Neuropsychotherapy

How the Neurosciences Inform Effective Psychotherapy

Klaus Grawe

• Editore: Routledge
• Anno: 2017
• ISBN:
  9781351556507
• Edizione: 1
• Argomento: Medicine
• Categoria: Clinical Medicine

Neuropsychotherapy is intended to inspire further development and continual empirical updating of consistency theory. It is essential for psychotherapists, psychotherapy researchers, clinical psychologists, psychiatrists, neuroscientists, and mental-health professionals.Profoundly important and innovative, this volume provides necessary know-how for professionals as it connects the findings of modern neuroscience to the insights of psychotherapy. Throughout the book, a new picture unfolds of the empirical grounds of effective psychotherapeutic work. Author Klaus Grawe articulates a comprehensive model of psychological functioning-consistency theory-and bridges the gap between the neurosciences and the understanding of psychological disorders and their treatment. Neuropsychotherapy illustrates that psychotherapy can be even more effective when it is grounded in a neuroscientific approach. Cutting across disciplines that are characteristically disparate, the book identifies the neural foundations of various disorders, suggests specific psychotherapeutic conclusions, and makes neuroscientific knowledge more accessible to psychotherapists. The book's discussion of consistency theory reveals the model is firmly connected to other psychological theoretical approaches, from control theory to cognitive-behavioral models to basic need theories.

CHAPTER ONE

INTRODUCTION

1.1 THE INSIGHTS GAINED IN THE NEUROSCIENCES ARE RELEVANT FOR EACH OF US

The “decade of the brain” has come and gone, but a century of progress in the brain sciences is on the horizon. Over the past 15 years, groundbreaking research has begun to illuminate the neural foundations of experience and behavior. Several more decades will pass before we will fully comprehend the baffling complexity of the brain’s basic processes, but even the knowledge that is already available suffices to significantly shake up our conventional understanding of ourselves as mind- and soul-bearing beings. The current neuroscientific paradigm shift is not linked to a single person, such as Copernicus or Darwin, but its implications are comparable to those earlier scientific revolutions.

The decade of the brain has massively accelerated the rate of progress in the neuro-sciences. The main reason for this acceleration has been the availability of new research tools, in particular, the newly available capacity to observe the brain in action, as it were. The recent development of neuroimaging and similar technologies has fueled an exhilarating dynamism in the neurosciences that at times appears truly mind-boggling. Indeed, nearly every month, renowned scientific journals such as Nature or Science publish neuroscientiflc research with exciting results that significantly extend our knowledge in this area. The only other scientific domain that can perhaps rival the dynamism and impact of the current neuroscientiflc knowledge revolution is genetics. Neuroscience overlaps, of course, with genetic research because neural plasticity is intrinsically linked with gene expression, as we shall see later (see chapter 2).

The current breakthroughs in the neurosciences did not emerge in a vacuum. They were preceded by a long series of important findings, recognized by 23 Nobel prizes awarded to neuroscientists in the 20th century. Indeed, these foundational insights reach back to the beginning of the past century. In 1906, the Spaniard Ramon y Cajal and the Italian Camillo Golgi—both neuroanatomists—were the first neuroscientists to be awarded the Nobel prize for medicine. In their day, a common assumption was still that the nervous system is a seamless network. Ramon y Cajal then developed the idea that the brain consists of single neural cells and that impulses are transmitted between neural contact points, which Sherrington later termed synapses. This key insight led many to herald Ramon y Cajal as the father of neuroscience. Until the 1950s, however, the view of the brain as a network of neurons and synapses remained a merely theoretical position. It was not until the development of the electron microscope that this position was confirmed as fact-—a fact that we now often regard as self-evident.

Twenty-one Nobel prizes for other outstanding research followed these early insights, and each marked an important step toward 21st-century neuroscience. In the year 2000, Arvid Carlsson and Paul Greengard were given the Nobel prize for their work on the role of dopamine in neural signal transmission, as was Erick Kandel for his groundbreaking work on the neural foundations of learning. With Kandel, we have arrived in the 21st century. His research group at Columbia University in New York remains one of the most productive of our day. Throughout this book, we shall sample often from the exquisite neuroscientific delicacies that Kendal’s team serves up seemingly effortlessly and at breathtaking speed.

What exactly are the neuroscientific revelations, then, that have the potential to permanently alter our human self-understanding—our conception of what it means to be human? I would argue that this isn’t so much about singular findings but rather about the overall conclusion emerging from the recent neuroscientific research. In Kandel’s words: “From these considerations it follows that all the brain processes—from the motoric regulation of movement to the most intimate lines of thought—are ultimately biological processes” (1996, p. 713). The brain scientist Joseph LeDoux has expressed this idea even more poignantly in the title of this last book: Synaptic Self: How Our Brains Become Who We Are. The last sentence in this book reads: “You are your synapses. They are who you are” (2002, p. 324).

LeDoux aims to show in his book how our synapses make us who we are. The question is no longer whether our personality emerges from neural structures and processes but rather, he is concerned with the specific mechanisms determining how we become ourselves. No topic, regardless of how thorny or controversial, is omitted. The question of free will becomes the question of how our brains accomplish the feat that we experience ourselves as the authors of our own feelings, thoughts, and actions. Indeed, conscious awareness has become somewhat of a favorite topic among leading neuroscientists. Their discussions do not concern themselves with the question of whether consciousness emerges from the brain, but rather, how specifically one should construe the emergence of consciousness from basic neural processes (Bachmann, 2000; Crick & Koch, 1990, 2003a, 2003b; Dehaene & Naccache, 2001; Edelman, 1989; Edelman & Tononi, 2000; Koch, 2003).

There is indeed a great deal for us to consider, then, if it is true that all that we think, know, believe, hope, suffer, decide, or do, is ultimately linked—down to the most minute detail—to the structures of neurons, synapses, and the processes among them. If even concepts such as mind and soul are ultimately—in their existence as well as their particular characteristics—a product of neural networks (see chapter 2), then it is indeed time to reconsider our conception of what it means to be human. The process by which other sciences receive and absorb the recent neuroscientific revelations has only just begun. Considerably more time will pass, however, before the new conception of human self-understanding has penetrated societal awareness more generally.

Modem philosophers have quickly recognized the societal relevance and explosive potential of the newly emerging neuroscientific findings and claims. Suddenly, fact-oriented scientists are appearing on the scene with statements about domains traditionally claimed by philosophy—-the question of free will, for instance, or that of human consciousness. In her 1986 book Neurophilosophy, Patricia Churchland was among the first to articulate how our very conception of the mind-body problem is altered by neuroscientific evidence. Churchland argued that traditional dualistic views had become untenable in light of the new evidence. Such earlier and now outdated views include, for example, the position advanced by brain scientist Paul Eccles (Popper & Eccles, 1977), who argued that the brain causally influences the mind and the mind as an independent entity also influences the brain. The new view, by contrast, holds that causality is unidirectional: From the brain to the mind, but not from the mind to the brain.

What are the implications for psychotherapy? Will it become a superfluous anachronism? Must psychotherapists surrender their turf to the psychopharmacologists? Not at all!

1.2 BRAIN, PSYCHOTHERAPHY, AND PSYCHOPHAMACOLOGY

If all mental processes are grounded in neural processes, then changes in mental processes should also be linked with detectable changes in neural processes. The evidence clearly indicates that mental processes can be effectively and permanently altered through psychotherapy. Inevitably, the effectiveness of psychotherapy—-in cases when therapy is effective, that is—is mediated by its effects on the brain. When therapy doesn’t alter the brain, it also cannot be effective. In LeDoux’s words: “Psychotherapy is fundamentally a learning process for its patients, and as such is a way to rewire the brain. In this sense, psychotherapy ultimately uses biological mechanisms to treat mental illness” (LeDoux, 2002, p. 299).

This is quite an unusual line of thinking for most psychotherapists, and not just for them. Let’s consider the position of Eric Kandel—who incidentally began his scientific career as a psychiatrist—in somewhat greater detail:

A fascinating association in this context is that psychotherapy, as far as it leads to substantial behavior change, appears to achieve its effect through changes in gene expression at the neuronal level. An analogue line of thinking suggests, then, that neurotic disorders are linked with changes in neural structure and function, just as specific forms of mental illness include structural (anatomical) brain changes. Consequently, any—successful—psychotherapeutic treatment of the neuroses and personality disorders would also trigger structural changes in the involved neurons. With the improved resolution of neuroimaging methods, we are now at the brink of the fascinating possibility to use these tools not merely for the diagnosis of mental illness but also to ensure the effectiveness of psychotherapies. (Kandel, 1996, p. 711)

To be sure, we are not there yet. But the direction toward which these developments can (and will likely) move is becoming increasingly clear. Indeed, it would seem a most attractive option to replace our current merely descriptive but nonexplanatory diagnostic systems (Diagnostic and Statistical Manual of Mental Disorders [DSM] and International Statistical Classification of Diseases and Related Health Problems [ICD])—which apart from their undeniable advantages are also plagued by a number of severe limitations (Beutler & Malik, 2002)—with a more functional taxonomy; one that classifies phenomena based on their pathogenesis. Truly immense progress would be achieved, indeed, if we were to determine with precision which aspects of the brain would have to be altered in order to attain specific desired changes in experience and behavior. The task of neuropsychotherapy research would then be to determine which kinds of events a patient must experience in order for the desired brain changes to follow. The task of the neuropsychotherapist, ultimately, would be to ensure that such theoretically needed experiences become concrete patient reality.

At this point, all of this remains Utopian. To turn the Utopia into reality, a lot more needs to be known; the research on the neural correlates of mental disorders has only just begun (see chapter 3). Nevertheless, it is abundantly clear that this knowledge will grow exponentially within the next decade because so many teams are now engaged in this quest. Psychopharmacologists are eagerly translating every knowledge gain into improved medication treatment. It is becoming clear, moreover, that targeted alterations of neurotransmitter balances in specific brain regions can lead to the same kinds of synaptic changes as those associated with learning experiences. The effects of psychopharmacological interventions would be massively improved, however, if they were not applied as indiscriminately—throughout the entire brain— as is currently the case (see Stahl, 1996).

One must remember as well, however, that the brain at all times remains dependent on experiences that are mediated by the senses. Even when the brain is under psychopharmacological influence, sensory experiences continue to have their effects upon the brain. When such experiences are negative, their consequences will be negative. Yet, a person’s experiences and their subjective meaning critically depend on his or her motivation and actions. Most experiences, after all, are not simply passively experienced—-not even those that create and maintain mental disorders. From the cradle to the grave, human beings are in a state of continuous motivation: constantly desiring to attain but also to avoid certain experiences. This principle holds true just as well for people with mental disorders. Regardless of how excellent their psychopharmacological treatment may be, they will also always benefit from instruction and support to bring about the needed increase in positive—and reduction in harmful—experiences. Once such concrete, positive life experiences are being realized, self-sustaining and healthier brain structures and processes can fall into place. Irrespective of the rate of pharmacological progress, then, we will continue to need a profession that has as its goal to take the time and develop the specialized expertise required to find out—in the individual patient case—which precise experiences are needed to attain positive change, a profession that aims to guide and support such a patient, to ensure that the needed experiences are turned into concrete reality. Thus, the neurosciences by no means render psychotherapy superfluous. On the contrary, the necessity of psychotherapy results from, and is clarified by, a neuroscientific perspective on mental disorders. I predict that even many of those who previously were skeptical toward therapy will thus come to view it as necessary and important.

Psychotherapy and pharmacological intervention are not just two alternative ways to achieve a largely equivalent outcome—one by a sensory and the other by a biochemical pathway. Their relationship can be characterized as neither alternative nor symmetrical. Without sensory experiences that satisfy their basic needs, human beings cannot live and attain happiness (see also chapter 4). The brain is designed for the purpose of experiencing need-satisfying events; human happiness is more than the right combination of neurotransmitters. An adequate neurotransmitter combination is undoubtedly important, and this biochemical prerequisite is fortunately also met for most people. When this precondition is not in place—regardless of what the causes might have been—it can be very helpful to pharmacologically reestablish this disturbed balance. In some cases, this might even be the only promising path. Once the balance is reestablished, the treated patient is then (again) on an equal level with those who are equipped by nature with the correct neurotransmitter mixture. But this equality is reestablished only in the biochemical aspect; nothing is decided about the future happiness or suffering of the person, which will continue to depend on the sensory events experienced by the person. And again, the principle holds true, even for the person treated with medication, that we are not just passive victims of our life experiences but also to a large extent actively determine them. In turn, the events that are experienced depend upon the person’s motivational potentials, on the abilities, knowledge, and situation-specific reactions that have formed in the person over the course of his or her life history.

All of this information is stored on a neural level in distinct memory systems and can be altered through new experiences. But these specific experiences are critical and indeed indispensable. To be sure, neurotransmitters can influence the activation threshold of problematic thought, emotion, action, and reaction potentials, but such pharmacological alterations could not result in the emergence of new memory traces. To create new memory content, which can then change subsequent experience and behavior, the person needs to take in new sensory experiences that change old memory content. Such new experiences do not come about by chance, even when the right neurotransmitter balance is in place. From a neuroscientific perspective, psychophar-macological therapy that is not coordinated with a simultaneous, targeted alteration of the person’s experiences cannot be justified. The widespread practice of prescribing psychoactive medication without assuming professional responsibility for the patient’s concurrent experience is, from a neuroscientific view, equally irresponsible.

In many cases, psychotherapy alone (without any pharmacological intervention) can achieve neural changes that are linked with positive consequences for the person’s experience and behavior. Neurotransmitter imbalances, then, can be corrected not only via pharmacotherapy but also via therapy alone (see chapter 3 for more detail on this point). Long before the advent of our artificially created psychoactive medications, naturally occurring life events were linked with fluctuations in serotonin and dopamine levels. Events that are specifically and professionally designed to bring about certain experiences can, of course, have similar effects. Thus, a neuroscientific perspective provides ample justification for psychotherapy alone, even when used without pharmacological cointervention. This holds true at least for those disorders and problems for which studies have provided solid evidence that psychotherapeutic interventions can effectively lead to improvement.

The use of pharmacotherapy alone—in the absence of the professional and competent structuring of the treated patient’s life experience—is not justifiable from a neuroscientific perspective. Such treatment implicitly assumes that the patient will somehow manage to encounter the right kinds of events on his or her own, without professional guidance. Cases in which this happened to work well cannot be used, however, to scientifically substantiate this widespread practice. For instance, when depressed patients are treated only with medication—a current common practice— the short-term effects are often quite good but not really so impressive across all treated patients. Averaging across the different types of antidepressive medication, the effect size of pharmacotherapy appears to be half a unit above the effect size associated with placebo (Joffe, Sokolow, & Streiner, 1996). The long-term relapse rate, however, appears to be nearly 80% among patients who experienced immediate improvement following treatment (Elkin, 1994). With continued psychotherapeutic treatment, this long-term relapse rate appears to be noticeably reduced (Elkin, 1994; Rush & Thase, 1999). As soon as medication no longer augments or inhibits synaptic transmission, and therefore no longer protects from negative life experiences, the patient’s life constellation that originally led to the depression can once again exert its noxious influence. This is even more likely because the patient on pharmacotherapy alone is unlikely to have learned what to do to be nondepressed without the protection offered by medication.

There are additional reasons for considering the patient’s life situation when prescribing pharmacological agents. That is, the effect of medication can be completely different in different ...