Scientific Papers

APPLIED NEUROSCIENCE: REINFORCING THE CENTRALITY OF THE THERAPEUTIC ALLIANCE IN CLINICAL NEUROPSYCHOTHERAPY AND COUNSELLING.

A BRIEF OUTLINE OF THE NEUROSCIENCE OF PSYCHOTHERAPY PRESENTED BY DR CHRISTIAN M WESTINGHOUSE

SYDNEY, 10 OCTOBER 2017.

[In keeping with ethical requirements names have been changed and personally identifiable information has been altered]

INTRODUCTION

Dr Chris Westinghouse is a generalist clinical psychotherapist and registered counsellor in private practice in the northern Sydney suburb of Epping, in Australia. His practice is informed by neuroscience, but in all other respects it is a “standard,” ethical, clinical psychotherapy and counselling practice. Since the practice is deeply influenced by the emerging Neuropsychotherapy paradigm postulated by Klaus Grawe, substantially expanded by Prof Pieter J Rossouw, and modelled upon the groundbreaking neuroscientific work of Eric Kandel (that demonstrated the brain to be primarily a neural network and not simply an electrochemical system), the underlying feature of therapy here is the pursuit of a physical and ambient environment of maximum client-experienced safety. This is defined as an “enriched environment,” characterized by a therapeutic alliance between therapist and client that is of the highest achievable quality and integrity. Dr Westinghouse’s practice is profoundly influenced by the integrated theoretical model postulated by Pieter Rossouw, and might be described as fundamentally “Rossouwian.”

A CASE OUTLINE - CONTEXT

James is a 24 year-old Australian male, employed as a banker, unmarried and romantically unattached, degree educated, in generally good health, physically fit and active, well groomed with a modest but meaningful social life, a few hobbies and creative interests, a gentle manner – an apparently “ordinary young man” at first glance. He lives alone in his own rented city apartment, and has ambiguous family attachments – describing his relationship with his family in affectionate terms, but cautioning that whilst there is some familial affection it does not run deep. James has been referred for psychotherapy by his family GP at his request in order to address episodes of depression that occur on average once monthly, and which present in tandem with profound self-esteem deficits, i.e. feelings that his life is, in his own words “valueless.” These maladies have in recent months intensified and James has experienced suicidal ideation. Since in all the normally observable aspects of his life James appears to be well, healthy and fully functioning, these feelings have alarmed him and he has sensibly sought professional help. He presents with no reported physiological symptoms, apart from restless sleep and appetite changes that occur only during his depressive episodes, which typically endure for three or four days before “wearing off.” His symptoms encourage him to be highly cautious about embracing new social connections, preferring the company of established friends.

EARLY CONVERSATIONS

In our earliest therapeutic conversations in my rooms James and I explored his life story, and he was encouraged to speak both broadly and sometimes in detail about the things that it contains – from apparently insignificant events and mundane experiences to those that he considers to have been formative. Conversations were guided, but I consciously refrained from value judgments or directiveness, to ensure that James would have the opportunity to discuss his subjective meaning-attribution, not just the facts, in a person-centred counselling style. Sometimes he was just needing to talk and to be heard, with no overt purpose or theme. Following the typical neuropsychotherapeutic approach, these sessions (and subsequent ones) were deliberately conducted with the primary goal of ensuring that James would feel both (a) safe in the physical environment of my consulting rooms as well as (b) feel safe in the psychological environment, i.e. feeling safe without the need for emotional or psychological “seatbelts.” We operate from an assumption that “safety in the therapeutic environment down-regulates stress responses.[1]” James embraced this method and quickly responded by becoming relaxed, conversational, uninhibited and both intellectually and emotionally engaged. This is, in my opinion, an ideal and productive scenario, important for many reasons, including the fact that it reinforced James’ orientation and his sense of being “in control.”[2] Rapport and an enduring therapeutic alliance were easily established and together we discovered more about James, and were able to focus on areas of his life that we explored more intensively using a Cognitive Behavioural Therapy (CBT) approach throughout, hybridized with person-centredness and sometimes some provocative Gestalt techniques. We might describe James as one of “the worried well,” though without the negative connotations that associate this syndrome with hypochondriasis:[3] “Their suffering is genuine, and their pain often greater than if something really was wrong with them.”

In the main I found him to be in full possession of his cognitive and therefore Cortical faculties, whilst occasionally he presented with a mild “brain fog,” especially when a therapy session took place in close time proximity to an episode of depressed mood.

Our emphasis has been on the quality of the processes of therapy, rather than on the pursuit of too-highly defined and specific objectives. Throughout, I have deliberately focused upon where James “is at,” and not presumed to make assumptions or to “squeeze him” into my own framework – it is his framework that matters, and working within his framework is what will bring therapeutic value over time.

THERAPEUTIC INTERVENTIONS

Given (a) that my client “is at where he is at,” and not somewhere else, and given (b) that my approach is a neuropsychotherapeutic one, how will this case proceed, from first interview to subsequent therapy sessions, and ultimately termination? The therapeutic methods and approach have been outlined above.

My ultimate objective from a neuropsychotherapeutic perspective is not to sell my client therapy, or to provide him with recipes, action plans and menus: my objective is to harness the simplest components of therapy for an outcome that is more profound and substantial and does not “meet the eye” at first glance. My modus operandi is in fact (a) to down-regulate James’ stress responses associated with his stress and anxiety by ensuring a profound and comprehensive sense of safety through the provision of an enriched environment (which is defined simply by the quality of the therapeutic alliance)[4] to defy his default neural firings from Limbic sources to more basic brain centres (which are his presenting default neural patterns of firing and result from the lightning-fast, single-synapse activation of his amygdala via the hypothalamus), whilst (b) permitting more productive neural patterns of firing from the Limbic parts of his brain toward his Prefrontal Cortex – the “genius” or “smart brain.” Magnetic Resonance Imaging (MRI) and Positron Emission Tomography (PET) scans typically show measurably diminished blood flow to these areas when stress overwhelms a person.

OBJECTIVE OF NEUROPSYCHOTHERAPY

Over time, then, my aim is to strengthen and cultivate neural connections between his Limbic system and his Prefrontal Cortex, down-regulating stress chemical activation, whilst discouraging and degrading his brain’s habitual and spontaneous reversion to default patterns of neural communication from his Limbic system to the primitive parts of the brain that exist mainly to ensure organismic survival. Our objective, therefore, is to promote a “thriving” brain, and not one that is caught in a neural loop that favours retreat into survival mode, and where the pursuit of safety dominates brain activity and becomes the habitual tendency.[5] The rationale for this is explained below.

BRIEF OUTLINE OF THE APPLICABLE NEUROSCIENCE

Like all humans, James is a product of his genes as well as his whole-of-life environment(s), both of which become relevant at conception, and both of which exert influence upon who and what James (and you and I) will become. In our opinion, “self,” the awareness of self, and the becoming of self is a lifelong physiological, psychological and social developmental process that begins at conception and continues until it is terminated by death.

MOTIVATION AND BASIC HUMAN NEEDS

Various theories exist about the key needs that drive human existence and organismic success which we describe in Rogerian[6] and Maslovian[7] terms as “self-actualisation,” and whilst it would be fatuous to say, “these are the ones and there are no others,” we typically consider that these are broadly the fundamental ones: first, humans need attachment and social connection; second, being salient organisms we need a sense of orientation and of being in control of our lives; third, we need motivation that results in the maximization of pleasure and the minimization of pain (“motivation” here refers to the need for the activation of brain activity, and not the popular meaning attributed to the word, as in “getting up and doing stuff”). It is not simple behavioural output.

Often unrecognized in this list is the fourth basic need that neuropsychotherapists focus upon, and this is the fundamental organic need for safety and security from which all else flows. We consider the experience of enduring safety to be most fundamental of all human needs. From a molecular neuroscience perspective we are aware, especially arising from the work of Paul Maclean and his exposition of “the triune brain,”[8] that our brains evolve sequentially “from the inside out, and from the bottom up,” and that they function in terms of fixed neurodevelopmental priorities that start with the evolution of the so-called “reptilian,” Primitive Brain Complex, or Basal Ganglia, brain structures whose function is dedicated primarily to the basic maintenance of life and little else, and that these structures arrive fully developed and functional at birth. Their centrality in the quest for organismic survival also means that they assert dominance over other higher order brain systems that include cognitive ones. These are the organs of the Pons, Medulla Oblongata and Brain Stem, and which are associated with the essential processes of survival, i.e. breathing, heart rate, body temperature and balance.

Second to evolve is the Paleomammalian Complex, the Limbic system that is involved in the impulses and regulation of emotions, among others, and which is like a kind of telephone exchange or hub that is vital for the exchange of information between different regions of the brain. These organs include the Thalamus, Hypothalamus, Amygdala, Hippocampus, Basal Ganglia and Nucleus Accumbens – all of which have specific, important and nuanced functions.

Third in the process of neuroanatomical development is the Neomammalian Complex, which we call the Neocortex, or Cerebral Cortex, which is the location of the higher order functioning that is unique (as far as we know) to humans, and which permits us to develop logic, reason, art, music, science, creativity, language – it is the headquarters of our executive functions, and plays the most significant role in the facilitation of change.[9] In psychotherapy that seeks to achieve new neural connections, we’re most interested in causing a proliferation of neurogenesis in the Prefrontal Cortex, because it is the seat of complex planning and behaviour, the expression of personality, decision-making and the moderation of social behaviour – the neural activities that make each of us special individuals.

THE ROLE OF THE STRESS RESPONSE CYCLE

So what’s this got to do with James? When James (or you and I) are exposed to external stressors of any kind our Limbic System kicks into gear very quickly. The stress response cycle is aimed at survival, or protection from threat, and activates a physiological response that arises from the first “alert” received and transmitted by the Thalamus to the Amygdala (so quickly that it is transmitted at the incredibly short distance of a single synapse), to the Hypothalamic-Pituitary-Adrenal Axis (HPA Axis), Corticotropin Releasing Factor (CRF) / Adrenocorticotropic Hormone (ACTH) is pumped into the Amygdala via the Anterior Pituitary Gland, Epinephrine (adrenalin) is produced, Norepinephrine (Ne) and Cortisol are released into the blood circulation (over a period of hours) and the body is “charged” to take action.[10] Fight or flight responses are now in play. Now the organism is in a state of stress, and default, tried and tested, primitive survival patterns of neural firing occur: the unsophisticated default pattern of behaviour is based upon the typical activation of survival mode, and that’s how the human species has survived threats from time immemorial. However, while our bodies and brains are preparing for a threatening onslaught and our primitive brain structures (rather than our Cortical ones) are being marshalled, there is a measurable and instantaneous deterioration of blood flow to the Cortex which continues to experience this “suffocation” well beyond the immediate reign of the stressor.

Therapists know only too well that patients who experience the stress of say, the loss of a loved one, a sudden and unwelcome change in life, trauma, an experience of uncontrollable incongruence and the concomitant up-regulation of the HPA system, are frequently left with a compromised Prefrontal Cortex for weeks, months and longer. Foggy brain syndrome is well known to everybody who has experienced stress, depression, anxiety – and fear. It is often profoundly debilitating and prevents normal, and sometimes even near-normal cognitive functioning. This is why we argue that the application of cognitive-based therapies are quite useless to clients who are in the throes of deep depression, stress, anxiety, panic etc., because the cognitive responses we want to encourage our clients to produce are simply not available.[11] Hence, the need to practice down-regulating therapy in what has come to be known as the “down-up” stress minimising style (securing primitive notions of survival and safety first), before gradually introducing “top-down” methods that harness higher and Cortical faculties to assert control of the emotional, intuitive Limbic system – once it is apparent that the Cortical compromise is being degraded and the client is capable of offering Cortical / cognitive collaboration. Cognitive therapists frequently make the mistake of assuming cortical capacity, when it is in fact unavailable. Our task as neuropsychotherapists is not to assume Cortical capacity, but to facilitate it.[12] We do this by encouraging neural firing from the Limbic area to the Cortex.

WHAT TO DO: COME CLOSER OR RUN AWAY?

Humans develop motivational schemata to deal with the consequences of threatening phenomena by developing habitual responses that are characterised by one of two schemas: those who constructively respond to controllable incongruence (the driver of adaptation, change and growth) develop what are called “approach schemata,” characterized by positive and controlled engagement with the world; those who habitually respond negatively or defensively and in survival mode to incongruence that they experience as uncontrollable develop what we call “avoidance schemata,” in which they behave in defensive, pro-survival modes. In approach schemata, people engage with properly functioning, optimal activation of Limbic-Cortical neural connections and are able to regulate the CRF-ACTH-Ne and Cortisol stress response to improve performance as well as neural proliferation in the Cortex, whilst those adopting avoidance schemata effectively disengage by reverting to Limbic-reptilian neural connections and consequently non-optimal behaviours as a result of the reinforcement of neural proliferation and additional neural connections to the reptilian, primitive and “survival-fixated” area of the brain.[13] Frequent repetition, the intensity of the stressful experience, its duration and the proximity of the phenomenon to our “fundamental self” will influence the propensity for entrenchment of the behaviour, i.e. the nurturing of default patterns of survival behaviours. This will accord with either approach schemata or avoidance schemata, and each operates on different neural pathways.[14] Again, we are reminded that “neurons that fire together wire together.” But it is not just the production of behaviour for the sake of behaviour that is occurring:

Over time, every person adopts a propensity for one or the other according to the Hebbian principle, “neurons that fire together wire together.” [15] We are not speaking just of casually and insignificant preferred behaviour patterns – we are, in fact, talking about a person’s tendency to activate ever-strengthening neural connections that become entrenched patterns of brain wiring and firing activity according to a concept we call “consistency” (when neuron A fires into neuron B the probability of neuron A firing into neuron B next time is higher than for neuron A to fire into neuron C).[16] One path leads toward psychopathology and apoptosis (the death of brain cells and cellular pathways). The other leads to a thriving individual with enhanced high order functioning capacity due to repetitive activation of Limbic-Cortical neural connections and neurogenesis (which is simply the generation of new neurons and the measurable proliferation of new neural connections).

At the heart of the matter, and in practical, unscientific terms, we want our patients to thrive through patterns of optimum neural connections and communication with the most enriching and positively-oriented functional areas of the brain on one hand; and we want our patients to spend less of their lives stuck in neural loops and becoming comfortable with their discomfort, which is evidenced by a default predisposition to obsess, consciously or unconsciously, about survival, on the other.

Research that includes Functional MRI and PET scans have demonstrated that the talking therapies are capable, on their own and without medicines in many cases, of increasing neural proliferation in the Cortical regions of the brain, sometimes in the space of mere weeks (depending, of course, on a host of other accompanying factors).

SUMMARY AND CONCLUSION

Hence, my objective is to continue to provide James with an enriched environment in which the core enabling experience is one of as-close-to-being-guaranteed safety, so that his brain “relaxes” and begins to embrace the possibility of a stimulating, thriving existence, with less concern for simply surviving. This is the essence of neuropsychotherapy: it is not the sophistication of the therapy modality or the technique we choose to apply that results in positive alteration of brain structure and functioning, but the authenticity of the therapeutic alliance, irrespective of the chosen therapeutic modality, and our clients’ ability to enjoy the spontaneous proliferation of neural connections in the Limbic-Cortical direction as a result of the safety provided by that enriched environment.

Progress has, so far shown evidence of improvement in James’ affect and he has reported a predictable decline in the frequency, duration and intensity of his depressive episodes. He reports no suicidal ideation. His anxiety about his anxiety appears to be almost absent, and the prospects for complete elimination are, in my opinion excellent. In fact, James appears to be observably more optimistic about life in general. Our work together continues, and has been expanded to include helpful aspects of healthy living that include sleep hygiene, nutrition, the importance of physical activity and social connections.

BIBLIOGRAPHY

Grawe, K. (2007), Neuropsychotherapy: How the Neurosciences Inform Effective Psychotherapy, Lawrence Erlbaum Associates.

Rossouw, P.J. (ed) (2014) Neuropsychotherapy: Theoretical Underpinnings and Clinical Applications. Sydney, Mediros.

Kandel, E.R. (1998) A New Intellectual Framework for Psychiatry, The American Journal of Psychiatry.

The American Journal of Psychiatry, Vol 164, January 2007.

Collingwood, J. (2016). Tackling the Fears of the ‘Worried Well’. Psych Central. Retrieved on October 9, 2017.

Rogers, C. (1961). On Becoming a Person pp350-1.

Maslow, A.H. Motivation and Personality. 2nd ed., Chapter 11. "Self-Actualizing People: A Study of Psychological Health."

MacLean, P.D. (1990). The Triune Brain in Evolution: Role of Paleocerebral Function. New York. Plenum Press.

Dahlitz, M (ed). The Nueropsychotherapist (various).

Hebb, D.O. (1949). The Organization of Behavior. New York: Wiley & Sons.

ENDNOTES

[1] Rossouw, P.J. (2014). Neuropsychotherapy: Theoretical underpinnings and clinical applications. Sydney, Mediros, p59.

[2] Rossouw, P.J. (2014). Neuropsychotherapy: Theoretical underpinnings and clinical applications. Sydney, Mediros, p59.

[3] Collingwood, J. (2016). Tackling the Fears of the ‘Worried Well’. Psych Central. Retrieved on October 9, 2017, from

https://psychcentral.com/lib/tackling-the-fears-of-the-worried-well/

[4] Rossouw, P.J. (2014). Neuropsychotherapy: Theoretical underpinnings and clinical applications. Sydney, Mediros, p61.

[5] Rossouw, P.J. (2014). Neuropsychotherapy: Theoretical underpinnings and clinical applications. Sydney, Mediros, p60.

[6] Rogers, C. (1961). On Becoming a Person pp350-1.

[7] Maslow, A.H. Motivation and Personality. 2nd ed., Chapter 11 "Self-Actualizing People: A Study of Psychological Health"

[8] MacLean, P.D. (1990). The Triune Brain in Evolution: Role of Paleocerebral Function. New York. Plenum Press.

[9] Rossouw, P.J. (2014). Neuropsychotherapy: Theoretical underpinnings and clinical applications. Sydney, Mediros, p51.

[10] Shakhar, A., Truitt, W. Rainnie, D., Sajdyk, T. (2005). Role of stress, corticotrophin releasing factor (CRF) and amygdala plasticity in chronic anxiety. US National Library of Medicine, National Institutes of Health accessed via www.ncbi.nlm.nih.gov/pubmed/16423710 on 10 October 2017.

[11] Rossouw, P.J. (2014). Neuropsychotherapy: Theoretical underpinnings and clinical applications. Sydney, Mediros, p7.

[12] Rossouw, P.J. (2014). Neuropsychotherapy: Theoretical underpinnings and clinical applications. Sydney, Mediros, p7.

[13] Rossouw, P.J. (2014). Neuropsychotherapy: Theoretical underpinnings and clinical applications. Sydney, Mediros, p30.

[14] Spielberg, J.M., Miller, G.A., Engels, A.S., Herrington, J.D., Sutton, B.P., Banich, M.T. & Heller, W (2011) Trait approach and avoidance motivation: Lateralized neural activity associated with executive function. NeuroImage, 54, 1, pp661-670. Quoted by Dahlitz, M.K. (ed) (2013). Klaus Grawe: Neuropsychotherapist. The Neuropsychotherapist, 2, pp128-129 in Rossouw, P.J. (2014). Neuropsychotherapy: Theoretical underpinnings and clinical applications. Sydney, Mediros, p30.

[15] Hebb, D.O. (1949). The Organization of Behavior. New York: Wiley & Sons.

[16] Rossouw, P.J. (2014). Neuropsychotherapy: Theoretical underpinnings and clinical applications. Sydney, Mediros, p10.