No Longer Strange Bedfellows? - c.ymcdn.com

10/28/2013

NEUROSCIENCE & PSYCHOTHERAPY: No Longer Strange Bedfellows?
NO LONGER STRANGE BEDFELLOWS
“Advances in neuroscience provide guidance for the
TPA 2013: PART 2 NEUROSCIENCE IN THERAPY development of psychological conceptualizations of mental

Timothy A. Urbin, PhD., MBA, HSP illness and treatment that go beyond a reductionistic
Clinical Psychologist/Neuropsychologist biological etiology.”*
Asst. Professor/Department of Family Medicine
Quillen College of Medicine • “Reductionist”?: trying to “reduce human nature and suf-
fering to biochemical malfunctions”*

• Reductionism IS still alive but progress in genomics is
showing it is the wrong path!

• * N. Cappas et.al. (2005). What psychotherapists can begin to learn from
neuroscience: Seven principles of a brain-based Psychotherapy. Psychotherapy:
Theory, Research, Practice, Training, 42, 3, 374-383.

Useful to psychotherapy? Important to understand?

• “neuroscience can be useful to psychotherapy in at least • “Affective processes appear to lie at the core of the self,
two ways”: and due to the intrinsic psychobiological nature of these
1. validation of existing psychotherapeutic theories and bodily-based phenomena recent models of human
interventions development, from infancy throughout the lifespan, are
2. suggesting directions to enhance current clinical moving towards brain-mind-body conceptualizations.”
practices
• Schore, A. (2003). Affect Regulation and the Repair of the Self.
* N. Cappas et.al. (2005). What psychotherapists can begin to learn from neuroscience:
Seven principles of a brain-based Psychotherapy. Psychotherapy: Theory, Research, • “After three decades of the dominance of cognitive
Practice, Training, 42, 3, 374-383. approaches, motivational and emotional processes have
roared back into the limelight.”

• Ryan (2007) Motivation and Emotion

• “The power of psychotherapy to change the brain rests in Clark & Beck (2010): Modified CBT

our ability to recognize and alter unintegrated or • “Empirical evidence consistent with this model… indicates
dysregulated neural networks.” (p.340*) the effectiveness of cognitive therapy could be associated
with reduced activation of the amygdalohippocampal
• *Cozolino, L. (2010) The Neuroscience of Psychotherapy: Healing the subcortical regions implicated in the generation of
Social Brain (2nd ed). New York: WW Norton & Co. negative emotion and increased activation of higher-order
frontal regions involved in cognitive control of negative
• Our human capacity to recognize problems also emotion.”
allows us to change our brain processes!
• “Deactivation of hypervalent dysfunctional schemas and
• “Thinking” allows us to meta-analyze our selves improved access to more reflective, adaptive modes of
thought and behavior are considered crucial to symptom
amelioration”

• Clark, D.A. & Beck, A.T. (2010). Cognitive theory and therapy of anxiety and
depression: Convergence with neurobiological findings. Trends in Cognitive
Sciences 14 (2010) 418–424

1

10/28/2013

Neuroscience & Psychotherapy Term #1: Self-directed Neuroplasticity

“There is no longer any doubt that psychotherapy • Term #1: ‘self-directed neuroplasticity’ to serve as a
can result in detectable changes in the brain.” general description of the principle that focused training
and effort can systematically alter cerebral function in a
• Etkin, Pittenger, Polan, & Kandel (2005) J. of predictable and potentially therapeutic manner”
Neuropsychiatry & Clinical Neurosciences
• Schwartz, J.M. & Begley, S. (2002) The Mind and the Brain:
Neuroplasticity and the Power of Mental Force. New York: Harper
Collins

• Neuroplasticity: Primary principles

• Use it or lose it
• What fires together, wires together

Term #2: Relationship Neuroscience Findings: Early Neurodevelopment

• Rapidly expanding field of knowledge • Relationships are key to outcomes of early stages
• Definition: “any work that uses neuroscience methods to • Critical “bonding” network develops in infancy and

understand close relationship processes or uses into 2nd year of life
relationship-relevant processes to advance knowledge of • New module forms in right orbital-frontal cortex by
the brain.”
• Healthy human connections: key to healthy brain! 2 ½ (parallels to Broca’s area in Left frontal lobe)
• Interdisciplinary work involving experts in neuroscience,
psychology, and biology- including biomarkers • Critical to self-regulation of emotion as well as
emotional interpretation of environment!
• E.g. stress (cortisol) and bonding (oxytocin) hormones
• Integral to “autoregulation” and “interactive regulation”
• See:

• Adams, Glenn. III. Kunkel, Adrianne D., Editors (2012) Relationship science :
integrating evolutionary, neuroscience, and sociocultural approaches .
Washington, D.C.: American Psychological Association

Effect of Early Neurodevelopment 2 Effect of Early Neurodevelopment 3

• Outcome of this early stage is critical and long lasting • Responds in msec to changes in either environment
• … “the most significant consequence of the stressor of
• Internal & External environments
early relational trauma is the lack of capacity for emotional
self-regulation” (Schore, 2002) • Verbal centers lag behind in assessing environment

• Becomes the source of our nonverbal (aka unconscious) • Typically follows the “lead” of the limbic system:
sense of who we are and how we think about the world • “Why do I feel this way? It must be because of …”

• Forms implicit memories: • NOTE: For adults, psychotherapy tries to help individual
recognize these emotional reactions and underlying
• “those things that you can’t quite put your finger on” implicit assumptions that are affecting their lives

• System is always monitoring internal and external • CBT attempts to shift “control” to “rational” centers
environments • Thinking taking charge of the override system!

• When you think “I don’t trust you…” or “Something’s • Expanded models of CBT are developing- e.g. schema therapy
wrong”, this system is already on! • Better long term stability/relapse prevention

2

10/28/2013

Progressive Developmental Goals Goal: Cognitive-Affective Balance
(based on Neuroscience)
KEY: Not the overall balance that matters,
• Facilitate a healthy approach to emotional regulation it is the flexibility to shift when needed!
• Approaches vary by age group
Early Adolescence Early Adulthood
Start: Environmental management (young child) Ideally!

To: Increased self-regulation (older child/teen)

To: Increased self-efficacy (teen/adult)

To: Healthy, emotionally balanced Adult

Managing Early Childhood Core childhood needs

• Primary caregiver is most influential • Safety: “Stable Base,” Predictability
• Love, Nurturing & Attention
• Close face to face interaction is important due to infant’s • Acceptance & Praise
limited vision (synchronized interaction) • Empathy
• Guidance & Protection
• Tone of voice and facial expression are critical • Validation of Feelings & Needs
• Imitating baby’s sounds is important for sense of social
• See Gottman & Gottman (2013) Emotion Coaching
connection
• When unmet, distress increases
• (NOTE: When treating children: focus on • If not successfully met, maladaptive long term
environment, quality of caregiver relationships, and
emotional-self regulation) schemas form

Memory systems Early Stress 5 elements of emotion coaching

Unmet Core Needs 1. Being aware of child’s emotions
2. Recognizing the emotion as an opportunity for intimacy
TOXIC STRESS
and teaching.
Hyper-responsive Chronic “fight or 3. Listening empathically and validating the child’s feelings
stress response; flight;” cortisol / 4. Helping the child verbally label emotions
5. Setting limits while helping the child problem solve
calm/coping norepinephrine • Outcome research: “coached" children grew up to

CHILDHOOD STRESS become "emotionally intelligent”

Changes in Brain Gottman J. (1998) Raising an Emotionally Intelligent Child
Architecture Gottman, J. & Gottman, J. (2013) Emotion Coaching. NY: Guilford Press

3

“Emotionally Intelligent”? 10/28/2013

• able to regulate their emotional states It is easier to build
• better at soothing themselves when they are upset strong children
• can calm down their hearts faster after an upsetting incident than to repair
• better at focusing attention broken men.
• relate better to other people, even in tough situations like Frederick
Douglass
getting teased in middle school
• better at understanding people
• have better friendships with other children
• better in school situations that require academic performance

Maladaptive Coping Styles What is a “Schema”?

• The ways in which a child adapts to a distressing childhood • “A schema is an extremely stable, enduring pattern that
environment (survival): develops during childhood or adolescence and is
elaborated throughout an individual’s life.”
1. Schema surrender (freeze) Limbic System
2. Schema avoidance (flight) Amygdala • Important beliefs & feelings about oneself and the world
3. Schema overcompensation (fight) • Individual “accepts” schema without question

• Many specific, individual coping responses, derived from • Not necessarily “conscious”!
these three broad styles • Typically maintained by right hemisphere and limbic system

• Long term: leads to behavior with self-fulfilling prophecies • Self-perpetuating and very resistant to change.
• The world is viewed through our schemas

• Rose, Neutral, or Gray colored glasses!

Schema Therapy General Schema Therapy Guidance

• An integrative, unifying theory & treatment 1. Identify patterns in behavior
• Consistent with current neuroscience studies a) Look beyond current identified triggers
• Problems are assumed to have significant origins in b) Link pattern of problems to life history and early origins

childhood & adolescent development 2. Educate them about pattern: “Reinventing Your Life”
• Designed to treat a variety of long-standing emotional 3. Acknowledge benefit of the behavioral responses in the

difficulties, with individuals & couples past (survival)
• Combines cognitive, behavioral, attachment, object 4. Increase awareness that responses are an impediment in

relations, and experiential approaches the present and likely in the future
5. Enhance self-efficacy by encouraging active awareness
• Specific “schema therapy” pioneered by Jeffrey Young
• Also expanded in CBT by Aaron Beck & Judith Beck of “self-theory” (“hypotheses”= self-talk)
6. Encourage “corrective experiences” (Perry) to test these

“hypotheses”

4

10/28/2013

Differences from “standard” CBT Remember: Monitor YOUR nonverbals!

1. Greater emphasis on the therapeutic relationship • Nonverbals are primary triggers for “override system”
• Identifying reactions in session is helpful
2. More emphasis on affective display during discussions • Potential priming of implicit memory system:
• Proxemics: proximity to another person
and variations in mood states
• Nonverbal: distance
3. More exploration & discussion of childhood origins and
• Kinesics: bodily movements of another person
developmental processes
• Nonverbal: Body posture, arm positions & movements
4. More emphasis on patterns/lifelong coping styles (e.g.,
• Paralanguage: how messages are delivered
avoidance and overcompensation)
• Nonverbal: Tone of voice, facial expressions, …
5. More emphasis on entrenched core themes/schemas

suggested by behavioral patterns

Critical Point for Psychotherapy Adolescents: Why DO they do the things they do?

• “The "autobiographical memories" that tell the story of our
lives are always undergoing revision precisely because
our sense of self is too. We are continually extracting new
information from old experiences and filling in gaps in
ways that serve some current demand. Consciously or
not, we use imagination to reinvent our past, and with it,
our present and future.” (p. 66)

• GARRY, M., & POLASCHEK, D. (1999). Reinventing yourself: Who you are is limited
only by your imagination. Psychology Today, 32(6), 65-69.

• NOTE: This article is readily understood by everyone. However, there are MANY
empirical research studies that have produced this now accepted conclusion.

Teenagers Adulthood

• Behaviors are primarily emotionally driven • Early Adulthood:
• Amygdala: “Maximize pleasure, Minimize pain” • 18-25: Struggle between emotional and rational systems

• Insight oriented approaches less effective: • Tendency to ignore “facts” that don’t fit “what they want”
• Affects decision-making: school, career, relationships,…
• Not “Why did you do that?” • 25-30: Integrated emotional and rational systems
• Frequently produces “Rationalizing” behavior • Time when “The lights come on!”
• May struggle with decisions that have been made
• Future focus may be more beneficial: • If significant emotional issues and maladaptive coping

• “The next time you are in this situation, what things can you do to styles remain when entering this stage, result may be a
prevent this problem from occurring?” psychological crisis

• “Where do you want to be in five years?” What are your dreams for
the future?” “What do you imagine your life will be like?” “What
things can you do now to make it more likely to happen?” “What
things are you doing now that may interfere with these goals?”

5

10/28/2013

The integrated brain at 25-30 y/o? General Therapy Guidance

• Jimi Hendrix: died September 18, 1970, age 27 1. Reduce impact of current crisis/presenting problem
 Goal: Initially reduce intensity of symptoms then reduce
• overdose barbiturates and alcohol frequency of occurrence (stabilize override system)

• Janis Joplin: died October 4, 1970, age 26 a. Use specific CBT approaches for depression, anxiety, etc.
b. Possible Medication as short term adjunct to psychotherapy
• “official cause of death was an overdose of heroin, possibly
combined with the effects of alcohol” 2. Increase skills needed to stabilize & prevent relapse

• Amy Winehouse: died July 23, 2011, age 26 • Goal: Reduce activation of “override” & Increase
“thinking”(cognition)
• alcohol poisoning
a. Develop Relaxation/Mindfulness skills to slow reactions
• Heath Ledger: died January 22, 2008, age 28 b. Improve self-care/wellness (sleep, nutrition, exercise)
c. Enhance skills in Communication, Problem solving…
• “accidental intoxication from prescription drugs” d. Identify patterns in behavior to aid prevention

• Kurt Cobain: died April 8, 1994, age 27

• “officially ruled a suicide by a self-inflicted shotgun wound

• Jim Morrison: died July 3, 1971, age 27

• “alleged to have died of a heroin overdose”

Cautions for psychotherapists General Therapy Guidance 2

• “Although informative, eliciting accounts of disability and 3. Reinforce awareness of successes (using MI if possible)
distress from patients may exacerbate negative
perceptions of self.” (Cappas et.al., 2005)  Goal: Enhance Self-Efficacy
 e.g. “You really did better… last time you… so this a positive change”
• Talking about trauma can reduce or exacerbate emotional  Begin delaying “fight, flight, or freeze” response
responses depending on the context used!  Assess perceived current “failures” to identify specific factors that

• Verbalize to client/patient that exploring these issues: may have affected actual outcome or perception of outcome
1. is important for your understanding of possible triggers • Problem solving & reframing
2. will not be an ongoing verbal focus of treatment (!)
3. Keeping a focus on traumatic events impairs healing 4. Enhance ability to predict situations that trigger relapse

 Goal: Enhance Self-Efficacy
 Increase sense of control/improve future orientation
 Expand exposure to situations that will “change the brain”!
 Enhance involvement of “Thinking” areas

“Corrective” Experiences: Increased Sense of Stress Event Activate
Vulnerability Negative
• Talking is NOT enough! TOXIC STRESS Schemas
• “Parts of the brain cannot be changed if they are
Sympathetic
not activated” (verbalize to client) Activation
• “The client must have opportunities for new
Hyper-responsive Chronic “fight or
experiences that will allow the brain either to stress response; flight;” cortisol /
break false associations or to decrease the
overgeneralization of trauma-related calm/coping norepinephrine
associations (corrective responses)”
Changes in Brain
• (Perry, ChildTraumaAcademy.org) Architecture

“What Fires Together, Wires
Together!”

6

10/28/2013

Increased self-efficacy Stress Event Increased Resilience Early Maladaptive Schemas
RTOelXaIxCatSioTnRESSkSills
• A broad, pervasive theme or pattern
“Time to Think”: Implement Parasympathetic • Comprised of memories, bodily sensations, emotions &
Healthy Adult response Activation
cognitions
Relaxation response; Decrease “fight or • Basis of beliefs about oneself and one's relationships with
calm/coping flight”: cortisol /
others
norepinephrine • Developed during childhood or adolescence
• Enhanced/reinforced throughout one's lifetime
Changes in Brain • Dysfunctional to a significant degree
Architecture
• Affects relationships, life satisfaction, career stability
“Use it or lose it”

The 18 Early Maladaptive Schemas Schema perpetuation

Disconnection & Rejection Impaired Limits • Routine processes by which schemas function and
• Emotional Deprivation • Entitlement perpetuate themselves.
• Abandonment • Insufficient Self-Control
• Mistrust/Abuse • Accomplished by cognitive distortions, self-defeating
• Social Isolation Other-Directedness behavior patterns and schema coping styles
• Defectiveness • Subjugation
• Self-Sacrifice • Schema will:
Impaired Autonomy • Approval Seeking • highlight or exaggerate information that confirms the
• Failure schema and
• Dependence Overvigilance & Inhibition • will minimize or deny information that contradicts it
• Vulnerability • Emotional Inhibition
• Unrelenting Standards • Unhealthy behavior patterns will perpetuate the
• Negativity/Pessimism schema's existence
• Punitiveness
• Therapist needs to clarify all of the above!

Example: MDD Schema Change/Healing in Therapy

• Evidence: “minimize or deny information that contradicts” • Point out when patient’s schemas seem to be triggered in

• Johnstone, T., van Reekum, C.M., Urry, H.L., Kalin, N.H. and Davidson, R. J. a session or in recent events
(2007) Failure to Regulate: Counterproductive Recruitment of Top-Down
Prefrontal-Subcortical Circuitry in Major Depression. The Journal of • Ask patient for trigger event, emotions & cognitions
Neuroscience, 27(33): 8877–8884
• Test validity of patient’s reaction: distinguish accurate
• Finding: In Major Depression, frontal activity intensifies
rather than suppresses responses within amygdala perceptions from schema-driven overreactions

• Rumination & Frequent verbal discussions with others • Link event in session with situations outside therapy

• Therapist tries to be aware when his/her own schemas

are being triggered to clarify interpersonal processes

7

10/28/2013

How does that make you feel? Where has the DSM failed us?

• “The results indicated that affect labeling, relative to other • DSM V: intended to incorporate more neuroscience
forms of encoding, diminished the response of the knowledge
amygdala and other limbic regions to negative emotional
images.” • DSM: Reinforces reductionist approaches

• Lieberman, M.D., Eisenberger, N.I., Crockett, M.J., Tom, S.M., Pfeifer, J.H., & • E.g. matching medications to diagnosis
Way, B.M. (2007) Putting Feelings Into Words : Affect Labeling Disrupts
Amygdala Activity in Response to Affective Stimuli. Psychological Science • Neuroscience research showing failure of this approach:
2007 18: 421-428 • “Lumps” together heterogenous groups under single label
• Creates artificial distinction between disorders with similar

neurobiological underpinnings
• “effective management of depression requires an

individualized approach that is tailored to the specific
symptom footprint of the presenting individual”

• Sharpley 2013

DSM Example: Depression Can Neuroscience Help?

• “although usually reported as a unitary diagnosis, major • See Sharpley et.al. (2013) propose:
depressive episode is composed of a range of different
symptoms that can occur in nearly 1500 possible • 4 Depression Types suggested based on DSM dx criteria:
combinations to fulfill the required diagnostic criterion” • Clinical content subtypes:
• 1: depressed mood
• Sharpley & Bitsikab (2013). Differences in neurobiological pathways of four "clinical • 2: anhedonic depression
content" subtypes of depression. Behavioural Brain Research, 256, 368-376 • 3: cognitive depression
• 4: somatic depression
Author identified “Highlights”:
• Depressive behavior is heterogenous. Different underlying neurobiological mechanisms =
• Four "subtypes" of depression were identified from symptoms. Different treatment approaches
• Each subtype has different behaviors and neurological pathways.
• Effective individualized treatment requires attention to these

differences.

Subtype 1: depressed mood Subtype 2: anhedonic depression

• “most easily recognized and familiar of the two key • See Sharpley et.al. (2013)
criteria”
• “less well-known than depressed mood” to public
• “early life experiences establish the ways in which future • “second of the two key symptoms”
events are perceived and how they affect adult mental • “hypothesized to result from imbalance in catecholaminergic
health”
systems, principally dopamine (DA)”
• “That learning has neurobiological mechanisms including • “characterized by a lack of interest in previously valued
changes to prefrontal cortex, hippocampal, and amygdala
functions induced by elevated HPA axis function and rewards”
elevated serum cortisol which accompany prolonged • “loss of “'desiring' factor for hedonic rewards”
stress and anxiety. In addition, prolonged psychosocial • “find it difficult to expend effort to obtain the rewards”
stress reduces serotonin release and uptake” • “overestimation of future costs and an underestimation of future

• “…use of treatments that re-establish serotonergic benefits”
function if required” • Increase Dopamine? (buproprion)
• Behavior Activation (Nike: “Just do it!”)

8

10/28/2013

Subtype 3: cognitive depression Subtype 3: cognitive depression

• See Sharpley et.al. (2013) • “Pharmacological treatments for cognitive deficits that
enhance sleep quality and normalize circadian rhythm
• “deficits in executive functioning (EF), particularly in young may be beneficial”
adults
• “selective attention, processing speed, vigilance, short-term memory • “behavioral activation - may have some benefit”
and working memory” • Increase activities with others
• Decrease time “ruminating” & talking about depression
• “Difficulty… seeing the world from an alternative (non- • Sleep hygiene
depressing) perspective, the inability to shift mental set has
been described as the most prominent EF impairment”

• “deficits in processing information, and a bias toward negative
interpretation of information”

• “concentration difficulties… appear to include only the
individual's ability to focus upon positive stimuli and emotions”

• “difficulties when in unstructured situations (such as being
alone, ruminating)”

Subtype 4: somatic depression Take Home Summary Points

• See Sharpley et.al. (2013) • We ARE trying to change the brain!

• “either hyper- or hypo-activated, implying that it is this • “Change your brain, change your life”
imbalance in physiological activity”
• Rapid changes are unlikely to be sustained
• “higher overall prevalence of depression among women is • Change takes time & persistence of therapist and patient
due to somatic symptoms of MDE alone (appetite, sleep, • Therapeutic relationship is essential to positive changes
fatigue) and not depressed mood, anhedonia or cognitive • Patient needs to understand goals and process
symptoms” • Understand the individual patient not the diagnostic label!
• Identify current behavior patterns and underlying schemas
• “Insomnia is one of the most common prodromal features” • Plan treatment based on this understanding
• “focusing upon the underlying physiological bases for
• Slow down “override” while enhancing “thinking”
them such as diet, sleep and exercise” • Thinking should “lead” in the adult, not follow!
• “may reduce MDE somatic symptoms with only marginal

reference to the other (emotional, cognitive) symptoms”

Suggested Readings Suggested Readings 2

• Abercrombie, H. C., Schaefer, S. M., Larson, C. L., Oakes, T. R., • Clark, D.A. & Beck, A.T. (2010). Cognitive theory and therapy of
Lindgren, K. A., Holden, J. E., Perlman, S. B., Turski, P. A., Krahn, D. anxiety and depression: Convergence with neurobiological findings.
D., Benca, R. M., & Davidson, R. J. (1998). Metabolic rate in the right Trends in Cognitive Sciences 14 (2010) 418–424.
amygdala predicts negative affect in depressed patients.
NeuroReport, 9, 3301 – 3307 • Feldstein-Ewing, S.W., Filbey, F.M., Hendershot, C.S., McEachern,
A.D., & Hutchison, K.E. (2011). Proposed Model of the
• Beauregard, M., (2007). Mind does really matter: Evidence from Neurobiological Mechanisms Underlying Psychosocial Alcohol
neuroimaging studies of emotional self-regulation, psychotherapy, Interventions: The Example of Motivational Interviewing. Journal of
and placebo effect. Progress in Neurobiology 81, 218–236 Studies on Alcohol and Drugs, 72, 903–916

• Banks, S.J. et.al. (2007). Amygdala–frontal connectivity during • Lieberman, M.D., Eisenberger, N.I., Crockett, M.J., Tom, S.M., Pfeifer,
emotion regulation. Social Cognitive Affect Neuroscience, 2(4): 303- J.H., & Way, B.M. (2007) Putting Feelings Into Words : Affect Labeling
312. doi: 10.1093/scan/nsm029 Disrupts Amygdala Activity in Response to Affective Stimuli.
Psychological Science 2007 18: 421-428
• Cappas, N.M., Andres-Hyman, R. & Davidson, L. (2005). What
psychotherapists can begin to learn from neuroscience: Seven • Messina I, Sambin M, Palmieri A, Viviani R (2013) Neural Correlates
principles of a brain-based psychotherapy. Psychotherapy: Theory, of Psychotherapy in Anxiety and Depression: A Meta-Analysis. PLoS
Research, Practice, Training, 2005, Vol. 42, No. 3, 374-383 ONE 8(9): e74657. doi:10.1371/journal.pone.0074657

9

10/28/2013

Suggested Readings 3 Schema Reference

• Siegle et.al (2006). Use of fMRI to Predict Recovery From Unipolar Material adapted from:
Depression With Cognitive Behavior Therapy. Am J Psychiatry 2006; A Client's Guide to Schema Therapy
163:735–738. David C. Bricker, Ph.D. & Jeffrey E. Young, Ph.D.

Schema Therapy Institute
• Available at:

http://www.davidbricker.com/clientsguideSchemaTherapy.pdf

• New York: W. W. Norton & Company

10