Therapy Isn't Brain Science

Therapy Isn't Brain Science

Knowledge Doesn’t Replace Clinical Skill

July/August 2013

Some years ago, during the heyday of the self-esteem movement, I was invited to teach at a large weekend drug and alcohol conference. Most of the presenters talked about how critical it was to build up clients’ positive self-concepts to help them stop using drugs. But while everyone seemed convinced that self-esteem was important, when I asked my workshop group what exactly self-esteem was and, more important, how they could help clients enhance theirs, the room went quiet.

“OK,” I said. “Let’s imagine that I’m hooked on drugs. Help me improve my self-concept. Help me out. What should I do?”

“Well, you could use operant conditioning,” someone suggested.

“Great!” I responded. “Condition me. Show me what you can do to help me improve my self-esteem.”

The room got quiet again. “I’d start by helping you heal your past traumas,” another person eventually volunteered.

“OK,” I said. “Let’s imagine that I was sexually abused as a child. Show me how to build up my self-concept in a way that’ll heal that.”

Again, the room went quiet. My point in keeping up this line of questioning for almost 20 minutes was to make a clear distinction between what psychologist and communications theorist Paul Watzlawick called descriptive language—which tells you about something—and injunctive language—which tells you what to do. It’s the difference between describing a meal to someone and handing over a recipe.

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Sunday, July 21, 2013 4:26:56 PM | posted by Earl R. Poteet, LCSW
I couldn't disagree more with the author that there is no application for the current neuroscience within the realm of therapy. I will use my own experience in working with soldiers as to the efficacy of using brain knowledge in helping them overcome significant barriers to successful treatment. For example, telling someone about the possible structural changes to the hippocampus, can help them to normalize their feelings of having issues with memory. Informing them of how activated the amygdala can get when it is subjected to certain triggers, gives them a sense that if they can identify triggers (either from childhood or adult experiences), they can then take steps to extinguish the reaction from the cues.

I have literally used the current knowledge of neuroscience as a starting point, to break down barriers to treatment, and to enter into the deeper work that needs to be done. In conclusion, I must say that by using neuroscience, it has given me an empathic connection to engage in successful therapy.

Monday, August 5, 2013 4:06:41 AM | posted by Dr. A.sridhara
I feel comfortable to quote the author "’s a simple matter of finding out exactly what the structure of someone’s personal experience of a problem is—rather than the content within that structure—and then experimenting with useful ways to change it."

Wednesday, August 14, 2013 1:14:42 PM | posted by Bette Boddy, LCSW
Very helpful. This is what I do but I always wondered if maybe I was "discounting" my clients' problems even though they were getting "better."

Monday, August 26, 2013 3:51:40 PM | posted by Brian J. Whelan, LCSW, CST, SEP
The author of the post is an NLP practitioner and coauthor of many books dedicated to the practice of NLP. I always find it baffling to find someone bash the very science that might give ones own approach some legitimacy. Judging by the Wikipedia post on the subject, legitimacy and credibility is something that NLP sorely needs. I am not knocking NLP itself, it is probably more effective than many approaches proclaimed as legitimate, but I will never understand practitioners who argue for ignorance. Those may seem like harsh words, but they aren't meant to be. We are all ignorant of what we don't know and we are ignorant of how, what we don't know, might help us or inform or improve our work. When we say, I don't need to know neuroscience because neuroscience won't change what I do that is effective, one is arguing for standing still and no longer growing and learning as a practitioner. One is arguing that what I do cannot be improved upon by more knowledge and understanding, even though I don’t yet know what the knowledge or understanding might provide me. It is like a Lifeguard arguing that one doesn't need to be trained in the science of drowning. To the lay individual drowning looks like someone thrashing, screaming and flailing in the water, but to the well trained life guard, who is educated on the subtle and almost imperceptible and quiet signs of desperation, drowning looks very different. If you are going to be a good life guard, you better study up, because intuitive skill isn't enough. Your skill has to be informed by the science of drowning, otherwise you don't know what you are dealing with or what you need to be looking for.
Our clients are drowning all the time while clinicians that think they are just innately skilled at this work, let them struggle unaware of the subtle signs of their distress. Many of their clients end up in my office, ready to give up on life, because "nothing has worked". In my view, had more psychotherapists been versed in clinical applications of brain science, those clients might not have wasted so much time and money trying to get better unsuccessfully, only to feel as if the last resort is to "end it all".

We face an epidemic of suicides among military veterans who are not being served by existing therapies and methodologies, yet we are also being encouraged by this author that we don't need to know neuroscientific theories of PTSD to do good work with our traumatized clients. I cannot think of a more dangerous suggestion. We are failing our veterans and they are ending their lives in epidemic fashion! What we, as a field, are doing for our veterans is inadequate. I believe it is in the application and understanding neuroscientific principles where the answer lies in helping these veterans. Even just explaining how the involuntary survival mechanisms of the brain works, gives a great deal of relief to traumatized clients. A clinician who does not know this, cannot provide them with a neuroscientific explanation, and therefore cannot give them this relief, not to mention shift from a potentially overactivating "talk therapy" perspective to a more psychophysiological right brain processing approach.

This problem is not unique to our own field. Medical doctors prescribe drugs all the time based upon what their pharmaceutical representatives tell them about how the drugs work rather than a detailed and sophisticated understanding of the biochemistry of both body processes and the drugs. Maybe they argue they don't need to know biochemistry to help their clients. I knew a medical doctor who prescribed Neurofeedback for someone suffering from urinary frequency. Six months later the client died of bladder cancer. That doctor was one who argued for her ignorance and overplayed her intuitive skill. I fear she still hasn’t learned her lesson.

So lets stop arguing for our ignorance. Many clinicians I meet who say similar statements, are the same ones who practically dissociate whenever they are in a lecture that starts to talk about science. They get confused and shut down, probably just like they did in elementary school when they were introduced to math before their brains were ready. (Maybe their teachers needed an understanding of brain development). Or maybe it was caused by overbearing parents who put too much pressure on them. Or maybe it is just laziness? Or maybe they just don’t know what they don’t know and how a deep understanding of the principles might change their practice and enhance the wellbeing of their clients. Whatever the cause of their resistance lets stop arguing for our limitations and the status quo.

While clinicians can apply many techniques, without actually understanding the rationale that went into their approach, but that isn’t to say that these methodologies weren’t developed by someone who was versed in a complex understanding of the science of the day. While I believe that I could train a 4 year old to apply the basic protocol of EMDR as effectively as many adults, I would prefer an adult who was well versed in the psycho-neurobiology of trauma applying the technique. I wouldn’t let an EMDR therapist who does not understand the intricacies of the neurobiology of trauma work with me or any of my complex PTSD clients. EMDR can be quite a simple and effective technique to apply, but without a sophisticated understanding of neuroscience, I don’t think most therapists will understand when and why their approach is going wrong.

So how does neuroscience help us in a clinical setting? Is it just theory, as the author above suggests, that bolsters our own ego and makes us look like “experts” to our clients, or is there actually a real substantive contribution that science has to how we practice? Most psychotherapists, if asked, will not be able to come up with a working definition of what an “emotion” actually is. Since that is our field of expertise, the fact that most clinicians don’t have a much more sophisticated definition than a 4 year old armed with a feeling or mood chart is disturbing. However, if we understand that according to neuroscience, emotion is a pre-organized sequence of adaptive strategies that prepare the body for adaptive survival that consists of changes is the both the body and the brain then we might abandon left brain “talk therapy” and insight oriented approaches for body based procedural memory, right brain approaches like Somatic Experiencing, Sensorimotor Psychotherapy, or Focusing. If we understand that the visceral physiological responses that represent an emotion (nausea, tightness, quickening heart, flushed skin, etc) send information back to the brain changing the brains state and thought process, we might apply or recommend visceral bodywork to soothe the anxiety of a client, rather than ask them to tell us the details of the story of what happened. If we understand that when a client tells the story of a traumatic event that Broca’s area shuts down and the right brain and lower brain sensorimotor areas light up, then we might change our approach to actually regulating physiology and assisting the body in completing incomplete survival oriented “pre-ordered sequences” that weren’t able to be completed at the time of the trauma. If we understand that 80% of the nerves going between the viscera and the brain are actually afferent (i.e. Sensory) then we might realize that visceral bodywork might be more effective than talk at addressing someones anxiety or to stabilize them physiologically when they are in an intensely dysregulated suicidal crisis. If we understand neuroscience we might save our breath trying to convince someone with a body image issue that they have a distorted perception and get them on a balance board doing activities that can reorganize and correct the insula’s faulty body map when that is the actual cause. If we understand the way animals in the wild discharge these pre ordered survival patterns through a sequence of behavior that resembles psychogenic seizures (seizures are considered trauma related) we might be able to help these clients come through this process gently and without fear that perpetuates and compounds their trauma and dysregulation. As Bessel van der Kolk states the “dorsolateral
prefrontal cortex (dlPFC), which is involved with insight, understanding, and
planning for the future, has virtually no connecting pathways to the brain centers that generate and elaborate emotions” and therefore it has limited efficacy in helping people “inhibit the automatic physical actions that emotions provoke”. Knowing this points out interventions towards biological and regulatory processes that are primarily mediated by the right brain. Neuroscience has shown us that mindfully tracking body sensation without
If we understand that the insula, medial prefrontal cortex, and anterior cingulate play a role in extinguishing fear arousal, that individuals with OCD and PTSD have deficiencies in these areas, and that mindfully tracking sensations without judgment causes increased growth in these areas, and that individuals who show resolution of OCD and PTSD symptoms have improved function in these areas, then we might engage our clients in mindfully tracking sensations instead of engaging them in the “talking cure”. I could go on and on about how knowledge of neuroscience helps us effectively understand and apply refined interventions to help our clients who have been otherwise failed by antiquated models and theories. The more I understand about neuroscience, the more refined my interventions and the more effective I find I am with my clients. Neuroscience has changed the way I practice and has so fundamentally transformed the way I work with clients that nothing that I do now remotely resembles what I was taught in school. I will continue to strive to be the best and most informed therapist I can be. I hope you won’t adopt the view of the author above. Don’t let you patience drown.

Brian J. Whelan, LCSW, CST, SEP

Friday, August 30, 2013 6:34:45 AM | posted by Samuel Skierski
It's not always what you think, it's how you think of what you think about. Brief therapy creates fast and lasting change.
Kudos, Steve Andeas

Friday, August 30, 2013 8:27:15 AM | posted by Holistic Hypnosis Hypnotherapy Los Angeles.
I agree with knowledge verses pragmatic ability to help. Why I became a Hypnotherapist. 25 years of reading psychotherapy left me frustrated. I knew more and more about people's difficulties with no greater ability to assist in their resolution. Neuro- science is part of the pursuit of curing emotional problems via Chemical means. Years ago I wrote a line in a poem, "Might as well to find a thought, dissect a brain." which was my attempt to debunk this kind pseudo rationality. I was incidentally a scientist in my orientation as a youth.

Friday, August 30, 2013 3:39:43 PM | posted by Nick Kemp
Good observations! Any therapist or practitioner working with clients week in week out would IMO probably agree. In the internet age so often folks forget that what actually creates genuine results for people trumps all the academic theory every time. That's not to say such research has not value, rather that real life substantive change is more useful...

Friday, August 30, 2013 6:01:29 PM | posted by Mark Ryan
Nice article Steve!

I think a lot of the knowledge of the effective "How" to helping people has been available for years.

Why work backwards from Neuro-science to a "how" when you could use the present working "Hows" to align with the new discoveries in Neuro-science?

Seems like a more efficient path.

Personally i think the "How" that has been learned in NLP - Hypnosis - Metaphor work and Bruce Ecker's Reconsolidation Coherence Therapy.... would be a great start to any new Therapists toolbox.

Enough to have a long and successful career that will align perfectly with the discoveries of the new Neuro-science.

Friday, August 30, 2013 8:10:49 PM | posted by Reza Venili
Thank you dear Steve for choosing a topic which is pervasive among the practitioners nowadays and doing so shows just how much observant you are of the intellectual market of the FoNLP.

As your student, I wanted to communicate a few things that came to my mind, regarding the article. I really enjoy your writings for many reasons amongst which is how you avoid cliches avoid regurgitated stuff. So to read that paragraph in which you mention 'the DSM-V and the 900 pages of description' seemed a bit out of character to me. Firstly it is a 'Diagnostic' manual and secondly there is a section named 'course' for every disorder in the book which proposes the course of treatment. These treatments may not be aligned with the kind of treatments that we hope for or the book might lack treatments for some of the disorders but still, to frame it as a '900 pages of problems' is to descend to the level of 'the word on the street' which you specifically invite us, the readers, to avoid.

The other point was 'the moral of the article' or 'the conclusion' which was not clear to me. Since in NLP and specially in this article you are inviting the readers to pay attention to the spirit of NLP which is 'Do what works', are you actually inviting the reader 'do not study neuroscience'? Surely you haven't written this relatively long article as a way of expressing 'I think Neuroscience is irrelevant' without any practical purpose in mind, have you? and even if it is just about that (expressing a concern), don't you think that this sort of 'expressions' would invite heavy & unnecessary criticisms from outside the field? I mean, at the moment, do we need to be known as people who 'argue for ignorance'? This probably comes from people who don't know you are a member of the board of an active group who rigorously study NLP.

Also, I'm a bit confused about the structure of the article and mainly about the relevancy of the 2 examples you presented (although I enjoyed them profoundly). If I understood it correctly, you first introduced your topic and then your claim and then you brought up 2 examples to show that no neuroscience was involved in these effective techniques. was that it? That is akin to saying "I believe wheels can not be used in an airplane. Now, to illustrate my point, let me give you examples of planes which do fine without wheels!" which is logically unnecessary and irrelevant to the argument, considering that they constitute almost 2/3 of the article. In fact, as you know it far better than me, we can not prove one method ineffective by telling anecdotes about the effectiveness of other methods. So, I couldn't find the point.

Anyways, I hope the feedback proves useful. I use the opportunity to sincerely thank you for everything positive you've done for NLP over the years, Steve.
All the best,

Sunday, September 1, 2013 2:12:26 AM | posted by Dr Martin Russell
" far, I haven’t seen any persuasive direct application of neuroscience to the practice of therapy."

Steve does address the idea of using neuroscience findings / theories, for the purpose of "normalizing" people's experience.

But beyond that, I too would be interested in identifying a concrete decription of a method, technique or application developed from neuroscience, or even a whole list of them.

This would be really valuable.

I look forward to people commenting here coming up to the challenge of providing the actionable specifics for this list.

Sunday, September 1, 2013 8:10:42 PM | posted by Edward
Very interesting article. This is what I do on a daily basis, NLP, hypnosis, EMT, etc ...

Tuesday, September 3, 2013 11:53:48 PM | posted by John Warren
I notice that you don't mention Neurofeedback or biofeedback based approaches such as capnometry/heart rate variability and so forth and how they might be utilised. Neurofeedback has several hundred papers testifying to it's usefullness whereas NLP has, as far as I'm aware, only single case studies with no mention of failures. I presume you do have failures, or would they be reframed in some way? There are many approaches other than NLP. Can't you acknowledge their input?

Wednesday, September 11, 2013 6:02:15 PM | posted by paul tsakeres
It's nice to know Steve, that you, your work is out there for us to model and utilize. Elegant in it's simplicity, the way you set up the change is impeccable. Thanx.

Saturday, September 14, 2013 4:45:11 AM | posted by harpreet bhatia
Really a wonderful article - exactly my sentiments!! Although I am also very interested in neurosciences, I agree that it is not a requirement to be a good therapist!!

Wednesday, September 18, 2013 7:31:11 PM | posted by jeffrey von glahn
I fully support Andreas. A probable reason may be that both of us became therapists long before “neuroscience” acquired its imaging machinery. We were able to attend to the practice of psychotherapy as it presented itself in clients’ experiences rather than viewing it through the lens of another frame of reference. Neuroscience AND the current mainstream view of psychotherapy share the same limited perspective on what psychotherapy can accomplish. Both view effective treatment as a better way to cope with your problem rather than resolving it. What would we think of a medical science that settled for the partial healing of an injury or an illness? The field of psychotherapy has burdened itself with a self-inflicted blind spot about the therapeutic value of emotional experiencing. The fear of re-traumatization is based on a false premise; i.e., that heightened emotional experiencing means that the person is being “re-hurt.” See my article in PN, May/June, 2012, as well as ones in PsycINFO. The key to the maximum effectiveness of any therapy is the unforced activation of the client’s emotional experiencing; i.e., it arises coincident with the support the client receives for his experiencing. I can cite six well known researchers who agree that research has yet to demonstrate why psychotherapy works. I claim it works because of the unforced activation of emotional experiencing, which is the factor shared by all effective therapies despite how they are said to work. In “Is crying beneficial?” (Current Directions in Psychological Science, 2008, 17(6)), the authors concluded that “empirical research on crying is in its infancy.” Given that our beloved profession has existed since the late 1800s and that clients have been crying ever since, this is an absolutely astounding statement. I regard clients’ crying as Psychotherapy’s Best Kept Secret. I’ve yet to see a neuroscience discussion of crying. The best advice that Dan Siegel can offer for how to handle heightened emotional experiencing is “name and tame.” The best that Louis Cozolino (The neuroscience of psychotherapy: Healing the social brain, 2nd. ed.) can offer for why psychotherapy works is as a placebo. This leaves me wondering why “science” is in “neuroscience.” In this same text, there also appears: “When all is well and we are in a state of calm, there is no reason to learn anything new. When our needs for food, companionship, and safety are satisfied, the brain has done its job and there is no reason to invest energy in learning,” as well as, “We…intuitively understand that people need to be motivated and aroused to learn.” Do you find yourself in this description of our psychological nature? I certainly don’t. Maslow refuted this view decades ago. I challenge neuroscientists to compare the brains of people who are psychologically healthy with those who aren’t and when clients cry in a therapeutic way.