Discoveries from the Black Box

How the Neuroscience Revolution Can Change Your Practice

Discoveries from the Black Box

This article first appeared in the September/October 2002 issue.

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 actually 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 laboratory-engineered 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: 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 Child-Friendly 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 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.

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 touchy-feely 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 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 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 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.

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.

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 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–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 integration.”

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 self-regulatory 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 many theories as the spokes and the brain as the hub, the ultimate mystery we’ll continue to explore.”


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Mary Sykes Wylie

Mary Sykes Wylie, PhD, is a former senior editor of the Psychotherapy Networker.

Rich Simon

Richard Simon, PhD, founded Psychotherapy Networker and served as the editor for more than 40 years. He received every major magazine industry honor, including the National Magazine Award. Rich passed away November 2020, and we honor his memory and contributions to the field every day.