappyandhealthy4-year-olddaughter.Shefoundherworkasanexecutiveinasmallinformationtechnologyfirminteresting.Shelikedhercolleagues,andwasavaluedmemberoftheteam.Aboutayearbefore,shehadstartedexperiencingpaininherhead,hands,andbackandbeganafruitlesssearchforacure.Thepainbecamethecenterofherattentionasherinterestandabilityinbeinganexecutive,friend,wife,andmothergraduallydiminished.Bythetimeshecamefortherapy,shewasspendingmostofherdaystakingmedication,sneakingawayfornaps,andwithdrawingtoherroomwhenevershecouldfindanexcuse.Therewasnolongeranyfunorrelaxationinherlife,andherhusbandhadbecomeseriouslyconcerned.

Givenherresistancetotherapyandfearofbeingseenascrazy,developingatherapeuticrelationshipwithJessewasslowgoing.Shereluctantlybegantoshareaboutherverytroubledchildhood.Jessefeltshehadobviouslyovercomehertraumaticpastbasedonherlatersuccessatworkandinhermarriage.Unfortunately,acommonoccurrenceinherchildhoodwastobelockedinherroombyherfatherasapreludetohimbeatinghermother.Shewouldlieinbed,frozenbybothoftheirscreams,hermother’scriesforher,andthelongominoussilencesthatfollowed.Asshetoldmeofhermother’sphysicalabuseatthehandsofherfather,sheremainedconfidentthattherewasnoconnectionbetweenherpresentphysicalpainandtheemotionalpainofheryouth.

Jessewouldeventuallybegintopoundonthedoorandyellforhermother.Asshegrewolder,however,shegaveupheroutwardprotestsandinsteadlayinbedcryingandclutchingherfaceandhead.Thisclutchingeventuallyturnedtoself-abuse,whichincludeddrivinghernailsintoherheadandshoulders,drawingblood,andeventuallyscarringherself.Sheshowedmesomeofherscarswithacombinationofshameandpride.Asshedescribedtheseexperiences,Ibegantosuspectthatherpainsymptomsmightwellbeimplicitsomaticmemoriesofhertraumaticpast.Thestressesinherpresentlife,includingthefactthatherowndaughterwasreachingtheageshehadbeenwhenshefirstbecameawareofthebeatings,couldallserveastriggersforthesememories.Fromapsychologicalperspective,her

physiologicalsufferingcouldbeseenasaformofloyaltyandcontinuedconnectiontohermother.IdecidednottosharetheseinterpretationsbecauseofJesse’sresistancetothepossible

psychologicaloriginsofherpain.Instead,Icontinuedtoencouragehertotalkaboutherchildhoodinasmuchdetailasshecouldtolerate.Shewentontotellmeaboutherteenageyears,whenshenursedhermotherthroughthefinalmonthsofaprolongedbattlewithcancer.ThroughoutmyworkwithJesse,Iavoidedanytalkofherphysicalpainandcontinuedtorefocusheronsharingchildhoodexperienceswithme.

Intheprocessofrepeatedlysharingstoriesfromherchildhood,hermemoriesbecameincreasinglydetailed.Heremotionstoo,becamemoreavailable,andbettermatchedtothesituationsshedescribed.Jesseexpressedherrageatherfatherforhisviolentbehavior,andrealizedthatshewasalsoangryathermotherfornotleavinghimwhenJessewasyoung.Assheworkedthroughthesememoriesandputthemintotheperspectiveofhercurrentlife,Jessegraduallycametoanunderstandingthatinsteadofremainingloyaltohermotherthroughphysicalsuffering,shecouldidentifywithherbybeingagoodparenttoherowndaughter.

Astherapyprogressed,webothcametonoticethattheintensityofherpainandthetimeshespentfocusingonitgraduallydiminished.Withoutmakingadirectinterpretation,theconnectionsinJesse’sbrainbetweenherphysicalandemotionalpainwereforged.Towardtheendofourlastsession,shethankedmeforhelpingher,althoughshedidn’tunderstandhowithappened.Jessewinkedatmeandsaid,“Youareatrickyfellow.”

TraumaticMemory

Memoriesarenothingbutthelashwithwhichyesterdayflogstomorrow.—PhilipMoeller

Ithaslongbeenrecognizedthathighlevelsofstressimpairlearningofnewinformation(Yerkes&Dodson,1908).Thisisbecausethebiochemicalandhormonalchangestriggeredbystressimpairproteinsynthesisandotherneuroplasticprocessesrequiredformemoryencoding.Traumacanalsoimpairintegrationacrossthedomainsofmemory,andiscapableofdissociatingtheusuallyintegratedtracksofsensation,emotion,behavior,andconsciousawareness.

WhenNEisadministeredtoratsafteranaversiveevent,lowdosesenhancememoryretentionwhereashighdosesimpairit(Introini-Collison&McGaugh,1987);thissupportsYerkesandDodson’stheorythatmoderatelevelsofarousalenhancememorywhereashighlevelsimpairit.InastudybyCahillandhiscolleagues(Cahill,Prins,Weber,&McGaugh,1994),subjectswerereademotionallyevocativeandneutralstoriesandshownrelatedslides.Halfofthesubjectsweregivenpropranolol(adrugthatdecreasestheeffectsofNE),andtheotherswerenot.Resultsdemonstratedthatsubjectswhoreceivedpropranololhadsignificantlyimpairedmemoryforemotion-arousingbutnotforneutralstories.

Activationoftheamygdalaandrelatedphysiologicalandbiologicalchangesareattheheartofmodulatingtraumaticmemory(Cahill&McGaugh,1998).Thereleaseofnorepinephrineduringthestressresponseservestoheightentheactivationoftheamygdala,thusreinforcingandintensifyingtraumaticmemories(McGaugh,1990).IndividualswithPTSDhavehadtheiramygdaloidmemorysystemsimprintedwithtraumaatsuchanextremelevelthattheirmemoriesareresistanttocorticalintegration(vanderKolketal.,1996).Thisresultsindecreasedattentiontoandprocessingofexternalstimuli,givingthetraumaticmemoriesmorepower(Laniusetal.,2001).Whenwethinkoftraumaoverwhelmingthedefenses,wecanalsothinkintermsofanintenseactivationofsubcorticalnetworksservingtoinhibit

theparticipationofthehippocampusandcortexinthememoryprocess.Traumaticexperiencecandisruptthestorage(encoding)ofinformationandtheintegrationofthe

varioussystemsofattentionandmemory(Vasterling,Brailey,Constans,&Sutker,1998;Yehudaetal.,1995;Zeitlin&McNally,1991).Memoryencodingforconsciousexplicitmemorycanbedisruptedwhenthehippocampusisblockedordamagedbyglucocorticoids,orisinhibitedbyheightenedamygdalaactivation.Thiscouldleadtoalackofconsciousmemoryfortraumaticandhighlyemotionalevents(Adamec,1991;Schacter,1986;Squire&Zola-Morgan,1991).Memoryintegrationcanbeimpairedbydisruptionofthecorticohippocampaltracksdedicatedtotheintegrationofnewmemoriesintoexistingmemorynetworks.Rememberthatthesesystemsalsoprovidecontextualizationintimeandspace,andintegrationofsensory,affective,andbehavioralmemorywithconsciousawareness.

Thus,althoughwemayhaveveryaccuratephysiologicalandemotionalmemoriesforatraumaticevent,thefactualinformationmaybequiteinaccurategiventheinhibitionofcorticohippocampalinvolvementduringthetrauma.Addtothisthetendencyofthelefthemisphereinterpretertoconfabulateastoryintheabsenceofaccurateinformation,andwemayhavewhatrepresentstheunderlyingmechanismsresponsibleforwhathasunfortunatelybeenreferredtoasfalsememorysyndrome(PazAlonzo&Goodman,2008).

TraumaticFlashbacksandSpeechlessTerror

Memoriesarecontrarythings;ifyouquitchasingthemandturnyourback,theyoftenreturnontheirown.

—StephenKing

Flashbacksarefrighteningexperiencescommonlyreportedbytraumatizedindividuals.Theyaredescribedasfull-bodyexperiencesoftraumaticevents,whichincludethephysiologicalarousal,sensorystimulation,andemotionalimpactofthetraumaticexperience.Inasense,thevictimofaflashbackistransportedbacktotheevent,andasfarasthebrainisconcerned,itishappeningagain.Flashbacksaresointensethattheyoverwhelmtherealityconstraintsofthepresentsituationandsendthevictimintoanall-too-familiarnightmare.

Thepoweroftraumaticflashbackswasdrivenhomeformeonedayinatherapysessionwithaprofessionalfootballplayerwhowasnearlytwicemysize.Whenrecallinghisearlyabuse,hebegantocrysoftlyashespokeofoneparticularlypainfulexperiencefromchildhood.Hedescribedinagonizingdetailhissmallbodygrowinglimpafterrepeatedblowsfromhisfather’sfists.Suddenly,hewasstandingoverme,breathingheavily,hisarmsdownathissides.Despitemyalarm,Imanagedtocalmlyaskhimwhathewasfeeling.Whilelookingintomyeyeshesaidinachild’svoice,“

Pleasedon’thurtmeanymore.”Hisfearofmedespitethedifferenceinoursizeswasastarkdemonstrationoftheall-encompassingnatureofflashbacksandtheirabilitytooverridecontemporaryreality.

Traumaticflashbacksarememoriesofadifferentnaturethanarethoseofnontraumaticevents.Tobeginwith,theyarestoredinmoreprimitivecircuitswithlesscorticalandlefthemisphereinvolvement.Becauseofthis,theyarestronglysomatic,sensory,andemotional,aswellasinherentlynonverbal(Krystal,Bremner,Southwick,&Charney,1998).Thelackofcorticohippocampalinvolvementresultsinanabsenceofthelocalizationofthememoryintime,sothatwhenitistriggered,itisexperiencedasoccurringinthepresent.Flashbacksarealsorepetitiveandstereotypic,oftenseemingtoproceedatthepaceatwhichtheeventsoriginallyoccurred.Thissuggeststhatalthoughthecortexmaycondenseand

abbreviatememoriesinnarrativeandsymbolicform,thesesubcorticalnetworksmaystorememoriesinmoreconcrete,stimulus-responsechainsofsensations,behaviors,andemotions.Inasensetheybecomeproceduralmemories,similartolearningtoplayapieceofmusicnotebynoteoracomplexdanceroutinestepbystep.

Inflashbacks,theamygdala-mediatedfearnetworksbiasedtowardtherighthemisphereandsubcorticalsystemsbecomedominant.Theamygdala’sdenseconnectivitywiththevisualsystemmostlikelyaccountsforthepresenceofvisualhallucinationsaspartofflashbacks.Bereavedindividualsoftenreportseeingtheirlovedonessittingintheirfavoritechairorwalkingacrosstheroominafamiliarway.Thosewhohavebeenattackedwillsometimesthinktheyseetheirattackeroutofthecorneroftheireye.Thisisincontrasttothehallucinationsinschizophreniathatinvolvethetemporallobesandareusuallyauditoryinnature.

Rauchandcolleagues(1996)tookeightpatientssufferingfromPTSDandexposedthemtotwoaudiotapes:Onewasemotionallyneutralandtheotherwasascriptofatraumaticexperience.Whiletheywerelisteningtothesetapes,patients’heartratesandregionalcerebralbloodflow(RCBF)weremeasuredviaPETscans.RCBFwasgreaterduringtraumaticaudiotapesinright-sidedstructuresincludingtheamygdala,orbitofrontalcortex,insular,anterior,andmedialtemporallobe,andtheanteriorcingulatecortex.Thesearetheareasthoughttobeinvolvedwithintenseemotion.

AnextremelyinterestingandpotentiallyimportantclinicalfindingwasadecreaseinRCBFinandaroundBroca’sarea(anareaoftheleftinferiorfrontalcortexthatcontrolsspeech).Thesefindingssuggestanactiveinhibitionoflanguagecentersduringtrauma.Basedontheseresults,speechlessterror—oftenreportedbyvictimsoftrauma—mayhaveneurobiologicalcorrelatesconsistentwithwhatweknowaboutbrainarchitectureandbrain–behaviorrelationships.ThisinhibitoryeffectonBroca’sareamayimpairtheencodingofconscioussemanticmemoryfortraumaticevents.Itwillthennaturallyinterferewiththedevelopmentofnarrativesthatservetoprocesstheexperienceandleadtoneuralnetworkintegrationandpsychologicalhealing.ActivatingBroca’sareaandrelatedleftcorticalnetworksofexplicitmemorymaybeessentialinpsychotherapywithpatientssufferingfromPTSDandotheranxiety-baseddisorders.

ActivatingBroca’sAreaDuringaFlashback

Hopewillneverbesilent.—HarveyMilk

Jan,seeingmeforaone-timeconsultation,reportedthatshehadsufferedseverephysicalandsexualabusethroughoutherearlychildhoodandintoherlateteens.Shetoldmeoverthephonethatherflashbackswereincreasinginfrequencytothreeorfouraday.Althoughhertherapisthadencouragedhertoexperiencethemandexpressheremotionsasmuchaspossible,Janfeltlikeshewasgettingworseinsteadofbetter.Expressingherfeelingsseemedtoonlytriggermorefrequentandintenseflashbacks.Shereportedbecominglessandlessfunctional,whichmadeherdecidethatsheneededadifferentapproachtotherapy.

JanarrivedatmyofficewithastackofdiariesandTheWallStreetJournalunderherarm.ItwashardtobelievethatthiswasthesamepersonIhadspokentooverthephone.Myfirstthoughtwasthatdissociationisanamazingdefense.Janwasawell-dressedwomaninhermid-40swhowasobviouslybrightandhadagooddealofself-insight.Thechildhoodexperiencessherecountedinmyofficewerehorrendous,andImarveledatherverysurvival.Herintelligenceandsheerwilltolivewereremarkable.

Itseemedobvious,however,thatherrepeatedreexperiencingofthesememorieswasnothelping.Thenatureofthesememorieswasnotchangingovertime,norweretheemotionsevokedbyhermemoriesdiminishing.Inthiscase,eachflashbackseemedtoretraumatizeheranew.

Shebeganbytalkingaboutherwork,andthendescribedthepsychotherapyandotherformsoftreatmentinwhichshehadengaged.Approximately10minutesintothesession,asshewasdiscussingthefamilymemberswhohadabusedher,shebegantohaveaflashback.Janreportedpaininvariouspartsofherbodyandcontortedasifwhatshewasdescribingwashappeningtoheratthatverymoment.Shebegantogagasthememoryofthesexualabusefromdecadesearlierwasevoked.Shewasreexperiencingthesepainfulepisodesnotonlyvisuallyinhermind,butassomaticmemoriesthroughoutherbody.

Asshecurledintoafetalpositiononthecouchandgaspedforbreath,mymindracedtryingtothinkofawaytohelp.RememberingtheresearchdonebyRauchandhiscolleagues,IdecidedtotrytoactivateBroca’sarea.IbeganspeakingtoJaninafirmbutgentlevoice,loudenoughtoreachherinthemidstofhertraumaticreenactmentbutnotsoloudastofrightenherandaddtohertrauma.IwonderedifitmatteredwhichearIspokeinto,andwhichearhasamoredirectconnectiontothelefthemispherelanguagecenters.Imovedclosertoher(carefulnottogettooclose)andrepeatedoverandover,“Thisisamemory,itisn’thappeningnow.Youarerememberingsomethingthathappenedtoyoumanyyearsago.Itwasaterribleexperiencebutitisover.Itisamemory.Itisnothappeningnow.”

AsIrepeatedtheseandsimilarstatements,IwasconcernedthatJanwouldbeunabletobreatheorthatmypresencemightcausehermorefear.Thewordsofoneofmysupervisorsflashedthroughmymind:“

Whateveryoudo,don’tpanic.”Iwasalsoencouragedbythefactthatshehadsurvivedthismanytimes.After10minutes(whichseemedtomelike10hours),shecalmeddownandreturnedtothepresent.JanreportedthatsheheardmespeakingasifIwerefaraway,butfocusedonmyvoiceandwordsasbestshecould.ItwasasifIwerethereinthepastwithher,callingtoherfromasafefuturewhereshewouldbeawayfromallthesepeoplewhohurther.

Attheendofthesessionshethankedmeandleft;Ididn’thearfromherforanumberofmonths.Whenshecalledoneafternoon,shereportedthatsincehervisitwithme,thenatureoftheseflashbackshadchanged.Shesaidshehadwantedtowaitbeforeshecalledmebecauseshedidn’texpectthatthechangewouldlast.Givenhermanyyearsinavarietyofunhelpfultreatments,itwaseasytobesympathetictohernegativeexpectations.Jandescribedthatsinceoursession,theflashbackswerelessphysicallyintenseandlessfrequent.Onafewoccasionsshehadevenbeenabletostoponethatwascomingonbythinkingofmywordsduringthesession:“Thisisjustamemory.Youaresafenow.Noonecanhurtyou.”

Perhapsmostinterestingwasthatshewasnowabletorememberduringherflashbacksthatshewasnotachild,thatshewasnottoblame,anditwasthosewhowerehurtingherwhowerebad.Althoughherothertherapistshadtoldherthisinthepast,onlyrecentlycouldsheprocessthesethoughtsduringherflashbacks.ItoldherthatIfelttheseweresignsthattheexperienceswerebeginningtobeconnectedtoherconsciousadultself,andthatnowshewasabletofightandcareforherselfeveninthefaceofherpast.Iencouragedhertokeeptalkingthroughouttheflashbackexperiencesandbringwithherasmuchassertiveness,anger,andpowerasshecouldmuster.Afterafewminutes,weendedourconversationandIsatback,struckathowneurosciencecouldindeedbeappliedtopsychotherapy.

ItisimpossibleformetoknowwithanycertaintywhetherwhatIhaddonewithJanduringouronemeetinghadanythingtodowiththechangessheexperiencedduringherflashbacks.Ifitdid,perhapstheactiveingredientwasthesimultaneousactivationoftheverbalareasofthelefthemispherealongwiththeemotionalcentersoftherighthemisphereandlimbicstructuresthatstoredtheflashbacks.Beingsimultaneouslyawareofinnerandouterworldsmaysupportahigherlevelofcorticalfunctioningandincreasednetworkintegration.Inotherwords,thisprocessresultsinamemoryconfigurationthatisno

longerimplicitonlybutinsteadbecomesintegratedwiththecontextualizingpropertiesofexplicitsystemsofmemoryinthecerebralcortex(Siegel,1995).

Speechlessterror,whichhasbeenrecognizedaspartofposttraumaticreactionssinceancienttimes,nowhasaneuralcorrelateconsistentwithwhatisknownaboutbrainfunctions.WhydoesBroca’sareabecomeinhibitedduringtrauma?Whywouldevolutionselectsilenceintimesofcrisis?Perhapswhenoneisthreateneditisbettertoeitherrunorfightorsimplykeepquietandhopetostayundetected.Inotherwords,evolutionhastaughtthebrainto“Shutupanddosomething!”whenindanger.Thefreezingreactionofanimals(beingstillandquietwhentheysenseapredator)allowsthemtobelessvisible(becauseastillandsilenttargetismoredifficulttodetect).Spokenlanguageissound,whichprimitivefearcircuitryisabletosilence.Perhapsthoseearlyprehumanswhohungaroundforconversationandnegotiationwithpredatorsdidn’tfarewellenoughtopassdownasmanygenesasdidthosewhoeitherkeptquiet,fought,orranaway.

TheAddictiontoStressandSelf-Harm

Everyformofaddictionisbad,nomatterwhetherthenarcoticbealcoholormorphineoridealism.

—C.G.Jung

AnotherclinicalphenomenonwithapossiblebiochemicalmechanismiswhatappearstobeanaddictiontostressexperiencedbysomepatientswithPTSD.Whileanxiousandillateaseinnormaldailylife,theyreportfeelingcalmandcompetentinriskyorlife-threateningsituations.Asocallednormallifeleavestraumatizedpersonsablankscreenontowhichtheirdysregulatedpsychescanprojectfearfulexperiences,keepingtheminastateofvigilanceandfear(Fish-Murry,Koby,&vanderKolk,1987).Thismaymotivatethecreationofstress,makingatraumatizedpersonvulnerabletocreatingnewtrauma.Thenewtraumawould,inturn,stimulatetheproductionofendogenousopioidsthatwouldleadtoanincreasedsenseofcalmandwell-being.Paradoxically,traumawouldleadtoasenseofcompetencyandcontrol.

Becausetheseindividualsaresophysicallyworndownbythislifestyle,theyoftenpresentintherapywithexhaustion,depression,andavarietyofmedicalconditions.Itisasiftheyhaveadrugaddiction,exceptthatitiscompletelyunconsciousandtheyaretheirownpharmacy.Initialworkwiththesepatientsshouldfocusonhelpingthemreducestressandlearntotolerateandunderstandtheanxietytriggeredbytheabsenceofstress.Thiscanusuallybeaccomplishedthroughacombinationofstress-reductiontechniques,medication,andpsychotherapy.

Theaddictiontostresshasarelatedbutmoreseverevariant:self-harm.Adultswhoengageinrepeatedself-harmcommonlydescribechildhoodsthatincludedabuse,neglect,oradeepsenseofshame.Thiscorrelationhasledmanytheoriststoexplorethepsychodynamicsignificanceofself-harmasanongoingnegativeattachmenttodestructiveparents.Alongtheselines,suicidehasbeendescribedasthefinalactofcompliancewiththeparents’unconsciouswishforthedeathofthechild(Green,1978).Thereappearstobeastrongassociationbetweenself-harmandattachmentdisordersbecauseself-injuriousbehaviorsareoftenaresponsetoabandonmentandloss.

Endogenousopioidsmayalsoplayaroleinsomeinstancesofself-harmandsuicide(vanderKolk,1988).Thisopioidsystem,originallyusedtocopewithpain,wasadaptedbylater-evolvingnetworksofattachmenttoreinforcethepositiveeffectsofbonding(Pitmanetal.,1990).Researchhasdemonstratedthatthefrequencyofself-harmdecreaseswhenpatientsaregivenadrugtoblocktheeffectsofendogenousopioids(Pitmanetal.,1990;vanderKolk,1988).Abstractingfromtheanimalmodel,this

wouldsuggestthattheendorphinsreleasedduringinjuryreversethefeelingsofdistressactivatedbyabandonment.Theanalgesiceffectsofthesemorphinelikesubstancesmayaccountforthereportsdescribingasenseofcalmandreliefafterindividualscut,burn,orhurtthemselves.Thus,self-injuriousbehaviorsmaybereinforcedbybothpsychologicalfactorsandtheendogenousopioidsystem.

Repeatedsuicideattemptsarereinforcedalsobytherapidattentionofhealthcareprofessionals,family,andfriends,whichmayboostendorphinlevelstriggeredbythearrivaloflovedones.Whenwovenintocopingstrategiesasameansofaffectregulation,thisattention-gettingbehaviorresultsinakindofcharacterologicalsuicidality(Schwartz,1979).Thisbehaviorparallelsthedistresscallsofprimateswhoseendorphinlevelsdropintheabsenceofthemother.Thereappearanceofthemotherresultsinaraisingoftheseendorphinlevelsandtheinfantdiscontinuesitscry.Characterologicalsuicidalitycancometoserveasimilarbiochemicalregulatorypurposeifthissystemwasinadequatelyformedduringchildhood.Althoughtherearemanysoundpsychologicalexplanationsfortherelationshipofchildhoodabusewithself-harmandsuicidality,apharmacologicalinterventiondesignedtoblocktheimpactofendogenousendorphinsmayalsoprovehelpful.

TheBrainandBorderlinePersonalityDisorder

Lifebeganwithwakingupandlovingmymother’sface.—GeorgeEliot

AccordingtoFreud,participationinanalysisrequiressufficientegostrengthtowithstandthestressoftherapywhilesimultaneouslymaintainingcontactwithreality.Basedonthisassumption,Freuddidhisbesttomakesurethathisprospectiveclientswerenotpsychotic.Psychoticindividualsarecharacterizedbyseveredistortionsofreality,thoughtdisorders,anddecompensationunderstress.Theyarealsounabletodifferentiatetheirtransferenceandotherprojectiveprocessesfromexternalreality.DespiteFreud’sbesteffortstoscreenouttheseclientsfromanalysis,everysooftenhegotasurprise.Peoplewhoappearedtobeneuroticwouldbecomepsychoticduringanalysis.Freudreferredtothesepeopleashavingpsychicstructuresontheborderlinebetweenneuroticandpsychotic.

Overtheyears,theconceptionofaborderlinepsychicstructurehasevolvedintowhatisnowcalledborderlinepersonalitydisorder(BPD).Aswehavealreadyseen,BPDmayrepresentonevariantofcomplexPTSD,anideasupportedbythefrequentoccurrenceofearlyabuse,trauma,andthepresenceofdissociativesymptomsinborderlineindividuals.Patientswhocarrythisdiagnosisarecharacterizedbythefollowing:

1. Hypersensitivitytorealorimaginedabandonment.2. Disturbancesofself-identity.3. Intenseandunstablerelationships.4. Alternatingidealizationanddevaluationofthemselvesandothers(black-and-white

thinking).5. Compulsive,risky,andsometimesself-destructivebehaviors.

Althoughthereareanumberoftheoriesconcerningitscause,manyfeelthattheetiologyofBPDstemsfromearlydeficitsinemotionalregulationandproblematicattachmentrelationships.Researchalsosuggeststhataffectivedisordersinthesepatientsandtheirparentsoccurabovechancelevels.Thismay

leadtoacombinationofparentalinstabilityandbiologicaldifficultiesofemotionalregulationwithinthechild.Overall,boththeirreportedhistoryandtheirsymptomssuggestthatearlyattachmentwasexperiencedastraumatic,emotionallydysregulating,andpossiblylifethreatening.

Ihavecometofeelthatborderlineindividualsprovideuswithawindowintotheintenseandchaoticexperienceofinfancy.Aswehaveseen(andthisiswhereourneuroscientificknowledgecomesinhandy),theamygdalaishighlyfunctionalatbirth.Rememberthattheamygdalaisatthecenterofneuralnetworksinvolvingbothfearandattachment.Thehippocampalandcorticalnetworksthateventuallyorganizeandinhibittheamygdalagrowgraduallythroughchildhood.Becauseofthisdevelopmentaltimetableandtheprolongeddependenceonothersforsurvival,theexperienceofrelationshipsmustsometimesbeasoverwhelminglyfrighteningtoinfantsasitistopatientswithBPD.

Thesymptomsthatemergeinthisdisordercausepatientstocreateproblematicandchaoticrelationshipsthatcanleadthemthroughalifetimeofabandonments.Itisevencommonfortherapiststoabandonthesepatientsbecauseoftheirintensecriticismandhostility.IfindthatconceptualizingBPDpatientsessentiallyasfrightenedchildrenhelpsmetaketheirattackslesspersonallyandmaintainatherapeuticstance.Isuspectthattheirprimitivefear,rage,andshameareaformofearlyimplicitmemoryactivatedbyrealorimaginedcriticismorabandonment.Whenthesememorynetworksaretriggeredduringtreatment,theyaresopowerfulthatthepatientisunabletomaintaincontactwithreality.WeseethesamephenomenainPTSDflashbacks,mostlikelystoredinthesameimplicitmemorysystems.ThisconfusedFreudbecausehebelievedeveryonewaseitherneuroticorpsychotic.BPDwasahorseofadifferentcolor.

ExaminingBPDinlightoftheneurosciencewehavereviewedinpreviouschapters,hereareafewoftheneurobiologicalprocessesthatmayexplainhowthesesymptomsbecomeencodedwithinneuralnetworks:

1. Amygdaloidmemorysystemsareprimedduringearlytraumaticattachmentexperiencestoreacttoanyindicationofabandonment.Asympatheticfight-or-flightreactionistriggered,andbaselinelevelsofstresshormonesareraised.

2. Orbitofrontalsystemsareinadequatelydevelopedduringattachmenttoengageinhealthyself-soothingandthesuccessfulinhibitionoftheamygdala.

3. Orbitofrontaldissociationmayresultindisconnectionbetweenright-andleft-hemisphereandtop-downprocessing,partlyaccountingforrapidanddramaticshiftsbetweenpositiveandnegativeappraisalsofrelationships.

4. Thenetworksofthesocialbrainareunabletointernalizeimagesfromearlyinteractionswithcaretakersthatcouldprovideself-soothingandaffectregulation.

5. Rapidfluctuationsbetweensympatheticandparasympatheticstatesresultinbaselineirritabilityandalowthresholdforsympatheticresponsestorealorimaginedabandonment.

6. Chronichighlevelsofstresshormonescompromisehippocampalfunctioning,decreasingthebrain’sabilitytocontrolamygdalafunctioningandexacerbatingemotionaldyscontrol.

7. Amygdaloiddyscontrolheightenstheimpactofearlymemoryonadultfunctioning,increasingthecontemporaryimpactofearlybondingfailures.

8. Hippocampalcompromisedecreasesrealitytestingandmemoryfunctioning,hinderingthemaintenanceofpositiveorsoothingmemoriesduringstatesofhigharousal.

9. Earlybondingfailuresleadtolowerlevelsofserotonin,resultingingreaterriskofdepression,irritability,anddecreasedpositivereinforcementfrominterpersonal

interactions.10. Self-harmduringdysregulatedstatesresultsinendorphinreleaseandasenseofcalm,

puttingtheseindividualsatriskforrepeatedself-abusivebehavior.

ThesearejustsomeofthefactorsthatmaybeinvolvedintheneurobiologyofBPD.Becausethisdiagnosishassofarbeenoutsidethepurviewofneurology,littlebrainresearchhasbeendonewithBPDpatients.However,neuropsychologicalfindingswiththesepatientsdosuggestdysfunctioninthefrontalandtemporallobes(Paris,Zelkowitz,Guzder,Joseph,&Feldman,1999;Swirsky-Sacchettietal.,1993).Executiveandmemoryfunctionswithinthesebrainnetworksdonotprovideadequateorganizationforthesepatients.Wehavelearnedthatthesefunctionsarebuiltandsculptedinthecontextofearlyrelationships;itmakessensethattheyareimpairedinBPDpatients.Thecentralconceptsinthetreatmentarestructureandlimitsetting,combinedwithflexibilityandpatience(justasitiswithraisingchildren).Thetherapistmustprovideanexternalscaffoldingwithinwhichtheclientcanrebuildthesebrainnetworksofmemory,self-organization,andaffectregulation.Onanotherlevel,thetherapistservesasanexternalneuralcircuittoaidintheintegrationofnetworksleftdisconnectedduringdevelopment.

NeuralNetworkIntegration

Thepatientdiscovershistrueselflittle-by-littlethroughexperiencinghisownfeelingsandneeds,becausetheanalystisabletoacceptandrespectthem.

—AliceMiller

Unresolvedtraumadisruptsintegratedneuralprocessing,sothatconsciousawarenessissplitfromemotionalandphysiologicalexperiences.Infact,dissociativesymptomsimmediatelyfollowingatraumaticeventarepredictiveofthelaterdevelopmentofPTSD(Koopmanetal.,1994;McFarlane&Yehuda,1996).Neurochemicalchangesandalackofintegrationofrightandlefthemispherefunctionsmayalsoimpedeinterpersonalbondingandbodilyregulation(Henry,Satz,&Saslow,1984).Childrenvictimizedbypsychological,physical,andsexualabusehavebeenshowntohaveasignificantlygreaterprobabilityofbrainwaveabnormalitiesintheleftfrontalandtemporalregions(Itoetal.,1993).Brainwavedyscoherencemayputindividualsathigherriskfordevelopingallformsofpsychiatricdisorders(Teicheretal.,1997).

Thebiochemicalchangesthatoccursecondarytotraumaenhanceprimitive(subcortical)stimulus–responsepairingofconditionedresponsesrelatedtosensation,emotion,andbehavior.Thesesamechangesunderminecorticalsystemsdedicatedtotheintegrationoflearningacrosssystemsofmemoryintoacoherentandconsciousnarrative(Siegel,1996).AsweunderstandmoreabouttheneurobiologicalprocessesunderlyingPTSD,wewillbetterlearnhowtotreatandpossiblypreventthisdebilitatingyetcurablementalillness.Therapiesofallkinds,especiallythosewithinthecognitiveschools,haveprovensuccessfulinthereintegrationofneuralprocessingsubsequenttotrauma.Systematicdesensitization,exposure,andresponsepreventioncanallenhancetheseintegrativeprocesses.

Summary

Thebrain’sreactiontotraumaprovidesuswithawindowtothefunctionsandeffectsofneuralnetworkdissociation.FromthephysiologicalsymptomsofadultPTSDtothecharacterologicaladaptationsof

long-termadjustmenttoearlytrauma,weseethebrain,body,andpsycheattemptingtosurviveinthefaceofoverwhelmingdysregulation.

Thearrayofadaptationstostressandtraumaareatthecoreoftheworkofthepsychotherapist.Thesafeemergencyofpsychotherapyactivatesdissociatedneuralnetworksandattemptstoreintegratethemintheserviceofdecreasedarousalandimprovedfunctioning.Fromthefirstmomentsoflife,stressshapesourbrainsinwaysthatleadustorememberexperiencesmostimportantforsurvival.

Weneedtoexpandournotionoftraumafromthefieldsofcombatandcatastrophiceventstothesmallandeverydayinteractionsonwhichwedependforoursurvival.Mostofourlearningisnottraumaticbutrathersubtle,nondramatic,andunconscious.Theinteractionsbetweenparentandchild,thepoliticsoftheschoolyard,andexperiencesofsmallvictoriesanddefeatsallcontributetoshapingwhowewillbecome.Weneedtoalwayskeepinmindthatasprimates,attachmentequalssurvivalandabandonmentequalsdeath.Thismayhelpusappreciatethepowerofparentalabuseandabandonmenttoshapechildrenfortherestoftheirlives.

Chapter15

TheSelfinExile:NarcissismandPathologicalCaretaking

Happinessishavingalarge,loving,caring,close-knitfamilyinanothercity.—GeorgeBurns

Eachofusisborntwice:firstfromourmother’sbodyoverafewhours,andthenagainfromourparents’psycheoveralifetime.Aswehaveseen,theorganizationofthesocialbrainisinitiallysculptedviaparent–childinteractions.Theseinteractionsshapetheinfrastructureofourmoment-to-momentexperienceofotherpeopleandoftheworld.Asthechild’sbraincontinuestoform,self-awarenessandself-identitygraduallycoalesce.Consciousnessandidentityarecomplexfunctionsconstructedfromthecontributionsofmultiple,primarilynonconscious,neuralnetworks.Pathologicalstateshighlightthefactthattheselfisafragileconstructionofthebrain.Furthermore,thereisconsiderableflexibilityinthelocation,experience,andorganizationoftheselfwithinourimagination.

Victimsofrapeandtorturefrequentlyreportout-of-bodyexperiencesduringtheirordeal.AyoungwomannamedJoannedescribedtome,ingreatdetail,howshestoodbehindaclosetdoor,watchingherselfbeingrapedfromacrosstheroomfromwhereitwasactuallyhappening.Anotherclient,Mark,whohadbeenbrutallyattackedwhilegettingintohiscarafterwork,toldmethathewatchedhimselffromacrossthestreetashewasrepeatedlystabbed.Theperceptionoftheselfisalsovulnerabletoalterationanddistortion.Anorecticclients,withtheirbonesprotrudingthroughtheirskinandtheirhealthinseriousjeopardy,insisttheylookfat.Patientswithmultiplepersonalitiesareperhapsthemostcomplexexampleoftheplasticityofself,becausetheygeneratemanydifferentsubpersonalitiesassociatedwithdifferentexperiencesandemotionalstates.

Narcissism,acommonformofselfdisturbance,isoftenrelatedtoareversalofthemirroringprocessduringchildhood.Narcissisticchildren’ssocialbrainsandsenseofselfarenotshapedbytheirownemergingemotionsandsensibilities;rather,theyaredeterminedbytheirparents’needfornurturance,attunement,andaffectregulation.WhatemergesinthenarcissistiswhatWinnicottcalledthefalseself,apseudo-adultembeddedinthenetworksofthelefthemisphereinterpreter,whichfiltersoutemotionalinputfromtherighthemisphereandthebody.Inthischapter,weexplorethereversalofthemirroringprocess,andtheadultconditionsofpathologicalcaretakingandcodependencythatemergefromtheseearlysuboptimalattachmentexperiences(Bacharetal.,2008).

SilentHammers

Icannotgiveyoutheformulaforsuccess,butIcangiveyoutheformulaforfailure—whichis…trytopleaseeverybody.

—HerbertSwope

Jerry,asuccessfulscreenwriter,cametotherapycomplainingofdepressionandexhaustion.Hislongworkhoursandlast-minutedeadlineskepthiminaconstantstateofstress.Hisminimalpersonallifecenteredonhisgirlfriend,Cara,whomhedescribedas“highmaintenance,”likeningtheirrelationshiptohavingasecondjob.JerryexperiencedhislifeasarelentlessstruggletopleaseCara,hisboss,andeveryoneheknew.Despitehisdepression,Jerryfeltguiltyaboutcomingtotherapy,andexpressedfearaboutwastingmytime;hefeltthathewasthehelper,nottheonewhoreceivedhelp.“Afterall,”hesaidtome,“youcouldbespendingyourtimeseeingsomeonewhoreallyneedsthehelp.”

Afterafewsessions,itbecamecleartomethatJerryhadspentthefirsthalfofhis39yearstakingcareofhisimmatureandself-centeredparents.Allofhissubsequentrelationshipsappearedtofallintoasimilarpattern.Althoughhedescribedhisromanticrelationshipsinpositiveterms,healsoreportedfeelingdeprivedofattentionandnurturance.Heseemedtobeattemptingtopleaseothersinordertogaintheloveandattentionhehadalwayslongedforfromhisparents.Hiseffortswouldinvariablyendinsadness,resentment,andwithdrawal.Althoughhewasexhaustedfromtryingsohardandfailingsocompletely,Jerrystillmaintainedthehopethathiseffortswouldsomedaypayoff.

WorkingwithJerrywasbothfascinatingandfrustrating.HequestionednearlyeverythingIsaid,revealinghisdistrustofanyone’sabilitytohelphim.Ontheotherhand,hisflairforthedramaticresultedinentertainingstoriesinalmosteverysession.Hehadanuncannyabilitytointuitmyinterests,andIwouldoftenlapseintobeingtheaudienceforhisone-manshow.IsoonrealizedthatJerryexperiencedmeasanotherpersontoentertainandtakecareofwhilehewaitedtoreceivecareinreturn.Atthesametime,heresistedmyeveryattempttohelphim.

Jerrywashesitanttodiscusshischildhood,sayingthatherememberedlittleofhislifebeforeheleftforcollege.Oursessionsconsistedprimarilyofstoriesofhisinteractionswithunappreciativeothersandhisattemptstoenlistmyunderstandingandsupportforhissideofthestory.Hewasbothcomfortedbymycompassionandannoyedwithmycontinuedsuggestionsthathepayattentiontohisinneremotionalworld,especiallywhenengagedwithothers.TheintensityofhisdefensesreflectedhisemotionalvulnerabilityandIneededtobecarefulnottomovetooquickly.Ontheotherhand,ifIwenttooslowly,hemightbecomeresentfulandterminatetherapy,ashehadendedsomanyotherrelationships.

Atsomepoint,Isuggestedthathewriteascreenplayabouthimself.JerryagreedandsooncreatedastoryaboutalittlemannamedHalwhosatatacontrolpanelinhishead.Halwasasortofship’scaptainatthehelmoftheU.S.S.Jerry.WhenJerrywasalone,HalwouldmonitorthepeopleinJerry’slife.AwallfullofTVscreenskepttrackofwheretheywere,whattheyweredoing,andwhethertheywerethinkingofJerry.Whenhewouldcomeintocontactwithanothership,likehisgirlfriendCara,HalwouldselectaholographicimageofJerryspecificallyforthatperson.HalhadascreentomonitorJerryfromtheperspectiveoftheothership,tomakesurethatthehologramhadthedesiredeffect.Hal’spurposewasbestdescribedbytheshowbusinessadage:“Givethepeoplewhattheywant.”

IwasimpressedbytheclarityofthestoryofHal.Jerrywastellingmethathissenseofselfwasorganizedaroundhistheoryofthemindsofothers.NothingaboutHalfocusedonJerry’sownthoughts,feelings,orneeds.Jerryonlyknewheneededtounderstandtheneedsofothers;forhim,thiswaslove;thiswaslife.IrealizedHalreflectedtheearlysculptingofJerry’ssocialbrainandhowhesurvivedchildhood.ThestoryofHalwasareflectionofimplicitmemory,symbolicallyrepresentingthecoreemotionaldramafromhisearlylife.Despitetheobviousnatureofthisstory,Jerryrefusedtoentertaininterpretations.Heseemedtohavegreatdifficultyexperiencingtheworldfromhisownpointofview.InJerry’sconsciousexperience,hewasHal.

Afewsessionslater,Jerryusedanothermetaphortoillustratehisinnerworld.Hedescribedhimselfasahouseonamoviesetwithaperfectlydetailedfacadebutnofinishedinterior;therewasnotrueplace

tolive.Ifyoulookedbehindthefacadetherewereonlyexposed2×4sandbarefloors.Hesaid,“Agooddirectorknowshowtoplacehiscamerastomaintaintheillusionofarealbuilding.”Inamomentofreceptivityandtrust,hetoldmethathisgoalfortherapywastofinishbuildinganddecoratingtheinteriorspacesohecouldstopworryingaboutcameraangles.Jerrywastiredoffeelinglikeafraudinaworldofrealpeople.Icouldfeelhisinnerworldshiftingashisemptinesssurfacedintoconsciousness.

ItoldJerry,“Aswegrow,thestoryofwhoweareiswrittenincollaborationwiththosearoundus,especiallyourparents.Theywatchus,listentous,andtrytohelpusputintowordswhatwestruggletoexpress.Thishelpsustowriteourstory.Whenparentsdidn’tgetthishelpaschildren,oraresufferingwithsomeproblem,theymaylooktotheirchildrentohelpthemfindthemselves.”

IthinkthisiswhatmayhavehappenedwithJerry’sparents.Helearnedtobesensitivetothemandattendtotheirneedswhentheyshouldhavebeenhelpinghimwritehisstory.Inasense,Jerry’sstorywaswrittenbydefault;inservingothershewashopingtofindhimself,andafteralltheseyearshewasstillsearching.IsuggestedtoJerrythathischoiceofawritingcareermayhavebeenanexpressionofhisdesiretowritehisstory.Althoughtherearemanygoodandhonorableaspectstoservingothers,Itoldhimthatitmaybemoreimportanttowriteanewstorywherehisownneedswouldbebalancedwiththeneedsofothers.

Jerryasked,“Isthiswhy,whenpeopleaskmehowIam,thefirstthingIthinkaboutishowothersinmylifefeel?”InoddedasIwatchedthemusclesinhisfacerelax.Anewunderstandingofafamiliarbehaviorwasemerging,andhisinnerworldwasbeingreorganized.Afteraperiodofsilence,hesaidsoftly,“Ievendoitwithyou,don’tI?Ipayyoutotakecareofme,butIendupentertainingyouandprotectingyoufrommyneedsandnegativefeelings.”Thesessionwasoverandhewalkedsilentlyoutoftheoffice.Iwonderedifhewouldbeabletowithstandthestressoftheseinsightsenoughtoreturnforournextsession.

Hedidcomeback,anduncharacteristicallytouchedmyshoulderashepassedmeonthewaytohisseat.“You’regonnathinkyou’reprettysmartwhenItellyouthisone.”Inoticedhisvoicehadchanged:Itwasnolongerthevoiceofanentertainer.Jerrywassharingthisexperiencefromadifferentplacewithinhimself.OnthepreviousFriday,hehadgoneoutwithCaraandtheydidn’tgetbacktoherapartmentuntil3:00A.M.Thecombinationofalcoholandexhaustionmadehimfallasleepassoonashisheadhitthepillow.Afterwhatseemedlikeonlyafewminutes,hewasjarredawakebythebangingofhammersoutsidethebedroomwindow.Hepickeduphisthrobbingheadandsawontheclockthatitwasnoteven7:00inthemorning.Jerrysaid,“Ifeltlikemyheadwasgoingtoexplode!”

Jerry’sfacebecameincreasinglytenseashedescribedthemurderousfantasiespassingthroughhismind.Heimaginedgoingoutsideandpunchingouttheentireteamofconstructionworkers.Justashewasabouttojumpupandrunoutside,Caralookedupathimwithanexpressionofexhaustedrageandsaid,“I’mgoingtogooutthereandkillthoseguys.”Apparently,theyhadbeenwakingherupthatwayformostoftheweek.

Fallingbackonthecouchinmyofficeandlettingoutasigh,Jerrybegantodescribehowherwordstriggeredsomethingaltogetherfamiliarwithinhim.“WhenIheardCara’sangerIbecameadifferentperson.Myexhaustionvanished.Ifeltenergizedandalive!Icompletelyforgotabouttheconstructionworkers.MytotalfocusinstantaneouslyshiftedtomakingCarafeelbetter.”Hedescribedjumpingupasifwell-restedandsaid,“Alittlebreakfastwillmakeyoufeelbetter.”HebecameoblivioustothesoundofthehammersandboundedintothekitchenasCarapulledthepillowsbackoverherhead.

Tenminuteslater,Jerrywasatthestovebrewingcoffee,fryingeggs,andabouttocallout“Breakfastisserved,”whenheagainnoticedthehammers.Hesaid,“IwasamazedthatIhadn’theardthemsinceIhadgottenoutofbed.”Herealizedthattheyhadn’tstopped,butfromthemomenthesawtheangeronCara’sface,hebecamecompletelyinvolvedinactivitiestocopewithherfeelings,utterlyignoringhisown.HerealizedthatattendingtoCara’sdistresscatapultedhimoutofhisown.

Ashestood,spatulainhand,thesefeelingstriggeredalong-forgottenmemory.Herememberedcominghomefromschooltofindhismothercrying,headdowninherarmsonthekitchentable.Jerryrememberedhisterrorashewentoverandstoodbesideher.Shedidn’trespondwhenheaskedherwhatwaswrong;shejustcontinuedsobbing.Hedidn’tknowwhattodoorwhotocall.Hisfatherhadleftthemmonthsbefore,andhismotherhadgrownmoresilentandwithdrawnwitheachpassingweek.Hestoodmotionless,notknowingifshewasevenawareofhispresence.

Hetriedtoengageherinconversation,tellingherabouthisdayatschool.Heeventoldsomeinappropriatejokesinthehopeofgettingherangryenoughtochaseafterhim.Sheremainedsilent,crushedbytheweightofhersadness.Jerryrecalledgrowingincreasinglydesperateandafraidastimepassed.Hestoodmotionlessastheafternoonlightturnedtodusk.Heeventuallycameupwiththeideatocookforherandwentovertothestovetofryhersomeeggs,theonlythingheknewhowtomake.Aftercollectingwhatheneeded,hepulledachairovertothestove,stoodonit,andstartedtocook.Thisseemedtogetherattention.Shecameoverandtheycookedtogetherinsilence.

Duringourfirstfewsessions,Jerryhadmentionedhisparents’divorce,hisfather’sdrinking,andhismother’sdepression.Hecharacterizedhishomeas“avaultofsilence”withverylittleinteractionorsharedactivities.Thefamilytooknomealsorvacationstogether;mostoftheirenergywasusedupinday-to-daysurvival.Hespokeofthesethingsinpassing,withlittleemotionandaninsistencethathischildhoodhadnoconnectiontohisadultdifficulties.Hesaidhehadcopedwithhisfamilysituationbyburyinghimselfinbooksandwritingstories.ThismemoryprovidedevidenceforwhatIhadsuspected;Jerryhadgrownupwithtoomuchstressandtoolittleparenting.Hehadlosthimselfineveryoneelse’sstoriesbuthadnotreceivedtheemotionalsupportandmirroringheneededtowritehisown.

Jerrycameawayfromtheexperienceofthehammersandthememoriestheytriggeredwithanewperspective.Hecouldsee,fromthisandotherchildhoodmemoriesthatbegantoemerge,howhewasconstantlyfrightenedbytheemotionalinstabilityanddistanceofhisparents.Itwasalsoclearthathe,likeHal,wasconstantlymonitoringthefeelingsandneedsofothers.Ifounditespeciallyfascinatinghowhisownanger,frustration,andexhaustiondisappearedinthefaceofCara’snegativefeelings.Helatertoldmethathefiguredthiswaswhyhefeltsouncomfortableandvulnerablewhenhewasn’tinarelationship.Neverhavinglearnedhowtoregulatehisownfeelings,itwassafertostayinthemindsofothers.

ThepoweroftheseinsightswasunsettlingforJerry,andittookhimmanyweekstogetbackontrack.Asheregainedhisequilibrium,webegantoapplythisnewknowledgetomoreaspectsofhislife.Thinkingbackonhisromanticpartners,herealizedthattheywereneverasgoodatanticipatingorattendingtohisneedsashewastotheirs.Thisimbalanceledhimtofeelunlovedanduncaredfor.Atonepoint,hestoodupabruptlyandshouted,“IblamedthemfornotbeingassickasIam.”Jerrycametounderstandthatfeelinglikeanemptyshellwasconnectedtonotknowinghisownfeelings.Hesaid,“MyfeelingswereneverimportantwhenIwasakid.It’smyfeelingsthataregoingtofurnishthoseemptyroomsinsideofmeandIhavetohavemyownfeelingstobewhole.”

TheseexperienceswereaturningpointinJerry’streatment.WecreatedacommonlanguageandusedittoexploreJerry’sinnerworld.HalgraduallyreplacedsomeoftheoldmonitorswithnewonesdesignedtotrackJerry’sownfeelings.Eventually,Halandhismonitorsbecameunnecessary.Attimes,Jerryfearedhewasbeingtooselfishbyconsideringhisownneeds.Hedidlosesomefriendswhoreliedonhisconstantandunilateralattention.CaraandJerrygrewcloser,however,andsheadmittedthatshelikedJerrybetterwhenhedidn’ttrytomakeherhappyallthetime.Jerryslowlyrecoveredfromhispathologicalcaretakingandgraduatedtobecomeacaringperson.

Jerry’sdifficultieshighlightanumberofprinciplesrelatedtothedevelopmentandorganizationofthebrainthatweexaminedinpreviouschapters.Duringchildhood,Jerry’sbrainadaptedtoademandingandnonnurturingemotionalenvironment.Fromearlyinlife,hissurvivaldependedonbeinghighlyawareofthefeelingsandneedsofhisparents.Theneuralsystemsofhissocialbrainbecamehypersensitiveto

hisparents’facialexpressions,bodylanguage,andbehaviors.ThishypersensitivityhelpedJerrymonitorhisparents’emotionsandbehaveinwaysthatregulatedtheirfeelingsandbondedthemtohim.Systemsnormallyusedtohelpchildrencometoexperiencethemselveswereusurpedtomonitorotherpeopleinhislife.ThiswashowHalwasborn.Jerry’smirroringskillscontinuedtobeutilizedinadulthoodwithhisfriends,employers,andtherapistthroughemotionalcaretakingandentertainingstories.

BecauseJerrydidn’thavehelpprocessingandintegratinghisownemotionsduringchildhood,theyremainedchaotic,frightening,andoverwhelminglongintohisadultyears.Caretakingwasreinforcednotonlybythoseheattracted,butbytheavoidanceofhisowndisorganizedemotionsbyattendingtothefeelingsofothers.Caretakingevolvedintoaformofaffectregulation,aswellasawayofconnectingtoothersviaafalseself(Hal).ThiswasdemonstratedbytheinstantaneousinhibitionofhisfeelingsofangerattheconstructionworkerswhenherealizedCarawasawakeandupset.Fromearlyindevelopment,hiddenlayersofneuralprocessingorganizedtheinhibitionofhisownfeelingsanddirectedhissocialbraintofocusontheinternalstateofothers.ThisneuralnetworkorganizationwasinplacepriortoJerry’sdevelopmentofself-consciousawareness,makingthiswayofexperiencingtheworldcompletelyunconsciousandanaprioriassumptioninhislife.

Jerry’sevolvingsenseofselfwasshapedviatheseprocesses,throughtheeyes,minds,andheartsofothers.Left-hemisphereprocessingnetworks,whichinhibitaffectandparticipateinthecreationofstoriesabouttheself,allowedJerrytobecomeafunctionaladultwithasuccessfulwritingcareer.Hisabilitytodescribehimselfsymbolically,firstasamonitoringrobotandthenasadirectorplanningcameraangles,reflectedhissubconsciousawarenessofhisself-organization.Withoutassistanceinconnectingtheseinsightstotheorganizationofhisconsciousself,theyremainedcorrectbutuselessbitsofinformationcontainedwithindissociatedneuralnetworks.

Interpretations—suchastheoneJerrymadeconnectinghiscookingeggsforCaraandtakingcareofhismother—triggeredemotionsofsadnessandloss.Makinghisdefensesconsciousappearedtoactivatetheemotionalnetworksthatthedefenseshadbeeninhibiting.Thehigherassociationareasinvolvedintheorganizationofconsciousawarenessappearcapableoftheplasticityrequiredforqualitativechangesofexperience.Implicitmemoriesofearlychildhood—storedwithinnetworksofthesocialbrain—wereexperiencedemotionallyandexpressedinavarietyofwaysincludingJerry’sdistrustoftheabilityofotherstohelphim.Thesewereechoesofhisdisappointmentinhisparents’inabilitytoassisthimwhenhewasyoung.

Jerry’sinsecureattachmentresultedinacomplexarrayofemotionalandbehavioraladaptations.Hislackofconsciousrecallformuchofhischildhoodwasoneexample.Anotherwashisunconsciousexpectationthattheexpressionofhisneedswouldbemetbymoreemotionalpain.AllofJerry’sstruggletoattainloveandcaringreflectedhisbrain’sadaptationtoachildhoodfullofimpingementsandtheabsenceofanintegratedandintegratingother.Jerry’sparentsdidnotassisthimincreatinganarrativeidentitygroundedinhisownexperience.Intherapy,IhelpedJerryapplyhisconsiderablecreativeskillstowritehisownstory.

InterpretationsandNeuralPlasticity

There’saworldofdifferencebetweentruthandfacts.Factscanobscurethetruth.—MayaAngelou

Youmayrememberthatinterpretationsaresometimesreferredtoasthetherapist’sscalpel.Inmakinganinterpretation,thetherapistpointsoutanunconsciousaspectofthepatient’sexperience,suchasadefense

heorsheisusingtoavoidnegativefeelings.Foraclientwhoemployshumortoavoidfeelingsofabandonmentafteradivorce,itmightentailremindinghimthatheisexperiencingmanysymptomsofdepressionorthathiseyesaremoist.Foranotherwhoisenragedataminorslightbyacoworker,aninterpretationmightconsistofconnectingherpresentfeelingstoemotionalmemoriesofabusefromapreviousrelationship.Inbothoftheseinstances,thetherapistaddresseswhatappearstobeadisconnectionamongdifferenttracksofcognitive,emotional,sensory,andbehavioralprocessing.

Whenaninterpretationisaccurateanddeliveredinanappropriateandwell-timedmanner,anumberofthingsoccur.Theclientgenerallybecomesquiet;theremaybeachangeinfacialexpressions,posture,andtoneofvoice.Veryoftentheclientwillbegintofullyexperiencetheemotionsagainstwhichheorshewasdefending.Thereisashiftfromfluentreflexivelanguagetospeakinginaslowerandmoreself-reflectivemanner.Someclientsreportbecomingconfusedordisoriented,whereasothersdescribephysiologicalsymptomsofpanicorgrief.Borderlineclientscandemonstrateextremereactionstointerpretations,includinglosingemotionalcontrolandfunctionaldecompensation.Theymaybecomeextremelyemotional,boltfromtheconsultingroom,andengageinself-injuriousbehavior.Patientsliketheseappearunabletocopewiththeemotionsreleasedwhentheirdefensesaremadeconscious.

Whatmightbehappeninginthebrainduringandafteranaccurateandwell-timedinterpretation?Eachinterpretationthathitshomeislikethedeathofasmallaspectofthefalseself.Mysuspicionisthatitbeginswithseeingpasttheproductsofthelefthemisphereinterpreter,whichdisinhibitstheactivationofsubcorticalcircuitscontainingnegativememories.Intheprocessofworkingthroughthesenewfeelings,theclientgraduallyregainsemotionalequilibrium,allowingforplasticityandnewlearninginprefrontalregions.Theconcurrentavailabilityofnegativesubcorticalmemoriesandtheenhancedabilityofthecortextocreatenewconnectionsallowsneuralnetworkscontainingvariouscomponentsofaparticularmemorytobecomeintegrated.Likebreakingandresettingabonethathashealedbadly,memoriesbecomeunstableandcanbereformedinamorepositiveway.Thisprocessallowspainfulimplicitmemoriestobeaccessedbycorticalnetworksforcontextualizationintimeandspace,andtoberegulatedandinhibitedwherenolongernecessary.

Bringingadefensetoconsciousnessactivatesboththecorticalnetworksthatorganizethedefenseandthesubcorticalnetworksthatcontainthenegativememoriesandassociatedaffect.Thisdisinhibitionresultsintheemotionalandphysiologicalarousalseenintherapyastheamygdalabecomesreactivatedandalertsthebodytotheolddanger.Thismayalsobethemechanismforregressionthroughthereactivationofoldsensory-motor-affectivememoriesstoredinnormallyinhibitedamygdaloidsystems.Thereismostlikelyashiftinhemisphericbiasfromlefttoright,correlatedwiththebreakthroughofnegativeemotions.Thisleft-to-rightshiftmayaccountforthecessationofreflexivesociallanguageofthelefthemisphereinterpreterandashifttogreaterself-awareness.

Interpretationsneedtoundergoaprocesscalledworkingthrough,meaningtheyneedtobestated,restated,andappliedtomultiplesituationsandcircumstances(paralleltorelapsepreventionincognitivetherapies).Thisprocessservestoconnectnewlearningtomultiplememorynetworks,andmayneedtoreachacertaincriticalmassofconnectionsthroughoutthebraintobecomereflexive.Workingthroughreflectstheexpansionandstabilizationofnewassociativematricesofmemory.Itisalsoreflectedintheconstructionofanewnarrativecontainingalteredaspectsofbehaviors,feelings,andself-identitythatserveasawaytoretainandreinforcenewlearning.

PathologicalCaretaking

Bythetimeamanis35,heknowsthattheimagesoftherightman,thetoughman,thetruemanwhichhereceivedinhighschooldonotworkinlife.

—RobertBly

Jerry’spathologicalcaretakingisonepossibleexpressionofadisturbanceofselfreferredtoasnarcissism.Narcissismischaracterizedbyatwo-sidedexistence:onereflectinganinflatedsenseofself-importance,theothermiredinemptinessanddespair.Theoriginofthisformationoftheselfoccurswhenachildlookingforloveandattunementinsteaddiscoversthemother’sownpredicament(Miller,1981).Thechild,robbedofthepossibilityofself-discovery,compensatesbycaringfortheparentunderarealorimaginedthreatofabandonment.

Brightandsensitivechildrenattunetoandregulatetheparents’emotionsandcometoreflectwhattheparentswantfromthem.Thesechildrenwillusuallyappearmaturebeyondtheiryearsandfindcomfortintheirabilitytoregulatethefeelingsofthepeoplearoundthem.Becauseoftheirpowertoregulatetheaffectofoneorbothparents,thesechildrenarefilledwithasenseofinflatedself-importance.MillerandWinnicottcallpathologicalcaretakingaparticularmanifestationofthefalseself,describedbyJerryasbothatheatricalfacadeandaninnerrobotmonitoringothers.

Theothersideofnarcissismreflectsaspectsofthechild’semotionalworldthathavefoundnomirroring.Thistrueself,orthepartthatisuniquetotheindividualandsearchingforexpression,isleftundevelopedandeventuallyforgotten.Thisemotionalcore(orinnerchild)secretlyandsilentlyawaitsparentingineachnewrelationshipwhiledutifullytakingcareoftheother.Thisaspectoftheemotionalselfistheemptiness,loss,andshameofbeingabandoned,andhowsurvivalwascontingentontakingcareofothers.Thisisthesourceofdepression,thesenseofbeingafraud,andlackofanemotionalconnectionwithlife.

Thedevelopmentofthesocialbrain(andthesubsequentformationofthesenseofself)becomesdedicatedtothepredictionof,andattunementto,themoodsandneedsoftheparentandothers.Thisabilityservestowardoffabandonmentanxietywhiletruncatingthedevelopmentofanunderstanding,expression,andregulationofone’sownfeelings.Suchchildrengrowintoself-awarenessexperiencingothers’emotionsastheirown,andanoverwhelmingsenseofresponsibility,orevencompulsion,toregulatetheemotionsofthosearoundthem.InJerry’scase,cookingbreakfastfortheupsetwomeninhislifehelpedhimavoidhisownpoorlyunderstoodanddysregulatedemotionalworld.

Thus,caretakingofothersservesasasubstituteforself-soothingabilitiesandinneremotionalorganization.Pathologicalcaretakerscometotherapyprimarilybecausetheyaredepressedandexhaustedbytheirinabilitytocreateaboundarybetweenthemselvesandtheneedsofothers.Althoughbeingwithothersishardwork,beingaloneisevenmoredifficultwhentheyarenotexhausted,becausetheyneedtoregulateotherstoavoidtheirinternalworld.Forthesepeople,abatteringorabusiverelationshipisfarlessfrighteningthansolitude.Caretakersaredifficultclientsbecausetheyhavelearnedduringearlyattachmentrelationshipsthathelpisnotforthcomingwhentheyareindistress.LikeJerry,theyhavecometobelievethatitisbesttoputtheirinnerneedsoutofmindandkeep“givingthepeoplewhattheywant.”

AliceMiller:ArchaeologistofChildhoodExperience

Iwasnotouttopaintbeautifulpictures….Iwantedonlytohelpthetruthburstforth.—AliceMiller

ThecentralimportanceofparentalrelationshipsinshapingthesocialbrainisnowherebetterarticulatedthaninaseriesofelegantlysimpleworksbytheViennesepsychotherapistAliceMiller.Herworkwithwhatshecalledgiftedchildrentargetedadults,likeJerry,whowereraisedbyparentswhoseemotional

needsweregreaterthantheirabilitytoattunetotheirchildren.Takingastandagainstheranalyticcolleagues,Millerreshapedthetherapeuticroleintooneofbeinganadvocateforthechildwithinheradultpatients.Reachingbackthroughtheyearstoreconnectwithlong-forgottenchildhoodexperiences,shereinterpretedmuchofherclients’adultbehaviorsasareflectionoftheiradaptationalhistories.Inobservingthenonverbalreenactmentofimplicitmemory,Millerformedhypothesesconcerningwhatherclientshadbeenexposedto,howtheiryoungbrainshadadapted,andwhatitwouldtaketounearththeabandonedtrueself.

Miller’sarchaeologicalviewofmemoryincludedtheawarenessthatmemoryfromdifferentdevelopmentalstagesreflectsdifferentmodesofprocessingandunderstanding.Inherroleasadvocate,shesawtherapyasaprocessinwhichtherapistshelpclientsunearththeirhistory,notfromthepointofviewoftheadultbutfromthatofthechild.Memoriesintheseimplicitsubcorticalnetworksdonotchangewithtime,butremainintheirinitialformastheywereexperiencedataveryyoungage.Millerformulatedthisviewfromclinicalexperienceratherthanaknowledgeofthemultiplesystemsofexplicitandimplicitmemory.

Millerusedthetermdoubleamnesiatodescribetheprocessbywhichthesechildrenhavehadtofirstforgetcertainpartsofthemselves(e.g.,feelings,thoughts,andfantasies)thatcouldnotbeacceptedortoleratedintheirfamily.Thesecondlayerofforgettingistoforgetthatthesefeelingshavebeenforgotten.Thesetwolayersofforgettingensuredthatsuchchildrenwouldnotslipbackintowantingwhatcouldnotbehad.Givenourknowledgeofthemultiplesystemsofmemoryandtheirdissociability,Miller’sdoubleamnesiaismostlikelygroundedinboththedisconnectionbetweensystemsofimplicitandexplicitmemory,andconstructingaself-narrativethatexcludesreferencetopersonalneeds.

Thelackofassistanceintheconstructionofaself-narrative,combinedwiththeheightenedanxietyandvigilancenecessaryforsurvivalwithnarcissisticcaretakers,leadstoadeficitintheconsolidationofautobiographicalmemory.Thememoriesarenotrepressed;rather,theyareunorganizedbyhippocampalcorticalsystemsthatwouldallowthemtobeaccessibletoconsciousconsideration.Inthislight,Miller’sworkisareconstructionofthepast,basedonavailableconsciousmemoryincombinationwithnonverbalexpressionsfromimplicitsystemsofmemory.Suchpatients’presentexperiencesareexaminedforemotionaltruths,thentracedbackthroughahypothesizedtrajectory.Thepatients’considerableempathicabilitycanbeutilizedtotheiradvantagebyaskinghowtheythinksomeotherchildmightfeelinasituationsimilartotheirown.Thismethod,usedanumberoftimes,isoftensuccessful.

ForMiller,giftedchildrenareexquisitelysensitivetothecuesofparentsandhavetheinnateabilitytomoldthemselvestotheirparents’consciousandunconsciousmessages.Thesearethechildrenwhooftencometobecalledcodependentandareoverrepresentedintheserviceprofessionssuchasdoctors,nurses,socialworkers,andtherapists.Inessence,theirjobsareanattempttoparlaytheirdefensesintoacareer.Jerry—withhissensitivity,intellect,andwit—fitwellinthiscategory.

AlthoughthegiftedchildrendescribedbyMillermaybequitefunctional,theyoftenfeelemptyanddevoidofvitality.Becausetheirvitalityandtrueselfarenotacceptable,theseareinhibitedandbanishedfromawareness.Thiscreatesavulnerability,notonlytodisturbancesinpersonalitybutalsototheunconscioustransmissionof“mirrorreversal”tothenextgeneration.Parentswhohavenotbeenadequatelyparentedthemselvescanlooktotheirchildrenforthenurturanceandcaretheywereunabletoreceiveyearsbefore.Millerstated,“Whatthesemothershadoncefailedtofindintheirownmotherstheywereabletofindintheirchildren,someoneattheirdisposalwhocanbeusedasanecho,whocanbecontrolled,iscompletelycenteredonthem,willneverdesertthem,andoffersfullattentionandadmiration”(1981,Chapter3).

Children’sinstincttobondwiththeirparentsdrivesthemtodosoregardlessofthetermsandconditions.Whensuchchildrenlookintotheirmother’seyesandfindnoreflectionbut,rather,“themother’sownpredicament,”theywillmoldthemselves(ifable)totheirmother’spsychicneeds.

Compulsivecompliance—initiallyadaptiveinresponsetonarcissisticorabusivecaretakers—becomesmaladaptiveinrelationshipswithothers,andinthedevelopmentoftheself(Crittenden&DiLalla,1988).Laterinlife,thegiftedchild’slackofrebellionbecomestheproblem.Unabletoattendtotheirownemotionalmemories,andthusunabletoconstructthestoryoftheirlives,thesechildrenconstantlysearchforsomeonewhoneedsnurturance.

Becauseheorshewascompletelyhelplessinchildhoodtoresistthecoercionoftheparents’unconscious,Millerfeltthatthechildwithintheadultpatientalwaysneedsanadvocate.Ourbrainsaredesignedtoadapttotheenvironmentalcontingenciespresentedtous.Rememberthatthechild’sfirstrealityistheparents’unconscious,transferredviaright-hemisphere-to-right-hemisphereattunementwellbeforeself-awarenessandself-identity.Becauseitisimplantedinearlyimplicitmemory,itisneverexperiencedasanythingotherthantheself.Millerwasquicktodescribethetragedyfortheparentswhomaybewellawareofthepainfromtheirownchildhoodandmayhavevowedtonevermaketheirchildrenfeelastheydid.Theintergenerationaltransmissioncontinuesbecauseitisreflexiveandunconscious,andbecauseeachgeneration,atsomelevel,protectstheimageoftheparentsandguardsagainstthepainoftheirownunfulfilledemotionalneeds.

Althoughpatientsdonotgenerallyhaveexplicitmemoryforearlyrelationshipswiththeirparents,Millerpositsthattheselearningexperiencesareimplicitlyrecordedinhowthepatientsthinkofandtreatthemselves.Thestrictnessandnegativityinthepatients’self-imageandsuperegowillexposetheirparents’negativeorindifferentattitudestowardthemyearsbefore(Miller,1983).Theseimplicitemotionalandbehavioralmemories—intheformofattitudes,anxieties,andself-statements—contributetothecontinuedrepressionofrealemotionsandneeds.

Becausechildrenequatepunishmentwithguilt,abuseandneglectcreateasenseofinnatebadness.AteachertoldDr.MillerthatafterseeingafilmabouttheHolocaust,severalchildreninherclasssaid,“ButtheJewsmusthavebeenguiltyortheywouldn’thavebeenpunishedlikethat”(Miller,1983,Chapter9).Thisassumptionofguiltonthepartofchildrenbothprotectstheparentandservesasthedevelopmentalcoreofanegativeself-image.Becausethisself-imageisorganizedandstoredbyimplicitsystemsofaffectivememory,thechild’slater-developingidentityformsaroundthisapriorinegativecore.Caretakingandcompulsiveperfectionismreflecttheongoingattempttocompensateforthecertaintyofunworthinessandanticipationofabandonment.

RenéMagritteandHisMother

Wemustnotfeardaylightjustbecauseitalmostalwaysilluminatesamiserableworld.—RenéMagritte

AchillingexampleofthereversalofthemirroringprocessisdemonstratedinapaintingbythesurrealistRenéMagritte,titledTheSpiritofGeometry(seeFigure15.1).Itdepictsamotherholdingachildbutwithastartlingtwist:Theirheadsandfaceshavebeenexchanged.Magrittewastheeldestofthreeboysinamiddle-classhouseholdinturn-of-the-centuryBelgium.Hismothersufferedfromdepressionthroughouthischildhood,andmademultiplesuicideattempts.Shewas,infact,lockedinherroomeachnightforherownprotection.Asayoungboy,Renéwaslockedinwithhertokeephercompany.OnecoldFebruarymorning,shemanagedtoslipoutofherroomanddrownedintheSambreriver.Renéwasobviouslynotsuccessfulinmakinghismother’slifeworthliving.

Basedonhisadultlife,itisfairtoassumethatRenéwasabrightandsensitivechild,andthathesufferedfromalackofpositivematernalattentionformostorallofhischildhood.Tolosehismotherto

suicideattheageof14servedasanadditionalblowtohissenseofsafetyasachild.ThispaintingsuggeststhattheyoungMagrittelookedintohismother’seyesandfoundfatigue,depression,andemptiness.Inhereyesheread,“Youbethemommy,I’llbethebaby,”andhecomplied.

Inretrospect,abiographersuggestedthatMagrittehimselfseemedatpeaceonlywhenhewas“tormentedbyproblems”(Gablik,1985).MuchofthebodyofMagritte’ssurrealistworkpresentsuswiththemessagethattheworldisnotwhatitappearstobe.Hisrespectablemiddle-classfamilyhadadarkandpainfulsecretatitscore,onethatbecameacentralaspectoftheyoungboy’sexperience.Althoughasanadult,Magritterepeatedlystatedthathisearlyexperienceshadnobearingonhisartisticwork,itisdifficulttoimaginethattheloss,betrayal,andabandonmentofhischildhooddidnotreverberateinhismanyworks,warningusnottobefooledbytheassumptionsonwhichwedepend.

Summary

Theseparationbetweenthetrueandfalseselvesreflectsthebrain’sabilitytodevelopdissociatedtracksofexperience.Earlytraumaandstressinnonhealingenvironmentscanevenresultintheformationofmultipleseparatepersonalities,nowreferredtoasdissociativeidentitydisorder(DID).Itislogicaltoassumethatthesedifferentexperientialstatesareencodedwithindifferentpatternsofneuralnetworkactivation.Theexistenceofpathologicalcaretaking,DID,andotherdisordersoftheselfdemonstrateitsfragilityanditsinclinationtoadapttowhateversocialrealitiesarepresentedtoit.

Thepurposeofboththebrainandtheselfissurvival.Foreachofus,theorganizationofourownself—includingourpersonality,defenses,copingstyles,andthelike—reflectstheconditionstowhichwehavehadtoadapt.Putanotherway,allaspectsoftheselfareformsofimplicitmemorystoredinneuralnetworksthatorganizeemotion,sensation,andbehavior.Thesenetworksaresculptedinreactiontorealorimaginedthreatsasthebrainstrivestopredictandcontrolitsphysicalandsocialenvironments.

PartVI.

TheReorganizationofExperience

Chapter16

TheEvolutionaryNecessityofPsychotherapy

Theuseless,theodd,thepeculiar,theincongruous—arethesignsofhistory.—S.J.Gould

Thehumanbrainisanamazingorgan,capableofcontinualgrowthandlifelongadaptationtoanever-changingarrayofchallenges.Ourunderstandingofhowthebrainaccomplishesthismandateincreaseswitheachnewtheoreticaldevelopmentandtechnologicaladvance.Atthesametime,weareuncoveringsomeofnaturalselection’smoreproblematicchoices.Ifnecessityisthemotherofinvention,thenevolutionitselfhascreatedthenecessityforpsychotherapybyshapingabrainthatisvulnerabletoawidearrayofdifficulties.

Overthelastcentury,psychotherapistshavedemonstratedthatmanyofthebrain’sshortcomingscanbecounterbalancedbytheapplicationofskillfullyappliedtechniquesinthecontextofacaringrelationship.Thus,inourabilitytolink,attune,andregulateeachother’sbrains,evolutionhasalsoprovidedusawaytohealoneanother.Becauseweknowthatrelationshipsarecapableofbuildingandrebuildingneuralstructures,psychotherapycannowbeunderstoodasaneurobiologicalintervention,withadeepculturalhistory.Inpsychotherapy,wearetappingthesameprinciplesandprocessesavailableineveryrelationshiptoconnecttoandhealanotherbrain.

Inthischapterwefocusonthefollowingeightproblematicaspectsofbrainfunctioningthatcausemanypeopletocometopsychotherapy:

1. Thesuppressionoflanguageandpredictivecapacityunderstress2. Divergenthemisphericprocessing3. Thebiastowardearlylearning4. Thetenacityoffear5. Thedamagingeffectsofstresshormones6. Thespeedandamountofunconsciousprocessing7. Theprimacyofprojection8. Unconsciousself-deception

Thiswillserveassomewhatofareviewinthatitdrawsonmanyoftheneuroscientificfindingspreviouslydiscussed.WewillthenapplysomeoftheseprinciplestoacaseofPTSD.

TheSuppressionofLanguageandPredictiveCapacityUnderStress

Whenaman’sknowledgeisnotinorder,themoreofithehasthegreaterwillbehisconfusion.

—HerbertSpencer

Whenanimalshearastrangeandpotentiallythreateningsound,theyfreezeintheirtracks,becomesilent,andscantheenvironmentfordanger.Thelogicbehindthisprimitivereflexisquiteclear—beingstillandsilentmakeuslesslikelytobeseenorheardaswepreparetorespondtoapotentialthreat.Researchsuggeststhatduringthesestatesofhigharousal,Broca’sarea,responsibleforspeechproduction,becomesinhibited.

Whilethisresponsemaybeapositiveadaptationinanimalswithoutlanguage,itisahighpriceforhumanstopayforbeingfrightened.Puttingfeelingsintowordsandconstructingnarrativesaboutourexperiencesareintegraltoemotionalregulation,theinterweavingofneuralnetworksofemotionandcognition,andtheexperienceofacoherentsenseofself.Perhapsmostimportant,alackoflanguagecanseparateusfromthehealingeffectsofpositiveconnectionswithothers.Thelossoftheabilitytoconstructnarrativesisespeciallyproblematicinsituationswhereindividualsareforcedintosilencebytheirabusers,orafterenduringthe“unspeakablehorrors”oftorture,war,orthedeathoffriendsandfamily.

Losingtheabilitytoverbalizefeelingsalsointerfereswithbuildingdescendinginhibitorycorticalnetworksdowntotheamygdala.Youmayhavehadatraumaticexperiencelikeanautoaccidentorrobberywhereyoufeltcompelledtotellthestoryoverandoveragaininthefollowingdaysandweeks.Intime,thepressuretotellothersdiminishesastheemotionsconnectedtothetraumaticeventsslowlydissipate.Isuspectthattellingthestorybuildscircuitry,whichcontributestoamygdalainhibitionandthedissipationoffear.

Justasputtingwordstogethertoformsentencesrequiressequencingandpredictingwhatcomesnext,sodoesmoment-to-momentsensorimotorfunctioning.So,besidesitsroleinlanguage,Broca’sareaalsocontributestonetworksofpredictionandanticipation.Thus,alongwithlossoflanguage,traumatizedindividualsmayalsoexperiencedifficultiesintheday-to-daynavigationoflifethattherestofushandleunconsciouslyandautomatically.ThisinhibitionofBroca’sareaisexacerbatedbytheamygdala’sabilitytoinhibitprefrontalfunctioningduringhighstatesofarousal.Thismaybeoneofthereasonsthattraumatizedindividualsseemtoexperiencemorethantheirshareofaccidents,badrelationships,andmisfortune.Thecombinedlossofwordsanddecreasedpredictiveabilitiesenhancethelong-termimpactofthetraumabyincreasingtheprobabilityofongoingstressandrevictimization.

The“talkingcure”stimulateslanguagenetworksandencouragesthecreationofadaptivenarrativesabouttraumaticexperience.Thetherapist’scaringpresence,availability,andskillpromoteamoderatestateofarousal,whichsupportstheneuroplasticprocessesnecessaryforbuildingdescendinginhibitoryfiberstolimbicandbrainstemcenters.PuttingfeelingsintowordsminimizestheactiveinhibitionofBroca’sareaandsupportsthebalanceofrightandlefthemisphereprocessing.Intherapy,westimulateBroca’sarea,disinhibitlanguage,restorepredictiveabilities,andsupportneuroplasticprocessesofadaptivelearning.

DivergentHemisphericProcessing

Themindisthelasttoknow.—MichaelGazzaniga

Overthecourseofprimateandhumanevolution,theleftandrightcerebralcorticeshavebecomespecializedtoservetheformationoftheconscious,linguisticselfintheleftandthesomatic,emotionalselfintheright.Itislikelythatasthehemispheresdifferentiated,itbecameincreasinglynecessaryforonetotakeexecutivecontrolofconsciousprocessing.Thereisconsiderableevidencethatthelefthemispheretookonthisfunction,alongwithaleadroleinmaintainingmoderatestatesofarousalandsocialconnectedness.Therighthemisphereconstantlyprovidesinformationtotheleft,butwhileweareawake,thelefthemispheremayormaynotallowthisinputintoconsciousness.

Thedisruptionofaproperintegrationandbalancebetweenleftandrighthemisphereinputcanresultindominanceofonehemisphereortheother.Aswehaveseen,theoverinhibitionoftherighthemispherebytheleftcanresultinalexithymia,whileanunderinhibitioncanresultinoveremotionality,magicalthinking,orauditoryhallucinations.Theproperintegrationandbalanceoftheleftandrightprefrontalcorticesarealsonecessaryfortheregulationofmood.Whenpeoplearetraumatized,thereisanincreasedlikelihoodthatthecoordinationbetweenleftandrightfunctioningwillbedisrupted.ThePTSDsymptomsofintrusionsarelikelytheclearestexampleofdeficitsofrighthemisphereinfiltrationoftheleft.

Whentraumaoccursinearlydevelopment,thehemispheresgrowtobelesscoordinatedandintegrated,resultinginproblemsinaffectiveregulationandpositivesocialawareness.PeoplewithhistoriesofchildhoodabuseandneglecthavebeenshowntohaveasmallercorpuscallosumandaremorelikelytosufferfromsymptomsofPTSD(DeBellisetal.,1999;Teicheretal.,2004).Theirbrainshavefewerconnectingfibersavailabletointegraterightandleftprocesses,andtheirdevelopmentischaracterizedbyadecreasedlateralintegration.Aswehavealsoseen,theleftandrightprefrontalcorticesarebiasedtowardpositiveandnegativeemotions,andadisturbanceofthehomeostaticbalanceofthetwocanresultinextremesofdepressionandmania.

Therapistsintuitivelyandintentionallyseektobalancetheexpressionofaffectandcognition.Weencourageoverintellectualizedanddefendedclientstobeawareofandexploretheirfeelings.Ontheotherhand,weprovideclientswhoareoverwhelmedbyanxiety,fear,ordepressionwithtoolstousethecognitivecapabilitiesoftheirlefthemispherestocounterbalancetheseemotions.Thecommonimbalancebetweenaffectandcognitioninmanyofourclientsrests,inpart,inthestrugglebetweenthehemispherestointegrateandlearnacommonlanguage.Thenarrativeswecreateintherapystrivetobeinclusiveoftheconsciousandunconsciousrealitiesofbothhemispheres.

TheBiasTowardEarlyLearning

Inthepracticaluseofourintellect,forgettingisasimportantasremembering.—WilliamJames

Atbirth,themoreprimitivestructuresofourbrainsresponsibleforsocialandemotionalprocessingarehighlydeveloped,whilethecortexdevelopsslowlythroughthefirstdecadesoflife.Muchofourmostimportantemotionalandinterpersonallearningoccursduringourfirstfewyearswhenourprimitivebrainsareincontrol.Wematureintoself-awarenesshavingbeenprogrammedbyearlyexperiencewithsensoryandemotionalassumptionsthatweacceptastruth.Asaresult,agreatdealofextremelyimportantlearningtakesplacebeforeweareconsciouslyawarewearelearning(Casey,Galvan,&Hare,2005).Formostofus,theearlyinteractionsthatshapeourbrainsremainforeverinaccessibletoconsciousmemory,reflection,ormodification.Thisartifactofevolution,expressedinthesequentialnatureofourneuraldevelopment,turnstheaccidentsofbirthandtheupsanddownsofeverydaylifeintothebeliefsandcausesforwhichwesufferanddie.

Earlyexperiencesshapestructuresinwaysthathavealifelongimpactonthreeofourmostvitalareasoflearning:attachment,emotionalregulation,andself-esteem.Thesethreespheresoflearningestablishourabilitiestoconnectwithothers,copewithstress,andfeelweareloveableandhavevalue.Givenhowlittlecontrolwehaveoverourearlyexperience,andthatanyonecanhavechildrenregardlessoftheircompetenceorsanity,anincredibleamountofhumanbrainbuildingislefttochance.Inaddition,wehaveseenthatearlyexperienceshapesgeneticexpression,whichimpactsourabilitytolearn,regulateouremotions,andnurtureourfuturechildren.

Itisobviousthatourdependencyonearlycaretakerscaninfluenceusinperfectlyterribleways.Weseethisinabusedandneglectedchildrenwhooftenenteradolescenceandadulthoodwithavarietyofsymptoms.Explosiveanger,eatingdisorders,drugandalcoholproblems,andotherformsofactingoutarecommon.Theyalsohaveidentitydisturbancesandapoorself-image,exacerbatedbyangryfeelingsandantisocialbehaviors.LikeaveteranwithPTSD,thebrainsofthesechildrenbecomeshapedtosurvivethecombatoftheirday-to-daylives,butareill-equippedtonavigatepeace.

Inpsychotherapy,wehavetoolsthatallowustoexploreearlyexperienceswiththepossibilityofcomingtounderstandoursymptomsasformsofsensory,motor,andemotionalmemory.Projection,transference,self-esteem,andinternalself-talkareallexpressionsofearlyimplicitmemoriesfromwhichwecangetaviewofearlyunrememberedinteractions.Makingtheunconsciousconsciousis,inpart,comingtoanawarenessandunderstandingoftheimpactofearlyexperience.Oncetheycanbeconsciouslythoughtaboutandplacedintoacoherentnarrative,wegaintheabilitytoreintegratedissociatedneuralnetworksofaffect,cognition,abstractthinking,andbodilyawareness.Thisprocessopensthedoortodecreasingshameandincreasingself-compassionwhilecreatingthepossibilityforhealing.

TheTenacityofFear

Itistheperpetualdreadoffear,thefearoffear,thatshapesthefaceofabraveman.—GeorgesBernanos

Atbirth,theamygdala,theexecutivecenterofourbrain,isfullydeveloped.Itsfirstjobistofigureoutwhoissafeandwhoisdangerous.Althoughtheamygdalabegrudginglycomestoshareexecutivecontrolwiththeprefrontalcortex,itremainscapableofhijackingthebraininstatesofdistressandfear.Theamygdala’sjobistorememberanyandallthreatsandtogeneralizetheseexperiencestoothersignsofdanger.Inotherwords,theamygdalaneverforgets.Itstendencytogeneralizeiswhyapanicattackoutsidethehomecanleadtoagoraphobiaorwhygettingscratchedbyacatcansoonmorphintoafearofallfurryanimals.Evolutionhasshapedourbrainstoerronthesideofcautionandbeafraidwheneveritmightberemotelyuseful.Incontrast,thehippocampusisconstantlyremodeledinresponsetonewinformationandcaneasilydifferentiateonefurryanimalfromanother.

Fearmakesourthinkingandbehaviormorerigid.Webecomeafraidoftakingrisksandlearningnewthings,whichresultsinatendencyforthosewhoaresicktoremainsick.Onerecognizedsymptomoftraumais“neophobia”orthefearofanythingnew.Onceourbrainshavebeenshapedbyfeartoperceive,think,andactinstereotypedways,wetendtoremaininrigidpatternsthatarereinforcedbyourverysurvival.Ourinternallogicisself-perpetuating,makingitdifficultforustofindanswersthataredifferentfromtheoneswealreadyknow.Ourchanceoflearningthenrestsingettinginputfromotherpeople.However,relationshipswithothersarealsodifficultbecausefearmaymakeuskeepthematarm’slength.Whenpeoplearehurtorafraid,caringrelationshipsarenoteasilyenteredintonoreasytobenefitfrom.

Opennessandtrustarefragilecreatures,evenwiththepeoplewelovemost.Thetrainingofthetherapistandthetherapeuticcontextaredesignedtoenhancesupportandtrust,

andprovideconsistentemotionalavailability.Withintheconsultingroom,therapistsattempttobeamygdalawhisperersandworktoreactivatenetworksofnewlearninginthehippocampusandprefrontalcortex.Warmth,empathiccaring,andpositiveregardcancreateastateofmindthatenhancesneuroplasticprocessesandincreasesthelikelihoodofpositivechange.Itnowappearsthattherapistshelppeoplegetovertheirfears,notbyerasingtraumaticmemoriesbutbybuildingnewconnectionstoinhibitthesememoriesfromtriggeringautonomicarousal.

TheDamagingEffectsofStressHormones

Manisanover-complicatedorganism.Ifheisdoomedtoextinctionhewilldieoutforwantofsimplicity.

—EzraPound

Forourmoreprimitivecousinswithsmallercorticesandsimplerenvironments,dangerisencounteredandquicklyresolved.Theyeitherescapeorgeteaten,winorlose.Butwhenyouaddahugecortexcapableofbuildingfreewaysandinformationsuperhighways,thebrainhastoadapttoaworldofconstantchallengewherethereisneveranyclearresolution.Alargecortexalsoaddsamemoryforthefutureandendlesspossibilitiesforanticipatoryanxiety.Beyondthiswenowhaveavastimaginationcapableofcreatingfrighteningfantasiesthatourprimitivebrainsareunabletodistinguishfromreality.

Stressfulsituationstriggerthereleaseofthestresshormonecortisol.Stresshormonesarecatabolic,whichmeanstheybreakdowncomplexcompoundsforimmediateenergy.Cortisol’smottois“livefortoday,fortomorrowwemaydie.”Asoneoftheglucocorticoids,itsjobistobreakdowncomplexcarbohydratesintousableenergyforourmuscles.Anotheractionofcortisolistocutdownonenergydedicatedtoproteinsynthesis.Becauseneuralgrowthandourimmunesystemdependonproteinsynthesis,prolongedhighlevelsofstresshormonesimpairourabilitybothtolearnandtoremainhealthy.Theconservationofourprimitivestresssystem,welladaptedforasimplelifeandasmallcortex,canleaveourmodernhumanbrainsbathedinhighlevelsofstresshormonesforlongperiodsoftime.Thisleadstocompromisesofbrainmaintenance,learning,andimmunologicalfunctioning.Becausechronicstressinhibitslearning,successfulpsychotherapydependsonourabilitytodownregulatestressinourclients.Fromspecificstressreductiontechniquestothesoothingeffectsofasupportiverelationship,stressmodulationandsuccessinpsychotherapygohandinhand.Thus,stressreductionskillsshouldnotbelimitedonlytospecificdiagnoses,becausetheyarealwaysnecessaryforpsychotherapytobesuccessful.

TheSpeedandAmountofUnconsciousProcessing

Manisreadytodieforanideaprovidedthatideaisnotquitecleartohim.—PaulEldridge

Inordertosurvive,animalshavetobetoughorfast.Thetortoiseandtheharearegoodexamplesofthesedifferent,butequallyviablesurvivalstrategies.Whileourelaboratecorticesseparateourbrainsfromtheirs,furtherdown,allthreeareprettysimilar.Ourexpandedcortexdoesallowusvastresponse

flexibilityoverourmoreprimitivecousins.Ofcourse,thinkingthroughoptionstakestimeandinsomecircumstances,aspeedyreflexisfarmoreadaptive.Becauseofthis,wehaveretainedmanyprimitivereflexesandsubcorticalexecutivecontrolofcertainfunctionsintheserviceofsurvival.Ourharelikebrainsallowustomakerapiddecisionsandhaveknee-jerkresponses.

Whileittakesapproximately500–600millisecondsforanexperiencetoregisterinconsciousawareness,theamygdalacanreacttoapotentialthreatinlessthan50milliseconds.Thismeansthatbythetimewehavebecomeconsciouslyawareofanexperience,ithasalreadybeenprocessedmanytimesinourmoreprimitiveneuralnetworks,activatingmemoriesandtriggeringimplicitmemoriesorganizedbypastlearning.Thisunconsciousbackdropshapestheperceptionofwhatisbeingconsciouslyattendedtoandconstructsourexperiencesofthepresentmoment.(Nomuraetal.,2003;Wiens,2006).Whenwefinallybecomeawareoftheoutcomeofthisprocess,weexperienceitasifwearelivinginthepresent,andactwithfreewillbasedonconsciousdeliberation.Thereisextensiveevidencethatthisisnotreallythecase.Weactuallyliveabout500millisecondsafterthemomentandourpastlearningseverelylimitsourfreewill.Theillusionsoffreewillandcontrolhaveobvioussurvivaladvantages,foremostofwhichistheabilitytobeassertiveandconfidentincomplexsituations.Thedownsideofthisstrategyiswhenwebecomesosureofourpersonalbeliefsthatweareunabletoconsideralternatives.

Ninetypercentoftheinputtothecerebralcortexcomesfrominternalneuralprocessing.Thismakessenseforrapidappraisalandreflexiveactionbasedonpastlearningbutalsoresultsincognitivedistortionsthatcankeepusfrightened,withdrawn,andconfused.Thinkoftheveteranyearsaftercombat,whoduckswhenhehearsacarbackfireorrunsforcoverasanewshelicopterfliesoverhead.Apersonwhoexperiencedearlyabandonmentmay,asanadult,beperfectlycapableofstartingnewrelationships.Atacertainpoint,however,intimacymaytriggerimplicitmemoriesofinsecureordisorganizedattachment,leadinghimtobecomefrightenedandfleefromapotentiallyhealthyrelationship(Koukkou&Lehmann,2006).Theimpulsetorun,drivenbyimplicitmemoriesembeddedinprimitivebraincircuitry,canbeoverpoweringandinescapable.ThetruereasonsforthisbehavioraresoaccuratelydescribedbyChristopherBollas(1987)asthe“unthoughtknown.”

Opennesstoquestioningone’sassumptions,especiallywhentheyareself-defeatingandincorrect,isakeypredictorofpositiveoutcomeinpsychotherapy.Onceclientsbegintounderstandthatwhattheyassumedtoberealityisactuallyapersonalfabrication,theyeitherfleeorbecomefascinated.Weattempttogetthemtoquestiontheirthoughts,beliefs,andassumptionsandto“actin,”thatis,tocometosessionsandtalkabouttheirimpulseswiththehopeofintegratinginhibitorycorticalinputwithprimitivememories,emotions,andurges.Attachmentschemas,transference,andself-esteemareallexamplesofimplicitmemoriesthatshapeanddistortconsciousawareness.TheseverypatternsofunconsciousprocessingledFreudtodeveloppsychoanalysisandtocreateatherapeuticcontextthatsupportedanexplorationoftheunconscious.Psychotherapyencouragesbeingskepticaloftheperceivedrealitiesofourbrains.Givenhowourbrainswork,thisisasoundstrategy,onewesharewithresearchscientistsandBuddhistmonks.

ThePrimacyofProjection

Itiseasytospotaninformedman—hisopinionsarejustlikeyourown.—MiguelDeUnamuno

Humanbrainspossesscomplexsocialnetworkswhichbecomeactivatedasweobserveandinteractwiththosearoundus(Cozolino,2006).Hoursafterbirth,webegintofocusonandimitatethefacial

expressionsofourcaretakers.Mirrorneuronsbegintolinkobservationsandactions,allowingusto(a)learnfromothersbywatchingthem,(b)anticipateandpredictactions,and(c)activateemotionalstatessupportiveofemotionalresonanceandempathy.Wealsopossessneuralcircuitsthatautomaticallyanalyzetheactionsandgesturesofothers,generatingatheoryoftheirmind—whattheyknow,whattheirmotivationsmaybe,andwhattheymightdonext.Aswithmirrorneurons,havinganautomatictheoryofwhatisonthemindofanotherallowsustopredictbehaviortoensureourownindividualsafetywhilesupportinggroupcohesionandthespreadofculture.

Theexistenceofthesesophisticatedsocialneuralsystemsreflectsthemillionsofyearsofnaturalselectionthathavebeenrefiningourbrain’sabilitytoreadtheemotions,thoughts,andintentionsofothers.Allofthisattentiontoothersclearlyshowsustheimportanceofsocialinformationprocessingtoourverysurvival.Asaresult,wearequicktothinkweknowothersbecausemindreadingisinstantaneousandobligatory.Inbiblicalterms,itisareflexivehabitofthesocialbraintoattendtothemoteinourbrother’seyeandnottothebeaminourown.Unfortunately,evolutionhasnotseenfittoinvestmuchneuralcircuitryintoself-awareness.Projectionisautomaticandlessensanxietywhileself-awarenessrequireseffortandgeneratesanxiety—whichdoyouthinkisgoingtobethenorm?

Giventhatweuseourinternalexpressionsasimplicitmodelsforhowweunderstandothers,itcouldbethatwhatFreudcalledthedefensemechanismofprojectionisactuallyasimplebyproductofhowourbrainsinterweaveourautomatictheoriesofothers’mindswithunderstandingsofourselves.Thismaybewhyweoftendiscoverourowntruthsinwhatwethinkandfeelaboutothers.Andsinceourindividualidentitiesemergefromdyads,perhapstheseparationofselfandotherisalwaysadiceydistinction,onethatmanyculturesdonotevenbotherwith.Thismayalsobewhyself-analysisisgenerallynotsuccessfulbecausethelogicofself-inquiryissointerwovenwithourimplicitassumptions.Themostnaiveobservercanseemanythingsaboutusthatwecannotseeinourselves.Incloserelationships,weprovideeachotherwithanothersetofeyesoutsideofourbodiesthatcanreflectourlivestousinwaysthatareimpossibletoperceiveonourown.

Intherapy,weteachourclientstoaskthemselvesifthepotiscallingthekettleblack:thatis,aretheirthoughtsandfeelingsaboutothersautobiographical?Whileincouplestherapy,weencourageourclientstostopmindreadingandlearntoactuallyasktheirpartnerswhatisontheirminds.Weengageinaparallelprocesswheneverweexplorehowmuchofourreactiontoaclientiscountertransferential.Inourtrainingastherapists,welearntoquestionourjudgmentandassumptionsinlightofourownpersonalhistories.Wealsolearntousemirrorneuronsandtheoryofmindtoenhanceourattunementwithourclientsandexploretheirinnerworlds.Takingbackourprojectionsandworkingwithtransferenceandcountertransferenceintherapyallowsustouseourthoughtsaboutothersaspotentialsourcesofpersonalinformation.

UnconsciousSelf-Deception

Menusethoughtstojustifytheirwrongdoings,andspeechonlytoconcealtheirthoughts.—Voltaire

Basedbothonneuralarchitectureandeverydayexperience,self-insightdoesnotappeartohaveexertedastrongpressureonnaturalselection.Infact,itmayhavebeenselectedagainstbecauserealself-knowledgecreatestheriskofdoubt,hesitation,anddemoralization.Defensesthatdistortourrealitycanhelpusbydecreasinganxiety,shame,anddepression.Atthesametimetheycanenhancesocialcoherencebyputtingapositivespinonthebehaviorofthoseclosesttous.Thisismostclearlyseeninamother’s

love.Awisejudgeoncesaidthateveryonehesendstoprisonhas“amotherwithaninnocentchild.”Self-deceptionnotonlydecreasesanxiety,italsoincreasesthelikelihoodofsuccessfullydeceivingothers.Ifwebelieveourownconfabulations,wearelesslikelytogiveawayourrealthoughtsandintentionsvianonverbalsignsandbehaviors.Reactionformation,orbehaviorsandfeelingsthatareoppositeofourtruedesires,isalsoquiteeffective.Freud’sdefensemechanismsandtheattributionalbiasesofsocialpsychologydocumentanarrayofthesedistortions.

Secureattachmentandegostrengtharecorrelatedwithourabilitytohearfeedback,acceptourownlimitations,anduselessreality-distortingdefenses—humorinsteadofrepressionandsublimationinsteadofdenial.Inpsychodynamicpsychotherapy,weprovideourclientsnotonlywithinterpretations,clarifications,andreflectionsbutalsowithanalternativeperspective(ourown)thattheycanutilizetohelpdiscoverthemselves.Bothclientandtherapistneedtoengageinrealitytesting,althoughthedefinitionofrealitycanbeslippery.Thisiswhyourownpersonaltherapyissoimportanttoourclients.Intoday’slargesocialgroups,self-awarenesshasbecomeincreasinglyimportantforsurvivalofthespecies,perhapsasimportantasself-deceptionistothesurvivaloftheindividual.Distortingrealitytoreduceone’sanxietymayallowtherichtogetricherandtherighteoustofeeljustified,butinthelongtermthereareconsequencestotheenvironmentandsocialsystemsthathavenegativeimpactsonusall.

Thesewaysinwhichthebrainandmindhaveevolvedhavecreatedawidevarietyofthreatstoouremotionalandphysicalwell-being.Isuspectthatyouhaverecognizedmanyofyourclients’problemsinthesediscussions,andperhapssomeofyourown.Theselegaciesofevolutionmakebothclientsandtherapistsvulnerabletodissociationanddistressandleadustoacommonsearchforsolutions.Let’stakealookatacasestudywherewecanexaminehowthesevulnerabilitiescanplayoutinlifeandintherapy.

Patrick

Manisbornbroken.Helivesbymending.—EugeneO’Neill

Patrick,amaninhismid-30s,cametotherapywiththecomplaintthathislifewas“unraveling.”Talkativeandobviouslybright,Patrickwasthekindofpersonwhocouldquicklylaunchintoanimatedconversation.Ifeltimmediatelydrawnintohisstoriesandfoundoursessionsinterestingandenjoyable.IsoonlearnedthathehadgrownupontheConnecticutcoast,thathisfatherwasafishermanwitha“drinkingproblem,”andthatbothhisparentshaddiedafewyearsearlier.Arecentphysicalaltercationduringarelationshipbreakuptriggeredhimtotakestockofhislife.“That’sjustnotme,”hesaid.“Something’sverywrong.”Overourfirstfewsessions,twothingsstoodouttome;helivedunderagreatdealofemotionalpressureandalcoholwasapervasivepresenceinhiscurrentlife.

Patrick’sinitialinterestwastounderstandwhathadhappenedinhislastrelationshipandduringthebreakup.Althoughhehadthesensethatsomebroaderissueslaybeneaththesurface,hewasunabletoarticulatewhattheymightbe.“That’syourjob,”hetoldmewithasmile.ItwasclearfromourdiscussionsthatalcoholhadbeenapartofPatrick’slifefromthebeginning.Hisfather’salcoholismhadmanynegativeeffectsonhimandeveryoneinhisfamily.BothPatrickandhisex-girlfrienddrankheavilyandalcoholwasalwayspresentduringtheirdisputes.ItbecameveryclearthatbothPatrickandhisfatherusedalcoholtocopewithanxiety,sadness,andloss.

Whatturnedouttobemyfirstimportantinterventionwasamatter-of-factquestionaboutwhetherhefelthehadadrinkingproblem.Givenhisfather’saddictionandallhehadtoldmeabouthislifelongrelationshipwithdrinking,Iexpectedtoheara“Duh!”andsomesympathyforbeingsoslowwitted.

Instead,Patrickwassurprisedandtakenabackbymyquestion.Itseemedthathehadnevergivenanyseriousthoughttobeinganalcoholichimself.Atfirst,Iwassurprisedbyhissurprise,andimpressedbyhisbrain’sabilitytocompartmentalizedifferentaspectsofawareness.Thepowerandpersuasivenessofhisearlylearningtonormalizealcoholanddenyemotionscreatedadissociationenablinghimtobeunawareoftheproverbialelephantintheroom.

Insteadofbeingdefensive,hebegandiscussinghisrelationshipwithalcohollikeaninvestigatorlookingforcluestoacrime.Hespontaneouslysharedthatmanydifficultiesinhisrelationshipsseemedtooccurwhiledrinking.Patrickcouldseethatheusedalcoholtodeadenhisemotionsandthatitcausedhimdifficultiesinschool,atwork,andinallofhisrelationships.Ashelistenedtotheunfoldingofhisownnarrative,hegraduallybecameawareofthefactthathesharedhisfather’saddiction.Bytheexpressionsonhisface,itwasclearthathewaslearningabouthimselfbylisteningtohisstory—astoryhehadlivedbutneverthoughtabout.Theroleofalcoholinhisfather’slifewasclearbutitneveroccurredtohimtoapplytheseinsightstohimself.Patrickwasintheprocessofusinglanguagetointegratenetworksofemotionandthought,andreevaluatingpastexperiencesfromaperspectiveofexpandedself-awareness.

Oncetherealityofhisownalcoholismwasfirmlyestablishedinconsciousthought,heaskedmewhatIthoughtheshoulddo.Againexpectinga“Duh!”Isaid,“Well,youcouldstopdrinking,joinAlcoholicsAnonymous,andtryworkingthesteps.”Andagain,Patrickreactedasifthiswereanovelideathathemighttryout.Basedonpastexperience,myexpectationwasthatwewouldbeworkingthroughhisresistanceforquiteawhilebeforehewouldgiveAAatry.But,truetohisword,hestoppeddrinking,gotinvolvedinAA,foundasponsor,andworkedthesteps.(Notetobeginningtherapists—thissortofthingalmostneverhappens.)Theopenness,enthusiasm,andrapiditywithwhichPatrickgainedawareness,explored,andtackledtheissuemademewonderwhathislifewouldhavebeenlikewithevenamodicumofinsightfulparentalguidance.Hisobviousintelligenceanddrivecouldhavebeenappliedtoallkindsofchallengeshadheonlybeentaughtalanguageforhisfeelings,learnedtobeself-aware,orappliedhisproblem-solvingskillstohisownlife.Hisearlychronicstress,combinedwiththefamilysilenceandshame,ledhimtoinhibitlanguageandconsciousawareness.

Likemanychildrenofalcoholics,Patrickwasgreatatgivingadvicetootherswhileremainingacompletemysterytohimself.Hisfather’sdrinking,financialdifficultiesinthefamily,andproblemswithhissiblingsalwaystookprecedenceoverhispersonalneeds.Therewasalmostnotimespentduringhischildhoodonhelpinghimlearnhowtocopewithnegativeemotions—alearnedandnotinnateability.Likesomany,hegrewupalone,surroundedbyfriendsandfamily,withonlytheabilitytoactouthisinneremotionalturmoil.Hischaoticinneremotionalworldaswellashiscopingstrategiesanddefensivestylesweresetearlyinlifeandheldonintoadulthood.Thefearofbothhisinternalchaosandofconfrontingitkepthimdrinkingandrunningfordecades.

Oncesober,theemotionsanddefensesbehindhisaddictionbegantoemerge.WiththehelpofAAhelearnedaboutthetypicalstrugglesandpitfallsofalcoholism.ThesemeetingseventuallyledhimtoexploretheprinciplesofAdultChildrenofAlcoholics(ACA),whichprovedtobeofevenmoreimportancetohimthantheimpactofhisowndrinking.Overthefollowingmonths,hisimpulsivityandimpatience,pathologicalcaretakingofothers,andinabilitytonavigatenegativeemotionsbecamethefocusoftherapy.Situationbysituation,wedeconstructedhisassumptionsandsearchedfornewwaysofthinking,feeling,andbehaving.Inessence,weweredoingtheworkthatshouldoccurinchildhoodduringcountlessinteractionswithparents.Thetenacityoffearisimpressive,causingmanyofustospendalifetimeavoidingthepainandconfusionofchildhood.

Duringoursessions,PatrickmentionedhisworkintheNewYorkfinancialdistrictduring2001.Forsomereason,Ihadneverthoughttoaskhimhowtheterroristattacksof9/11impactedhimand,similarly,heneverbroughtitup.WhenIaskedifandhowhewasaffected,heoffhandedlymentionedthathelostmanyfriendsbutdidn’tthinkhehadsufferedanyilleffects.Histoneofvoicesoundedhauntinglysimilar

towhenhedescribedhisearlyfamilylifesoIaskedhimtotellmeabouthisexperienceandinresponsehetoldmethefollowingstory:

IwaslivinginNewJerseyatthetimeandcommutedtoWallStreetviaferryacrosstheHudson.Ioversleptthatmorning,soinsteadofbeingatworkat8:30,Iwasstillcrossingtheriverat9.Halfwayacross,someofusnoticedsmokerisingfromdowntown.PeoplebegangatheringatthefrontoftheshiptoseewhatlookedlikeafireneartheTradeCenter.Minuteslater,asouthboundplanetrackingtheHudsonpassedlowoverhead.WeallwatchedasitpassedovertheStatueofLiberty,bankedhardleft,andheadedbacktowardManhattan.

Asthesecondplanehitwewerecloseenoughtothedockstoseepeoplerunningthroughthepark.Theconcussionshockfromtheexplosionmadeeveryonemoveforwardandbackinasurrealway,likebladesofgrassinthewind.Whentheplanehitthesecondtower,weknewwewereunderattack.IwasenragedandanxioustoreachthedocktoseewhatIcoulddotohelp.IrememberedmyfathertalkingaboutPearlHarborandhowheandhisfriendsstoodinlineattherecruitingofficethenextmorning.

Asweapproachedthedock,thecrowdsrushedforwardtoescapethecarnageandchaosbehindthem.Butjustbeforewereachedthedock,theferryslowedandreverseddirectiontoavoidbeingswampedbythemassivecrowd.AsweheadedbacktoNewJersey,IbeganthinkingaboutthepeopleIknewwhoworkedintheTradeCenterandimaginedwhatitwouldbeliketobeinthosebuildingsastheyburned.IrememberfeelingnumbasIstaredatthehugeplumeofsmokerisingabovethecity.WhenwegotbacktoJerseyweallstoodintheterminalwatchingthetelevisionasthebuildingscollapsed,firstoneandthentheother.Someofthewomencriedandevensomemen;westoodthereinshock,leaningagainstoneanotherforsupport.

ThephonesweredownandtherewasnothingIcoulddobutimaginewheremyfriendswereandiftheyhadsurvived.OnceIarrivedbackhome,Icouldn’ttakemyeyesoffthetelevision.FromtimetotimeIwouldseesomeoneIknew,dazedandcoveredwithdust,staggeringpastthecamera.IeventuallynoticedthatithadgrowndarkandIwashungry.Iwasabletoconnectwithmygirlfriendlaterthatnight,andthenextdaywedrovesouthinasortofwakingcoma.Eventuallywefoundahotelroomandgotdrunkforafewdays.

BothPatrick’sreactiontotheimpactof9/11andhisownalcoholismwereprocessedinadisassociatedmanner.Thisdefenseparalleledhowhedealtwithhisexperiencesandfeelingsfromchildhood.Earlyinlifehelearnedtostayawayfromhisemotionsthroughdenial,hypomanicactivity,andcombativesports.Drinking,working,andsocializinghadallbecomecompulsivewaysofavoidingorinhibitinghisfeelings.Hisintellectallowedhimtosucceedintheworkplaceandrationalizehisunhealthybehaviors.Butuponawakeningeachday,hediscoveredthesamesad,frightening,andlonelyworld.

Themanynegativeeffectsofhavinganalcoholicparentarewellknown.Thefearanduncertaintycreatedbythealternatingpresenceandabsenceofthealcoholiccombinedwithanincreasedprobabilityofextremeemotionalreactionscanhaveadevastatingimpactonallaspectsofdevelopment.Thesechildrenoftenlearnnottobeneedyastheydevelopafalseselftotakecareoftheparentandmaintaintheartificeofahappyhome.Unfortunately,theyneverreceivethehelptheyneedtoarticulatetheirexperiencesanddevelopacomfortinginnerworld.Theirearlyterrorpersistsinnetworksofimplicitmemorybuttheylackmechanismsforexpressionorsocialconnectionthatcouldhealthem.Thus,theyrecreatethechaosfromwhichtheyaresodesperatelytryingtoescapebyactingouttheiremotionswhileestablishingrelationshipswithabusiveoremptyothers.

AtfirstitwasdifficultforPatricktofocusonhisownfeelingsandpersonalissues.Hisinitial

attentionkeptreturningtotheproblems,shortcomings,andlimitationsofhisgirlfriend.Itwasonlyafterhebecamelessagitatedandmoreself-reflectivethathecouldseethatheandhisgirlfriendsharedmanyofthesameproblems.Likemostofus,hefounditeasiertofocusonherproblemsratherthanhisown.Hisgradualimprovementrequiredthathereorienthisfocusontohisownbehaviorsandfeelings.NextPatrickhadtodevelopalanguagewithwhichtodescribeandsharehisinnerworld.Andfinally,overandoveragain,hehadtoexperiencehislifefromtheinsideout,andlearntoconnectwithothersasanotherhumanbeingratherthanacaretakerorragingalcoholic.

Summary

Thesophisticationofthehumanbrainreflectsmillionsofyearsofevolutionaryadaptationwhereoldstructureswereconservedandmodifiedwhilenewstructuresemergedandexpanded.Countlessinteractivenetworksanddesigncompromisescreatedfertilegroundforthedisruptionofsmoothintegrationofneuralsystems.Theverycomplexityofthedevelopmentandfunctioningofthebrainisalsowhatmakesitsuchafragilestructure.Assumingthatthetrillionsofcomponentsarriveintheirproperplacesandworkaccordingtotheirgenetictemplates,thereareahostofotherchallengestointegratedpsychologicalfunctioning.Thediscontinuityofconsciousandunconsciousprocesses,multiplememorysystems,differencesbetweenthehemispheres,hiddenprocessinglayers,andmultipleexecutivestructuresareallpotentialsourcesofdissociationanddysregulation.Disruptioninthecoordinationandhomeostaticbalanceoftheseneuralsystemsistheneurobiologicalsubstrateofpsychologicaldistressandmentalillness.

Evolutionisdrivenbythephysicalsurvivalofthespeciesandthus,muchofthebrain’sfunctioningiscenteredaroundautomaticfight-or-flightmechanismsasopposedtoconsciousandcompassionatedecisionmaking.Becauseofthis,theconsciousandunconsciousmanagementoffearandanxietyisacorecomponentofourpersonalities,attachmentrelationships,andidentities.Theconsiderabledegreeofpostnatalbraindevelopmentandthedisproportionateemphasisonearlychildhoodexperiencesinthesculptingofthebrainaddtoourvulnerabilitytopsychologicaldistress.

Psychotherapistsaretrainedtousetheirsocialbrainsasatooltoconnecttoandmodifythebrainsoftheirclients.Throughinterpersonalneurobiologicalprocesses,therapistsserveasanexternalregulatorycircuittohelpreestablishtheoptimalflowofenergyandinformation.Thisisdoneforthecircuitswithinandamongthecerebralhemispheres,andthroughalllevelsoftheneuraxisfromtheprimitivelowerregionstothemostrecentlyevolvedcomponentsoftheneocortex.Itisthroughthisincreasedintegrationthatmoreoptimalmentalprocessingisestablishedandsymptomsarereplacedwithfunctionalbehavior.

Chapter17

TeachingOldDogsNewTricks:StimulatingNeuralPlasticity

Itisnotthestrongestofthespeciesthatsurvive,notthemostintelligent,buttheonemostresponsivetochange.

—CharlesDarwin

Psychotherapyhassurvivedformorethan100yearsintheabsenceofanacceptedbrain-basedmodelofchange.Theoldviewofthebrainasapredeterminedandstaticentitynecessitatedthatthedevelopmentofpsychotherapybeindependentfromthebiologicalsciencesofeven20yearsago.Fortunately,currentneuroscientificfindingsdonotsupportneurologicalfatalismbutfindabraincapableofconstantlyadaptingtonewchallenges.Infact,therapistshavelearnedtoutilizeattachment,emotionalattunement,andnarrativesastoolstomodifythebrain.

Therapistsoftenlamentthefactthatparentsdon’tdoabetterjobduringtheirchildren’searlydevelopment,whenrelationshipshavesuchapowerfulimpactontheirbrains.Butifweapproachthebrainfromtheperspectiveofongoingplasticity,whatarewecapableofinourconsultingrooms?Howplasticisthebrain?Canplasticitybeenhanced,andhowmuchofaneffectcanthetherapeuticrelationshiphaveonthebrain?Thesequestionsarecentraltopsychotherapy,becausewerelyonthebrain’sabilitytochangewellaftertraditionalsensitiveperiodshavepassed.

Researchonimprintingofparentalfiguresingeese(Lorenz,1991)andtheimportanceofperiodsofvisualexposureinthedevelopmentoftheoccipitallobesincats(Hubel&Wiesel,1962)havebeenstandardfareinundergraduateeducationandpopularscienceforhalfacentury.Unfortunately,thesestudieshavecreatedtheimpressionthatthetimingofbraingrowthisentirelypredeterminedbytemplategenetics(DNA)andthatearlyexperiencesbecomeindeliblyetchedintoourneuralarchitecture(Rutter&Rutter,1993).Extractingtheconceptsofimprintingandcriticalperiodsfromethologyandapplyingthemtohumandevelopmentturnsouttobequitemisleading(Michel&Moore,1995).Wenowknowthatgeneticexpressioniscontrolledbyexperiencesthroughoutlife,andthatchangesintheenvironment,bothgoodandbad,continuetohavepositiveandnegativeeffectsonus.Also,ourbrainsaremorecomplexandexpandedinregionsthatmaintainmoreneuroplasticproperties.Thus,learninginhumansisfarmorecomplexandflexiblethantheoriginalconceptionsofimprintingandcriticalperiodsledscientiststobelieve(Hensch,2004).

Recallthatsensitiveperiodsaretimesofexuberantgrowthinneuralnetworks,correspondingwiththerapiddevelopmentoftheskillsandabilitiestowhichtheyarededicated(Chugani,1998;Fischer,1987).Althoughthereisnodoubtthattheseperiodsexist,whatisinquestionistheindelibilityoflearningduringthesetimes,aswellasthepossibilitiesofmodifyingwhentheyoccurduringdevelopment.Asneurosciencefindsmoreexamplesofneurogenesisandneuroplasticity,andepigeneticprogrammingtakingplaceinmaturebrains,thereisanincreasingrecognitionthatweretaindifferentkindsofneural

plasticitythroughoutlife(Bornstein,1989).Theresearchonneuralplasticityhashistoricallyfocusedonthebrain’sabilitytoadaptafterearly

braininjury(Goldman,1971;Goldman&Galkin,1978;Henryetal.,1984).Today,plasticityisunderstoodtobeabasicprincipleofhealthybrainsatanyage.Ratherthanlackingplasticity,theadultbrainisnowseenashavinganincreasedtendencytowardneuralstabilizationwhileretainingtheabilityfornewlearning.Therealsoappearstobeashiftinhowinformationisprocessedinamannermoreappropriatetodifferentstagesoflife,whichisanotheraspectofitsplasticreorganization(Cozolino,2008;Stiles,2000).Thisvitalshiftinperspectivehasledtoarapidexpansionofinterestinandexplorationoftheneurobiologicalmechanismsoflifetimelearningandchange(Rosenzweig,2001).

Use-DependentPlasticity

Educationisnotapreparationforlife;educationislifeitself.—JohnDewey

Youwillrememberthatchangesinsynapticstrengthinresponsetoaninnerorouterstimulusarebelievedtobethebasisforlearning.Theprocessoflong-termpotentiation(LTP)prolongsexcitationofcellassembliesthataresynchronizedandinterconnectedintheirfiringpatterns(Hebb,1949).Thisisonlyasmallpieceofavastlycomplexsetofmechanismsandinteractionsshapingtheconnection,timing,andorganizationofthefiringbetweenthebillionsofindividualneuronswovenintoneuralnetworks.

Plasticityreflectstheabilityofneuronstochangethewaytheyrelatetooneanotherastheyadapttochangingenvironmentaldemands(Buonomano&Merzenich,1998).Thiscanoccurinthemodulationofsignaltransmissionacrosssynapses,changesintheorganizationoflocalneuralcircuits,andintherelationshipbetweendifferentfunctionalneuralnetworks(Trojan&Pokorny,1999).Ithasbeendemonstratedthatportionsofthecortexinvolvedinsensoryandmotorfunctionsreorganizeinresponsetochanginguses,afterinjury,andduringskilllearning(Braunetal.,2000;Elbertetal.,1994;Karnietal.,1995).Violinistshavelargercorticalrepresentationsinareasdedicatedtothefingersofthelefthandthandonon-stringplayers(Elbertetal.,1995),Braillereadersdemonstratesimilarpatternsofcorticalplasticityinsensoryregions(Sterretal.,1998a,1998b);andcabdrivershavelargerhippocampiincorporatingmorevisual-spatialknowledge(Maguireetal.,2006).

Theseandotherstudieshavedemonstrateduse-dependentplasticityinbothcorticalandsubcorticalregions.Becauseoftheirearlymaturationandorganization,sensory-motorareashavebeenthoughttohavetheearliestsensitiveperiodsandthemostpermanentneuralorganization.Theextensiveplasticitydiscoveredintheseregionssuggeststhatexecutiveandassociationareasofthefrontalcortex(whicharecharacterizedbytheiradaptationtochange)shoulddemonstrateevenmoresynaptogenesis,alteredsynapticconnections,andpotentiallyneurogenesis(Beatty,2001;Dalla,Bangasser,Edgecomb,&Shors,2007;Gould,Reeves,Graziano,etal.,1999;Hodge&Boakye,2001;Mateer&Kerns,2000).Infact,researchhasfoundacontinualincreaseinwhitemattervolumeinthefrontalandtemporallobesofmaleswellintothefifthdecadeoflife(Bartzokisetal.,2001).

Theactivationandorganizationofthecortexappearscapableofcontinualchange,withexpansionandcontractionofcorticalrepresentationalternatingwithvaryingamountsofstimulationanddeprivation(Polley,Chen-Bee,&Frostig,1999).Inotherwords,thebrainiscapableofmoreandfasterfunctionalreorganizationthanpreviouslythought(Ramachandran,Rogers-Ramachandran,&Stewart,1992).Ourabilitytolearnnewskillsandinformationthroughoutlifeisclearevidenceforongoingneuralplasticity.

Thestudyofthespeed,degree,andnatureofneuralplasticityisavastnewscientificfrontier,andthepotentialtoenhanceplasticityhasprofoundimplicationsforneurosurgery,education,neurorehabilitation,andpsychotherapy(Classen,Liepert,Wise,Hallett,&Cohen,1998;Johansson,2000).

EnhancingPlasticity

Lifeisgrowth.Ifwestopgrowing,technicallyandspiritually,weareasgoodasdead.—MoriheiUeshiba

Aswelearnmoreaboutthebiologicalmechanismsofsensitiveperiods,thepossibilityofcontrollingthembeginstoemerge(Moriceau&Sullivan,2004).Whatifneuroscientistscouldlearnhowtoreinstatesensitiveperiodsinadultsduringpsychotherapy?Huangandhiscolleagues(1999)foundthatthesensitiveperiodofthevisualcortexwasacceleratedincertaingeneticallyalteredmice.Itturnsoutthatageneticvariationinthesemiceresultsintheearliersecretionofbrain-derivedneurotrophicfactor(BDNF),aneuralgrowthhormone.CouldBDNFreestablishsensitiveperiodsandbeusedtostimulatemoreexuberantlearningatanytimeduringlife?

KangandSchuman(1995)foundthatBDNFandNT-3(anotherneurotrophicfactor)enhancedLTPactivitywhenintroducedtothehippocampusofanadultrat.Inarelatedstudy,itwasfoundthatastrainofmicewithhigherlevelsofN-methyl-D-aspartate(NMDA)receptorshadenhancedperformanceinlearningandmemorytasks(Tangetal.,1999).NMDA,aneurotransmitterinvolvedintheformationofassociationsamongneurons,isnecessaryforcorticalreorganization,andhastheabilitytospecifycertaintranscriptionalprocessesrelatedtoneuralplasticity(Jablonskaetal.,1999;Rao&Finkbeiner,2007;Wanisch,Tang,Mederer,&Wotjak,2005).NMDAreceptorshavealsobeenshowntobenecessaryfortheinitiationofLTPinmonkeys(Myersetal.,2000).

ThisworkhasledtothesuggestionthattheuseofD-cycloserine,whichenhancestheactivationofNMDAreceptors,mayboosttheeffectofsomeformsofpsychotherapy.OnestudyshowedanimprovedeffectofexposuretherapywithphobicindividualsafterusingD-cycloserine(Ressleretal.,2004).Theeffectsofcholinergicstimulationsuggestitalsoplaysaroleinneuralplasticitybyactivatingneuralgrowthhormones(Cowan&Kandel,2001;Zhu&Waite,1998).Futureresearchwiththesebiologicalsubcomponentsoflearningandmemorymayleadtopharmacologicalinterventionsthatcouldenhancethebrain’sabilitytolearnwhiletakingpianolessons,preparingfortheGREs,orduringcertaincriticalphasesofpsychotherapy(Davis,Myers,Chhatwal,&Ressler,2006).

Justafewyearsago,theconventionalwisdominneurosciencewasthatwewerebornwithalltheneuronswewouldeverhave.Morerecentresearchhasfoundanincreasingnumberofareaswithinthebrainwherenewneuronsaregenerated.Stemcells,thebasicstructureformanytypesofcellsthatarecapableofrenewingthemselvesindefinitely,havesofarbeenfoundintheolfactorybulbandaportionofthehippocampuscalledthedentategyrus(Jacobsetal.,2000).Whenthebiologicalprocessesthatstimulatestemcellsareunderstood,neurosurgeonsmaybeabletotriggerthegrowthofnewtissueindamagedareas(Hodge&Boakye,2001).

Theunderlyingbiochemistryoftheprocessesofneuronalgrowthisalsobeinginvestigatedandmaysomedaybeutilizedtoenhanceandsupportplasticity(Akaneya,Tsumoto,Kinoshita,&Hatanaka,1997;Barde,1989)andtreatneurodegenerativedisorderssuchasAlzheimer’sandParkinson’sdiseases(Carswell,1993).Theaccelerationorreestablishmentofsensitiveperiods,theenhancementoflearningandmemoryviabiochemicaladjustments,andthecultivationofnewcellsallsuggestthefuturepossibilityofintentionalandstrategicenhancementofneuralplasticity.Whilethesepotentialbiological

interventionsarecausesforhope,wearecurrentlycapableofenhancingplasticitythroughourday-to-daybehaviorsandinteractions.

EnrichedEnvironmentsandStimulatingLives

Intellectualgrowthshouldcommenceatbirthandceaseonlyatdeath.—AlbertEinstein

Ithasbeenknownfordecadesthatenrichedandstimulatingearlyenvironmentscanhaveapositiveandlong-termimpactonbothneuralarchitectureandneurochemistry.Researchhasdemonstratedthatwhenratsareraisedincomplexandchallengingenvironments,theyshowadvancesinmanyaspectsofbrainbuilding(seeTable17.1).Anenrichingenvironmentenablesmammalstobuildlarger,morecomplex,andmoreresilientbrains.

TABLE17.1TheImpactofEnrichedEnvironmentsinExperimentalAnimals

IncreasesIn

Weightandthicknessofcortex1

Weightandthicknessofhippocampi2

Lengthofneuronaldendrites3

Synapsesamongneurons4

Activityofglialcells5

Levelsofneuralgrowthhormones6

Levelsofneurotransmitters7

Levelofvascularactivity8

Levelofmetabolism9

Amountofgeneexpression10

Levelsofnervegrowthfactor11

Theeffectsoftheenvironmentinstimulatingbraingrowtharesorobustthatitoccurseveninsituationsofmalnutrition.Ifratsaremalnourishedbutplacedinenrichedenvironments,theywillhaveheavierbrainsthanwell-fedbutless-stimulatedrats.Thesefindingsexistdespitethefactthatthemalnourishedratsweighsignificantlyless(Bhide&Bedi,1982).Althoughnutritionalandenvironmentaldeprivationoftengohandinhand,somedeficitsmaybereversedinadulthood.Placingadultratsinenrichedenvironmentsenhancessynapticplasticityandamelioratestheeffectsofearliernervoussystemdamageandgeneticallybasedlearningdeficits(Altman,Wallace,Anderson,&Das,1968;Kolb&Gibb,1991;Maccarietal.,1995;Morley-Fletcher,Rea,Maccari,&Laviola,2003;Schrottetal.,1992;Schrott,1997).

Althoughcontrolledstudiesofnutritionalandenvironmentaldeprivationarenotpossiblewithhumans,somenaturallyoccurringsituationsoffersimilarinsightsintothepowerofenvironmentalenrichment.AstudyofKoreanchildrenadoptedbyfamiliesintheUnitedStatesfoundthatenvironmentalenrichmentcounteractedtheirearlymalnutritionanddeprivation.Onmeasuresofheightandweight,thesechildreneventuallysurpassedKoreanaverages,whiletheirIQscoresreachedorexceededaveragesforAmericanchildren(Winick,Katchadurian,&Harris,1975).Inadifferentstudyofpostmortembrainsamplesofolderadults,aconsistentrelationshipwasfoundbetweenthelengthofdendritesinWernicke’sareaandthesubjects’levelofeducation(Jacobsetal.,1993).Ithasalsobeensuggestedthatanenrichedenvironmentmayimprovepoststrokerecoveryinhumans(Ulrich,1984).

Thetheoryofcognitivereserve,whicharosefromtheseobservations,hastriggeredresearchcomparingthebrainsandcognitivefunctioninginlaterlifeofpeoplewithvaryinglevelsofchallengeandstimulation.Thecognitivereservehypothesissuggeststhatstimulatinglivesbuildmoreneuralmaterial,andthemoreyoubuild,themoreyoucanaffordtoloseandstillfunctioninacompetentmannerlaterinlife(Richards&Deary,2005;Stern,Alexander,Prohovnik,&Mayeux,1992).Anumberofthesestudiessupporttheideathatthosewhohavehadmoreeducationandchallengingoccupationstendtohavebrainsthatagebetterandresisttheonsetandprogressionofdementia.

Itisbelievedthatthecognitivedeclinesassociatedwithnormalagingarerelatedtothegradualdegenerationofdendrites,neurons,andthebiochemicalmechanismsthatsupportneuralhealthandplasticity(Jacobs,Driscoll,&Schall,1997;Morrison&Hof,2003).Peoplewithmorecognitivereservetypicallyhavehadbetterdiets,higherqualityeducations,andmoreintellectuallychallengingjobsthanthosewithlowerreserve(Sternetal.,2005;Whalley,Deary,Appleton,&Starr,2004).Factorslikelargerbrainsize,earlylearning,andgreateroccupationalattainmentareassociatedwithgreatercognitivereserveandseemtomitigatetheeffectsofAlzheimer’sdisease,traumaticinjury,andthegeneralimpactofbrainaging(Compton,Bachman,Brand,&Avet,2000;Kessleretal.,2003;Scarmeasetal.,2004;Schmandetal.,1997;Staff,Murray,Deary,&Whalley,2004;Sternetal.,1995).

Skillsmostdependentuponfrontalfunctions—suchasverbalfluency,controlledprocessing,andtheabstractthinkingdemandedbyhigh-complexityoccupations—appeartocontributemosttocognitivereserve(

Ardila,Ostrosky-Solis,Rosselli,&Gomez,2000;LeCarretetal.,2003).So,whilebeingacollegeprofessordoesnotprotectagainstcognitivedecline,fortunatelyforme,itmayslowdownsomeofitsmanifestations(Christensen,Henderson,Griffiths,&Levings,1997).About25%ofolderindividualsshowingnosymptomsofAlzheimer’sdiseasewhilealiveshowsignificantAlzheimer’s-relatedbrainpathologyuponautopsy(Ince,2001;Katzmanetal.,1989).Thosewithmoreeducationhadasignificantlygreateramountofplaquesandtanglesyetfunctionedaswellasotherswithlessadvanceddisease(Alexanderetal.,1997).Thissuggeststhatindividualswithmoreeducationcansustainagreateramountofneuraldamage,andstillmaintainthesamelevelofcognitivefunctioningasthosewithlesseducation.

Studieshavealsofoundthatexpectedage-relatedintellectualdeclinecanbehaltedorreversedinmanyolderadultsbyincreasingenvironmentalandsocialstimulation(Schaie&Willis,1986).Themostprobableexplanationwouldbethattheseexperiencescorrelatewithbiologicalprocessesthatenhanceplasticity,creatingmoreelaborate,complex,andflexiblebrains.Giventhatpsychotherapyisanenrichedenvironmentforsocial-emotionallearning,wecanassumethatthechallengesweprovideourclientsbuildmorecomplexandresilientbrains.Researchhasyettoexplorethepossibilitiesofenhancedlongevityandbrainhealthinthosewhoengageinpsychotherapy.

ModerateStatesofArousal

IamalwaysdoingthatwhichIcannotdo,inorderthatImaylearnhowtodoit.—PabloPicasso

Somethingwedoinallformsofpsychotherapythatenhancesneuralplasticityispayattentiontocreatingmoderatestatesofarousalinourclients.Regulatingsubjectiveunitsofdistressinsystematicdesensitization,balancingconfrontationandempathicattunementinpsychoanalysis,orcraftingthe“safeemergency”ofGestalttherapyallreflectanappreciationforthedelicatebalancebetweenchallengeandsupport.Weintuitivelyunderstandthatpeopleneedtobemotivatedandarousedtolearn,whilesimultaneouslyfreefromtheautonomicactivationthatshutsdowncorticalplasticity.Knowinghowtofindandkeepclientsinlearning’ssweetspotisavitalelementoftheartofpsychotherapy.

Thenontechnicalstorygoessomethinglikethis:Whenalliswellandweareinastateofcalm,thereisnoreasontolearnanythingnew.Whenourneedsforfood,companionship,andsafetyaresatisfied,thebrainhasdoneitsjobandthereisnoreasontoinvestenergyinlearning.Attheotherextreme,statesofhigharousalanddangerarenotimefornewcorticallearningbutacallforimmediatelimbicaction.Astateofmindsomewherebetweenthetwoappearsoptimalfornewlearningandproblemsolving(Anderson,1976).Anattitudebestdescribedasinterest,enthusiasm,orcuriosityisthoughttostimulatepositivearousal.Insecureattachment,thechildisabletousetheparentasasafehavenandavoidexperiencingautonomicactivationinresponsetostress.Asimilarprocessislikelytotakeplaceinasecuretherapeuticalliance,allowingclientstoverbalizetheirexperienceratherthandefendingthemselvesorfleeingfromthesituation.

Theformalizationofthisnotioninexperimentalpsychology,describedinaclassicpaperbyRobertYerkesandJohnDodson(1908),cametobeknownastheinverted-Ulearningcurve.Contrarytoexpectation,theyfoundthatmicelearnedtoavoidamoderateshockfasterthanoneofhighorlowintensity.Theychartedtheirfindingonagraphwitharousalonthex-axisandlearning(performance)onthey-axis(seeFigure17.1).Overtheyearsthissamephenomenonwasfoundacrossspeciesinavarietyoflearningtasks(Broadhurst,1957;Stennet,1957).Whilethisresearchtookplacebeforeweknewanythingabouttheneurochemistryoflearning,itmakessensethatthissameinverted-Upatternwillbereflectedintheunderlyingneurobiologicalprocessesoflearning(Baldi&Bucherelli,2005).

Wenowknowthatlearningdependsonbuildingnewdendriticstructures,andontheabilityofthesestructurestointerconnect.Buildingdendritesisdependentonthesynthesisofproteinsguidedbygenetictranscription,whileneuronalfiringshapesthearchitectureofthesedendritestoencodenewlearning.Notsurprisingly,thehormonessecretedbytheHPAaxisinresponsetostress(cortisol,norepinephrine,andendorphins),aswellasotherlearningmechanisms(NMDAreceptors,BDNFsecretion,etc.),modulatelearningonthesameinvertedU-shapedcurve(Hardingham&Bading,2003;Parsons,Stöffler,&Danysz,2007).Atmoderatestatesofarousal,amygdalaactivationopenswindowsofmodulatedstimulationwheretop-downplasticityisfacilitated(Popescu,Saghyan,&Paré,2007).Atmoderatelevelsofarousal,theseandmanymoresystemsenhancelearning,whileathighandlowlevelstheyinhibitnewlearning,inthissameinverted-Upattern.

FIGURE17.1TheInverted-ULearningCurve

Hippocampalneuronsrequirelowlevelsofcortisolforstructuralmaintenance,whilehigherlevelsofcortisolinhibittheirneuroplasticproperties(Gould,Woolley,&McEwen,1990).CortisolimpactslearningandplasticitybyregulatingtheproteinsynthesisrequiredfordendriticgrowthandpatternsofneuralconnectivitysuchasLTP,LTD,andprimedburstpotentiation(alow-thresholdversionofLTP)inthissamepattern(Diamond,Bennett,Fleshner,&Rose,1992;Domesetal.,2005;Lupien&McEwen,1997;Roozendaal,2000).Highlevelsofstressalsotriggerendorphinrelease,whichimpedesbothproteinsynthesisandtheconsolidationofexplicitmemory(Introini-Collison&McGaugh,1987).SeeTable17.2forasampleoffindingssupportingthispatternofthebiochemistryofarousalanditseffectsonlearning.

Overall,thevariousneuralsystemsdedicatedtolearningandarousalaretightlyinterwoven.Theyworktogethertoactivateplasticityandlearningwhenitisneededtoadapttochallenge,andturnitoffintheabsenceofchallengeorwhenthebodyneedstobemobilizedforimmediatesurvival.Theinverted-Ulearningcurvereflectsboththeunderlyingneurobiologicalprocessesandthemanyovertmanifestationsoflearningseeninthelaboratory,classroom,andconsultingoffice.Byunderstandingtheseprinciples,wecanusethemtooptimizeneuralplasticityintheserviceofpositivebrainchange.

TABLE17.2TheInverted-UCurveofLearningandArousal

mRNAexpression1

CortisollevelsVerbalmemory2Socialmemory3Spatialmemory4Hipprimeburstpotentials5Long-termpotentiation6

NorepinephrinelevelsOlfactoryplasticity7

EndorphinlevelsProteinsynthesisandmemoryconsolidation8

AttachmentPlasticity

Organicmatter,especiallynervoustissue,seemsendowedwithaveryextraordinarydegreeofplasticity.

—WilliamJames

Attachmentininfancyisusuallyconceptualizedasrelationshipspecific,whileattachmentinadulthoodisthoughtofasageneralaspectofcharacter.Earlyattachmentpatternsmaybecomegeneralizedandself-perpetuatingbecauseoftheirimpactonourneurobiology,ourabilitytoregulateouremotions,andtheexpectationswehaveofourselves,others,andtheworld.Thesensory,emotional,andbehavioralsystemsinfluencedbyearlyattachmentexperiencescanshapeourbrainsinwaysthatmakethepastamodelforcreatingthefuture.

Wehavelearnedagreatdealfromattachmentresearch:howourprimitivebondinginstinctsregulateanxiety,howcategoriesofattachmentreflectaparent’sbehaviorandachild’sreactiontostress,andhowattachmentschemasarecarriedintoadulthood,affectingourchoiceofpartners,thenatureofourrelationships,andthewayweparentourownchildren.Theenthusiasmwehaveaboutthepowerofattachmentcategoriestoexplainemotionaldevelopmentoftenfailstoacknowledgetheconsiderablefluctuationofattachmentstylesovertime.Inoursearchforastraightforwardexplanationofintimatehumanrelationships,itiseasytooverlooktheinstabilityofattachment.

Inanattempttosupportthepredictivepowerofattachmentschemas,fluctuationandchangeareattributedtomeasurementproblemsoruncontrolledexternalvariablessuchaspositiveandnegativelifeeventsorchangingrelationships.Butweseldomconsiderthatanattachmentschemashouldchangebecausewethinkofitasapersonalitytrait.Aswesawintheanimalresearch,maternalattentiontoratpupswasmediatedbytheenvironmentinwaysthatmadethepupsabetterfittotheenvironmenttowhichthemotherwasresponding.Perhapsbecauseourbrainsaresomuchmorecomplex,ittakesgreatereffortandtimeforustochange,buttheroleofattachmentmaybeessentiallythesameinhumans.

Inhumansubjects,weseethatadecreaseinsecurityorthemaintenanceofinsecurityduringadolescenceismorelikelytooccurinthepresenceofpsychological,familial,orenvironmentalstressors.Adolescentswhoseetheirmothersassupportivearemorelikelytogainsecurity,whilematernaldepressioncorrelateswithashiftfromsecuretoinsecureattachment(Allenetal.,2004;Hamilton,2000;Weinfield,Sroufe,&Egeland,2000).Overallsecureattachment,whilenotimpervious,appearsmoreresistanttochangethaninsecureattachment,whilenegativelifeeventsoperatetomaintaininsecureattachment(Hamilton,2000;Kirkpatrick&Davis,1994;Thompson,1982).Thesefindingscertainlyparalleltheanimalliterature.Themajorimplicationforpsychotherapyfromallofthesefindingsisthatinsecureattachmentissubjecttochangeasaresultofpositivesocialinput(Pilowskyetal.,2008).AsshowninTable17.3,theconsistencyofattachmentratings,primarilysecureversusinsecure,is24–64%dependingonthestudy.Thismaybebadnewsforthoseinterestedinattachmentasastabletrait,butgoodnewsforthoseofusinthebusinessofchange.

Asapsychotherapistwhoisveryinterestedinpositivechange,themessinessoftheattachmentconstructandthevariabilityofthedatacomeasgoodnews.Iwantattachmentschemastobeamalleableformofimplicitmemory,sorelationshipswithclientscanaltertheminasalubriousmanner.Inthisway,psychotherapybecomesaguidedattachmentrelationshipforthepurposesofassistedhomeostasis(moderatestatesofarousal)andeventualrepairofinsecureattachmentschemas(Aminietal.,1996;Cappas,Andres-Hyman,&Davidson,2005;Corrigan,2004;Siegel,1999).

TABLE17.3AttachmentPlasticity

TimeSpan PercentageofSubjectswithSameAttachmentClassification Source

6monthsduringinfancy 62(N=100) Vaughnetal.,1979

7monthsduringinfancy 53(N=43) Thompson,Lamb&Estes,

19822yearsduringinfancy 60(N=189) Egeland&Farber,19843.5yearsduringchildhood 24(N=223) Vondraetal.,2001

Childhoodtoadolescence 63(N=30) Hamilton,2000

Childhoodtoadolescence 42(N=84) Lewis,Feiring,&

Rosenthal,2000Childhoodtoadolescence 39(N=57) Weinfieldetal.,2000

Childhoodtoadulthood 64(N=50) Watersetal.,2000

17weeksduringadulthood 55(N=33) Lawsonetal.,2006

20sessionsofadulttherapy 34(N=29) Travisetal.,2001

Thesestudiesreflectanarrayofages,targetpopulations,andmethodsofassessingattachment.

Althoughthereisevidenceoforganizedattachmentschemasbyourfirstbirthday,theydonotappear

tobesetinneuralstone.Thesenaturallyoccurringchangesandthefactthatweattachandreattachwithmanypeoplethroughoutourlivessuggeststhattheunderlyingneuralsystemsmaintaintheirplasticity.Ifyoudoubtthis,askgrandparentswhethertheyfeelattachedtotheirgrandchildren.Insupportoftheneuroplasticityofattachmentnetworks,researchsuggeststhatadultscancreatesecureattachmentfortheirchildrendespitenegativeexperiencesintheirownchildhood.Earnedautonomy,throughthesubconsciousintegrationofearlynegativeexperiences,resultsintheabilitytoserveasasafehavenforone’sownchildren.

Thus,thepowerfulshapingexperiencesofchildhoodcanbemodifiedthroughpersonalrelationships,psychotherapy,andincreasedself-awareness.Theabilitytoconsciouslyprocessstressfulandtraumaticlifeeventsappearstocorrelatewithmoresecureattachment,flexibleaffectregulation,andanincreasedavailabilityofnarrativememory.Theintegrationofneuralcircuitryacrosscognitive,behavioral,sensory,andemotionaldomainsisthelikelyneuroanatomicalsubstrateofthisearnedautonomy.Ahealingrelationshipwithasecurepartnerorwithagood-enoughtherapist,inwhichpastpaincanbeprocessedandresolved,supportsearnedautonomyandneuralintegration.

ThePowerofaHealingRelationship

Beingdeeplylovedbysomeonegivesyoustrength,whilelovingsomeonedeeplygivesyoucourage.

—LaoTzu

Becauseourbrainsaresocialorgansinterwovenwiththebrainsofthosearoundus,relationshipshaveadirectimpactonthebiologyofthebrain.Psychotherapyissuccessfulinlargepartbecauseofthetherapist’sempathicabilitiesandtheclient’sbeliefinthetherapist’shumanityandskill.Throughtheinstillationofoptimismandhope,atherapist(oranyhealer)usespowerfulmechanismsofmindtoshapethefunctioningofthebrain.Themind’simpactonthebrainhasbeenstudiedinavarietyoffieldsfromsocialneurosciencetopsychoneuroimmunology,andreferredtoastheeffectsofexpectancy,placebo,orself-fulfillingprophecy.Theseareallexamplesofthemindleadingthebrainviathepowerofrelationships.

Thetermplacebo,Latinfor“Ishallplease,”reflectstheancientideathatresponsetoaninactivetreatmentresultsfromthepatient’sdesiretoliveuptothedoctor’sexpectations.Theplaceboeffecthasbeenexpandedtoincludesugarpillsandothernonactivetreatments,incontrasttowhatareconsideredtobeactivechemicalcompounds.Moregenerally,theplaceboeffectistheexpectationforillnessoutcomebasedonwhatthepatientisledtobelievebythedoctor.MoermanandJonas(2002)suggestedrenamingit“themeaningresponse,”reflectiveofthefactthattheplaceboeffectismediatedviathemeaningassignedtoitbythepatient.Untilmoderntimes,medicinemenandwomen,shamans,andwitchdoctorsunderstoodandutilizedthisphenomenonintheirroleastribalhealers(Frank,1963).Similarly,theexpectancyeffectislikelyatplayinthefactthatillChineseAmericansbornduringinauspiciousyearshavesignificantlyshorterlifespans.Thesizeofthiseffectisproportionaltohowstronglytheyholdontotraditionalculturalbeliefs(Phillips,Ruth,&Wagner,1993).PlaceboeffectsareseenasanuisanceinWesternscience,andthepatientsbenefitingfromthemarepathologizedasweakminded,impressionable,ormalingering.

Moderntechnologicalmedicinehasledtoadeclineintheuseofthemeaningresponseastheroleofthedoctorhasshiftedfromhealertotechnician.Thisisespeciallyironicgiventhatplacebocontrolgroupsareastapleoftheresearchuponwhichtheirclinicaldecisionmakingshouldbebased.Don’tthetime,money,andeffortexpendedinthisstandardofresearchmethodologysupportthepowerofpatientexpectancytoimpactsymptomexpression?Perhapsdoctorshavebecomefartooimpressedwiththeirtechnologywhileneglectingthepoweroftheirhumanity.

Inasimilarmanner,expectancyandplaceboeffectsareusuallyrelegatedtothecategoryofnonspecificeffectsinpsychotherapyoutcomeresearch.Iwouldarguethattheseeffectsareinfactspecific—thatis,weknowexactlywhatsocialandpsychologicalfactorsleadtohealing.CarlRogersoutlinedthemwellduringthe1960saswarmth,acceptance,caring,andunconditionalpositiveregard.Epidemiologistscallthemsocialsupport,networkconnectivity,andsharedspiritualbeliefs.Wewillsomedaybeabletospecifyandmeasuretheneuroanatomicalandbiochemicalmechanismsofpositivehumaninteractions.

Differentactivationpatternsinthebrainduringsuccessfulplaceboresponsereflectthemultipleneuralpathwaysinvolvedinmind–brainregulation.Inneuroscienceterms,theplaceboeffectisanexampleoftop-downcorticalmodulationofmood,emotion,andimmuneactivity(Beauregard,2007;Ocshneretal.,2004).Theplaceboeffectreliesheavilyupontheprefrontallobestointegratesocialexperienceswithpositiveaffectandanoptimisticstateofmind.Inthesamewaythatamothercanshapeachild’sbrainbystrokinghishairandtellinghimthatthingswillgetbetter,adoctorcaninfluenceaclient’simmunesystembypresentinganoptimisticprognosisandprojectingconfidenceabouttheproposedtreatment.

Theplaceboeffectisasocialphenomenonthatlikelyactivatesthesamerewardsystems(dopamine-

serotonin-endorphin)triggeredbylovingtouchandtheanticipationofpositiveconnectionsandfeelings(Esch&Stefano,2005;Fricchione&Stefano,2005).Theamygdala,whichregulatesourexperienceoffearandpain,isinhibitedbypositiveemotionsandactivatedbynegativeemotions(Neugebaueretal.,2004).Weknow,forexample,thatplaceboandopioidanalgesiashareacommonneuralpathway,whichstronglysuggestswearecapableofopioidself-administration(Parienteetal.,2005).

Therearemanyexamplesofthesocial,top-downregulationofemotion.Whenawomanholdsherhusband’shandinthefaceofthreat,fearactivationisattenuated.Notsurprisingly,thebettershefeelsabouttherelationship,thegreaterthesoothingeffectofhishandwillbe(Coan,Schaefer,&Davidson,2006).Soothingtouchisobviouslypowerful,butsotooisasoothingfacialexpressionorakindwordcommunicatedinanattunedemotionalstate.Someevidenceforthishasbeenfoundwhenlevelsofarousal(asmeasuredbyskinconductance)weremonitoredsimultaneouslyinclientsandtherapistsduringsessions.Duringstatesofmatchedarousal,thereweresignificantlymorepositivesocialandemotionalinteractionsbetweenclientandtherapistthanwhentheywereoutofsync(Marci,Ham,Moran,&Orr,2007).

EveninParkinson’sdisease,itisbelievedthattheanticipationofpositivereward(afrontal-corticalprocess)stimulatesthereleaseofdopaminefromthenucleusaccumbens(asubcorticalregioncalledtheventralstriatum).BecausedopaminedepletionisthecentralcauseofParkinsoniansymptoms,thisreleaseofdopamineresultsinsymptomaticimprovement.SeeTable17.4foranoutlineofstudiesthathavedemonstratedchangesinneuralactivationrelatedtotheplaceboeffect.

TABLE17.4TheImpactofPositiveExpectancy(Placebo)onBrainActivation

MajorDepressionIncreasedactivityinprefrontal,anteriorcingulate,premotor,parietal,posteriorinsula,andposterior

cingulate1Decreasedactivityinsubgenualcingulate,parahippocampus,andthalamus2

PainDisordersIncreasedactivityinlateralandorbitalPFC,anteriorcinglate,cerebellum,rightfusiformgyrus,

parahippocampus,andpons3Increasedactivityintherightdorsolateralcortex,anteriorcingularcortex,andmidbrain4Increasedbilateralorbitofrontalactivityandanteriorcingulatecortexcontralateraltopainstimulus5Reducedactivityinanteriorcingulatecortex,anteriorinsula,andthalamus6Increasedactivityintheprefrontalcortex7Activatedendogenousopioidsindlpfc,anteriorinsula,andnucleusaccumbens8

Parkinson’sDiseaseReducedactivityinsubthalamicnuclei9Increaseinstriataldopamine10

Whenphysiciansencouragetheirpeerstousetheplaceboeffecttoenhanceillnessoutcome,thesuggestionsareverysimilartothebasicprinciplesofclient-centeredtherapy.Forexample,anarticleintheJournalofFamilyPracticesuggesteda“sustainedpartnership”withpatientscharacterizedbyaninterestinthewholeperson,knowingthepatientovertime,caring,sensitivityandempathy,beingviewedasreliableandtrustworthy,adaptingmedicalgoalstotheneedsofthepatient,andencouragingfullparticipationbythepatient(Brody,2000).AnotherphysicianinapiecefromtheBritishMedicalJournalasked,“Forathousandyearstheactionoftheplacebohasmadevastnumbersofpatientsfeelbetter.Havewetodayprovidedaconsultationinwhichtheplacebodoesnotact?”(Thomas,1987,p.1202).Thesearetheaspectsoftraditionalhealingstillemployedbypsychotherapythatappeartohavebeenlostinmoderntechnicalmedicine.

Theimplicationsofthepoweroftheplaceboeffecttochangethebrainareprofound.Ouraweoftechnicalmedicineleadsustounderestimatetheimportanceofthedoctor’sroleashealer,andpatients’abilitiestocontributetotheirownhealingthroughthemodulationoftheirendogenousbiochemistry.Therearemanywaysinwhichthepoweroftheplaceboeffectcouldbeharnessedandusedtoincreasetheeffectivenessofmedicaltreatmentincludingincreasingvisits,encouragingandsupportiveinteractions,andshapingpatients’experiencesbytellingthemwhatpositiveoutcomestheyshouldexpect(Walach&Jonas,2004;seeTable17.5foralistoftheirsuggestions).Ironically,weareonlyrequiredtotellclientsofthemanyrisksandnegativesideeffects,whichlikelyguidetheirresponsetotreatmentintheoppositedirection.

TABLE17.5LeveragingthePlaceboEffectinMedicalTreatment

IncreasefrequencyofcontactDeterminewhattreatmentsyourpatientbelievesinAlignbeliefsamongpatient,doctor,family,andcultureBesureyoubelieveinthetreatmentyouareadministeringInformpatientsaboutwhattheycanexpectDelivertreatmentinawarmandcaringwayListenandprovideempathyandunderstandingTouchthepatient

Findingsfromthemedicalresearchsupportingthepowerofspecificdoctor-patientinteractions.AdaptedfromWalachandJonas(2004).

Allofthe“givens”ofclassicalhealingandpsychotherapyhavebeensqueezedoutofmodernWesternmedicine.Perhapsthesenonspecificingredientsofahealingrelationshipwillsomedaybeinterwovenwiththetechnicalaspectsofmodernmedicine.

Summary

Thepowerofpsychotherapytochangethebrainrestsinourabilitytorecognizeandalterunintegratedordysregulatedneuralnetworks.Asknowledgeofneuralplasticityandneurogenesisincreases,sowillourabilitytoimpactandalterthebrain.Thepossibilityexiststhatsensitiveperiodscanbereinstatedinthecontextofpsychotherapy,andthatstresscanbeutilizedinacontrolledmannerto“editandre-edit”emotionalmemories(Postetal.,1998).Althoughthepracticalapplicationoftheseprinciplestohumansremainsonthedistanthorizon,thepossibilitiesoftheinvolvementofpsychotherapyinbrainsculptingareevident.Itiscertainthatpsychotherapistsarealreadyenhancingplasticitywithoutthehelpofgeneticmanipulationorchemicalinterventions.

Therapyisasafeemergencybecauseofthesupportivestructureinwhichdifficultemotionallearningtakesplace.Aclient’ssenseofsafetyisenhancedbythetherapist’sskill,knowledge,andconfidence,whichsupportemotionalregulationandmaintainingmoderatestatesofarousal.Itisquitepossiblethatthecaring,encouragement,andenthusiasmofthetherapistalsoreinforcelearning,neuralgrowth,andplasticitythroughtheenhancedproductionofdopamine,serotonin,andotherneurochemicals(Barad,2000;Kilgard&Merzenich,1998;Kirkwood,Rozas,Kirkwood,Perez,&Bear,1999).Successfultherapeutictechniquesmaybesuccessfulbecauseoftheirveryabilitytochangebrainchemistryinamannerthatenhancesneuralplasticity.

Intherecentshifttoneuraloptimism,criticalperiodsofneuraldevelopmentarebeingreconsideredasimportantbut,perhaps,notthefinalwordonneuralstructure.Theimpactofenrichedenvironmentshasdemonstratedthebrain-buildingcapacityofpositiveexperiencesthroughoutthelifespan.Morerecentresearchinneuralplasticity(e.g.,use-dependentplasticity,neurotransmitteralteration,stemcellimplantation)suggeststhatnewexperiences,andfuturepotentialbiologicalinterventions,maybecapableofprovidinguswithmanytoolswithwhichtorebuildthebrain.Psychotherapyisonthevergeofanexplodingnewparadigm:thepsychotherapistasneuroscientist.

Chapter18

ThePsychotherapistasNeuroscientist

Inthisfieldwearemerelyatthefoothillsofanenormousmountainrange…unlikeotherareasofscience,itisstillpossibleforanindividualorsmallgrouptomakeimportantcontributions.

—EricKandel

Psychotherapistsareappliedneuroscientistswhocreateindividuallytailoredenrichedlearningenvironmentsdesignedtoenhancebrainfunctioningandmentalhealth.Weareskilledatteachingclientstobecomeawareofunconsciousprocessing,takeownershipoftheirprojections,andriskanxietyintheserviceofemotionalmaturation(Holtforthetal.,2005).Inourwork,illusions,distortions,anddefensesareexposed,explored,andtestedormodifiedwithunderstandingsclosertoreality.Implicitmemory—intheformofattachmentschemas,transference,andsuperego—aremadeconsciousandexplainedasexpressionsofearlyexperiences.Weuseacombinationofempathy,affect,stories,andbehavioralexperimentstopromoteneuralnetworkgrowthandintegration.

Throughallofthiswork,subcorticalnetworksthatstorememoriesoffears,phobias,andtraumasareactivatedandmadeaccessibleforintegrationwithcorticalinhibitorycircuitry.Thisessentialintegrationallowsforlinkageamongexplicitandimplicitcircuits,consciousawareness,andthecontrolofnegativememories,sensations,andemotions.Regardlessoftheclient’sparticularproblem,psychotherapyteachesamethodtohelpusbetterunderstandanduseourbrains.Andasthedialoguebetweenpsychotherapyandneurosciencecontinuestoevolve,anincreasingnumberofscientificfindingswillbeappliedtoboththeoryandclinicalpractice.

Importantfactorsinthetherapeuticprocesshavebeenidentifiedasanempathicandsupportiverelationship,maintenanceofmoderatestatesofarousal,activationofbothcognitionandemotion,andco-constructionofnarratives.Asafeandempathicrelationshipestablishesanemotionalandneurobiologicalcontextconducivetoneuralplasticity.Italsoservesasascaffoldwithinwhichaclientcanbettertoleratethestressrequiredforneuralreorganization.Wehavealreadyseenthatbirdsareabletolearntheirsongsaftersensitiveperiodswhenexposedtootherbirdssinging,butareunabletolearnthesamesongsheardfromataperecorder(Baptista&Petrinovich,1986).Undercertainconditions,birdsrequirepositivesocialinteractionsandnurturanceinordertolearn(Eales,1985).Andthestrongertherelationshipbetweenhumantrainersandtheirbirds,thegreaterthelearningwillbeforboth(Pepperberg,2008).Thesestudies,combinedwithwhatweknowaboutchangesinbiochemistryduringinterpersonalinteractions,suggestthatapositiveandattunedrelationshipenhancesneuralplasticityandlearning.Thenearlyinsatiabledriveofadolescentstobeinconstantcontactwithoneanothermayreflecttheunderlyingdriveforneuralstimulationduringthiscrucialdevelopmentalperiod.Emotionalexpressionandmodulationhavebeenincorporatedintopsychotherapybecauseoftheirimpactontheseunderlying

biologicalprocesses.Theimportanceoftheactivationofbothemotionandcognitionisrecognizedbymost

psychotherapists.Releasingemotionsassociatedwithpainfulmemories,facingafearedsituation,orexperimentingwithnewinterpersonalrelationshipsallinvolvesomesortofstress,anxiety,orfear.Althoughthiswayofthinkinghasbeenacceptedclinically,wenowhaveconsiderableevidencetosupporttheideathatmoderatelevelsofarousaloptimizetheproductionofneurotransmittersandneuralgrowthhormonesthatenhanceLTP,learning,andcorticalreorganization(Cowan&Kandel,2001;Zhu&Waite,1998).

Traumaundoubtedlychangesusinmanyways,fromourstartleresponsetoourattachmentsandself-identity.Dissociationinreactiontotraumarepresentsabreakdownofneuralintegrationandplasticity.Intherapy,weusemoderatelevelsofarousaltoaccesscorticalmechanismsofplasticityincontrolledwayswithspecificgoals.Thesafeemergencyoftherapyprovidesboththepsychologicalsupportandthebiologicalstimulationnecessaryforrebuildingthebrain.Muchofneuralintegrationandreorganizationtakesplaceintheassociationareasofthefrontal,temporal,andparietallobesservingtocoordinate,regulate,anddirectmultipleneuralcircuitsofmemoryandemotion.

Theimportanceoftheco-constructionofnarrativesisgroundedinthecoevolutionofthecerebralcortexandlanguage,reflectingtheevolutionofourbrainsassocialorgans.Languagewithinsignificantrelationshipshasshapedthebrainduringevolutionandcontinuestodosothroughoutourlives.Becauseofthis,narrativesembeddedwithinanemotionallymeaningfulrelationship(likepsychotherapy)arecapableofresculptingneuralnetworksthroughoutlife.Throughtheuseofautobiographicalmemory,wecancreatenarrativesthatbridgeprocessingfromvariousneuralnetworksintoacohesivestoryoftheself.Narrativesallowustocombine—inconsciousmemory—ourknowledge,sensations,feelings,andbehaviorssupportingunderlyingneuralnetworkintegration.

Theco-constructionofnarrativeswithparentsservesasamediumoftransferoftheinternalworldoftheparenttothechild,fromgenerationtogeneration.Thesenarrativesreflecttheimplicitvalues,problem-solvingstrategies,andworldviewsoftheparents.Theyalsoservetodefineustoourselvesandothers,andguideusthroughourcomplexsocialworld.Themoreinclusiveournarrativesareintermsofblendingsensation,emotion,andcognition,thegreaterourongoingabilitytointegratemultipleneuralnetworks.Researchinattachmenthasdemonstratedthatthecoherenceandinclusivenessofnarrativescorrelatewithbothattachmentsecurityandself-reflectivecapacity(Main,1993;Fonagy,Gergely,Jurist,&Target,2002).

Intheprocessofevolution,differentlevelsoflanguagehaveemergedthatappeartoparalleldifferentlayersofconsciousness:

1. Areflexivesociallanguage(ofthelefthemisphereinterpreter)servesthepurposeofcreatingalogicallycohesiveandpositivepresentationtoothers.Thislanguageevolvedfromgroomingandhandgestureswiththeprimarygoalofgroupaffiliationandcoordination.

2. Aninternallanguage,alsoreflexive,allowsustohaveprivatethoughts,planandguidebehavior,anddeceiveothers.Thereisanaspectofinternallanguagethatpreservesearlylearningexpressedthroughcriticalvoicesinourheads,reflectingearlyshameexperiences.

3. Athirdlanguage,oneofself-reflection,appearstobefarlessreflexiveandarisesinstatesofopenness,lowdefensiveness,andsafety.

Althoughthefirsttwolevelsoflanguageoccurspontaneously,self-reflectivelanguagerequireshigherlevelsofneuralnetworkintegration,affectregulation,andcognitiveprocessing.Reflexivelanguagekeepsusinthepresentmoment,whilereflectivelanguagedemonstratesourabilitytoescapefromthepresentmoment,gainperspectiveonourthoughtsandfeelings,andmakedecisionsaboutwhatwewouldliketochangeandhowtochangeit.Attainingandutilizingthisleveloflanguageisonegoalofpsychodynamicpsychotherapy.

Threelevelsoflanguagesharingacommonlexiconcanresultinagreatdealofconfusion.Manypeoplereportfeelingcrazybecauseofthesimultaneousandcontradictorybeliefstheystrugglewithonaday-todaybasis.Psychotherapyofteninvolvessortingouttheseaudiotracksinordertoprovideuswithaclearerideaofjustwhatisgoingoninthere.Theco-constructionofnarratives,inthecontextofahealingrelationship,whichsortouttheseinnercontradictionsmaywellbetheoptimalcontextforsignificantplasticityinsocioemotionalneuralnetworks.

DiagnosisandTreatment

Theprincipalactivitiesofbrainsaremakingchangesinthemselves.—MarvinL.Minsky

Functionalbrainimaginghasopenedawindowtothelivinghumanbrainintheactsofmotortasks,imaginingafearedsituation,beingempathic,ortellingalie.Anexaminationofareasactivatedduringtheseandmanyotherbehaviorshasenhancedourunderstandingofwhichneuralnetworksparticipateinvarioushumanfunctions.Althoughtheapplicationofscanningtechnologytopsychopathologyisstillinitsinfancy,therehavealreadybeenmanyimportantandprovocativefindings.Asscanningtechniquesbecomemorepreciseandthehardwaremoreaffordable,theywillnodoubtbecomeincorporatedintothepracticeofpsychotherapy.

Neuroimaginghasthepotentialtoaidindiagnosis,treatmentselection,andthepredictionoftreatmentoutcome(Etkinetal.,2005;Linden,2006).Aspartofaninitialassessment,itcouldhelptherapistspinpointareasofneuralactivationandinhibition.Treatmentplanningwilleventuallycometoincludespecificpsychotherapeuticandpharmacologicalinterventionstoenhancethegrowthandintegrationofaffectednetworks.Regularscansduringthecourseoftherapymaysomedaybeausefuladjuncttopsychologicaltests,aswaysoffine-tuningthetherapeuticprocessandmeasuringtreatmentsuccess.

Associationsbetweenpsychiatricsymptomsandchangesintherelativemetabolismofdifferentareasofthebrainareintheprocessofbeinguncovered.Wehavealreadyseenlowerlevelsofmetabolismintheleftprefrontalcorticesofdepressedpatients(Baxteretal.,1985,1989)andincreasedmetabolismintherightprefrontalandlimbicregionofpatientswithPTSD(Rauchetal.,1996).TheimportanceoftherightfrontalregioninPTSDissupportedbyclinicalevidencesuchastheonsetofPTSDafterinjurytotherightfrontalarea(Berthier,Posada,&Puentes,2001)anda“cure”ofPTSDsymptomsafterarightfrontallobestroke(Freeman&Kimbrell,2001).TheinhibitionofBroca’sareaduringintensefearstatesisalreadyafocusofcognitive-behavioraltherapies,andareactivationofthelanguagecentersmaybecomeastandardmeasureofsuccessinthetreatmentofPTSDandotheranxiety-relateddisorders.Allofthesefindingssupporttheexistenceofspecificcircuitryinvolvedintherecognition,reaction,andregulationofanxietyandfearintheaftermathoftraumaticexperiences.

Thefocusofthisnewwork,however,issomewhatdifferentthantheoldlocalizationtheoriesthatattributeddisordersofbehaviortospecificareasofthebrain.Wenowunderstandthateachregionofthe

brainparticipatesinmultipleneuralsystemswithhighlycomplexinteractionsandhomeostaticfunctions.Thus,itisactuallytherelationshipbetweenclinicalsymptomsandrelativeactivitylevelsofspecificneuralnetworksthataresalient.Theneurobiologyofobsessive-compulsivedisorder(OCD)hasbeenofparticularinterestinthisregard.AneuralcircuitthoughttomediateOCDincludestheompfcandsubcorticalstructurescalledthecaudatenucleus,globuspallidus,andthalamus.Thiscortical-subcorticalcircuit,involvedwiththeprimitiverecognitionofandreactiontocontaminationanddanger,becomeslockedintoanactivationloopinpatientswithOCD(Baxteretal.,1992).Itishypothesizedthattheompfc,orsomeothercomponentoftheOCDcircuit,activatesthecircuitwithaworrysignal,decreasinginhibitionofthethalamus,whichinturnexcitestheompfcandcaudate(Baxteretal.,1992).Theresultisafeedbackloopthatishighlyresistanttoinhibitionorshuttingdown.

NetworkHomeostasisandTreatmentOutcome

Theconstantconditionswhicharemaintainedinthebodymightbetermedequilibria.—WalterCannon

Considerableevidencesupportstheideathatthereregulationofneuralnetworksparallelssomeofthesymptomaticchangeswewitnessinpsychotherapy.Ingeneral,decreasesinfearandanxietycorrelatewithactivationreductionsinbottomandrighthemisphereregions.InOCD,thereisareductioninactivationinaregiondedicatedtothecontrolandinhibitionofimpulses(ompfc).Inthesuccessfultreatmentofsocialandspiderphobias,thereisadecreaseinactivationinlimbicandprimitivecorticalareasandinrighthemisphereprocessing,parallelingthedecreasedfearactivationthatgoesalongwithsymptomreduction.Insituationswherethereisadeficitincognitiveprocessingsuchasinschizophreniaandbraininjury,weseesymptomreductioncorrelatedwithincreasedfrontalactivation.Keepinmindthatthecorrelationsdonotprovecausalrelationships;changesinbrainactivationpatternscouldalsobesecondarytosymptomaticchanges,orbothcouldbeduetosomethirdunknownfactor.

PatternsofbrainactivationinbothpanicdisorderandPTSDareabitmorecomplex.Inbothofthesedisorders,sensoryandmemorynetworksarehijackedbytheamygdalaandbecomeinternalsourcesoffear.Whilestudieshavenotyetfocusedonchangesinbrainactivationrelatedtopositivetreatmentoutcome,wecanspeculatethatpositivetreatmentresponsewouldcorrelatewithdecreasedactivationintheamygdala,sensorymotorareas,andthecerebellum(Bryantetal.,2008;Pissiotaetal.,2002),alongwithincreasedompfcactivation(Phanetal.,2006;Williamsetal.,2006).Therewouldalsobeadecreasedactivationinregionsdedicatedtoautobiographicalmemory,andanincreaseintheprocessingofinformationfromthecurrentexternalenvironment(Sakamotoetal.,2005).

Psychotherapyoutcomeresearchwithanumberofdisordershasfoundchangesinbrainactivationparallelingsymptomaticimprovement.Ineachcase,treatmentseemstohavereestablishedahomeostaticbalancebetweeninteractiveneuralnetworksthatwerepreviouslyoutofbalance.Table18.1outlinesthestudiesthathavebeenperformedtomeasuretheneuralcorrelatesofsuccessfultherapyacrossavarietyofpatientpopulations.

TABLE18.1

SuccessfulPsychotherapyandChangesinNeuralActivation

DiagnosisandTreatment Result

OCDBTvs.fluoxetine Both:Decreasedmetabolisminrightcaudate1

BTvs.fluoxetine BT:LeftompfcactivationcorrelatedwithpositiveresponseFluoxetine:changesintheoppositedirection2

BTvs.controls DecreasedCBFinrightcaudate3

CBT DecreasedmetabolisminrightcaudateCBTandfluoxeitine Increasedbilateralgreymatter4

Increasedrightparietalwhitematter5

SocialphobiaCBTvs.citalopram Both:decreasedamygdala,hippocampal,andadjacentcortexactivation

CBT:decreasedperiaqueductalgrayactivationCitalopram:decreasedthalamicactivation6

SpiderphobiaCBT Decreasedactivationinparahippocampalgyrusanddlpfc7

CBT DecreasedPFCactivationbiasedtowardrighthemisphere8

CBT Decreasedactivationintheinsulaandanteriorcingulate9

Post-traumaticstressdisorderEMDR(casestudy) Increasedactivationinanteriorcingulateandleftfrontallobe10

PanicdisorderCBTvs. CBT:RHdecreasesininferiortemporalandfrontalregionsAntidepressants LHincreasesininferiorfrontal,medialtemporal,andinsula

Antidepressants:RHdecreasesinfrontalandtemporallobesLHincreasesinfrontalandtemporallobes11

CBT Decreasedactivationinrighthippocampus,leftACC,leftcerebellumandponsIncreasedactivationinmedialprefrontalcortex12

MajordepressivedisorderCBTvs.paroxetine CBT:decreasedfrontalactivation/increasedlimbic

Paroxetine:changesintheoppositedirection13

CBTvs.venlafaxine Both:decreasedbilateralopfcandleftmpfcactivationandincreasedactivationinrightoccipital-temporalcortex14

IPTvs.venlafaxine IPT:increasedactivationinrightposteriorcingulateandrightbasalgangliaVenlafaxine:increasedactivationinrightposteriortemporalandrightbasalganglia15

IPTvs.paroxetine Both:decreasedactivationinprefrontalcortexBoth:increasedactivationininferiortemporalandinsula16

IPTvs.paroxetine Both:symptomreductionwithdecreasedfrontalactivationBoth:positivecorrelationwithcognitivesymptoms17

SchizophreniaCognitiverehab Increasedfrontalactivationwithimprovedperformance18

Cognitiverehab Increasedactivationinrightinferiorfrontalcortexandoccipitallobe19

Traumaticbraininjury

Cognitiverehab Globalactivationincreasein3of5patients20

Theresultsshowninthistableshouldbeconsideredpreliminarybecauseofsmallsamplesizesandvariationsinmethodology.

BT,behaviortherapy;CBT,cognitive-behavioraltherapy;IPT,interpersonaltherapy;EMDR,eyemovementdesensitizationandreprocessing.AdaptedandexpandedfromRoffmanetal.(2005).

FunctionalscanstudieshavedemonstratedthatimprovementofOCDsymptomsiscorrelatedwith

decreasedactivationoftheompfcandcaudatenucleus(Rauchetal.,1994).Especiallyinterestingtopsychotherapistsisthefactthatthesechangesinbrainmetabolismarethesamewhetherpatientsaresuccessfullytreatedwithpsychotherapyormedication(Baxteretal.,1992;Schwartzetal.,1996).Althoughpsychotherapyandmedicationarethefirstchoicesfortreatment,theyarenotalwayssuccessful.Scan-guidedpsychosurgeryforpatientswhodonotrespondtoanyotherformsoftreatmentcandisruptrunawayfeedbackbyseveringneurallinkswithintheOCDcircuit(Biveretal.,1995;Irle,Exner,Thielen,Weniger,&Ruther,1998;Rubinoetal.,2000).

Becausesymptomscanhavemultipleunderlyingcauses,diagnosesaidedbyneuralnetworkactivitycouldimprovediagnosticaccuracy.Increasedspecificitywillnaturallyleadtoincreasinglyspecificpsychotherapeuticandpharmacologicalinterventions.Tourette’ssyndrome—adisordercharacterizedbyinvoluntaryvocalizationsandmotortics—oftenoccursinindividualswhoalsosufferwithOCD,enuresis,orADHD.Thisisnotacoincidence,becausethesedisordersshareunderlyingneuralcircuitryandneurotransmitters(Cummings&Frankel,1985).Theyallstemfromproblemswiththeinhibitionofsubcorticalimpulsesbythefrontalcorticalareas.Thus,structural,biochemical,andregulatoryabnormalitiesintheseinterrelatedtop-downnetworkscanresultinallfourconditions.Whenthiscircuitismorefullyunderstood,symptomsofOCD,ADHD,enuresis,andTourette’ssyndromemayallbecomesubsetsofsomefuturediagnosisreferredtobytheneuralnetworksresponsibleforthesefunctions.

Inanxietyanddepression,somestudiesshowthattherapyachievesresultsthroughincreasedcorticalversussubcorticalactivation,whileothersshowchangesintheactivationpatternswithinthefrontallobes(Portoetal.,2009).Andwhilepsychotherapyandmedicationcanbothleadtosymptomreduction,thereisonlypartialneuroanatomicaloverlapinhowtheyachievetheirresults(Roffmanetal.,2005).Inotherwords,thesameresultscanbeachievedbydifferenttreatmentstrategiesandthroughchangesinthebalanceamongdifferentneuralnetworks.Thisisinnowaybadnewsforpsychotherapy.Cognitivetherapybyexperiencedtherapistsisequallyefficaciousasmedicationinmoderatetoseveredepression(DeRubeisetal.,2005).Fordepressedpatientswithahistoryofchildabuse,psychotherapyhasbeenshowntobemoreeffective,withtheadditionofmedicationshowingsmallbenefits(Nemeroffetal.,2003).

TheCentralityofStress

It’snotstressthatkillsus,itisourreactiontoit.—HansSelye

Althoughsomestressisanormalpartoflife,early,prolonged,orseverestresscanresultinsignificantandlong-termimpairmentsinlearning,attachment,andphysiologicalregulation(Glaser,2000;O’Brien,1997;Sapolsky,1996).Stressplaysaroleintheexpressionandseverityofmost,ifnotall,psychiatricandmedicaldisorders.Therefore,assessingandtargetingstressasafocusofpsychotherapeuticinterventionshouldalwaysbeanaspectofhealingrelationships.Sincetherapistsaretrainedtothinkintermsofdiagnosticcategoriesandtreatmentmodalities,stressoftenfliesunderourdiagnosticradar.Understandingandworkingtoregulateourclients’stressiscentraltopsychotherapeuticsuccessbecauseofitsimpactonneuroplasticprocesses.

Anemergingconceptintreatmentinvolvesbufferingvictimsofstressfromneuralcompromisebyalteringtheirneurochemistry.Onewayofaccomplishingthisistoblockthesecretionoruptakeofnorepinephrineandglucocorticoidssoonafteratraumaticexperience(Brunetetal.,2008;Liuetal.,1997;Meaneyetal.,1989;Watanabe,Gould,Daniels,Cameron,&McEwen,1992).Ithasalsobeenfoundthattheneurotransmitterneuropeptide-Yisfoundinhigherconcentrationsintheamygdalasofindividualswhorespondmorefavorablytohighlevelsofstress(Morganetal.,2000).Artificiallyincreasinglevelsofneuropeptide-Ymaybufferthenervoussystemfromsomeofthedamagingeffectsofstress.

ChemicalblockadeordisruptionofparticularamygdalacircuitsmaydecreasesomeofthesymptomsofPTSDsuchasthestartleandfreezeresponses(Goldstein,Rasmusson,Bunney,&Roth,1996;Lee&Davis,1997).Ithasevenbeensuggestedthatstimulationoftheamygdalacouldleadtotheextinctionofconditionedfear(Li,Weiss,Chaung,Post,&Rogawski,1998).UnderstandingtheroleofLTPandotherformsofplasticityintheamygdala,aswellasitsroleinfearconditioning,mayprovideanotheravenueforfutureinterventionsinpsychosisandPTSD(LaBar,Gatenby,Gore,LeDoux,&Phelps,1998;Rogan&LeDoux,1996;Rogan,Staubli,&LeDoux,1997).

Wehaveseenthathigherlevelsofmaternalattentioninratsdecreasethepups’subsequentHPAactivationinresponsetostress(Liuetal.,1997).AlthoughIdoubtthatencouraginghumanmotherstolicktheirchildrenwillbeofmuchhelp,humaninfantsdemonstratethesamepatterninresponsetomaternalmassage(Fieldetal.,1996),andwithinsecurelyattachedrelationships(Spangler&Grossman,1993).Maternaldepression,separation,anddeprivationareseverestressorsforinfants,resultinginavarietyofnegativebiological,emotional,andsocialconsequences(Gunnar,1992).Aggressivetreatmentofdepressioninnewmothers,alongwithteachingthemhowtomassageandbetterinteractwiththeirinfants,maycounteractsomeofthenegativeimpactofmaternaldepression.Therapyfocusedonresolvingamother’sattachmentdifficultiesorpasttraumapriortogivingbirthmayalsobehelpfulinreducingstressintheirinfants,children,andadolescents(Trapolini,Ungerer,&McMahon,2008).

Anincreasedappreciationoftheeffectsofmaternalseparationmayguideusastotheadvisabilityofoptionalinfant–motherseparation.Whereseparationisunavoidableincasesofillnessanddeath,theabilitytolessentheimpactofstresshormonesviainterpersonalandchemicalinterventionsmaypreventproblemslaterinlife.Giventheamountofexposureinoursocietytostressfuleventssuchasabuse,neglect,abandonment,andcommunityviolence,theimpactofseverestressonmothersandthedevelopingbrainsoftheirchildrenshouldbeaseriouspublichealthconcern(Bremner&Narayan,1998).

Researchfindingssuggestthatearlystressleadstoavulnerabilitytodepressionlaterinlife(Widom,DuMont,&Czaja,2007).This,inpart,ismediatedbydeficientorganizationoffrontalcircuitry,andtheestablishmentoflowerlevelsofexcitatoryneurotransmittersandgrowthhormonesduring

sensitivedevelopmentalperiods.Earlychildhoodexperiencesleadingtoabiastowardrighthemisphereactivationmayalsoplayaroleinthelong-termdevelopmentofdepression.Aswediscussedinthechapteronlaterality,magneticstimulationofthelefthemisphereofdepressedpatientsandtherighthemisphereofpatientswithmaniahasshownpromisingresultsandmayserveasafuturealternativetoelectroconvulsivetherapy(Grisaruetal.,1998;Kleinetal.,1999;Tenebacketal.,1999;Pascual-Leoneetal.,1996).

Inlinewiththesefindings,activationofthelefthemispherethroughsensorystimulationresultsinahigherdegreeofself-servingattributionsandpositiveaffect(Drake&Seligman,1989).Relativeleftfrontalactivationappearslinkedtoastateofmindof“self-enhancement,”whichmaydecreasetheriskforpsychopathologyandbemanipulatedbychangesinattitudeorpracticessuchasmindfulnessmeditation(Tomarken&Davidson,1994).Themoreweunderstandtherelationshipbetweenlateralityandaffect,themorewemaybeabletoincorporatetechniquesofselectiveactivationofrightandlefthemispheresintomultimodaltreatmentsformooddisordersandotherpsychiatricdifficulties.

PTSDisprimarilymediatedandmaintainedbyneurobiologicalprocessesoutsideconsciouscontrol.TheactivationofBroca’sareainthefaceofhighlevelsofaffectappearstobeanimportantmechanismofactioninmostinterventionswithpatientssufferingfromPTSDandotheranxietydisorders.Weknowthattheompfcmodulatesandinhibitsamygdalaactivity,theverycircuitweareactivatingwhenwehelpclientstoemploycognitiontoinhibittheirfears.

Despitenewtheoriesconnectingneuralcommunicationandpsychopathology,nomajorformofpsychotherapyhasemergedwiththestatedgoalofneuralnetworkintegration.Thisbeingsaid,techniquessuchasthecalorictestandtheeyemovementsusedinEMDRseemtoinvolveleft-rightandtop-downintegrationasanactiveelement.Previously,wediscussedthephenomenonofsensoryneglect,whichoccurswhenthereisdamagetotherightparietallobe(assumedtoberesponsiblefortheintegrationofsensoryandmotorinformationfrombothsidesofthebrain).Inthecalorictest,stimulationwithcoldwatertotheleftearresultsinrapidside-to-sideeyemovementswhileactivatingregionsoftherighttemporallobe(Fribergetal.,1985).Althoughtherehasbeenonereportofpermanentremissionofsensoryneglectwiththistreatment,formostthecureisonlytemporary(Rubens,1985).Thebilateralactivationofattentionalcentersinreactiontothecalorictestresultsinincreasedintegrationofpreviouslydissociatedattentionandinformation-processingsystems(Bisiachetal.,1991).

InthetreatmentofPTSDwithEMDR,pasttraumaticeventsarerecalledandsubjectedtoaprotocolthatinvolvesfocusingattentiononideas,self-beliefs,emotions,andbodilysensations.Inaddition,EMDRusesperiodicstimulationthroughwatchingthetherapist’shandgoingbackandforthorhavingthelegstouchedalternately(Shapiro,1995).Thisbilateralandalternating(side-to-side)stimulationmayservetoactivateattentioncentersinbothtemporallobesinamannersimilartothecalorictest.Alternatingactivationmay,infact,enhanceneuralnetworkconnectivityandtheintegrationoftraumaticmemoriesintonormalinformationprocessing.

TechniquessuchasEMDRmaythwartorreversethebrain’stendencytowardneuralnetworkdissociationsecondarytotrauma.Bilateralstimulationmayenhancethereconsolidationoftraumaticmemorieswithcortical-hippocampalcircuitsprovidingcontextualizationintimeandplace.Activationofthesesamecircuitscreatesthepossibilityofbuildingdescendinginhibitorylinkstosubcorticalsensory-affectivememorycircuits(Siegel,1995).Thus,theright-leftstimulationofattentionmaysimultaneouslytriggerintegrationofaffectwithcognition,sensation,andbehaviorthroughoutthebrain.

Oncetherelationshipsamongneuralcircuitsaremorefullyunderstood,psychotherapistsmayemploytheseandothernoninvasivetechniquestostimulatethebraininwaysthatenhanceneuralnetworkintegration.Couldactivationofrighthemisphereemotionalregionsduringtherapywithalexithymicpatientsaidintheintegrationofemotionalprocesseswithlefthemispherelinguisticcircuitry?Couldactivationofthelefthemisphereduringemotionaldyscontrolinborderlinepatientsenhancetheirability

togaincognitiveperspectiveandemotionalregulation?Forconditionsinvolvingtoomuchemotionalinhibition,newlearningmaybestimulatedbycreating

moderatelevelsofaffectintherapy;thislearning,inturn,maycreateabiochemicalenvironmentmoreconducivetotheintegrationofemotionalcircuitryintoconsciousness(Bishof,1983;Chambersetal.,1999).ThismaybetheunderlyingneurobiologyofFreud’sbeliefthatthepresenceofaffectisnecessaryforchange.Simultaneousactivationofneuralnetworksofemotionandcognitionmayresultinabindingofthetwoinawaythatallowsfortheconsciousawarenessandintegrationofemotion.

TreatmentRationalesandCombinations

SometimesIlieawakeatnight,andask,“WherehaveIgonewrong?”Thenavoicesaystome,“Thisisgoingtotakemorethanonenight.”

—CharlesSchulz

Thefundamentalpremiseputforthinthisbookisthatanyformofpsychotherapyissuccessfultothedegreetowhichitpositivelyimpactstheunderlyingneuralnetworkgrowthandintegration.Iexpectfutureresearchtocontinuesupportingthisbasichypothesis.Furthermore,evolvingtechnologieswillprovideuswithincreasinglyaccuratewaysofmeasuringactivitywithinthebrainandagreaterunderstandingofexactlywhatitiswearemeasuring.Myhopeisthatincludingneuralnetworkactivityinourcaseconceptualizationmayhelptoestablishacommonlanguageforustoselect,combine,andevaluatethetreatmentsweprovide.Itwill,onehopes,helpustomovepastdebatesbetweencompetingschoolsofthoughttoamoreinclusiveapproachtopsychotherapy.

Onelongandhard-foughtdebateabouttreatmentcontinuesbetweensupportersofpsychopharmacologyandpsychotherapydespiteempiricalsupportforbothapproaches,individuallyandincombination.Brainfunctioningoffersusawaytolookmoredeeplyintotheeffectsofbothtalkandmedicationinregulatingthebrainandstimulatingneuroplasticity.Patientswhocometoseemeforpsychotherapyareoftenadamantintheirrefusaltoconsidermedication.SomefeelfrightenedorshamedifIsuggesttheuseofdrugsasanadjuncttopsychotherapy.AtthesametimeIknowthatmanydiscounttalktherapyandwillonlyseekhelpfromtherapistswhowillprescribemedication.Allclientscouldbenefitfromeducationaboutbrainfunctioningandthepotential(evensynergistic)powerofbothinterventions.Ontheonehand,thetherapeuticalliancesupportspositiveexpectancy,medicationcompliance,andpsychologicalwell-being.Ontheother,medicationcanhelptoachieveastateofbodyandmindthatallowsclientstobenefitfrompsychotherapy.

Manypatientswhosufferbraindamageresultingfromaccidentsparticipateinmultimodalrehabilitationprogramsthatincludephysical,cognitive,andpsychosocialinterventions.Thegeneralapproachtorehabilitationafterbraininjuryistofirstassesswhichsystemshavebeendamagedandwhichhavebeenspared.Thenextstepistodevelopaprogramthatplaystothepatients’strengthsandattemptstocompensatefortheirweaknesses.Trafficandindustrialaccidentsoftenresultindamagetothefrontalcortex,makingdisordersofattention,concentration,memory,executivefunctioning,andemotionalregulationcommoninneurologicalrehabilitation.Thesesamedifficultiesarecommoninmanyformsofpsychologicaldistressandpsychiatricillness.

Thetraditionalsplitbetweenmindandbrainhasresultedintheseparatedevelopmentofthefieldsofpsychotherapy,neuropsychology,andrehabilitation.Whenpsychologicaldifficultiesareconceptualizedinthecontextofabrain–behaviorrelationship,applyingtechniquesfromcognitiverehabilitationinpsychotherapybecomesaninterestingpossibility.Forexample,abnormalitiesoffrontal

lobefunctioninghavebeenfoundinOCD,depression,andADHD.Becausethesedisorderssharemanysymptomsafflictingpatientswithbraininjury,psychotherapypatientswiththeseandotherpsychiatricdiagnosesmaybenefitfromthestrategiesofcognitiverehabilitation(Parente&Herrmann,1996).

Anexampleofthiswasgiveninanearlierchapter,whenIdiscussedhowthesimplememorystrategiesIusedtoassistmypatientSophiainrememberingherappointmentshelpedustoestablishasolidalliance.Myworkingassumptionwasthatacombinationofdecreasedhippocampalvolumeduetochronicstressandhypometabolisminthetemporallobesrelatedtodepressioncreatedreal,brain-relatedmemorydysfunctions(Bremner,Scott,etal.,1993;Brodyetal.,2001).Thesuccessofcognitive-behavioraltreatmentswithdepressedandanxiouspatientsunderlinestheimportanceoffocusingonbasicissuesofrealitytesting,focusedattention,andemotionalregulationinordertosupportprefrontalfunctioning(Schwartz,1996).

Findingswithborderlineclientsofdamageordysfunctionofthefrontalandtemporallobessupporttheuseofcognitiverehabilitationtechniqueswiththispopulation(Parisetal.,1999;Swirsky-Sacchettietal.,1993).Thismayhelpexplainwhyborderlinepatientsrequireincreasedlevelsofstructuretoscaffoldtheirerraticexecutivecontrolandemotionalinstability.Manipulationandorganizationofthephysicalenvironment,sensorystimulation,andthetypeandamountofactivityallimpactbrainfunctioning.Psychoeducationandenlistingfamilyandfriendsinthetherapeuticprocess(asutilizedextensivelyinrehabilitationafterbraindamage)arealsopotentialmechanismsofchange.Agoodexampleofthisisdialecticalbehavioraltherapy(Linehan,1993),whichcombinesexposure,cognitivemodification,skillsdevelopment,andproblem-solvingskillstosupportprefrontalfunctioning.

Diagnosticandtreatmentapproachesfocusedoncognitivedeficitsservetodecreaseshameandhelptocreateastrongertreatmentalliance.Highlystructuredskill-buildingtechniques,inthecontextofsupportandunderstanding,mayprovidedisorganizedpatientstheopportunityforearlyandclearlymeasurablesuccessexperiences.Asourunderstandingofneuralnetworksrelatedtomemory,affect,andbehaviorexpands,prostheticaidstothesesystemswillbecreatedandappliedinthepsychotherapycontext.Increasinginterdisciplinarycoordinationofthiskindwillrequiremorecomprehensivetrainingforpsychotherapists,notonlyinneurosciencebutalsoincognition,memory,andrehabilitationscience.Removingthetraditionalbarriersbetweenpsychotherapyandrehabilitationmayleadtoahigherqualityofcareandgreatertreatmentsuccess.

WhyNeuroscienceMatterstoPsychotherapists

Insciencetheimportantthingistomodifyandchangeone’sideasasscienceadvances.—HerbertSpencer

Thepsychotherapistashealerexistswithinalongtraditionofrabbis,priests,medicinewomen,andshamans.Atthesametime,findingsinsocialneurosciencemakeitclearthatwearealsointhecurrentscientificmainstream.Incontrasttotechnologicalmedicine,weunderstandourprofoundpersonalroleinthehealingrelationshipwhilesimultaneouslyrespectingthesubjectiveexperienceofourclients.Intheabsenceofabrain-basedmodelofchange,theleadersofourfieldshavelearnedtostimulateandguideneuroplasticprocessestohelpbuild,integrate,andregulateourclients’brains.Butwhydoesanacademicunderstandingofneurosciencemakeanydifferencetoourwork?Hereareafewthoughts.

Onapracticallevel,addinganeuroscientificperspectivetoourclinicalthinkingallowsustotalkwithclientsabouttheshortcomingsofourbrainsinsteadoftheproblemswiththeirs.Thetruthappearstobethatmanyhumanstruggles,fromphobiastoobesity,areconsequencesofbrainevolutionandnot

deficienciesofcharacter.Identifyingproblemsthatweholdincommonanddevelopingmethodstocircumventorcorrectthemisasolidfoundationuponwhichtobaseatherapeuticalliance.

Aswecometobetterunderstandtheneuralcorrelatesofmentalhealthandemotionalwell-being,wemaybeabletousethisknowledgetoaidusindiagnosisandtreatment.Neurosciencemayalsosomedayprovideuswitharationaleforaninformedeclecticismaswellasadditionalmeansofevaluatingoutcome.Wewillbeabletoseewhichcombinationoftreatmentsimpactstargetedneuralnetworksandhowchangesintheactivationofthesecircuitscorrespondwithsymptomexpression.Neurosciencecanalsoprovideacommonlanguagetocommunicatewithphysicians,pharmacologists,andneurologistswhomayalsobetreatingourclients.Finally,ifyouareanythinglikeme,youmightfindaneuroscientificperspectivetobeanexcitingadditiontomanycaseconceptualizations.

Sometherapistsbristleattheintegrationofneuroscienceandpsychotherapy,callingitirrelevantorreductionistic.IthinkIunderstandtheirperspectiveandconcerns—ifyouhaveamodeloftherapythatworks,whybotherwiththebrain?WouldRogers,Kohut,orBeckhavebeenbettertherapistsiftheyhadbeentrainedasneuroscientists?Probablynot.Ontheotherhand,itishardformetograsphowthebraincouldbeirrelevanttochangingthemind.AndwhileIdislikereductionismasmuchasthenextperson,doesn’tatendencytowardreductionismsaymoreaboutthethinkerthanthenatureofnaturalphenomena?Ourknowledgeofneurosciencehighlightsthefactthatweprimateshavecomplexandimperfectbrainsandshouldremainskepticalaboutwhatwethinkweknow.Inotherwords,primateswouldbewisetodoubttheirbeliefsandremainopentonewideas.

Itishumblingandmorethanalittlefrighteningtorealizethatwerelyonwhatmaybethemostcomplexstructureintheuniversewithlittleknowledgeofhowitworks.Buteventhoughweareonlyatthedawnofunderstandingthebrain,anappreciationofitsevolutionaryhistory,developmentalsculpting,andpeculiaritiesofdesigncansurelyencourageustobegintouseitmorewisely.Practicalthings—likeunderstandingtheneuraldamageresultingfromdrugs,stress,andearlydeprivation—shouldinfluenceeverythingfrompersonaldecisionmakingtopublicpolicy.Theneuralnetworkdissociationthatoftenresultsfromexposuretocombatshouldmakeuspaycloserattentiontothosewhomweputinharm’sway.Evenourtendenciestodistortrealityinthedirectionofpersonalexperienceandegocentricneedsshouldleadustoexamineourbeliefsandopinionsmorecarefully.

Wenowknowthatmindandbrainareindivisibleandthatdisorderstraditionallythoughtofaspsychologicalneedtobereconceptualizedtoincludetheirneurobiologicalmechanisms.Andifbraindysfunctioniscentraltoaclient’sdifficulties,the“mostilluminatinginterpretation”maynotbeasvaluableasalittleaccurateneurobiologicalknowledge(Yovell,2000).

Self-awarenessisarelativelynewphenomenoninevolutionaryhistory.Psychotherapyincreasesneuralintegrationthroughchallengesthatexpandourexperienceofandperspectiveonourselvesandtheworld.Thechallengeofexpandingconsciousnessistomovebeyondreflex,fear,andprejudicetoamindfulnessandcompassionforourselvesandothers.Understandingthepromiseandlimitationsofourbrainsisbutoneessentialstepintheevolutionofhumanconsciousness.

Inconclusion,ourbrainsareinescapablysocial,theirstructuresandfunctioningdeeplyembeddedinthefamily,tribe,andsociety.Andwhilethebrainhasmanyshortcomingsandvulnerabilities,ourabilitytolinkwith,attuneto,andregulateeachother’sbrainsprovidesuswithawayofhealing.Thisiswhythepowerofhumanrelationshipsisattheheartofpsychotherapy.Frommyperspective,thevalueofneuroscienceforpsychotherapistsisnottoexplainawaythemindorgeneratenewformsoftherapy,buttohelpusgrasptheneurobiologicalsubstratesofthetalkingcureinanoptimisticandenthusiasticcontinuationofFreud’sProjectforaScientificPsychology.

Credits

Table6.1:1.DavidsonandFox,19822.Canlietal.,19983.Wheeler,Davidson,&Tomarken,19934.Davidson&Fox,1982;Harmon-Jones&Allen,19985.Tomarken,Davidson,Wheeler,&Dass,19926.Coan,Allen,&Harmon-Jones,2001;Davidsonetal.,1990;Ekman&Davidson,1993;7.Urryetal.,20048.Fox&Davidson,19889.Harmon-Jones&Allen,199810.Harmon-Jones&Sigelman,200111.Harmon-Jones&Sigelman,200112.Davidsonetal.,199013.Fox&Davidson,198614.Canlietal.,199815.Davidson&Fox,198216.Wheeleretal.,199317.Kalin,Shelton,Davidson,&Kelley,200118.Fox&Davidson,198819.Davidson&Fox,1989

Table7.1:1.Minagawa-Kawaietal.,2008;Nitschkeetal.,20042.Berthozetal.,2002;Mitchell,Banaji,&Macrae,20053.Mitchell,Macrae,&Banaji,20064.Gusnardetal.,20025.Goel&Dolan,20016.Frey&Petrides,2000;Nobreetal.,19997.Ongur&Price,20008.Becharaetal.,1998;Gallagheretal.,1999;Gehring&Willoughby,2002;Kringelbach,2005;Kruegeretal.,2006;O’Doherty,20049.Becharaetal.,1994;O’Dohertyetal.,200210.Matsumoto&Tanaka,200411.McGuireetal.,199612.Dias,Robbins,&Roberts,1996;Simpson,Drevets,etal.,2001;Simpson,Snyder,etal.,2001;Quirk&Beer,200613.Malloyetal.,1993;Teasdaleetal.,1999;Beeretal.,200614.Koechlin,Ody,&Kouneiher,2003;15.Diasetal.,1996;Fuster,1997;Nagahamaetal.,200116.Knight&Grabowecky,199517.Rezaietal.,1993;Petrides,Alivisatos,&Frey,200218.Henson,Shallice,&Dolan,199919.Levesque,Eugène,Joanette,Paquette,etal.,200320.Pascual-Leoneetal.,199621.Krogeretal.,2002;Malloyetal.,1993;Teasdaleetal.,199922.Mitchelletal.,200623.Gray,Braver,&Raichle,2002

Table7.3:1.Tamm,Menon,&Reiss,20062.Bushetal.,1999;Tamm,Menon,Ringel,&Reiss,20043.Tammetal.,20044.Rubiaetal.,19995.Yu-Fengetal.,20076.Tammetal.,20047.Zangetal.,20058.Yu-Fengetal.,20079.Lou,Henriksen,&Bruhn,198410.Leeetal.,200511.Castellanosetal.,200212.Casey,Castellanos,&Giedd,199713.Lietal.,200714.Markisetal.,200715.Mackieetal.,200716.Ashtarietal.,2005

Table8.1:1.Dehaene,Molko,Cohen,&Wilson,20042.Victor&Roper,20013.Siriguetal.,19964.Colby,1998;Driver&Mattingley,19985.Newmanetal.,20036.Rorden,Mattingley,Karnath,&Driver,

1997;Snyder&Chatterjee,20047.Karnath,1997;Ungerleider&Haxby,19948.Schwartzetal.,20059.Battellietal.,2001;Claeysetal.,200310.Griffithsetal.,199811.Snyder&Chatterjee,200412.Anderson&Mountcastle,198313.Piaetal.,2004

Table8.2:1.Griffithsetal.,19982.Chochonetal.,19993.Newmanetal.,20034.Uddinetal.,20055.Dehaeneetal.,20036.Molkoetal.,20037.Chochonetal.,19998.Molkoetal.,2003;Rushworth,Krams,&Passingham,20019.Newmanetal.,200310.Newmanetal.,200311.Antaletal.,200812.Grefkes&Fink,2005;Wolpert,Goodbody,&Husain,199813.Wolpertetal.,199814.Jonidesetal.,199815.Wagneretal.,200516.Marshuetzetal.,2000;VanOpstal,Verguts,&Fias,200817.Husain&Nachev,200718.Astafievetal.,200319.Mountcastle,199520.Orbanetal.,199921.Castelli,Glaser,&Butterworth,2006;Fiasetal.,2003;Lemeretal.,200322.Fiasetal.,200723.Ruby&Decety,200124.Iaccobonietal.,2004;Jackson&Decety200425.Vogeleyetal.,2004

Table12.1:1.Bredyetal.,2003;Champagneetal.,20082.Weaver,Grant,&Meaney,2002;Weaver,Meaney,&Szyf,20063.Garoflosetal.,2008;Menard,Champagne,&Meaney,20044.Liuetal.,20005.Zhangetal.,20056.Menardetal.,20047.Weaveretal.,20048.Caldji,Diorio,&Meaney,20039.Caldji,Diorio,Anisman,&Meaney,2004;Caldjietal.,199810.Braun&Poeggel,200111.Champagneetal.,200312.Champagneetal.,2001,2003,200613.Cameron,Fish,&Meaney,2008

Table12.2:1.Zhangatal.,20022.Maraisetal.,20083.Leventopoulosetal.,20074.Caldjietal.,2000;Hsuetal.,2003;5.Rees,Steiner,&Fleming,20066.Blaiseetal.,20077.Brakeetal.,20048.Kuhn&Schanberg,19989.Kalinichevetal.,200210.Coutinhoetal.,200211.Weaveretal.,200612.Ovscharoff&Braun,200113.Akbarietal.,2007

Table12.3:1.McCormicketal.,2000;Meaneyetal.,1988,1991;O’Donnelletal.,1994;Smythe,Rowe,&Meaney,19942.Sarrieau,Sharma,&Meaney,19883.Plotsky&Meaney,19934.Kosten,Lee,&Kim,20075.Siviy&Harrison,20086.Garoflosetal.,20077.Valléeetal.,19978.Valléeetal.,19999.Costelaetal.,1995;Tejedor-Realetal.,199810.Weaveretal.,200011.Colletteetal.,2000

Table13.1:1.Krugersetal.,20062.Wantanabe,Gould,&McEwen,19923.Alonso,20004.Sapolsky,19905.Dranovsky&Hen,2006;Kelly,Mullany,&Lynch,2000;Phametal.,2003;Prickaertsetal.,20046.Kuhlmann,Piel,&Wolf,2005;Kirschbaumetal.,1996;Newcomeretal.,1994,19997.West,1993;Lupienetal.,19988.Bremner,Scott,etal.,19939.Bremner,Southwick,etal.,1993;Vythilingametal.,200210.Bremneretal.,1995;1997;Bremner,2006;deLanerolleetal.,198911.Villarrealetal.,200212.Falkai&Bogerts,1986;Nelsonetal.,199813.Bourdeauetal.,2002;Condren&Thakore,2001

Table17.1:1.Bennett,Diamond,Krech,&Rosenzweig,1964;Diamondetal.,19642.Kempermannetal.,1998;Walsh,Budtz-Olsen,Penny,&Cummins,19693.Kolb&Whishaw,19984.Kolb&Whishaw,19985.Kolb&Whishaw,19986.Ickesetal.,20007.Nilssonetal.,19938.Sirevaag&Greenough,19889.Sirevaag&Greenough,198810.Guzowski,Setlown,Wagner,&McGaugh,200111.Torasdotteretal.,1998

Table17.2:1.Fujikawaetal.,20002.Abercrombieetal.,2003;Andreano&Cahill,2006;Domesetal.,20053.Takahashietal.,20044.Conrad,Lupien,&McEwen,1999;Kerr,Huggett,&Abraham,1994;Parketal.,2006;Yauetal.,19955.Diamondetal.,19926.Pavlidesetal.,19957.Sullivan,Wilson,&Leon,19898.Introini-Collison&McGaugh,1987

Table17.4:1.Maybergetal.,20022.Maybergetal.,20023.Kongetal.,20064.Parienteetal.,20055.Petrovicetal.,20026.Wageretal.,20047.Wageretal.,20048.Zubietaetal.,20059.Benedettietal.,200410.Fuente-Fernandezetal.,2001

Table18.1:1.Baxteretal.,19922.Brodyetal.,19983.Nakatanietal.,20034.Schwartzetal.,19965.Lazaroetal.,20096.Furmarketal.,20027.Paquetteetal.,20038.Johansonetal.,20069.Straubeetal.,200610.Levin,Lazrove,&VanderKolk,199911.Praskoetal.,200412.Sakaietal.,200613.Goldappleetal.,200414.Kennedyetal.,200715.Martinetal.,200116.Brody,Saxena,Stoessel,etal.,200117.Brody,Saxena,Schwartz,etal.,200118.Penadesetal.,200219.Wykesetal.,200220.Laatschetal.,1999

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THENORTONSERIESONINTERPERSONALNEUROBIOLOGY

AllanN.Schore,PhD,SeriesEditorDanielJ.Siegel,MD,FoundingEditor

Thefieldofmentalhealthisinatremendouslyexcitingperiodofgrowthandconceptualreorganization.Independentfindingsfromavarietyofscientificendeavorsareconverginginaninterdisciplinaryviewofthemindandmentalwell-being.Aninterpersonalneurobiologyofhumandevelopmentenablesustounderstandthatthestructureandfunctionofthemindandbrainareshapedbyexperiences,especiallythoseinvolvingemotionalrelationships.

TheNortonSeriesonInterpersonalNeurobiologywillprovidecutting-edge,multidisciplinaryviewsthatfurtherourunderstandingofthecomplexneurobiologyofthehumanmind.Bydrawingonawiderangeoftraditionallyindependentfieldsofresearch—suchasneurobiology,genetics,memory,attachment,complexsystems,anthropology,andevolutionarypsychology—thesetextswilloffermentalhealthprofessionalsareviewandsynthesisofscientificfindingsofteninaccessibletoclinicians.Thesebooksaimtoadvanceourunderstandingofhumanexperiencebyfindingtheunityofknowledge,orconsilience,thatemergeswiththetranslationoffindingsfromnumerousdomainsofstudyintoacommonlanguageandconceptualframework.Theserieswillintegratethebestofmodernsciencewiththehealingartofpsychotherapy.