Illustrating why and how Psychotherapy works in practice: A perspective from Neuroscience

The following information from neuroscience, offers the reader who may be interested a brief introduction to some of the science behind psychotherapy. While it is difficult to avoid the use of technical terms and concepts, I have tried to keep these to a minimum. The professional practice of psychotherapy has, since its beginnings over one hundred years ago, been attempting to explain and illustrate why and how it works. This has been a huge ongoing challenge due to the relational nature of psychotherapy and difficulties with finding workable methods of objective measurement. It is through rapid advances in neuroscience that we can now begin to illustrate why psychotherapy works and how it works. It is very important that this information is made available to people for whom the process may otherwise seem vague, immeasurable and therefore difficult to understand the value of  investing the time, trust, money and commitment required.

What is Neuroscience?

Neuroscience is the scientific field of study of the activities and links between behaviour and brain activity. Through neuroscience research we have come to understand that a great deal of human mood and other mental activity, originates through the activity of what are called neural networks or pathways in the brain. Psychotherapy is increasingly able to draw on the findings of neuroscience to both increase its efficacy and to explain how it takes positive effect.

The focus for the study of neuroscience is our brain. The brain is the center for processing information from our full body experience. The brain is a highly specialised internal social organisor. It is central to the creation of our understanding and responses according to our perceptions, experience and our formulation of meaning in the world. Fortunately it can change as we learn and this is key to psychotherapy. The brain used to be described in terms of areas of functionality but it is now discussed in terms of neural networks or pathways and their effects when activated. So what are ‘neural networks?  Neural networks are pathways in the brain, which are made up of complex sequences of multiple individual neurons (of which there are 100 billion in a human brain). Such pathways set in place our thinking patterns, response patterns etc. These sequences can fire or be inhibited from firing depending on the release or withdrawal of transmitter or transmitter inhibiting substances. While some of the language here is a a bit technical this is an example which might be helpful;  anti-depressant medication such as prozac and lexapro have been specifically designed to keep a neuro-transmitter called ‘serotonin’ available for neural firing. It seems that this firing activity can be helpful in combating depression although the full picture of how this works has yet to be discovered. A reduction in the availability of serotonin often seems to be present with the experience of depression.

Serotonin is one of several chemicals called neurotransmitters that pass messages between nerve cells that are involved in depression. Each nerve cell generally uses one of these chemicals to pass on messages to adjacent nerve cells. If there is not enough serotonin released by the first nerve cell, it won’t be able to cause the next one to ‘fire’ – the message won’t get through. This is one of the changes that appears to be important in causing depression. The nerve cells normally recycle serotonin by soaking it back up again. The SSRIs (anti-depressant medications such as prozac) work by stopping (inhibiting) this re-uptake of serotonin. As the serotonin is not soaked up again, more will be present to pass on messages to nerve cells nearby. SSRIs work selectively on serotonin – they don’t stop the other types of neurotransmitter chemical being soaked up by the nerve cells.

Neural networks interconnect and this allows for the evolution and development of increasingly complex skills, abilities and abstract functions. Neurons  depend on their ability to link with other neurons for completing a task and staying functional. They send and receive messages from each other via chemical messengers, if they don’t do this on a constant basis they literally shrink and die. This is implicit in the phrase ‘use it or lose it’ in relation to the ability to perform particular tasks or retain awareness of how to carry out certain functions. An example here might be a journey that you regularly take or a recipe that you regularly use, if you stop using it for a period of time you may find yourself forgetting some details.  In addition to the neural networks half the volume of the brain is made up of what are called ‘glial cells’. Glial cells play a role in the construction, organisation and maintanence of neural systems. While little is yet known about them, glial cells appear to participate in neural communication both by modulating synaptic transmission and by carrying their own messages.

In understanding the social brain, the focus is less on the surface but largely on the areas hidden from view, where the earlier developing structures central to our experience of self and others reside. For social and emotional functioning it is the increasingly being illustrated that it is the right hemisphere and not the left, that is the dominant side of activity. Perhaps the most exciting revelation from neuroscience is that the brain is not fully formed in early (young) life as previously believed, but that it is a dynamic structure that can undergo modification and re-development across our lifespan. This finding is referred to as brain ‘plasticity’. For psychotherapy this means that changes in neural firing patterns can be positively directed and changed through clients having access to effective and informed therapeutic interventions.

Neuroscience; taking us to the imprints of trauma and difficult experience.

The fundamental behavioural tendency of all organisms is to approach what is life sustaining and to avoid what is dangerous. The modern human brain is a culmination of millions of years of evolutionary adaptation through learning. The human brain still contains its early evolutionary structures which are primarily concerned with survival, and are embedded in the base of the brain. Theses structures are often referred to as the reptilian or primitive brain. More recent evolution has given us the larger conscious, cognitive and more complex structures (cortex) that sit high up behind our foreheads. There is a dilemma here for information processing as the lower structures activate faster than the more complex processing  of the larger but slower, cortex.  This means, for example, that we can sometimes find we react in ways that we didn’t intend or wish we hadn’t, afterwards feeling dismayed and confused with a sense of ‘why did I say/do that?’. It is like a survival defensive/protective instinct takes over, and it cannot wait for conscious consideration and evaluation – ‘safety checking’. Although conscious input is possible when levels of stress are elevated, emotional and cognitive processes are more commonly influenced and propelled by the impulsive energy from the primitive brain areas. Stress indicates threat thus instinctively survival is at stake – even if this set off by ‘mammy has just caught me with my hand in the cookie jar’.  It is this aspect of physiology shaping our psychology that is in the spotlight for psychotherapeutic interventions. Focusing intensely around subconscious aspects of responses and assumptions can provide an individual with insight. This insight can give space to form more fully considered responding that through focused attention can positively change the pathways of perceiving and responding.

Donald Hebb, a Canadian neuropsychologist coined the phrase ‘neurons that fire together, wire together‘. This is more technically referred to as experience-dependent neuroplasticity. It means, in effect, that whatever we repeatedly sense, feel, want and think slowly but surely sculpts our neural structure. 

As you read this, a trillion support cells, 80-100 billion neurons are signaling each other in a network with about half a quadrillion connections called synapses. All this incredibly fast, complex, and dynamic neural activity is continually changing your brain. Active synapses become more sensitive, new synapses start growing within minutes, busy regions get more blood since they need more oxygen and glucose to do their work, and genes inside neurons turn on or off. Meanwhile, less active connections wither away in a process sometimes called neural Darwinism: the survival of the busiest.

All mental activity in both conscious and unconscious experience is based on the capacity and optimal development of neural activity. Intense, prolonged, or repeated mental/neural activity will leave an enduring imprint in neural structure and determine how we consequently perceive and process information.   Like an underground stream that by its continuous flow over time carves a path through solid rock leaving the surface unchanged – our experience, perceptions and responding patterns are often set deep within our brain structures, beyond conscious awareness . 

The reality that ‘neurons that fire together wire together‘ is both good and bad as it means that while we can adapt to positive environment and stimulation we can also adapt to negative unhealthy environments and pathological others. The resulting adaptation may help us survive difficult experiences but this very adapting can impede later healthy development. Because the first few years of life are a period of exuberant brain development, early negative interpersonal experiences become a primary source of the symptoms for which people seek relief in psychotherapy.

Optimal sculpting of the pre-frontal cortex through early healthy relationships allows us to think well of ourselves, trust others, regulate our emotions, maintain positive expectations, and utilise our intellectual and emotional intelligence in moment-to-moment problem solving. The transformative power of intimacy has its roots in the evolution and development of the brain through parenting, friendship and other relationships. It is this power that is harnessed and applied to create the conditions which through brain plasticity can be used to shape positive neural network change, through the focused relational process of psychotherapy.

Neuroscience; Psychotherapy and implicit memory

The sources of most psychological difficulties are framed by memory. The everyday firing patterns of neural networks that are triggered by various stimuli and events will evoke particular associations held in memory, this process is largely unconscious. We need this so that we don’t have to learn everything anew everyday (a concept played with in the films ‘Groundhog Day’ and ’50 First Dates’). When neural firing happens in response to a trigger, it will activate a network that will link up many relevant pieces from memory to help us to create context and formulate an appropriate response. However we don’t usually have consciousness access to nor objective management of this. For example, there is a loud bang outside, one person rushes out because they fear a large tree has fallen, meanwhile their neighbour rushes out angry that someone is making noise. It is the same sound (which turns out to be a firework) yet it has set off a different set of assumptions and responses fom each person. It is through memory that we assess, perceive and create expectations essential to our survival and well being, thus setting down the route for particular firing patterns. We now know that there are two forms of memory, explicit (consciously known) and implicit (unconsciously known). From a scientific perspective, we understand explicit memory better and frequently use therapeutic methods such as CBT and other issue-focused counselling approaches to work at this level. When it comes to implicit memory however, there is a need for therapeutic methods that can access the unconsciously known triggers that underlie entrenched, returning or profound difficulties, stuckness or developmental blocks. As our earliest memories are implicit and these memories underpin all experiences, a method that supports implicit processing is key to accessing any developmental blocks. This is not about the recall of events but more about the sensation of experience, the source of which may never be recalled clearly. Such methods are ones that do not require conscious recall and are not dependent on verbal communication. Primary associations between intimacy, anxiety, love and shame are forged in early implicit memory and become the core of our attachment schema and our ability to regulate emotions. It is important therefore that we can find ways and methods that reach this level of therapeutic engagement to redress any traumatic or difficult experience.

Research has shown that when meeting a new person or situation sensory experience takes at least 400-500 milliseconds to reach conscious awareness, implicit memory is significantly faster, registering its assessment in about 14 milliseconds.

As implicit memory is not conscious it cannot therefore be thought about or talked about. It can only be expressed through underlying aspects of attitudes, beliefs and behaviours etc. Issue focused therapies that address the presenting symptoms work largely with explicit memory. They are therefore unlikely to have a language to support or address non-verbal expression of implicit memory.

If the source of the difficulty is in implicit memory it is here that we must get to in order to effect real change, long term. The implicit experience is sensed first and creates a frame through which the explicit information will be shaped, met and interpreted. Issues and difficulties that are addressed through counselling and cognitive methods and may gain short term or situation specific improvements. However if the difficulty lies in implicit memory they may remain unaddressed at source and so may take a new route to surface in expression. As implicit memory is outside of conscious awareness, the person is unaware of its influence and effects on their perception of people and events and the restricted experiences they may live in.

Jungian Sandplay as a method for reaching implicit memory

We need to have fluently  integrated brain functioning to fully process experience. When we are overwhelmed by traumatic or difficult experiences, our brain can loose the ability to maintain neural integration. As a result memories stored implicitly in sensory and emotional networks may be dissociated from cognition, knowledge and perspective. We then become vulnerable to intrusions of past experiences that are triggered by environmental and internal cues. In addition heightened stress and trauma have an inhibitory effect on language production, and the safe and appropriate encoding of memory. This can cause interference with the development of coherent narratives, that serve to process experience and lead to neural network integration and psychological healing. The process of psychotherapy seeks to reintegrate these dissociated networks by consciously or symbolically processing traumatic memories within a safe and protected space. This reintegration in turn allows the networks of conscious cortical processing to develop the ability to manage and contain the affects of past traumatic memories.

Jungian Sandplay as the name suggests, is the use of sand in a tactile sensory experience of play that by its nature engages right brain activity, which is associated with unconscious experience. This method involves the coordinated use of words, emotions and bodily expression, a combination that requires the simultaneous participation of both brain hemispheres. The client also has access to shelves of objects and figurines which may also be used in the experiential play and image creation. While a particular object may be chosen by the client for its specific and conscious personal meaning or purpose or no particular reason at all, it will also activate other important symbolic possibilities, creating a language for implicit memory expression and reintegration.

Containing this process within the context of Jungian thought and developmental psychology, creates an environment where connections can be made in a felt, sensory or symbolically meaningful way. Through recent developments in neuroscience, we are beginning to understand why the therapeutic relationship is key to positive long term change and how this happens, including the effects of mirror neuron firing and affect regulation. Those of us following these developments can now be present with our clients in ways that maximise therapeutic effect. Our understanding of mirror neuron firing and their connections to human relationships has continued to expand and deepen. What is becoming increasingly apparent is that human self awareness is a more recent development in our evolutionary history, arising out of our experience in relationships with others, our ability to symbolise and the tools provided to us by culture.