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Transforming the Therapeutic Experience
We all know that use of the therapist's self is critical in therapy and that therapy, like any good relationship, implies mutual emotional regulation. In psychodynamic parlance, a good therapeutic alliance balances the powerful tides of transference and countertransference, while maintaining a vital, but controlled, sense of mutual emotional attachment. Knowledge of brain science makes explicit the neural underpinning for this mutual regulation (and dysregulation), helping us attend to this inner dialogue, both aurally and somatically, with more awareness and skill.
A client we'll call Ilyana came to one of us after a family catastrophe: her son had murdered his wife and was serving a life sentence in prison as a result. The court had awarded custody of the grandchildren to the daughter-in-law's mother, who refused to let Ilyana see them. In one blow, she'd lost her daughter-in-law—whom she adored—her two grandchildren, and, in effect, her son. These traumatic events reactivated the brain-based patterns that were the legacy of her upbringing by a harsh, puritanical mother and an alcoholic father, a pattern reinforced by three episodes of major depression in her adult life. Her brain had learned how to be depressed even before the current traumatic losses and stress. In her distress, she'd cut herself off from nearly all her family and friends, she'd become extremely nervous and felt she couldn't handle even the smallest setbacks, and, overall, felt desperately low.
Having grown up in the era of the Pax Medica, I (LL) was expert in diagnosing Ilyana's problems. As a specialist in evidence-based treatment and psychotherapy research, I was also reasonably expert in the techniques managed-care case managers would like me to use to help her—primarily medications and CBT. But I knew all too well that a straight DSM diagnosis often misses much about the client's character and situation. As a result, the conventionally correct "treatment" plan frequently ends in failure.
Sitting with Ilyana, I visualized her brain thrown into a crash dive by her daughter-in-law's murder and the loss of her grandchildren. Acute stressors flood the brain with the stress hormone cortisol and change its metabolism and eventually its morphology. As her amygdala becomes more active, a nearby module, the hippocampus, likely becomes less efficient. The hippocampus is like a librarian, taking in the welter of sensory information about the outside world from many different parts of the brain and organizing it in forms that can be explicitly remembered. Rich in receptors for cortisol, the hippocampus acts like a thermostat during periods of normal stress and turns down the hypothalamic-pituitary-adrenal (HPA) axis, in effect, shutting off the alarm caused by the amygdala's reactions.
But chronic cortisol elevations—an inevitable consequence of severe, long-term stress—can erode the hippocampal functioning. Chronic stress can actually cause the hippocampus to shrink, impairing a person's ability to attend to and remember what's happening in the outside world. When this happens, the healthy push-pull equilibrium between the amygdala and the hippocampus (in which the amygdala promotes sympathetic arousal, including the eventual release of cortisol, and the hippocampus down-regulates it breaks down. It seemed to me that that this dynamic was at the bottom of Ilyana's constant feeling of being on edge and her overreactions to ordinary stressors.
What Ilyana told me about her years growing up—and what I experienced as her attachment-based insecurity during our therapy—suggested that her brain had coped with excessive levels of cortisol for nearly her entire life. Over time, these dynamics had resulted in an unusual vulnerability to depression: her hippocampus had lost some of its ability to take in features of the outside world, her overactive amygdala promoted a more or less continual sense of danger and vulnerability; and right-brain dominance biased her cerebral architecture toward a set point of sadness and melancholy. Since Ilyana regarded any ambiguity as threatening, she readily interpreted the ebb and flow of changing facial expressions and tones of voice in others as signaling catastrophe.
On a recent vacation, she became acutely anxious and depressed after a spat with her boyfriend, who'd accused her of looking to him "for a kind of security that a person can only find in themselves." Ilyana was convinced the relationship was doomed because "I'm so screwed up. I hate being alone, but with my luck, this is how I'll end up: alone." From a kind of crouched position in her chair, she looked up at me and asked pleadingly, "How can I come to grips with things so I don't feel so overwhelmed all the time?"