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Discoveries from the Black Box:
How the neuroscience revolution can change your practice
Mary Sykes Wylie, Richard Simon
Psychotherapy Networker
The human brain is a wet, coconut-sized, walnut-shaped organ, the color of raw liver and the
consistency of an overripe peach. Comprised of billions of nerve cells, each connecting
electrochemically with an average of 10 thousand others, it's the most complex biological entity
known on earth. The number of possible interconnections among its neurons exceeds the
estimated number of atoms in the universe. Just as remarkably, it can make such intricate and
baffling self-transformations that many insist it will never be fully understood by its own kind.
Because how it works is such a dumbfounding investigative riddle--the equivalent of studying a
mirror with a mirror--therapists have preferred until recently to approach its actual functioning
through the metaphor of the black box, rather than peel back the skin of the peach to discover
what goes on inside.
Over the last couple of decades, however, technology has allowed us to open the black box,
leading to what some have touted as the biological sequel to the Copernican revolution. Magnetic
Resonance Imaging (MRI), Positron Emission Tomography (PET) and CAT scans can now
photograph the brain at work and play and even after therapy. With electron microscopes, the
nuclear tagging of living human molecules, and other biochemical investigative techniques,
scientists can now see what happens in different parts of the brain when an alcoholic looks at a
martini, or a schizophrenic has a hallucination, or a meditator experiences spiritual transcendence.
Scientists have decoded the way memory and learning actully occur in the synaptic connections
of a tiny sea slug--theoretically no different from what occurs in our own brains. Researchers
have also identified individual "mirror neurons in monkeys," single neurons that fire both when a
monkey performs a meaningful act--such as eating a peanut--and also when a monkey sees
another monkey perform an act. Scientists think that this capacity for neural mirroring helps us
interpret other people's actions and feelings, and may be the neurophysiological basis for
empathy.
Increasingly, therapists are trying to make sense of the cavalcade of discoveries like these,
regularly trumpeted in the research literature and the popular press. What will the rapidly
expanding understanding of the brain mean for our traditionally low-tech profession? Already
practitioners are applying unconventional therapeutic techniques, like Eye Movement
Densensitization and Reprocessing (EMDR), Vagus Nerve Stimulation (VNS), and Thought Field
Therapy (TFT), whose methods presumably rely on neurobiological healing processes not
activated by mere words. Some believe that such approaches are just a preview of what's to come,
as we continue to deepen and expand our understanding of how the brain works. They speculate
that psychotherapy's most fundamental practices may increasingly be challenged by
neuroscientific advances.
An exuberant, if somewhat tongue-in-cheek vision of the high-tech therapy of the future has been
provided by prominent NIMH researcher Norman E. Rosenthal, in his recent book The Emotional
Revolution. He imagines a not-so-distant clinical encounter of the future: "After relating your
problems to your psychiatrist, she or he will ask you to put your head in a scanner. Watching
while you talk, you will see how your amygdala guns into action when you discuss your
obnoxious boss. Your right prefrontal lobe will glow with rage and despair, while the
corresponding part on the left wilts, pale and lusterless." During the next few sessions, the
therapist might "stimulate you electrically at various trigger points, . . . flash lights, massage you
or help you reprogram your responses with a series of musical tones. On rescanning your brain,
you and your doctor will be happy to see that the amygdala has settled down and your left
prefrontal lobe has come into its own, reassuring you that everything is manageable and life is not
so bad after all."
Will wordbound interventions take a back seat to the surgical implantation of laboratoryengineered molecules that target specific neurochemical imbalances within the brain? Some
believe that the day is not far off when therapeutic treatment routinely involves special viruses
attached to corrective DNA, or newly harvested stem cells designed to solve the most deeply
seated genetic problems and repair damage from PTSD. Those on the cutting edge of
neuroscience consider medications like Prozac and Zoloft old-fashioned dinosaur drugs, more
like bulldozers in their physiological effects than the precision technologies that await us.
Rosenthal believes we'll "shake our heads ruefully about the days when we needed to use
medicines that were so imprecise in their actions, by trial and error with messy side effects."
Much current clinical interest in brain functioning, however, is fueled, not by the prospect of
pharmacological breakthroughs or the kind of futuristic scenarios Rosenthal spins out, but by a
basic reconsideration of fundamental assumptions. Most therapists once believed that
neuroscience stood in opposition to the basic optimism of their calling, reinforcing the
countertherapeutic view that temperament and psychological health are genetic givens and
change very little after birth. But what has more recently emerged from neurobiologists'
experimental labs is increasing evidence of the plasticity of the human brain.
Scientists once thought the number of neurons and their interconnections was permanently fixed:
the brain you were born with was physically the brain you died with. Now the rankest of
neuroscience heresies--that the brain produces brand-new cells in maturity--has become generally
accepted, as has the idea that the brain is changing and growing continuously throughout life,
shaped as much by experience as genetic heritage. Every passing sensation, everything we learn,
every human contact we make causes millions of neurons to fire together, forming physical
interconnections called neural maps or networks, the architecture of all our experiences.
Some studies suggest that the process of neural growth can be startlingly fast. In one experiment,
rats trained to use their minds (so to speak)--getting more toys, exercise, handling, and tasks to
perform--increased their brain weight by 7 to 10 percent in 60 days and increased the number of
cortical synapses by about 20 percent. It's also known that repetition increases the strength of the
changes and the longevity of neural networks, particularly in the cerebral cortex and
hippocampus. A corollary is that neglected neural patterns fade away, and unused neurons die.
"Use it or lose it," seems to be the hard law of brain development--which is why many scientists
now believe there's good empirical evidence that keeping mentally active and fit throughout life
protects people against mental decline, even Alzheimer's disease.
In the past few years, studies using advanced neuroimaging have begun to examine the
neurological impact of psychotherapy. In 2001, a controlled study in the Archives of General
Psychiatry, led by Arthur L. Brody, established that patients treated with either medications or
psychotherapy showed clinical improvement (somewhat higher for the medicated patients) and
more normal metabolic activity in the prefrontal cortex and temporal lobe--regions associated
with depression. A 1996 PET-scan study of patients suffering from obsessive compulsive
disorder, led by UCLA psychiatrist Jeffrey Schwartz and published in the February issue of the
Archives, demonstrated that cognitive-behavioral therapy worked as effectively as medications:
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both kinds of treatment normalized metabolism in the caudate nucleus, an area correlated with
OCD symptoms.
Encouraged by breakthroughs in mapping the brain and a newfound belief in its malleability,
some clinicians are incorporating a fuller appreciation of neurobiology into their everyday work
with clients. In effect, they're taking the brain out of its black box and opening it up for discussion
in the consulting room. "I do things differently in my office every day because of what I know
about the brain," says psychiatrist Daniel Siegel, author of The Developing Mind and associate
clinical professor of psychiatry at the UCLA School of Medicine. "I not only have a model of the
brain that I must take out maybe three or four times a week with different patients, but I have a
chalkboard I constantly use to draw brain diagrams to help people see their problems in a
different light. Patients keep telling me things like, 'You know last week when you drew that
picture of the brain? I finally understood my amygdala. It's changed my whole view of what's
been going on with me all these years.'"
Focusing on the brain isn't just another layer of explanation for behavior in a field that has never
been short of psychological explanations. "People experience the understanding of their own
brains as something very near --an incredibly compelling way of grasping the most intimate
details of their moment-to-moment functioning," says psychologist Marcia Stern, author of ChildFriendly Therapy. Ten years ago, she started meeting with a study group of colleagues at New
York's Ackerman Institute to apply clinically the latest brain-related research findings.
Knowledge of the brain's processes helps patients "understand their own behavior and the
behavior of other people in their families in a new way--for example, how easily our thinking
brains can become hijacked by our feeling brains--while dramatically diminishing the amount of
shame and blame that gets passed around." For Stern, the result has been a marriage of
neurobiology and family systems therapy that has revolutionized her work and addresses a vital
missing piece in the puzzle of making change last: "Every clinician at one time or another realizes
that words are not enough," she says. "So often the results you see in your office don't carry over
when people go home. The challenge of therapy is always to get clients from intention to action.
Helping people understand their own brains and the unique way they process information can
help bridge that gap and make change stick."
Critics argue that the incorporation of a neurobiological perspective into psychotherapy is
premature, based on far more speculation than validated scientific findings. The danger, they
insist, is a popularization of complicated findings that misrepresent the science of the brain and
could lead to a neurobiological reductionism that ignores the complexities unearthed over the past
century of clinical practice. In response, the loosely organized but growing cadre of brain-savvy
clinicians argues that the nature of clinical practice has always been to move more quickly than
formal science. Most insist they use neurobiology to complement existing clinical models, not to
supersede them. Whatever their clinical variations, conversations with them point toward an
emerging core of lessons being drawn from the new brain science, lessons that are changing and
enriching their work.
Lesson 1: The brain is profoundly interpersonal.
We're used to thinking of the brain as a bounded entity, a "command central," which sits in
splendid isolation in our heads. However, neuroscientists are finding that much brain function is
an interpersonal phenomenon. Not only do brain structures and functions provide the means by
which we connect with and make sense of one another, but through relational experience, parts of
the brain, literally, grow. In fact, the brain, as we know it, is inconceivable without social
relationships: "The traditional idea of the brain has been the single-skull view--an organ encased
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inside us whose functioning is determined primarily by our inborn biology," says Siegel, who
coined the term interpersonal neurobiology to describe how advances in research have created a
conceptual bridge among biology, attachment research, development psychology, brain science,
and systems theory. "But we survived as a species not so much because of our physical brawn,
but due to our interpersonal capacity. More and more, we're realizing that evolution has designed
our brains to be shaped by our interpersonal environment."
Siegel posits a "multiskull view" of the brain, a way of understanding that brain processes take
place through people's interactions with one another. "The best way to define the mind is as the
flow of energy and information," says Siegel. "That flow can happen between neurons in a
person's skull, as well as between two people. Without being reductionistic, the cultural
transmission of meaning ultimately comes down to a neuronal process."
So far, the most closely studied example of brain-to-brain connections in social relationships
comes out of attachment research. Scientists have long accepted that a poverty of relationships
early in life leads to psychological deficits, but we're now learning how a lack of quality
relationships can create parallel physiological deficits within the infant's brain. How two brains
interact--say, a parent and a baby in an intense, emotional relationship--determines the strength of
the neuronal connections through which we feel our feelings and form emotional bonds with
others. This research has given us our clearest picture of how physical structures of the brain
depend on social connections.
Scientists have particularly focused on the development of the brain's orbitofrontal cortex, an area
strategically located behind the eyes, between the "higher," thinking areas and the "lower,"
emotional areas. This region integrates and coordinates cognitive and emotional processes,
helping us regulate emotional arousal and control our impulses. Sometimes called the "center of
free will," it enables us to think before we act. But just as important for the parent-child bond is
the fact that the orbitofrontal cortex is wired to read facial expressions and is uniquely sensitive to
face-to-face communication. Thus it enables us to evaluate signals from other people and respond
appropriately to them. Some scientists think that one reason autistic children cannot connect with
other people may be that they have abnormalities in this area.
A sensitive and responsive parent helps grow the connections in this part of the infant's brain by
communicating--or "collaborating," as Siegel calls it--with the baby, via eye contact, facial
expression, gestures, tone of voice, and so on. The baby gurgles happily to its mother, the mother
picks it up and "answers" with a smile and a joyful, "Ooh, what a sweet baby," or the baby cries
in pain or frustration and the father soothes and consoles it, or the parent gradually calms down an
overexcited child at bedtime. These interactions--ordinary, routine, repeated innumerable times-stimulate the growth of synapses in the orbitofrontal cortex that enable children to moderate their
frustration, rage, and fear, and to respond flexibly to other people.
A securely attached child develops the neural pathways for resilience. Even when her parents are
upset or impatient, her brain's wiring "knows" from experience that they won't abandon her and
will reconnect after the storm has passed. Kids who don't get this kind of back-and-forth parental
attention may grow up more or less at the mercy of their emotions, unable to manage their rage
and aggression, calm their anxieties, console themselves in their sadness, or tolerate high levels of
pleasure and excitement. Furthermore, they'll be more likely to suffer social disconnection:
unable to interpret others' social cues because of deficits in their orbitofrontal cortices, they'll
have trouble joining in the rhythm of relational exchange. In short, from the beginning, relating
isn't a discretionary activity, something we can do without. As an organ, the brain must make
human connections to develop a healthy, working mind.
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Just as a grasp of neurobiology can enrich our understanding of the parent-child relationship, it
can expand our view of human functioning throughout the life cycle, particularly in light of our
increasing appreciation of the plasticity of brain structures and processes. Handicapped by limited
training and the old black-box conception, most clinicians typically leapfrog over the role clients'
neurobiology plays in their social relationships and presenting difficulties. But helping clients
become students of their own brain styles can sometimes short-circuit years of insight-based
therapeutic work. What may have seemed intractable resistance or deep-seated pathology can
often be better seen as an information-processing style. The therapeutic task can then be
transformed from psychological archaeology to the more manageable challenges of living with
one's own brain. The shift from a purely psychological to a more biopsychosocial paradigm can
be liberating to both client and therapist, getting away from the shame-or-blame syndrome and
introducing new choices. The therapeutic focus moves from asking "why" to determining "what
now?"
"I had a client who always thought of herself in very negative terms, as kind of picky and
obsessive," recalls Marcia Stern. "She complained to me that any time she went to a conference
or meeting, she had to get up earlier than everybody else and make sure to get a seat in the first
row. Her friends would laugh at her and tell her how neurotic she was. But once we looked more
closely at her behavior from the viewpoint of how her brain worked, a different picture emerged.
She realized how she was compensating for her distractability and how hard it was for her to filter
out sensory information so she could pay better attention. Once she was able to do that, she went
from a negative explanation of her behavior--'I am neurotically obsessive'--to a compassionate
view of how this behavior was a way of taking care of herself."
Lesson 2: Emotions organize the brain.
Until recently, emotions were deemed too vague, too fleeting, too much the province of touchyfeely types, to be worthy of serious scientific study. With the advent of brief therapies and the
emphasis on cognitive strategies for change, many clinicians have come to regard emotions as the
professional equivalent of quicksand: "Watch out! You'll get mired in there!"
But in the field of neuroscience--yes, the antiseptic realm of hyperrational, white-coated
technicians--emotions are very much in fashion. Over the last decade, neuroscientists have
learned that, on a neurobiological level, emotions are integral to such mental processes as
cognition, perception, memory, and physical action. Instead of being tidily housed in the limbic
system (called the paleomammalian brain--a more primitive area than the neomammalian cortex),
emotions are regulated along the same brain circuits that govern social relationships and the
processes of making meaning. Emotions are neurologically intertwined with the experience of
selfhood.
In evolutionary terms, emotions are crucial to survival. The need to appraise and respond to a
potential threat comes up too fast to address consciously, so before we're aware of what we're
responding to, we respond emotionally, priming the brain and body for action. Hence, in a quite
real sense, we're always in the process of catching up with our emotions.
One reason emotions are in vogue is that it's now possible to do microscopic experiments that
reveal brain processes down to the microlevel of neurons and synapses. The development of these
techniques, with sci-fi names like PET (positron emission tomography) and QEEG (quantitative
electroencephalography), have for the first time literally put emotions on the map of the brain.
Today's scientists can study emotional changes in the brain of living animals and humans in real
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time. Using chemicals to trace the neural circuits that produce fear in behaviorally conditioned
mice, we can observe how the brain processes emotions on the scale of individual neurons.
Emotions can be regarded as dynamic processes that interact continuously with other emotions,
with cognition and perception, with the social environment (including therapy), and, just as
significantly, with bodily states. It's doubtful that we'd even experience emotions without the
body, for emotions are basically bodily responses triggered by brain circuitry. Our heads are
hostage to our bodies. As every therapist knows, our body-driven emotions--fear, anxiety,
depression--regularly hijack rational thought. Let's take a close-up look at how emotion wields its
influence in the brain.
A stimulus-eliciting fear (for example, a shadowy figure looming toward us on a deserted street at
night) bypasses the cognitive centers and goes straight to the amygdala, an almond-shaped
structure in the limbic brain, a structure that might be called the brain's "early warning" module--a
place of no words, no cognition, no consciousness. The amygdala sets off a full-body hormonal
response that can bypass the conscious brain, and is experienced physically as overwhelming,
irrational, uncontrollable fear.
After the first amygdala-produced shock, the frontal cortex engages, reinforcing the original
visceral fear or letting us know that the "dangerous stranger" is only a businessman carrying a
briefcase. The fear process reverses, and we calm down. Therapy with clients subject to phobias,
anxiety attacks, or PTSD teaches people, in part, how to beef up the frontal cortex--making them
more thoughtful, better able to bring reason to bear on their fears, and less liable to freak out
when they get on an airplane or go home for Thanksgiving dinner with their fractious, conflicted
families.
But reflection takes us only so far. A crucial feature of brain anatomy is that more connections
run from the amygdala to the cortex than the other way around--which means that the amygdala
has more power to control the cortex than vice versa, a bit like Mike Tyson facing off with
Woody Allen. Worry, anxiety and stress--all near relatives of fear--probably stem from the
amygdala, and are notoriously resistant to our own attempts to reason ourselves out of them.
Once fearful reactions or traumatic memories are burned into the amygdala, they tend to lock the
mind and body into a recurring pattern of arousal, flooding with stress hormones and irrational
fear.
We have difficulty restraining an excited amygdala. Noted neuroscientist Joseph LeDoux, author
of The Emotional Brain, argues that phobias and neurotic fears--indeed, all strong emotional
memories--are neurobiologically indelible. Therapies that "extinguish" phobias or help patients
"work through" irrational fears can stop the symptoms and gain the person some freedom from
them, but whatever the conscious experience, the neuronal residue of the fear remains intact in
the amygdala, and may someday return to stalk again--a phenomenon observed by many
clinicians treating previously traumatized clients in the wake of 9/11. "A phobia can be in
remission (the sight of a snake no longer elicits paralyzing anxiety) and then the patient's mother
dies and snakes regain their propensity for producing terror," says LeDoux.
In fact, the difficulty of therapy may reflect the fact that some neural networks maintaining
dysfunctional behavior record fears set down at a young age in the amygdala, the one part of the
brain that never forgets. That's why therapy is seldom successfully done in a session or two, and
is never simply a matter of "explaining" to people how irrational their thinking is, or how
counterproductive their behavior. Therapy can be "such a long and difficult process," says
LeDoux, "because the neocortex is using imperfect channels of communication to try and grab
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hold of the amygdala and control it. It's like trying to find your way from New York to Boston by
way of country roads rather than superhighways"--or perhaps like trying to reverse a waterfall.
What all this means is that the old therapeutic saws about helping clients feel their feelings is
right on the money: emotions are powerful forces in the service of reason. Therapy isn't just about
behavioral change. In brain terms, that would be incomplete. Choice, self-determination, personal
freedom unimpeded by crippling fears and hidden motives--dare one say "self-actualization"?--all
depend on a healthy appreciation of our emotional roots. It isn't that emotions are better than
reason, or that feelings say more than words, but, as neuroscience suggests, the expression of
emotion and the use of reason are each manacled without the other.
Recognizing the centrality of emotion in brain functioning underlines the profoundly
collaborative nature of therapy. In struggling for meaning, weaving stories, and airing grievances,
therapist and client are interacting neural net to neural net. "When a therapist speaks to a patient
and the patient listens, the therapist is not only making eye contact and voice contact," argues
Nobel Prize-winning neuroscientist Eric Kandel, also a psychiatrist and a vigorous champion of
psychotherapy, "but the action of neuronal machinery in the therapist's brain is having an indirect
and, one hopes, long-lasting effect on the neuronal machinery in the patient's brain, and quite
likely, vice versa."
Some therapists studying the interplay of biology and psychology suggest that therapy works
primarily via emotion on procedural memory circuits--the implicit, nonconscious memory that
governs automatic habits of behavior and thinking, as well as involuntary emotional responses.
To understand how these changes occur, we need to grapple with neuromodularity. According to
Siegel, "neuromodularity creates a state in which neuron connectivity is more likely to happen
and [therefore] the brain is more plastic. This happens through the release of neurotransmitters
like serotonin and norepinephrine." In lay terms, this means that the more brain networks engaged
(especially those involved in emotion), the more pliable the circuitry. Imagine rigging a model of
the brain with tiny light bulbs: the more bright spots you see, the more ripe for change the brain
is. "As a teacher I use this basic brain principle all the time," says Siegel. "You have to make
something personally relevant to the students or their brains won't be engaged. It's not just about
students repeating things or listening to a lecture. They have to get emotionally involved in a
context of psychological safety. The same thing holds for therapy."
Though good parenting gives rise to healthy brain organization and development, a nurturing
therapy relationship allows for reorganization and development where structure and development
may have been lacking. When a therapist emotionally resonates with a client, clinicians like
Siegel believe it reproduces the unconscious, supportive, nonverbal bond that well-attached
infants and parents share: "The most consistent finding in psychotherapy research is that when a
relationship of trust and acceptance develops between therapist and client, regardless of clinical
method, therapy works," says Siegel. "The openness and emotional availability of the therapist
seems to be the triggering mechanism. Openness and emotional availability are also the prime
features of secure attachment. You take those three areas of research--psychotherapy, attachment,
and neurobiology--and you can make the following statement: psychotherapy which works is
using an interpersonal relationship to change self-regulatory circuits of the brain. It isn't just that a
person temporarily feels better. At the level of the brain, therapy changes the mind by changing
neuronal connections."
For all his knowledge of brain functioning, Siegel applies a large measure of clinical intuition in
developing with clients the kind of bond that he thinks creates the necessary emotional conditions
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for therapy to have the fullest impact. He recently saw a client who came to therapy in a
dissociated state a few days into a painfully stifling visit with family members she hadn't seen in a
long time. In the session, she sat for some time unable to articulate her emotional state. She felt
thwarted, smothered, and confused. Sitting across from her, Siegel felt his body became almost
unbearably tense, his mind muffled in blankness, barren of strategic ideas. As he realized the
brain-to-brain effect of what was happening between himself and his client, he did something no
one had taught him in graduate school--from somewhere deep in his right hemisphere, he let out a
mighty grunt of anguish. That reaction, he believes, turned the session around.
"My grunting showed her that we were together," he recalls. "She could see that somewhere
inside of me was some bodily process that was very much what she was struggling with, but
couldn't even articulate. You might say the grunt created a bond of nonverbal attachment on the
level of the limbic system of the brain. Even if you don't buy that kind of explanation, whatever
happened enabled her to begin to find words for describing how her sense of self had been
contorted in her relationship with her mother. If I just said in the typically neutral therapeutic
way, 'What's going on with you?' I don't think that could have happened. We needed that grunt to
connect."
Clearly, Siegel's approach with this client is only one way of establishing a consulting-room
environment in which the emotionally integrative work envisioned by brain-savvy therapists can
take place. "Neuroscience teaches us that there are parts of the brain that you can't reach with
language and that it's very important for therapists to know how to access them," says Pepperdine
University psychologist Louis Cozolino, author of The Neuroscience of Psychotherapy. "It also
teaches us about the importance of simultaneously activating dissociated networks in the brain-the fear circuits, and language circuits, for instance--in ways that enable clients to reorganize their
neural connections."
Lesson 3: Tailoring interventions to clients' brain styles can increase therapy's effectiveness.
Talking therapy, as the term implies, has traditionally been a left-brain business, largely tailored
to the needs of people at home in the world of words. Nevertheless, as attentive clinicians know,
many people are more at home in nonrational, nonverbal modes of communication (visual,
kinesthetic, tactile, metaphorical), particularly with the material that therapy often seeks to
address. While the science of brain styles and brain dominance is still rather raw, a small
vanguard of clinicians are already busy crafting innovative strategies that reflect this new
knowledge. Harvard associate psychiatry professor John Ratey, author of A User's Guide to the
Brain, has put it this way, "As therapists learn more about the brain and how it takes in and
processes information, it will change the kinds of questions they ask patients. Instead of
reflexively asking, 'How do you feel?' therapists will increasingly try to find out about how
clients perceive the world. They'll find out more not only about how clients feel, but how they
fear, see, and even smell things. They'll tune into their clients' movement habits and other aspects
of their behavior that show how their brains work and how to communicate with them."
For some clinicians, an interest in brain style seems like the next step in developing the
postmodern notion that meaning is individually constructed. What could have a greater effect on
how someone constructs reality than how that person's brain processes information? They insist
that you needn't subscribe to any specific therapeutic model to add brain-friendly interventions to
your repertoire. All you need is an openness to observing clients more closely and a curiosity
about what brain science can teach us about how to grasp their experiential world.
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For Marcia Stern, differences in brain styles are just a fact of everyday family life. "If I bought
software and I was in the car, I'd stick it in the CD changer right then if I could," she says. "But
my husband would take the manual home and underline it. A week later, he still wouldn't have
touched the CD. Research shows that more people are like me: hands-on doers, tactile learners.
Therapy, which is often so verbal, should reflect the full range of brain and learning styles people
have. But the fact is that it usually doesn't."
In her everyday work as a clinician, Stern is careful to design multisensory interventions that help
people take therapy home with them, especially people who may enter treatment diagnosed with
learning differences and cognitive variations that affect language, attention, and concentration.
"Instead of talking to families about vicious cycles, for example, and trying to explain why they
should avoid the old, more-of-the-same approach in dealing with some family issue, I write down
the sequence of events as dictated by clients, each step on a separate strip of paper. When we've
identified and written down the first step in the cycle, we staple the ends of that strip together to
form a circle, with the writing facing outward. We repeat this with each step in the cycle, linking
it through the preceding step to form another link in the paper chain. When clients examine the
sequence of an event, they learn where in the sequence the "chain" can be broken to produce a
different outcome. In this hands-on way, we get beyond words and concepts. They actually get to
see what we're talking about. It's so concrete when you see your behavior on a piece of paper. It's
hard to run away from."
It could be argued that the focus on brain style only formalizes something that good clinicians
have always known: to engage clients, one must avoid ponderous diagnostic descriptions of
problems and find ways to give people a new handle on what may be a familiar difficulty. "When
a child who repeatedly is in trouble in school because he curses constantly comes into my office
diagnosed with 'intermittent explosive disorder,' that isn't going to get us very far," says Stern.
She relies on catchy, vivid images that speak to the brain in a different language. "So I might say,
'I know what the problem is. You only know words that push people away. You haven't learned
words that bring people to you. You need to learn to be a better people magnet." Or she may ask
an overwrought child to picture fire engines in his brain rushing out on a rescue mission and to
understand that, once out of the station, the engines may take a while to quiet down. This kind of
description makes a connection between his experience and how his brain operates, distancing
him from his own reactivity. Says Stern, "It also gets clients curious about their brains and how
they create their unique reality, but it's very much in the now. A lot of what I do is to help people
understand a problem using a framework that incorporates biology, psychology, and social
contexts. It gives families a new way to talk about old problems and new doors to open for
intervention."
Laurie Leitch, a therapist in Washington, DC, has been using more brain-wise interventions in her
practice ever since she took a training in neurotherapy, an advanced form of biofeedback. She
now regularly uses interventions that draw upon her knowledge of brain structure and function.
The idea is to activate more of the brain than is typically engaged through standard interventions.
Says Leitch, "I try to promote brain connectivity, which means accessing different parts of the
brain and activating competency-based ego states." So if a client is struggling with some part of
herself that she experiences as a stumbling block, explains Leitch, "I often use a protocol that
incorporates drawing, tracing by hand, choosing three words that describe both the part she's just
drawn and a part she considers to be a competent resourceful part, as well as a belief each part has
about itself." Each activity is designed to trigger different structures and sense modalities in the
brain--whether visual or kinesthetic or language-based.
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One tool Leitch often relies on is a "brain dominance profile" that assesses not just right and left
brain dominance, but also the dominant eye, ear and hand, reflecting more fully people's
particular styles for processing information and learning. Under stress and in new learning
situations (e.g., therapy sessions) people have less access to their non-dominant brain, eye, ear,
and hand. Knowing each client's dominance profile can help depathologize entrenched negative
beliefs they have about themself and/or family members. Leitch offers as an example her work
with Jill and Pamela, a lesbian couple besieged by conflict and disappointment. At intake, the two
came across as opposites: Jill was emotional, expressive and dramatic while Pamela was logical
and self-contained. According to Leitch, Jill's complaint was that Pamela "didn't listen to a thing I
say...she just doesn't care."
Pamela's dominance profile revealed that she was left-brain dominant and also left-ear dominant.
Because Pamela's dominant ear is linked to her right brain--not her dominant hemisphere--Leitch
concluded that hearing would not be her best sense during stressful situations. Thus, it wasn't that
Pamela didn't listen or didn't care, Leitch explained to the couple, but that she was truly
struggling to hear.
"In our sessions, I began asking Jill to write her concerns to Pamela instead of saying them," says
Leitch. "Between sessions, they'd 'debrief' their fights on email. It's also interesting to note that
Pamela is right-handed, so writing connected her to her dominant (left) hemisphere. She is also
right-eye dominant, which makes reading easy for her even under stress." While Leitch readily
concedes that this was certainly not all this couple needed to get on a more stable footing,
understanding their brain dominance patterns helped each let go of negative beliefs about the
other and begin to develop more creative ways to communicate.
Though the attempt to incorporate an understanding of the brain expands the traditional
theoretical framework of therapy, the application of this knowledge invites a range of approaches
and methods. Many of them revolve around the perennial clinical issue of how to rebalance
thought and feeling, engagement and distance. An example might be a familiar presenting
problem in couples therapy: a wife craving more intimacy and a husband who seems emotionally
cut off. "It could be that there wasn't much nonverbal communication of an attuned sort in the
man's childhood," says Daniel Siegel. "As a result, he didn't develop much of his right brain
social processes. That means that his wife has a left hemisphere and a right hemisphere, but the
man functions largely out of his left brain, leaving her right brain understimulated and feeling that
the relationship is dead."
With such couples, Siegel may say something like this to the wife: "Your right hemisphere craves
intimate communion with your husband, but you describe feeling there's nothing happening in
your connection with him and actually you're feeling disconnected from yourself. That's because
your sense of self is experienced in the right hemisphere, and without a right-brain connection
with your husband, it's hard to feel yourself."
To the husband, Siegel might say, "I think you've done the best you could, but, as you've
described them, there wasn't much nonverbal connection or communion in your family of origin.
Here's the problem now. You have two brains in one skull. Both you and your wife do. But you,
personally, are only using half your resources. You just haven't had the opportunity to develop a
part of your mind that can make your life more satisfying. You're only working with half your
gears, and your life and marriage could be so much fuller."
According to Siegel, "The idea is to take the situation initially out of the realm where she's
blaming him for her loneliness and he's blaming her for her intrusive demands and bring it to the
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level of the brain. "I'm certainly not saying that the brain explanation obviates the need for
couples work or makes other kinds of therapy irrelevant," he explains. "But it leads to a first step
of working with my client through guided imagery and other nonverbal methods to develop a
right hemisphere vocabulary so that therapy can be a more multidimensional experience. When
people start activating their right brains, amazing things can begin to happen and suddenly the
relationship comes alive."
Lesson 4: Narrative is fundamental to brain function and attachment.
To measure the value of neuroscience solely on the basis of specific clinical methods, or even its
potential for innovative psychiatric technologies, is to miss the point. Perhaps the real revolution
in neuroscience lies in the way it illuminates some old and paradoxical truths about human nature.
Our brains are shaped by experience, but they also shape our experiences. We're buffeted by our
"animal" emotions, but our emotions also drive human will and choice. Our brains determine who
we are as individuals, but the way individual brains develop is determined by relationships with
others. And the greatest paradox seems to be that our brains are biologically programmed to
program themselves, to create and recreate themselves throughout life.
There's no greater example of the brain's innate powers of self-creation than the universal human
practice of constructing narratives, of drawing from the raw stuff of experience the stories with
which our brain explains itself--to itself and other brains. "Storytelling is central to every culture,
and when you find that kind of universality, you know it's not just social learning but reflects
something deep-seated in our genes," says Siegel, who believes that the neurological subplot, if
you will, of the well-made story involves the integration of the brain's left and right hemispheres.
"Coherent stories are an integration of the left hemisphere's drive to tell a logical story about
events and the right brain's ability to grasp emotionally the mental processes of the people in
those events," he adds. Storytelling also relies on the prefrontal short- and long-term memory
systems and the cerebellum--once thought to coordinate only physical movement, but now
believed to coordinate different emotional and cognitive functions. Storytelling involves
planning, sequencing ideas, using language coherently, shifting attention, and interacting
appropriately with other people. The ability to tell a good story is a measure of mental health and
a well-functioning brain.
The most striking empirical indication of storytelling's role in mental health and development
may come from a series of studies involving the Adult Attachment Interview (AAI), a research
protocol that assesses the level of relational attachment. In the mid-1990s, Mary Main, the
primary researcher, now at University of California, Berkeley, and then graduate student Ruth
Goldwyn, found that a child's attachment to a parent could be better predicted by listening to the
how a pregnant couple related their autobiographical narrative than by measures of intellectual
function, personality assessment, or socioeconomic status. A year after the initial assessment,
children's attachment to their parent could be predicted with 75 percent accuracy, based on the
AAI assessment. The idea is that by measuring the "coherence" with which people describe their
life story--its emotional content, plausibility, completeness, relevance, brevity, and clarity--you
can determine how securely bonded their child will be. Additional research suggests that secure
children will then develop the capacity for coherent narrative themselves--good narrative is,
literally, something their parents can pass on.
Why is storytelling paramount? Stories link the factual to the emotional, the specific to the
universal, the past to the present. A child hearing a story thinks, "There are others like me." A
storytelling parent models coping skills and provides a template for self-expression, logic, and
how to prioritize. In sharing stories, parent and child are connected at many levels of mind--
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which translates to many levels of the brain. Siegel speculates: "For a parent to engage in the
process of telling a coherent story about his or her life reflects a fundamental capacity for that
parent's brain to integrate memory, knowledge, and feeling. It appears that this ability in the
parents' brain nurtures their children's own neural integration." And the process of integration
then guides their capacity for self-regulation and full adult development.
People tell their stories in therapy. That's how they explain themselves. But they also learn to tell
stories, learn how to organize and make something whole from sometimes chaotic feelings of
pain and confusion. The enterprise of therapy is itself a kind of story: there are psychoanalytic
stories, cognitive-behavioral stories, family therapy stories, probably TFT and EMDR stories.
Different stories resonate with the brains of different patients. "Therapy evolved because
language organizes the brain in some primary, fundamental way," says Cozolino. "What we know
of the brain suggests that therapy is successful to the degree to which it builds and integrates
neural networks. In therapy, we teach clients that the more ways they have of interacting with
others, experiencing themselves, and understanding life, the more likely they are to find new
ways of approaching their problems. Therapy is a process of helping clients rewrite the story of
their lives while simultaneously building neural networks and reorganizing neural intagration."
Psychotherapy is perhaps the area where the human brain's capacity for storytelling is most
deeply engaged--not only telling old stories, but making sense of what has always seemed
irrational, and making up newer, better stories, with better plotlines, stronger characters, and more
promising outcomes. Even the reduction of the mind to "nothing but" the physical brain, even the
way the physical brain functions, become stories we tell ourselves about ourselves, providing
meaning, worldviews, and political and social agendas. Our predisposition to stories probably
explains our interest in brain science.
Neuroscience researcher Jaak Panksepp of Bowling Green State University posits what he calls a
"seeking system" in the brain--the inner urge to find and get, to discover and learn, to understand,
to satisfy curiosity. This system underpins primitive urges, like the urge to hunt. It informs
complex behaviors, like the search for knowledge, spiritual connection, love. The need to satisfy
curiosity about ourselves--where we come from, who we are, how we developed, what we're
made of--compels the creation of the evolving story of the brain and how it grows. As John Ratey
puts it, "Whatever the advances of neurobiology and our ability to relieve symptoms, I don't think
that we'll ever undo the need for understanding people's history."
For most therapists practicing today, training made no more of the physical brain in the head than
the hair on the head. For future generations of therapists, training will certainly change: curricula
will have to face the accumulation of knowledge coming from neuroscientists. Meanwhile, those
already in practice will increasingly be required to play catch-up with the emerging understanding
of such clinically relevant areas of knowledge as neural networks and brain structures, the selfregulatory processes underlying our experience of emotion, and the intricacies of neuronal
integration.
With at least 500 therapeutic methods, all proffering special theories and techniques,
psychotherapy has often been likened to a Tower of Babel. But now a new organizing principle
has begun to give the field an uncharacteristic coherence. "Most of us have been indoctrinated
into particular theories and methods based on the accidents of our training," says Louis Cozolino.
"But the one thing all perspectives have in common is that they're ultimately the underlying
operating principles of the human brain. In the future, as we understand more, I think we'll
develop a common language within mental health based on the impact different interventions
have on specific neural circuits. An image of the field might come to look like a wheel, with our
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many theories as the spokes and the brain as the hub, the ultimate mystery we'll continue to
explore."
Mary Sykes Wylie, Ph.D., is a senior editor of the Psychotherapy Networker .
Richard Simon, Ph.D., is the editor of the Psychotherapy Networker and author of One on One:
Interviews with the Shapers of Family Therapy. We are grateful for the contributions made to this
piece by freelance writer Judith Schwartz. Letters to the Editor about this article may be sent to:
[email protected].
The Brain in the Palm of Your Hand
by Danny Siegel
If you take your thumb and bend it into your palm and fold your fingers over the top, you will
have in front of you a surprisingly accurate rough model of the brain. Of course, the brain is made
up of impossibly complex interconnections among 10 to 20 billion neurons and can hardly be
reduced to a human fist. Nonetheless, we can take a shortcut, as a lot of neuroscientists do, divide
the brain into three major areas--the cortex, the limbic system, and the brain stem--and talk about
what role they play in the larger system.
Now, hold your curled up hand--the "brain"--so that you are looking at your exposed fingernails.
The "eyes" in this imaginary head will be just in front of the two center fingernails, the "ears" will
be coming out the side, the top of the head will be at the top of your bent fingers, the back of the
head will correspond to the back of your fist, and the neck will be represented by your wrist.
Looking "inside" the head, your wrist represents your spinal cord coming up from your back.
Then the center of your palm symbolizes the brain stem, which emerges from the spinal cord. The
brain stem, the lowest area of the brain, is an interface between the brain and the outside world: it
takes in information from perceptions, from the body, and it regulates states of wakefulness and
sleep.
If you raise your fingers up and reveal the thumb curled into your palm, you're looking at the area
symbolizing the limbic structures, which generally mediate emotion and generate motivational
states. This crucial function influences processes throughout the brain. Emotion is not simply
based or limited to the limbic circuits, but appears to influence virtually all neural circuits and the
mental processes that emerge from them.
For clinicians, several regions of the limbic system are especially important to know. First is the
hippocampus, which is important for integrating processes that result in "explicit memory" or
factual and autobiographical memory. (Remember that the brain is divided into a left side and a
right side, so there are really two hippocampi, as there are two of most structures in the brain.)
The amygdala, represented on the second to last segment of your thumb, is more toward the
center of the temporal lobe. The amygdala is important for processing emotions, especially
sadness, fear, and anger. Processing means generating the internal emotional state and the
external expression as well as the perception of such states in others. The amygdala, for example,
has face-recognition cells, which become active in response to emotionally expressive faces. It is,
in fact, one of the important appraisal centers in the brain that evaluate the meaning of incoming
stimuli.
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Then, toward your thumbnail, we can imagine the anterior cingulate cortex. Some people think of
this region as the chief operating officer of the brain. It helps coordinate what we do with our
thoughts and our bodies. Some experts include the hypothalamus here as part of the limbic
system. The hypothalamus is a crucial neuroendocrine center, which initiates hormonal secretions
and neurotransmitter flow involved in coordinating many brain-body functions, including the
experience of hunger and satiety.
Putting your fingers back over your thumb will represent the third major area of the brain: the
cerebral cortex. Also known as the neocortex or cortex, this region sits at the top of the brain and
is generally regarded as the center of the most evolved functions of reflection and awareness-functions that distinguish human beings from other animals. The cortex has lobes that mediate
distinct functions. In mental health, we're interested in the frontal part of the cortex, called the
frontal lobe. Symbolized by the front of your fingers from the second-to-last knuckles down to
your fingernails, the frontal lobe mediates reasoning and associational processes. Its front part is
called the prefrontal cortex, and this is symbolized by your last knuckles down to your
fingernails.
Two major areas of the prefrontal cortex are the side parts called the dorsolateral or lateral
prefrontal cortex, where your two outside fingernails are. These are the centers for working
memory, the chalkboard of the mind, which enable us to remember a phone number long enough
to dial it, or a sentence long enough to say it. The middle part includes the orbitofrontal region, so
called because it's behind the orbit of the eyes. In the hand model, the orbitofrontal cortex is
symbolized by the middle two fingers, from the last knuckles down to the fingernails.
The orbitofrontal cortex is the only area of the brain that is one synapse away from all three major
regions of the brain. It sends and receives neurons to and from the cortex, limbic structures and
brain stem, integrating these three areas into a functional whole. This unique structural position
gives it a special functional role in integrating the complex system of the brain.
An important function that the orbitofrontal cortex is believed to help control is the regulation of
the autonomic nervous system, the branch of our nervous systems that regulates body functions
such as heart rate, respiration, and peristalsis. It has two branches: the sympathetic, which is like
an accelerator, and the parasympathetic, which resembles a braking system. Together, the
regulation of the two systems keeps the body balanced, ready to respond with heightened
sympathetic arousal to a threat, for example, and able to calm itself down when the danger is past.
This region is of particular relevance to psychotherapists, because it integrates so many aspects of
the brain that are central to good mental and emotional functioning. In addition to regulating the
autonomic nervous system, the orbitofrontal cortex regulates emotion and emotionally attuned
interpersonal communication (often involving eye contact). It appears to play a critical role in the
human capacity to sense other people's subjective experience and understand interpersonal
interactions. The orbitofrontal cortex also has to do with response flexibility, i.e., the ability to
take in data, think about them, consider various options for responding, and then produce an
adaptive response. Finally, it is believed that the orbitofrontal cortex is essential for selfawareness and autobiographical memory.
If the orbitofrontal region is impaired in some way or temporarily shut down in coordinating the
activity of related regions (such as the anterior cingulate cortex, amygdala, and hippocampus), the
individual may experience a sense of disconnection from others and a breakdown in the reflective
sense of self, while exhibiting knee-jerk responses rather than flexibility of response.
Neuroscientists now suspect that trauma may impair this region's capacity for neural integration,
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which is fundamental to emotional recovery from traumatic events. One can hypothesize, for
example, that flashback states involve the entry into a lower mode of automatic or primitive
response when the orbitofrontal region--which enables us to integrate mental, physical, and
emotional experience---has been impaired.
Daniel Siegel, M.D., is associate clinical professor of psychiatry at the UCLA School of Medicine
and author of The Developing Mind .
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