The Neuroscience of Psychotherapy

Second Edition
The Neuroscience of Psychotherapy
Healing the Social Brain

• Second Edition •

Louis Cozolino
Foreword by Daniel J. Siegel

W. W Norton & Company

New York • London
Unless otherwise noted, figures were created by the author.

Copyright © 2010, 2002 by Louis J. Cozolino All rights

reserved

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from this book, write to: Permissions, W. W. Norton &
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Library of Congress Cataloging-in-Publication Data Cozolino,

Louis J.

The neuroscience of psychotherapy: healing the social brain

/ Louis J. Cozolino.—2nd ed.
p. cm.
Includes bibliographical references.
ISBN 978-0-393-70642-0 (hardcover) 1. Psychotherapy. 2.
Neurosciences. 3. Brain—Research. I. Title.
RC480.5.C645 2010
616.89'14—dc22

2009043708
ISBN: 978-0-393-70657-4

W. W. Norton & Company, Inc., 500 Fifth Avenue, New York,

N.Y. 10110
www.wwnorton.com
W. W. Norton & Company Ltd., Castle House, 75/76 Wells
Street, London W1T 3QT
 This book is dedicated to my family:
my mother’s courage, my father’s determination, and
the memory of my grandparents. Together they somehow
instilled within me the belief that all things are possible.
Contents

Foreword
Preface to the Second Edition

Part I. Neuroscience and Psychotherapy: An Overview

1. The Entangled Histories of Neurology and Psychology
2. Building and Rebuilding the Brain: Psychotherapy and
Neuroscience
3. Neural Integration in Different Models of Psychotherapy

Part II. How the Brain Works: The Legacy of Evolution

4. The Human Nervous System: From Neurons to Neural
Networks
5. Multiple Memory Systems in Psychotherapy
6. Laterality: One Brain or Two?

Part III. The Organization of Experience and the

Healthy Brain
7. The Executive Brain
8. Consciousness and Reality
9. From Neural Networks to Narratives: The Quest for
Multilevel Integration
 Part IV. The Social Brain
10. The Social Brain
11. Building the Social Brain: Shaping Attachment Schemas
12. The Neurobiology of Attachment

Part V. The Disorganization of Experience

13. The Anxious and Fearful Brain
14. Trauma and Neural Network Dissociation
15. The Self in Exile: Narcissism and Pathological Caretaking

Part VI. The Reorganization of Experience

16. The Evolutionary Necessity of Psychotherapy
17. Teaching Old Dogs New Tricks: Stimulating Neural
Plasticity
18. The Psychotherapist as Neuroscientist
Credits
References
Foreword

Louis Cozolino’s contributions to the Norton Series on

Interpersonal Neurobiology have been instrumental in
moving this new interdisciplinary field forward. The first
edition of The Neuroscience of Psychotherapy inaugurated
the series, which now includes 16 titles. With this second
edition, Lou has extended and deepened interpersonal
neurobiology’s basic view that integration is at the heart of
well-being. I loved the first edition and have learned a
tremendous amount from reading this exciting and
extremely accessible updated edition. Readers new to
interpersonal neurobiology (IN) will find this a wonderful
place to start their journey, as Lou deftly brings the latest in
cutting-edge science together with the healing art of
psychotherapy. Those familiar with the field will find this a
welcome addition to their IN library of texts written with the
clinician in mind.
As the founding editor of the IN series, I have been proud
to oversee the publication of these books that explore
various dimensions of psychotherapy and science. Though
each of the individual authors of and contributors may not
articulate their work with the same vocabulary, their
contributions have all added to the research and clinical
synthesis that forms an educational foundation for IN as a
multidisciplinary and synthetic way of knowing about what it
means to be human. Ours is a complex species: We have
inherited a nervous system whose evolution has left us with
many mechanisms not suited to modern life. And we live
within relationships that have shaped and continue to shape
how our social brains are constructed within families,
communities, and society. Cultural evolution continues to
mold our synaptic architecture, influencing how we
experience our inner, subjective lives and learn to
communicate with one another.
This complexity could easily make us as clinicians move
away from science to approach healing from an intuitive
way of knowing alone. My hope in founding the field of IN
has been that we would be able to see the forest for the
trees, so to speak, and not get distracted by details, with all
of their fascinating and nuanced complexities, but rather
become enriched by all of this cutting-edge unfolding of new
knowledge and ideas. But, this certainly is a challenge. In
the busy lives of clinicians (and just plain everyday life), the
tremendous amounts of data emerging from ever-expanding
fields of science can be daunting. What we are trying to do
with the IN series is to provide a forum for those working at
the creative boundary between the chaos of overwhelming
knowledge and the order of an intellectual framework. Lou
Cozolino rides that edge like a master surfer, bringing
together emerging findings from neuroscience with the
beauty and power of healing relationships. It’s a magnificent
adventure, and you will need to take a deep breath and hold
on as he takes you along with him through the various
dimensions of science to see psychotherapy from new and
helpful vantage points.
A framework that can be helpful in this important quest
views clinical work as involving a triangle of well-being
comprising the three points of Mind, Brain, and
Relationships. This is a visual metaphor depicting the most
foundational dimensions of our human lives, the essence of
our subjective and our objective lives. This is a triangle
revealing the flow of energy and information. Relationships
are how we share energy and information with one another.
The brain is here the extended nervous system distributed
throughout the entire body, which is a mechanism through
which energy and information flows. And the mind, in part,
is how that flow is regulated—how we see and shape energy
and information as it moves through our bodies and through
our relationships.
Psychotherapy entails shaping these elements of our
triangle toward well-being. From the IN perspective, health
is achieved by promoting integration in our lives: Our minds
come to monitor and modify our internal and interpersonal
worlds toward the linkage of differentiated elements. The
mind is a process that is both embodied and relational. In
this view we can use our minds to cultivate integration,
which promotes harmony; the lack of integration leads to
chaos or rigidity. From the IN standpoint, we can see, for
example, the various psychiatric symptoms and syndromes
as revealing the chaos and rigidity that emerge from
impairments to integration. Clinical assessment can detect
when chaos and rigidity are present and identify the neural
or interpersonal domains in which integration is lacking.
Focusing on the need to enhance differentiation and
promote linkage, an IN clinician is offered the framework
with which to evaluate, so he or she can then create a
treatment plan based on the centrality of integration in the
cultivation of well-being. Beyond just eliminating symptoms,
this view defines health and offers practical steps to
promote the integration at the heart of living a harmonious,
creative, and meaningful life.
Providing us with a rich and varied tapestry that weaves
up-to-date science with his decades of fabulous work as a
clinician and master educator in the field of mental health,
Professor Cozolino is our guide in this eye-opening
exploration of integration and the pathway toward health.
Both our patients’ and our own lives can greatly benefit
from this fruitful journey of discovery. Welcome to the world
of integration and interdisciplinary thinking!
  
Daniel J. Siegel, MD
Founding Editor, The Norton Series on Interpersonal
Neurobiology
Preface to the Second Edition

It has been extremely gratifying to witness the first edition

of The Neuroscience of Psychotherapy play a role in
introducing a new generation of therapists to the complex
and fascinating world of the brain. Over the years, this book
has created many opportunities for me to interact with
students, teachers, and therapists who are curious about
the biological basis of human behavior. Their enthusiastic
feedback has strengthened my belief in the relevance of
neuroscience to clinical practice and my dedication to the
integration of mind and brain.
There are a number of reasons for this new edition. The
first is that I’ve discovered the truth of the saying “writing is
the process of rewriting what you have already rewritten,”
an urge that, for me, didn’t diminish with the publication of
the first edition. Second, the energy and enthusiasm
generated by neuroscience in the 1990s has continued to
build momentum and bear fruit. New technologies have
broadened our window to neural functioning; empirical
discoveries have led us into new areas of exploration; and
increasingly sophisticated theories have fueled our
imaginations. Finally, the findings relevant to psychotherapy
and mental health from all this new research continued to
accrue and called out to be included in The Neuroscience of
Psychotherapy.
This second edition contains a few new chapters that
focus on attachment, epigenetics, and the construction of
consciousness. There is also a discussion of some of the
evolutionary shortcomings of the human brain that make us
so susceptible to psychological distress. You will notice that
this second edition embodies a shift in perspective toward
social neuroscience, and the recognition that the human
brain is a social organ. Reflecting this shift is the change in
the book’s subtitle from Building and Rebuilding the Human
Brain to Healing the Social Brain: Less mechanistic and
grandiose perhaps, and also more human. I hope you enjoy
the fruits of this labor of love.
I want to thank Lauren Harb, Tehniat Mirza, Vanessa
Streiff, Denise Duval, and Nazanin Moali for their assistance
in the preparation of this manuscript. Thanks also to Andrea
Costella and Deborah Malmud for being highly competent
and compassionate rocks at the center of the storm. And
finally, thanks to my family, friends, clients, students, and
colleagues for their caring, support, energy, and love.
 
Louis Cozolino
Los Angeles, September 2009
The Neuroscience of Psychotherapy
Second Edition
PART I.

Neuroscience and Psychotherapy: An Overview

Chapter 1

The Entangled Histories of Neurology and

Psychology

We must recollect that all of our provisional ideas in

psychology will presumably one day be based on an
organic substructure.
—Sigmund Freud

How does the brain give rise to the mind? Where do the
brain and mind meet, and by what means do they interact
with one another? These are difficult questions—so difficult,
in fact, that the common reaction is to focus on either the
mind or the brain and act as if the other is irrelevant (Blass
& Carmeli, 2007; Pulver, 2003). The problem with this
approach is the barrier it creates to understanding that the
human experience of brain and mind is essentially a unified
process (Cobb, 1944). Neurology and psychology are
simultaneously pushed apart by academic and intellectual
politics while being drawn together by their common
psychobiological foundation. The entangled histories of
neurology and psychology reflect the push and pull of these
powerful opposing forces (Ellenberger, 1970; Sulloway,
1979).
Freud started out as a rebel, a neurologist curious about
the mind. I suspect he was frustrated with the mind–brain
partisanship of medical school, and longed to work with
others who shared his interests. At the age of 29, Freud won
a traveling fellowship to spend the fall and winter of 1885 at
the Salpêtrière Hospital on the left bank of Paris. The choice
of the Salpêtrière was based on the reputation of Professor
Jean-Martin Charcot, a man considered an expert on both
mind and brain. In Charcot, Freud sought a teacher who was
well established, confident, and unafraid of the no-man’s-
land between mind and brain. One can imagine Freud’s
excitement as he walked the streets of Paris on his way to
meet the great man, a possible kindred spirit.
Charcot specialized in patients suffering from what was
then called hysteria. These patients had symptoms, such as
seizures or paralysis, that mimicked neurological illnesses
but were without apparent physical cause. A classic
example is a condition called glove anesthesia, in which
feeling is lost in one or both hands beginning at the wrist. In
these patients, the hands appear to take on symbolic
significance; perhaps they have been used to commit some
taboo act that triggered overwhelming guilt or fear. It was
believed that a conflict within the mind was converted into a
bodily symptom.
The 1880s were also a time when the ability of the
subconscious mind to control behavior (as demonstrated
through hypnosis) burst into popular awareness. Charcot
used hypnosis during clinical demonstrations to illustrate his
emerging theories about mind–body interactions. The
months Freud spent at Salpêtrière with Charcot had a
profound effect on him. He came to believe that hidden
mental processes do indeed exert powerful effects on
consciousness, and that hysterical symptoms result not
from malingering or feigning illness, but from the power of
the unconscious mind embedded within the neural
structures of the brain. Hysteria, from this perspective,
reflected the capacity of traumatic experience to reorganize
the brain and disrupt conscious experience. Dissociative
splits between consciousness and behavior demonstrated to
Freud that the brain is capable of multiple levels of
conscious and unconscious awareness. In the decades to
come, he would explore the use of language, emotion, and
the therapeutic relationship to reconnect them. Freud
returned to Vienna in February 1886, and opened his own
clinical practice 2 months later. Despite his entry into the
medical establishment, he continued his rebellion later that
year with the presentation of a paper on the existence of
hysteria in males. Deeply fascinated by the unconscious,
Freud remained its most ardent explorer until his death in
1939.
In the years following his residency at Salpêtrière, Freud
expanded on Charcot’s thinking in many significant ways.
He placed the unconscious in a developmental context by
tracing the genesis of hysterical symptoms to childhood
experiences. He came to believe that hysterical patients
suffered from the unconscious emotional aftereffects of
repressed childhood memories. Furthermore, Freud
connected the development of the individual to the
evolution of the species. Influenced by the ancient idea that
we contain within us the biological history of our primitive
ancestors, he included the importance of instinctual drives
such as sexuality, rage, and envy in his developmental
theories. Freud believed that beneath our civilized exteriors,
there exists within us a more primitive being, accounting for
many of the contradictions of modern “civilized” behavior.
Freud argued that in order to understand who and what
we are, we need to understand the primal unconscious
elements of experience. He called this the id—the primitive
and uncivilized life energy that we share with our reptilian
and mammalian ancestors. This concept was met with
understandable hostility by Freud’s repressed and rational
contemporaries. At that time, physicians were pillars of
European culture, highly invested in their superiority over
the animal kingdom and steadfast in their right and
obligation to subjugate the “primitive” people of the world.
Needless to say, linking civilized humans to animals (to say
nothing of his idea that children have sexual desires) made
Freud and his theories scandalous in respectable circles.

Freud’s Abandoned Project

The seemingly irreconcilable dichotomies and

paradoxes that formerly prevailed with respect to
mind vs. matter…become reconciled in a…unifying
view of mind, brain, and man in nature.
—Roger Sperry

In the late 1800s, the doors to the microscopic world of the

nervous system opened for the first time. Technical
improvements in the microscope and newly developed
staining techniques led to the discovery of both neurons and
the synapses through which they communicate. The
existence of synapses revealed that the nervous system is
not a single structure, but instead is made up of countless
individual processing units. Furthermore, that humans
shared these neurons with all other living creatures
supported the Darwinian idea of our common ancestry with
other animals. Around this same time, the work of Wernicke
and Broca showed that specific areas of the brain were
responsible for different aspects of language. The dual
neuroanatomical notions of synaptic transmission and the
localization of specific functions to different areas of the
brain provided rich theoretical soil for new ways of
understanding the brain.
Inspired by Darwin, Charcot, and the opening of the
microscopic neural world to investigation, Freud wrote The
Project for a Scientific Psychology (Freud, 1968). In The
Project, he postulated that what we witness of conscious
and unconscious behavior is organized by and stored within
the brain’s neural architecture. As part of this work, he drew
simple sketches of interconnecting neurons to represent
human impulses, behaviors, and psychological defenses.
These sketches depicted the interactions among drives, the
organs of the senses, and mechanisms of inhibition.
According to his colleagues, Freud became obsessed with
the idea of constructing a neurobiological model of the mind
(Schore, 1997b). Despite his enthusiasm, Freud realized that
his dream for psychology to be based in an understanding of
the nervous system was far ahead of its time, and at odds
with prevailing religious beliefs and medical dogma. For
these and other reasons, he suppressed the publication of
The Project until his death.
Perhaps Freud kept the Project to himself because he
feared that it would be relegated to the same sort of
obscurity as the case of Phineas Gage. Gage, a 19th-century
railroad foreman, had a metal bar pass completely through
his head as a result of an accident, causing the destruction
of the middle portions of his frontal cortex. This particular
area of the brain has since been shown to be involved with
judgment, planning, and emotional control. Although Gage
had no specific motor or language deficits, those who knew
him said that “Gage was no longer Gage” (Benson, 1994).
His emotionality, relationship abilities, and the quality of his
experience were all dramatically altered. Because Gage’s
symptoms involved his personality and emotions, the
publication reporting his case received little attention for
most of the 20th century. Not only was it outside the realm
of behaviors that neurologists felt comfortable addressing,
but there was also a bias against relating human personality
to neurobiological mechanisms (Damasio, 1994).
Freud, the neurologist, became all but forgotten as his
psychological theories moved further and further from their
biological roots. He chose instead to utilize the more
palatable and accessible metaphors of literature and
anthropology to provide the primary vocabulary for
psychoanalysis. Unfortunately, Freud’s shift from the brain
to metaphors of mind opened psychoanalysis to all sorts of
criticism throughout the 20th century. Metaphors such as
the Oedipal and Electra complexes were seen as contrived
fictions, shielding them from scientific evaluation. Perhaps
Freud anticipated that in the future, psychoanalysis would
eventually be integrated with its neurobiological substrates.
This would only happen when the time was right for a
synthesis based in an equal partnership of both sciences
(Pribram & Gill, 1976).
The time for such an integration has arrived, and respect
for psychological processes have taken a strong enough
hold within both the scientific community and general
culture that we can avoid a reduction of the mind to basic
biochemical processes. On the contrary, an appreciation for
the structures and functioning of the brain by
nonneurologists has become the norm. It is in this spirit that
we turn our attention to ways of thinking about the brain
that enhance our understanding of human experience. We
begin with a model of the brain that provides a bridge
between the fields of neuroscience, evolution, and the
origins of the unconscious.

The Triune Brain

He who joyfully marches in rank and file…has been

given a large brain by mistake, since for him the
spinal cord would suffice.
—Albert Einstein

In the 1970s, the neuroscientist Paul MacLean presented a

theory that emphasized the conservation of more primitive
evolutionary structures within the modern human brain
(MacLean, 1990; Taylor, 1999). MacLean called his idea the
triune brain. Very much in line with the theories of Darwin
and Freud, it provides an evolutionary explanation that may
account for some of the contradictions and discontinuities of
human consciousness and behavior.
MacLean described the human brain as a three-part
system that embodies our evolutionary connection to both
reptiles and lower mammals. Think of it as a brain within a
brain within a brain, with each successive layer devoted to
increasingly complex functions and abilities. At the core is
the reptilian brain, relatively unchanged through
evolutionary history, responsible for activation, arousal,
homeostasis, and reproductive drives. The paleomammalian
brain (or limbic system), which is central to learning,
memory, and emotion, wraps around the reptilian brain. The
highest layer, the neomammalian brain or cerebral cortex,
organizes conscious thought, problem solving, and self-
awareness (MacLean, 1985).
MacLean suggested that our three brains don’t
necessarily communicate or work well together because of
their differing “mentalities” and the fact that only the
neomammalian brain is capable of consciousness and verbal
communication (MacLean, 1990). This is a fundamental
issue that connects evolution, neuroscience, and
psychotherapy. What Charcot and Freud called dissociation
and hysteria could well have been the result of inadequate
integration and coordination among these different,
cohabiting brains. MacLean’s description of the nonverbal
reptilian and paleomammalian brains unconsciously
influencing processing in the neomammalian brain roughly
parallels Freud’s distinction of the conscious and the
unconscious minds.
The model of the triune brain serves the valuable
function of providing a connective metaphor among the
artifacts of evolution, the contemporary nervous system,
and some of the inherent difficulties in the organization of
human experience. This conservation of our evolutionary
history alongside our modern neural networks confronts the
therapist with the challenge of simultaneously treating a
human, a horse, and a crocodile (Hampden-Turner, 1981).

Ah, If Only It Were So Simple!

The large brain, like large government, may not be

able to do simple things in simple ways.
—Donald Hebb

A superficial reading of MacLean’s work might lead us to the

idea that each layer of the triune brain evolved
independently and sequentially, and that they all cooperate
in a hierarchical fashion like a military chain of command.
This is clearly not the case. In reality, the reptilian and
paleomammalian brains have continued to evolve alongside
the neomammalian brain. Earlier structures are not
conserved “as is” from past generations, but also undergo a
process of exaptation—the modification of earlier evolving
brain structures for new applications in networks dedicated
to alternative or more complex functions (Cacioppo &
Berntson, 2004). Thus, all three layers continue to evolve
along with the emergence of ever more complex vertical
and horizontal neural networks. This conservation and
modification of neural networks has led to an amazingly
complex brain capable of a vast array of functions from
monitoring respiration to performing mathematical
computations. This makes understanding functional
neuroanatomy from a study of the contemporary brain quite
a challenge.
An example from space exploration may prove useful in
understanding the neuroanatomist’s dilemma. When Apollo
13 approached the moon, difficulties with the air supply
system left the crew with just a few hours of oxygen (Lovell
& Kluger, 1994). In the face of this crisis, scientists on earth
removed nonessential components from a mock spacecraft
and constructed a new air supply system. Pieces of
upholstery, plastic bags, duct tape, and electrical wiring
were used in innovative ways to serve new functions. The
instructions on how to build this makeshift device were then
conveyed to the Apollo 13 crew. This scenario is much closer
to the crafting of the modern brain than imagining an
engineer sitting down with a blank sheet of paper. An
engineer of the future presented with this bootstrapped air
purification system would have a difficult time figuring out
what it is and why it was built the way it was. Although
there are obvious differences between the Apollo 13
scenario and natural selection, both are examples of a
pragmatic adaptation with existing materials to an
environmental crisis.
The multiple roles played by the cerebellum offer a prime
example of both neural conservation and exaptation. The
cerebellum is a primitive brain structure. At its core is the
vermis, centrally involved in balance. In fish, the vermis
helps them to swim upright. In humans, it coordinates
vestibular functioning and helps us to sit up and walk
without falling. During evolution, as our brains and bodies
became more complex, the cerebellum expanded to
coordinate gross and then fine motor movements—a logical
development for a structure initially at the core of the ability
to swim. In an interesting and surprising twist, the later-
evolving portions of the cerebellar lobes are involved in the
organization and coordination of language, memory, and
reasoning (Schmahmann, 1997). It appears that the
cerebellum’s ability to process, sequence, and organize vast
amounts of sensory-motor information was utilized by the
evolving brain as part of the neural infrastructure of higher
cortical processes.
Just as balance and motor behavior require constant
monitoring of posture and the inhibition of unnecessary and
distracting movements, so, in their own ways, do attention,
concentration, memory, and language. The same timing
mechanisms involved in locomotion seem to have been
conserved for sequential processing in thought and
language. Although the cerebellum is considered a primitive
brain structure, its evolution involved vertical networking
with most of the cortex, suggesting that the vertical
networks that connect the horizontal layers of the triune
brain may serve as clues to its evolutionary history
(Alexander, DeLong, & Strick, 1986; Cummings, 1993).
In addition to horizontal and vertical networks, evolution
has also selected for increasing differentiation between the
left and right hemispheres. Certain areas of the brain have
become specialized for specific skills, such as language and
spatial abilities. Still other areas, such as those in the
prefrontal cortex, serve to organize and control the activity
of multiple other regions. Keep in mind that the brains of
men and women also have many differences and that the
brain changes as we grow up and grow older (Cozolino,
2008). Many of these differences are especially important to
the processes of attachment and affect regulation so central
to psychotherapy.
Neural networks relevant to psychotherapy exist
throughout the brain—some are evolutionarily primitive,
others developing more recently. Some are fully functional
from birth, while others take decades to mature. This is why
an understanding of both evolution and development is vital
in capturing the full picture of human experience.

The Interpersonal Sculpting of the Social Brain

It is difficult to give children a sense of security unless

you have it yourself. If you have it, they catch if from
you.
—William Menninger
The theory that ontogeny recapitulates phylogeny refers to
the concept that the evolution of the species is recreated in
the gestation and development of each individual. To use
MacLean’s terms, we pass through the reptilian and
paleomammalian stages before we develop into a fully
human being. Although the theory of recapitulation is in
most ways incorrect (Gould, 1977), some interesting
parallels exist between our evolutionary history and the
process of human development.
At birth, the reptilian brain is fully functional and the
paleomammalian brain is primed and ready to be organized
by early experiences. The cortex, on the other hand,
continues to slowly grow into the third decade and matures
throughout life. Thus, much of our most important emotional
and interpersonal learning occurs during our early years
when our primitive brains are in control. The result is that a
great deal of learning takes place before we have the
necessary cortical systems for explicit memory, problem
solving, or perspective. Consequently, many of our most
important socioemotional learning experiences are
organized and controlled by reflexes, behaviors, and
emotions outside of our awareness and distorted by our
immature brains. To a great extent, psychotherapy owes its
existence to these artifacts of evolution and development.
The slow development of the cerebral cortex maximizes
the influence of experience in building the brain. That so
much of the brain is shaped after birth is both good and bad
news. The good news is that the individual brain is built to
survive in a particular environment. Culture, language,
climate, nutrition, and parents shape each of our brains in a
unique way. In good times and with good-enough parents,
this early brain building will serve the child well throughout
life. The bad news comes into play when factors are not so
favorable, such as in times of war or in the case of parental
psychopathology or separation (Benes, Taylor, &
Cunningham, 2000). The brain is then sculpted in ways that
assist the child in surviving childhood but may be
maladaptive later in life. It is in these instances that a
therapist attempts to restructure neural architecture in the
service of more adaptive behavior, cognition, and emotion.
Building the human brain is vastly complex. Rebuilding it is
a difficult and fascinating challenge.
A portion of the brain called the anterior cingulate—
centrally involved with maternal behavior, nursing, and play
—appears in the evolution of early mammals (MacLean,
1985). Before this, animals had to be prepared to survive on
their own at birth. Good examples are newborn sea turtles
that hatch from their eggs high on a beach and make a mad
instinctual dash toward the ocean. With the evolution of
maternal care, children are allowed to develop more slowly
within a supportive, scaffolding environment. In the course
of evolution, primates have experienced increasingly longer
periods of maternal dependence. This luxury allows for the
evolution and development of more complex brains, as well
as an increasing impact of parenting and early experiences
on how the brain is built.
Konrad Lorenz (1991) found that geese imprint (bond to
attachment figures) during a limited period of time soon
after birth. If baby geese saw Lorenz first, they would follow
him as if he were their mother. Lorenz also found that when
these geese reached sexual maturity 2 years later, they
would “fall in love” with the kinds of geese they had been
exposed to during their imprinting period. He even noted
that a baby goose, which originally imprinted on him, fell in
love with a human girl from the next town when he reached
sexual maturity and would fly there to see her. These early
experiences seemed to be permanently etched into the
brains of Lorenz’s geese.
This principle of imprinting can be seen in humans in the
more flexible and complex form of attachment schema. The
early interpersonal environment may be imprinted in the
human brain by shaping the child’s neural networks and
establishing the biochemical set points in circuitry dedicated
to memory, emotion, safety, and survival. Later, these
structures and processes come to serve as the
infrastructure for social and intellectual skills, affect
regulation, and the sense of self.
Prolonged dependence in childhood has allowed for the
development of a neocortex so complex that we have
become capable of spoken and written language, self-
consciousness, and the construction of both private and
social selves. Although these abilities create tremendous
possibilities, brainpower does have its downside. We are
now also capable of becoming anxious about things that will
never happen, depressed by imagined slights, and
saddened by potential losses. Our imaginations can
simultaneously create exciting new worlds, as well as the
fears that prevent us from living in them. It is obvious that
despite the evolution of consciousness and rationality, our
primitive emotional brains and their early development
continue to exert a great deal of influence over us.

Summary
Although Freud began his career attempting to create a
brain-based psychology, the theories and technology
available to him did not allow him to carry out this project.
Various ways of thinking about the brain (like MacLean’s),
although limited, provide models that bridge the gap
between psychology and neurology. Evolution’s legacy is a
complex brain, vulnerable to a variety of factors that can
disrupt the growth and integration of important neural
networks. The field of psychotherapy has emerged because
of the brain’s vulnerability to these developmental and
environmental risks. But how can psychotherapists
synthesize and incorporate both the mind and the brain into
our work? The following chapter presents a model of neural
networks, how they develop, and how we attempt to alter
them during treatment. It is from this perspective that we
will then examine the relevance of the nervous system to
our work.
Chapter 2

Building and Rebuilding the Brain:

Psychotherapy and Neuroscience

I know of no more encouraging fact than the

unquestionable ability of man to elevate his life by a
conscious endeavor.
—Henry David Thoreau

Although psychotherapy originally emerged from neurology,

differences in language and worldview have limited
collaboration among the two fields for most of the 20th
century. While psychotherapists developed a rich
metaphoric language of mind, neurologists built a detailed
database of brain–behavior relationships. As we approached
the 21st century, neuroscience began providing us with
tools to explore what happens in the brain during early
development, and later in psychotherapy. A return to Freud’s
Project of a biological psychology is finally at hand.
At the heart of the interface of neuroscience and
psychotherapy is the fact that human experience is
mediated via two interacting processes. The first is the
expression of our evolutionary past via the organization,
development, and functioning of the nervous system—a
process resulting in billions of neurons organizing into neural
networks, each with its own timetable and requirements for
growth. The second is the contemporary shaping of our
neural architecture within the context of relationships. The
human brain is a “social organ of adaptation” stimulated to
grow through positive and negative interactions with others.
The quality and nature of our relationships become encoded
within the neural infrastructure of our brains. It is through
this translation of experience into neurobiological structures
that nature and nurture become one.
At the heart of psychotherapy is an understanding of the
interwoven forces of nature and nurture, what goes right
and wrong in their developmental unfolding, and how to
reinstate healthy neural functioning. When one or more
neural networks necessary for optimal functioning remain
underdeveloped, underregulated, or underintegrated with
others, we experience the complaints and symptoms for
which people seek therapy. We now assume that when
psychotherapy results in symptom reduction or experiential
change, the brain has, in some way, been altered (Kandel,
1998).
How does psychotherapy change the brain? How is
memory stored and how can the quality of experience
change? Before we can address these questions we have to
first get an idea of how the brain is organized and how it
performs some of its many functions. We will discuss the
building and rebuilding of neural networks, the role of
enriched environments, and the part played by stress in
changing the brain. We will also explore the central role of
the therapeutic relationship in this change process, as well
as the importance of the expression of emotion and the
therapeutic use of language.

Neural Networks

A forest of these trees is a spectacle too much for one

man to see.
—David Douglas
So far we have used the term neural networks in a general
way; I would like now to get a bit more specific. Neurons are
the microscopic processing units that make up all parts of
the nervous system. When we talk of the frontal cortex,
amygdala, or hippocampus, we are literally talking about
large numbers of individual neurons organized to perform a
set of functions. The neurons within these systems need to
be able to organize and reorganize in such a way as to allow
us to learn, remember, and act as we adjust to different
situations. Because each neuron is limited to either firing or
not firing, the diverse capabilities of the nervous system
come from the complex interaction of individual neuronal
signals. A simplistic analogy is an old-fashioned billboard
consisting of rows and columns of thousands of light bulbs.
Although each individual bulb is limited to being either on or
off, the pattern created by these lights can spell out words,
form images, and through precise timing, create the illusion
of movement. In a similar fashion, patterns of neural firing
come to represent specific information within the brain and
throughout the nervous system.

FIGURE 2.1
The Feedforward Neural Network

A depiction of sixteen neurons in a simple feedforward

circuit
 To accomplish the complexity required for behavior,
neurons organize into neural networks. A neural network
can range from just a few neurons in a simple animal to
trillions of neural interconnections in brains such as our
own. Neural networks encode and organize all of our
behaviors from basic reflexes, such as pulling our hand
away from a hot stove, to our ability to simultaneously
comprehend the visual, emotional, and political significance
of Picasso’s Guernica. Neural networks can interconnect
with multiple other networks, allowing for interaction and
integration. Because we will be referring to neural networks
throughout the chapters to come, it is important to keep a
good visual image in our minds as we proceed.
 FIGURE 2.2
The Feedforward and Feedback Neural Network

A slightly more complex model in which information is fed

backwards and each neuron can communicate with all of its
neighbors.

Figures 2.1 and 2.2 depict simple neural networks, with

each circle representing an individual neuron. Starting with
Figure 2.1, you will notice that the flow of information moves
from left to right across the four columns of neurons. On the
left, some of the input neurons are firing in response to
some stimulus (1 = firing/0 = nonfiring). In turn, their firing
stimulates the activation of some set of neurons within the
hidden layers of processing, which leads to the firing of a
set of output neurons, which results in a particular
experience or behavioral reaction. Figure 2.2 represents a
step toward a more accurate model, with information
flowing in both directions and an increased level of
interaction among neurons. Each of the connections will
have either an excitatory or inhibitory effect on other
neurons. This mosaic of firing patterns, the network’s
instantiation, will determine which set of output neurons
fire. Making things slightly more complicated, instead of 16
neurons there are millions, each of which can be connected
to thousands of others.
Instantiations are sculpted by experience and encode all
of our abilities, emotions, and experiences into one or more
forms of memory. It is the consistency of these firing
patterns that results in organized patterns of behavior and
experience. Once these neural patterns are established,
new learning modifies the relationship of neurons within
these networks. At other times, new learning may occur
when we shape one neural network to inhibit the activation
of another. When we talk of building and rebuilding the
brain, neurons are our basic building blocks and neural
networks are the structures that we build and sculpt.
Learning within neural networks occurs as a result of trial
and error. Feed-forward and feedback information loops
form complex patterns of excitation and inhibition among
neurons within the hidden layers. This process eventually
leads to consistent and adaptive output. This is
demonstrated in a soon-to-be toddler, who repeatedly tests
and refines her balance, leg strength, and coordination with
each new attempt to walk. Her brain drives her to keep
trying while recording her successes and failures within
neural networks responsible for balance, motor
coordination, and visual tracking. In this same way, neural
networks organize behaviors, emotions, thoughts, and
sensations that are shaped throughout life.
 I remember being surprised to find a table of random
numbers in an appendix of my college statistics textbook. At
first, I thought this to be a waste of paper, assuming that
anyone could generate random numbers on their own.
When I shared my thoughts with the professor, he assured
me that much research had gone into demonstrating that
we are incapable of generating random numbers. He said
that as hard as we might try, we cannot avoid generating
specific patterns of numbers. This finally makes sense to me
based on neural network organization: We are unable to
engage in random actions because our behaviors are guided
by patterns established through previous learning to which
we automatically return. And while not being able to
generate random numbers is of little consequence to us in
our day-to-day lives, the tendency to make the same
mistakes again and again is cause for a great deal of human
suffering. This tendency to repeat patterns of thought and
behavior is what led the psychoanalyst Wilhelm Reich to say
that people tend to remain sick because they continue to
find the same wrong solutions to the problems they hope to
change.

Neural Network Growth and Integration

Plasticity then, in the wide sense of the word, means

the possession of a structure weak enough to yield to
an influence, but strong enough not to yield all at
once.
—William James

The growth and connectivity of neurons is the basic

mechanism of all learning and adaptation. Learning can be
reflected in neural changes in a number of ways, including
changes in the connectivity between existing neurons, the
expansion of existing neurons, and the growth of new
neurons. All of these changes are expressions of plasticity,
or the ability of the nervous system to change in response
to experience. Although the first two forms of plasticity have
been recognized in humans for decades, the birth of new
neurons (neurogenesis) was only recently discovered in
regions involved with ongoing learning, such as the
hippocampus, the amygdala, and the frontal and temporal
lobes (Eriksson et al., 1998; Gould, Reeves, Graziano, &
Gross, 1999; Gould, Tanapat, Hastings, & Shors, 1999;
Gross, 2000).
Existing neurons grow though the expansion and
branching of the dendrites they project to other neurons in
reaction to new experiences and learning (Purves &
Voyvodic, 1987). This process is reflected in the connectivity
among neurons in our simple schematic diagrams. Neurons
interconnect to form neural networks, and neural networks,
in turn, integrate with one another to perform increasingly
complex tasks. For example, networks that participate in
language, emotion, and memory need to become integrated
in order for us to recall and tell an emotionally meaningful
story with the appropriate words, correct details, and proper
affect.
Association areas within the cortex serve the roles of
bridging, coordinating, and directing the multiple neural
circuits to which they are connected. Although the actual
mechanisms of this integration are not yet known, they are
likely to include some combination of communication
between local neuronal circuits and the interactions among
functional brain systems (Trojan & Pokorny, 1999). Changes
in the synchrony of activation of multiple neural networks
may also play a role in the coordination of their activity and
the emergence of conscious awareness (Crick, 1994; Konig
& Engel, 1995).

Genetic Inheritance and Gene Expression

 Evolution consists of the gradual transformation of
organisms from one condition of existence to another.
—Ernst Mayr

Now that most of science has gotten beyond the basic

debate of nature versus nurture, we can acknowledge that
the growth and organization of the brain reflects a complex
yet subtle blending of genetic and environmental influences.
Toward this end, it is much more helpful to think of genes in
terms of serving both a template and a transcription
function (Kandel, 1998). As templates, genes provide the
organization of the uniform structures of the brain, which
are generally unaffected by environmental influences,
except in cases of prenatal genetic abnormalities. These
structures and functions, such as the general layout of the
nervous system and basic reflexes, are inherited via our
DNA and shared by all healthy members of our species. This
is the aspect of genetic inheritance traditionally thought of
as “nature.”
On the other hand, the expression of many genes
depends on experiences that trigger their transcription
(Black, 1998). Transcription genetics controls the more
subtle aspects of the brain’s organization, such as the
specific sculpting of later developing neural networks and
the levels of specific neurotransmitters available to different
brain systems. In fact, the majority of our cortex is added
after birth in an experience-dependent fashion through this
transcriptional process. Nurture, therefore, influences brain
development via the selective activation of genes that
shape the experience-dependent aspects of development.
How does this happen?
Experience results in the expression of certain genes
which trigger the synthesis of proteins that build neural
structures. Through genetic transcription, existing neurons
grow different kinds of receptors, expand their dendritic
structures, and adjust their biochemistry. For example,
although identical twins raised in the same household may
have identical genes for schizophrenia, only one may
develop the illness. This is believed to be the result of the
expression of different genes based on the unique
interactions between each child and his or her environment.
The transcription function of genes allows for ongoing
neural plasticity throughout life and provides the basis for
enriched experiences (like psychotherapy) to benefit both
the adolescent and adult brain. In a later chapter we will
explore the links between maternal nurturance and the
early building of the brain that result in different levels of
learning, emotional regulation, and attachment behavior.

The Role of Enriched Environments

It is always with excitement that I wake up in the

morning…. It’s my partner.
—Jonas Salk

The brain is not a static organ; it continually changes in

response to environmental challenges. Because of this, the
neural architecture of the brain comes to embody the
environment that shapes it. You could also think of our
neural architecture as a tangible expression of our learning
history. The early research on neural plasticity began by
exploring the impact of different types of environments on
brain development. In these studies done primarily with
rats, enriched environments took the form of more diverse,
complex, colorful, and stimulating habitats, while
impoverished environments were relatively empty
monochromatic enclosures. It was found that animals raised
in enriched environments had more neurons, more synaptic
connections among neurons, a greater number of blood
capillaries, and more mitochondria activity (Diamond, Krech,
& Rosenweig, 1964; Kempermann, Kuhn, & Gage, 1997,
1998; Kolb & Whishaw, 1998; Sirevaag & Greenough, 1988).
These findings demonstrate that a brain which is challenged
comes to be more complex, active, and robust. Subsequent
research with humans has yielded similar results for
individuals with more education and more complex and
challenging occupations.
For humans, enriched environments include the kinds of
challenging educational and experiential opportunities that
encourage us to learn new skills and expand our knowledge.
Higher levels of education, practicing skills, and continued
engagement in mental activities all correlate with more
neurons and neural connections (Jacobs & Scheibel, 1993;
Jacobs, Schall, & Scheibel, 1993). Higher levels of education
and reading ability have also been shown to correlate with a
diminished impact of dementia later in life (Schmand, Smit,
Geerlings, & Lindeboom, 1997). Interestingly, brain regions
dedicated to certain skills can actually hijack cells in
adjacent neural areas to serve their needs to develop skills
like playing an instrument or learning Braille (Elbert, Pantev,
Wienbruch, Rockstroh, & Taub, 1995). There is no doubt that
the human brain grows in response to challenge and new
learning.
Psychotherapy can be thought of as a specific type of
enriched environment that promotes social and emotional
development, neural integration, and processing complexity.
The way the brain changes during therapy will depend upon
the neural networks involved in the focus of treatment.

Learning and Stress

Every stress leaves an indelible scar, and the

organism pays for its survival after a stressful
situation by becoming a little older.
—Hans Selye
Mild to moderate stress (MMS) activates neural growth
hormones supportive of new learning (Cowan & Kandel,
2001; Gould, McEwen, Tanapat, Galea, & Fuchs, 1997;
Jablonska, Gierdalski, Kossut, & Skangiel-Kramska, 1999;
Myers, Churchill, Muja, & Garraghty, 2000; Pham,
Soderstrom, Henriksson, & Mohammed, 1997; Zhu & Waite,
1998). Thus, MMS may be utilized to enlist naturally
occurring neurobiological processes in the service of new
learning. Although we use the term stress in animal
research, humans also demonstrate arousal in the form of
curiosity, enthusiasm, and pleasure. Humans can also be
motivated to learn new skills and take on new challenges to
relieve discomfort and stress. These motivational states
have all been recognized for their role in successful
outcomes from psychotherapy.
Dissociation is a common result of the high levels of
stress associated with traumatic experiences. Characterized
by a disconnection among thoughts, behaviors, sensations,
and emotions, dissociation demonstrates that the
coordination and integration of these functions is an active
neurobiological process. Because all of these functions are
seamlessly and unconsciously interwoven during normal
states of awareness, it is easy to overlook the fact that their
integration is a central component of mental health.
The power of mild to moderate levels of stress to trigger
neural plasticity is a key element in the success of
psychotherapy or any learning situation. As opposed to
traumatic experiences, the controlled exposure to stress
during therapy enhances new learning and increases neural
integration. As therapists, we intuitively work to regulate
stress and integrate neural networks, a process that is
essentially the opposite of the dissociation observed in
reaction to trauma. Healthy functioning requires proper
development and functioning of neural networks organizing
conscious awareness, behavior, emotion, and sensation.
 As in early development, the repeated exposure to stress
in the supportive interpersonal context of psychotherapy
results in the ability to tolerate increasing levels of arousal.
This process reflects the building and integration of cortical
circuits and their increasing ability to inhibit and regulate
subcortical activation. Affect regulation, especially the
modulation and inhibition of anxiety and fear, allows for
continued cortical processing in the face of strong emotions,
allowing for ongoing cognitive flexibility, learning, and
neural integration.
In this process the therapist plays essentially the same
role as a parent, providing and modeling the regulatory
functions of the social brain. As affect is repeatedly brought
into the therapeutic relationship and successfully managed,
the client gradually internalizes these skills by sculpting the
neural structures necessary for autoregulation. As in
childhood, the repeated cycle of attunement, rupture of the
attunement, and its reestablishment gradually creates an
expectation of reconnection (Lachmann & Beebe, 1996).
The learned expectation of relief in the future enhances the
ability to tolerate more intense affect in the midst of the
stressful moment.
As a therapist, one of my primary goals is to shift my
clients’ experience of anxiety from an unconscious trigger
for avoidance to a conscious cue for curiosity and
exploration. One of my patients described it metaphorically
as using anxiety as a compass to help guide him to and
through his unconscious fears. Becoming aware of anxiety is
then followed with an exploration and eventual
understanding of what we are afraid of and why. The next
step is to move toward the anxiety with an understanding of
its meaning and significance. In this way, anxiety becomes
woven into a conscious narrative with the possibility of
writing a new outcome to our story. This process reflects the
integration of cortical linguistic processing with conditioned
subcortical arousal in the service of inhibiting, regulating,
and modifying maladaptive reactions.
As we will see later when discussing the building of the
social brain, biological and environmental factors during
childhood can result in long periods of dysregulation. Early
deprivation or chronic stress increase the chances of
damage to the brain, deficits in memory and reality testing,
and the prolonged utilization of primitive defenses (Brown,
Henning, & Wellman, 2005; Radley et al., 2006; Sapolsky,
1985). With increased nurturance and support, stress
hormone levels decrease; physical comfort and soothing
talk with caretakers helps the brain to integrate experience.

Emotional Tolerance and Affect Regulation

Few things are brought to a successful issue by

impetuous desire, but most by calm and prudent
forethought.
—Thucydides

Although we usually think of the cortex as a giant hard drive

capable of storing huge amounts of data, another primary
role of the cortex is inhibition. Take for example the grasping
reflex we are all born with. This powerful grip allowed our
ancestors to hold onto their mothers as they moved through
trees and over land. During the early months of life this
grasping reflex is soon inhibited by descending cortical
circuitry. The inhibition of this and other reflexes allow for a
cortical takeover of these functions during development. So
we sacrifice the grasping reflex for the finger dexterity
necessary to manipulate digits, write, and use tools. Later in
life if we have the misfortune of succumbing to dementia,
this and other early reflexes begin to reappear as our cortex
gradually loses its inhibitory ability. In a similar fashion, our
prefrontal cortex is shaped by experience to inhibit and
control subcortical functional activation, which eventually
results in our ability to regulate our emotions. Early
attachment relationships establish the experiences that
shape these neural networks and allow us to regulate our
emotional experience.
Assistance with experiencing increasing levels of positive
and negative affect is a vital component of both parenting
and psychotherapy. The gradually increasing tolerance for
stress builds our brains, expands neural organization of
emotional and cognitive integration, and creates networks
of descending control to help inhibit and regulate affect
(Schore, 1994). Emerging from childhood with an ability to
experience a range of emotions and tolerate stress serves
both as a means of brain growth and continued
development throughout life.
During our first few years, we have the repeated
experiences of going from a comfortable, regulated state to
a state of dysregulation. We become frightened, cold, wet,
and hungry, and show our displeasure with facial
expressions, bodily postures, vocalization, and crying. In the
presence of good-enough parenting, our signals are
attended to, the source of our displeasure diagnosed, and
we are helped back into a regulated state. Across thousands
of these temporal-emotional experiences, we go from
regulation to dysregulation to reregulation. These
experiences shape secure attachment and the expectation
of positive outcomes. The summation of these experiences,
stored throughout our nervous system, becomes the
sensory-motion-emotional background of our experience.
In the absence of adequate assistance in regulating
affect or making sense of emotions, the brain organizes a
variety of defensive coping strategies. These defenses vary
in the degree to which they distort reality in order to
achieve their goal of reducing anxiety. This distortion is
accomplished in circuits of unconscious memory that control
anxiety and fear (Critchley et al., 2000). The neural
connections that result in defenses shape our lives by
selecting what we approach and avoid, what our attention is
drawn to, and the assumptions we use to organize our
experiences. Our cortex then provides us with
rationalizations and beliefs about our behaviors that help
keep our coping strategies and defenses in place, possibly
for a lifetime. These neural and psychic structures can lead
to either psychological and physical health, or illness and
disability.

Psychopathology and Neural Network Integration

In a structure as complex as the human brain a

multitude of things can go wrong. The wonder is that
for most people the brain functions effectively.
—Seymour Kety

If everything we experience is represented by

instantiations within neural networks, then by definition,
psychopathology of all kinds—from the mildest neurotic
symptoms to the most severe psychosis—must also be
represented within and among neural networks. In line with
this theory, psychopathology would be a reflection of
suboptimal development, integration, and coordination of
neural networks. Patterns of dysregulation of brain
activation found in disorders such as depression and
obsessive-compulsive disorder support the theory of a brain-
based explanation for the symptoms of psychopathology.
Difficulties in early caretaking, genetic and biological
vulnerabilities, or trauma at any time during life can result
in the lack of integration among networks. Unresolved
trauma can cause ongoing information processing deficits
that disrupt integrated neural processing. For example,
dissociative symptoms following trauma—reflecting the
disconnection among networks of behavior, emotion,
sensation, and cognition—predict the later development of
posttraumatic stress disorder (Koopman, Classen, & Spiegel,
1994; McFarlane & Yehuda, 1996). Children victimized by
psychological, physical, and sexual abuse have a greater
probability of demonstrating electrophysiological
abnormalities in executive regions of the brain vital to
neural network integration (Ito et al., 1993; Teicher et al.,
1997).
In general, psychological integration suggests that the
conscious cognitive functions of the executive brain have
access to information across networks of sensation,
behavior, and emotion. A primary focus of neural integration
in traditional talk psychotherapy is between networks of
affect and cognition. Dissociation between the two occurs
when high levels of stress inhibit or disrupt the brain’s
integrative abilities among the left and right cerebral
hemispheres as well as among the cortex and limbic
regions. The integration of the left and right hemispheres
can be disrupted while the circuits of the reptilian and
paleomammalian brains can be unlinked from the conscious
neomammalian cortex.
This unlinking may not be an evolutionary accident. As
valuable as language can be for humans, evolution appears
to have selected for the shutdown of language (and a
decrease in cognitive processing) when confronted with
threat. The resulting disruption of information processing
may be the most common cause of neural network
dissociation. Cortical networks responsible for memory,
language, and executive control (in its many forms) become
inhibited and underperform during times of overwhelming
stress. The very way that the brain has evolved to
successfully cope with immediate threat appears to have
created a vulnerability to longer term psychological distress:
Enter psychotherapy.
Applying this model, psychotherapy is a means of
creating or restoring coordination among various neural
networks. Research has demonstrated that successful
psychotherapy correlates with changes in activation in areas
of the brain hypothesized to be involved in disorders such as
obsessive compulsive disorder and depression (Baxter et al.,
1992; Brody, Saxena, Mandelkern, et al., 2001; Brody,
Saxena, Schwartz, et al., 1998; Schwartz, Stoessel, Baxter,
Martin, & Phelps, 1996). The return to normal levels of
activation and homeostatic balance results in reestablishing
positive reciprocal control among relevant neural structures
and networks.

Psychotherapy and Neural Network Integration

The only thing they (neural connections) can do…is to

deepen old paths or to make new ones.
—William James

A basic assumption of both neuroscience and psychotherapy

is that optimal functioning and mental health are related to
increasingly advanced levels of growth, integration, and
complexity. On a neurological level, this equates to the
integration and communication of neural networks
dedicated to emotion, cognition, sensation, and behavior
and a proper balance between excitation and inhibition. On
an experiential level, integration is the ability to live life—
love and work—while employing a minimum of
defensiveness. Growth and integration are optimized by a
positive early environment, including stage-appropriate
challenges, support, and parents who are capable and
willing to put feelings into words. These factors lead to
positive affect regulation, biological homeostasis, and a
quiet internal milieu allowing for the consolidation of the
experience of subjectivity and a positive sense of self.
From the perspective of neuroscience, psychotherapy
can be understood as a specific kind of enriched
environment designed to enhance the growth of neurons
and the integration of neural networks. The therapeutic
environment is individually tailored to fit the symptoms and
needs of each client. I propose here that all forms of
therapy, regardless of theoretical orientation, will be
successful to the degree to which they foster appropriate
neuroplasticity. Further, I also propose that neural plasticity,
growth, and integration in psychotherapy are enhanced by:

1. The establishment of a safe and trusting

relationship.
2. Mild to moderate levels of stress.
3. Activating both emotion and cognition.
4. The co-construction of new personal narratives.

Although psychotherapists do not generally think in

“neuroscientific” terms, stimulating neuroplasticity and
neural integration is essentially what we do. We provide
information to clients about our understanding of their
difficulties in the form of psychoeducation, interpretations,
or reality testing. We encourage clients to engage in
behaviors, express feelings, and become conscious of
aspects of themselves of which they may be unaware. We
dare them to take risks. We guide them back and forth
between thoughts and feelings, trying to help them
establish new connections between the two. We help clients
alter their description of themselves and the world,
incorporating new awareness and encouraging better
decision making. With successful treatment, the methods
being used are internalized so that clients can gain
independence from therapy and we do this all in the context
of a warm, supportive, committed, and consistent
relationship. These same factors are at play across
psychodynamic, systems, and cognitive-behavioral
approaches to treatment.
 The broad context in which these processes can
successfully occur is one of increasing levels of affect
tolerance and regulation and the development of integrative
narratives that emerge from the client–therapist
relationship. In the context of empathic attunement within a
safe and structured environment, clients are encouraged to
tolerate the anxiety of feared experiences, memories, and
thoughts. In this process, neural networks that are normally
inhibited become activated and available for inclusion into
conscious processing (Siegel, 1995). Interpretations in
psychodynamic therapy, exposure in behavioral therapies,
or experiments in differentiation from a systems perspective
all focus on this goal. Through the activation of multiple
cognitive and emotional networks, previously dissociated
functions are integrated and gradually brought under the
control of cortical executive functions. Narratives co-
constructed with therapists provide a new template for
thoughts, behaviors, and ongoing integration.

Pathways of Integration

It is the harmony of the diverse parts, their symmetry,

their happy balance; in a word it is all that introduces
order, all that gives unity.
—Henri Poincaré

Given that information flows simultaneously in multiple

directions through many neural networks, optimal neural
integration likely involves maximizing the flow and flexibility
of energy through neural networks (Pribram, 1991). Using
this model, psychopathology can be caused by difficulties
not just in a specific region of the brain, but also in the
interactions among participating systems (Mayberg, 1997;
Mayberg et al., 1999). Numerous processing networks
combine affect, sensation, behavior, and conscious
awareness into an integrated, functional, and balanced
whole—the neural substrate for what Freud called the ego.
The ego is essentially shorthand for how the organization of
the self comes to be expressed in dimensions such as
personality, affect regulation, coping styles, and self-image.
The primary directions of information flow relevant to
psychotherapy are top-down (cortical to subcortical and
back again) and left-right (across the two halves of the
cortex). Keep in mind that these information loops need to
communicate with each other as well as with many other
processing systems. Top-down or bottom-up integration
would include MacLean’s linkup among the three levels of
the triune brain and the unification of the body, emotion,
and conscious awareness. This is called top-down because
these circuits form loops that go from the top of our head
down into the depths of the brain and back up again. Top-
down integration includes the ability of the cortex to
process, inhibit, and organize the reflexes, impulses, and
emotions generated by the brainstem and limbic system
(Alexander et al., 1986; Cummings, 1993). Frontal lobe
disorders often result in a disinhibition of impulses and
movements normally under its control such as obsessive-
compulsive and attention deficit disorders. Within this
category I include what has been referred to as dorsal-
ventral integration, connecting cortical with limbic
processing (Panksepp, 1998; Tucker, Luu, & Pribram, 1995).
Left-right or right-left integration involves abilities that
require the input of both the left and right cerebral cortex
and lateralized limbic regions for optimal functioning. For
example, adequate language production requires an
integration of the grammatical functions of the left and the
emotional functions of the right. Left-right integration allows
us to put feelings into words, consider feelings in conscious
awareness, and balance the positive and negative affective
biases of the left and right hemispheres (Silberman &
Weingartner, 1986). A balance among the left and right
prefrontal cortices is also necessary for the proper balance
of affect and emotion. Alexithymia (the inability to put
words to feelings) and somatization disorder (the conversion
of emotional conflicts into bodily illness) may reflect left-
right dissociation (Hoppe & Bogen, 1977). There is also
evidence that depression and mania correlate with
dysregulation of the balance of activation between the left
and right prefrontal cortices (Baxter et al., 1985; Field,
Healy, Goldstein, Perry, & Bendell, 1988).
The right hemisphere is more highly connected with the
body and the more primitive and emotional aspects of
functioning. The left hemisphere is more closely identified
with cortical functioning, whereas the right is more densely
connected with limbic and brainstem functions (Shapiro,
Jamner, & Spence, 1997). For example, states of stress,
anxiety, and fear result in increased activation in the right
cortex and subcortical structures (Rauch et al., 1996;
Wittling, 1997). This bias is also relevant to the organization
of social emotional attachment patterns, transference, and
affect regulation (Minagawa-Kawai et al., 2008). Much of the
integration of top-down and left-right systems is mediated
through interactions among regions of the frontal cortex,
our primary executive system.
Due to the interconnectivity between left-right and top-
down neural networks, examining integration from either
the vertical or horizontal dimension alone is overly
simplistic. Studies of metabolic activity in specific areas of
the brain in pathological states reveal differences in both
cortical and subcortical structures on both sides of the
brain. This research suggests that restoring neural
integration requires the simultaneous reregulation of
networks on both vertical and horizontal planes. It is also
important to remember that although we are discussing
brain functioning from the perspective of neural networks,
an equally meaningful discussion could focus on the impact
of pharmacological agents on the modulation and
homeostatic balance of these same networks (Coplan &
Lydiard, 1998). This perspective helps us to understand why
both psychotherapy and medication can result in shifts of
neural activity and symptom reduction and why together
they may work better than either one alone (Andreasen,
2001).
Neural network integration can also be accomplished
through the activation of conscious language production
(top and left) with more primitive, emotional, and
unconscious processes (down and right) that have been
dissociated due to stress or trauma. Depending on their
theoretical orientation, therapists facilitate the process of
network integration by supplying challenges of all kinds. An
analyst may use interpretations to enhance awareness of
inhibited, repressed, or dissociated thoughts and emotions.
A cognitive-behavioral therapist will expose a client to a
feared stimulus combined with relaxation training, allowing
normally inhibited cortical circuitry to integrate with the
subcortical circuitry that controls fear. Research across all
forms of psychotherapy supports the hypothesis that
positive outcomes are related to utilizing both support and
challenge in the combined engagement of thought and
affect (Orlinsky & Howard, 1986). Both the quality of the
interpersonal connection and creating the proper learning
environment appear essential.

Psychotherapy and Parenting

Parents are like shuttles on a loom. They join the

threads of the past with threads of the future and
leave their own bright patterns as they go.
—Fred Rogers

We have talked a little about the parallels between positive

parenting and successful psychotherapy; these similarities
reflect the commonality of the conditions required for
building and rebuilding the brain. Mutual eye gaze and
escalating positive emotional interactions between parent
and child stimulate the growth and organization of the brain.
In the future, we may discover scientific evidence that the
interpersonal experience of psychotherapy impacts the
neurobiological environment of the brain in ways that
stimulate neural plasticity and neurogenesis. Although the
various schools of therapy tend to accentuate their
differences, the therapeutic relationship itself may be the
most powerful curative agent.
The warmth, acceptance, and unconditional positive
regard demonstrated by Carl Rogers’s work embodies the
broad interpersonal environment for the initial growth of the
brain and continued development later in life (Rogers,
1942). Having spent a brief period of time with Dr. Rogers as
a student, I can attest to the power of his interpersonal style
and therapeutic technique. I am sure he left many, including
myself, with the fantasy of being available for adoption.
Primary goals of parenting include providing a child with
the capacity for self-soothing and the ability to form positive
relationships. This allows the child to face the challenges of
life and benefit from healing life experiences. The successful
mastery of challenges throughout life leads to taking on
even more complex challenges that will promote
increasingly higher levels of neural network development
and integration. When internal or external factors prevent
an individual from approaching challenging and stressful
situations, neural systems will tend to remain
underdeveloped or unintegrated.
In a review of hundreds of studies examining the
outcome of psychotherapy, Orlinsky and Howard (1986)
looked for those factors that seemed to relate to success.
They found that the quality of the emotional connection
between patient and therapist was far more important than
the therapist’s theoretical orientation. Patients who are
motivated to change and are able to work collaboratively
with their therapists also do better. Therapists’ professional
experience was positively related to success, as were the
use of interpretation, a focus on transference, and the
expression of emotion. The continual involvement of both
cognitive and emotional processing during treatment seems
essential for positive change.
Psychotherapy, like parenting, is neither mechanical nor
generic. Each therapist–client pair creates a unique
relationship resulting in a particular outcome. The
importance of the unconscious processes of both parent and
therapist is highlighted by their active participation in the
co-construction of new narratives of their children and
patients. As we will see in research on attachment, each
parent’s unconscious plays a role in the creation of the
child’s brain, just as the therapist’s unconscious contributes
to the context and outcome of therapy. This underscores the
importance of proper training and adequate personal
therapy for therapists, who will be putting their imprint on
the hearts, minds, and brains of their clients.

Summary
In this chapter we have explored some initial concepts in
the integration of psychotherapy and neuroscience based
on common principles within both fields. We have equated
psychological health with optimal neural network growth
and integration. Both the brain and the self are built in a
stepwise manner by experience. The nervous system is
made up of millions of neurons while human experience is
constructed within countless moments of learning. The
psychological difficulties for which patients seek
psychotherapy are a function of inadequate growth and
integration within and between these same networks. The
aspects of development that foster positive brain
development and those in therapy that promote positive
change are emotional attunement, affect regulation, and the
co-construction of narratives.
In the following chapter, we turn our attention to major
models of psychotherapy in use today. By examining their
theories and techniques, we will see how they have been
shaped by underlying principles related to the growth and
integration of neural networks. It is my belief that the
development of psychotherapy has always been implicitly
guided by the principles of neuroscience. All forms of
therapy are successful to the degree to which they have
found a way to tap into processes that build and modify
neural structures within the brain.
Chapter 3

Neural Integration in Different Models of

Psychotherapy

The techniques of behavior therapy and

psychotherapy have relied on the principles of brain
plasticity, generally without realizing it, for nearly one
hundred years.
—Nancy Andreasen

Like other scientific discoveries, psychotherapy developed

from a combination of trial-and-error learning, the intuition
of its founder, and plain luck. Each school of psychotherapy
offers an explanation of mental health and illness as well as
why its strategies and techniques are effective. Fortunately,
the effectiveness of an intervention does not depend on the
accuracy of the theory used to support it. For example,
there was a time when psychoanalysts attributed the
success of electroshock therapy to the need of a depressed
person to be punished. The treatment worked and still works
despite the lack of a solid understanding of its mechanisms
of action.
Although each approach to psychotherapy is experienced
as a fundamental truth by its disciples, all modes of therapy
are actually heuristics. Heuristics are interpretations of
experience or ways of understanding phenomena. The value
of a heuristic lies in its ability to organize, explain, and
predict what we observe. Neuroscience is another heuristic,
one that we are using in the present discussion to explain
the mechanisms of action of psychotherapy; in other words
how and why it works. It is my belief that neuroscience is a
helpful heuristic that will lead us to a fuller understanding of
the process of psychotherapy and may also serve as a
rational means of selecting, combining, and evaluating
treatment modalities.
In this chapter we examine, in broad strokes, some of the
primary approaches to psychotherapy. These overviews are
presented in order to provide a context in which to
understand and organize the neuroscientific concepts in the
coming chapters. In taking a sample of general theoretical
approaches to psychotherapy, we will look for common
elements among them, and how these elements may relate
to neural network development and change. Remember,
from the perspective of neuroscience, psychotherapists are
in the brain-rebuilding business.

Psychoanalytic and Psychodynamic Therapies

Being entirely honest with oneself is a good exercise.

—Sigmund Freud

Freud’s psychoanalysis, the original form of psychodynamic

therapy, has spun off countless variants in its century-long
existence. Ego psychology, self-psychology, and schools of
thought connected to names such as Klein, Kernberg, and
Kohut have all attracted considerable followings. Despite
their differences, psychodynamic forms of therapy share
theoretical assumptions such as the existence of the
unconscious, the power of early childhood experiences, and
the existence of defenses that distort reality in order to
reduce anxiety and enhance coping.
The exploration of the unconscious and its connection to
our evolutionary past may be Freud’s greatest legacy. He
remained true to Charcot by exploring the multiple levels of
human awareness and designed many techniques to bring
the unconscious into conscious awareness. The power of
trauma, especially during childhood, and its ability to shape
the organization of the mind were also examined in great
detail. Freud theorized that early attachment and relational
difficulties, neglect, or trauma result in developmental
arrests or “fixations” that delay or derail the adult’s
potential to love and work. From the standpoint of
neurobiology, most of Freud’s work addressed the
discontinuities and dissociations between networks of
conscious and unconscious processing. Freud focused on the
role of overwhelming emotion as the cause of unintegrated
neural processing.
Freud’s psychic self contains the primitive drives (id), the
demands of civilization to conform for the benefit of the
group (superego), and those parts of the self (ego) that
attempt to negotiate the naturally occurring conflicts
between the two. In its role as a diplomat in the fight
between id and superego, the ego utilizes many elaborate
defenses to cope with reality. Ego strength, or our ability to
navigate reality with a minimum of defensiveness, reflects
the integration of neural networks of emotion and thought,
and the development of mature defenses. The more
primitive or immature the defense mechanism, the more
reality is distorted and the more functional impairment
occurs. Sublimation, for example, enables us to convert
unacceptable impulses into constructive and prosocial
goals. Mature defenses, like sublimation or humor, allow us
to assuage strong feelings, keep in contact with others, and
remain attuned to a shared social reality.
Less mature defenses, such as denial and dissociation,
result in greater distortion of reality and difficulties in both
work and relationships. Defenses are often invisible to their
owners because they are organized by hidden layers of
neural processing that are inaccessible to conscious
awareness. What Freud called defenses can be seen as ways
in which neural networks have adapted to cope with
emotional stress. People seek treatment when their defense
mechanisms cannot adequately cope with repressed
emotions, or when symptoms become intolerable.
Despite a conscious awareness that something may be
wrong, the hidden layers of neural processing continue to
organize the world based on the prior experiences that
shaped them. As we will see in later chapters, the neural
circuitry involved with fear has a tenacious memory and can
invisibly influence conscious awareness for a lifetime. Part of
psychodynamic therapy is an exploration and uncovering of
this unconscious organization of experience. Freud’s
projective hypothesis described the process by which our
brains create and organize the world around us. As the
clarity of a situation decreases, the brain naturally
generates structure and projects it onto the world. The way
we organize and understand ambiguous stimuli gives us
clues about the architecture of the hidden layers of neural
processing (how our unconscious organizes the world). From
the projective hypothesis came the invention of projective
tests such as Rorschach’s ink blots, free association, and an
emphasis on the importance of dreams as the “royal road to
the unconscious.”
As part of the projective hypothesis, psychodynamic
therapists often provide minimal information about
themselves, allowing the client to project onto them implicit
(unconscious) memories from past relationships. This form
of projection, transference, results in the client placing
expectations and emotions from earlier relationships on the
therapist, which allows them to be experienced and worked
through firsthand. It is through this transference that early
relationships for which we have no conscious recollection
are brought fully into therapy. Freud felt that the evocation
and resolution of the transference was a core component of
a successful analysis. In Freud’s words, only transference
renders “the invaluable service of making the patient’s
buried and forgotten love emotions actual and manifest”
(Freud, 1975, Chapter 7).
Resistance represents aspects of implicit memory
presented by the client that it is up to the therapist to
decipher. Early experiences of rejection, criticism, or neglect
from parents result in shame, which can evolve into a child’s
negative self-image. The resultant self-criticism (superego)
manifests in disrespect for anyone who shows the child love
or respect. An example of this is expressed in the Groucho
Marx line, “I’d never join a club that would have me as a
member.” In therapy, this may manifest as a strong distrust
of the therapist’s intentions or his or her ability to be of
help.
Interpretations are one of the psychodynamic therapist’s
most important tools. Sometimes called the “therapist’s
scalpel,” interpretations attempt to make the unconscious
conscious. Based on observations of all levels of the client’s
behavior, the therapist attempts to bring the processing of
the hidden layers to the client’s attention. Repeated and
skillful attention to unconscious material via interpretations,
confrontations, and clarifications results in a gradually
expanding awareness of unconscious processes and the
integration of dissociated top-down and right-left processing
networks.
Accurate, successful interpretations are sometimes
accompanied by feelings of disorganization, anger, or
depression. This is because when defenses are made
conscious and are exposed for what they are, they lose their
effectiveness, leading to a disinhibition of the emotions that
they have been successfully defending against. In other
words, the networks containing the negative emotions
become disinhibited and activated. For example, if
intellectualization is being used to avoid the shame and
depression related to early criticism, recognition of the
defense will bring these feelings and related memories to
awareness.
 Emotions play a central role in the success of
psychodynamic therapies. The neural networks that
organize emotions are often shaped to guide us away from
thoughts and feelings for which we were punished or
abandoned. Unconscious anxiety signals continue to shape
our behavior, leading us to remain on tried-and-true paths
and avoid situations that trigger our unremembered past.
An emphasis on the evocation of emotion and cognition is
an important contribution of psychoanalysis and reflects
fundamental underlying neurobiological processes of health
and illness.
Across psychodynamic forms of therapy, conscious
awareness is expanded, emotions are explored, and the
expression of repressed or inhibited emotions is
encouraged. Feelings, thoughts, and behaviors are
repeatedly juxtaposed, combined, and recombined in the
process of working through. The assumptions and narratives
from the past are edited based on new information, and
those about the present and future are reevaluated. The
overall goal is combining emotion with conscious awareness
and rewriting the story of the self. These processes, when
successful, enhance the growth, integration, and flexibility
of neural networks and human experience.

Rogerian or Client-Centered Therapy

The curious paradox is that when I accept myself just

as I am, then I can change.
—Carl Rogers

Against the dominant background of psychoanalysis, Carl

Rogers (1942) emerged with a form of therapy he referred
to as “client-centered.” In stark contrast to a theory-based
analysis of the patient, Rogers emphasized creating a
relationship that maximized the individual’s opportunity for
self-discovery. Rogers’s approach gained rapid acceptance
in the nonmedical community and by the 1960s came to be
the dominant form of counseling (Gilliland & James, 1998).
When different approaches to therapy are compared for
effectiveness, the general agreement is that the perceived
quality of the client–therapist relationship has the highest
correlation with reported treatment success. Some have
gone as far as saying that the curative element is the
therapeutic relationship itself, rather than any specific
techniques. This would certainly have been Rogers’s belief,
for he believed that the curative aspects of therapy were
the therapist’s warmth, acceptance, genuineness, and
unconditional positive regard. His emphasis on interpersonal
congruence foreshadowed the focus on emotional
resonance and empathic attunement in later-emerging
forms of psychotherapy such as object relations and
intersubjectivity (Kohut, 1984; Stolorow & Atwood, 1979).
Over the last century, the therapist attributes suggested
by Rogers and what we have come to think of as the best
possible attitudes for optimal parenting have become
essentially identical. Rogerian principles lead to a minimized
need for defensiveness and shame while maximizing
expressiveness, exploration, and risk taking. Rogers was
likely describing the best interpersonal environment for
brain growth during development and neural plasticity in
psychotherapy when he stated that client-centered therapy
“aims directly toward the greater independence and
integration of the individual rather than hoping that such
results will accrue if the counselor assists in solving the
problem. The individual and not the problem is the focus.
The aim is not to solve one particular problem, but to assist
the individual to grow, so that he can cope with the present
problem and later problems in a better-integrated fashion”
(Rogers, 1942, Chapter 2).
During my training in client-centered therapy, I was
struck by the power of Rogers’s approach. I found it
immensely difficult to maintain his supportive stance, and
often struggled to keep myself from directing my clients,
giving advice, and pushing them to change. To my
astonishment, I found that providing clients with a
supportive relationship led to insights on their part that
mirrored the interpretations I struggled to suppress. Clients
often expressed a mixture of sadness and appreciation
when they realized how much they longed to be listened to
without fear of judgment and shame.
What might be going on in the brain of a client in client-
centered therapy? In the Rogerian interpersonal context, a
client would most likely experience the widest range of
emotions within the ego scaffolding of an empathic other.
The activation of neural networks of emotion makes feelings
and emotional memories available for reorganization.
Rogers’s nondirective method activates clients’ executive
networks and their self-reflective abilities. Supportive
rephrasing and clarification of what clients say may also
enhance executive functioning. This simultaneous activation
of cognition and emotion, enhanced perspective, and the
emotional regulation offered by the relationship may
provide an optimal environment for neural change. Clients,
scaffolded by the therapist’s support and stimulated by his
or her words, can then work to rewrite their stories.
We know that social interactions early in life result in the
stimulation of both neurotransmitters and neural growth
hormones that participate in the active building of the brain.
By recreating a positive parenting relationship, it is likely
that the empathic connectedness promoted by Rogers
actually stimulates biochemical changes in the brain
capable of enhancing new learning. For example, studies
with birds have demonstrated that the ability to learn their
songs is enhanced when exposed to live singing birds
versus tape recordings of the same songs (Baptista &
Petrinovich, 1986). Other birds are actually unable to learn
from tape recordings and require positive social interactions
and nurturance in order to learn (Eales, 1985). We will see
later how maternal contact and nurturance in rats protect
the brain from the damaging effects of stress (Meaney,
Aitken, Viau, Sharma, & Sarrieau, 1989; Plotsky & Meaney,
1993).
Studies such as these demonstrate that social
relationships have the power to stimulate the neural
plasticity required for new learning. The interpersonal and
emotional aspects of the therapeutic relationship, referred
to as a nonspecific factor in the psychotherapy outcome
literature, may be the primary mechanism of therapeutic
action. As we will see in a later chapter, these nonspecific
factors are, in fact, quite specific, as early maternal care has
been linked to increased neural plasticity, emotional
regulation, and attachment behavior. In other words, those
who are nurtured best survive best within a positive and
safe environment. Unfortunately, the social isolation created
by certain psychological defenses reinforces the rigidity of
neural organization as the client avoids the interpersonal
contexts required to promote healing. In these instances,
the therapeutic relationship may serve as a bridge to once
again connect with others.

Cognitive Therapies

It’s not what happens to you, but how you react to it

that matters.
—Epictetus

Cognitive therapies highlight the centrality of a person’s

thoughts, appraisals, and beliefs in guiding his or her
feelings and actions. They emphasize that negative
thoughts, skewed appraisals, and erroneous beliefs can
create psychological problems. Cognitive therapy focuses on
the identification and modification of dysfunctional thoughts
with the ultimate goal of improved affect regulation (Beck,
Rush, Shaw, & Emery, 1979; Ellis, 1962). The primary
targets of cognitive-behavioral therapy have been
depression, anxiety, obsessive-compulsive disorder,
phobias, and panic disorders.
Depressed patients tend to evaluate their world in
absolute terms, take details out of context, and experience
neutral comments and events as negative. Common
depressive thoughts include the expectation of failure
despite many past successes, and thoughts that one is
alone despite being surrounded by friends and family. In
cognitive therapy, the patient is educated about these
common distortions and encouraged to engage in reality
testing and self-talk designed to counteract negative
reflexive statements.
In anxiety disorders, fear comes to organize and control
the patients’ lives. High levels of anxiety inhibit and distort
rational cognitive processing. Cognitive interventions with
these patients often include educating them about the
physiological symptoms of anxiety such as a racing heart,
shortness of breath, and sweaty palms. These patients are
taught that feelings of dread are secondary to autonomic
symptoms and should not be taken as seriously as they feel.
A focus on understanding normal biological processes
usually redirects the client away from catastrophic
attributions that serve to increase anxiety.
With clients suffering with phobias or PTSD,
psychoeducation is combined with exposure and response
prevention, in which the client faces the feared stimulus
(e.g., venturing outside or thinking about a negative event)
without being allowed to retreat back to the safety of home
or a state of denial. Exposure is usually systematic, gradual,
and paired with relaxation training used to aid in the
downregulation of physiological arousal. This process
combines increased cortical processing (thought) with
subcortical activation (emotion) to allow for integration with
cortical circuitry in order to permit habituation, inhibition,
and eventual extinction via descending cortical networks.
How does this translate into what is going on in the brain
during cognitive therapy? Research has demonstrated that
disorders of anxiety and depression correlate with changes
in metabolic balance among different brain regions. For
example, symptoms of depression correlate with activation
imbalance within the prefrontal cortex—lower levels of
activation in the left and higher levels in the right (Baxter et
al., 1985; Field et al., 1988). This supports the hypothesis
that mental health correlates with the proper homeostatic
balance between neural networks. Symptoms of obsessive-
compulsive disorder correlate with changes in activation in
the medial (middle) portions of the frontal cortex and a
subcortical structure called the caudate nucleus (Rauch et
al., 1994). Posttraumatic flashbacks and states of high
arousal correlate with higher levels of activation in right-
sided limbic and medial frontal structures. Importantly, high
arousal also correlates with decreased metabolism in the
expressive language centers of the left hemisphere (Rauch
et al., 1996).
Of all the different types of therapy, specific links have
been found between successful cognitive-behavioral
therapy and changes in brain functioning. As described in
the last chapter, changes in brain functioning and
symptomatology in both obsessive-compulsive disorder and
depression have been found after successful psychotherapy
(Baxter et al., 1992; Brody, Saxena, Mandelkern, et al.,
2001; Brody, Saxena, Schwartz, et al., 1998; Schwartz et al.,
1996). These findings strongly suggest that therapists can
utilize cognition to alter the relationship among neural
networks in a way that impacts their balance of activation
and inhibition. In striving to activate cortical processing
through conscious control of thoughts and feelings, these
therapies enhance left cortical processing, inhibiting and
regulating right hemispheric balance and subcortical
activation. The reestablishment of hemispheric and top-
down regulation allows for increases in positive attitudes
and a sense of safety that counteract the depressing and
frightening effects of right hemisphere and subcortical
(amygdala) dominance (Ochsner & Gross, 2008).
Although cognitive-behavioral therapy is carried out in an
interpersonal context of collaboration and support, it places
far less emphasis on the therapeutic relationship than do
Rogerian and psychodynamic approaches. The inherent
wisdom of this approach with depressed and anxious
patients lies in the fact that disorders of affect need
activation of cortical executive structures. Given that
emotions are contagious, a deeper emotional connection
might result in the therapist attuning to dysregulated states
and sharing in the patient’s depressed, anxious, and panicky
feelings. While emotional attunement with these feelings is
helpful, it has been my experience that after the working
relationship is established, challenging thoughts and
encouraging new behaviors can often be far more beneficial
to the therapeutic process than empathy alone. The
structured aspect of cognitive-behavioral therapy may
protect both therapist and patient from the power of
negative affect.

Systemic Family Therapy

We must not allow other people’s limited perceptions

to define us.
—Virginia Satir

There is increasing evidence that neural networks

throughout the brain are stimulated to grow and organize by
interaction with the social environment. Early relationships
become encoded in networks of sensory, motor, and
emotional learning to form what dynamic therapists call
inner objects. These inner objects have the power to soothe,
arouse, and dysregulate, depending on the quality of our
attachment experiences with significant others. These
unconscious memories organize our inner worlds when we
are with others and when we are alone. Thus, we constantly
experience ourselves in the context of others.
This is one reason systems therapists question the
validity of diagnosing and treating people in isolation. They
believe that in our day-to-day experience we simultaneously
exist in two realities: our present families and our
multigenerational family histories. This perspective is
especially relevant when working with children who have
yet to form clear ego boundaries between themselves and
their family. Some adult patients who have not successfully
individuated also demonstrate unclear boundaries between
their own thoughts and feelings and those of family
members. Regardless of age, however, the basic principles
are the same.
Murray Bowen, a prime contributor to systems thinking,
presented a model that is compatible with an exploration of
the underlying neuroscience of psychotherapy. His
perspective is based on the recognition that a family
provides both emotional regulation and a platform for
differentiation. He defines differentiation as the
development of autonomy—a balance between the
recognition of the needs of self and others. Differentiation
involves the regulation of anxiety and a balance of
integration of affect and cognition. Bowen would say that
anxiety is the enemy of differentiation. That is, the more
frightened people are, the more likely they are to dissociate
and the more dependent and primitive they become in their
interaction with others (Bowen, 1978).
When this regression occurs, family members try—
consciously and unconsciously—to shape the family in a
manner that reduces their own anxiety. The alcoholic needs
the problem to go unmentioned, while the family needs to
put on a good front to the outside world. Dysfunctional
family patterns such as this one sacrifice the growth and
well-being of one or more members (often the children) to
reduce the overall level of anxiety in the family. The
cognitive, emotional, and social world of an alcoholic family
is shaped by the avoidance of feelings, thoughts, and
activities that expose their shameful secret to conscious
awareness and the outside world. The development of the
children becomes distorted by the adaptations necessary for
their survival within the pathological system. Unfortunately,
the roles and rules of the family designed to decrease
anxiety maintain the pathologies of some and create new
pathologies in others.
Over time, the dysfunction becomes embedded in the
personality and neural architecture of everyone in the family
and they collude to maintain the system, because they now
all require the status quo in order to feel safe. These
experiences become embedded into their neural
architecture and are carried forward into adult relationships.
As a result, many of us re-create the dysfunction from our
family of origin in our choice of partners and how we shape
the families we build as adults. Each family’s problems are
determined by the multigenerational, unconscious shaping
of both neural structure and behavior. The functioning of
brains and family dynamics reflects how they have been
organized. The dysfunctional brain, like the dysfunctional
family, is shaped by the avoidance of thoughts and feelings,
resulting in the dissociation of neural systems of affect,
cognition, sensation, and behavior, as well as a lack of
human differentiation.
As in other forms of psychotherapy, the goal of systems
therapy is to integrate and balance the various cortical and
subcortical, left and right hemisphere processing networks.
This process requires a decrease in anxiety from high to low
or moderate levels. High levels of affect block thinking,
whereas moderate levels enhance neuroplastic processes,
which in turn support cognition and emotion. In essence,
Bowen is highlighting that the simultaneous activation of
cognition and emotion leads to neural integration. Increased
differentiation of individuals within a family will decrease the
overall rigidity of the system. This process also allows family
members to become more responsive to the needs of others
and less reactive to their own inner conflicts.
The first step in systems therapy is to educate the family
about these concepts and to explore the history of both
sides of the family through the past few generations. In the
context of systems theory and family history, the problems
brought into relief often become more understandable.
Uncovering family secrets and reality testing around the
myths and projections of each family member allow for
cortical processing of primitive and unconscious defenses.
The process of family therapy involves a series of
experiments with increasingly higher levels of
differentiation. Communication skills, assertiveness training,
and exercises in new forms of cooperation can all increase
cortical involvement with previously reflexive or regressive
emotions and behaviors. Often the person with the
symptoms needs to take more responsibility, while
pathological caretakers must learn to accept nurturance.
Each member of the family needs to achieve a balance
between autonomy and interdependence. Ultimately,
psychological, interpersonal, and neural integration are
different levels and manifestations of the same process.

Reichian and Gestalt Therapy

I am not in this world to live up to other people’s

expectations, nor do I feel that the world must live up
to mine.
—Fritz Perls
Wilhelm Reich, one of Freud’s early disciples, felt that
memory and personality are shaped and stored not just in
the brain but throughout the entire body. Because of this,
Reich not only paid careful attention to his clients’
musculature, posture, and breathing, but also encouraged
them to express themselves physically during analysis. By
beating their fists, stomping their feet, and using
exaggerated breathing techniques, they attempted to
release normally inhibited emotions. Reich highlighted the
importance of the therapist’s interpretation of the nonverbal
messages of the body, making them available for conscious
consideration. His theories led to the development of Rolfing
(which uses deep body massage to evoke and process
memories) and Gestalt therapy (which focuses on drawing
attention to nonverbal aspects of communication and
increased self-awareness).
Reich (1945) believed that the major focus of
psychotherapy should be the analysis of the character,
something he saw as similar to Freud’s notion of ego. While
Freud focused on verbal communication, Reich’s major
contribution was to draw more attention to the nonverbal
and emotional aspects of the therapeutic interaction. He
contended that the problems people bring to therapy are
embedded in their character armor, shaped during
development as an adaptation against real or imagined
danger. Character armor forms as a result of
misattunement, neglect, or trauma at the hands of
caretakers. This armor is preverbal and organizes during the
first years of life. According to Reich, early defenses take
shape at all levels of the nervous system, become encoded
in our entire being, and are, like the air we breathe, utterly
invisible to us. The defenses identified by Reich reflect
emotional memories from early preverbal experiences that
are stored in sensory, motor, and emotional networks of
early memory. Because character armor is invisible to its
owner, the therapist’s job is to make the client aware of its
existence, expression, and meaning.
Gestalt therapy is a unique expression of Reichian theory
that is particularly relevant to the notion of neural
integration. Gestalt, a German word meaning “whole,”
reflects the orientation of bringing together an awareness of
conscious and unconscious processes; in other words,
seeing the whole picture. Gestalt therapy’s charismatic
founder, Fritz Perls, used the term safe emergency for the
experience that psychotherapists strive to create in
treatment (Perls, Hefferline, & Goodman, 1951). A safe
emergency is a challenge for growth and integration in the
context of guidance and support. It is also a wonderful way
to describe an important aspect of good parenting.
Therapists create this emergency by exposing clients to
unintegrated and dysregulating thoughts and feelings while
offering them the tools and nurturance with which to
integrate their experiences. Safety is provided in the form of
a supportive and collaborative therapeutic relationship,
often in the context of a group. The emergency is created by
an unmasking of defenses, making unacceptable needs and
emotions conscious, and by bringing into awareness
dissociated elements of consciousness.
The stories a patient tells about his or her problems are
often seen, in the Gestalt context, as self-deceptions. They
serve to keep from awareness those feelings that are
relevant to healing but less acceptable. Unconscious
gestures, facial expressions, and movements are first
brought to awareness, then exaggerated, and finally given a
voice with the purpose of understanding and integrating
experience. The therapist points out contradictions, such as
making positive statements while shaking the head “no,” or
smiling while talking about a painful experience. These
contradictions are explored as indications of internal
conflicts to be brought into awareness. Again, the focus is
on bringing to conscious (cortical) awareness the automatic,
nonverbal, and unconscious processes primarily organized
in right hemisphere and subcortical neural networks.
Gestalt therapy emphasizes the identification and
exploration of projection, identifying it as an avenue for
discovering aspects of the self that have been difficult or
impossible to accept. In the popular “empty chair”
technique, patients alternately play the role of different
parts of themselves to fully articulate the different sides of
inner conflicts. The Gestalt therapist believes that
maximizing awareness of all aspects of the self—including
cognition, emotion, behavior, and sensation—will result in
increased maturation and psychological health. This process
depends on the integration of the neural networks
responsible for each of these functions.

Common Factors

My work as a psychoanalyst is to help patients

recover their lost wholeness and to strengthen the
psyche so it can resist future dismemberment.
—C. G. Jung

In reviewing these different psychotherapeutic modalities, a

number of principles emerge that unify the various
therapeutic schools. The first is that psychotherapy values
openness, honesty, and trust. Each form of psychotherapy
creates an individualized experience designed to examine
conscious and unconscious beliefs and assumptions, expand
awareness and reality testing, and encourage the
confrontation of anxiety-provoking experiences. Each
perspective explores behavior, emotion, sensation, and
cognition in an attempt to increase awareness of previously
unconscious or distorted material. The primary focus of
psychotherapy appears to be the integration of affect, in all
its forms, with conscious awareness, and cognition.
 Intellectual understanding of a psychological problem in
the absence of increased integration with emotion,
sensation, and behavior does not result in change. All forms
of treatment recognize the need for stress, from the subtle
disruption of defenses created by the compassion of Carl
Rogers to the exposure to feared stimuli in exposure
therapies. There is a recognition that the evocation of
emotion coupled with conscious awareness is most likely to
result in symptom reduction and personal growth. Whether
it is called symptom relief, differentiation, ego strength, or
awareness, all forms of therapy are targeting dissociated
neural networks for integration.
When theories of neuroscience and psychotherapy are
considered side by side, a number of working hypotheses
emerge. First, given that the human brain is a social organ,
safe and supportive relationships are the optimal
environment for social and emotional learning. Empathic
attunement with the therapist provides the context of
nurturance in which growth and development occur. By
activating processes involved in secure attachment,
empathic attunement likely creates an optimal biochemical
environment for neural plasticity.
Second, we appear to experience optimal development
and integration in the context of a mild to moderate level of
arousal or what we might call optimal stress. Suboptimal
affect regulation during development can result in
symptoms, maladaptive defenses, and psychopathology.
Optimal stress will create the most favorable neurobiological
environment for neural plasticity and integration. Although
stress appears important as part of the activation of circuits
involved with emotion, states of mild to moderate arousal
seem ideal for consolidation and integration. In states of
high arousal, sympathetic activation inhibits optimal cortical
processing and disrupts integration functions. The ebb and
flow of emotion over the course of therapy reflects the
underlying neural rhythms of growth and change.
 Psychodynamic therapies alternate confrontations and
interpretations with a supportive and soothing interpersonal
environment (Weiner, 1998). The systematic desensitization
of cognitive-behavioral therapy pairs exposure to feared
stimuli with psychoeducation and relaxation training in the
presence of a coach and ally (Wolpe, 1958). Bowen’s family
systems approach focuses on pairing anxiety reduction with
experiments in increasing levels of independent and
differentiated behavior (Bowen, 1978). All forms of
successful therapy strive to create safe emergencies in one
form or another.
A third hypothesis is that the involvement of affect and
cognition appears necessary in the therapeutic process in
order to create the context for integration of neural circuits
with a high vulnerability to dissociation. It has been said
that, in psychotherapy, “understanding is the booby prize.”
It is a hollow victory to end up with a psychological
explanation for problems that remain unchanged. On the
other hand, catharsis without cognition does not result in
integration either. The ability to tolerate and regulate affect
creates the necessary condition for the brain’s continued
growth throughout life. Increased integration parallels an
increased ability to experience and tolerate thoughts and
emotions previously inhibited, dissociated, or defended
against. Affect regulation may be the most important result
of the psychotherapeutic process across orientations,
because it allows for a reconnection with the naturally
occurring salubrious experiences in life.
Repeated simultaneous activation of networks requiring
integration with one another most likely aids in their
integration. Repetitive play in children and the phrase
“working through” in therapy best reflect this process. This
concept parallels the principle from neuroscience that
“neurons that fire together, wire together” (Hebb, 1949;
Shatz, 1990). The simultaneous activation of neural circuits
allows them to stimulate the development of connections
within association areas to coordinate and integrate their
functioning.
Fourth, the co-construction of narratives between parent
and child or therapist and client provides a broad matrix
supporting the integration of multiple neural networks.
Autobiographical memory creates stories of the self capable
of supporting affect regulation in the present and the
maintenance of homeostatic functions into the future.
Memory, in this form, may maximize neural network
integration as it organizes vast amounts of information
across multiple processing tracks. Thus, language is an
important tool in both neurological and psychological
development.

Sam and Jessica

The deepest principle in human nature is the craving

to be appreciated.
—William James

Being human mean communicating with others. Humans

have many channels of communication, including touch, eye
contact, tone of voice, and words. Through our interactions
we have the power to impact one another at every level.
One of my most powerful experiences of the truth of this
fact did not take place in a seminar or consulting room, but
rather at the home of a friend. I had volunteered to watch
his two young children for a few hours while he ran some
errands. I had known Jessica and Sam, 4 and 6 years old, all
their lives. I was someone on an outer ring of their universe,
an attractive combination of familiar and new, and
completely unprepared for what was about to happen. The
minute their father left, they shifted from low to medium to
high gear and I found myself in the midst of a frenzy of
excitement.
 Toys began flying out of closets and storage containers;
games were begun and tossed aside; videos were started,
stopped, and replaced—a succession of Indian princes,
mermaids, lion kings, ladies, and tramps. After what felt like
hours, I glanced at my watch to find only 15 minutes had
passed! Four more hours at this pace? I wasn’t sure I could
survive. I kept trying to refocus Sam and Jessica’s activity,
to no avail. At one point, as we dashed from bedroom to den
to living room, I sank to the floor in the hall, and propped
myself up against the wall. When they realized that I wasn’t
right behind them, they ran back to find me.
They stood panting, one on either side of me, wondering
what new game I had concocted. My suggestion that we sit
and talk for awhile passed unnoticed. After a few seconds,
Sam looked at his sister and yelled, “Show Lou how you
burp your dolly!” Both let out a scream and Jessica soon
returned with an adorable squishy doll. As I reached for the
doll to hold and admire it, Jessica threw the doll on the floor
face first and drove her fists into its back. As Jessica and
Sam took turns crushing the doll into the carpet, I watched
in horror, completely identifying with the doll. I had to hold
back my urge to save the poor thing from her vicious
attackers.
I quickly reminded myself that I was feeling sorry for a
ball of cotton and that I should turn my attention back to the
children. I also realized that rescuing the doll would be
scolding Sam and Jessica for their behavior, which I did not
want to do. I struggled to make sense of what was
happening and asked myself if there might be some
symbolic message in the way they were treating this doll.
Jessica and Sam had experienced a great deal of stress in
their brief lives in the forms of severe physical illness,
surgery, drug addiction in the family, and an understandably
overwhelmed support system. The frantic activity I was
witnessing may have reflected the accumulated anxiety
from all they had gone through, mixed with normal
childhood exuberance. But how might knowing this be
helpful to these two beautiful children?
As I reflected on these things I was hit by the notion that
perhaps the doll represented both Sam and Jessica. This doll
needed to be burped. It needed the help of an adult to
alleviate its discomfort and regain a sense of comfort and
equilibrium. Perhaps Sam and Jessica were showing me that
when they needed to be comforted, they were met with
more pain, or, at the very least, insufficient understanding
and warmth. Might their behavior be a message? “Please,
we need nurturance and healing!” Their world seemed
chaotic and unsafe, a whirlwind; these were the same
feelings they had created within me during the last half
hour. Was their behavior a form of communication?
They had each taken a number of turns “burping” the
doll and I suspected that their attention would soon turn to
me. What to do or say? I didn’t want to burp the baby their
way, and my thoughts about what was happening would be
meaningless. I could feel my anxiety growing when finally,
they both turned to me and cried in unison: “Your turn!” I
hesitated. The chant of “Burp the baby, burp the baby”
began to rise. I looked at both of them and said, “I know
another way to burp a baby. Here’s how my mom burped
me.” A cheer went up. I suspect they assumed that I was
going to set the doll on fire or put it in the microwave.
I gently picked up the doll and brought it to my left
shoulder. Rubbing its back in a circular motion using my
right hand, looking down at it with tenderness, I quietly said,
“This will make you feel better, little one.” A silence fell over
the hallway. I looked up to find Jessica and Sam transfixed,
as if hypnotized. Their eyes followed the slow circles of my
hand, heads tilted like puppies. Their bodies relaxed, their
hands limp at their sides, calm for the first time.
After following the movement of my hand for about 30
seconds, Jessica looked up at me and softly asked, “Can I
have a turn?” “Of course you can,” I told her. At first I
thought she meant that she wanted a turn burping the baby.
But then carefully, almost respectfully, she took the doll
from me and placed it on the floor with its back against the
wall. She stepped over to me, climbed over my crossed legs
and put her head on my shoulder where the doll’s head had
been. She turned to me and almost inaudibly said, “I’m
ready now.” As I rubbed Jessica’s back, I felt her growing
more and more limp as she melted into my shoulder and
chest. I half expected Sam to tear her off, climb on himself,
and turn it into a wrestling match. When I looked over to
him, I could see that he was in the same posture and state
of mind he had been in watching me burp the doll. He
eventually looked up at me and asked, “Can I have a turn?”
Before I could answer, Jessica lifted her head slightly and
told him, “In a minute.”
After a while, she gave up her spot on my shoulder and
Sam had his turn being “burped.” It felt wonderful to hold
them in this way and give them something they seemed to
need so badly. After a few turns for each of them, we went
into the den, curled up on the sofa, one of them under each
of my arms, and watched a movie. Actually, I watched the
movie—they dozed off after only a few minutes. While my
eyes followed the frenetic animation on the screen, my
breathing paced theirs and I shared the peace they seemed
to be feeling.
I marveled at how they managed to communicate their
pain and confusion by creating these same feelings in me.
Emotion is truly contagious and a powerful source of human
connection. By having them set the initial pace of our play, I
told them I respected their way of coping. Through the use
of the doll, they communicated that when they needed
soothing their anxiety was often met with more of the same.
When I burped their doll in a caring and loving way, I
showed them that I was capable of soothing them if they
were feeling bad. By asking me to burp them, they told me I
was trusted. In falling asleep, they said, “We feel safe and
we know you will watch over us while we rest.” While none
of this was spoken, the communication was clear.
Our interactions with the doll changed Sam and Jessica’s
state of mind and body as well as my own. I believe that it
not only impacted their attitudes and behaviors that
afternoon, but may have also changed their brains in some
small but perhaps permanent way. I could see this reflected
in their faces and hear it in the tone of their voices;
something fundamental had changed that affected their
entire beings. I provided them with a metaphor through
which they could reorganize their experience, have their
needs met, and regulate their emotions. Together, the three
of us co-constructed a new narrative for them to use as a
way of soothing themselves and each other.
Were this process to be repeated enough times, their
brains could reorganize around this metaphor of nurturance
and holding and enhance communication between networks
of cognitive and emotional processing. Perhaps Sam and
Jessica could internalize a model of self-holding and
nurturance that would help them navigate future
challenges. This kind of interaction is at the heart of all
forms of psychotherapy, regardless of philosophy or
technique. All forms of therapy have their own versions of
integrative metaphors, serving to reorganize neural
networks and alter human experience, hopefully, for the
better.

Summary
In this chapter we have discussed some of the basic
principles connecting the historical and conceptual
connections between psychotherapy and neuroscience. Four
common factors related to the nature of social relationships,
optimal stress, the activation of affect and cognition, and
the co-construction of narratives emerge from the review. In
the chapters to come, we will explore the components and
organizing principles of the nervous system. These basic
concepts will help us understand the neural mechanisms of
the building and rebuilding of the brain.
Part II.

How the Brain Works: The Legacy of Evolution

Chapter 4

The Human Nervous System: From Neurons to

Neural Networks

All functions of mind reflect functions of brain.

—Eric Kandel

Studying the human brain is a daunting task. In fact, the

human brain is so vastly complex that it would take tens of
thousands of pages to do justice to what is known about its
structure and function. But how much do we really need to
know about the brain to help us in our work as therapists?
My belief is that a basic understanding of the nervous
system, without getting lost in the details, would be very
helpful. With this as our goal, we will move through a
thumbnail sketch of the basic structures, functions, and
development of the nervous system. Keep in mind that this
is a skewed look at the human nervous system biased
toward those structures, processes, and theories that will be
relevant to the chapters to come.

Neurons

It is impossible, in principle, to explain any pattern by

invoking a single quantity.
—Gregory Bateson

The basic unit of the nervous system is the neuron, which

receives and transmits signals via chemical transmission
and electrical impulses. There are an estimated 100 billion
neurons in the brain, with between 10 and 100,000 synaptic
connections each, creating limitless networking possibilities
(Nolte, 2008; Post & Weiss, 1997). Neurons have fibers
called axons covered with myelin, an insulator that
enhances the efficiency of communication. Because neurons
myelinate as they develop, one way of measuring the
maturity of a neural network is to measure its degree of
myelinization. Multiple sclerosis—a disease that breaks
down myelin—results in a decrease in the efficiency of
neural communication, negatively impacting cognition,
affect, and movement (Hurley, Taber, Zhang, & Hayman,
1999). The white matter of the brain is white because
myelin is white (or at least light in color). Gray matter
consists primarily of neural cell bodies.
When a neuron fires, information is carried via an
electrical charge that travels down the length of its axon.
Neurons communicate with one another across synapses
(the spaces between neurons) via chemical messengers
called neurotransmitters. The combination of these two
complementary processes creates the brain’s
electrochemical system. Many neurons develop elaborate
branches, called dendrites, which form synaptic connections
with thousands of dendrites from other neurons. The
relationships formed among these dendrites organize the
complex networking of the nervous system.

Glia

Complex, statistically improbable things are by their

nature more difficult to explain than simple,
statistically probable things.
—Richard Dawkins
Although the focus of neuroscience research is usually on
neurons, they make up only half the volume of the cerebral
cortex. The other half of our brain is made up of
approximately one trillion cells known as glia. One reason
we know so much more about neurons is that they are
approximately 10 times larger than glial cells. It has long
been known that glia play an important supportive role in
the construction, organization, and maintenance of neural
systems. More recently, it has become apparent that they
are also involved in neural network communication and
plasticity (Allen & Barres, 2005; Pfrieger & Barres, 1996;
Sontheimer, 1995; Vernadakis, 1996). Neural plasticity
refers to the ability of neurons to change the way they are
shaped and relate to one another as the brain adapts to the
environment through time.
Astrocytes, the most abundant kind of glia, have been
shown to participate in the regulation of synaptic
transmission and to be involved in the coordination and
synchronization of synaptic activity (Fellin, Pascual, &
Haydon, 2006; Newman, 1982). There now appears to be
glial as well as neural transmission. There is also the distinct
possibility that astrocytes both shape and modulate
synapses (Halassa, Fellin, & Hayden, 2007). Through
evolution, the ratio of glial cells to neurons has steadily
increased, leading some to believe that our expanding
cognitive sophistication is, in part, related to the
participation of astrocytes in information processing
(Nedergaard, Ransom, & Goldman, 2003; Oberheim, Wang,
Goldman, & Nedergaard, 2006). We will revisit this in a later
chapter when we discuss Einstein’s glial cells and his
exceptional imaginal abilities.

Neurogenesis
 What we teach today is part biology and part history…
but we don’t always know where one ends and the
other begins.
—J. T. Bonner

Neurogenesis, the birth of new neurons via cell division,

occurs in the lower regions of the ventricles, the fluid-filled
cavities within our brains. Some fish and amphibians, which
demonstrate ongoing neurogenesis, possess nervous
systems that continue to grow in size throughout life (Fine,
1989). During evolution, it appears that primates may have
traded much of their capacity for neurogenesis to continue
building existing neural networks in order to retain past
learning and develop expert knowledge. In other words, if
instead of being replaced, neurons are retained and
continually modified through the branching of their
dendrites in reaction to new experience, more refined
learning may result (Purves & Voyvodic, 1987). Neurons do
not appear to have a life span, but die off either as a
function of normal apoptosis or because their biochemical
environment becomes inhospitable. High levels of cortisol, a
lack of blood flow, or the buildup of harmful free radicals can
all lead to neuronal death.
The traditional wisdom concerning neurogenesis in
vertebrates, and especially primates, has been that new
neurons are no longer created after early development
(Michel & Moore, 1995; Rakic, 1985). Despite considerable
evidence to the contrary, this dogma held sway through
most of the 20th century. However, research continues to
demonstrate that new neurons are formed in the brains of
adult birds (Nottebohm, 1981), tree shrews (Gould et al.,
1997), primates (Gould, Reeves, Fallah, et al., 1999), and
humans (Gould, Reeves, Graziano, et al., 1999). Further,
neurogenesis is regulated by environmental factors and
experiences such as stress and social interactions (Fowler,
Liu, Ouimet, & Wang, 2002).
 Humans have maintained the ability to create neurons in
areas involved with new learning, such as the hippocampus,
the amygdala, and the cerebral cortex (Eriksson et al.,
1998; Gould, 2007; Gross, 2000). The importance of these
discoveries and the abandonment of the old dogma cannot
be underestimated. Nobel-prize-winning neuroscientist Eric
Kandel referred to Nottebohm’s discovery of seasonal
neurogenesis in birds as having resulted in one of the great
paradigm shifts in modern biology (Specter, 2001).

Neural Systems

I believe in God, only I spell it Nature.

—Frank Lloyd Wright

As the brain develops and matures, neurons organize in

more and more complex neural networks tailored to carry
out the numerous functions of the nervous system. The two
most basic divisions of the nervous system are the central
nervous system (CNS) and the peripheral nervous system
(PNS). The CNS includes the brain and spinal cord, whereas
the PNS is comprised of the autonomic nervous system and
the somatic nervous system. The autonomic and somatic
nervous systems are involved in the communication
between the CNS and the sense organs, glands, and the
body (including the heart, intestines, and lungs).
The autonomic nervous system has two branches, called
the sympathetic and parasympathetic nervous systems. The
sympathetic system controls the activation of the nervous
system in response to a threat or other form of motivation.
The parasympathetic system balances the sympathetic
system by fostering conservation of bodily energy,
immunological functions, and repair of damaged systems. A
third system referred to as the smart vagus operates in
parallel to the parasympathetic branch of the autonomic
nervous system and is dedicated to fine-tuning bodily
reactions, especially in social situations (Porges, 2007).
These three systems will be of particular interest in later
chapters, when we discuss attachment and the effects of
stress and trauma.
Although MacLean’s formulation of the triune brain is
seen as too simplistic by most neuroscientists, many still
recognize the tripartite division of the brain into the cerebral
cortex, the limbic system, and the brainstem. Each layer is
thought of as having different responsibilities. The
brainstem—the inner core of the brain—oversees the body’s
internal milieu by regulating temperature, heart rate, and
basic reflexes such as blood flow and respiration. The
structure and functions of the brainstem were shaped
during our genetic history and are fully formed and
functional at birth. The reflexes we see in the newborn who
grasps her mother, suckles her breast, and knows to hold
her breath when put under water are genetic memories
retained from our tree-dwelling ancestors.
The outer layer of the brain, the cerebral cortex, is first
organized by, and then comes to organize, our experiences
and how we interact with the world. As we grow, the cortex
allows us to form ideas and mental representations of
ourselves, other people, and the environment. Distinct from
the brainstem, the cortex is experience dependent, which
means that it is shaped through countless interactions with
our social and physical worlds. In this way we grow to adapt
to the particular niche into which we are born.
The two halves of the cerebral cortex have gradually
differentiated during primate evolution to the point where
each has developed areas of specialization, referred to as
lateral dominance or specialization. Language is the best-
understood example of lateral specialization. The two
cerebral hemispheres communicate with each other
primarily via the corpus callosum, which consists of long
neural fibers that connect the two. Although the corpus
callosum is the largest and most efficient mode of
communication between the hemispheres in adults, there
are a number of smaller cortical and subcortical
interconnections between the two halves of the brain (Myers
& Sperry, 1985; Sergent, 1986, 1990).
The cortex has been subdivided by neuroanatomists into
four lobes: frontal, temporal, parietal, and occipital (Figure
4.1). Each is represented on both sides of the brain and
specializes in certain functions: the occipital cortex
comprises the areas for visual processing; the temporal
cortex for auditory processing, receptive language, and
memory functions; the parietal cortex for linking the senses
with motor abilities and the creation of the experience of a
sense of our body in space; and the frontal cortex for motor
behavior, expressive language, executive functioning,
abstract reasoning, and directed attention. The term
prefrontal cortex is often used to refer to the foremost
portion of the frontal lobe. Two additional cortical lobes, the
cingulate and insula cortices, are gaining increasing
recognition as distinct and important areas of the cortical-
subcortical interface. They are involved in the integration of
inner and outer experience, linking the rest of the cortex
with somatic and emotional experience.
 
Between the brainstem and the cortex lies a region
referred to as the limbic system, which is involved with
learning, motivation, memory, and emotion. Because this
book focuses on development and psychotherapy, you will
notice repeated references to two limbic structures. The first
is the amygdala, a key component in neural networks
involved in attachment as well as the appraisal and
expression of emotion throughout life (Cheng, Knight, Smith,
& Helmstetter, 2006; Phelps, 2006; Strange & Dolan, 2004).
The other is the hippocampus, which organizes explicit
memory and the contextual modulation of emotion in
collaboration with the cerebral cortex (Ji & Maren, 2007).

Neurotransmitters and Neuromodulators

Brains exist because the distribution of resources

necessary for survival and the hazards that threaten
survival vary in space and time.
—John Allman

Recall that, within the nervous system, neurons

communicate with each other via chemical messengers
called neurotransmitters. Different neural networks tend to
utilize different sets of neurotransmitters, which is why
certain psychotropic medications impact different
symptoms. Chemicals that serve as neurotransmitters
include monoamines, neuropeptides, and amino acids.
Neuromodulators (e.g., the hormones testosterone,
estrogen, cortisol, and other steroids) regulate the effects of
the neurotransmitters on receptor neurons. Amino acids are
the simplest and most prevalent neuromodulators.
Glutamate is the major excitatory amino acid in the brain
and central to neural plasticity and new learning (Cowan &
Kandel, 2001; Malenka & Siegelbaum, 2001). Interactions
with one of its primary receptors, N-methyl-D-aspartate
(NMDA), regulates long-term potentiation and long-term
depression, thereby shaping the relationship between
neurons (Liu et al., 2004; Massey et al., 2004; Zhao et al.,
2005).
The monoamines—including dopamine, norepinephrine,
and serotonin—play a major role in the regulation of
cognitive and emotional processing (Ansorge, Zhou, Lira,
Hen, & Gingrich, 2004). All three are produced in different
areas of the brainstem and are carried upward via
ascending neural networks to the cortex. Dopamine,
produced in the substantia nigra and other areas of the
brainstem, is a key neurotransmitter in motor activity and
reward reinforcement. Too much dopamine can result in
mood changes, increased motor behavior, and disturbed
frontal lobe functioning, which, in turn, can cause
depression, memory impairment, and apathy. Parkinson’s
disease results from damage to the substantia nigra and a
consequent loss of dopamine. Many believe that
schizophrenia is caused by too much dopamine, which
overloads sensory processing capabilities and creates
hallucinations and delusions.
Norepinephrine, produced in the locus coeruleus and
other brain regions, is a key component of the emergency
system of the brain and is especially relevant for
understanding stress and trauma. High levels result in
anxiety, vigilance, symptoms of panic, and a fight-flight
response. Norepinephrine also serves to enhance memory
for stressful and traumatic events. Serotonin, generated in
the raphe nucleus, is distributed widely throughout the brain
and plays a role in arousal, the sleep–wake cycle, and the
mediation of mood and emotion (Fisher et al., 2006).
Popular antidepressant medications such as Prozac and Paxil
cause higher levels of available serotonin in the synapses
and higher levels of neurogenesis (Encinas, Vaahtokari, &
Enikolopov, 2006).
The group of neurotransmitters known as neuropeptides
includes endorphins, enkephalins, oxytocin, vasopressin,
and neuropeptide-Y. These compounds work together with
neuromodulators to regulate pain, pleasure, and reward
systems. The endorphins tend to modulate the activity of
monoamines, making them highly relevant for
understanding psychiatric illnesses. Endogenous endorphins
(endorphins produced by the body) serve as an analgesic in
states of physical pain. They are also involved with
dissociation and self-abusive behavior, as we will discuss in
a later chapter on trauma. The relationship between the
monoamines and neuropeptides is vitally important to the
growth and organization of the brain.

Glucocorticoids/Cortisol

We’re lousy at recognizing when our normal coping

mechanisms aren’t working. Our response is usually
to do it five times more, instead of thinking; maybe
it’s time to try something new.
—Robert Sapolsky

Cortisol, the most important glucocorticoid, is often referred

to as the “stress hormone.” It is produced in the adrenal
glands in response to a wide variety of everyday challenges.
The term glucocorticoid comes from the fact that it was first
recognized for its role in glucose metabolism. With further
study, however, many more functions of cortisol were
uncovered. Glucocorticoid receptors (GRs) are found in
almost all of the tissues of our bodies. At normal levels and
over short periods, cortisol enhances memory, mobilizes
energy, and helps to restore homeostasis after stressful
situations. Glucocorticoids stimulate gluconeogenesis and
the breakdown of lipids and proteins to make energy
available to us for emergencies. If we have to fight or flee,
we are going to need energy.
Cortisol evolved to be useful for periods of brief stress
which, when resolved, allow GRs to signal the adrenal
glands to shut down production. Prolonged cortisol release,
on the other hand, can weaken the immune system by
preventing T-Cell proliferation. In fact, the synthetic form of
cortisol is called hydrocortisone and is used to treat
inflammation and allergies by inhibiting natural
immunological responses. Sustained high levels of cortisol
disrupt protein synthesis, halt neural growth, and disturb
the sodium-potassium balance to the point of neural death.
Early and prolonged stress has been correlated with
memory deficits, problems with affect regulation, and
reduction of volume in brain regions including the
hippocampus and amygdala (Buchanan, Tranel, & Adolphs,
2006).
It is believed that sustained high levels of glucocorticoids
early in life can have a negative impact on brain
development and make a child more vulnerable to
subsequent stress. It has been shown that maternal
behavior in rats stimulates the development of GRs in the
brains of their pups. Greater density of GRs in the brain
results in enhanced feedback to the adrenal glands, which
serves to shut down cortisol production. This is one of the
underlying neurobiological correlates associating maternal
attention with resilience and positive coping later in life. The
production and availability of these neurochemicals shape
all of our experience, from bonding and affect regulation to
cognitive processing and our sense of well-being. Regulation
of these neurochemicals to control psychiatric
symptomatology is the focus of the field of
psychopharmacology (Gitlin, 2007; Stahl, 2008).

Genetics and Epigenetics

I am convinced that it will not be long before the

whole world acknowledges the results of my work.
—Gregor Mendel

At the forefront of the science of genetics is Abbot Gregor

Mendel, who, in the garden of his ancient abbey, discovered
many of the principles of inheritance that still hold true. It
turns out that his discoveries with pea plants apply to
animals and humans because the underlying mechanisms of
heredity are similar for all complex life forms. As you
probably remember, his findings included dominant and
recessive genes and the principles of segregation and
independent assortment.
With the benefits of modern technology, Mendel’s
observations of the natural world were later understood to
be the effects of template genetics, or the way in which
genes and chromosomes combine to pass along traits from
one generation to the next. We now know that our genetic
information is coded in four amino acid bases (adenine,
thymine, guanine, and cytosine) that flow from DNA to
messenger RNA (mRNA) to protein. Although this
understanding was a huge leap forward in our knowledge of
the underlying processes of genetic transmission, it
accounts for only about 2% of genetic expression. The
scientific term for the other 98% of genetic material was
“junk,” once thought to be accumulated debris of natural
selection. It turns out, however, that some of this junk plays
an important role in guiding introns and exons, which help
determine whether specific elements of the genetic code
get expressed or lie dormant.
Biologist C. H. Waddington coined the term epigenetics
by combining the words genetics and epi, Greek for over or
above. Epigenesis describes the transformation of cells from
their original undifferentiated state during embryonic
development into a specific type of cell. Thus, epigenetics is
the study of how our genotype is orchestrated into our
phenotype. Understanding the elements of epigenetics may
help us grasp why identical twins with the same genes may
differ in phenotype, that is, why one becomes schizophrenic
and the other does not.
This gets us back to the old nature-nurture debate and
the question: What do we inherit, and what do we learn
from experience? Our best guess is that almost everything
involves an interaction between the two. While we inherit a
template of genetic material (genotype), what gets
expressed (phenotype) is guided by noncoded genetic
information that is experience dependent. Experience can
include anything from toxic exposure to a good education;
high levels of sustained stress to a warm and loving
environment; feast to famine. Thus, many more genes are
involved with the regulation of what is expressed than with
the direct synthesis of protein. So while template genetics
may guide the early formation of the brain during gestation,
the regulation of gene expression directs its long-term
development in reaction to ongoing adaptation to the social
and physical worlds. Epigenetics is a term used to describe
this change in the phenotypic expression of genes in the
absence of a change in the DNA template.
An example of this process of particular relevance to
emotional development and psychotherapy is the impact of
early stress on the adult brain. Meaney and his colleagues
(1991) believe that early environmental programming of
neural systems has a profound and long-lasting effect on
the hypothalamic-pituitary-adrenal (HPA) axis, which
regulates an individual’s responsivity to stress. Research
with rats has demonstrated that the stress of early maternal
deprivation downregulates the degree of neurogenesis and
the response to stress during adulthood (Mirescu, Peters, &
Gould, 2004; Karten, Olariu, & Cameron, 2005). Just as
important for us, these processes are reversible later in life.
As therapists, we attempt to reprogram these neural
systems via a supportive relationship and the techniques we
bring to bear during treatment. In other words, we are using
epigenetics to change the brain in ways that enhance
mental and physical well-being.

Views of the Brain

When considering the abilities and complexities of the

brain, one is struck by the incredible efficiency and
splendor expressed in gray and white matter.
—Julian Paul Keenan
Throughout most of the history of neurology, the human
brain was only examined after injury or death. The location
of brain damage during autopsy was linked to the nature
and severity of the patient’s clinical symptoms during life.
Brain development was studied by examining and
comparing the brains of humans and animals at different
ages. These brains were compared for size; the number of
neurons, synapses, and dendrites; the degree of
myelinization; and other aspects of neural maturation.
Newer techniques allow us to examine brain structure in
living subjects. Through the use of computerized
tomography (CT) and magnetic resonance imaging (MRI),
we are able to see two-and three-dimensional pictures of
the living brain. Both of these techniques provide a series of
cross-sectional images of the brain through its many layers.
CT scans do this via multiple X-rays. MRI scans utilize radio
waves and a magnetic field to study the magnetic
resonance of hydrogen molecules in the water present in
different brain structures. In determining brain–behavior
relationships, these measures need to be evaluated on the
basis of whether they are causes or correlates of the
disorder being studied (Davidson, 1999). In their present
practical applications, radiologists learn to read these
images for the presence and locations of tumors or lesions
in order to assist surgeons in their work. These scans have
become an indispensable tool in neurology.
The functioning of the brain can also be measured in
many ways. Clinical and mental status exams, tests of
strength and reflexes, and neuropsychological assessment
all require a patient to perform physical or mental
operations that are tied to known neurobiological systems.
These clinical tests are supplemented by a number of
laboratory tests that measure different aspects of brain
functioning. The electroencephalograph (EEG) measures
patterns of electrical activity throughout the cortex. There
are characteristic brainwave patterns in different states of
arousal and stages of sleep. Epilepsy or the presence of
tumors will demonstrate characteristic alterations of normal
electrical functioning, allowing EEGs to be used as
diagnostic tools. EEGs can also be used to measure brain
development, because neural network organization is
characterized by the replacement of local erratic discharges
with more widespread and constant wave patterns (Barry et
al., 2004; Field & Diego, 2008b; Forbes et al., 2008).
The most exciting new tools in neuroscience are the
various brainscanning techniques providing us with a
window to the brain in action. Positron emission
tomography, single photon emission tomography, and
functional magnetic resonance imaging measure changes in
blood flow, oxygen metabolism, and glucose utilization,
which tell us about the relative activity of different regions
of the brain. Using these techniques, neuroscientists can
now explore complex activation–deactivation patterns of
brain activity in subjects performing a wide range of
cognitive, emotional, and behavioral tasks (Drevets, 1998).
Most of these newer scanning techniques are still somewhat
experimental, and methodological standards regarding their
use and interpretation continue to evolve. These methods,
and those yet to be developed, will vastly enhance our
understanding of the brain. As they grow increasingly more
accurate and specific, so too will our knowledge of neural
network functioning.

Brain Development and Neural Plasticity

Swiftly the brain becomes an enchanted loom, where

millions of flashing shuttles weave a dissolving
pattern—always a meaningful pattern—though never
an abiding one
—Sir Charles Sherrington
Experience sculpts the brain through selective excitation of
neurons and the resultant shaping of neural networks.
Paradoxically, the number of neurons decreases with age
while the size of the brain increases. The surviving neurons
continue to grow from what look like small sprouts into
microscopic oak trees. This process of growth and
connectivity is sometimes referred to as arborization.
In order for a neuron to survive and grow, it must wire
with other neurons in increasingly complex
interconnections. Just as we survive and thrive through our
relationships with others, neurons survive and grow as a
function of how “well connected” they are. Through what
appears to be a competitive process referred to as neural
Darwinism, cells struggle for connectivity with other cells in
the creation of neural networks (Edelman, 1987). Cells
connect and learning occurs through changes of synaptic
strength between neurons in response to stimulation.
Repeated firing of two adjacent neurons results in metabolic
changes in both cells, which provides an increased
efficiency in their joint activation. In this process, called
long-term potentiation (LTP) or Hebbian learning, excitation
between cells is prolonged, allowing them to become
synchronized in their firing patterns and joint effectiveness
(Hebb, 1949). LTP is believed to be a fundamental principle
of neuroplastic learning. Underlying LTP is the constant
reaching out of small portions of the dendrites in an attempt
to connect with adjacent neurons. When these connections
are made, neurons synthesize new protein to build more
permanent bridges between them.
Through LTP, cell assemblies organize into functional
neural networks that are stimulated through trial-and-error
learning. This is only one small piece of a vastly complex set
of interactions involving the connection, timing, and
organization of firing within and between billions of
interconnected neurons in the CNS (Malekna & Siegelbaum,
2001). Early in development, there is an initial
overproduction of neurons that gradually decreases through
the process of pruning, or apoptosis. Neural Darwinism
applies to both the survival of neurons and the synaptic
connections among them. Synapses that are formed may be
subsequently eliminated if they become inactivated or
inefficient (Purves & Lichtman, 1980). In fact, elimination of
synaptic connections in the cortex continues shaping neural
circuitry through adolescence and into adulthood (Cozolino,
2008; Huttenlocher, 1994).
In contrast to the brainstem and limbic system, the
cortex is immature at birth and continues to develop
throughout adulthood. Because of this developmental
timing, brainstem reflexes organize much of the infant’s
early behaviors and the behavior of a newborn is dominated
by subcortical activity. The neonate will orient to the
mother’s smell, seek the nipple, gaze into her eyes, and
grasp her hair. A good example of a brainstem reflex is the
Moro reflex, by which the infant reaches out with open
hands and legs extended, putting the infant into a position
conducive to grasping and holding (Eliot, 1999). The child’s
eyes reflexively orient to the mother’s eyes and face and a
baby’s first smiles are controlled by brainstem reflexes to
attract caretakers. In fact, children born with a genetic
malformation that results in having only a brainstem are still
able to smile (Herschkowitz, Kegan, & Zilles, 1997). These
reflexes enhance physical survival and jump start the
attachment process by connecting parent and child, while
enhancing their bond.
As anyone who has been pregnant can tell you, babies
begin to engage in spontaneous activity of the arms and
hands well before birth. While the baby is practicing using
its arms and legs, parents-to-be grow increasingly excited as
these signs of activity grow in frequency and strength. After
birth, newborns continue to move all parts of their bodies,
allowing them to discover their hands and feet as they pass
in front of their faces. Although these movements may look
random, they are the brain’s best guess at which
movements will eventually be needed. These reflexive
movements jump start the organization of motor networks
to build the skills the child will need later on (Katz & Shatz,
1996).
Through months and years of trial-and-error learning,
these best guesses become shaped into purposeful and
intentional behaviors that are reflected in the organization
of underlying neural networks (Shatz, 1990). As sensory
systems develop, they provide increasingly precise input to
guide neural network formation for more complex patterns
of behavior. As positive and negative values are connected
with certain perceptions and movements—such as the
appearance of the mother and reaching out to her—
emotional networks will integrate with sensory and motor
systems. In the development of these and other systems,
we find the sequential activation of reflexive and
spontaneous processes priming neural development, which
comes to be shaped by ongoing experience.

Cortical Inhibition and Conscious Control

He who conquers others is strong; he who conquers

himself is mighty.
—Lao-Tzu

The gradual attenuation of neonatal reflexes and

spontaneous behavior corresponds with rising levels of
cortical activity and involvement in behavior. As the cortex
develops, vast numbers of top-down neural networks
connect it with subcortical areas. These top-down networks
provide the pathways for inhibiting reflexes and bringing the
body and emotions under increasing cortical control. An
example of this is the development of the fine motor
movements between the thumb and forefinger that are
required to hold a spoon. Primitive grasping reflexes allow
only for the spoon to be held in a tight fist, rendering it
useless as a tool. The developing cortex enables the
grasping reflex to be inhibited, while cortical networks
dedicated to finger sensitivity and hand–eye coordination
mature. Thus, a vital aspect of the development of the
cortex is inhibitory—first of reflexes, later of spontaneous
movements and even later of emotions and inappropriate
social behavior.
Only through repeated trial-and-error learning are early
clumsy movements slowly shaped into functional skills.
Children and their brains intuitively know this and will resist
being held back or helped too much. When we attempt to
help, a child’s impatient protest of “Let me do it!” reflects
instinctual wisdom of the importance of trial-and-error
learning in the growth of neural networks. This makes for
many years of messes and boo-boos. Another good example
of the process of brain maturation is our ability to swim. The
newborn’s brainstem reflex to hold its breath and paddle
when dropped into water is lost (inhibited by higher brain
circuitry) just weeks after birth. The skills involved with
swimming need to be relearned as cortically organized skills
in years to come. Motor networks need to be taught body
movements, as breathing becomes timed and synchronized
with each stroke.
Cortical inhibition and descending control are also central
to affect regulation. The rapidly changing and overwhelming
emotions displayed by very young children reflect this lack
of control. As the middle portions of the frontal cortex
expand and extend their fibers down into the limbic system
and brainstem, children gradually gain increasing capacity
to regulate their emotions and find ways to gain soothing,
first through others, and eventually by themselves. When
these systems are damaged or developmentally delayed,
we witness symptoms related to deficits in attention,
emotional regulation, and impulse control.
 We see the changes in motor control and posture as a
child moves from being able to sit upright without help at
about 6 months, to crawling at about 9 months, and then to
walking without help by about 1 year. At 2 years, a child will
walk up and down stairs; by 3 she can peddle a tricycle. As
these skills are shaped, so too are the brain systems
dedicated to balance, motor control, visual–spatial
coordination, learning, and motivation that control them.
The growth, development, and integration of neural
networks continue to be sculpted by environmental
demands. In turn, neuronal sculpting is reflected in
increasingly complex patterns of behavior and inner
experience.

Sensitive Periods

The principal activities of brains are making changes

in themselves.
—Marvin L. Minsky

The brain continues to grow as long as we continue to learn,

essentially until the day we die. Early brain development is
highlighted by periods of exuberant neural growth and
connectivity called sensitive periods triggered by the
interaction of genes and experience. These sensitive periods
are times of rapid learning during which thousands of
synaptic connections are made each second (Greenough,
1987; ten Cate, 1989). The timing of sensitive periods varies
across neural systems, which is why different abilities
appear at different ages.
The most widely recognized sensitive period is the
development of language. At 24 months, an average child
understands and uses about 50 words; this increases to
1,000 words by 36 months (Dunbar, 1996). The extent of
neural growth and learning during sensitive periods results
in early experience having a disproportionate impact on our
brains, minds, and experiences. As we learn of the brain’s
ability to create new neurons and retain plasticity
throughout life, the importance of sensitive periods takes on
new meaning. The question for therapists is: How amenable
are these established structures to modification? This is a
topic we will come back to again and again in later chapters.
The growth of neurons and the development of
increasingly complex neural networks require large amounts
of energy. Patterns of increasing glucose metabolism during
the first year of life proceed in phylogenic order, meaning
that the development of more primitive brain structures
precedes those which evolve later (Chugani, 1998; Chugani
& Phelps, 1991). Early sensitive periods account for the
higher level of metabolism in the brains of infants compared
to adults. Ever notice how warm a baby’s head is? It has
been estimated that in rats’ brains, 250,000 synaptic
connections are formed every second during the first month
after birth (Schuz, 1978). Just imagine what the number
must be for humans.
Networks dedicated to individual senses develop before
the association areas that connect them to one another
(Chugani, Phelps, & Mazziotta, 1987). The growth and
coordination of the different senses parallel what we also
witness in such behavioral changes as hand–eye
coordination and the ability to inhibit incorrect movements
(Bell & Fox, 1992; Fischer, 1987). As the cerebral cortex
matures, a child at 8 months is able to distinguish faces and
compare them to his or her memory of other faces. It is
around this period that stranger anxiety and separation
anxiety develop. As the brain matures, we witness
increasing cortical activation and the establishment of more
efficient neural circuitry firing in increasingly synchronous
patterns.
Although both the left and right cerebral hemispheres are
developing at very high rates during the early years of life,
the right hemisphere appears to have a relatively higher
rate of activity and growth during the earliest years (Chiron
et al., 1997). During this time, vital learning in the areas of
attachment, emotional regulation, and self-esteem are
organized in neural networks biased toward the right
hemisphere. Somewhere around age 3, this pattern of
asymmetrical growth shifts to the left hemisphere.

Summary
The maturation and sculpting of so much of the cortex after
birth allows for highly specific environmental adaptations.
The caretaker relationship is the primary means by which
physical and cultural environments are translated to infants.
It is within the context of these close relationships that
networks dedicated to feelings of safety and danger,
attachment, and the core sense of self are shaped. The first
few years of life appear to be a particularly sensitive period
for the formation of these networks. It may be precisely
because there is so much neural growth and organization
during sensitive periods that early interpersonal
experiences may be far more influential than are those
occurring later. The fact that they are preconscious and
nonverbal makes them difficult to discover and more
resistant to change. Because these neural networks are
sculpted during early interactions, we emerge into self-
awareness preprogrammed by unconsciously organized
hidden layers of neural processing. The structure of these
neural networks organizes core structures of our experience
of self.
Chapter 5

Multiple Memory Systems in Psychotherapy

To “do memory” is essentially to engage in a cultural

practice.
—Kenneth Gergen

The process of psychotherapy is totally dependent upon

memory. From what we know of clients’ past and current
lives, to their ability to bring the lessons of therapy into
practice, everything depends on their ability to learn and
remember. Yet, despite its central role in our work, the
majority of clinical psychologists, psychiatrists, family
therapists, and social workers receive little or no training in
the hows and whys of memory. In this chapter we explore
various aspects of memory and their role in both mental
illnesses and psychotherapy.
Psychotherapists have traditionally divided memory into
the broad categories of conscious, preconscious, and
unconscious. Conscious memory is expressed in
recollections of the past, the content of previous therapy
sessions, and reports of current day-to-day life. The
preconscious contains memories that are not the focus of
current attention but which can easily be brought into
conscious awareness with a minimum of difficulty.
Unconscious memory unavailable to conscious consideration
can manifest in behaviors, attitudes, and feelings as well as
in more complex forms such as defenses, self-esteem, and
transference. Much of the training of psychodynamic
therapists is the identification and deciphering of
unconscious memory into a form that is accessible to the
patient.
Freud believed that a fundamental goal of therapy is to
make the unconscious conscious. From the perspective of
rebuilding the brain, this goal can be described as
increasing the interconnection and integration of neural
networks dedicated to unconscious and conscious memory.
This process makes understanding the evolution,
development, and functioning of the various systems of
memory crucial to conceptualizing and treating
psychological distress and mental illnesses. It also aids in
explaining to clients some of the paradoxes and confusion
they experience based on the variety of ways their brains
process information.

Resistance to Therapy or Memory Deficit?

Our sense of worth, of well-being, even our sanity

depends upon our remembering. But, alas, our sense
of worth, our well-being, our sanity also depend upon
our forgetting.
—Joyce Appleby

For almost a year, I treated a woman named Sophia who

had experienced repeated traumas and chronic stress
dating back to early childhood. Among the many issues she
brought to treatment were family conflict, early sexual
abuse, and current relationship problems. One of Sophia’s
long-standing complaints was severe memory difficulties,
especially when it came to remembering names, dates, and
appointments. In high school her teachers told her she was
stupid because she was unable to recall what was said in
class from one day to the next. Sophia was so embarrassed
by her inability to remember names that she avoided
parties and all but essential work gatherings. On the other
hand, her memory for emotionally laden experiences was
like a steel trap, continually evoking fear and sadness.
Sophia was convinced that the part of her brain responsible
for remembering shame was very different from the one
that recalled names.
Sophia had gone to many therapists throughout her adult
life, repeatedly missed appointments, and had been told she
was resistant to treatment. Sophia found this very
frustrating but had no explanation of her own. Based on her
history, these therapists assumed that her problems with
memory were caused by denial, avoidance, or repression,
and encouraged her to face her fears. While each therapist
offered their own interpretation of her defensiveness to
treatment, none rang true, and she usually terminated
therapy after just a few sessions. Certain that it was her
fault, Sophia’s treatment failures led her to feel increasingly
hopeless about ever finding the help she needed. The
annoyance and “criticism” she received from therapists also
increased her feelings of shame. Although she feared our
work together would meet the same fate, she was willing to
give therapy one more try.
After learning her history, I shared a bit of neuroscience
to help her better conceptualize her issues with memory. My
mini lecture focused on the destructive role of early and
prolonged stress on the development and well-being of the
hippocampus and associated neural networks responsible
for explicit memory. I suggested that we begin our work by
studying memory together and exploring pragmatic ways to
improve it. Along the way we experimented with the use of
memory aids from the field of cognitive rehabilitation.
Daytimers, watches with alarms, and personal digital
assistants (PDAs) all proved useful. (The development of
smart phones now allows us to carry all of these functions in
one device, a real boon to many patients.)
 For the first 2 months, Sophia and I scheduled telephone
contact every other day for a few minutes. During these
contacts, we exercised her memory, checked on the various
strategies we had set up during our previous session, and
reinforced her successes. Initially, Sophia needed help
learning to remember to use her strategies that helped her
remember. Utilizing her memory aids and checking them on
a regular basis gradually became automatic even if, in the
moment, she would forget why she was checking her book
or calling me.
After 6 weeks, Sophia was consistently able to remember
appointments. This success stimulated confidence in herself
and in therapy. She began to see that her memory problems
in no way meant she was stupid or harbored deep
psychological problems. On the contrary, her self-respect
increased as our discussions helped her to realize how much
she had accomplished in her life despite her traumatic
history and struggles with memory. Once memory-related
issues were no longer an impediment to maintaining
consistent contact, we shifted the focus of treatment to the
impact of her life experiences on her relationships and
career. The initial focus of therapy, using a formulation from
neuroscience and cognitive rehabilitation, turned out to be a
necessary first step in a sustained and successful
therapeutic relationship. From this point, the therapy was
characterized by a more traditional psychodynamic
approach with regular memory checkups and adjustments
to her strategies.
Many psychological disorders manifest a variety of
memory deficits. Any disorder that results in substantial
arousal and triggers the secretion of the stress hormone
cortisol can damage neural networks of explicit memory. In
fact, most psychiatric disorders reveal high rates of cortisol
and smaller hippocampi, both of which are correlated with
memory disturbances. In addition to problems with
remembering, some illnesses serve to distort both learning
and memory. Depression, for example, results in a negative
bias in the recollection and interpretation of past, present,
and future events (Beck, 1976). It also leads us to
selectively scan the environment, which reinforces negative
perceptions. Depression convincingly demonstrates the
influence of emotional states in the organization of
conscious memory, sometimes called state-dependent
memory. Clients report that if they wake up depressed,
everything looks worse than it did the day before, even
though they know, intellectually, that nothing has changed.
The rapid (and unconscious) networks of emotion shape
our understanding of the world microseconds before we
become aware of our perception. Through similar
mechanisms, our past experiences create our expectations
for the future. Implicit, unconscious memories, created in
dysfunctional situations years before, can repeatedly lead
us to re-create unsuccessful but familiar patterns of
thought, emotion, and behavior. Thus, our perception of the
world is a creation based on past experience.

Multiple Memory Systems

Memory…is the diary that we all carry about with us.

—Oscar Wilde

Research and clinical experience support the existence of

multiple memory systems, each with its own domains of
learning, neural architecture, and developmental timetable
(Tulving, 1985). Learning within all systems of memory is
dependent on the process of long-term potentiation in the
Hebbian synapses we have already discussed, as well as the
dendritic remodeling and changes in the relationships
between neurons (Hebb, 1949; Kandel, 1998). The two
broadest categories of memory are explicit and implicit. The
concepts of explicit and implicit memory, although similar in
some ways to Freud’s concept of the conscious and
unconscious, do not directly overlap.
Explicit memory describes conscious learning and
memory, including semantic, sensory, and motor forms.
These memory systems allow us to recite the alphabet,
recognize the smell of coconut, or play tennis. Some of
these memory abilities remain just beneath the level of
consciousness until we turn our attention to them. Implicit
memory is reflected in unconscious patterns of learning
stored in hidden layers of neural processing, largely
inaccessible to conscious awareness. This category extends
from repressed trauma to riding a bicycle, to getting an
uneasy feeling when we smell a food that once made us
sick. Explicit memory is the tip of our experiential iceberg;
implicit memory is the vast structure below the surface.
Many of our daily experiences make it clear that we have
multiple systems of explicit and implicit memory. For
example, moving your fingers over the keypad of an
imaginary phone sometimes helps you recall a phone
number. This process demonstrates that implicit systems of
motor and visual memory can aid in the explicit recall of
numbers. Another example is a phenomenon common
among older adults, in which they have difficulty learning
new information but easily recall stories from their youth.
This may be because the networks involved in the storage
of long-term explicit memory are distributed throughout the
cortex and are more resistant to the effects of aging than
those responsible for short-and medium-term memory
(Schacter, 1996).
Thinking back to the triune brain, each tier is involved
with different aspects of memory functioning. The reptilian
brain contains instinctual memories, the lessons of past
generations (genetic memory) that control reflexes, and
inner bodily functions. The paleomammalian brain (limbic
system) contributes to emotional memory and conditioned
learning—a mixture of primitive impulses and survival
programs sculpted by experiences. These two systems are
nonverbal and comprise aspects of the Freudian
unconscious. The neomammalian brain, although largely
unconscious in its processing, contains networks responsible
for explicit verbal memory biased toward the left
hemisphere.
Because of the order in which they develop, implicit and
explicit memory (detailed in Table 5.1) are referred to as
early and late memory. Systems of implicit memory are
active even before birth, as demonstrated in the newborn’s
instincts to orient to the sound of her mother’s voice (de
Casper & Fifer, 1980). During the first months of life, basic
sensory memories combine together with bodily and
emotional associations (Stern, 1985). These networks allow
for the sight of one’s father to be paired with raised arms, a
smile, and a good feeling. Somatic, sensory, motor, and
emotional experiences help sculpt neural networks during
the first few years into a sense of a physical self.
 
TABLE 5.1 Multiple Memory Systems

A number of the basic distinctions between implicit and

explicit systems of memory
 
IMPLICIT   EXPLICIT
Early Developing   Late Developing
Highly Functional at   Matures later with Hippocampus
Birth and Cortex
Subcortical/Amygdal   Cortical/Hippocampal Bias
a Bias
Nondeclarative   Declarative
Emotional   Organized by Language
Visceral/Sensory-   Visual Images
Motor
 Context Free   Organized within Episodes and
Narratives
Procedural Learning   Conscious Organization of
Experience
Behavior Patterns   Construction of Narrative Self
and Manual

 
The development of conscious memory parallels the
maturation of the hippocampus and higher cortical
structures over the first years of life (Fuster, 1996; Jacobs,
van Praag, & Gage, 2000; LeDoux, 1996; McCarthy, 1995).
Childhood amnesia or the absence of explicit memory from
early life likely results from this maturational delay and
other developmental changes in how our brains process
information. In the absence of explicit memory, however, we
learn how to walk and talk, whether the world is safe or
dangerous, and how to attach to others. These vital early
lessons, stored in networks throughout our brain, lack
source attribution; that is, we do not remember how we
learned them. Although many of us think we have explicit
memories from the first years of life, these are most likely
constructed later and attributed to an earlier time in our life.
Explicit memory can be sensory and linguistic, as we
associate and remember sights, sounds, and smells with
words and organize them in conscious memory. For most of
us, words and visual images are the keys to conscious
memory. Different types of semantic memory include
episodic, narrative, and autobiographical, which can all be
organized sequentially. Autobiographical memory maintains
the perspective of the narrator at the center of the story.
Stories about the self combine episodic, semantic, and
emotional memory with the self-awareness needed for max-
imal neural network integration (Cabeza & St. Jacques,
2007). This form of memory is especially important for the
formation and maintenance of emotional regulation, self-
identity, and the transmission of culture.
Overall, the development of the different systems of
memory reflects the early primacy of implicit memory for
learning in sensory, motor, and emotional networks. These
early-forming neural networks depend on the more primitive
brain structures such as the amygdala, thalamus, and
middle portions of the frontal cortex (Figure 5.1). As the
cortex and the hippocampus continue to develop over the
first few years of life, there is a gradual maturation of the
networks of explicit memory. These systems provide for
conscious, contextualized learning and memory that
becomes more consistent and stable over time.
The various systems of memory are distributed
throughout the brain and where a particular memory is
stored depends on the type of memory and how it is
encoded (McCarthy, 1995). A good example of the
distribution of memory comes from an experiment
measuring cerebral blood flow while subjects were asked to
name pictures of either animals or hand tools (Martin,
Wiggs, Ungerleider, & Haxby, 1996). Naming both animals
and tools resulted in increased activity in the temporal lobes
and Broca’s area. This makes sense, because the temporal
lobes are known to be important for the organization of
memory whereas Broca’s area organizes verbal expression.
More specifically, naming tools activated areas in the left
motor cortex involved in the hand movements that would be
used to control them (Martin et al., 1996). This suggests
that part of our “tool memory” is stored in neural networks
that utilize them. While there is overlap of activation during
picture naming, the nature of the visual image triggers brain
areas relevant to what is depicted. Thus, memory is a form
of internal enactment of whatever is being recalled.
The portion of the visual system activated by pictures of
animals is an area involved with very early stages of visual
processing. This may be a reflection of how evolution has
shaped the primitive areas of our visual brains to recognize
and react quickly to threats from possible predators
(animals chosen for this study happened to be a bear and
an ape, both evolutionarily relevant based on their potential
danger to us). Research has consistently demonstrated that
the occipital lobe becomes activated when something is
seen and, later, imagined. In the case of the imagined
memory, the prefrontal area also becomes activated,
reflecting its role in processing the instructions, staying on
task, and accessing imagination. How neural networks in the
prefrontal cortex know how to do this is as yet unknown
(Ungerleider, 1995).
Although these studies focus primarily on cortical
activity, psychotherapy often involves the retrieval of
subcortical emotional memories. Emotional memories rely
on subcortical structures such as the amygdala and
hippocampus: both central to upcoming discussions of
psychopathology and the impact of childhood experiences,
stress, and trauma on adult functioning.

Amygdaloid Memory Networks

Nothing fixes a thing so intensely in memory as the

wish to forget it.
—Michel de Montaigne

The amygdala, the central hub of fear processing, is located

within the limbic system and beneath the temporal lobes on
each side of the brain. It is fully developed by the eighth
month of gestation, so that even before birth, we are
capable of experiencing intense physiological states of fear.
During the first few years of life we are dependent on
caretakers for external modulation of the amygdala until we
are able to regulate it ourselves. In some ways the
amygdala is our first cortex, playing a significant role in the
networks involved in emotional learning (Brodal, 1992).
Portions of the amygdala (the basolateral areas) have
evolved in tandem with the expansion of the cerebral cortex
in humans along with our abilities to assess the
environment (Stephan & Andy, 1977).
The amygdala’s neural connectivity supports its
participation in the integration of the different senses within
humans, with a special emphasis on vision (van Hoesen,
1981). It functions as an organ of appraisal for danger,
safety, and familiarity in approach-avoidance situations
(Berntson et al., 2007; Elliott, Agnew, & Deakin, 2008;
Sarter & Markowitsch, 1985). In association with medial
areas of the frontal cortex, it connects emotional value to
the object of the senses based on both instincts and
learning history, and translates these appraisals into bodily
states (Davis, 1992; LeDoux, 1986). It is a central neural
player in associating conscious and unconscious indications
of danger with preparation for a survival response (Ohman,
Carlsson, Lundqvist, & Ingvar, 2007). Most important for
psychotherapy is that it plays a “behind the screens” role in
creating emotional bias in conscious processing by spinning
our experience in ways that make us, for example, see the
glass as half empty or half full (Kukolja et al., 2008).
Two circuits of sensory input reach the amygdala in the
adult brain. The first comes directly from the thalamus and
the other first loops through the cortex and hippocampus
before reaching the amygdala (LeDoux, 1994). The first
system serves rapid responses during survival decisions
based on a minimum of information. The slower second
system adds cortical processing (context and inhibition) to
appraise ongoing perceptions and behaviors. The
amygdala’s direct neural connectivity with the
hypothalamus, limbic-motor circuits, and many brainstem
nuclei allows it to trigger a rapid survival response. The
emotional power of phobias and flashbacks is greatly
enhanced by the activation of intense somatic arousal
provided by this direct connectivity.
Thus, the amygdala is one of the key components of
affective memory, not just in infancy but throughout life
(Chavez, McGaugh, & Weinberger, 2009; Ross, Homan, &
Buck, 1994). In a fully developed brain, the amygdala also
enhances hippocampal processing of emotional memory by
stimulating the release of norepinephrine and
glucocorticoids via other brain structures (McGaugh, 2004;
McGaugh et al., 1993). Through these chemical messages,
the hippocampus is alerted to the importance of
remembering what is being experienced—a key component
of new learning. The activation of the sympathetic nervous
system alters the chemical environment within and between
neurons, enhancing LTP and neural plasticity. We will return
to this topic in greater detail in later chapters, when we
discuss the impact of stress and trauma on the brain.

The Amygdala and Unusual Experiences

The “uncanny” elements we know from experience

arise either when repressed childhood complexes are
revived by some impression, or when primitive beliefs
that have been “surmounted” appear to be once
again confirmed.
—Sigmund Freud

Given the amygdala’s early development and its unique role

in learning and memory, abnormalities of amygdala
functioning may be involved in some unusual human
experiences. Electrical stimulation of the amygdala has
been shown to result in a wide variety of bodily sensations,
feelings of anxiety, déjà vu, and memory-like hallucinations
(Chapman, Walter, Markham, Rand, & Crandall, 1967;
Halgren, Walter, Cherlow, & Crandall, 1978; Penfield & Perot,
1963; Weingarten, Cherlow, & Holmgren, 1977). Because of
its low seizure threshold, subtle seizure activity may trigger
the amygdala to activate normally inhibited sensory and
emotional memories that then break through into conscious
awareness (Sarter & Markowitsch, 1985). These primitive
memories may also become triggered by sensory cues of
past fears and account for posttraumatic intrusions (van der
Kolk & Greenberg, 1987). Individuals under stress may be
particularly vulnerable to the intrusion of powerful but
conscious memories, even from very early childhood
(Cozolino, 1997).
Primary process thinking and dreamlike experiences are
more likely to merge with conscious awareness in situations
of decreasing contextual cues, as in near-sleep states or
conditions of sensory deprivation (Schacter, 1976).
Decreasing contextual cues lessen the ability of the
corticohippocampal systems to utilize past learning to make
sense of present experience and inhibit amygdala input to
conscious awareness. This may account for the success of
projective testing in tapping into unconscious processing. In
attempting to make sense of ambiguous situations,
subcortical circuits are more likely to guide conscious
awareness.
Individuals with temporal lobe epilepsy (TLE) often
experience extreme religiosity, suggesting that stimulation
of the amygdala can infuse everyday experience with a
sense of deep significance. In other words, its ability to
inform the rest of the brain that we are experiencing
something highly significant can be applied in an
inappropriate manner leading to odd and delusional
thinking. The central nucleus of the amygdala also has a
high density of opioid receptors, which are biochemical
mechanisms of bonding and attachment behavior
(Goodman, Snyder, Kuhar, & Young, 1980; Herman &
Panksepp, 1978; Kalin, Shelton, & Lynn, 1995; Kalin,
Shelton, & Snowdon, 1993) that are also implicated in
alterations of consciousness. This suggests that unregulated
activation of the amygdala may be a neurobiological trigger
for the religious preoccupations occurring in some
individuals with TLE. The fact that hypergraphia (writing a
lot) can also be a symptom of TLE has led many to
speculate that some religious texts have been driven by
unusual amygdala activation stimulated by seizure activity.

Hippocampal Memory Networks

A memory is what is left when something happens

and does not completely unhappen.
—Edward de Bono

The hippocampi, shaped like seahorses on either side of the

human brain, are essential structures for the encoding and
storage of explicit memory and learning (Zola-Morgan &
Squire, 1990) and play a central role in the organization of
spatial and temporal information (Edelman, 1989; Kalisch et
al., 2006; O’Keefe & Nadel, 1978; Selden, Everitt, Jarrard, &
Robbins, 1991; Sherry, Jacobs, & Gaulin, 1992). The
hippocampus also participates in our ability to compare
different memories and make inferences from previous
learning in new situations (Eichenbaum, 1992). If damaged,
it can prevent new learning from occurring, condemning the
victim to forgetting everything a few seconds after it is
experienced (Squire, 1987).
The hippocampus is noted for its late maturation, with
the myelination of cortical-hippocampal circuits continuing
into early adulthood (Benes, 1989; Geuze, Vermetten, &
Bramner, 2005). The late development of the hippocampus
and its connectivity with the cortex reflects both its delayed
functional availability and prolonged sensitivity to
developmental disruption and traumatic insult. It remains
particularly vulnerable to hypoxia (lack of oxygen)
throughout life. Mountain climbers and deep sea divers who
may experience periods of decreased oxygen availability
have been shown to have hippocampal damage and short-
term memory deficits. Gradual atrophy of the hippocampus
appears to be a natural component of aging, along with a
corresponding decrease in explicit memory abilities
(Gartside, Leitch, McQuade, & Swarbrick, 2003; Golomb et
al., 1993).
Research suggests that sustained stress results in
excessive exposure of the hippocampus to glucocorticoids
(cortisol), released in response to acute stress (Sapolsky,
1987). Prolonged high levels of glucocorticoids can result in
dendritic degeneration, cell death, increased vulnerability to
future neurological insult, and inhibited hippocampal
functioning (Kim & Diamond, 2002; Watanabe, Gould, &
McEwen, 1992). Patients suffering from post-traumatic
stress disorder (PTSD) secondary to childhood trauma or
combat exposure, prolonged depression, temporal lobe
epilepsy (de Lanerolle, Kim, Robbins, & Spencer, 1989), and
schizophrenia (Falkai & Bogerts, 1986; Nelson, Saykin,
Flashman, & Riordan, 1998) have also been shown to have
hippocampal cell loss. Decreases in hippocampal volume
have been shown to correlate with deficits of encoding
short-term into long-term memory and an increased
vulnerability to psychological trauma (Bremner, Scott, et al.,
1993; Gilbertson et al., 2002). Given that chronic stress
correlates with decreased hippocampal volume, and that so
many patients in psychotherapy have experienced chronic
stress, it is logical to assume that many patients (like
Sophia) have difficulty in those functions which depend
upon the hippocampus.

Amygdaloid-Hippocampal Interaction
 The struggle of man against power is the struggle of
memory against forgetting.
—Milan Kundera

The relationship between the amygdala and hippocampus is

extremely important to human experience and contributes
significantly to top-down and left-right integration. The
participation of the amygdala is biased toward both right
and down systems, whereas the hippocampus plays a large
role in left and top processing. Put another way, the
amygdala has a central role in the emotional and somatic
organization of experience, whereas the hippocampus is
vital for conscious, logical, and cooperative social
functioning (Tsoory et al., 2008). Their relationship will
impact affect regulation, reality testing, resting states of
arousal and anxiety, and our ability to learn emotional and
more neutral information. The level and quality of the
functional connectivity of the amygdala and hippocampus
will be impacted by temperament, life stress, and epigenetic
factors (Canli et al., 2006).
Douglas and Pribram (1966) suggested that the
amygdala and hippocampus play opposite roles in an
attention-directing process. By accentuating small
differences among inputs, the amygdala heightens
awareness of specific aspects of the environment (attention)
whereas the hippocampus inhibits responses, attention, and
stimulus input (habituation) (Douglas, 1967; Kimble, 1968;
Marr, 1971). The amygdala is involved with generalization,
while the hippocampus is involved with discrimination
(Sherry & Schacter, 1987). In other words, the amygdala will
make us jump at the sight of a spider, while the
hippocampus will help us to remember that this particular
spider is not poisonous, so we shouldn’t worry. Their proper
balance will also allow us to stay close to others even when
they cause us upset.
 We can immediately see the relevance of these two
systems to psychotherapy. The amygdaloid memory system,
organizing early shame experience, makes the patient with
borderline personality disorder react to the perception of
abandonment when little or none exists in reality. Therapy
with this patient would utilize the hippocampal-cortical
systems to test the reality of these amygdala-triggered cues
for abandonment in order to inhibit inappropriate reactions.
This reality testing helps us to distinguish real abandonment
from innocent triggers such as someone showing up a few
minutes late for an appointment and inhibit inappropriate
emotional reactions. Remember, for a young primate,
abandonment means death. The catastrophic reaction of
borderline patients to abandonment is a result of the fact
that, to them, it is experienced as life threatening.
Flashbacks, memories from traumatic experiences, likely
reside in amygdaloid-driven memory networks. PTSD
victims describe flashbacks as powerful and multisensory,
often triggered by stress, and experienced as if they were
occurring in the present (Gloor, 1978; LeDoux, Romanski, &
Xagoraris, 1989; van der Kolk & Greenberg, 1987). These
flashbacks also have the characteristic of being stereotyped
and repetitive (van der Kolk, Blitz, Burr, Sherry, & Hartmann,
1984), suggesting that they are not subject to the
assimilating and contextualizing properties of the cortex and
hippocampus. A model of dual memory processing,
paralleling the amygdala/hippocampal distinction made
here, has been previously proposed as underlying
mechanisms in both PTSD (Brewin, Dalgleish, & Joseph,
1996) and the reemergence of past fears and phobias
(Jacobs & Nadel, 1985).
Given the reciprocal nature of amygdaloid and
hippocampal circuits, impairment of the hippocampus
should lead to an increased influence of the amygdala in
directing memory, emotion, and behavior. This imbalance
toward the amygdala would also disrupt affect regulation.
Depressed patients are overwhelmed by their negative
feelings and unable to engage in adequate reality testing.
Indeed, Sheline and her colleagues noted both decreased
hippocampal and amygdaloid volume in depressed patients
(Sheline, Wang, Gado, Csernansky, & Vannier, 1996;
Sheline, Gado, & Price, 1998). Dysregulation of
hippocampal-amygdaloid circuits are likely involved in
depressive symptomatology and disturbed reality testing
(Pittenger & Duman, 2008). Research with rats has found
that increased levels of serotonin leads to enhanced
neurogenesis in the hippocampus (Jacobs et al., 2000). This
suggests that Prozac and Paxil may be effective in treating
depression because they boost hippocampal volume and its
ability to moderate amygdala activation.

The Intrusion of Early Implicit Memory Into Adult

Consciousness

All our knowledge has its origins in our perceptions.

—Leonardo da Vinci

Early memories stored in circuits of the amygdala and right

hemisphere can intrude into adult consciousness in a variety
of ways. They become especially relevant to psychotherapy
when they are the result of trauma and impact our ability to
love and work. Children who suffer early abuse may enter
their school-age years agitated, aggressive, and destructive.
They may engage in fights, property damage, setting fires,
or hurting animals, resulting in criticism, punishment, and
social exclusion. Although these behaviors are expressions
of their memories of abuse, others react with criticism and
retaliation. This feedback, in combination with the emotional
damages from their abuse, evolves into an ever-deepening
negative self-image.
 In the absence of an explicit memory of their early
trauma, these children’s behavior is not experienced by
them as a reaction to a negative past event, but as an
affirmation of their inner feelings of essential badness.
Because these experiences date back to the formation of
preverbal sensory, motor, and affective memory systems,
victims often report feeling “evil to the core.” This is
common in children who grow up in cults or with highly
authoritarian or abusive parents. The kids of soldiers, police
officers, and ministers appear to be at particular risk for the
internalization of a negative self-image. Children of parents
with obsessive-compulsive disorder can also find they hold
an extremely negative view of themselves. While a person
with OCD needs order, cleanliness, and control, a newborn
brings just the opposite into their life. The child’s early
implicit memories are likely to be centered around being a
source of annoyance, anxiety, and disgust to their parents.
The formation of attachment schema (a key form of
implicit memory) guides and shapes relationships
throughout life. Given that so many clients come to therapy
with relationship difficulties, this implicit memory system
may be one of the most important to explore in
psychotherapy. These same networks of social memory give
rise to the phenomenon of transference, a process that
brings these early unconscious memories into the consulting
room as they are played out between client and therapist.
Enactments in psychotherapy, involving the interplay
between unconscious elements within the patient and the
therapist, also activate these implicit memories.
We have all experienced having our buttons pushed by
someone; many of these “buttons” are the emotional traces
of personal experiences, stored in implicit systems of
memory. Overreacting to something implies that the
difference between an appropriate reaction and how we
actually react is attributable to a sensitivity based on our
learning history. The most common distortions based on the
input of early memory are in the direction of shame, a
primary socializing affect starting at about 12 months
(Schore, 1994). Individuals who are “shame based”
(Bradshaw, 1990) can find criticism, rejection, and
abandonment in nearly every interaction, resulting in a life
of chronic anxiety, a struggle for perfection, exhaustion, and
depression.
Silence is an ambiguous stimulus that activates systems
of implicit memory. Silence may be golden, but in therapy it
evokes a variety of implicit memories. The reaction of
clients to the silence teaches us something of their
emotional history. During periods of silence, many clients
assume that the therapist is thinking critical thoughts. They
imagine the therapist thinks they are boring, stupid, a waste
of time, or a bad client. These feelings usually mirror those
based in problematic relationships with one or both parents.
Furthermore, these feelings are deep seated and tenacious,
often taking many years to make conscious, examine, and
modify. On the other hand, some clients find silence to be a
form of acceptance and a relief from the pressures of being
articulate and communicative. These stark differences in
client reactions to the similar situations are convincing
evidence of the workings of implicit memory and their
effects on conscious experience.
A similar phenomenon occurs in individuals who become
uncomfortable when they try to relax without any
distractions. The emotions, images, and thoughts that
emerge in conditions of low stimulation (or the absence of
distraction) may hold clues to the workings of our brains
and the aftereffects of early learning. Defenses to escape
negative feelings come to require constant action and
distraction to keep us from becoming frightened or
overwhelmed.

The Malleability of Memory

 The only paradise is paradise lost.
—Marcel Proust

The false memory debate of years past highlighted many

shortcomings in the knowledge of therapists when it came
to understanding the workings of memory. Highly publicized
legal cases of repressed memory and clinician contribution
to the co-construction of false memories have resulted in
increased understanding and training focused on the
processes of memory. Most therapists are now aware of the
vulnerability of conscious memory to suggestion, distortion,
and fabrication from both client and therapist (Loftus, 1988;
Paz-Alonso & Goodman, 2008).
Research has demonstrated that memory can be
implanted in experimental situations where the subject soon
becomes certain that the false memories have actually
occurred (Ceci & Bruch, 1993; Loftus, Milo, & Paddock,
1995). A therapist’s belief that her client has been abused
may influence that patient to unconsciously fabricate a
memory that they both then come to believe is true. This
process is a clear demonstration of both the malleability of
memory and the power of co-constructed narrative in
shaping experience (Alberini, 2005; Anderson, Wais, &
Gabrieli, 2006; Dudai, 2006; Nielson, Yee, & Erickson, 2005).
Given that memory is encoded among neurons and
within neural networks, the malleability of memory is an
observable manifestation of the plasticity of these neural
systems. This malleability is certainly a stumbling block to
our justice system, which relies so heavily on eyewitness
testimony. The hundreds of convictions that have been
overthrown by new DNA methods attest to the inadequacy
of our present standards of eye-witness evidence. But from
the perspective of psychotherapy, this plasticity provides an
avenue to the alteration of destructive memories. Revisiting
and evaluating childhood experiences from an adult
perspective often leads to rewriting history in a creative and
positive way. The introduction of new information or
scenarios to past experiences can alter the nature of
memories and modify affective reactions.

The Magic Tricycle

The greatest weapon against stress is our ability to

choose one thought over another.
—William James

Sheldon was a man in his late 60s who came to therapy for
help with his many anxieties and fears. As a child, his
parents had hidden him from the Nazis in a storage room
behind the home of family friends. One day, after finding
out that she and Sheldon’s father would soon be taken to
the concentration camps, Sheldon’s mother told him to be a
good boy, said goodbye, and left. While the family friends
were kind to him, he spent his days alone with few toys, his
small tricycle, and some scraps of food. Describing these
days, Sheldon recalled alternating states of terror and
boredom, during which he would either sit and rock or ride
his tricycle around in slow tight circles. The slightest noise
would startle him and he feared that each passing siren
might be the police coming for him. Each day, exhausted by
fear, he would eventually fall asleep.
The intervening decades had not diminished the impact
of his experiences during the war; 60 years later, he still
found himself reflexively rocking or walking in small slow
circles when he became frightened. His life felt like one
long, fear-filled day. In repeatedly recalling these
experiences in treatment, he sometimes mentioned how he
wished he could have left the house where he was hidden
and traveled down the narrow streets to his grandmother’s
house. Sheldon remembered long afternoons he spent there
before the war, listening to stories of her childhood on her
father’s farm. His grandmother and his parents perished in
the war, and he never saw them again.
One day, I asked him for permission to change his
memories just a bit. After a few quizzical looks he agreed to
close his eyes and tell me the entire story again, at which
point I would interrupt him and make some suggestions. As
he came to the part of the story where he rode around in
circles, I asked him, “What would you do if this was a magic
tricycle and it could take you through walls without getting
hurt?” I felt Sheldon had sufficient ego strength to allow him
to simultaneously engage in the role-play while staying fully
in touch with present reality.
After some hesitation, Sheldon said, “I would ride right
through the house and out onto the sidewalk.”
“Fine,” I said. “Let’s go!” Sheldon had been primed for
our imaginary therapy play because he had spent many
enjoyable hours of storytelling, cuddling, and laughing with
his grandchildren. I felt that an imaginative task like this
was not only accessible to him but would also serve the
purpose of bridging the positive affect from his
grandchildren to his lonely and frightened experiences as a
child. Imagining he was making up the story for his
grandchildren might also help him cope with the
embarrassment of doing this with another adult.
After some mild hesitation, he pedaled through the
house. As he got close to the door, however, he said,
“They’ll see me and kill me.”
“What if the magic tricycle has the power to make you
invisible?” I asked.
“I think that’ll do,” said Sheldon, and he pedaled through
the front of the house and out onto the sidewalk. Once he
got out of the house, he knew what to do. He described the
street to me as he pedaled toward his grandmother’s house.
The storekeepers, the neighbors, the park, his rabbi, even
some of his young friends were all alive in his memories.
Sure enough, when he finally got to his grandmother’s
house she was home and, as always, happy to see him. He
told his grandmother about his invisible tricycle and how
scared he was in his hiding place. He went on to tell her of
the end of the war, his travels, and raising his family. Finally,
almost like a prayer, Sheldon told her how, many years from
now, she would have the most beautiful great-great-
grandchildren living in freedom, redeeming her suffering.
Over the next few months, whenever Sheldon
experienced his childhood fears and anxieties, we would
revisit his story and modify different details. These changes
seemed to grow more detailed and more vivid in his mind.
His imagination gave him the power to master many of his
past fears. Because memory is modified each time it is
remembered, Sheldon’s brain was able to gradually
contaminate his painful childhood with his present safety
and joy (Bruner, 1990). He even began to tell his
grandchildren stories about a little boy with a magic tricycle
who accomplished great things with his courage and wit.
Sheldon was a very special man who was able to take
advantage of the malleability of memory to make his inner
world a safer place. Nothing had changed about his
childhood except that now, when he remembered his hiding
place, he also remembered his magic tricycle.
An important part of restructuring memory is something
Freud called Nachtraglichkeit, which means the ability to
reconceptualize a memory based on evolving maturity. This
process requires being able to hold the memory in mind
without being emotionally overwhelmed and simultaneously
bringing it into the present, picturing it as it would look from
the perspective of who we are and what we know today.
Both Freud’s idea and Sheldon’s experiences highlight the
fact that memory is an evolving process that is subject to
positive influence.
The construction and reconstruction of autobiographical
narratives requires that the semantic processing of the left
hemisphere integrate with the emotional networks in the
right. Storytelling also invokes participation of the body as
we gesture and act out the events we are describing. As
such, narratives are a valuable tool in the organization and
integration of neural networks prone to dissociation.
Because we can write and rewrite our own stories, new ones
hold the potential for novel ways of experiencing. In editing
our narratives, we change the organization and nature of
our memories and, hence, reorganize our brains. This is a
central endeavor in many forms of psychotherapy.

Summary
As a boy in the early 1960s, I remember being fascinated by
news stories of Japanese soldiers attacking tourists on tiny
islands in the South Pacific. During World War II, the
Japanese navy left soldiers on many islands throughout the
Pacific but never retrieved them at the end of the war.
Decades later, pleasure crafts would innocently land on
these islands only to be attacked by soldiers who thought
the war was still being fought. They had dutifully kept guns
oiled and remained vigilant for decades in anticipation of an
American attack. I was awed by their loyalty and saddened
by the thought of the years they spent fighting a war that
no longer existed.
Like these soldiers, early amygdala-based memory
systems retain struggles, stress, and trauma from a time
before conscious memory. We may grow and move on to
new lives, yet our implicit memory systems retain old fears.
While remaining vigilant for signs of attack for early
attachment pain, approaching intimacy can set off all of the
danger signals. Therapists are trained to be amygdala
whisperers who land on these beaches, attempting to
convince the loyal soldiers within implicit systems of
memory that the war is over.
Chapter 6

Laterality: One Brain or Two?

Though the brain is enclosed in a single skull, it is

actually made of two separate lumps…which are
designed to disagree with each other.
—Jonah Lehrer

We now switch our focus from the multiple and diverse

systems of memory to another realm of neural complexity—
cortical laterality. As you know, the human cerebral cortex is
divided into right and left hemispheres, each controlling the
opposite side of the body. The term laterality refers to the
specialization of certain tasks to one side of the brain or the
other, and is reflected in how the hemispheres differ in their
organization, processing strategies, and neural connectivity.
Keep in mind also that laterality shows variability among
individuals, and left-and right-handed people, as well as
males and females.
Although most neural processing requires the
contribution of both hemispheres, there are situations when
the hemispheres not only think differently but also compete
with one another. This struggle for dominance and control
may be one cause of our psychological struggles, giving
new meaning to why we sometimes feel “beside ourselves”
or “of two minds.” By the end of this chapter, you may be
left wondering whether we in fact have one brain or two.
John Hughlings Jackson, the eminent 19th-century
neurologist, believed that the left side of the brain was, for
most people, the “leading” side. This seemed logical given
Broca’s finding that the left hemisphere was responsible for
our ability to use semantic language. Jackson later
suggested that the right hemisphere was the leading side of
the brain in visual-spatial abilities.
Over the years, it has become clear that dividing the
brain into two discrete halves is not the best approach.
Given that most neural systems integrate circuitry from the
left and right sides of the brain, research attempting to
localize functions in one hemisphere or the other often
results in “untidy” findings (Christman, 1994). When we
speak of functions of the right or left brain, we are more
accurately referring to functions that are either represented
more fully or performed more efficiently in one hemisphere
than the other. Over the past 40 years, much has been
written about the artistic right brain and the logical left.
Although this view may be appealing to the imagination, it
is far too simplistic. Assigning specific functions to particular
areas of the brain needs to be done with both caution and
the recognition that our knowledge is still evolving.

Evolution and Development

A scientific truth does not triumph by convincing its

opponents and making them see the light, but rather
because its opponents eventually die and a new
generation grows up that is familiar with it.
—Max Planck

Lateral specialization is an evolutionary choice, and does

not exist in all animals. Many birds and fish, for example,
have identical hemispheres. These animals are able to sleep
one hemisphere at a time, allowing them to keep swimming
or flying to avoid predators, continue feeding, or rest during
long migrations. Although redundant hemispheres provide
certain benefits, such as a backup system in case of injury,
hemispheric specialization via natural selection promotes
neural complexity. Through human evolution, the right and
left cerebral hemispheres have become increasingly
dissimilar (Geschwind & Galaburda, 1985). Lateral
dominance appears to have been delegated depending on
the functional domain in question (Cutting, 1992; Goldberg
& Costa, 1981; Semmes, 1968). For example, areas of the
left and right cortices have become specialized in the
organization of the conscious linguistic self in the left and
the physical emotional self in the right.
During the first 2 years of life, the right hemisphere has a
growth spurt that parallels the rapid development of
sensorimotor, emotional, and relational capabilities (Casey,
Galvan, et al., 2005; Chiron et al., 1997; Thatcher, Walker, &
Giudice, 1987). The child learns hand–eye coordination,
crawling, and walking while becoming attached to
caretakers. An organized sense of the body in space and the
embodied self form in subcortical and cortical networks
involving the thalamus, cerebellum, and parietal cortex. At
the same time, middle portions of the prefrontal cortex are
maturing and integrating with subcortical structures to
establish the basic structures of emotional regulation and
attachment. During this period, the development of the left
hemisphere is slowed a bit and reserved for later-developing
functions (Gould, 1977).
In the middle of the second year, a growth spurt occurs
in the left hemisphere and an explosion in language and
locomotion launches children into the broader physical and
social worlds. In the frontal lobes, there is a shift of
development to the dorsolateral areas, linking back to other
cortical regions, that sculpts the language network (Tucker,
1992) while connecting the movements of hands and eyes
to visual stimuli and words. The corpus callosum begins to
develop at the end of the first year, is significantly
developed by age 4, and continues to mature past the age
of 10. Because of this slow maturation, the two hemispheres
at first function relatively autonomously, gradually gaining
interconnection and coordination through childhood (Galin,
Johnstone, Nakell, & Herron, 1979).
A great deal of what is known about the functions of the
different hemispheres has been the result of the split-brain
research of Sperry and his colleagues (Sperry, Gazzaniga, &
Bogen, 1969). Split-brain patients are individuals suffering
from medication-resistant epilepsy, who have their corpus
callosum surgically severed to limit seizures to one side of
the brain. Presenting information separately to each of their
hemispheres has revealed divisions of awareness and
specialization in a range of cognitive and emotional tasks,
thereby expanding our knowledge of cortical laterality
(LeDoux, Wilson, & Gazzaniga, 1977; Ross et al., 1994;
Sperry, 1968).

Lateral Asymmetry

All organs of an animal form a single system…and no

modification can appear in one part without bringing
about corresponding modifications in all the rest.
—George Cuvier

The earliest form of language was most likely hand

gestures, which may explain why handedness and language
functions are so closely linked in the brain. Most of us are
right-handed (controlled by the left brain) and have
semantic language lateralized in the left hemisphere. Neural
networks for both spoken and sign language are located in
the left hemisphere for most adults, and damage to the left
hemisphere usually results in language disturbances such as
aphasia (Corina, Vaid, & Bellugi, 1992). In left-handed or
ambidextrous individuals, lateralization of language is
somewhat less clear. As the semantic functions of the cortex
expanded during evolution and language became more
descriptive and useful, words gradually replaced gestures in
importance. Our present use of hand gestures to augment
spoken language may betray this evolutionary path. Our
tendency to use hand gestures even when talking on the
telephone suggests that they not only play a role in
communication but also in organizing and supporting our
thinking.
The left hemisphere appears to be more involved in
conscious coping and problem solving than the right. This is
most likely a function of its language skills and prosocial
orientation. The left hemisphere functions best within the
middle range of affect and is biased toward positive
emotions and approach behaviors (Silberman &
Weingartner, 1986). Strong affect, especially anxiety and
terror, result in high levels of right hemisphere activation
and appears to inhibit the left hemisphere and language—
hence, the experience of stage fright and speechless terror.
It has been suggested that Wernicke’s area in the left
temporal lobe, known to be centrally involved in language
comprehension, acts as a probability calculator for other
forms of behavior as well as language (Bischoff-Grethe,
Proper, Mao, Daniels, & Berns, 2000). Given the rapidity
with which we process speech, Wernicke’s area may process
what is heard based as much on what it expects to hear as
what is actually said. This would certainly help to explain
why human communication can be so problematic and
misunderstandings so common. Broca’s area may have
similar predictive functions, which allow us to speak faster
than we think and even, at times, be surprised by what we
hear ourselves saying (Nishitani et al., 2004). In fact,
William James, one of the fathers of American psychology,
said that he needed to hear himself talk to know what was
on his mind.
For most individuals, the right hemisphere processes
information in a holistic fashion and is densely connected to
the limbic systems and the viscera (Nebes, 1971). The left
hemisphere, on the other hand, processes information in a
linear, sequential manner and has less connection with the
body. The right hemisphere is heavily wired to the limbic
system and is more directly involved in the regulation of the
endocrine and autonomic nervous systems than the left
(Wittling & Pfluger, 1990). It also contains centers within the
parietal lobes that might contain a representation of the
entire body.
The right hemisphere is generally responsible for both
appraising the safety and danger of others and organizing a
sense of the corporeal and emotional self (Devinsky, 2000).
Appraisal simply means attaching a positive or negative
association to a stimulus, while emotion is the conscious
manifestation of this appraisal process (Fischer, Shaver, &
Carnochan, 1990; Fox, 1991). The vast majority of appraisal
occurs at an unconscious level. This is why the right
hemisphere is more often associated with the unconscious
mind, that is, what guides our thoughts and behavior
outside of our awareness.
The bias against left-handedness across many cultures
may reflect an intuitive understanding of the left hand’s
(right brain’s) relationship to the dark, primitive aspects of
our nature. These biases likely date back into prehistory,
when the left hemisphere may have exerted less inhibitory
control over the right. Think about the French word gauche
and the Italian sinestre for left and all their tasteless and
evil connotations. By offering the right hand in greeting,
early humans may have been more likely to behave in a
civilized manner, and less likely to act out selfish or violent
impulses. An examination of cave drawings in Southern
Europe suggests that the bias toward right-handedness has
existed for at least the last 5,000 years (Coren & Porac,
1977).
Although the left hemisphere generally produces
semantic language, it is unclear whether it has any
advantage in language comprehension. The right
hemisphere may, in fact, be better at comprehending the
emotional aspects of language such as the tone of voice or
the attitude with which words are said (Searleman, 1977).
Emotions in general, the ability to evaluate emotional facial
expressions, and visual-spatial and musical abilities are
primarily right-hemisphere processes (Ahern et al., 1991).
Damage to the right hemisphere results not only in an
impairment of our ability to assess facial gestures, but also
to comprehend other nonverbal aspects of communication
such as hand gestures and tone of voice (Blonder, Bowers,
& Heilman, 1991).

Laterality and Emotion

When angry, count to four; when very angry, swear.

—Mark Twain

Evidence suggestive of a relationship between laterality and

emotionality was first observed in cases of damage to the
prefrontal cortex. Patients with damage to the left
hemisphere appeared to be far more likely to have a
depressive reaction than those with damage to the right
(Gainotti, 1972; Goldstein, 1939; Sackheim et al., 1982). It
was later found that the closer these lesions were to the
prefrontal regions, the more severe the symptoms of
depression (Robinson et al., 1984). Right brain-damaged
patients were also found to describe experiences with less
emotional intensity than left brain-damaged patients or
normal controls (Borod et al., 1998).
Imaging studies have shown that people without brain
damage who suffer from depression have lower levels of
glucose metabolism and cerebral blood flow in the left
prefrontal cortex (Galynker et al., 1998; Kalia, 2005; Mathew
et al., 1980). In addition, people experiencing mania in the
absence of brain damage demonstrate decreased right
prefrontal activity (Al-Mousawi et al., 1996). These studies
expand the association between laterality and emotion to
the general population. An examination of Table 6.1 reveals
that the left hemisphere is biased toward positive affect,
safety, and positive social approach, as well as anger and
aggression directed toward others. Overall, the left side of
the brain appears to be in charge of the successful
navigation of the social world.

TABLE 6.1
Laterality and Emotion

Increased left hemisphere activation occurs in

response to:
Happy stimuli1
Positive pictures2
Positive affect in response to positive films3
Approach-related dispositional tendencies4
More positive disposition5
Smiling and facial expressions of enjoyment6
Reported well-being7
Infant smiling in response to mother approach8
Trait anger9
State anger10
State aggression11

Increased right hemisphere activation occurs in

response to:
Facial expressions of disgust12
Tastes associated with disgust13
Negative pictures14
Avoidance behavior15
Negative affect in response to negative films16
Threat-related vigilance17
Stranger approach18
Maternal separation19

The intimate association between emotion and cognition

has been demonstrated in many laterality studies. For
example, sad faces are rated as relatively sadder when
presented to the left visual field compared to the right
(Sackheim et al., 1988). Negative stimuli are consciously
perceived most often when presented to the right
hemisphere (Smith & Bulman-Fleming, 2004). Research has
shown that anesthesia of the left hemisphere results in
greater expressions of negative emotions and less prosocial
explanations of experience (Dimond & Farrington, 1977;
Ross et al., 1994). Orienting eye gaze to the left (stimulating
the right hemisphere) results in decreased optimism, while
the opposite is true with rightward eye gaze (Drake, 1984;
Thayer & Cohen, 1985). Righthemisphere-biased neural
processing correlates with low self-esteem (Persinger &
Makarec, 1991).
Higher levels of left prefrontal activation have been
associated with a resilient affective style, faster recovery
following negative events, and lower levels of the stress
hormone cortisol (Davidson, 2004; Jackson et al., 2003;
Kalin, Larson, Shelton, & Davidson, 1998). While there
appears to be an overall bias of positive left/negative right,
the picture is more complicated. The hemispheres are also
lateralized for social/private and approach/avoidance
(left/right) behavior. These patterns of left/right activation
suggest that health and happiness may be associated with
general lateral balance as well as the ability to be
aggressive and express anger biased toward the left and
grief and shame biased toward the right.

The Integration of the Body in the Right Hemisphere

The body never lies.

—Martha Graham

The parietal lobes, located above our ears toward the top of
our heads, are at the crossroads of neural networks
responsible for vision, hearing, and sensation. They serve as
a high-level association area for the coordination and
integration of these functions. The anterior (front) portion of
the parietal lobes organizes tactile perception, while the
posterior (back) portion interconnects the senses to
organize sensory-motor with conceptual events (Joseph,
1996). Accordingly, cells in the parietal lobes respond to
hand position, eye movement, words, motivational
relevance, body position, and other factors relevant to the
integration of experience.
The purpose of the association of all of these high-order
processing networks is to provide a coordinated and
integrated awareness of one’s own body and its relation to
the external environment (Ropper & Brown, 2005). This
makes sense in that the parietal lobes evolved from the
hippocampus, which, in lower mammals, serves as a
cognitive map for external space (O’Keefe & Nadel, 1978).
Part of the job of the parietal lobes is to organize an
integrative map of our bodies in space, which is available for
conscious reflection. Thus, damage to the parietal lobes,
especially on the right side, results in a variety of
disruptions in our experience of the self and the world
around us.
 Although the left hemisphere seems to contain a network
to monitor attention on the right side of the body, the right
hemisphere of right-handers has a specialized ability to
direct attention bilaterally to both the right and left sides of
“extrapersonal space” (Mesulam, 1981). Hemi-neglect, or
the denial of the existence of the left side of the body, can
result from lesions to the right parietal lobe. When neglect is
severe, the patient behaves as if the left half of the world
has ceased to exist. Patients with hemi-neglect will dress
and put makeup only on the right side of their bodies while
denying ownership of their left arm or leg. Asked to draw
the face of a clock, they may put all 12 numbers on the
right side or simply stop at 6 o’clock.
The phenomenon of hemi-neglect has also been shown
to exist in imaginary space. Bisiach and Luzzatti (1978)
examined two patients with right parietal injuries and left-
sided neglect who were asked to describe the Piazza del
Duomo in Milan. The piazza was very familiar to both
patients. But when asked to imagine the piazza from one
end, they could recall and describe the details on their
imagined right side and not their left. Later, they were asked
to reimagine the piazza from the other end. Looking back to
where they previously pictured themselves sitting, they
were now able to accurately describe what was on the right
side but not on the left. In other words, once they imagined
turning around 180 degrees, they now had access to
memories that they were unable to remember just a short
while earlier. Further, the information they provided
previously was no longer accessible. This remarkable
demonstration suggests neural networks that organize and
attend to the body in space are also utilized in imagination.
In later research, Bisiach and his colleagues (Bisiach,
Rusconi, & Vallar, 1991; Cappa, Sterzi, Vallar, & Bisiach,
1987; Vallar, Sterzi, Bottini, Cappa, & Rusconi, 1990) found
that vestibular stimulation via cold water irrigation of the
left ear (the caloric test) in patients with right parietal lobe
lesions resulted in temporary remission of their left hemi-
neglect. Putting cold water into the left inner ear stimulated
areas within the right temporal lobe and caused the patients
to orient toward the left (Friberg, Olsen, Roland, Paulsen, &
Lassen, 1985). Although the mechanism of action is not
certain, one possible explanation could be that activation of
the right temporal lobe resulted in a reintegration of right
and left hemispheric attentional processes, bringing the
world temporarily into an organized whole (Rubens, 1985).
This theory is supported by the fact that being shown fearful
faces also appears to overcome the attentional neglect of
these patients (Tamietto et al., 2007). The survival value of
these faces may surpass a higher threshold established in
the hemi-neglect phenomenon.

The Language Network and the Left Hemisphere

Interpreter

All men are frauds. The only difference between them

is that some admit it. I myself deny it.
—H. L. Mencken

The left hemisphere language network relies on the

convergence of auditory, visual, and sensory information
from the temporal, occipital, and parietal lobes. Wernicke’s
area in the temporal lobe receives input from the primary
auditory area and organizes it into meaningful bits of
information. The convergence zone connects sounds, sights,
and touch, so that cross-modal connections can be made,
allowing us to name things we touch and hear without visual
cues. It is also necessary for the development of sign
language, where words take the form of gestures. This
sophisticated and highly processed information projects
forward to Broca’s area where expressive speech is
organized.
 Neural networks linking language areas to the rest of the
frontal lobes allow both spoken and internal language to
guide behavior and regulate affect. Although the semantic
aspects of language are usually lateralized to the left
hemisphere, the right contributes the emotional and
prosodic element of speech. The integrative properties of
language may be unequaled by any other function of the
brain. Creating and recalling a story requires the
convergence of multisensory emotional, temporal, and
memory capabilities that bridge all vectors of neural
networks. In this way, language integrates, organizes, and
regulates the brain, and is therefore used to great benefit in
everyday storytelling as well as in psychotherapy.
Consistent findings across a variety of settings have led
to a general acceptance that the verbal neocortex organizes
conscious experience and embodies the social self as arbiter
of rules, expectations, and social presentation (Nasrallah,
1985; Ross et al., 1994). Working with split-brain patients,
Gazzaniga and his colleagues found that the left hemisphere
could create an explanation of experience when right
hemisphere information was unavailable (Gazzaniga,
LeDoux, & Wilson, 1977). Gazzaniga (1989) later developed
the concept of the left hemisphere interpreter that
synthesizes available information and generates a coherent
narrative for the conscious social self.
The strategy of filling in gaps in experience and memory,
and making a guess at an explanation, parallels
confabulatory processes seen in patients with psychosis,
dementia, and other forms of brain damage. Confabulation
appears to be a reflexive function of the left hemisphere
interpreter as it attempts to make sense of nonsense,
organize experience, and present the self in the best
possible light. This phenomenon is likely related to Freudian
defense mechanisms that distort reality in order to reduce
anxiety.
 A good example of this kind of confabulatory behavior
was demonstrated by S.M., a 77-year-old suffering from
parietal and temporal lobe atrophy in her right hemisphere.
One day her son saw her using sign language in front of the
mirror in her bedroom (Feinberg & Shapiro, 1989). When
asked what she was doing, the patient told him that she was
communicating with the “other S.M.” She went on to tell him
that there was another S.M. who was identical to her in
appearance, age, background, and education who was
always in the mirror. She and the other S.M. had gone to the
same school, but did not know each other from that time.
The other S.M. also had a son with the same name who
looked just like him.
S.M. and her double were identical in every respect,
except that the other S.M. had a tendency to talk too much
and did not communicate as well as she did in sign
language. If her son or the examiner appeared behind her in
the mirror, she would correctly label that person’s mirror
reflection. Thus, the phenomenon of a double was only
evident for her own image. When it was pointed out that
this was her own image in the mirror, she would reply, “Oh
sure, that’s what you think” (Feinberg & Shapiro, 1989,
Chapter 3). While S.M.’s comprehension and identification of
herself and the world had been disrupted by her right
hemisphere lesion, her left hemisphere interpreter remained
intact. It is somewhat comical to think that she experienced
her reflection in the mirror as talking too much and being
less skilled than herself in sign language. Perhaps the left
hemisphere interpreter may explain why we are all above
average in our own minds.
This confabulatory and positive self-bias of S.M. versus
her reflection is a perfect example of the left hemisphere
interpreter at work. It also reflects the brain’s basic instinct
to engage in explanatory behavior for things it cannot
understand. Some version of the interpreter concept has
previously been used to explain the development of
paranormal beliefs (Cozolino, 1997), schizophrenic delusions
(Maher, 1974), and religious beliefs (Gazzaniga, 1995). The
concept is especially relevant to psychotherapy, because
the construction of reality is at work in the worldviews of
patients with character disorders, the defense mechanisms
of neurotics, and the day-to-day reality of healthy
individuals. The left hemisphere interpreter is an internal
press agent for the self, putting a positive spin on what is
experienced and how it is presented to others. If the
interpreter is not doing its job adequately, as in the case of
left hemisphere damage or decreased activation of the left
frontal cortex, we can become realistic, pessimistic, and
depressed.

Communication and Coordination Between the

Hemispheres

Is the brain, which is notably double in structure, a

double organ,
“seeming parted, but yet a union in partition”?
—H. Maudsley

As our left and right hemispheres differentiated during

evolution, each came to gain dominance for specific
functions after failed experiments with transcortical
democracy (Levy, Trevarthan, & Sperry, 1972). At the same
time, the blending of the strengths of each hemisphere
allows for the maximum integration of our cognitive and
emotional functioning. When we are awake, the right
hemisphere constantly provides information to the left.
Nasrallah (1985) suggested that this input relates to
intuition, feelings, fantasy, and visual images. The
momentary bubbling up of feelings or images, which are
then quickly lost, may reflect one aspect of the intrusion of
right hemisphere processing into left hemisphere control.
The filtration of right hemispheric processes may be
necessary to allow us to remain focused on the tasks in
which we are engaged, although it may not necessarily
register, understand, or allow the information into
consciousness.
What happens when the hemispheres find themselves
disconnected from one another? Jason and Pajurkova (1992)
reported a case of a 41-year-old right-handed man who
suffered damage to the front portion of his corpus callosum
and the medial portion of his frontal cortex. The most salient
aspect of his behavior after his injury was that the two sides
of his body seemed to be in conflict with one another.
During neuropsychological testing, the patient’s right hand
would attempt to perform a task but the left would move in
and disrupt what had been accomplished. When he would
try to go down a set of stairs, his right foot would lead but
then his left hand would grab the doorjamb and refuse to let
him move forward. He found himself unable to do things
that required the cooperation of both hands.
The patient said, “My left foot and my left hand want to
do the opposite of what my right one does all the time”
(Jason & Pajurkova, Chapter 13). On another occasion he
stated, “My left hand doesn’t go where I want it to” (Chapter
13). In each situation, the right hand and side (controlled by
the left hemisphere) attempted to carry out the conscious
will of the patient. But the left side (controlled by the right
hemisphere) would have no part of it. The authors reported
that it seemed as if the right hemisphere was acting like a
spiteful sibling, competing for attention and control (Jason &
Pajurkova, 1992). Although this conflictual behavior
decreased over time, it was still evident 6 months after the
injury. Similar left–right conflicts, usually resolving in the
first few weeks after surgery, have also been reported in
split-brain patients.
It is clear in these cases that the left hemisphere is
experienced as the conscious self (ego) while the behavior
of the right hemisphere is experienced as a force from
outside the self (ego-alien). The experience and behavior of
such patients suggests not only alternate ways of
processing information in each hemisphere, but also two
separate wills. The unconscious and oppositional quality of
the behavior of this client’s right hemisphere suggests that
the left hand may have been acting out unconscious
emotional reactions.

Right-Left Integration and Psychopathology

We use our brains too little and when we do, it is only

to make excuses for our reflexes and instincts.
—Martin Fischer

I postulated earlier that neural network integration should

correlate with mental health, while dissociation or
imbalance among neural networks should correlate with
mental illness. If this is true, we can assume that integration
between the right and left hemispheres is one element of
optimal brain functioning. It turns out that anxiety, affective
disorders, psychosis, alexithymia, and psychosomatic
conditions have all been linked to deficits in the integration
and balance among the cerebral hemispheres.

Anxiety and Depression

Anxiety is love’s greatest killer…

—Anaïs Nin

As mentioned earlier, each hemisphere has an emotional

bias, and so it appears that the proper balance of right-left
activation allows us to experience a healthy mix of positive
and negative emotional experiences, as well as to regulate
and manage anxiety (Silberman & Weingartner, 1986). The
left hemisphere has a bias toward positive affect, prosocial
behavior, and assertiveness, all of which help us to connect
with others and find safety in the group, while the right
hemisphere’s bias toward suspiciousness and negativity
keeps us vigilant and alert to danger.
Frontal lobe activation, when biased toward the right
hemisphere, correlates with the signs and symptoms of
depression (Nikolaenko, Egorov, & Freiman, 1997). The
same phenomenon holds true for anxiety. Primates with
extreme right frontal activity are more fearful and
defensive, and have higher levels of stress hormones, than
do those with activity biased toward the left hemisphere
(Kalin et al., 1998). Adults with a history of childhood
trauma demonstrate a significantly greater shift to right
hemispheric processing when asked to think about
unpleasant memories (Schiffer, Teicher, & Papanicolaou,
1995). Activation of many structures of the right hemisphere
is also evident during posttraumatic flashbacks (Rauch et
al., 1996).
If anxiety and depression are, in part, the result of a bias
toward right hemisphere processing, then any form of
successful treatment will enhance a rebalancing of these
systems. Cognitive therapies for both anxiety and
depression utilize rational thought that may work by
activating left hemisphere processes to regain lateral
balance. Symptomatic relief can also be achieved by a
downregulation of the right hemisphere processes through
relaxation training.
An unfortunate artifact of the evolution of laterality may
be that the right hemisphere is biased toward negative
emotions while also having primary control over emotional
self-awareness (Keenan et al., 1999). In addition, because
there is so much early, unconscious right hemisphere
emotional learning, early negative experiences have a long-
lasting yet hidden impact on our self-esteem, attitudes, and
personalities. These aspects of laterality may create a bias
toward shame, guilt, and pessimism while possibly
explaining the neurobiological mechanism underlying
Nietzsche’s statement that “Man is the only animal who has
to be encouraged to live.”

Alexithymia and Psychosomatic Illness

It is precisely because a child’s feelings are so strong

that they cannot be repressed without serious
consequences.
—Alice Miller

Alexithymia—the inability to consciously experience and

describe feelings—is characterized by deficits in the
awareness and integration of right hemisphere functions.
These patients are not prone to depression or mania but
instead have a poverty of emotional expression and
experience. They are able to recognize that others have
feelings, but report being unable to locate any within
themselves.
From a psychodynamic perspective, these patients seem
trapped in secondary process thinking, disconnected from
their inner physical and emotional worlds. Patients with
alexithymia are described as having a concrete or stimulus-
bound cognitive style, restricted imagination, and a lack of
memory for dreams (Bagby & Taylor, 1997). They have
difficulty benefiting from traditional modes of talk therapy
because of their inability to bring emotions into the session,
or to use imagination or role-playing to expand their
thinking about themselves. Although the neurological
correlates of this disorder are still unknown, alexithymia has
been described as a “bidirectional interhemispheric transfer
deficit” (Taylor, 2000). The resultant failure of the
integration of affect and cognition leaves the conscious self
of the left hemisphere with little input from the emotional,
intuitive, and imaginative right.
Patients with other psychiatric disorders reveal patterns
similar to those with alexithymia. Hoppe (1977) found that
patients with psychosomatic disorders have characteristics
similar to those with alexithymia such as impoverished
dreams, a paucity of symbolic thinking, and trouble putting
feelings into words. Similar difficulties were also found in
Holocaust survivors, split-brain patients, and individuals
with traumatic brain injuries. Hoppe and Bogen (1977)
hypothesized that problems during development or
underlying genetic processes could lead hemispheres to
organize and function autonomously. The theory of such an
“interhemispheric transfer deficit” was supported by
research with patients suffering from PTSD and alexithymia
who were found to have deficits in transferring sensorimotor
information between hemispheres (Zeitlin, Lane, O’Leary, &
Schrift, 1989).

Psychosis

Reality is merely an illusion, albeit a very persistent

one.
—Albert Einstein

Whereas normal states of awareness are comprised of an

integration and balance of right and left hemisphere
processing, psychosis may be a result of the intrusion of
right hemisphere functioning into conscious awareness.
Hyperactivation of the right hemisphere, or a decrease in
the inhibitory capacities of the left, may diminish the ability
to filter primary process input from the right hemisphere.
This shift in right-left bias may occur for many reasons,
including changes in levels of important neurochemicals
such as dopamine, neuroanatomical abnormalities, or
changing activation in subcortical brain areas such as the
thalamus. Schizophrenic patients and their close relatives
demonstrate reduced left hemisphere volumes in the
hippocampus and the amygdala, which has been shown to
correlate with thought disorder (Seidman et al., 1999;
Shenton et al., 1992).
Auditory hallucinations, or hearing one or more voices
talking, are a core symptom of schizophrenia. In fact, the
term schizophrenia means split mind. These aberrant,
intrusive, and ego-dystonic experiences may reflect right
hemisphere language (related to primary process thinking
and/or implicit memories) breaking into left hemisphere
awareness. These voices, often heard as single words with
strong emotional value, are experienced as coming from
outside the self. For example, patients report hearing
profanities or critical words (jerk, idiot) as people walk by
them on the street. Command hallucinations to hurt oneself
or others or to engage in dangerous behaviors have the
same qualities. Schizophrenic patients appear to openly
struggle with shameful aspects of their inner world (likely
stored in the right hemisphere) that the rest of us are better
able to inhibit, repress, and deny.
In psychosis, primary process thinking breaks into normal
states of awareness to create what are diagnosed as deficits
in reality testing and thought disorders. Patients describe
this as a feeling of dreaming while awake and struggling to
make sense of the simultaneous superimposition of primary
and secondary process experiences. This attempt to make
sense out of nonsense fires up the left hemisphere
interpreter, leading to the elaboration of bizarre delusions
(Maher, 1974). Although a hemispheric model of psychosis
is still speculative, tests of lateral dominance (measured by
a listening task) have shown that decreased lateral
dominance in these patients correlates with more severe
psychotic symptoms (Wexler & Heninger, 1979).
 Inspired by both modern science and ancient texts, the
neuropsychologist Julian Jaynes (1976) developed a theory
of the evolution of human consciousness based on the
increasing ability of the left hemisphere to inhibit input from
the right. Jaynes argued that prior to 1000 B.C., the two
halves of the human brain acted independently; the right
hemisphere unconsciously controlled the body, while the left
witnessed and described the social environment and actions
of the body. This model of laterality may have reflected an
intermediate evolutionary stage between having two modes
of conscious awareness and our current bias toward right
hemisphere inhibition.
Jaynes suggested that when our forebears were in
situations of extreme stress, such as combat, the right
hemisphere provided auditory commands to the left, which
were experienced as coming from outside the self. This
could reflect an internalized auditory memory of the tribal
leaders and warriors, commands similar to those reported
by modern-day schizophrenics. With the expansion of the
corpus callosum and increasing dominance of the left
hemisphere, a more unified sense of self grounded in the
left hemisphere has become dominant and able to inhibit
these inner voices. Jaynes felt that psychotic symptoms
seen in patients in modern times may be the result of a
breakdown of the left hemisphere’s capacity to inhibit these
messages from the right.

Laterality and Psychotherapy

Happiness is not a matter of intensity but of balance,

order, rhythm and harmony.
—Thomas Merton

The proper balance and integration of the right and left

hemispheres does not appear to be a given in the course of
development. I strongly suspect that left-right integration is
an experience-dependent process that relies on adequate
assistance with affect regulation through secure
attachment. It is also dependent on the co-construction of
narratives where a model is presented for the recognition
and labeling of feelings, as well as integrating them into
experience. Psychotherapy can serve as a means to
reintegrate the patient’s disconnected hemispheres through
reality testing, emotional expression, and putting words to
feelings in the context of a caring relationship.
Examples from psychiatry and neurology strongly
suggest that psychological health is related to the proper
balance of activation, inhibition, and integration of systems
biased toward the left and right hemispheres. Genetic and
neuroanatomical factors can combine with early neglect or
trauma to interfere with the development of optimal neural
network integration and regulation. The similarity between
hemispheric specialization and Freud’s notion of the
conscious and unconscious mind has not been lost on
psychotherapists. Right hemisphere functions are similar to
Freud’s model of the unconscious in that they develop first
and are emotional, nonverbal, and sensorimotor (Galin,
1974). This nonlinear mode of processing allows the right
hemisphere to contain multiple overlapping realities, similar
to Freud’s primary process thinking most clearly
demonstrated in dreams. The linear processing of conscious
thought in the left hemisphere parallels Freud’s concept of
secondary process, which is bound by time, reality, and
social constraints.
When patients come to therapy, the left hemisphere
interpreter tells its story. But something is usually wrong:
the story does not fully account for what is happening in
their lives. The narratives that organize their identities
inadequately account for their experiences, feelings, and
behaviors. The right hemisphere also speaks via facial
expressions, body language, emotions, and attitudes. Thus,
we listen to both stories for the congruence between the
verbal narrative, and nonverbal and emotional
communication. In this process, we analyze the integration
and coherence of left-right and top-down neural networks. A
primary tool across all models of therapy is editing and
expanding the self-narrative of the left hemisphere to
include the silent wisdom of the right.
Hopefully, the therapist will be better integrated than the
client in a therapeutic relationship. This will allow the
therapist to react to what is said with emotion, resonate
with the client’s emotions, and then share thoughts about
those emotions with the client. Thus, the therapist’s ability
to traverse the colossal bridge between his or her own right
and left hemispheres serves as a model and guide for the
client.
Another way of describing therapy from the perspective
of laterality is that we teach clients a method by which they
can learn to attend to and translate right hemisphere
processing into left hemisphere language. We teach them
about the limitations and distortions of their own conscious
beliefs presented by their left hemisphere interpreter. Many
clients need to be suspicious of the ideas that their left
hemispheres offer them. This is why reality testing is so
important for treatment success. It is the therapist’s job to
hear what is not said, resonate with what the client is
unable to consciously experience, and communicate it back
to him or her in a way that will allow it to become
integrated. This human process serves hemispheric
integration.

Summary
The integration of dissociated processing systems is often a
central focus of treatment. Gradually, clients come to learn
how the therapist gathers and interprets the information
presented to them (Gedo, 1991). This process closely
parallels what is done during positive interactions with
parents during childhood. If the method taught during
childhood is maladaptive, it leaves the child (and later the
adult) in a state of limited self-awareness and neural
network dissociation. The learning of these skills in therapy
occurs in the context of emotional and cognitive integration,
requiring the participation of both hemispheres, reflective
language, feelings, sensations, and behaviors. In the
language of neuroscience, we are integrating dissociated
systems of memory and processing systems by teaching
new strategies for integrating rational and emotional
information. These processes aid in the construction of a
more inclusive self-narrative, which, in turn, serves as a
blueprint for ongoing neural integration.
Part III.

The Organization of Experience and the Healthy

Brain
Chapter 7

The Executive Brain

My own brain is to me the most unaccountable of

machinery—always buzzing, humming, soaring
roaring diving, and then buried in mud. And why?
What’s this passion for?
—Virginia Woolf

Through countless adaptational challenges and the process

of natural selection, we find ourselves with staggeringly
intricate and sophisticated brains: Ferraris—not Fords.
Ancient networks have been conserved, expanded, and
reorganized, while new networks have emerged and
combined to perform increasingly complex functions. In the
process, some executive functions remained with earlier
evolving networks, and some moved up to frontal and
prefrontal regions, while still others were assumed by the
mind and the social group.
The control of the vast majority of our bodily and mental
functions is on automatic pilot. Under normal circumstances,
we pay virtually no attention to breathing, walking, talking,
and thousands of other complex processes. We can drive a
car safely (and mindlessly) for hours while conversing and
listening to music. All of this automaticity allows us to focus
our conscious attention on just a small fraction of what is
happening at any given moment.
The executive cortical areas in our prefrontal lobes are
some of the latest neural systems to evolve and the slowest
to develop during childhood and adolescence. In many
respects these systems continue to develop throughout life,
allowing the potential for increasing perspective,
compassion, and wisdom. The executive brain contains the
control mechanisms that enable us to attend to a particular
activity, filter out distractions, make decisions, and act in an
organized and purposeful way. If these functions are carried
out successfully, we feel calm and safe enough to turn our
attention inward for contemplation, imagination, and self-
awareness. These capabilities, in turn, create the possibility
for art, religion, philosophy, and other uniquely human
endeavors.
Think for a moment of a large corporation with a CEO at
the top of its executive hierarchy. Lower level managers,
who specialize in particular areas of operation, are
employed by the corporation to control thousands of diverse
functions. Utilizing multiple lower level executives frees the
CEO to monitor market forces, keep an eye on the
competition, and plan for the future. Just as a CEO is freed
from the everyday concerns of production, building
maintenance, and bill paying, the executive areas of the
cerebral cortex are freed from attention to basic bodily
functions, well-learned motor behavior, and visual-spatial
organization. The executive brain participates in more basic
functions only in situations that are novel and problematic.
Although the executive areas of the brain are
traditionally thought of as being responsible for our rational
abilities, they actually combine sensory, motor, memory,
and emotional information to shape ideas, plans, and
actions. This broader view of executive functioning has been
guided, in part, by an increasing appreciation of the
contribution of emotion and intuition in decision making
(Damasio, 1994). Because so much of brain functioning is
unconscious, nonverbal, and hidden from conscious
observation, the executive brain is also strongly influenced
by nonconscious processes. Psychotherapy calls on the
executive brain to update and reorganize the relationship
among the conscious and unconscious networks they
oversee in the service of mental and physical health.
For the purpose of the present discussion, we will focus
primarily on the executive functions of the frontal and
prefrontal cortices. What we know about these areas is
based on a combination of primate and human research,
naturalistic observations, and clinical evidence with human
patients. Although the focus here is on the frontal and
prefrontal cortices, we will return to the idea of multiple
executive regions in a later discussion of the parietal lobes.

The Frontal and Prefrontal Cortices

The highest possible stage in moral culture is when

we recognize that we ought to control our thoughts.
—Charles Darwin

The frontal and prefrontal cortices are the prime candidates

for behavioral and emotional executive functioning in
primates and humans. Their organization and connectivity
provide for the integration of cognitive and emotional
processing (Fuster, 1997). Because there are no primary
sensory areas in the frontal cortex, they are entirely
dedicated to the association of information that has already
been highly processed in other neural systems throughout
the brain (Nauta, 1971). For example, projections from the
parietal regions contain integrated visual, motor, and
vestibular information, whereas those from the temporal
lobe have already combined sensory information with
socioemotional appraisal.
Although the human frontal lobes initially evolved to
organize complex motor behavior, the expansion of the
prefrontal lobes added capacities for planning, strategy, and
working memory. Neurons and neural networks within the
frontal cortex organize our behavior through time (Fuster,
Bonder, & Kroger, 2000) by sustaining a memory for the
future (Ingvar, 1985) that keeps in mind the eventual
consequences of behaviors about to be performed (Dolan,
1999; Watanabe, 1996). The ability to remember the past
and predict the future is essential for survival. Broca’s area,
in the left frontal cortex, for example, which controls
expressive speech, is located adjacent to the area of the
motor cortex dedicated to the lips and tongue. This
proximity reflects the coevolution and interdependence of
spoken language and fine motor control. Because of the
evolutionary links between motor behavior and cognition,
some theorists consider cognition to be a derivative of
motor behavior (Wilson, 1998). Support for this idea may
exist in that much of our symbolic and abstract thinking is
organized by the visceral, sensory, and motor metaphors
that permeate our language (Johnson, 1987).
As we have seen, networks in both hemispheres feed
highly processed sensory-motor information forward to the
frontal cortex. Simultaneously, multiple hierarchical
networks, which loop up and down through the cortex,
limbic system, and brainstem, provide the frontal cortex
with somatic and emotional information (Alexander et al.,
1986). The convergence of all of these networks within the
frontal and prefrontal lobes allows them to synthesize
diverse information and coordinate our attention, emotions,
and cognition with action.
The prefrontal cortex also participates in constructing
ideas about the beliefs, intentions, and perspective of
others in a process called theory of mind (Goel, Grafman,
Sadato, & Hallett, 1995; Stuss, Gallup, & Alexander, 2001).
Damage to the prefrontal cortex in early childhood usually
results in deficits in the development of theory of mind,
including learning social roles, perspective taking, and
empathic abilities (Dolan, 1999). Damage in the same areas
later in life can also result in deficits in these abilities,
sometimes referred to as pseudopsychopathy (Meyers,
Berman, Scheibel, & Hayman, 1992). Because empathy
requires conceptual understanding, emotional attunement,
and the ability to regulate one’s own affect, damage to any
area of the prefrontal cortex may impair different aspects of
empathic behavior (Eslinger, 1998). Empathic thinking
requires both cognitive flexibility and affect regulation in
order to pull back from the environment, put our current
needs aside for the moment, and imagine the feelings of
others.
The act of murder is the ultimate expression of a lack of
empathy. As a group, people who have committed murder
demonstrate significantly lower glucose metabolism in both
dorsal and orbital portions of the frontal areas. This finding
exists in the absence of indications of brain damage or
decreased metabolism in other areas of the brain (Raine et
al., 1994). Although antisocial behavior is a complex
phenomenon, correlations exist between deficits in affect
regulation, impulse control, and the inability to relate to the
experience of others.
The classic example of damage to the orbitomedial
prefrontal cortex (ompfc) is the case of Phineas Gage
(Harlow, 1868; Damasio, 1994). Mr. Gage was a young and
well-respected New Hampshire railroad foreman who was
known for his maturity and “well-balanced” mind. An
accident on the job sent an inch-and-a-quarter-wide iron bar
up through his head, obliterating much of his ompfc.
Although free of any “neurobehavioral” deficits from the
accident (such as aphasia, paralysis, or sensory loss), his
workmates reported that Gage was “no longer Gage.” After
the accident he was unable to control his emotions, sustain
goal-oriented behavior, or adhere to social conventions. He
went from being a young man with a promising future to an
aimless and unsuccessful drifter.
The Cortex and Inhibition

What a man’s mind can create, man’s character can

control.
—Thomas A. Edison

When we think of the human cerebral cortex, we may think

of the accomplishments of music, art, and culture—products
of cortical and especially prefrontal evolution. Although we
focus on these visible and impressive products of the human
brain, the hidden role of the cortex in inhibiting itself and
other brain structures is a vital aspect of the brain’s
capabilities. Consider this example: we are born with a
broad array of primitive brainstem reflexes conserved from
our primate ancestors. One of these is the grasping reflex,
which allows us to pick up infants by putting our index
fingers in their palms and lifting. For the first few months of
life infants can hold their own weight, after which they are
no longer able to hold on.
It is believed that this grasping reflex is a holdover from
a time when newborn monkeys had to hold onto their
mothers’ fur to free the mothers’ hands to traverse
branches and gather food. So although this behavior is no
longer required for survival by humans, it has been
conserved within our genetic blueprint. The only possible
role it may play for us is to enhance the experience of
bonding between newborn and parent. Many parents are
captivated and enthralled by the fact that their infant grasps
them and holds on so strongly. Over the first few months of
life this reflex gradually diminishes as descending fibers
from the cerebral cortex connect with the brainstem regions
that trigger them. But why does the cortex make this
inhibitory process such an early priority? After all there is so
much to learn. The most likely reason is that before the
cortical motor areas can begin to shape the dexterity of the
hands and fingers, they need to be released from the
control of this primitive reflex. In other words, before we can
move each of our fingers independently and in coordination
with each other, they need to be free from the tendency to
act together for a single purpose.
Now fast forward to later in life, when this same child is
60, 70, or 80 years old. Her children notice that she seems
forgetful and becomes disorganized from time to time, and
wonder if there may be something wrong. The family doctor
refers her to a neurologist who performs a series of clinical
tests. In one of these tests, the doctor asks her to hold her
arms out straight in front of her with her hands open and
palms facing down. Extending his arms under hers with his
palms up, the doctor slides his fingers under her arms from
the elbows up towards her hands. As he reaches her wrists,
he curls his fingers slightly and holds them rigid. As the
doctor’s fingers slide under the palms and then the fingers
he is looking to see if the touch of his hand triggers her
fingers to curl inward and grasp his own. If they do, he will
try it again after telling her not to grasp his fingers. If it
happens again, it is likely that the touch of his hand is
triggering the same brainstem grasping reflex that she
showed early in life. Why is this clinically significant?
It turns out that the reflexes in the newborn do not
dissolve, but rather remain embedded within the brainstem
throughout life, and are continually inhibited by descending
fibers from the cortex. With diseases like dementia, the
neurons in the cortex gradually die off and the cortex
becomes increasingly compromised. So what the doctor is
looking for are signs of compromise of cortical inhibitory
functioning suggestive of a potential stroke, tumor, or the
onset of dementia. Early reflexes that reemerge after
damage to the brain in adulthood are referred to as cortical
release signs (Chugani et al., 1987).
This inhibitory cortical function is not limited to primitive
reflexes; it is in play when we are able to keep ourselves
from reacting in games of Simon Says when Simon doesn’t
say, or hold our tongues in emotional situations where
saying something would only make things worse. A major
neurobiological component of secure attachment is the
building of descending fibers from orbital and medial
regions of the prefrontal cortex down to the amygdala and
other limbic structures, which allow the child to first use
parents as emotional scaffolding for the regulation of fear,
and later to be able to regulate her own fear through self-
talk, memory of positive outcomes, and proactive problem
solving (Ghashghaei, Hilgetag, & Barbas, 2007).

The Prefrontal Cortex

One of the most remarkable aspects of an animal’s

behavior is the ability to modify that behavior by
learning, an ability that reaches its highest form in
human beings.
—Eric Kandel

The prefrontal cortex is generally divided into two divisions;

the first consists of the orbital and medial regions (ompfc)
and the second comprises the dorsal and lateral areas
(dlpfc). Although physically contiguous, the orbitomedial
and dorsolateral prefrontal areas differ in their connectivity,
neural architecture, biochemistry, and function (Wilson,
O’Scalaidhe, & Goldman-Rakic, 1993). Research with
primates has demonstrated that although both areas play a
role in inhibition and control, the dlpfc is involved when the
decision is attentional, and the ompfc when it involves
emotional information.
The ompfc, first to evolve and first to develop during
childhood, sits at the apex of the limbic system and is richly
connected with subcortical networks of learning, memory,
and emotion (Barbas, 1995). These connections, and their
bias toward the right hemisphere, are associated with the
extremes of emotional processing. Like the right and left
hemispheres with which they are linked, the ompfc and
dlpfc can demonstrate various degrees of integration and
dissociation.

TABLE 7.1
Functions of the Prefrontal Lobes

Orbital and Medial Regions

Attachment1
Social cognition2
Thinking about a similar other3
Self-referential mental activity4
Appreciating humor5
Encoding new information6
Sensory-visceral-motor linkage7
Estimating reward value and magnitude8
Sensitivity to future consequences9
Achieving goals10
Stimulus-independent thought11
Inhibitory control in emotional processing12
Decisions based on affective information13

Dorsal and Lateral Regions

Cognitive control14
Directing attention15
Organizing temporal experience16
Organizing working memory17
Organizing episodic memory (right)18
Voluntary suppression of sadness19
Learning motor sequences20
Decisions based on complex information21
Thinking about a dissimilar other22
The integration of emotion and cognition23

The cognitive and emotional intelligences in which they

specialize have different developmental timetables and
learning contexts. Orbital and medial prefrontal areas begin
to organize emotional developmentin the context of
interpersonal relationships—from the first moments of life.
During the first 18 months of life, the ompfc shares a
sensitive period of development with the right hemisphere.
Dorsolateral areas exhibit an initial lag and then a growth
spurt with the development of language and the exploration
of our physical and conceptual worlds.
Our prefrontal cortex has two overarching and
interwoven areas of function, the regulation of affect and
attachments on the one hand, and the synthesis and
coordination of cognitive and motor processes on the other.
Although these two tasks seem quite different, each is
dependent upon the other. Abstract thinking and problem
solving are particularly dependent on adequate emotional
regulation, which, in turn, can be accomplished by using
rational thought and problem solving. The prefrontal cortex
also appears necessary for metacognition—our ability to
observe our stream of consciousness, revisit memories, and
think about our thinking, which depends upon the
integration of affect and cognition.
We can observe an array of functions in which the
prefrontal lobes participate by examining the kinds of
problems that emerge when they are injured (see Table 7.2).
We can also see that different regions of the prefrontal
cortex specialize in different functions. With most traumatic
brain injuries, like the one suffered by Luis, whom you will
soon hear about, all of these areas are negatively impacted.
On the other hand, more localized lesions may result in
some of these symptoms and not others. Each psychiatric
illness, too, has its characteristic profile of cognitive
distortions, difficulties with emotional regulation, and
deficits of self-awareness and self-monitoring reflective of
different patterns of frontal lobe involvement.
Problem solving—which requires emotional regulation,
sustained attention, and cognitive flexibility—is a central
executive function that can become impaired with frontal
compromise. Some patients get stuck in a particular way of
thinking (perseveration), while others have difficulty utilizing
abstract concepts (concrete thinking). They may have
difficulty in remembering the outcome of past behaviors and
repeatedly apply the same unsuccessful solutions to new
problems. Patients with frontal deficits often have a difficult
time monitoring social interactions, such as keeping the
listener’s perspective in mind and abiding by social rules.

TABLE 7.2
Manifestations of Prefrontal Compromise

Orbital and Medial Regions Dorsal and Lateral

Regions
Social and Emotional Loss of Executive
Disinhibition Function
Tactlessness or silly attitude Forgetfulness
Decreased social concern Distractibility
Sexual exhibitionism and lewd Decreased memory for
conversation the future
Grandiosity Decreased anticipation
Flare with anger and irritability Poor planning ability
Restlessness Deterioration of work
quality

Apathy Loss of Abstract

Attitude
Decreased attention Concreteness
Loss of initiative Stimulus bound
Lack of spontaneity Loss of aesthetic sense
Indifference Perseveration
Depression Set stuckness

Luis

The very essence of instinct is that it’s followed

independently of reason.
—Charles Darwin

Luis was in a serious auto accident a few days after his 20th
birthday. He and his parents came in to see me after his
neurologist suggested they all might benefit from family
therapy. At the time of their first appointment, I opened the
door to find eight people packed tightly into my small
waiting room. As Luis, his parents, and five younger siblings
filed into my office, I noticed the scars and indentations
across Luis’s forehead and imagined the damage beneath
them. I knew from talking with his neurologist that he had
sustained severe injuries to his prefrontal cortex and that he
had become impulsive, irritable, and occasionally violent.
Luis now possessed limited inhibitory capacity, reasoning
abilities, and almost no ability to be guided by social
expectations.
After we all settled in my office, I turned to the father and
asked how I could help him help his family. He immediately
became tearful, shook his head slowly from side to side, and
rubbed his hands together. “He drives too fast,” he said
quietly. “I don’t!” exclaimed Luis. “Except for that one
time!” Everyone in the family looked away and appeared
embarrassed. It was immediately clear that talking back to
his father was part of the problem. Although he had always
been somewhat impulsive, his parents claimed that he was
far worse than before the accident. I suspected that no
matter how impulsive Luis might have been before the
accident, this disrespectful behavior was new. This effect of
Luis’s accident was apparent just a few seconds into the
session.
As the family discussed their situation, I found out that
Luis’s parents had moved to the United States from Mexico
shortly before his birth, and had adapted well to their new
home. Despite their successful acculturation, they remained
true to traditional Mexican values of loyalty to the family
and respect for elders. In this context, Luis’s reflexive and
loud contradiction of his father was a source of shame for
everyone except Luis. His injury had damaged the networks
that allowed him to monitor and control his own behavior
and take into account the expectations of others. A year
after the accident he returned to his auto repair job but was
unable to focus on his work or get along with coworkers and
customers. The descending networks of cortical inhibition
had been compromised through the loss of so many
prefrontal neurons.
Luis didn’t remember anything about his accident and, in
fact, had no memory for the weeks before or after the
event. He read the police reports to discover that he had
lost control of his car while street racing and crashed into a
pole. His injuries were compounded by the fact that he was
not wearing a seat belt and had installed a steel steering
wheel without an airbag. Was this the foolishness of
adolescence or evidence reflecting his lack of judgment
prior to the accident? His mother reported that he spent
most of his time at home with her, and that his behavior
was erratic and sometimes frightening. At times he would
cry for no reason, yell at her and the others, and jump in her
car and race off. A few times, he went into a rage and threw
furniture around the house. He had also made sexual
statements and cursed using Jesus’s name during the
holidays, upsetting everyone in the family. Family members
were confused and torn between their loyalty to Luis and
their disgust with his behavior.
Automobile, industrial, and recreational accidents, as
well as community and domestic violence, all contribute to
the increasing number of people who experience traumatic
brain injury. Because the frontal areas are located directly
behind the forehead, they are also most likely to be
damaged in fights and accidents. Although patients with
head injuries come from all walks of life, young males are
disproportionately represented. Their youthful impulsivity,
risk taking, and lack of judgment, all dependent on
prefrontal and frontal lobe functioning, make them more
vulnerable to damaging these very regions. The massive
reorganization of prefrontal brain areas along with
biochemical and hormonal changes during adolescence
likely contribute to these dangerous behaviors (Spear,
2000). Many of these young men may have already had
frontal deficits or slowed frontal development prior to their
accidents, amplifying more typical adolescent risk taking. In
this way, frontal injuries often compound preexisting deficits
of impulse control and judgment, complicating treatment
and recovery.
Treatment with Luis and his family was multifaceted. I
began by educating the entire family about the brain and
Luis’s particular injuries. The specific information was less
important than labeling his behaviors as symptoms of his
injury. I targeted in particular his cursing and sexual
statements, which were, in their minds, connected to his
character and spiritual health. By sharing case studies of
others with them, I was able to show that Luis’s symptoms
were part of a pattern of pathological disinhibition related to
his brain damage and not the result of moral lapses or bad
parenting.
More specific interventions included enrolling Luis in an
occupational therapy program to help him develop the
instrumental and interpersonal skills needed to obtain and
maintain employment. As the oldest son, it was important
for him and the rest of the family that he be productive and
regain a sense of self-worth. One of my goals was to reduce
his resistance to taking medication that would help him with
his anxiety and depression caused by his changed
circumstances. I also worked with Luis and his family to
develop skills related to stress reduction and anger
management. We turned these exercises into family role-
playing games that alleviated tension and allowed everyone
to participate in helping Luis.
Over time, Luis was able to apply his knowledge of cars
to a part-time job in an auto parts store. His occupational
therapist helped him establish routines that allowed him to
successfully use the computer. Antidepressants proved
helpful with both his mood and irritability, and the role-
playing games became woven into the family’s everyday
interactions. All of these improvements made the occasional
outbursts more tolerable and more easily seen as part of his
illness. Luis was so very fortunate to have the unquestioning
love and support of a strong and involved family.

The Orbitomedial Prefrontal Cortex

Opinion is ultimately determined by the feelings, and

not by the intellect.
—Herbert Spencer
Tucked under and between the lobes of the frontal cortex
and sitting directly above the eyes, the ompfc is densely
connected to the anterior cingulate, amygdala, and other
structures of the basal forebrain (Heimer et al., 2008; Zahm,
2006). These networks are of special interest to
psychotherapists because they both generate and regulate
emotion and attachment (Kern et al., 2008; Levesque et al.,
2004; Rogers et al., 2004; Wager et al., 2008; Walton et al.,
2003). The anterior cingulate—involved with attention,
reward-based learning, and autonomic arousal—first
appeared during evolution in animals demonstrating
maternal behavior, nursing, and play (Devinsky, Morrell, &
Vogt, 1995; MacLean, 1985; Shima & Tanji, 1998).
Consequently, damage to either the ompfc or the anterior
cingulate results in deficits of maternal behavior, emotional
functioning, and empathy. As described earlier, disorders of
emotional control are also seen with damage to these
regions, including inappropriate social behavior,
impulsiveness, sexual disinhibition, and increased motor
activity (Price, Daffner, Stowe, & Mesulam, 1990).
The ompfc is vital for appraisal—interpreting complex
social events and linking them with their emotional value
via connections to the amygdala and other subcortical
structures. A good example of this is the ability of the ompfc
to modulate the amygdala’s reaction to fearful faces based
on the context in which the faces are presented (Hariri,
Bookheimer, & Mazziotta, 2000). So while the amygdala will
alert us to the sight of an angry face, the ompfc will include
information about additional environmental variables and
information based on past learning. If the ompfc recognizes
the face as that of a feared predator, the fight-or-flight
response will be activated. If the ompfc adds that it is the
face of a distressed baby, we may approach the child to find
out what is wrong and if there is something we can do to
help. Damage to either the amygdala or ompfc at any time
during life can result in an inability to organize vital social
information in a useful manner, resulting in deficits in
communication and connection.
Research has demonstrated that the ompfc also
calculates the magnitude of reward or punishment value of
our behavior such as approaching another for help and
winning or losing money while gambling. Estimating reward
value is a joint operation between the ompfc and the
amygdala (Dolan, 2007; Gottfried, O’Doherty, & Dolan,
2003). Much of this analysis occurs out of conscious
awareness and is commonly called intuition. Those of us
who are good at “reading” people or gambling might just be
aware of having a feeling about a particular decision. In
actuality, basal forebrain and somatosensory areas work
together to appraise huge amounts of information that
provide us with this feeling about what to do even if it is
sometimes contrary to our conscious logic (Damasio, 1994).

The Dorsolateral Prefrontal Cortex

Two things control men’s nature, instinct and

experience.
—Blaise Pascal

The dorsal and lateral regions of the prefrontal cortex (dlpfc)

integrate information from the senses, the body, and
memory to organize and guide behavior. The dlpfc performs
a variety of functions, including directing attention,
organizing working memory, learning motor sequences, and
organizing temporal experience (Fuster, 2004). The dlpfc is
the latest developing region of the cortex and continues to
mature into the third decade of life. This gradual maturation
of neural networks is vital to attention and judgment. It can
be tracked by looking at the increasing complexity of school
curricula and later through the slow decline of automobile
insurance rates from the teens into the 30s. The role of the
dlpfc in interacting and coping with the environment is
highlighted by the reduced spontaneity and flattened affect
seen when they are damaged.
A component of the integration of top-down, cortical, and
limbic processing occurs in the communication between the
ompfc and the dlpfc. The bias of these regions toward the
right and left hemispheres respectively allows them to also
support the integration of the left and right cerebral
cortices. In addition, the dorsal and lateral areas of the
frontal cortex evolved to network with the hippocampus
while the medial regions became densely interwoven with
the amygdala. Thus, the communication among prefrontal
regions provides pathways of integration for the
hippocampal and amygdaloid memory systems described
earlier.

Emotion and higher cognition can be integrated, i.e.,

at some point of processing, functional specialization
is lost, and emotion and cognition conjointly and
equally contribute to the control of thought and
behavior. (Gray et al., 2002, p. 4115)

Like a tennis doubles team, the ompfc and the dlpfc

depend on one another’s performance for optimal
functioning. If the ompfc is not doing an adequate job
regulating amygdala activation, heightened levels of
autonomic arousal will interfere with dlpfc-directed cognitive
processes (Dolcos & McCarthy, 2006). This is why we may
have difficulties in comprehending and solving even the
most basic problems when we are frightened or distraught.
On the other hand, if the dlpfc is not properly processing
and managing environmental demands, the resultant
anxiety will overtax and eventually disrupt emotional
regulation. In essence, both inner and outer worlds need to
be balanced and adequately regulated for optimal
functioning.
Attention-Deficit/Hyperactivity Disorder

Thinking is the momentary dismissal of irrelevancies.

—Buckminster Fuller

Jimmy, an elfin 8-year-old, was referred to me to assess

whether or not he had attention-deficit/hyperactivity
disorder (ADHD). Before meeting him, I read notes from his
parents, teachers, and soccer coach that described his
behavior. All agreed he was more distracted and energetic
than other children his age. His coach noted Jimmy’s
inability to stay focused on the game; one teacher described
him as a bundle of energy; his father wrote, in big letters,
“Exhausting!” Jimmy’s restlessness and impulsivity made it
difficult for other kids to interact with him, and his mother
felt he was becoming isolated as his peers sought calmer
company.
I walked into the testing room to find Jimmy’s mother
slumped in a chair with her face in her hands. She did not
react when I entered the room and I wondered if she might
be crying. I scanned the room, looked behind the chair and
small sofa, but could not see Jimmy anywhere. Before I
could speak, Jimmy shouted, “I’m up here!!” Startled, I
looked up and saw him perched on top of a six-foot storage
unit. I saw his mother momentarily pick up her head, roll her
eyes, and lower it back down into her hands. She wasn’t
crying, just overwhelmed. It was clear that while making a
diagnosis might not be difficult, getting through the
assessment process would require stamina and patience.
Jimmy did have ADHD, with the same symptoms his
father had when he was a boy. ADHD does sometimes run in
families. Apparently, his father still suffered from many
symptoms of distractibility and restlessness that created
difficulties in his work and relationships. After many failed
career attempts, he found considerable success in real
estate. The constant movement and transient relationships
utilized his energy and personality, while his choice of a
business partner—who excelled at handling the details of his
sales—protected him from his deficits in attention. Being a
stable husband and father, however, proved more
problematic.
The treatment for Jimmy included behavioral therapy to
help with his attention and social skills, martial arts classes,
and stimulant medications. These and other interventions
were designed to boost frontal functioning through
biochemical and behavioral interventions (social skills and
teaching him to stop and think), and by giving him
constructive avenues through which to channel his
considerable energy. Individuals like Jimmy who suffer from
ADHD are characterized by an inability to sustain attention
and inhibit extraneous impulses, thoughts, and behaviors.
These individuals can be easily lost in daydreams or be in
constant motion. They are also in danger of leaping before
they look. In fact, Jimmy had been injured a year earlier
when he raced into a neighbor’s backyard and jumped into
the pool before noticing it had been drained for repair.
Since Satterfield and Dawson (1971) first pointed to a
dysfunction of frontal-limbic circuitry, ADHD has been
understood to be a disorder of executive control. The
common explanation from psychiatrists to parents is that
their children have a lag in frontal lobe development that
results in a disinhibition of impulses from lower in the brain
and difficulties with tasks which require sustained attention.
They are also told that there is a good chance their child will
“grow out of it” as the frontal lobes mature. In the
meantime, stimulant medications will turbocharge these
lagging frontal regions, allowing for more functional
behavior. While this is a good anecdotal explanation, the
underlying mechanisms and the etiology of ADHD are likely
much more complicated.
Functional imaging research comparing ADHD to non-
ADHD subjects reveals a variety of patterns of higher and
lower levels of activation throughout the brain. And like
most psychiatric disorders, ADHD is heterogeneous and
emerges from a spectrum of genetic, biological, and
interpersonal factors (Sun et al., 2005). It is likely that the
explanations of the causes and treatments of the disorder
lie within hierarchical networks between the attentional and
inhibitory circuitry of the frontal and parietal cortex, and
subcortical networks in the striatum and cerebellum that
trigger and organize motor behavior. It is unwise, however,
to necessarily posit these deficits in the frontal lobe because
complex behaviors rely on far-reaching circuitry that can
demonstrate similar dysfunctions regardless of where in the
network the problems exist (Seidman, Valera & Makris,
2005; Willcutt et al., 2005).
Stimulant medications (such as Ritalin) may be working
on the frontal lobes, the striatum (Vaidya et al., 1998), the
cerebellum (Anderson et al., 2002), or more systemically by
boosting general levels of dopamine and norepinephrine
(Arnsten, 2000; Arnsten & Li, 2005). All we can be sure of is
that it is rebalancing this hierarchical circuitry in a way that
decreases motor agitation while enhancing attention.
Because the brain works in interactive networks, the safest
working hypothesis at this point is that there is a problem in
the hierarchical neural networks that both activate and
regulate behavior and attention (Durston et al., 2003; Lee et
al., 2005; Rubia et al., 1999).
Think of playing a game of Simon Says. Simon Says tests
our abilities to respond to the command while monitoring
and inhibiting our behavior based on whether or not Simon
says. The winner will be someone with well developed,
balanced, and integrated bottom-up networks of motor
responses and top-down networks of inhibitory control.
When we hear a command in the absence of the words,
“Simon says,” we feel our body react and the tension of
inhibition as we exert control to stop ourselves. The
popularity of this game with small children reflects the
development of these systems as well as a way to exercise
voluntary control over impulses. When individuals with
ADHD engage in tasks similar to Simon Says, they show a
lower level of activity in the usual cortical areas dedicated
to inhibition and instead rely on a more diffuse and less
effective group of neural structures as compensatory
mechanisms (Durston et al., 2003; Schulz et al., 2004; Zang
et al., 2005).
Children with ADHD have difficulties in organizing their
behavior when they are confronted with situations that
require them to inhibit motor responses and sustain
attention to addressing complex tasks. Thus, they have
difficulties in learning, which requires attending to and
recalling verbal material, complex problem solving, and
planning. They require much more motivation to maintain
attention, and so they often excel at video games, which
capture their attention and for which their ability to shift
attention serves them well.
Our understanding of the brains of individuals with ADHD
is still limited, and a variety of findings have emerged from
research using various imaging techniques (Bush, Valera, &
Seidman, 2005). Table 7.3 lists some of the studies that
point to an array of differences between ADHD and non-
ADHD individuals using different measurement methods.
The best guess at this point is that individuals diagnosed
with ADHD likely reflect a number of subgroups with
different types of brain involvement. They suffer from a
number of different processes reflected in the size, shape,
and function of their brains. The usual cortical systems of
attentional control and inhibition appear compromised while
other networks attempt to compensate. Subcortical
structures involved in motor movements are also affected in
ways that result in greater but less organized impact on
experience and behavior.
 TABLE 7.3
Attention-Deficit/Hyperactivity Disorder

Functional Magnetic Resonance Imaging (fMRI)

Decreased Activation In
Parietal attentional systems1
Anterior-mid cingulate cortex2
Supplemental motor area3
Right middle prefrontal cortex4
Right inferior frontal cortex, left sensorimotor cortex and
bilateral cerebellum lobes and vermis5

Increased Activation In
Left temporal gyrus6
Basal ganglia, insula, cerebellum7
Right anterior cingulate cortex8

Regional Cerebral Blood Flow (rCBF)

Hypoperfusion or Decreased Activation
White matter regions of the frontal lobes and caudate
nuclei9

Hyperperfusion or Increased Activation

Right striatum and somatosensory area10

Brain Morphology
Smaller cerebral and cerebellar volume11
Smaller right prefrontal and caudate volume12
Reduction of left cortical convolutional complexity in boys13
Cortical thinning in adults in right parietal, dorsolateral, and
anterior cingulate areas—all involved with attentional
control14
Loss of cerebellar volume15
Decreased frontal and cerebellar white matter density16
 Lastly, I want to mention a phenomenon I have
witnessed repeatedly over the years—children who are
diagnosed with ADHD and treated with medication but are
better described as using a manic defense to cope with
overwhelming anxiety. An assessment of the psychological
state of the household—parental relationship, parental
psychopathology, emotional context of siblings and
extended family, external stressors, and so on, can all go a
long way in sorting out a proper diagnosis. Chronic stress
negatively impacts frontal lobe functioning and can result in
memory impairment, poor impulse control, and deficits of
attention (Birnbaum et al., 1999).

Summary
Executive functioning is a complex evolutionary
accomplishment that we are still in the process of
understanding. Many regions across the prefrontal regions
and throughout the cortex contribute to our abilities to
focus, organize our thoughts, regulate our emotions, and
create the experience of self. Head injury, ADHD, and other
psychiatric illnesses provide selective insight into the results
of dysregulation or loss of neural networks central to
executive processing. As our knowledge of neural networks
expands, perhaps we gain a greater understanding of how
the mind emerges from the wetware of the brain.
Chapter 8

Consciousness and Reality

People are accustomed to look at the heavens and to

wonder what happens there. It would be better if they
would look within themselves…
—Kotzker Rebbe

At the heart of psychotherapy are two interwoven

processes; the first is the way in which our brains and minds
construct reality, while the second is our ability to modify
these constructions to support mental health and well-
being. In other words, why are we so vulnerable to
constructing distorted realities, and how can we learn to
counterbalance these distortions? People come to therapy
because one or more aspects of their lives are not how they
would like them to be. Most often our clients know what
they should be doing differently but cannot bring
themselves to make changes. They come in with a feeling
that something within them is holding them back. The
answers to their questions can usually be found in the
architecture of the hidden layers of neural processing—
those networks within the brain that construct our reality,
guide our experience, and shape our identity.
Prior to my training as a clinical psychologist, I spent
many years studying the beliefs and practices of Eastern
religions. One of the first things I discovered was that
Buddhism is less akin to Western religious traditions than to
the analytic introspection of William James or the
selfanalysis of Sigmund Freud. At the core of Buddhist
teachings is the belief that the experience of world and self
are illusions (Maya) and that our minds and senses fool us
into attributing significance to things that are, in
themselves, devoid of meaning. In other words, “reality” is a
construction of the mind which we take to be an external
truth. So, at the heart of both dynamic psychotherapy and
Buddhism is the fundamental belief that our conscious
experience is a creative fiction subject to distortion.
Although controversial, the way in which the brain
generates consciousness, including its many distortions,
may have been subject to the pressures of natural selection.
That is, our creative fictions may be sculpted to enhance
survival rather than to maximize perceptual accuracy. While
the way in which our brains construct consciousness and
reality may have some survival advantages, we turn our
focus here to those aspects which impair our relationships
and limit self-insight. You will soon see that the take-home
message from psychoanalysis, Buddhism, and neuroscience
is to be a skeptical consumer of the offerings of your mind.

Beware of Maya

We don’t see things as they are; we see things as we

are.
—Anaïs Nin

Let’s begin by taking a look at some of the illusions of

consciousness through which we construct reality. The first
is that our conscious awareness comes together at some
specific location within our heads and is presented to us on
a screen. This Cartesian theater—an homage to Descartes’s
articulation of mind–body dualism—creates the subjective
illusion of self as a nonphysical spirit inhabiting the body as
opposed to being one with it (Dennett, 1991). This spirit,
some religions believe, can leave the body upon death, go
to heaven, or occupy a new body in the next life.
A second illusion is that our experience occurs in the
present moment and that conscious thought and decision
making precede feelings and actions. In fact, our brains
react to internal and external stimuli in as little as 50
milliseconds, yet it takes more than 500 milliseconds for
conscious awareness to occur. During this half-second,
hidden layers of neural processing shape and organize these
stimuli, trigger related networks, and select an appropriate
presentation for conscious awareness (Panksepp, 1998).
Although we tend to think of our brains as processing
information from the environment, the vast majority of the
input to the cerebral cortex comes from what is already
inside the brain. And because our senses are shaped by
experience, they are also silent contributors to the
construction of reality (Gibson, 1966).
The projection onto the screen of our Cartesian theater is
actually generated within the hidden layers of our neural
architecture prior to conscious awareness. This leads us to
assume that the world of our experience and the objective
world are one and the same. We also tend to believe that
we have all the necessary information we need to make
choices. In truth, we often have little or no access to the
information or logic upon which we base our decisions. In
addition, we possess a powerful reflex to confabulate in the
absence of knowledge (Bechara, Damasio, Tranel, &
Damasio, 1997; Lewicki, Hill, & Czyzewska 1992). What we
call intuition is likely the result of rapid and unconscious
processing that can be so surprising to us that it is often
attributed to occult knowledge or psychic powers.
A third illusion, which relies on the first two, is that our
thoughts and behaviors are under conscious control (Bargh
& Chartrand, 1999; Langer, 1978). This hubris leads us to
consistently overestimate the authority we have over an
outcome, while underestimating the role of chance,
unconscious influences, and outside forces (Taylor & Brown,
1988). So although we may feel as if we are at the wheel of
our lives, it might be more accurate to say that most of us
are trying to steer our lives with the rearview mirror.
The illusions of the Cartesian theatre, living in the
present moment, and being in total control of our actions
can be successfully exposed on cognitive and neurological
grounds. Yet the ubiquity of many perceptual and cognitive
distortions in everyday human interaction, provides
convincing evidence for the existence of nonconscious
processing (Levy, 1997). And unlike bothersome
psychological symptoms, these illusions and distortions are
invisibly woven into the warp and woof of our perception,
memory, and character (Reich, 1945).
By definition, hidden layers of neural processing cannot
be directly observed. Like black holes, we are made aware
of their existence by their effects upon the visible world.
Hidden layers can make the same situation a source of
pleasure or dread, acceptance or rejection, pride or shame.
They will highlight some aspects of experience while
diminishing others, orient us to certain aspects of the
environment, and completely block awareness of others.
Our hidden layers translate past experience into an
anticipated future, converting past trauma into a self-
fulfilling prophecy of future suffering (Brothers, 1997; Freyd,
1987; Ingvar, 1985). This carryover of past learning into the
present where it may be irrelevant or destructive is certainly
one of the contemporary human brain’s major design flaws.

Perceptual Biases and Self-Deception

The most erroneous stories are those we think we

know best—and therefore never scrutinize or
question.
—Stephen Jay Gould
The consistency of many perceptual and cognitive biases
across individuals reflects our shared neural organization
and functioning. Some of these biases are the result of
natural limits to our perspective and judgment, while others
may have evolved to help us cope with living in an uncertain
and dangerous world. Although many of our perceptual
biases appear to serve us, they can also lead to the kinds of
problems that often become the focus of psychotherapy.
Social psychologists have identified a number of
consistent errors in human judgment that can be especially
damaging to relationships among individuals, groups, and
nations. Our tendency to explain the behavior of others
based on aspects of their character, while explaining our
own behaviors as a result of external factors, is referred to
as the fundamental attribution error (Heider, 1958). In other
words, others flunk tests because they are not smart
enough or are too lazy to study; we fail because the test
wasn’t fair or because the professor wasn’t very good. An
extension of this attributional bias leads to a phenomenon
called blaming the victim, where individuals victimized by
crime or poverty are believed to have done something to
create their misfortune (Ryan, 1971).
While individual perspectives are limited and incomplete,
this does not stop us from assuming that we possess the
true view of the world. This egocentric bias leads us to
reflexively believe that anyone who sees the world
differently from ourselves is misguided or dull-witted.
Unfortunately, it also leads mortal enemies to both believe
that God is on their side. While an egocentric bias is
reflexive and self-evident, maintaining a balanced
perspective requires sustained mindful effort.
Another bias organized within our hidden layers is called
belief perseverance—the tendency to attend to facts
supportive of existing beliefs while ignoring others (Lord,
Ross, & Lepper, 1979). The hidden layers are conservative,
holding onto thoughts, feelings, and behaviors that have
been associated with past survival (Janoff-Bulman, 1992).
Thus, we scan for examples that prove preexisting beliefs
and ignore ones which contradict them. This tendency is
likely driven by the tenacity of fear memories stored within
the amygdala and our desire to avoid the possibility of
danger in the unknown. This may explain why prejudices
continue to persist in the face of conflicting evidence.
One reason that our abilities of self-deception may have
been selected during evolution is because they aid in the
deception of others. The more we believe our own
deceptions, the less likely we are to give away our real
thoughts and intentions via nonverbal signals. In fact, it
requires considerable more brain power to lie than to tell
the truth, and even more to convince others that we are
being honest with them when we are lying (Ganis et al.,
2003). Good poker players raise the skill of social deception
to an art by keeping a poker face while learning the “tells”
of their opponents. Actions and beliefs that are the opposite
of our true desires can be quite effective in deceiving
others. It has also been noted that “people are remarkably
reluctant to consider impure motives in a loud moralist”
(Nesse & Lloyd, 1992, p. 611) despite the repeated and
well-publicized downfall of one moral crusader after another.
In fact, the best con artists are often so convincing that their
victims refuse to accept that they have been cheated at all.
The distortions of the psychodynamic unconscious—
reflected in defense mechanisms such as reaction
formation, denial, humor, and intellectualization—are
thought to keep thoughts and feelings out of conscious
awareness to help us regulate negative emotions. Defense
mechanisms may enhance survival by reducing shame,
minimizing anxiety, and decreasing awareness of
depressing and demoralizing realities. Some defenses also
support social cooperation and lead us to either overlook or
put a positive spin on the bad behavior of family and
friends. Freud recognized that we can see the workings of
defense mechanisms and other aspects of the unconscious
in the way that we organize and understand ambiguous
stimuli. In a condition of reduced external structure, our
hidden layers organize the world, make predictions, and
highlight certain thoughts and feelings while ignoring
others. You may remember that Freud referred to this
phenomenon as the projective hypothesis.
Therapists employ the projective hypothesis to explore
the architecture of their clients’ unconscious. Some try to
remain as neutral as possible to allow clients to project
feelings and thoughts onto them in a process referred to as
transference. In a similar manner, projective tests like the
Rorschach present ambiguous stimuli to evoke idiosyncratic
perceptions of the material. Finally, because of their
uninhibited nature, Freud was impressed with the value of
dreams in providing us with insight into hidden layers,
calling them “the royal road to the unconscious.”
Most forms of psychotherapy attempt to shine the light
of conscious awareness on belief perseverance and
attribution biases, and undermine the conservative nature
of the hidden layers. Others engage in a deep exploration of
the dynamic unconscious, defenses, and primitive emotional
states. By encouraging clients to be open to new ideas,
explore the connections within their hidden layers, and take
responsibility for positive change, we challenge them to
reorganize the neural networks of their hidden layers.

Searching for the Still Point

Men are disturbed not by things, but by the view

which they take of them.
—Epictetus

By now it is clear that our brains are in the business of

constructing rather than conveying reality. This perspective
is in sharp contrast to the modern Western notion of the
brain as a combination camera, tape recorder, and
computer. If our electronic equipment really did function like
our brains, we would replace them at the first opportunity.
But I’m sure you would agree that, imperfect as they are,
we would take our brains over a machine any day. Few of us
would want to sacrifice feelings of love, inspiration, and
passion for the sake of accuracy or efficiency.
Once we wake up to how our brains work, what do we
do? How can we overcome or at least cope with our
distortions, impulses, and unconscious drives in constructive
and healthy ways? Fortunately, our brains contain structures
and networks that allow us to counteract some of the more
problematic workings of our hidden neural layers. Let’s
begin an exploration of the evolution of consciousness with
ice cream.
I’m a person who has been on a diet all my life with
limited success. I could do well all day—eat properly and
exercise—but at night, I would seem to have no self-control.
I would go into each day feeling bad about the night before
and vow to do better, only to fail again. Years into therapy I
mentioned this in a session and was given the following
suggestion: “Pay attention to your thoughts, feelings, and
fantasies during the transition from doing well to your loss
of control.” It turned out that, depending on the day, I felt
exhausted, stressed, lonely, or dissatisfied with one thing or
another on these evenings. When my therapist asked what I
did with these negative and painful feelings, I was stumped.
I didn’t remember doing anything with them—they seemed
to just dissolve. As I struggled to make sense of this
process, I recalled a vivid memory.
I was a young boy of 5 or 6 standing in my
grandmother’s kitchen and had just expressed being upset
about something. I could feel my unhappiness expressed in
the muscles of my face and recall my grandmother’s face
mirroring mine. Without saying a word she pivoted around,
opened the freezer, took out a large box of Neapolitan ice
cream (chocolate, vanilla, and strawberry in three neat
rows), tore off the cardboard tab holding the lid closed,
buried a spoon in the ice cream, and handed me the entire
box. Also without a word I went to the sofa, lay down, put
the quart of ice cream on my chest and began eating. In
fact there were no words at all. There was no memory of
discussing how I felt. Whatever bad feelings I may have
been having quickly dissolved in a haze of glucose.
The similarity of this memory to my experience in my
adult life was striking. My hidden layers had learned a
pattern—feel tired, sad, stressed, or disappointed; get lots
of calories; watch TV; and the feelings pass. These early
memories were encoded in hidden layers and guided my
behavior when triggered by similar states of mind. Being the
first grandchild in an extended family that had experienced
a great deal of sadness and loss, I realize in retrospect that
no one could cope with my sadness. I was the hope for a
better future where there would be no pain. Having no
language with which to process my feelings, I could only
deal with them through actions. As long as I continued to
act this process out without awareness of what was
happening, it continued in a stereotyped manner much like
a posttraumatic flashback.
What is it that allows us to become self-aware, generate
explanations, and modify long-standing ways of being? How
do we expand conscious awareness in ways that allow us to
change? Obviously, something has to change in the way our
brains process information when we benefit from
psychotherapy. Let’s explore two central regions involved in
awareness and change—the prefrontal and parietal cortices.
Because behavior is easily observable, neurologists have
traditionally focused on the manifest results of brain injury
such as deficits in language, motor behavior, and memory.
At the same time, there has been significant confusion and
misunderstanding when it comes to changes in subjective
experience. I have worked with many clients who perform
within normative ranges on objective tests of memory and
intellect, but complain that their inner worlds are no longer
the same. Some use the metaphor of a house and say that
some rooms are no longer accessible to them. Others have
described blackboards they could use to work out problems
that have been lost. These subtle and elusive aspects of
human experience have received little attention from
neurologists. What is even more difficult for clients is to
perform well on objective tests of memory and problem
solving, and be told that they have fully recovered, when in
fact they know better. Their use of three-dimensional
metaphors like houses and blackboards to describe inner
experience may be telling. Is the house as an archetype for
the self (as Carl Jung suggested) more than myth?
How does the brain achieve conscious awareness? Where
is the seat of consciousness? The answer to both of these
questions is that we don’t yet know. At this point, we must
be satisfied with discovering pieces of this complex puzzle
of consciousness that will be assembled sometime in the
future. Because executive problems often arise after
damage to the prefrontal areas, it is generally assumed that
consciousness and self-awareness reside within these
regions, but the key to understanding consciousness
extends beyond the frontal lobes. We can be somewhat
confident that consciousness emerges from the coordination
of many processes throughout the brain and that the
prefrontal lobes are major players. I would suggest that
another major contributor to our conscious experience is our
parietal lobes. Let me explain why.

The Parietal Lobes

The soul never thinks without a mental picture.

—Aristotle
You may remember that the parietal lobes evolved from the
hippocampus which, in lower mammals and humans,
organizes an internal three-dimensional map of the external
environment (Joseph, 1996; O’Keefe & Nadel, 1978). This is
especially useful in navigating a habitat for foraging,
storing, and retrieving food. The hippocampi of mother rats
actually increase in size when they have babies, in
preparation for having more mouths to feed. The
hippocampi of cab drivers in London are larger than those of
other Londoners, because of their need for a detailed inner
map of a large and complicated city (Maguire, Woollett, &
Spiers, 2006). It seems that the parietal lobes developed a
parallel capacity for constructing and navigating a map of
internal, imaginal space.
Curiously, some studies of primate brain evolution
suggest that expansion of the parietal and not the frontal
lobes is most characteristic of the transition to the human
brain (von Bonin, 1963). Could the fact that we don’t think
of the parietal lobes as a component of the executive brain
reflect a cultural bias of equating individuals with their
external behavior rather than the quality of their inner
experiences? The parietal lobes’ interconnections with the
rest of the cortex allowed for the integration of working
visual memory, attentional capacities, and bodily awareness
necessary for these imaginal abilities. This suggests that our
self-awareness was likely built in a stepwise manner during
evolution through a series of overlapping “maps”—first of
the physical environment, then of self in environment, and
later of self as environment. Thus, the growth of imaginal
abilities allowed us to create an increasingly sophisticated
inner topography.
The lower parts of the parietal lobes develop through the
first decade of life in parallel with our increasing abilities in
reading, calculations, working memory, and three-
dimensional manipulation (Joseph, 1996; Klingberg,
Forssberg, & Westerberg, 2002; Luna, 2004). Cells in these
inferior parietal regions respond to hand position, eye
movement, words, motivational relevance, body position,
and many other components of the integration of physical
experience in space. Left parietal damage disrupts
mathematical abilities while damage to the right parietal
lobe results in disturbances of body image and the neglect
of the left side of the body. Despite these florid and
debilitating symptoms, patients are either oblivious to or
deny the significance of their deficits, which suggests that
the parietal lobes serve an executive role in the organization
of self-awareness. Damage to the parietal lobes disrupts the
experience of location, self-organization, and identity—in
other words, who and where we are (see Table 8.1).

TABLE 8.1
Manifestations of Parietal Compromise

Left Parietal Compromise Results In

Gerstmann syndrome, which includes the following
symptoms:
Right-left confusion
Digital agnosia (inability to name the fingers on both
hands)
Agraphia (inability to write)
Acalculia (inability to calculate)1
The symptoms of Gerstmann syndrome are linked through a
unitary deficit in spatial orientation of body—sides,
fingers, and numbers2

Right Parietal Compromise Results in Deficits Of

Mental imagery and movement representations3
Visual-spatial awareness4
Visual-spatial problem solving5
Temporal awareness and temporal order6
Spatial perception7
Somatosensory experience8
Detecting apparent motion9

The analysis of sound movement10

Spatial-temporal abnormalities11
Contralateral neglect of the body and external space12
Denial of hemiparalysis and neglect13

The posterior parietal regions weave together sensory

information about our physical environment with networks
of organized motoric actions and intentions which (along
with the frontal lobes) create goal-directed action plans
(Anderson, Snyder, Bradley, & Xing, 1997; Colby &
Goldberg, 1999; Medendorp, Goltz, Crawford, & Vilis, 2005).
In combination with episodic and working memory, this
would provide a work space for decision making about
whether or not to perform an action—should I eat the ice
cream or is something else going on that I should pay
attention to? Utilizing these abilities, a frontal-parietal
network could support the integration of perception and
action over time (Quintana & Fuster, 1999).
Parietal activation occurs during a wide variety of
cognitive tasks, suggesting that high-level association areas
involved in the coordination of sensory and motor
processing underlie what we experience as abstract
(nonphysical) processes (Culham & Kanwisher, 2001;
Jonides et al., 1998). It is likely that evolution has used
these core visual-spatial networks to serve as an
infrastructure for language and higher cognitive processes
(Klingberg et al., 2002; Piazza et al., 2004; Simon et al.,
2002). The parietal lobes participate in our conscious
awareness of visual experience, voluntary actions, and a
sense of agency during actions (Chaminade & Decety, 2002;
Decety et al., 2002; Rees, Kreiman, Koch, 2002; Sirigu et al.,
2003). The multimodal representation of space in the
posterior parietal areas integrates our goal-directed
behavior and attention with higher cognitive functions
(Andersen et al., 1997; Bonda et al., 1996; Corbetta &
Shulman, 2002; Culham & Kanwisher, 2001).
Like the frontal lobes, areas of the parietal lobes become
activated by novelty and appear to be involved in coding
intentions and calculating the probability of success (Platt &
Glimcher, 1999; Snyder, Batista, & Andersen, 1997; Walsh,
Ashbridge, & Cowey, 1998). These findings point to the fact
that the parietal lobes are far more than sensory-motor
association areas, but are involved in the deployment of
attention, understanding the environment, and constructing
the experience of self (see Table 8.2).
The medial parietal area can be conceptualized as the
central structure for self-representation, self-monitoring, and
a state of resting consciousness (Lou et al., 2004). Damage
at the junction of the parietal and temporal lobes correlates
with out-of-body experiences and a variety of other
disturbances of identity and self (Blanke & Arzy, 2005).
There is also evidence to suggest that the parietal lobes
participate in the creation of internal representations of the
actions of others within us (Shmuelof & Zohary, 2006). In
other words, we internalize others by creating
representations of them in our imaginations. This allows us
to both learn from others and carry them with us when they
are absent. These inner objects, as described in
psychoanalysis, likely serve as the infrastructure of the
construction and maintenance of our experience of self
(Macrae et al., 2004; Tanji & Hoshi, 2001).
 
TABLE 8.2 Functions of the Parietal Lobes
 Hemisphere Function
Right Analysis of sound movement1
  General comparison of amounts2
  Attention3
  Self-face recognition4
Left Verbal manipulation of numbers5
  Mathematics6
  Multiplication7
  Motor attention8
 
Bilateral Findings
Visual-spatial work space9
 
Visual-spatial problem solving10
Visual motion11
Construction of a sensory-motor representation of the
internal world in relation to the body12
nternal representation of the state of the body13
Verbal working memory14
Retrieval from episodic memory15
Sequence and ordering of information in working memory16
Controlling attention to salient event and maintaining
attention across time17
Preparation for pointing to an object18
Grasping19
Movement of three-dimensional objects20
 
A sense of “numerosity” defined as nonsymbolic
approximations of quantities (l)21
Processing of abstract knowledge22
Perspective taking (r)23 Processing of social information (r)24
Taking a third-person perspective (r)25
 
(l) left hemisphere (r) right hemisphere

Some sort of frontal-parietal network appears to be

essential to our experience of self. Neural fibers connecting
the middle portions of these two areas appear to serve a
general integrative function of linking right and left
hemispheres, limbic and cortical structures, as well as
anterior and posterior regions of the cortex (Lou et al.,
2004). Frontal-parietal networks work together to analyze
the context and location of specific variables, work to
interrupt ongoing behavior, and direct attention to new
targets (Corbetta & Shulman, 2002; Peers et al., 2005).
Frontal-parietal circuits are also involved in the sustained
focus and updating of information in working memory (Edin
et al., 2007; Sauseng et al., 2005). They may together give
rise to a global work space or central representation
allowing for conscious working memory and self-reflection
(Baars, 2002; Cornette, Dupont, Salmon, & Orban, 2001;
Taylor, 2001).
The frontal-parietal network may be primarily responsible
for the construction of the experience of self (Lou, Nowak, &
Kajer, 2005). A properly functioning frontal-parietal network
allows for the successful negotiation of our moment-to-
moment survival and the ability to turn our attention to
inner experience. A compromised or poorly developed
prefrontal cortex can ensnare us in “a noisy and temporally
constrained state, locking the patient into the immediate
space and time with little ability to escape” (Knight &
Grabowecky, 1995, p. 1368). Without the ability to reflect on
and sometimes cancel reflexive motor and emotional
responses, there is little freedom (Schall, 2001). A similar
phenomenon can occur with anxiety, as in obsessive-
compulsive disorder. When the medial frontal lobes are
incapable of adequate affect regulation, victims become
“stuck” to the environment or “stimulus bound” and unable
to override reflexive reactions (Brown et al., 1994).

Constructing a Self

I never came to any of my discoveries through the

process of rational thinking.
—Albert Einstein

Creating a quiet internal world allows for private thought,

self-reflection, and traveling through time via episodic
memory. Quiet moments can then serve as the grounds for
mentalization, creativity, and consolidating the self
(Winnicott, 1958). Victims of frontal brain injury lose this
ability and are constantly distracted by sensory and
emotional experience, are unable to maintain focus, and
suffer deficits of imagination. These individuals become
trapped in time, unable to disengage from the constant
stream of sensations, emotions, and demands of their inner
and outer worlds. Although they retain consciousness, for
them, attention, concentration, affect regulation, and
motivation become problematic, while higher level
metacognitive processes become impossible.
Winnicott (1962) suggested that the ego and one’s sense
of self consolidate during the periods of quiescence when
children feel safe and calm in the presence of their parents.
Good-enough parenting scaffolds the child, allowing him or
her to go “inside” and rest in imagination and the
experience of self (Stern, 1985). This may serve as an
important mechanism of the transmission of neural
organization from parent to child. It is rare to find a child
who is able to be still and centered and feel safe in the
presence of chaotic adults. We believe that early caretaking
builds and shapes the cortex and its relationships with the
limbic system, which supports emotional regulation,
imagination, and coping skills. To this we now must add the
development of the parietal lobes in the construction of
internal space.
As a child I had an imaginary retreat. I would close my
eyes and picture the back of my grandmother’s closet,
always piled high with shoe boxes. Behind these boxes was
a hidden door just large enough for me (but not an adult) to
squeeze through. Once through the door, there was a flight
of stairs leading up to a large room resembling a medieval
laboratory, the kind with a resident sorcerer. This was a safe
place for me—quiet and private—where I could imagine
other worlds, reflect on life, and fantasize about the future.
The evolution and expansion of the parietal lobes were likely
essential to the emergence of this kind of imaginal self.
One study has shown that when experienced meditators
engage in meditation, the frontal lobes become less active
while the parietal lobes become more active, reflective
perhaps of a shift from outer to inner attention (Newberg et
al., 2001). Other studies have shown a shift to left
hemisphere activation and stronger immune response with
meditation (Davidson, Kabat-Zinn, et al., 2003).
Interestingly, inferior regions of the right parietal lobe
become activated when we witness others being still. This
may explain how meditating on inanimate objects or statues
of a tranquil Buddha may help us feel centered within
ourselves (Federspiel et al., 2005). This may also be a part
of internalizing calm parents as a model for self-reflection.
Johnson (1987) asserts that the experience of our bodies
provides the internal basis for meaning and reasoning with
our sense of numbers, quantity, and space growing out of
bodily experience. The brain’s ability to take our physical
experience and use it metaphorically is the basis of
imagination. For example, jumping down a slide may serve
as a sensory-motor metaphor for falling in love. The child’s
experience of emerging from under the covers into the light
of day provides a metaphor for religious enlightenment later
in life. The balance provided by the vestibular system may
be the model for psychological and emotional stability, and
ultimately for leading a more balanced life (Frick, 1982).
Physical metaphors provide a contextual grounding in time
and space that helps us grasp our experience and may
serve as an infrastructure of higher cognitive processes.
Albert Einstein, who did poorly in math during his formal
education, went on to solve some of the universe’s most
complex mysteries. He intuited relationships between time,
matter, and energy, which contributed to the development
of atomic energy and brought us a step closer to
understanding the workings of the universe. I remember my
seventh grade math teacher praising us with the phrase
“Little Einstein.” As you can imagine, many neuroscientists
were interested in having a look at Einstein’s brain to see if
and how it differed from yours and mine. In comparison to
91 other brains, Einstein’s was different only in the size of
the inferior parietal lobe (Witelson, Kigar, & Harvey, 1999).
A subsequent examination of the same region revealed
lower ratios of neurons to glial cells when compared to other
areas of Einstein’s brain as well as to the brains of other
people (Diamond et al., 1966; Diamond, Scheibel, Murphy, &
Harvey, 1985). It is highly likely that this enhanced neural-
glial relationship enhanced neuronal activity and led to
superior visual-spatial abilities (Nedergaard et al., 2003;
Oberheim et al., 2006; Taber & Hurley, 2008).
These neuroanatomical findings are especially interesting
in light of Einstein’s reported use of mental imagery to solve
complex conceptual problems. Einstein described
translating numerical equations into images that he would
manipulate in imagination, come up with solutions, and
translate back into equations. This ability to conceptualize
and manipulate three-dimensional objects in imagination
appears to separate us from other primates and may be a
uniquely human evolutionary accomplishment (Orban et al.,
2006; Vanduffel et al., 2002). Based on his description of his
problem-solving strategies and the findings concerning his
brain, it is possible that Einstein’s unusual parietal lobes
may have been central to his genius.
Einstein’s difficulty in navigating the simple demands of
day-to-day life was notorious, making him the archetypical
absent-minded professor. Interestingly, one study has
shown that the volumes of the frontal and parietal lobes
demonstrate significant negative correlation (Allen,
Damasio, & Grabowski, 2002). Being absent-minded may
have been the price he paid for an overdeveloped parietal
lobe. Research suggests that inner imaginal space enhances
the possibility for creative problem solving, empathy, and
compassion. Perhaps this is one of the reasons that Einstein
turned his attention to world peace and other humanitarian
concerns later in life.

The Executive Brain in Psychotherapy

All of our final decisions are made in a state of mind

that is not going to last.
—Marcel Proust

As stated earlier, the brain is an organ of adaptation, a

process that continues for as long as we live. Given their
role as high-level association areas sculpted by ongoing
experience, the frontal and parietal lobes likely retain a
great degree of neural plasticity. This plasticity and their
joint roles in the synthesis of physical, social, and emotional
information make these regions primary targets of
psychotherapy. In line with this, psychotherapy requires that
we step away from reflexive behavior and the immediate
demands of the environment to reflect upon our
experiences in sophisticated ways. Acting in instead of
acting out provides us with the interpersonal and
intrapsychic space to try on new truths. Consider my client,
Sandy, who found herself trapped in a mysterious cycle of
changing attitudes and moods.
Sandy came to therapy in her mid-40s with the usual
concerns about relationships, family, and career. Although
her mood was generally upbeat and positive, she
occasionally came to sessions feeling irritable, deflated, and
hopeless, leading me to think that she might be suffering
from bipolar disorder. When I mentioned her fluctuating
moods, she was distressed that they were noticeable to
others. She told me that she had discounted their
importance because they didn’t seem to relate to events in
her life, “just hormones I guess.”
Once Sandy began to focus her attention on these
moods, she reaffirmed that they seemed to come out of
nowhere and disappear just as mysteriously. When she was
down, she felt like a fraud, and planned to quit her job and
leave her husband. “When I feel this way,” she said, “I just
lose the will to live.” On further reflection she realized that
these mood states had been part of her life for as long as
she could remember—recalling instances as far back as
elementary school.
We monitored and discussed her experiences through a
number of mood cycles and engaged in considerable
speculation about their origin. Her father was prone to
moodiness and she had a maternal aunt who had a
“nervous breakdown” decades earlier, which made us
consider a genetic inheritance or modeling behaviors that
she saw as a child. Sandy struggled to find thoughts,
feelings, or events in her life that would precipitate them
and discovered that they did not coincide with anything
related to her work, family, menstrual cycle, exercise, or
diet. All serious medical conditions were ruled out, her only
physical complaint being her allergies and frequent sinus
infections. On the outside chance there was some
relationship between her use of antihistamines and her
mood changes, we created a mood chart that included her
use of medication.
Although we did not find any connection between mood
and medication, it did turn out that she consistently lost her
will to live a day or two before suffering a sinus infection.
Her mood would then improve shortly after the onset of her
respiratory symptoms and headaches. Once we made this
connection, we waited for the next dip in mood to see if it
would again be followed by a sinus infection. Sure enough,
the same pattern emerged. Although we still did not know
what affected her mood, the timing did suggest that it was
related to the cycle of her allergies and sinus infections. Up
to this point, our work together depended upon Sandy’s
ability to reflect on her experiences, analyze her reactions
to situations, and think about her thinking. Now it was time
to develop Sandy’s memory for the future, and create some
experiments focused on alternative plans and actions.
We decided to anticipate her next dip in mood with a new
plan. We agreed that she would stop evaluating her life on
days that she lost her will to live. She was not allowed to
think about leaving her husband or her job, or assess her
worth as a person. Instead, the mood dip would be a cue for
her to go to the health food store, buy vitamin C and zinc
tablets, and rearrange her schedule to reduce stress. She
also made an appointment with a new allergist. In essence,
her assignment was to remember the future in the present.
Sandy had to remain mindful of the possibility that what she
experienced as negative emotions was really a result of
biological changes related to a physical illness and not a
collapse of character or impending global catastrophe. We
worked on developing a safe internal place for her to retreat
to at these times, where she could soothe and comfort
herself and focus on healing.
Over time, the association between sinus infections and
mood changes held up—we had created a new narrative
with far more explanatory power than the one it replaced.
For some unknown reason, Sandy’s biochemistry reacted to
infection with a sharp drop in mood, most likely related to
drops in serotonin and dopamine. The psychological
depression experienced as a result of these changes led her
to reinterpret, in a negative way, the value of all aspects of
her existence. How she dealt with these feelings was neither
pleasant nor adaptive. By being mindful of this process and
using her frontal and parietal executive functions to
associate experiences with new meanings, she was able to
engage in different behaviors and create a better outcome.
We had converted what usually led to an existential crisis
into a trigger for enhanced self-awareness, self-care, and
medical management.
Sandy needed to learn how to pay attention to her
feelings, reflect on them with past experiences in mind, and
follow a new plan of action contrary to old reflexive
patterns. These important frontal functions allowed Sandy to
escape from automatic and detrimental behaviors. She was
able to modify stimulus-response connections by escaping
the present moment both in therapy and then in her day-to-
day life, first imagining and then executing a new scenario.
As Sandy learned to understand the functioning and
fluctuations of her brain, she was able to utilize executive
functions and an imaginal self to gain insight, perspective,
and change dysfunctional patterns of behavior.

Summary
The exploration of human consciousness is a vast new
frontier for neuroscience where there may always be more
questions than answers. We know consciousness exists; we
just have no idea of how it emerges from the functioning of
the brain. An inherent challenge to this exploration will
always be the conflict of interest involved when something
is studying itself with all the bias and distortion that
interferes with objective observation. There is no easy way
around this.
Chapter 9

From Neural Networks to Narratives: The Quest

for Multilevel Integration

There is no greater agony than bearing an untold

story inside you.
—Maya Angelou

It appears that nature has retained a fundamental strategy

of connecting things—be they neurons, neural networks, or
individual people—into more complex organizations. As we
zoom in to look at groups of neurons and zoom out to look
at groups of people, the same basic principles of
connectivity and homeostatic balance appear to hold true.
As we learn about the necessary synergistic connectivity of
neural networks, we are also coming to understand the
relationship between network imbalance and mental
distress. From extreme PTSD to everyday neurosis, we all
exhibit a pattern of integration and dissociation reflective of
our adaptational history and the health of our brains. At the
level of the experience of self, networks dedicated to
sensation, perception, and emotion seamlessly integrate
into the emergence of conscious experience ( Damasio,
1994; Pessoa, 2008; Fox et al., 2005). Let’s take a look at
the impact of a somewhat simple breakdown of neural
network integration on the experience of self.
A few years ago, a young man in his late teens came in
for a therapy session. The previous September, Craig had
left home to attend his first year of college, but by mid-
December, something had gone haywire. His parents were
called by the dean and told that Craig had not been going to
classes for weeks. They were also informed by the resident
advisor that 5 days earlier, Craig had locked himself in his
room, thrown all of his and his roommate’s possessions out
of the window, and was listening to the same song 24 hours
a day. His parents raced to campus to find him in the middle
of an acute psychotic episode.
Craig had been released from the hospital where I
worked just a few weeks earlier and it was good to see him
once again independent and active. As he walked across my
office, I could see his movements were slowed by the
medications that were keeping his hallucinations at bay. I
had seen Craig in individual and group therapy for
approximately a month. His symptoms had slowly cleared
and he was released to his parents’ care a week earlier. This
was his first session since being discharged. After he settled
in, I asked him how things had been going since he left the
hospital. Slowly, and in a soft voice, he told me that life was
pretty good and that he enjoyed playing his guitar and
working on some new songs. He wasn’t feeling paranoid or
hearing voices like he had been weeks ago, his sleep and
appetite were okay, and he felt like he was ready to return
to school. “There’s only one problem, Doc. I don’t feel
comfortable at home because my parents and brother have
been replaced by doubles.”
“Doubles?” I asked him. “What do you mean, doubles?”
Craig started by saying that he had gotten a strange
feeling about his parents and brother when they came to
visit him in the hospital, but he figured he was off because
of the medication. But once he got home, he discovered the
reason for his strange feelings. “After a while I realized that
they’ve been replaced by doubles!”
I gave him my best quizzical therapist expression and
asked what made him think they were doubles. Craig
described how they were excellent copies and well prepared
to trick him. He asked them scores of questions he thought
only his parents and brother could answer and, sure
enough, they got them right. “Whoever is doing this to me is
good!” he said with nervous admiration. When I asked him
again how he could be so sure they were replacements, he
replied with annoyance, “Don’t you think I would know my
own parents?”
This syndrome of suspecting impostors, called Capgras
syndrome, can occur alone but usually appears in tandem
with some other brain dysfunction such as schizophrenia,
temporal lobe epilepsy, or head injury (Serieux & Capgras,
1909). Although the neurobiology of Capgras syndrome is
not definitively understood, there has been ongoing
speculation that it is a disconnection syndrome that
somehow separates networks of perception, emotion, and
conscious analysis (Alexander, Stuss, & Benson, 1979;
Merrin & Silberfarb, 1979). An EEG study found “abundant
and severe EEG abnormalities” in 21 Capgras patients in the
area of the temporal lobes. This led the authors to suggest
that the delusion of impostors may be caused by a
“dysrhythmia” of brainwaves in networks responsible for
matching faces with emotional familiarity (Christodoulou &
Malliara-Loulakaki, 1981).
Capgras syndrome does not affect the neural networks
responsible for recognizing familiar faces. Craig could see
that these people he took for imposters were physically
identical to his parents and brother. But Craig’s experience
was that they no longer felt like his parents—the emotional
“glow” of recognition of loved and familiar people was
missing (Hirsten & Ramachandran, 1997). We can
hypothesize that a disconnection or lack of coherence
occurrs between the circuits of the temporal lobes
responsible for face recognition and the ompfc-amygdala
axis, which would add the emotional reaction of seeing a
loved one. With this connection somehow disrupted, Craig’s
still intact left hemisphere explanatory circuitry created a
delusion of imposters; an explanation that is logical if you
accept the experiential premise. The people in Craig’s home
looked and acted like his family, but without the usual input
from the emotional circuitry responsible for the feeling of
familiarity, his left hemisphere interpreter concluded that
they must be imposters.
Most of us have felt the firing of these familiarity circuits
in an exaggerated form when we unexpectedly run into a
friend in an unusual place. Our shock of recognition leads to
the inevitable, “Oh my God, what are you doing here?” Craig
was experiencing what amounts to the opposite of this
experience. He expected to have the feeling of recognition
but didn’t. This is probably what he was referring to when he
said, “Don’t you think I would know my own parents?”
Capgras syndrome may well be the opposite of a déjà vu
experience, where something which is actually new is paired
with a feeling of familiarity. Déjà vu is likely a random firing
of familiarity circuits in an unfamiliar setting. The fact that
strong déjà vu experiences are often reported by patients
with temporal lobe epilepsy suggests that their out-of-
control electrical firing is activating the amygdala, which is
deep within the temporal lobes.
The delusion of impostors generated by the left
hemisphere interpreter may be similar to the attributions
made about déjà vu experiences such as past lives,
clairvoyance, and other paranormal beliefs. This very
normal impulse to make sense of nonsense is also seen in
schizophrenics, who attempt to create a logical explanation
for their bizarre sensory experiences (Maher, 1974). In the
face of experiencing thoughts being inserted in their heads,
patients ask themselves, “Who would have the technology
to do such a thing?”
When I worked in Boston, patients pointed the finger at
MIT, while the people I treated in Los Angeles suspected Cal
Tech. Delusional beliefs can become quite central to a
client’s life as well as tenacious and difficult to dislodge. For
example, when three patients, each of whom believed they
were Christ, were housed together, each came to believe
that the other two were delusional (Rokeach, 1964).

Pathways of Integration

All organs of an animal form a single system…and no

modification can appear in one part without bringing
about corresponding modifications in all the rest.
—George Cuvier

The long and circuitous path of brain evolution has not

provided us with a brain that is simple in function or
straightforward in design. We have already seen how the
brain consists of different memory systems, two
hemispheres with different processing capabilities, and
multiple executive systems controlling different skills and
abilities. We have also explored how, when these systems
get out of sync, psychotherapy attempts to reconnect and
balance them.
Although we are just beginning to understand functions
and the complexities of our neural pathways, some
consistent findings are beginning to emerge. As we
discussed in an earlier chapter, the two main pathways to
consider are top-down and left-right. It is also important to
always keep in mind that they are not independent of one
another because top and left areas have developed certain
special connections, as have the bottom (subcortical) and
the right hemisphere. Another important point to keep in
mind is that these top-down and left-right systems involve
multiple structures along the way, each with its own unique
contribution and potential role in network functioning. We
should also add two more specific pathways, the
relationships between regions within the frontal lobes (the
ompfc and the dlpfc), and between the hippocampus and
amygdala. These systems also have particular associations
with both top-down and left-right integration.
Let’s review the general map of the brain’s pathways of
integration. In Table 9.1, notice the alignment of these four
pathways. Top-down, left hemisphere, dlpfc, and the
hippocampus are aligned on the left because they tend to
be connected more heavily with one another than with
those in the column on the right. They also tend to be
involved with conscious, rational, and language-based
functions. Bottom-up processing, the right hemisphere, the
ompfc, and the amygdala appear to have more dense
connectivity among themselves and are more likely to be
involved with unconscious, somatic, and emotional
functions. So, for example, Capgras syndrome may reflect a
disconnection of bottom-up emotional processing involving
the amygdala and right hemisphere from the top-down and
left hemisphere cognitive analysis of sensory experience.
 
TABLE 9.1 Pathways of Integration

Top   Bottom (subcortical)

(cortical)
Left   Right hemisphere
hemispher
e
dlpfc   ompfc
Hippocam   Amygdala
pus

 
There is presently a great deal of research focused on
breaking down these functional networks into finer and
more precise distinctions and generating models of
processing paths and organizational patterns. Separating
the roles of each region of the brain in each hemisphere is
also under exploration, as is the mapping of patterns of
activation (instantiations) for different symptoms and
diagnostic groups (Dougherty et al.,2004). As with all of this
research, we have to keep in mind that age, gender, and life
experiences all play a role in how these networks organize
and function in each individual. For our present purposes, I
have chosen to focus on these general categories because
of their obvious applicability to psychotherapy and mental
health.

Top-Down–Bottom-Up

The complexity of the nervous system is so great, its

various association systems and cell masses so
numerous, complex and challenging, that
understanding will forever lie beyond our most
committed efforts.
—Ramon y Cajal

Although there are many vertical circuits that cut across the
horizontal strata of the brain, important top-down networks
for psychotherapists are those connecting the ompfc and
amygdala. The ompfc and the amygdala are connected by
dense bidirectional networks that feed physiological and
emotional information upward to the cortex while allowing
the ompfc to modulate the output of the amygdala to the
autonomic nervous system (Ghashghaei & Barbas, 2002;
Ghashghaei et al., 2007; Hariri et al., 2000, 2003). Think of
the amygdala as a primitive structure designed to link
immediate threat with a rapid survival response. Think of
the ompfc as having the ability to gather and update
information and use it to predict potential outcomes and
shape behavior (Dolan, 2007; Rosenkranz, Moore, & Grace,
2003). Perhaps a good analogy is a squad of soldiers trained
to fight and survive (amygdala and anatomic nervous
system) and a general who is an expert strategist who
continues to keep an eye on the entire battlefield, update
his strategy, and adjust long-range goals (ompfc).
In the normally functioning brain, the balance of ompfc–
amygdala activation reflects a dynamic moment-to-moment
balance of focused attention and emotional arousal
(Simpson, Drevets, et al., 2001; Simpson, Snyder, et al.,
2001). When faced with a psychosocial stress, we see
elevated cortisol levels along with increased activation in
the amygdala and lower levels of activation in the ompfc
(Kern et al., 2008). Higher levels of ompfc activity are
believed to reflect an inhibition of affective processes and
an enhanced focus on the outside world, while a decrease
suggests a shifting of attention to internal processes. As
negative affect decreases, so does amygdala activation,
while activation in the ompfc increases (Urry et al., 2006). It
is now believed that each of us has a unique homeostatic
balance of this circuitry which shapes our emotional
regulation and affective style (Davidson, 2002).
Let’s think about what happens in the human brain
during public speaking. For most individuals, getting up in
front of a group to speak results in increased cortical
activation. This makes sense because we need our cortex to
process the cognitive demands of giving a talk. But when
socially phobic individuals get up to speak, there is a
decrease in cortical activity and an increase in amygdala
firing along with bodily symptoms of anxiety and panic
(Tillfors et al., 2001). This may help us understand the
phenomenon of stage fright, where people either forget
their lines or find it impossible to speak when faced with an
audience. High levels of cortisol, dopamine, and bottom-up
inhibition from the amygdala can all take the prefrontal
cortex “off-line” during stress (Arnsten & Goldman-Rakic,
1998; Bishop, Duncan & Lawrence, 2004). This “amygdala
hijack,” as it is called in the self-help literature, is the
takeover of executive functioning by the amygdala and
other subcortical systems (Goleman, 2006).
The balance and integration of the ompfc and amygdala
are influenced by everything including past trauma, current
stress, and serotonin levels (Hariri, Drabant, & Weinberger,
2006; Heinz et al., 2005). When people suffer from
symptoms of depression or anxiety, there is a general
decrease in cortical activation and an increase in anterior
regions of the cingulate and insula (Kennedy et al., 2007;
Mayberg et al., 1999). This balance reverses as mood
lightens with or without treatment (Kennedy et al., 2001). It
has also been found that pretreatment metabolism in these
and other regions predicts response to antidepressant
medication (Davidson, Irwin, et al., 2003; Pizzagalli et al.,
2001; Saxena et al., 2003; Whalen et al., 2008; Wu et al.,
1999).
As we saw earlier, sadness and depression also reflect a
left-right imbalance. Left-biased prefrontal activation
downregulates negative affect in nondepressed individuals
while depressed individuals show bilateral frontal activation
(Johnstone et al., 2007). These findings highlight the fact
that the modulation of mood is likely to occur
simultaneously on multiple planes of homeostatic balance—
top-down, left-right, and so on. Thus, a shift away from
depression may reflect a dual regulatory shift from right and
down to top and left activation. Keep in mind that conflicting
results have also been found, so our understanding of these
processes is still just developing (Holthoff et al., 2004).
Within this broad top-down system there are likely
numerous subsystems involved in emotional regulation.
Different studies have demonstrated a variety of activation
patterns in broad top-down networks in tasks of affect
regulation and the voluntary suppression of emotions
(Anderson & Green, 2001; Beauregard, Lévesque, &
Bourgouin, 2001; Phan et al., 2005). For example, the
coordination of activity between the amygdala and the
anterior cingulate has been shown to be correlated with trait
anxiety and a susceptibility to depression (Pezawas et al.,
2005). Suppressing cigarette craving correlates with
increased activation in the cingulate cortex and an inhibition
of sensory and motor regions as subjects respond to
smoking-related stimulus cues (Brody et al., 2007).
The anterior cingulate, amygdala, and insula are
modulated by the processing of internal somatic experience
during biofeedback training while the anterior insula is
involved with the interaction between the accuracy and
sensitivity of the feedback (Critchley et al., 2002). This may
be the same circuitry activated during therapy as we
integrate conscious awareness with somatic, emotional, and
memory processing. Simultaneous top-down and left-right
inhibition is likely responsible for what Freud called
repression. As prefrontal and anterior cingulate regions are
inhibiting conscious recall of explicit memories, left frontal
networks can be simultaneously inhibiting negative somatic
and emotional memories stored in right-biased systems
(Anderson & Green, 2001). The result would be a lack of
conscious recall of a threatening experience and a
dissociation of experience from conscious awareness.

Left Hemisphere–Right Hemisphere

The interpretive mechanism of the left hemisphere

is…constantly looking for order and reason, even
when there is none—which leads it continually to
make mistakes.
—Michael Gazzaniga

As we saw in an earlier chapter, left-right integration is

required for proper language functioning, bodily awareness,
emotional regulation, and many other essential human
processes. As we will soon discuss, the emergence of
storytelling and narrative structure as universal aspects of
human culture may have emerged, in part, to assist in the
integration and coordination of the two very different brains.
A greater left-hemisphere advantage in verbal processing
has been shown to be a predictor of a more favorable
outcome in cognitive-behavioral therapy (Bruder et al.,
1997). This suggests that those individuals with more left-
lateralized language abilities may also have stronger
inhibitory capacities over emotional experience stored in the
right. It has been shown that good readers have less
interhemispheric connectivity and are better at processing
rapidly changing sensory input (Dougherty et al., 2007). For
some tasks, less integration and cooperation are an
advantage, especially when speed or focus of attention are
factors. Having the input of both hemispheres may be quite
adaptive when we are solving complex social and emotional
problems, but is likely to slow us down and make us stumble
if we need to engage in fast and automatic behavior
(Cozolino, 2008).
A form of treatment used to readjust right-left balance is
transcranial magnetic stimulation (TMS). TMS is a
noninvasive, painless technique for the stimulation and
inhibition of neural firing. A coil of wires is placed on the
scalp that generates a magnetic field strong enough to
penetrate the skull. This magnetic field is transformed into
current flow in the brain that temporarily excites or inhibits
select areas, which can be applied either as a single pulse
or repetitively (rTMS). Depending on its frequency, it either
increases or decreases cortical excitability—fast rTMS
increases activation while slow rTMS decreases it
(Daskalakis, Christensen, Fitzgerald, & Chen, 2002).
In several studies, patients with treatment-resistant
depression experienced symptomatic improvement after a
series of fast rTMS treatments applied to the left prefrontal
cortex (Pascual-Leone et al., 1996; George et al., 1997;
Figiel et al., 1998; Teneback et al., 1999; Triggs et al., 1999).
These repeated magnetic pulses to the left hemisphere may
have increased activity and shifted the balance of mood in a
more positive direction. Slow rTMS applied to the right
prefrontal cortex resulted in similar improvements in
depressive symptoms (Klein et al., 1999; Menkes et al.,
1999). Slower frequency rTMS to the right prefrontal cortex
was thought to inhibit right frontal functioning and have less
adverse side effects (Schutter, 2009).
Studies of rTMS and depression lead us to the conclusion
that the technique’s ability to both stimulate the left
hemisphere and inhibit the right hemisphere may prove
equally useful in depressed patients. Current views take the
position that restoring the balance between left and right
prefrontal cortex activity is more important in treating
depression than establishing clear increases in left-sided
activity. If rTMS can have a positive effect on depressive
symptoms, might it work in the reverse manner for mania?
Studies in this area are less extensive, but findings do
suggest some effectiveness of rTMS in the treatment of
mania when it is applied at high frequency to the right
prefrontal cortex (Belmaker & Grisaru, 1999; Grisaru et al.,
1998; Michael & Erfurth, 2002; Saba et al., 2004). The
procedure has been approved by Health Canada for clinical
use but not in the United States, where its application is
limited to clinical research.

Dlpfc–Ompfc

Modern Psychology takes completely for granted that

behavior and neural function are perfectly correlated,
that one is completely caused by the other…. It is
quite conceivable that some day this assumption will
have to be rejected.
—Donald Hebb
As a whole, the prefrontal cortex sculpts experience and
behavior through a complex array of inhibitory and
excitatory activities (Knight, Staines, Swick, & Chao, 1999).
You will recall that the prefrontal cortex is divided into four
regions and that the dorsal and lateral regions tend to
engage in coordinated activity as do the orbital and medial
areas. Because of these connections they are often referred
to as the dlpfc and ompfc. The location of prefrontal
activation varies depending on the emotional salience of the
task; the more emotional the task, the more ompfc
activation—the more cognitively demanding a task, the
more the dlpfc takes center stage (Goel & Dolan, 2003;
Northoff et al., 2004; Schaefer et al., 2002). As the cognitive
demands of a task increase, there is a decrease in activation
not only in the ompfc, but also in the amygdala and anterior
cingulate, which are closely linked to the ompfc (Pochon et
al., 2002; Rushworth & Behrens, 2008). This is likely the
reason why engaging in cognitive tasks, like word or math
problems, often reduces anxiety.
The dlpfc exerts control over neural processing based on
higher order rules (environmental context, prediction, etc.)
while the ompfc does the same from the perspective of
lower order rules (impulse, drives, emotions, etc.). From this
we get the sense that top-down and bottom-up processing is
interwoven with the balance of activation between the dlpfc
and ompfc, respectively. Interestingly, when people make
decisions congruent with implicit racial and gender biases,
the ompfc and amygdala become more active, while the
dlpfc shows more activity when we express beliefs that are
incongruent with prejudice (Knutson, Mah, Manly, &
Grafman, 2007). This reflects what we already know—more
primitive impulses drive prejudice while education and
expanded perspective allow us to go beyond our reflexive
limitations.
Experiencing the world from a first-person perspective
and tasks of self-regulation activate ompfc regions while
situation-focused regulation activates dlpfc systems
(Ochsner et al., 2004). The ompfc becomes involved in
diverse tasks that require differing kinds and degrees of self-
referential knowledge (Ochsner et al., 2005). Within the
ompfc, the decoding of the mental states of others based on
observable cues such as facial expressions may rely on the
right ompfc while reasoning about their mental states may
be lateralized to the left ompfc (Sabbagh, 2004). When we
consider the types of issues brought into psychotherapy, it
is likely that we are working to build, integrate, and balance
the ompfc and dlpfc.
Consider what we do when we assist clients in shifting
from their own perspective to looking at a situation from
another point of view, to thinking about the situation once
again from a more objective perspective. We are calling
upon the ompfc and dlpfc in different ways as we attempt to
guide them to a more holistic perspective of a life situation.
This process most likely enhances the growth of ompfc and
dlpfc systems, while building new brain networks to bridge
the two for higher level awareness. Optimal functioning
necessitates coordination, flexibility, and complementarity
between these modes of functioning. When the ompfc and
dlpfc are in proper balance, they create the possibility of
true cognitive-emotional integration (Gray et al., 2002). In
situations of stress and trauma the ompfc and dlpfc are
capable of either mutual dissociation or inhibition (Roberts &
Wallis, 2000). An inability of the ompfc to modulate stress
will result in a decrease of activation in the dlpfc during a
cognitive memory task and cause a performance deficit
(Dolcos & McCarthy, 2006; Drevets & Raichle, 1998).
Building strong connections between ompfc-dlpfc circuits
creates resilience to stress and a hedge against resorting to
dissociation, as well as greater affect tolerance and ego
strength.
Hippocampus–Amygdala

Emotions have taught mankind to reason.

—Marquis De Vauvenargues

The hippocampus and amygdala both play central roles in

learning and memory. The amygdala (in connection with the
ompfc) organizes emotional experience and (in moderate
states of arousal) signals the hippocampus about what is
important to learn. On the other hand, the hippocampus
(along with the dlpfc) participates in the cognitive
evaluation of situations that will inform the amygdala when
to ramp up or back down on its emotional reaction. In other
words, I can see that the dog is wagging his tail so perhaps I
don’t need to be as afraid of being bitten. Since the
activation of emotion and the cognitive analysis of
experience are both necessary for normal functioning, the
proper regulatory balance of the hippocampus and
amygdala is vital.
The hippocampus is necessary for forming new explicit
memories while the amygdala organizes highly stressful and
traumatic learning. At low levels of arousal, amygdala
activation supports hippocampal learning by boosting the
biochemical aspects of neural plasticity. At higher levels of
arousal, the amygdala stimulates HPA activation, which
interrupts hippocampal learning while supporting fear-based
amygdala learning (Kim, Koo, Lee, & Han, 2005; Kim, Lee,
Han, & Packard, 2001). In essence, during states of high
arousal, hippocampal and amygdala networks become
dissociated, resulting in a disconnection between visceral-
emotional (amygdala) and declarative-conscious
(hippocampal) processing (Williams et al., 2001). Thus,
optimal learning requires a balance of amygdala and
hippocampal participation.
Many people, perhaps even the majority of clients in
psychotherapy, do not come for treatment of a major
psychiatric illness. Most clients who are somewhat “less ill”
have so far not been included in extensive (and expensive)
outcome research that includes brain imaging studies. Many
people seek psychotherapy simply because, as they often
say themselves, life has somehow gotten out of balance.
This may mean that their fears and worries have taken
control of their lives and limited their ability to function or
find happiness in the world. Others find themselves devoid
of emotion and without empathy for others, leading them to
seek therapy to save their marriages and relationships with
their children. Many have the sense that they are not living
up to their potential or get in their own way when it comes
to worldly success and emotional satisfaction.
These clients are often referred to as the “worried well,”
implying that they should somehow get over themselves
and get on with life. My sense is that this group of patients,
in which I would include myself, also suffer various versions
of a homeostatic imbalance. An exaggerated reliance on
intellectual defenses, overemotionality, or a negative
attachment experience can become established as self-
perpetuating patterns that lead to social isolation and
underperformance. All of these suboptimal lifestyles are
most likely reflected in biased patterns of neural activation,
which become the focus of psychotherapy. While
psychotherapy is a relatively recent and culture-specific
development in human history, talking to one another,
seeking out advice, and exchanging stories likely go back to
the first humans. Thus, the talking cure exists within a
matrix of beings who share the gift of gab. I suggest to you
that the evolution of the brain and the development of
narratives have gone hand in hand.

From Neural Networks to Narratives

 [Words] leave finger marks behind on the brain, which
in the twinkling of an eye become the footprints of
history.
—Franz Kafka

The evolution of the human brain is inextricably interwoven

with the expansion of culture and the emergence of
language. Thus, it is no coincidence that human beings are
storytellers. Through countless generations, humans have
gathered to listen to stories of the hunt, the exploits of their
ancestors, and morality tales of good and evil. It has long
been supposed that these stories support the transmission
of culture while promoting psychological and emotional
stability. Stories connect us to others, prop up our often
fragile identities, and keep our brains regulated. Thus, I
believe that both the urge to tell a tale and our vulnerability
to being captivated by one are deeply woven into the
structures of our brains.
Narratives perform an array of important functions
including:

Grounding our experience in a linear sequential

framework
Remembering sequences of events and steps in
problem solving
Serving as blueprints for emotion, behavior, and
identity
Keeping goals in mind and establishing
sequences of goal attainment
Providing for affect regulation when under stress
Allowing a context for movement to self-
definition.

For most of human history, oral communication and

verbal memory were the medium and repository of our
accumulated knowledge. The ongoing value of stories to
each of us is highlighted in today’s world by the energy we
invest in television, movies, magazines, and everyday
gossip. The drive of older folks to repeatedly tell the same
stories is matched by the desire of young children to hear
them again and again. This inter-locking conduit of culture
across generations carries memories, ideas, and ideals
through time. The importance of narratives in human
evolution is further underscored by the fact that our ability
to remember and recall stories is essentially limitless. In
fact, the astonishing abilities of memory experts rely on
placing discrete pieces of information into narratives that
expand the capacity of working memory to the limits of their
imagination.
Although stories may appear imprecise and unscientific
(Oatley, 1992), they serve as powerful tools for high-level
neural network integration (Rossi, 1993). The combination
of a linear storyline and visual imagery woven together with
verbal and nonverbal expressions of emotion activates and
utilizes dedicated circuitry of both left and right
hemispheres, cortical and subcortical networks, the various
regions of the frontal lobes, and the hippocampus and the
amygdala. The cooperative and interactive activation
involved in stories may be precisely what is required for
sculpting and maintaining neural network integration while
allowing us to combine our sensations, feelings, and
behaviors with conscious awareness. Further, stories link
individuals into families, tribes, and nations and into a group
mind linking each individual brain. It is likely that our brains
have been able to become as complex as they are precisely
because of the power of narratives and the group to support
neural integration.
Much of neural integration takes place in the association
areas of the frontal, temporal, and parietal lobes, which
serve to coordinate, regulate, and direct multiple neural
circuits. They are our conscious switchboard operators, able
to use language and stories to link the functioning of
systems throughout the brain and body. An inclusive
narrative structure provides the executive brain with the
best template and strategy for the oversight and
coordination of the functions of mind. A story well told,
containing conflicts and resolutions, gestures and
expressions, and thoughts flavored with emotion, connects
people and integrates neural networks.

A Story Well Told

Man’s mind, once stretched by a new idea, never

regains its original dimensions.
—Oliver Wendell Holmes

Have you have ever watched the faces of small children as

they listen to a gifted storyteller? You can see the unfolding
drama reflected in their eyes, on their faces, and throughout
their bodies. Listeners will experience a range of drastically
shifting emotions, be absorbed in every detail, and even
shout out warnings to characters in danger. Narratives allow
us to place ourselves within alternate points of view and
increase our understanding of the experience of ourselves
and others. We can escape our bodies in imagination to
other possible selves, ways of being, and worlds that have
yet to be created.
Through stories we have the opportunity to ponder
ourselves in an objective way across an infinite number of
contexts. In life and in therapy, we can use stories to
imagine our problems happening to someone else or view
ourselves at a distance (externalization). We can share
versions of possible selves and receive input from others.
Finally, we can experiment with new emotions, actions, and
language to edit the scripts of our lives (Etchison & Kleist,
2000). Our ability to edit narratives summons us to try on
new ways of being. (Recall the case of Sheldon and his
magic tricycle.)
What makes for a good story? Why can I sit through
Pretty Woman or A Few Good Men over and over again, even
though I know exactly how they end? If you take a
screenwriting class you learn that there is a formula for
successful narrative structure. Every story needs a hero, a
protagonist with whom we can identify. The protagonist is
facing an external challenge and possesses an inner wound
that causes him persistent pain. For both Richard Gere and
Tom Cruise, this pain came from their emotional
estrangement from their fathers. At first the hero either
avoids the challenge or fails, leading him to question his
ability to succeed or even his desire to change. The
challenge confronting the hero is at first resisted, then
rejected, and eventually accepted. During the journey, the
hero leaves behind old definitions of self and travels into
uncharted territory. Some inner transformation takes place
that allows him to face his demons, succeed in his worldly
challenge, and solidify his identity. Richard Gere accepts
Julia Roberts and Tom Cruise faces down Jack Nicholson.
This is essentially the universal Myth of the Hero,
describing the transition from adolescence to adulthood
(Campbell, 1949). Redemption—a word commonly used for
this transition—can happen at any age. The adolescent
struggling to attain adult status, the emotionally shut-down
Scrooge faced with his history of loss, or a client trying to
make sense of early deprivation have, at their core, a wound
that needs healing. My explanation would be that what we
share in common—brain, culture, language, and the fight for
growth and survival—are the underlying motives of the
heroic narrative. Another way of saying this is that what we
share in our common struggle for survival and meaning is
deeper and more powerful than those things which make us
appear different.
Narratives and Emotional Regulation

Good psychiatry is a blend of science and story.

—Jeremy Holmes

As the language areas of the left hemisphere enter their

sensitive period during the middle of the second year of life,
grammatical language in the left integrates with the
interpersonal and prosodic elements of communication
already well developed in the right. As the cortical language
centers mature, words are joined together to make
sentences and can be used to express increasingly complex
ideas flavored with emotion. As the frontal cortex continues
to expand and connect with more neural networks, memory
improves and a sense of time slowly emerges and
autobiographical memory begins to connect the self with
places and events, within and across time. The emerging
narratives begin to organize the nascent sense of self and
become the bedrock of our sense of self in interpersonal and
physical space.
As our experience of self and the stories we tell about
ourselves become interwoven, self-identity becomes the
center of narrative gravity (Dennett, 1991). As children we
are told by others, and gradually begin to tell others, who
we are, what is important to us, and what we are capable of.
These self-stories are shaped by culture and co-constructed
with parents and peers. And although it does sometimes
seem that children are little scientists discovering the world,
what we often miss is that they are primarily engaged in
discovering what the rest of us already know, especially
about them (Newman, 1982). This serves the continuity of
culture from one generation to the next as we reflexively
strive to recreate ourselves.
The role of language and narratives in neural integration,
memory formation, and self-identity makes them a powerful
tool in the creation and maintenance of the self (Bruner,
1990). Stories are powerful organizing forces that serve to
perpetuate both healthy and unhealthy forms of self-
identity. There is evidence that positive self-narratives aid in
emotional security while minimizing the need for elaborate
psychological defenses (Fonagy, Steele, Steele, Moran, &
Higgitt, 1991). In the same way, anxious and traumatized
parents pass along their negative experiences in the stories
they tell. The recognition of the negative power of personal
narrations containing negative self-statements stimulated
the development of rational and cognitive-based therapies
(Ellis, 1962). Let’s look at the role of a positive narrative for
a young boy.
Seven-year-old Trevor was brought to see me because his
parents were concerned that he might have “something
troubling him.” He was very close to his grandfather who
had passed away 6 months earlier, but he didn’t seem to
have a reaction to this loss. While his parents felt they had
done everything they could to encourage him to talk about
his feelings, he didn’t have that much to say. Trevor seemed
to be a normal kid with interests in science, video games,
and computers. As he became comfortable, we hung out,
played, and talked about all kinds of things. During our
second session, he mentioned that he liked doing puzzles,
so I purchased a few and brought them to the office.
Before our session, I spread one of the puzzles out on my
desk. I put together a few pieces to give him a jump start
and had to quell my own compulsive impulse to keep going.
He was excited when he noticed it and asked if he could
help me work on it. “Certainly,” I said, and we sat down to a
session of puzzling. It didn’t take long for me to realize that
he was having difficulty and I wondered if I had chosen one
that was too difficult for him. The last thing I wanted to do
was to give him a failure experience.
I offhandedly suggested that we didn’t have to work on
the puzzle if he would prefer to do something else. “Maybe
this one is too hard for us,” I said. “No,” he replied, “don’t
give up. We’ll get it.” Impressed by his determination, we
continued to move pieces around in search of colors and
patterns. Every once in a while, I would leave a piece in
front of him that I knew would fit with something he was
holding. I became more and more amazed at his patience
and dedication. Many boys his age would move on to
something else or just clear the table with the swipe of an
arm.
After a while, I heard Trevor mumbling under his breath.
He was repeating something over and over like a song or
mantra. I leaned over, slowly putting my ear closer and
closer to him so I could make out his words. Finally I could
hear, “I think I can, I think I can.” He was chanting the
theme of “The Little Engine That Could.” He was the little
train that kept on keeping on. I immediately felt my eyes
well up and had to resist the urge to hug him. Sure enough,
he slowly got the hang of it and made lots of progress.
I later found out from his parents that the Little Engine
was his favorite story and one his grandfather loved to tell
him. They told me he wanted to hear it exactly the same
way each time and if they made a mistake on any word he
would stop and correct them. It was clear that this Little
Engine was a kind of hero to him, and he used it when he
was stressed by a challenging situation to regulate his
anxiety and keep himself moving ahead. Part of this heroic
story was likely the memory of a loving grandfather whom
he carried inside of him. The Little Engine became a way for
us to share about his grandfather. Trevor was showing me
the power of a story to soothe and inspire. I came to realize
that his grandfather had done a wonderful job of becoming
part of Trevor’s experience of himself and preparing him for
his death. I learned that Trevor’s loss was complicated
because, in many ways, he still had his grandfather with
him. I believe that Trevor’s ability to use narrative in this
way and his internalization of his grandfather’s love bode
well for his healing.
 To serve their important role in emotional regulation,
narratives need to have a brief summary or hook that can
be held in mind in the present moment. This summary,
which can be a word, a phrase, a visual image, or even a
gesture, can instantaneously evoke the beginning, middle,
and end of the narrative, and especially its message. In
Trevor’s case, it was the phrase “I think I can.” This
decreased his anxiety, enhanced his problem solving, and
allowed him to discover his true competence.
Putting feelings into words (affect labeling) has long
served a positive function for many individuals suffering
from stress or trauma. Labeling emotions correlates with
decreased amygdala response and an increase in right
prefrontal activation (Hariri et al., 2000). It has also been
found that amygdala–right frontal activation are inversely
correlated and that this homeostatic balance is mediated by
the ompfc (Lieberman et al., 2007). This suggests that the
labeling process may require both the lateral and medial
prefrontal regions in order for cognitive processes to have a
modulatory impact on our emotional activation (Johnstone
et al., 2007). The narrative, which simultaneously activates
an array of networks, enhances metabolic activity and
neural balance.
The perception of control has been shown to reduce
emotional arousal and stress. It is likely that cognitive
processes involved in prediction and control activate frontal
functioning and downregulate amygdala activation. In other
words, thinking we have some control puts us in a state of
mind that prepares us to think and activates prefrontal
functioning, which reduces our emotionality. As a self-
fulfilling prophecy, believing you are an efficacious person
stimulates frontal activation, making you a more efficacious
person (Maier et al., 2006).
Even writing about your experiences supports top-down
modulation of emotion and bodily responses. In a large
series of studies, James Pennebaker (1997) and others have
instructed subjects to journal about emotional issues of
personal importance, especially experiences related to close
personal relationships. These studies have revealed
increased well-being including a reduction in physical
symptoms, physician visits, and work absenteeism
(Pennebaker & Beall, 1986; Pennebaker, Kiecolt-Glaser, &
Glaser, 1988). This sort of journaling has also been found to
correlate with greater T-helper response, natural killer cell
activity, and hepatitis B antibody levels as well as lower
heart rate and skin conductance levels (Christensen et al.,
1996; Petrie et al., 1995; Petrie, Booth, & Pennebaker,
1998). Journaling about emotional issues likely increases
prefrontal activation, downregulating the negative
emotional activation of the amygdala (Dolcos & McCarthy,
2006). Our ability to tame the amygdala (and the HPA axis)
in this way results in a cascade of positive physiological,
behavioral, and emotional effects.

Levels of Language and Self-Awareness

The less men think, the more they talk.

—Baron de Montesquieu

Language is not one entity used for a single purpose. During

the evolution of culture, types and uses of language
expanded along with the sophistication of the brain.
Through self-reflection, most of us become aware that we
seem to shift back and forth among different perspectives,
emotional states, and ways of using language. Introspection
provides us with a window to shifts in states of mind that
reflect the activation and integration of different neural
networks. I am aware of at least three levels of language
processing that take place within my clients and myself
during these shifting states of mind; a reflexive social
language, an internal dialogue, and a language of self-
reflection.
Reflexive social language (RSL) is a stream of words that
services the maintenance of ongoing social relatedness and
communication. Primarily a function of left hemisphere
processing, RSL mirrors activity within the interpersonal
world and is designed to grease the social wheels. Verbal
reflexes, clichés, and overlearned reactions in social
situations provide a loose but meaningful web of
connections. Most of us experience this whenever we
automatically say something positive to avoid conflict, or
tell people we are fine regardless of what’s troubling us. The
natural clichés of RSL are as automatic to us as walking and
breathing. This level of language serves the same purpose
as grooming in most types of primates.
In addition to RSL, we are also aware of the
conversations we seem to carry on with ourselves inside our
heads. This internal dialogue often departs in content and
tone from what we express to others. And while RSL is
driven by social cooperation, internal dialogue is shaped by
personal emotions and is usually experienced as a
conversation between two aspects of the self. Internal
dialogue may have evolved on a separate track from social
language to allow for private thought as well as deceiving
others. It may also be one of the primary ways in which
right hemisphere processing participates in conscious
awareness. RSL and internal dialogue are like overlearned
motor skills that serve to maintain preexisting attitudes,
behaviors, and feelings. Like RSL, internal dialogue is
primarily reflexive and based on semantic routines and
habits reflecting our learning history. We hear in our heads
the supportive or critical voices our parents implanted early
in life. So while RSL keeps us in line with the group, internal
dialogue keeps us in line based on early programming.
When we find ourselves reflecting on RSL and internal
dialogue, a new level of language seems to emerge, one of
self-reflection. In this state of mind, our thoughts and words
focus on the reflexive thoughts, feelings, and behaviors we
usually engage in. This third level of language is less a
mechanism of social control than a vehicle of thoughtful
consideration and potential change. It employs executive
function and serves to develop a theory of our own mind.
Much of therapy consists of uncovering and exploring
reflexive social language and internal dialogue, both of
which reflect unconscious aspects of the self. In this process
we develop the language of self-reflection, learning that we
are not only our social reflexes plus the voices that haunt us
but are also the one that can observe, listen, and judge
what we hear these voices say.
As the language of self-awareness is expanded and
reinforced, we learn we are capable of evaluating and
choosing whether to follow the expectations of others and
the mandates of our childhoods. The language of self-
reflection, when contrasted with RSL and internal dialogue,
most likely reflects a higher level of integration. In this
language, cognition is blended with affect so that there can
be feelings about thoughts and thoughts about feelings. At a
very deep level, this language leads us to meditation, where
we learn to quiet our thoughts and move beyond words.
Therapy attempts to create this metacognitive vantage
point from which the shifting states of mind that emerge
during day-to-day life can be thought about. This is
accomplished by interweaving the narratives of client and
therapist and hopefully leading them in a more healthful
direction. You begin by making clients aware of one or more
of the narrative arcs of their life story and then help them
understand that change is possible and offering alternative
story lines. As the editing process proceeds, new narrative
arcs emerge, as do possibilities to experiment with new
ways of thinking, feeling, and acting. The importance of the
unconscious processes of both parent and therapist is
highlighted by their active participation in the co-
construction of the new narratives of their children and
patients. This underscores the importance of the proper
training and adequate personal therapy for therapists who
will be putting their imprint on the hearts, minds, and brains
of their clients.
In essence, therapists hope to teach their clients that
they are more than their present story but can also be
editors and authors of new stories. When we evolved the
capacity to examine our narratives (metacognition) and see
them as one option among many, we also gained the ability
to edit and modify our lives (White, 2001). The narrative
process allows us to separate story from self. It is like taking
off your shirt to patch a tear and then putting it back on.
This allows us to have the experience of a self that is
separate from our behaviors, feelings, actions, and
problems. The fact that someone can say, “I’m not myself
today,” implies the capacity for self-reflection and
comparison between a current state of mind and our
everyday self-narrative. The ability to take other
perspectives also enhances our empathy for others.

Abbey

Do not dwell in the past, do not dream of the future,

concentrate the mind on the present moment.
—Buddha

Like most things, our narratives are both good and bad.
Unexamined, they keep us in negative patterns. Seen and
understood, they provide a means of change. Thus,
unraveling all of the conscious and unconscious material
that supports a narrative arc can take considerable time and
bring many challenges. Here is an example.
Abbey, an extremely bright and charismatic woman,
came to my office with tears in her eyes and a smile on her
face. Even before she sat down, Abbey launched into a
description of all the positive events that had happened to
her and her family over the last week. Seeing the pain in her
eyes and the rigidity of her body, my face must have
reflected the sadness I was feeling. My expression seemed
to make Abbey avoid my eyes and speak even faster. From
time to time, I would attempt to break in and ask her what
she was feeling.
Abbey ignored my questions, talking at an ever faster
pace. She reminded me of how, as a child, I would cover my
ears and hum when my mother was about to say,
“Bedtime!” I soon realized that all I could do was sit, listen,
and wait. I sat across from her and tried to remain true to
my feelings, allowing them to show in my eyes and facial
expressions. Eventually her speech slowed and she became
quiet and hung her head. Her feelings seemed to have
finally caught up with her, the impulsive stream of reflexive
social language finally coming to a halt.
I was considering what to say when she spoke: “I caught
myself blabbing on.” It was good to see that Abbey could
employ her language of self-reflection and share her
observations with me. I asked her what she had been
thinking about while sitting in silence. Abbey replied, “I was
thinking of what an idiot I am and how I must bore you with
endless prattle about my stupid life.” Now she was sharing
the content of her internal dialogue, likely programmed
early in life. She seemed deflated, depressed, and ashamed
of herself. As a reaction against her own shame, she
attacked. “What a stupid job you have, sitting in this office
every day, listening to people’s problems. Why don’t you
get out of here and get a life?” Abbey soon lowered her face
into her hands and began to sob. I could see that not only
was she sharing with me the voices in her head and her
fears and doubts, but she was also projecting onto me her
anger, confusion, and frustration. Her internal dialogue was
hurting her and she wanted me to know how she felt. I said,
“Being criticized can be really painful.” She instantly knew I
was talking about the victimization by her inner voices now,
and by her parents as a child.
When she spoke again, she told me of the emptiness she
felt from the loss of her husband a few months earlier (until
this point she had denied its having much impact on her). It
had become clear to her over the last few minutes that she
had been coping with her sadness by burying herself in a
flurry of words, social activities, and taking care of others.
After a few minutes of silence and deep sighs, Abbey began
to talk about how much she missed his hugs, good advice,
and the feeling of safety of having him around. Abbey was
now speaking in the language of self-reflection. She was
able to mourn the death of her husband in this state of
mind.
When clients shift to the language of self-reflection, the
changes in their tone, manner, and mood are palpable. I
imagine at this moment that clients have the clearest
perspective on their thoughts, behaviors, and feelings. They
speak more slowly because the organization of sentences
takes time when they no longer rely on clichés and semantic
habits. Emotions bubble up and clients feel safe enough to
express them in a process that enhances affect regulation.
This is when I feel most confident about a client’s ability to
join me as a collaborator in the therapeutic process. These
states are usually fleeting and often not supported by
family, friends, or the day-to-day demands of modern life.
Therapy sometimes needs to become somewhat subversive
and conspiratorial as client and therapist attempt to work
against all the forces of habit and social momentum that
keep us consistently unhealthy. It has been said that the
challenge of increased self-awareness is remembering we
are more than our reflexes and defenses (Ouspensky, 1954).

Summary
The focus on integration exists at each level of nature’s
complexity from neurons to narratives to nations. As
systems become more complex, it takes more sophisticated
mechanisms and increasing amounts of energy to support
their continuing interconnection and homeostatic balance.
In this chapter we have explored the axes of neural
integration as well as the narratives that help us coordinate
the government of systems that comprise our brains and
construct our conscious experience. Although
psychotherapy deals in stories, it turns out that they
emerged from brain evolution to serve the purposes of
increasing complexity, coordination, and connectivity
between us. This is one of the many connections between
interpersonal relationships and brain functioning that make
psychotherapy a neuroscientific intervention.
Part IV.

The Social Brain

Chapter 10

The Social Brain

Our brains and bodies are designed to function in

aggregates, not in isolation.
—John Cacioppo

Using evolution as an organizing principle, we begin with

the assumption that our highly social brains have been
shaped by natural selection because banding together in
groups enhances survival. The more tightly interwoven we
are as a group, the more eyes, ears, hands, and brains we
have available to us. We know that the expansion of the
cortex in primates corresponds to increasingly large social
groups and the development of language, problem-solving,
and abstract abilities. Our larger and more complex brains
not only allow for a greater variety of responses to
challenging situations and across diverse environments, but
also process the vast amount of social information needed
to support communication and group coordination.
Increasingly sophisticated social groups allowed for task
specialization such as hunting, gathering, and prolonged
and dedicated caretaking. Caretaking specialization, in turn,
allowed for longer postnatal development and brains built
not by genetic preprogramming but by lived experience. So,
while many animals need to be immediately prepared upon
birth to take on the challenges of survival, human infants
have the luxury of years of total dependency as they learn
the complexities of the group. With the expanding size of
primate groups, the grooming, grunts, and hand gestures
adequate in small groups were gradually shaped into
spoken language. As social groups grew even larger, more
cortical geography was needed to process increasingly
complicated social information. This coevolution of
relationships, language, and brain allowed for the
development of higher levels of symbolic and abstract
functioning. In other words, early caretaking and intimate
relationships are a fundamental building block in the
evolution of the human brain.
Despite the fact that our brains are social organs,
Western science studies each individual as a single, isolated
organism rather than one embedded within the human
community. This way of thinking leads us in the West to
search for technical and abstract answers to human
problems instead of looking at day-to-day human
interactions. Take, for example, how physicians responded
to the high mortality rate among children in orphanages
during the last century. Assuming that microorganisms were
to blame, they separated children from one another and
ordered their handling to be kept to a minimum to reduce
the risk of contamination. Despite these mandates, the
children continued to die at alarming rates, leading staff to
fill out admissions forms and death certificates during intake
for the sake of efficiency. It was not until children were held
and played with by consistent caretakers and allowed to
interact with one another that their survival rate improved
(Blum, 2002).
The notion of the brain as a social organ emerged in
neuroscience during the 1970s as animal researchers slowly
began to appreciate that neuroanatomy, neurochemistry,
and social relationships are inextricably interwoven. The
notion that primates possess neural networks specifically
dedicated to social cognition was initially proposed by Kling
and Stecklis (1976), who found that damage to certain brain
structures in primates resulted in aberrations of social
behavior and a decline in group status. Since then,
scientists have been exploring the varied neural terrain
activated during social interactions. Subsequent research in
the expanding field of neuroscience has uncovered multiple
sensory, motor, cognitive, and emotional processing
streams that contribute to interpersonal intelligence
(Karmiloff-Smith et al., 1995).
Many of these findings have led to the growing
realization that the lessons learned during a century of
dynamic psychotherapy may have important neuroscientific
implications. The most basic is that we are born into
relationships and come to our individual identity while
resting upon social connectivity. Another is that social
interactions affect everything from our biology to our
intellectual abilities. Neuroscience researchers are slowly
coming to the realization that the scope of their scientific
observation needs to expand to include relationships.
Neuroscientists already possess the perfect model for
understanding interdependency—the individual neuron. We
know that neither the individual neuron nor the single
human being exist in nature. Without mutually stimulating
interactions, people and neurons wither and die. In neurons,
this process is called apoptosis, while in humans, it is called
anaclitic depression. From birth until death, each of us
needs others who seek us out, show interest in discovering
who we are, and help us to feel cared for and safe.
Relationships are our natural habitat, while the isolated
brain is an abstract concept. Thus, understanding the brain
requires knowledge of the person embedded within a
community of others. Therapists, teachers, and parents
intuitively grasp this profound reality just as laboratory
scientists often do not. We are now in a position to help
research scientists know where to look as they explore how
the brain grows, learns, and changes throughout life.
The Social Synapse

Life is the continuous adjustment of internal relations

to external relations.
—Herbert Spencer

As we discussed earlier, individual neurons are separated by

small gaps called synapses. These synapses are inhabited
by a variety of chemical substances engaged in complex
interactions that result in neural transmission. This activity
stimulates neurons to survive and modify themselves and
each other. Over vast expanses of evolutionary time,
synaptic transmission has grown increasingly intricate to
meet the needs of a more complex brain. A parallel process
has also been occurring in the evolution of the social
synapse.
The social synapse is the space between us. It is also the
medium through which we are linked together into larger
organisms such as families, tribes, and societies. When we
smile, wave, and say hello, these behaviors are sent
through the space between us via sights, sounds, odors, and
words. These electrical and mechanical messages received
by our senses are converted into electrochemical impulses
within our brains. These signals stimulate new behaviors,
which, in turn, transmit messages back across the social
synapse. From the moment we are born, our very survival
depends upon connecting to those around us through touch,
smell, sights, and sounds. If we are able to connect with
nurturant others whose brains are primed to accept us as an
extension of themselves, then we can bond, attach, and
survive.
The band of communication across the social synapse is
extremely broad and includes unconscious messages sent
via posture, facial expression, eye gaze, pupil dilation, and
even blushing. As we grow increasingly interdependent, our
inner experience becomes more visible through these and
other means of communication, in order to enhance the
strength of our attachments (Cozolino, 2006). Contact with
others across the social synapse stimulates neural
activation, which influences the internal environment of our
neurons. This activation in turn triggers the growth of new
neurons as well as the transcription of protein, which builds
neurons as they expand, connect, and organize into
functional networks. A basic assumption is that loving
connections and secure attachments build healthy and
resilient brains, while neglectful and insecure attachments
can result in brains vulnerable to stress, dysregulation, and
illness.
Early bonding experiences not only strengthen the
networks of the social brain, they also promote the building
of the brain as a whole by stimulating metabolic arousal.
Physical and emotional interactions between mother and
child result in a cascade of biochemical processes,
enhancing the growth and connectivity of neural networks
throughout the brain (Schore, 1994). Face-to-face
interactions activate the child’s sympathetic nervous
system and increase oxygen consumption and energy
metabolism. Higher levels of activation correlate with
increased production and availability of norepinephrine,
endorphins, and dopamine, enhancing the child’s pleasure
during positive connections (Schore, 1997a). The vital
importance of these early interactions to the building of the
entire brain may help to explain the death of
institutionalized children deprived of interaction and love
(Spitz, 1946).
You may remember from an earlier chapter that a
sensitive period is a window of time when exuberant growth
and connectivity occur in specific neural networks. The
onset and conclusion of these periods are genetically and
environmentally triggered, and correspond with the rapid
development of skills and abilities organized by each
network. Thus, early experiences have a disproportionately
powerful role in sculpting the networks of attachment and
affect regulation due to the strength of learning during
these sensitive periods (Ainsworth, Blehar, Waters, & Wall,
1978). Just as positive experiences equip us with feelings of
self-assurance and optimism, suboptimal bonding
experiences become stored within implicit memory, carried
into adulthood, and become woven into our adult
relationships. Nowhere are these organizing principles more
evident than in psychotherapy.

Attunement and Reciprocity

Mirror neurons show how strong and deeply rooted is

the bond that ties us to others.
—G. Rizzolatti and C. Sinigaglia

Attunement and reciprocity are aspects of the attachment

process that reflect mutual awareness, turn taking, and
emotional resonance. Mother–infant emotional attunement
during the first year is predictive of the toddler’s self-control
at 2 years, even when temperament, IQ, and maternal style
are controlled for (Feldman, Greenbaum, & Yirimiya, 1999).
A mother’s ability to resonate with her infant’s internal
states and translate her feelings into words will eventually
lead to the child’s ability to associate feelings with words. As
the child grows, the pairing of feelings with words enhances
the integration of vertical and horizontal networks dedicated
to language and emotions. Early emotional regulation,
established via mother–infant synchrony, contributes to the
organization and integration of neural networks and the
eventual development of self-regulation in the child.
Stage-appropriate attunement maximizes the possibility
of neural growth, network coherence, and secure
attachment. The combined sense of safety, freedom from
anxiety, and excitement generated via attunement provides
the affective background for the experience of vitality and
spontaneous expression. For the newborn, attunement may
be communicated via stroking and cuddling; for a 4-year-
old, it means helping him or her learn to share with a
sibling. A 16-year-old, on the other hand, may need
assistance with creating and staying focused on goals for
the future, while a 30-year-old will benefit from financial
advice and some free babysitting. This safe emotional
background created by proper attunement, reciprocity, and
loving kindness parallels an optimal educational and
psychotherapeutic relationship.
The building of the social brain during the first 2 years is
driven by the attunement between the right hemispheres of
the parent and the child (Schore, 2000). It is through this
connection across the social synapse that the unconscious
of the mother is transferred to the unconscious of the child.
The right-hemisphere-biased circuits of the social brain
come online at birth and appear to have their sensitive
periods during the first 2 years of life (Chiron et al., 1997).
The mother seems to regress to a state of preoccupation
with her infant in the last months of pregnancy, and
continues in this state for a number of months after giving
birth (Winnicott, 1963). This maternal preoccupation
involves an increased sensitivity to the visceral and
emotional experience of the child in order to attune to his or
her primitive means of communication. The mother’s
purposeful regression allows her to lend her capacity to
translate bodily states into words and actions that are
soothing to the infant.

Jump-starting Attachment

A mother understands what a child does not say.

—Jewish proverb
Even before birth, mothers and children engage in complex
and reciprocal interactions. Communication occurs through
sound, movement, and touch, while their shared
biochemical environment informs the child about his or her
mother’s state of mind and body. Prior to the formation of
cortically organized social neural networks, we possess a
number of primitive reflexive behaviors that jump-start and
stimulate the development of the more sophisticated forms
of attachment behavior to come. These reflexes reach
across the social synapse and allow us to become quickly
integrated with our parents. The process of transmitting the
communication style of the mother, family, and culture
begins immediately at birth.
Within the first hours after birth, newborns open their
mouths and stick out their tongues in imitation of adults,
and after 36 hours they are able to discriminate among
happy, sad, and surprised facial expressions (Field,
Woodson, Greenberg, & Cohen, 1982). Seeing happy faces
causes newborns to widen their lips, while sad faces elicit
pouting, and surprised expressions result in wide-open
mouth movement. Infants look primarily at the mouth for
happy and sad faces, whereas they alternate between the
eyes and mouth in response to expressions of surprise,
suggesting they are capable of selecting different visual
targets based on the types of information presented to them
(Field et al., 1982).
Over 20 involuntary reflexes have been identified in the
newborn. Some—like the rooting and sucking reflexes—help
the infant obtain nurturance, while the palmar grasp
(automatic hand grasp) and the Moro reflex (reaching out of
the arms) help the child hold onto the caretaker. These early
reflexes, controlled by the brainstem, are gradually inhibited
by the cortex and replaced by conscious, flexible, voluntary
behavior. Reflexes such as these increase the newborn’s
chances of survival by enhancing his or her physical and
emotional connection to mother and father. The old image
of the infant as a passive recipient of stimulation has been
replaced with a view of the infant as a competent
participant in the social environment.
One of my clients told me of his first interaction with his
son: “A few seconds after he was born, the nurse handed
him to me and told me to put him in a small bed under a
heat lamp. I dutifully crossed the delivery room and gently
placed him under the lamp. The light was very bright and he
squinted hard, making his face look like a bunch of wrinkles.
I put my hand over his face to shield his eyes and he
instinctively reached up and took my thumb in his left hand
and my pinky in his right and pulled my hand onto his
cheek. He was now about 90 seconds old and had become
my son. I felt the glow of pride about how clever he was,
while simultaneously feeling a surge of protectiveness. This
was obviously a very intelligent child with a bright future.”
In this way, reflexes provide the dual function of creating
physical connection and ensuring the emotional investment
of the adults upon whom the infant relies.
Although specific words are meaningless, the tone and
prosody of the parents’ voices hold center stage. Even
strangers will instinctively raise the pitch of their voice when
talking with babies to match their hearing abilities. A mother
reflexively holds her baby against her body after birth,
maximizing skin contact and helping the infant’s
hypothalamus establish a set point for temperature
regulation. The infant and mother gaze into each other’s
eyes, linking their hearts and brains, while nursing
establishes the lifelong relationship between nutritional and
emotional nurturance (food equals love).
The warm and happy feelings associated with holding,
touching, and nursing, the pain of separation and the joy of
reunion, are all stimulated through a variety of primitive
neurochemicals that support bonding and attachment.
Through this biochemical cascade, mother–child interactions
stimulate the secretion of oxytocin, prolactin, endorphins,
and dopamine, resulting in warm, positive, and rewarding
feelings. These biochemical processes, in turn, stimulate
neural activation and the structural maturation of the brain
while shaping attachment circuitry (Fisher, 2004; Panksepp,
1998).
The secretion of endogenous endorphins results in
feelings of well-being and elation. It actually does feel better
when a loved one kisses your boo-boo because endorphins
are also natural analgesics. These opiates are strongly
reinforcing and serve to shape our preferences from early in
life (Kehoe & Blass, 1989). Research with primates suggests
that the activation of the opioid systems of mother and child
propels and regulates the attachment process. When
parent–child primate pairs engage in touching and grooming
behavior, endorphin levels increase in both (Keverne,
Martens, & Tuite, 1989). During separation, the
administration of nonsedating morphine has the same
soothing effect on the infant as does the reappearance of
the mother. When naltrexone (a drug that blocks the effects
of endogenous opioids) was administered to infant primates,
rodents, and dogs, proximity seeking increased (Kalin et al.,
1995; Knowles, Conner, & Panksepp, 1989; Panksepp,
Nelson, & Siviy, 1994).
Reflexively orienting the head to the sound of the
mother’s voice increases the possibility of eye contact while
the instinct to seek circles and complex figures directs the
baby’s attention toward the mother’s eyes and face.
Prolonged mutual gazing stimulates metabolic activity and
neural growth, while reflexive smiling evokes positive
feelings and expressions in caretakers, further stimulating
the infant’s brain.
Close examination of the bidirectional protoconversation
between a mother and her baby demonstrates that infants
have far more influence on their mothers than previously
thought (Bateson, 1979). A baby does not simply react to its
mother, but instead learns how to affect her feelings and
behaviors. Both mother and infant adjust to each other’s
gestures, behaviors, and sounds in a sort of lyrical song and
dance (Trevarthen, 1993). It is through this language of
intersubjectivity that children learn from their mothers
about the fundamental safety or dangerousness of the
world. Protoconversation over the first year of life serves as
the interpersonal and emotional scaffolding into which
semantic language and narratives will gradually emerge.
The growth spurt of the right hemisphere provides the
neural substrate for the development of the emotional
components of language.

The Importance of Eyes

There is a road from the eye to heart that does not go

through the intellect.
—G. K. Chesterton

The eyes are a primary point of orientation for infants. They

play a significant role in bonding and social communication.
Throughout the animal kingdom, eyes play a crucial role in
determining the safety or danger posed by others. Gaze
aversion (visual cutoff) is an important social behavior that
indicates dominance hierarchy in both primates and
humans. Direct eye gaze is a threat signal in primates (De
Waal, 1989), and the recognition that we are being looked at
results in increased heart rate and amygdala activation
(Nichols & Champness, 1971; Wada, 1961). What must it be
like for primates trapped in zoos who have hundreds of
human primates filing by and staring at them each day?
Robert De Niro’s “Are you lookin’ at me?” monologue in Taxi
Driver is a dramatic example of the relationship between
eye gaze, threat, and dominance.
Learning the language of eyes provides us with valuable
information about our environment and what might be on
the minds of others. We reflexively look up when we see
other people doing so; in these situations, the eyes serve as
a source of social communication about possible threats in
our environment. Elaborate neural circuits have evolved to
monitor the direction of eye gaze of potentially dangerous
others in order to anticipate their next move. On the other
end of the spectrum, the connection among the eyes, the
visual system, and emotion can be easily witnessed in the
delight a child takes in a game of peek-a-boo. Thanks to the
neurochemistry of bonding, the smiles and laughter elicited
from a child during peek-a-boo are just as addicting for
adults. There is a surge of good feelings in both children and
caretakers with each reappearance of the eyes. Similarly,
consider the way two people in love can stare endlessly into
each other’s eyes, constantly recharging feelings of
happiness.
During infancy, mutual gaze between caretaker and child
is a primary mechanism for promoting brain growth and
organization. In their exploration of the environment,
toddlers regularly check back to see the expression on their
parent’s face. If the parent looks calm, the child will feel
confident to explore further. A frightened look from the
parent may result in the child seeking proximity and
decreasing exploration. This use of the eyes and facial
expressions to encourage or inhibit toddler activities is
referred to as social referencing (Gunnar & Stone, 1984).
In therapy, the way a patient experiences your gaze (as
caring or threatening) is an aspect of transference that may
provide important cues to early bonding experiences. An
identical expression will, for some patients, lead to a
request that the therapist not stare at them, while it will
make others feel attended to and cared for. Although some
patients prefer to lie down and look away from the therapist,
others want to keep an eye on you. These reactions reflect
the eyes’ ability to elicit emotions from the patient’s
interpersonal history stored within networks of implicit
memory. Thus, exploring the clients’ reaction to your gaze
may yield valuable information.

Recognizing Faces and Reading Facial Expressions

Laughter is the sun that drives winter from the human

face.
—Victor Hugo

A vital function of the social brain is to recognize faces and

assign a value to them; in other words, are they familiar or
strange, friend or foe—should I stay or should I go? This
involves both determining identity (who is this?) and using
facial expressions to guess the other person’s emotional
state and intentions (what are they up to?). The first part of
this process involves the complex task of recognizing a face
from all possible angles, an analysis that is easy for a child
but continues to elude the fastest computers. Although the
recognition of faces involves both hemispheres, it is a
function most suited to the visual-spatial mechanisms and
holistic processing strategies of the right hemisphere.
Research with primates has demonstrated that a
particular region of the temporal cortex contains cells that
are responsive to faces, their identity, and various facial
expressions (Perrett et al., 1984). Neurons activated
specifically by faces have also been detected in the
amygdala connecting the reading of others’ faces to our
own autonomic reactions, emotions, and behaviors
(Leonard, Rolls, Wilson, & Baylis, 1985; Perrett, Rolls, &
Caan, 1982). The temporal cortex contributes its abilities for
complex recognition tasks (i.e., the countless combinations
of facial features), while the amygdala and the ompfc add
the emotional elements to processing social information.
Together they give us the ability to approach friendly faces
and make us wary of potential enemies.
 Our temporal lobes contain neurons dedicated to faces
that are essential to our ability to relate to others. Besides
being able to recognize faces and the behaviors of others,
we need to experience other people as being different from
inanimate objects. You are probably familiar with autism and
Asperger syndrome; both disorders are characterized by
profound deficits in the ability to relate to others. In
interacting with individuals suffering from these disorders, I
have been left with the feeling that, to them, I am no
different from any other object in the room. Not surprisingly,
research has demonstrated that individuals with autism
process faces in an area of the right temporal lobe normally
used to process objects (Schultz et al., 2000). This finding
reflects one of the many neuroanatomical mechanisms
underlying profound disorders of relationship.

Mirror Neurons

Behavior is the mirror in which everyone shows their

image.
—Johann Wolfgang von Goethe

Another way in which we link up across the social synapse is

with the help of what are called mirror neurons. Let me first
describe how they were discovered. Using microsensors,
neuroscientists are able to record the firing of single
neurons in monkeys’ brains. This recording can take place
while they are aware, alert, and interacting with other
monkeys. Through such methods, neurons were discovered
in the premotor areas of the frontal cortex that fire when
another primate or the experimenter is observed engaging
in a specific behavior, such as grasping an object with a
hand (Jeannerod, Arbib, Rizzolatti, & Sakata, 1995). Some of
these neurons are so specific that they only fire when an
object is grasped in a certain way by particular fingers
(Rizzolatti & Arbib, 1998). What is even more interesting is
that these very neurons fire when the monkey itself
performs the same action (Gallese, Fadiga, Fogassi, &
Rizzolatti, 1996).
These neurons have been dubbed mirror neurons
because they fire both in response to an observation of a
highly specific relationship between an actor and some
object and when the action is performed by the observer.
Thus, mirror neurons serve to connect our visual and motor
systems with frontal systems responsible for goal-directed
behavior. For obvious reasons, the same sort of studies are
not possible in healthy human subjects. However,
noninvasive scanning technologies have been used to
extend these findings to human brains. One such study
demonstrated that areas in our brain analogous to those
containing mirror neurons in primates are activated during
both the observation and the execution of hand actions
(Nishitani & Hari, 2000). Support for the relationship
between these areas in the monkey and Broca’s area in
humans comes from positron emission tomography studies
showing activation in Broca’s area during the active or
imagined carrying out of hand movements (Bonda, Petrides,
Frey, & Evans, 1994; Decety, 1994; Grafton, Arbib, Fadiga, &
Rizzolatti, 1996).
The fact that mirror neurons fire when the same action is
observed or performed leads to some interesting
hypotheses about their role in learning and communication.
It has always been known that both humans and primates
can learn by observation. Because mirror neurons activate
for both observation and action, they may be the
mechanism for one-trial learning. Also, because these
neurons have been found in Broca’s area in humans, mirror
neurons may be involved in the imitation, learning, and
expression of language (Gallese et al., 1996). Shared
actions and turn taking may have been the genesis of
protoconversation and semantic language. Some language
learning may be jump-started by these mirror neurons
within Broca’s area, as the sounds and lip movements of
caretakers are imitated. The alternation of mirroring and
turn taking seen in mother–infant interactions may be a
contemporary reflection of the early evolution of language
(Iacoboni, 2008; Rizzolatti & Sinigaglia, 2008).
The most interesting application of mirror neurons to
psychotherapy is that the facial expressions, gestures, and
posture of another will activate circuits in the observer
similar to those which underlie empathy. Seeing a sad child
cry makes us reflexively frown, tilt our heads, say
“aawwhhhh,” and feel sad too. Watching an athlete walk off
the field with his head held high and chest pushed out can
lead us to feel energized and proud. In these and other
ways, mirror neurons may bridge the gap between sender
and receiver, helping us understand one another and
enhance the possibility of empathic attunement (Wolf,
Gales, Shane, & Shane, 2000). The internal emotional
associations linked to mirror circuitry are activated via
outwardly expressed gestures, posture, tone, and other
pragmatic aspects of communication. Thus, our internal
emotional state—generated via automatic mirroring
processes—can become our intuitive “theory” of the internal
state of the other. These structures are at the core of our
ability to develop intimate relationships, be attuned to one
another, and aid our children in shaping a healthy and
balanced sense of self.

Winnicott and the Emergence of the Person

Many patients need us to be able to give them a

capacity to use us.
—Donald Winnicott
Donald Winnicott, an English pediatrician and
psychoanalyst, developed some basic principles that
provide a helpful way of thinking about the social processes
which shape these neural structures. His work with mothers
and children led him to coin terms such as good-enough
mothering, holding environment, and transitional object,
which have become part of the basic lexicon of child
development. His ideas have been highly influential both
because of their relevance to everyday experience and their
freedom from obscure jargon.
Winnicott described the core of mothering as providing a
facilitating and holding environment, which requires both
the mother’s empathic abilities and respect for the
autonomy of the child. A mother’s devotion to her child
allows her to offer an expanding scaffolding that constantly
adapts to her child’s changing needs and abilities. Winnicott
defined the early and intense focus on the baby as primary
maternal preoccupation, and understood it to include the
mother’s absorption into and attunement to the experiences
with her baby’s primitive developmental state. In this
process, she utilizes the biochemistry of attachment and the
circuits of the social brain to bridge the social synapse
between herself and her child. The good-enough mother, in
Winnicott’s thinking, is a mother who does an adequate job
in this difficult, complex, and constantly shifting process of
adaptation (Winnicott, 1962).
Winnicott believed that to talk of an infant separate from
its mother was a theoretical abstraction. What actually
exists is a symbiotic infant–mother dyad within which the
child is nurtured and its social brain is formed, and from
which the infant eventually emerges as an individual
psychological being. Because an internalized mother and
the representation of the mother–infant dyad remain as
organizing principles of the social brain, they continue to
impact us throughout our lives. In this way, an adolescent or
adult with good-enough mothering is never really alone.
 A central component of development from Winnicott’s
perspective depends on the mother’s ability to mirror her
child. Mirroring is the process by which a mother attunes to
her child’s inner world and gives form to his or her formless
fantasies, thoughts, and needs. Mirroring serves the
purpose of taking the disorganized processes within the
child, naming them, and making them a part of the
relationship. The child then learns about his or her inner
world through the relationship. Although many decades
before their discovery, Winnicott was describing a process
that relies on mirror neurons to support this deep
attunement between mother and child.
It is not uncommon for women in the third trimester of
their pregnancy or in the first months after giving birth to
report that they feel they have lost IQ points. Although
these changes are often attributed to the effects of
hormones and sleep deprivation, they may also be related
to a shift in bias to the right hemisphere. A shift away from
logical and orderly left-hemisphere thinking to right-
hemisphere-biased processing may allow the mother an
increased level of emotional and physiological sensitivity
that enhances the intuitive elements of attachment. A shift
of brain coherence toward the right hemisphere would
explain the decrease in linear semantic processing and
memory abilities reported by new mothers and mothers-to-
be. Although such a shift might be very useful for
attunement with an infant, it could be detrimental to
functions best performed by the left, such as finding the
right words, remembering appointments, and following
logical arguments. Many new mothers report an increasing
need during the first year to get out into the world of adults
or back to work. This need may parallel a shift back to
previous levels of left-right hemisphere balance.
As the mother gradually recovers from a deep
preoccupation with her infant and again becomes interested
in other areas of life, the child is forced to come to terms
with some of his or her own limitations. In an appropriately
attuned parent, a graduated failure of adaptation will
parallel the infant’s increasing abilities, frustration
tolerance, and affect regulation. Winnicott used the term
impingement to describe the impact on the child of
maternal misattunements. These can take the form of not
appropriately anticipating the child’s needs, interfering with
the need for quiet and calm, and even underestimating his
or her abilities. Parents have to fail to adapt in different
ways in order for their children to face the challenges
necessary for adequate development.
Minor impingements are challenges that create moderate
and manageable levels of stress which the child is able to
cope with and master. These experiences likely promote and
may even maximize brain growth and neural network
integration. Major impingements overwhelm the child’s
ability to cope and integrate experience in a cohesive
manner, resulting in dissociated networking and functional
disabilities. Gradual minor impingements force the infant to
grow, whereas major impingements can result in derailment
of positive adaptation and the solidification of defense
mechanisms. Minor impingements are learning-enhancing
experiences, whereas major impingements result in
decreased neural integration and hamper the child’s
development.
One of Winnicott’s most clinically useful concepts has
been the idea of the development of a true and false self.
Secure attachments and a sense of a safe world create the
context for the development of the true self, which
represents those aspects of the self that develop in the
context of manageable (minor) impingements, support,
encouragement, and proper meaning by the caretaker.
Respect for the autonomy and separateness of the child
motivates the parent to discover the child’s interests,
instead of imposing his or her own upon them. The true self
reflects our ability to tolerate negative feelings and
integrate them into conscious awareness and to seek out
what feels right for us in our activities, ourselves, and our
relationships with others. Winnicott’s true self is obviously
one in which neural network development has been
maximized, affect is well regulated, and emotions and
cognition are well integrated. The true self reflects an open
and ongoing dialogue among the heart, the mind, and the
body.
What Winnicott called a false self results from major
impingements for which the child is unprepared. Prolonged
impingements can result in chronic emotional dysregulation.
For example, neglect, abuse, or continuous states of shame
can overwhelm the child’s natural development and lead to
the dominance of emotional defenses. These stressful
relationships will also inhibit neurogenesis and proper brain
development (Stranahan, Kahlil, & Gould, 2006). When self-
involved or pathological parents use children for their own
emotional needs, the child can become compulsively
attuned to the parents, creating a false self designed to
regulate the parents’ needs. Without appropriate assistance
in developing his or her self-reflective capacity, such
children live through reflexive social behavior and never
learn that they have feelings and needs of their own that
should be expressed and nurtured. Winnicott understood
therapy most generally as a process of controlled regression
to a childhood state with the purpose of succeeding in
developing a true self in the present which was thwarted in
early life (St. Clair, 1986).

Shame

Every word, facial expression, gesture, or action on

the part of a parent gives the child some message
about self-worth. It is sad that so many parents don’t
realize what messages they are sending.
 —Virginia Satir

During the first year of life, healthy parent–child interactions

are primarily positive, affectionate, and playful. Due to their
limited mobility, infants stay in close proximity to
caretakers, who provide for their many bodily and emotional
needs. As the infant transforms into a toddler, a parent’s
role comes to include protecting the child from danger such
as falling down stairs, being bitten by stray dogs, or drinking
fabric softener. The emergence of normal, incessant
exploratory behavior in toddlers is driven by the brain’s
intense need for stimulation and growth. Due to the
toddler’s increasing motor coordination and exploratory
drive, parents find themselves protectively saying “no”
beginning at about 18–24 months (Rothbart, Taylor, &
Tucker, 1989). Affection and attunement, experienced as
unconditional during the first year, come to be tied to limit
setting, control, and early attempts at discipline.
Shame, appearing early in the second year of life, is both
a powerful inhibitory emotion and a mechanism of social
control. Thus the positive face-to-face interactions that
stimulated excitement and exhilaration during the first year
come to include expressions of disapproval and anger.
Shame is represented physiologically by a rapid transition
from a positive to negative affective state and from
sympathetic to parasympathetic dominance. This shift is
triggered by the expectation of attunement to a positive
state, only to receive negative emotions from the caretaker
(Schore, 1994). While it may be hard to believe, toddlers
expect their parents to be just as excited as they are about
covering the floor with milk or plopping their toys in the
toilet. Parental reactions of disapproval or anger are, at first,
confusing and difficult to comprehend but soon come to
shape the biology and psychology of the child.
Behaviorally, people in a shame state look downward,
hang their head, and round their shoulders. This same state
(submission) is shown by your pet dog when he hunches
over, pulls his tail between his legs, and slinks away as you
upbraid him for some canine faux pas. Similarly, this
posture in humans reflects social exclusion, loss, and
helplessness. During early socializing experiences, shame is
the emotional reflection of a lost attunement with the
caretaker, drawing its power from the child’s primal need to
stay connected for survival. Prolonged and repeated shame
states result in physiological dysregulation and negatively
impact affect regulation, attachment, and the development
of networks of the social brain (Schore, 1994).
The return from a state of shame to attunement results
in a rebalancing of autonomic functioning, supports affect
regulation, and contributes to the gradual development of
self-regulation. Repeated and rapid return from shame to
attuned states also consolidates into an expectation of
positive outcomes during difficult social interactions. These
repairs are stored as visceral, sensory, motor, and emotional
memories, making the internalization of positive parenting a
full-body experience. Thus, the continual experience of
attunement, misattunement, and reattunement creates a
kind of body memory which becomes an expectation of a
positive outcome for relationships and life. Children left in a
shamed state for long periods of time may develop
permanently dysregulated autonomic functioning along with
depression, hopelessness, and despair. As the child
graduates into increasingly complex peer group relations,
these same physiological processes are connected to
popularity, social status, and dominance within groups at
school and on the playground.
Because shame is a powerful, preverbal, and
physiologically based organizing principle, the overuse of
shame in the process of parenting can predispose children
to developmental psychopathology related to affect
regulation and identity (Schore, 1994; Schore & Schore,
2008). As part of his therapeutic programs, John Bradshaw
(1990) refers to “inner child work” as addressing the long-
standing power of these early shame experiences, which he
calls “toxic shame.” Shame needs to be differentiated from
the later-occurring phenomenon of guilt. Guilt is a more
complex, language-based, and less visceral reaction that
exists in a broader psychosocial context. Guilt is related to
unacceptable behaviors, whereas shame is an emotion
about the self that is internalized before the ability to
distinguish between one’s behavior and one’s self is
possible. If guilt is “I did something bad,” then shame is “I
am bad.” We see this often, in individuals who spend their
lives taking care of others and doing good deeds in an
attempt to make up for some “sin” that they cannot recall.

The Consolidation of the Self

Never be afraid to sit awhile and think.

—Lorraine Hansberry

In Winnicott’s view, too many impingements prevent the

infant from experiencing what he called formless
quiescence: those moments of safety and calm that teach
the child the world can be a safe place. It is in these quiet
moments that the experience of self is consolidated, neural
networks integrate, and fantasy and reality are gently
combined. In essence, good-enough parenting results in the
belief in a benign world where one is safe to build an
internal experience of self (Winnicott, 1958). Thus, Winnicott
felt that a major achievement of early attachment was the
capacity to be alone, an ability learned by being alone in the
presence of a competent caretaker. These experiences
create enough security to allow feelings in the child to
spontaneously bubble up with the confidence that they will
be manageable and understandable. In this state of mind,
the need to employ defenses to cope with external threat
and inner emotions is at a minimum. At the same time,
parietal-frontal systems involved in imagination and the
creation of an inner sense of self become activated.
The manic defenses we often see in our clients result
from the lack of the capacity to be alone. Impulsive
behaviors and thoughts, disconnected from self-reflective
processes, serve to inhibit emotions because to these
individuals, to feel is to feel bad (Miller, Alvarez, & Miller,
1990). Slowing down stimulates discomfort, sadness,
isolation, and shame, which become background affect
throughout life. If manic defenses are chronically employed,
they can become a way of life and keep children and adults
from constructing inner imaginal experience and a sense of
self. Sadly, many children with manic defenses are
mistakenly diagnosed with ADHD. They are medicated to
help them cope, while the real problem goes unresolved.
People with manic defenses often mask their inability to
be alone by stirring up a constant whirlwind of activities,
social interactions, and phone calls. Despite their outward
success, and their narcissistic and grandiose attitudes, they
often have great difficulties in relationships and report
feelings of despair and emptiness. Exploration of their
histories usually points to patterns of insecure attachments
in which achievement served as the currency for
acceptance. Constantly escalating levels of activity are
reinforced by praise from others and the avoidance of the
negative feelings that bubble up when the patients are quiet
or alone. These people often have a hard time relaxing or
taking a vacation because the lack of distractions leaves
them open to the intrusion of uncomfortable feelings for
which they have no effective coping skills.
The inability to be alone is seen most clearly in
individuals with borderline personality disorder, who have a
catastrophic reaction to real or imagined abandonment. For
these people, separation is experienced as a threat to their
very survival in much the same way as an infant reacts to
the absence or loss of a parent. Their catastrophic reaction
in adulthood is likely the activation of an implicit memory of
overwhelming abandonment fears from a time before object
constancy or self-regulation. It is as if the child within these
patients is in a holding pattern, awaiting proper parenting.
The extremely emotional life-and-death reactions in
borderline patients may be our best window to the chaotic
and often frightening emotional world of early childhood.

Summary
The brain is a social organ connected to other brains via the
social synapse. Primitive reflexes jump-start the attachment
process and are gradually replaced by voluntary behaviors.
The motivation to stay connected is driven by biochemical
systems we share with our primitive ancestors. While there
are multiple channels of communication between us, vision
is an important link across the social synapse and the
expressive face a focal point of social information. Theories
of psychological development by Winnicott, Freud and
others provide us with models for the development of mind
embedded in these more basic neurobiological processes.
The development of a sense of self requires periods of
freedom from external threat and inner turmoil. It also
requires the development of frontal-parietal systems
responsible for inner imaginal space. Children constantly
buffeted by external chaos can remain trapped in a
“selfless” state where they are witness to internal impulses
and external behaviors with little or no ability to either
understand or control what they are doing.
Chapter 11

Building the Social Brain: Shaping Attachment

Schemas

Experience is a biochemical intervention.

—Jason Seidel

While Winnicott observed and worked with mother–infant

pairs in his consulting office, John Bowlby was performing
naturalistic observations of primates in the wild and children
in orphanages. He was especially interested in mother–child
bonds, the importance of exploratory behavior, and the
impact of separation and loss on healthy development. His
experiences led him to develop the concepts of attachment
figures, proximity seeking, and a secure base (Bowlby,
1969). Bowlby’s observations and the subsequent scientific
findings in attachment research are easily integrated with
Winnicott’s theories of bonding and attachment.
Bowlby’s work, which highlighted the importance of
specific caretakers to a child’s sense of security, resulted in
a major shift in the care of institutionalized children. To
encourage bonding, children who had previously been cared
for by whomever was available, were now assigned
consistent caretakers. In addition, this change in attitude
changed the role of nurses and caretakers from only
custodians of small babies into emotional attachment
figures. In essence, they were told that becoming attached
should not be avoided. Subsequently, Mary Ainsworth and
her student Mary Main developed research methods to test
Bowlby’s theories. Decades of attachment research
followed, providing us with some fascinating tools to study
the sculpting of the social brain during childhood, as well as
the long-term impact of early experiences later in life.
Bowlby suggested that early interactions create
attachment schemas that predict subsequent reactions to
others. Schemas are implicit memories that organize within
networks of the social brain, based on experiences of safety
and danger with caretakers during early sensitive periods. A
secure attachment schema enhances the formation of a
biochemical environment in the brain conducive to
regulation, growth, and optimal immunological functioning.
Insecure and disorganized attachment schemas have the
opposite effect, and correlate with higher frequencies of
physical and emotional illness.
Bowlby believed attachment schemas to be a summation
of thousands of experiences with caretakers that become
unconscious, reflexive predictions of the behaviors of
others. Attachment schemas become activated in
subsequent relationships and lead us to either seek or avoid
proximity. They also determine whether we can utilize
intimate relationships for physiological and emotional
homeostasis. These implicit memories are obligatory; that
is, they are automatically activated even before we become
conscious of the people with whom we are about to interact.
They shape our first impressions, our reaction to physical
intimacy, and whether we feel relationships are worth
having. They trigger rapid and unconscious moment-to-
moment approach-avoidance decisions in interpersonal
situations. Attachment schemas are especially apparent
under stress because of their central role in affect
regulation. Attachment is mediated by the regulation of the
autonomic nervous system by the social brain, and a
cascade of biochemical processes that create approach and
avoidance reactions as well as positive and negative
emotions. Schemas shape our conscious experience of
others by activating rapid and automatic evaluations
hundreds of milliseconds before our perceptions of others
reach consciousness.
Empirical research into attachment schemas began with
Ainsworth’s naturalistic in-home observations of mothers
interacting with their children (Ainsworth et al., 1978).
These mothers were found to fall into three categories:
available and effective (free autonomous), dismissing and
rejecting (dismissing), and anxious and inconsistent in their
attentiveness (enmeshed/ambivalent). The belief was that
these different caretaking styles would create differing
coping and interpersonal styles in their children. So the next
step was to determine whether the children of mothers in
each category displayed differences in their attachment
behaviors, especially when stressed or frightened.
The method developed to study the children’s
attachment behavior is called the infant strange situation
(ISS). The ISS consists of placing an infant and its mother in
a room, then having a stranger join them. After a period of
time, the mother exits the room, leaving the child alone with
the stranger. Another brief period follows, and then the
mother returns. Children’s reunion behavior, or how they
respond to the return of their mother, is rated to determine
their attachment style. This situation was chosen because of
Bowlby’s observation that being left alone with an unknown
other evokes distress calls in young primates. The
attachment schema of the child, or the expectation of being
soothed by the mother, should be aroused by the stress of
the situation and reflected in his or her reunion behavior.
Does the child seek comfort from the mother or ignore her?
This research was begun with a number of questions: Does
the child have a hard time being comforted? Does the child
soon feel safe and return to play, or is he or she anxious,
clingy, or withdrawn? These and other behaviors are the
focus of the ISS scoring system and are thought to reflect
the child’s experience and expectation of the mother’s
soothing capacity.
Four categories of the infants’ reactions to their mothers’
return have been derived from the ISS: secure, avoidant,
anxious-ambivalent, and disorganized. Furthermore, a
relationship was found between ISS categories and the
maternal behavior originally derived from in-home
observations. The general findings were as follows: children
rated as securely attached sought proximity with the mother
upon her return, were quickly soothed, and soon returned to
exploratory or play behavior. These children, comprising
approximately 70% of the sample, seemed to expect that
their mothers would be attentive, helpful, and encouraging
of their continued autonomy. Securely attached children
appeared to have internalized their mothers as a source of
comfort, using them to feel safe. These mothers were seen
as effective in their interactions with their children and had
become “a background context for seeking stimulation
elsewhere” (Stern, 1995, Chapter 6).
Avoidantly attached children tended to ignore their
mothers when they returned to the room. They would
glance over to the mother as she came in, or shun contact
altogether. These children tended to have dismissing and
rejecting mothers and appeared to lack an expectation that
she would be a source of soothing and safety. Avoidantly
attached children behaved as though it was easier to
regulate their own emotions than seek comfort from their
mothers, whose misattunement or dismissal might well
compound their stress.
Children rated as anxious-ambivalent sought proximity
but were difficult to soothe and slow to return to play.
Anxious-ambivalent children, who often had enmeshed or
inconsistently available mothers, may have their stress
worsened by their mothers’ distress. Their slow return to
play and emotional regulation may be a reflection of their
mothers’ anxiety and lack of internalized safety. These
children tended to cling more and explore their environment
less.
Finally, there was a group of children who engaged in
chaotic and even self-injurious behaviors. On reunion with
their mothers, they demonstrated odd behavior such as
turning in circles or falling to the ground. They would freeze
in place or be overcome by trancelike expressions. During
later research, these children were included in a fourth
category called disorganized attachment. These chaotic
behaviors were demonstrated in conjunction with secure,
avoidant, and anxious-ambivalent behaviors and were often
present in children whose mothers suffered from unresolved
grief or trauma. Parents of children in this category
demonstrate frightened and frightening behavior to their
children, inducing an alarm state in the child. In this
biological paradox, the child’s brain has an innate drive to
move toward the mother. However, since the parent is also
a source of alarm, the child is faced with an approach-
avoidance conflict. The resulting inner turmoil dysregulates
the child to the point that his or her adaptation and coping
skills—even motor abilities—appear to become
disorganized. The fear and chaos of the mothers’ internal
worlds can be observed in their children’s behavior.
The transmission of trauma from parent to child is both
powerful and insidious. A traumatized mother who creates
alarming experiences for her child leaves the child no choice
but to stay with and depend on the source of the alarm. The
child’s safe haven is replaced with repetitive trauma by
proxy and emotional dysregulation (Olsson & Phelps, 2007).
This process creates a new generation of victims. In
research with Holocaust survivors, indications of parental
trauma were found to be reflected in the biochemistry of
their nontraumatized children (Yehuda et al., 2000; Yehuda
& Siever, 1997). Further compounding the child’s
dysregulating environment, the trauma-related behaviors of
victims will lead them to be avoided by other children in
normal social interactions. It is not surprising that children
with avoidant and disorganized attachment schema are also
shown to have higher levels of stress hormones and other
biological markers of trauma and sustained stress (Spangler
& Grossman, 1993).

Parents Talk of Their Childhoods

A Freudian slip is when you say one thing but mean

your mother.
—Unknown

The relationships discovered between attachment schemas

and parenting style raised the question of whether a
parent’s early attachment experiences influenced parenting
style decades later. While it was assumed that the parenting
styles of adults are somehow shaped by childhood
experiences, there was no empirical support for this transfer
from one generation to the next. Because implicit memory
is inaccessible to our conscious mind, and explicit memories
of childhood are shaped by so many emotional factors, a
measure was needed that could bypass the usual distortions
of memory and all of our defense mechanisms. An
extremely interesting research tool that appears to have
succeeded in this task is the Adult Attachment Interview
(AAI) (Main & Goldwyn, 1998).
The AAI consists of a series of open-ended questions
about childhood relationships and early experiences such as
these:

I’d like you to try to describe your relationship

with your parents as a young child…if you could
start from as far back as you can remember.
Choose adjectives that reflect your relationship
with your mother, father, and so on.
 Which of your parents did you feel closest to and
why?

Although the AAI gathers information about what

individuals remember of their childhood, it also provides the
data for a linguistic analysis of the coherence of the
narrative’s organization and presentation. Coherence
analysis is conducted based on what are called Grice’s
maxims and include an examination of both the logic and
understandability of the narrative based on the following
four principles:

1. Quality: Be truthful, and have evidence for what

you say.
2. Quantity: Be succinct, and yet complete.
3. Relevance: Stick to the topic at hand.
4. Manner: Be clear, orderly, and brief.

Scoring takes into account the integration of emotional and

experiential materials, gaps in memory and information, and
the overall quality of the presentation (Hesse, 1999).
The AAI bypasses the left hemisphere interpreter by
examining the quality of the brain’s synthesis of the various
cognitive and emotional components of explicit and implicit
memory. Siegel (1999) proposed that the coherence of the
AAI narrative parallels the level of neural integration
attained during childhood, providing a window to early
attachment experiences and emotional regulation. In
essence, the AAI gets at how individuals put feelings into
words, resolve traumatic experiences, and integrate the
various networks of information processing across emotion,
sensation, and behavior in making sense of their lives. It
does all of this while simultaneously bypassing the problems
inherent in self-report measures about the past.
 Four categories emerge from the AAI that appear to
correspond to the findings of the in-home observations and
the infant strange situation. Mothers and fathers with
securely attached children tended to have more detailed
memories, as well as a realistic and balanced perspective of
their parents and childhood. Adhering well to Grice’s
maxims, they were able to describe these experiences in a
coherent narrative that was understandable and believable
to the listener (Main, 1993). This group, called autonomous,
demonstrated an integration of cognitive and emotional
memories, had processed their negative experiences, and
was therefore more fully available to their children.
The second group of parents, associated with avoidantly
attached children, demonstrated a lack of recall for
childhood events and large gaps in memory for their
childhood. This lack of recall is believed to reflect a
disruption of the integration of cognitive and emotional
elements of autobiographical memory. This could be due to
trauma, chronic stress, or a lack of assistance in learning to
regulate affect from their own parents early in life. They also
demonstrated an overall dismissing attitude toward the
importance of their early relationships, just as they were
dismissive of their own children now. The narratives of these
parents were incoherent both due to missing information
and a tendency to either idealize or condemn their parents.
They gave the impression that they were defending against
fully acknowledging their histories through denial and
repression.
A third group of parents, rated as enmeshed or
preoccupied, tended to have anxious-ambivalently attached
children. Their narratives contained excessive, poorly
organized verbal output that lacked boundaries between the
past and present. They appeared preoccupied, pressured,
and had difficulty keeping the perspective of the listener in
mind.
 Last, the unresolved/disorganized group of parents had
highly incoherent narratives disrupted by emotional
intrusions and missing or fragmented information. Their
narratives not only reflected the disorganization of verbal
and emotional expression, but also the devastating impact
early stress had on the development and integration of their
neural networks. The content of their narratives confirmed
chaotic and frightening childhood experiences which we can
assume were devastating to the integration and
homeostatic balance of both body and brain. See Table 11.1
for a summary of attachment findings.
 
TABLE 11.1 Summary of Attachment Findings

In-Home Infant Adult Attachment

Observations Strange
of Mothers Situation
Interview
Free Secure Autonomous
autonomous Infant seeks Detailed memory
Emotionally proximity Balanced perspective
available Easily Narrative coherency
Perceptive and soothed/returns
effective to play
Dismissing Avoidant Dismissing
Distant and Infant does not Dismissing/denial
rejecting seek proximity Idealizing
Infant does not Lack of recall
appear upset
Enmeshed- Anxious- Enmeshed-preoccupied
ambivalent ambivalent Lots of output
Inconsistent Infant seeks Intrusions, pressured,
availability proximity preoccupied
Not easily Idealizing or enraged
soothed
 Not quick to
return to play
Disorganized Disorganized Unresolved/disorganized
Disorienting Chaotic Disoriented
Frightening or Self-injurious Conflictual behavior
frightened Unresolved loss
Traumatic history

 
The power of the relationship between parent and child
attachment patterns was demonstrated by Fonagy and his
colleagues when they administered AAIs to expectant first-
time parents (Fonagy, Steele, & Steele, 1991a). Over a year
later, when the children reached their first birthday, their
attachment patterns were assessed using the ISS. In 75% of
these cases, the child’s attachment pattern was predicted
by the coherence of the parent’s narrative and attachment
style many months before birth. Parents of infants who
came to be securely attached were able to provide a fluid
narrative with examples of interactions, had few memory
gaps, and presented little idealization of the past. These
parents did not seem to have significant defensive
distortions, were able to express negative feelings without
being overwhelmed, and listeners tended to believe what
they were saying. It is not a big stretch to see that these
parents were best able to provide the kind of good-enough
social environment providing a balance between safety and
challenge, attunement and autonomy.
We now have some evidence that parents’ capabilities
for attachment to an infant begin to take shape in their own
childhoods. Their skill as parents will depend on their
empathic abilities, emotional maturity, and neural
integration: in essence, how they were parented as children.
As a child, a young girl may begin to imagine someday
having children of her own. The shaping of her virtual
children will be influenced by both her fulfilled and
unfulfilled needs. The empathy and care each parent
received as well as the assistance they experienced in
articulating and understanding their inner worlds will
influence future parenting abilities. A mother’s childhood
can determine whether she is prepared to emotionally
provide for her newborn or if she will unknowingly require
her child to give her the attention she failed to receive when
she was young (Miller, 1981).
Because attachment schemas are part of implicit
memory, this level of caretaking occurs automatically and
connects our unconscious childhood experiences across the
generations. In this way, a parent’s unconscious is a child’s
first reality. Interestingly, negative events in childhood are
not necessarily predictive of an insecure or disorganized
attachment schema or future parenting style. Working
through, processing, and integrating early experiences, and
constructing coherent narratives, are more accurate
predictors of a parent’s ability to be a safe haven for his or
her children. This earned autonomy, through the healing of
childhood wounds, appears to interrupt the transmission of
negative attachment patterns from one generation to the
next.
The inference that parents who are rated as autonomous
have higher levels of neural integration is based on the fact
that they are able to access and connect cognitive and
emotional functioning in a constructive and useful manner.
They do not appear to be suffering the effects of unresolved
trauma or dissociative defenses and have attained a high
degree of affect regulation, as demonstrated by their ability
to meet the demands of parenting with ongoing grace. They
are able to remember and make sense of their own
childhoods and are available to their children both verbally
and emotionally. Their children develop attachment
schemas that make them secure in the expectation that
their parents are a safe haven and will soothe and assist
them when threats arise. Not surprisingly, parents’
emotional insight and availability to themselves appears to
parallel their emotional availability to their children.
The three nonsecure patterns of attachment research all
reflect lower levels of psychological and neurological
integration. They also correlate with the use of more
primitive psychological defenses associated with
disconnections among streams of processing within the
brain. The lack of recall and black-and-white thinking of the
dismissing parent likely reflect blocked and unintegrated
neural coherence. This brain organization then results in
decreased attention and emotional availability to the child.
The enmeshed parent has difficulty with boundaries
between self and others, as well as between past memories
and present experiences. These internal and interpersonal
issues then lead to inconsistent availability and a flood of
words that dysregulate the child. Thus the child, who is also
anxious and ambivalent, will seek proximity but have a
difficult time returning to play because of the unpredictable
availability, as well as the confusing and emotionally
dysregulating nature of the parent’s messages and
emotions. The internalized mother, instead of being a
source of security and autonomic regulation, becomes
organized as a destabilizing state of mind and body.
Maternal and paternal instincts—in fact all caretaking
behaviors—are acts of nurturance that depend upon the
successful inhibition of competitive and aggressive
impulses. Too often, however, that inhibition is incomplete
and some of us are unable to be good-enough parents.
When a parent abuses, neglects, or abandons a child, the
parent is communicating to the child that he is less fit.
Consequently, the child’s brain may become shaped in ways
that do not support his long-term survival. Nonloving
behavior signals to the child that the world is a dangerous
place and tells him to not explore, discover, or take
chances. When children are traumatized, abused, or
neglected, they are taught that they are not among the
chosen. They grow to have thoughts, states of mind,
emotions, and immunological functioning that are
inconsistent with well-being, successful procreation, and
long-term survival. With all due respect to the old adage, we
could also say that what doesn’t kill us makes us weaker.
The tragedy of this lies in the fact that early experiences
have such a disproportionately powerful impact on the
development of the infrastructure of the brain. As highly
adaptive social organs, our brains are just as capable of
adjusting to unhealthy environments and pathological
caretakers as they are to good-enough parents. While our
brains become shaped to survive early traumatic
environments, many of these adaptations may impede
health and well-being later in life. Negative interpersonal
experiences early in life are a primary source of the
symptoms for which people seek relief in psychotherapy.
Secure attachments represent the optimal balance of
sympathetic and parasympathetic arousal, whereas their
imbalance correlates with insecure attachment patterns
such as fight or flight and splitting (Schore, 1994). The
balance of these two systems becomes established early in
life and translates into enduring patterns of arousal,
reactivity to stress, and possible vulnerability to adolescent
and adult psychopathology. Poor attachment patterns lead
to long-lasting emotional and physical over-or underarousal
throughout the body and the brain.
Secure and insecure attachment schemas are quite
different. Securely attached children do not produce an
adrenocortical response to stress, suggesting that secure
attachment serves as a successful coping strategy. On the
other hand, those with insecure attachment schemas do
show a stress reaction, demonstrating that insecure
attachment is better described by a model of arousal rather
than of successful coping (Izard et al., 1991; Nachmias,
Gunnar, Mangelsdorf, Parritz, & Buss, 1996; Spangler &
Grossman, 1993; Spangler & Schieche, 1998). In other
words, the behavior of insecurely attached individuals is an
expression of the state of their autonomic arousal in
response to fear.

Narrative Co-construction

The wise man must remember that while he is a

descendant of the past, he is a parent of the future.
—Herbert Spencer

Parent–child talk, in the context of emotional attunement,

provides the ground for the co-construction of narratives.
These narratives, in time, become the mass of our inner
experience and the parameters of our personal and social
identities. When verbal interactions include references to
sensations, feelings, behaviors, and knowledge, they
provide a medium through which the child’s brain is able to
integrate the various aspects of its experience in a coherent
manner. The organization of autobiographical memory that
includes input from multiple neural networks enhances self-
awareness and increases the ability to solve problems, cope
with stress, and regulate affect. This integrative process is
what psychotherapy attempts to establish when it is absent.
Co-constructed narratives form the core of human
groups, from primitive tribes to modern families. The
combined participation of caretakers and children in
narrating shared experiences organizes memories, embeds
them within a social context, and assists in linking feelings,
actions, and others to the self. The creation and repetition of
stories help children to develop and practice recall abilities
and have their memories shaped in relationships (Nelson,
1993). This mutual shaping of memory between child and
caretaker can serve both positive and negative ends.
Positive outcomes include teaching the importance of
accuracy of memory, imparting of cultural values, and
shaping the child’s view of herself based on her role in the
story. Negative outcomes include the transfer of the
caretakers’ fears and anxieties into the child’s narratives so
that they become central themes in the experience of the
child (Ochs & Capps, 2001).
When caretakers are unable to tolerate certain emotions,
they will be excluded from their narratives or shaped into
distorted but more acceptable forms. The narratives of their
children will come to reflect these editorial choices. At the
extreme, parents can be so overwhelmed by the emotions
related to unresolved trauma that their narratives become
disjointed and incoherent. On the other hand, narratives
that struggle to integrate frightening experiences with
words can serve as the context for healing by
simultaneously creating cortical activation and increasing
descending control over subcortically triggered emotions.
Parental narratives, both coherent and incoherent, become
the blueprint not only for the child’s narratives, but for the
organization and integration of their neural circuitry. As it
turns out, there appears to be a relationship among the
complexity of a child’s narratives, self-talk, and the security
of the child’s attachment.
Main and her colleagues (Main, Kaplan, & Cassidy, 1985)
studied a group of 6-year-old children who, at 1 year, were
assessed in the infant strange situation. They discovered
that securely attached children engaged in self-talk during
toddlerhood and spontaneous self-reflective remarks at age
6. They also tended to make comments about their thinking
process and their ability to remember things about their
history. These processes of mind, which insecurely attached
children often lack, reflect the utilization of narratives in the
development of self and self-identity. They also point to a
more sophisticated ability to metacognize (think about
thinking), that represents a high level of neurolinguistic self-
regulation. What we are witnessing appears to be the
internalization of their parents’ self-regulatory mechanisms.
As you might expect, child abuse correlates with less secure
attachment patterns in children and a decreased ability to
talk (or think) about their internal states (Beeghly &
Cicchetti, 1994).
Fonagy, Steele, Steele, Moran, et al. (1991) studied the
relationship between infant security and reflective self-
functioning in mothers and fathers. They found a strong
correlation between measures of self-reflection and
narrative coherence. In fact, when reflective self-function
was controlled for in the statistical analysis, coherence no
longer related to infant security. This suggests that the
relationship between coherence and reflective self-
functioning is powerful, and that the ability to reflect on the
self plays an important role in the integration of multiple
processing networks of memory, affect regulation, and
organization. In discussing these results, the researchers
suggested, “The caregiver who manifests this capacity at its
maximum will be the most likely to be able to respect the
child’s vulnerable emerging psychological world and reduce
to a minimum the occasions on which the child needs to
make recourse to primitive defensive behavior characteristic
of insecure attachment” (Chapter 11).
When the parents’ inability to verbalize internal and
external experiences leaves the child in silence, the child
does not develop a capacity to understand and manage his
or her own inner and outer world. The ability of language to
integrate neural structures and organize experience at a
conscious level is left unutilized. When children with
nonhealing parents experience trauma early in life, the
stress of each new developmental challenge is multiplied. In
the same way, language, in combination with emotional
attunement, is a central tool in the therapeutic process,
creating the opportunity for neural growth and neural
network integration.
 A child who is able to achieve this ability with the help of
someone other than the primary caretaker, may be able to
earn a higher level of integration and security than would be
predicted by his or her parents’ rating on the Adult
Attachment Interview. This may come from other significant
people in the child’s environment who are able to attune to
the child’s world and assist in the child’s articulation of his
or her emotional life. This might explain some of the earned
autonomy seen in parents with negative childhood
experiences but with coherent narratives and the ability to
provide a safe haven for their children. Earned autonomy is
convincing evidence that early negative experiences can be
rein-tegrated and repaired later in life. Personal growth has
the ability to heal because the social brain remains plastic.
Attachment patterns formed in childhood can be
relatively stable into adulthood and have been shown to
impact romantic love, interpersonal attitudes, and
psychiatric symptoms (Brennan & Shaver, 1995; Hazan &
Shaver, 1990). Adult children of anxious parents repeatedly
return to them throughout life, still seeking comfort and a
safe haven. Many of these children become parents to their
parents, taking care of the people they wish would and
could care for them. They continue to return to an empty
well; each time the bucket is lowered there is the hope that
it will contain the nurturance they need. Each returning
empty bucket reinforces their lack of safety.

Child Therapists

Treat people as if they were what they ought to be

and you help them to become what they are capable
of being.
—Goethe
A question that commonly arises among therapists,
adoptive parents, and mental health legislators is, “When is
it too late?” At what age do the negative effects of early
abuse, trauma, and neglect become permanent? Getting to
the heart of the issue, the true question becomes: Who is
worth seeing as a client, adopting as a child, or investing
public funds in for rehabilitation? In my mind, these are
moral rather than scientific questions. I have become very
skeptical of “experts” who think they have found answers to
any issue in neuroscience. My bias is to trust in plasticity
and our own ingenuity to discover new solutions to these
problems. Here is a study that may give us some guidance
as we consider these issues.
To test the impact of maternal deprivation, Harry Harlow
isolated newborn monkeys not only from their mothers, but
from any and all contact with other monkeys. Beyond
minimal contact related to taking care of their basic needs,
these young monkeys were left alone in a cage with a few
toys and little else. Pictures of these isolate monkeys are
heartbreaking—they huddle in corners, rock, bite
themselves, and stay curled up in a fetal position. It is as if
they are trapped in an autistic hell waiting to be born into
the social world.
When these isolated monkeys are then introduced into a
standard monkey colony at 6 months of age, they are
understandably terrified. They don’t seem to understand
what is going on, retreat from curious others, and do their
best to avoid interaction. At first it was tempting to think of
this 6-month period as a cutoff point for attachment
plasticity. Perhaps attachment circuitry had gone through a
hard-wired critical period and, by 6 months, it was too late
to learn how to be social. But as with every conclusion in
neuroscience, there needs to be caution.
Harlow and Suomi (1971) wondered if therapy could help
these isolate monkeys overcome their fear and allow them
to join the social world of the colony. But how do you do
therapy with a monkey? Would you choose Gestalt,
cognitive-behavioral, or psychoanalytic treatment?
Ultimately what was chosen was a combination of play and
attachment therapy. The “therapists” chosen for the job
were normal 3-month-old monkeys, who were selected
because they were smaller, craved playful contact, were
less aggressive, and probably less threatening than same-
aged peers.
Therapy consisted of three 2-hour sessions per week for
4 weeks—a total of 24 hours of “treatment.” When the
“therapists” arrived for the session, the isolates were
terrified and retreated. The therapists approached, touched,
and climbed on their older clients. The isolates tried to
retreat while their anxiety and self-stimulating behavior
increased. Again the therapists engaged, touched, climbed
on, and got in the face of their clients. Apparently, when it
comes to play and social engagement, a 3-month-old
monkey won’t take no for an answer. As the sessions
continued it was reported that the isolates gradually came
to habituate and accept their therapists’ interventions.
These interactions interrupted autistic, self-stimulating
behavior, and the clients eventually began to initiate
physical contact and interact with their younger therapists.
Therapy was so successful that the authors stated, “By 1
year of age, the isolates were scarcely distinguishable from
the normal therapists in terms of frequencies of exploratory,
locomotive, and play behavior” (p. 1537).
After a course of treatment, when these former isolates
were introduced to the colony, they did much better, and
were able to find a role within the group and social
hierarchy. Were they impaired? Most likely, early deprivation
had a long-lasting impact, but it appeared to the
researchers that they had attained a functional social
recovery. These results surprised Harlow and Suomi because
of their prior assumptions about critical periods. They also
help remind me to keep an open mind, and remember that
giving up on a child or client is not something I am ever
willing or prepared to do.

Summary
Neuroscience suggests that an important aspect of love is
the absence of fear. If therapists and adoptive parents can
create an environment that minimizes fear and maximizes
the positive neurochemistry of attachment through human
compassion, attachment circuitry can be stimulated to grow
in ways which are not only healing, but that allow victims of
abuse and neglect to risk forming a bond with another.
Because the process of attachment is, at heart, a way in
which social animals initially regulate fear, and later their
affective lives, modifying insecure attachment, first and
foremost, requires the establishment of a safe and secure
relationship. Therapists work diligently to establish this type
of relationship for each client and to create an experience
similar to what the 3-month-old monkeys were able to give
their senior isolates: the experience of social connection in
the absence of threat or rejection.
There are probably thousands of studies supporting what
we all intuitively know—childhood experience affects
emotional and physical health later in life. While there are
plenty of psychological and social theories that attempt to
explain this relationship, we are beginning to put together
the biological mechanisms of action of these findings. The
general question is, how do early social experiences shape
our neurobiology in ways that can influence us decades
later?
Chapter 12

The Neurobiology of Attachment

Offspring inherit, along with their parents’ genes, their

parents, their peers, and the places they inhabit.
—Leon Eisenberg

Reflected in the architecture of each of our brains is the

coming together of our evolutionary history, the generations
preceding our birth, and our unique relationship with our
parents (Eisenberg, 1995). Hundreds of studies have
demonstrated the ways in which early experience is
correlated with physical and emotional health later in life.
Research in psychoanalysis, epidemiology, developmental
psychology, and psychiatry have all supported what we
think of as common sense: A good childhood is better than a
bad one; positive parental attention is important; and less
stress early in life is a good thing. Of course, each field
explains these findings from its own theoretical model and
tends to see other perspectives as secondary.
Recent research in molecular biology offers us a
groundbreaking view into the underlying mechanism of the
effects of early experience on genetic expression, that is,
how early experience triggers gene expression to guide our
brains onto particular adaptational trajectories. In contrast
to the correlations found in other fields of study, this new
work explores causal biological links between maternal
behavior and the building of the brains of children.
 When we think about having an internalized mother, our
thoughts usually stray to images of a kind smile, a warm
hug, feeling safe, and being loved. Depending on the
culture, you may remember your mom serving Thanksgiving
dinner, stirring tomato sauce, or frying chicken. Those of us
who are less fortunate may have images of rageful
behavior, endless criticism, or a mother passed out on the
couch after a long day of drinking. These conscious
autobiographical memories are but one layer of an
internalized mother. Another level, deeper and just as
meaningful, is how these early experiences shaped the
neurobiological processes of our brains.
In this chapter we climb up and down the evolutionary
ladder from humans to rats and back again to humans. It
turns out that we have learned a great deal by exploring
how the behavior of mama rats influences the brains of their
pups. The conservation of structures and functions during
evolution provides us with a good animal model of the
effects of maternal behavior on the brain. Although this
research has yet to be done with humans, the behavioral
and neurobiological parallels between rats and humans are
striking, making rats very helpful in understanding the
interpersonal aspects of neurobiology. We also explore
networks of the human brain that rely on similar shaping
during early experience, as well as some other ways in
which epigenetics factors may impact everything from the
timing of menopause to human longevity. In places, this
chapter is heavy on the science, so be prepared to read
certain sections over a few times. I have put most of the
specific data in tables to act as an overview and guide to
particular studies for those who wish to do follow-up
reading.

The Evolution of Complexity

 Who takes the child by the hand takes the mother by
the heart.
—German proverb

Let’s set the stage to look at these studies with the

assumption that our social brains have been shaped by
natural selection because being social enhances survival.
Our best guess is that larger and more complex brains allow
for more diverse responses in challenging situations and
across diverse environments. Our brains allow us to fashion
clothing, build houses with heating systems, and create
sophisticated farming techniques that allow us to expand
our habitats and sources of food. But does this explain why
we have relationships?
We know that the expansion of the cortex in primates
correlates with increasingly large social groups. The benefit
of living in a tribe is not just in the safety of numbers, but
also in the ability of groups to have task specialization such
as hunting, gathering, and caretaking. So, while many fish
and reptiles need to be born immediately prepared to take
on the challenges of survival, human infants have years of
total dependency during which their brains can grow and
adapt to very specific environments. This larger window of
time for adult–child interactions allows for increasingly
sophisticated postnatal brain development and increased
investment in each child (Kaplan & Robson, 2002). This
expanded social investment enhances the child’s chances of
survival, which in turn increases the chances of our genes
surviving into the next generation (Allen, Bruss, & Damasio,
2005; Charnov & Berrigan, 1993). Thus, the development of
the brain, group organization, caretaking, and social
communication co-evolved in a mutually interdependent
manner.
There are many interesting theories about how humans
evolved to be the complex social creatures we are. The big
story probably goes something like this:
 Larger group size enhanced the probability of
survival, but required bigger and more complex
brains to process social information, and so
larger brains were selected.
More complex brains require longer periods of
development and result in prolonged periods of
child dependency.
Longer periods of dependency require more
attention and dedication to nurturance,
caretaking specialization, and social structures
that can support this specialization.
As the size of primate groups expanded,
grooming, grunts, and hand gestures became
inadequate and were gradually shaped into
spoken language.
Complex social structures encouraged the
development of more sophisticated
communication, leading to the development of
oral and written language.
As social groups grew in size and language
became more complex, a larger cortex was
needed to process increasingly complex
information.
Language and culture provide our expanding
brains the ability to record and accumulate
history and information, and develop technology.
The accomplishments of culture allow for even
greater group size and more sophisticated
brains.

It is very likely that some version of this evolutionary

narrative shaped the contemporary human brain. But
despite some remarkable advances, we have continued to
be governed by the basic biological principles of
homeostasis, fundamental approach-avoidance choices, and
flows of electrical and chemical information throughout our
brains and bodies. Like every living system, from a single
neuron to complex ecosystems, the brain depends on
interaction with other brains for its survival. Because
increasing complexity requires greater interdependency, our
brains have come to exist more and more profoundly within
a matrix of other brains.
At birth, the human brain is dependent on caretakers for
its survival and growth. The prolonged and sophisticated
parenting that has evolved in primates scaffolds an
increasing amount of postnatal growth and development.
This allows each human brain to be a unique blending of
nature and nurture as it builds its structures through
interactions and molding itself to its environment. Parents’
nonverbal communications and patterns of responding to
the infant’s basic needs also shape the baby’s perceptions
of the world and its sense of self. Because the first few years
of life are a period of exuberant brain development, early
experience has a disproportionate impact on the
development of neural systems.
Genes first serve to organize the brain and trigger
sensitive periods, while experience orchestrates genetic
transcription in the ongoing adaptive shaping of neural
systems, so that experience becomes the actual hardware
of our brains. This structure, in turn, organizes other brains,
allowing experiences to be passed through a group and
carried forward across generations. While being embedded
in a group comes with many challenges, it also comes with
an ability to interactively regulate each other’s internal
states and assist in neural integration.

Environmental Programming

The group consisting of mother, father, and child is

the main educational agency of mankind.
 —Martin Luther King Jr.

The transduction of bonding experiences into

neurobiological structure is a fascinating area of study. It
carries deep implications for how relationships throughout
life impact our experience and thereby shape our brains.
Michael Meaney and his colleagues have been studying this
question in great depth for many years. Their work has
taken advantage of naturally occurring variation in the
maternal behavior of mother rats (dams) to explore the
impact of their ministrations on the brains of their pups.
Mother rats lick, nurse, and retrieve their pups when they
roll out of the nest. These three behaviors are easily
observed and counted by willing undergraduates, and
correlated with behavioral and biological variables in the
brains of both mothers and children.
The work of Meaney and others has provided us with
ample evidence that mother rats pass on their genes
through DNA and shape genetic expression through their
behavior. Environmental programming is a term used to
describe this orchestration of epigenetic factors during
development (Fish et al., 2004; Meaney & Szyf, 2005;
Sapolsky, 2004). Thus, two mechanisms of inheritance exist:
slow changes across many generations through mutation
and natural selection, and rapid changes in genetic
expression during each generation (Clovis et al., 2005;
Cameron et al., 2005; Meaney & Szyf, 2005; Zhang, Parent,
Weaver, & Meaney, 2004). Their research has thus far
revealed three primary ways in which maternal behavior
impacts variations in brain structure—learning and
plasticity, the ability to cope with stress, and later maternal
behavior in adulthood. A mother’s impact on the way her
daughter will mother her children serves as a parallel
channel of inheritance that is highly sensitive to
environmental conditions.
 Genetic expression is programmed by experience
through the alteration of the chromatin structure and the
methylation of DNA (Szyf, Weaver, & Meaney, 2007). In
effect, the genome is like a keyboard while these processes
select the notes to be played. Methylation is a process by
which a methyl group is added to DNA. This has been shown
to be a reversible but stable modification to DNA that is
passed along to daughter cells and can lead to long-term
gene silencing. Low licking/grooming mothering results in
increased glucocorticoid receptor methylation, decreased
glucocorticoid receptor (GR) expression, and an increased
stress response. Licking/grooming decreases methylation,
increases GR expression and downregulates the stress
response (Weaver et al., 2007). So as we show affection and
kindness to our children, we may be building more resilient
brains, an expression of genetic variation that would likely
have made Lamarck smile.
Three different research methods have been employed to
study the effects of maternal behavior on genetic
expression. In the first model, the amount of attention is
measured and the behaviors and brains of pups in high-and
low-attention groups are compared. The second examines
the effects of periods of maternal deprivation, while the
third uses handling of the pups by human researchers as the
experimental manipulation. Because it has been found that
human handling stimulates more maternal attention, the
first and third categories may turn out to be one and the
same (Garoflos et al., 2008).
Levels of maternal attention have been shown to either
stimulate or silence gene expression in the domains of
neural growth and plasticity, modulation of hypothalamic-
pituitary-adrenal (HPA) activity, and programming of future
maternal behavior (Szyf, McGowan, & Meaney, 2008).
Neural growth is stimulated via the activation of brain-
derived neurotrophic factor (BDNF), cFos, and messenger
RNA expression in a variety of brain areas, processes tied to
the biochemistry of neuroplasticity and learning. Stress
reactivity is controlled via levels of benzodiazepine,
oxytocin, and glucocorticoid receptors in many regions of
the brain. Higher levels of maternal attention result in more
of these receptors being formed, allowing for the dampening
of fear and anxiety and an increase in exploratory behavior.
Maternal behavior is governed by the growth and activation
of medial optic areas (the rats’ version of our ompfc) as well
as the regulation of oxytocin and estrogen receptors
(Neumann, 2008). See Table 12.1 for some of the specific
findings in each area of study.
In essence, rats who receive more maternal attention
have brains that are more robust, resilient, and nurturing of
others. They are able to learn faster and maintain memories
longer. They are less reactive to stress and are thus able to
use their abilities to learn at higher levels of arousal and
across more difficult situations. They will also suffer less
from the damaging effects of cortisol by downregulating it
sooner after a stress response. And finally, females growing
up with more attentive mothers pass these positive features
on to their children. The mechanisms for the association in
humans between early secure attachment and healthier
minds and bodies is likely similar but far more complex.
 
TABLE 12.1 The Impact of Maternal Attention

Maternal Study Findings

Action
  Neural Growth and Plasticity
Licking Increased synaptic density, longer dendritic
branching, and increased neuronal survival1
Licking Increased neuronal survival in the
hippocampus2
Licking Fos expression in the hippocampus and
 parietal and occipital cortex3
Licking/nursing Increased NMDA and BDNF expression and
increased cholinergic innervation of the
hippocampus4
 
  Modulation of HPA Activity
Licking Increased medial PFC dopamine in response
to stress and increased startle inhibition5
Licking/nursing Decreased fear reactivity 6
Licking/nursing Increased epigenetic expression of
glucocorticoid receptor gene promoter in
the hippocampus7
Licking/nursing Increased mRNA expression in medial
prefrontal cortex, hippocampus, and the
basolateral and central regions of the
amygdala8
Licking/nursing Increased levels of benzodiazepine
receptors in the lateral, central, and
basolateral regions of the amygdala and the
locus coeruleus as well as increased levels
of alpha 2 adrenoreceptor density and
decreased CHR receptor density in the locus
coeruleus9
 
  Modulation of Future Maternal
Behavior
Nursing call Enhanced metabolic activation in precentral
medial cortex, anterior cingulate cortex, and
lateral thalamus10
Licking Elevated levels of estrogen mRNA and more
maternal behavior later in life11
Licking/nursing Increased levels of oxytocin and estrogen
receptors in medial preoptic areas (and
 increased maternal behavior when they
have their own pups)12
Licking Less sexual behavior in females and less
likely to become pregnant after giving
birth13

 
Maternal attention stimulates the expression of BDNF,
the most abundant neurotrophins in the brain. Among its
many functions, BDNF modulates glutamate-sensitive NMDA
receptors which, in turn, regulate both long-term
potentiation, long-term depression, and neuroplasticity
(Alonso et al., 2002; Bekinschtein et al., 2008; Monfils,
Cowansage, & LeDoux, 2007). While cortisol inhibits the
production of BDNF (and new learning), higher levels of
BDNF appear to both buffer the hippocampus from stress
and encourage ongoing plasticity (Pencea et al., 2001;
Radecki et al., 2005; Schaaf, de Kloet, & Vregendenhil,
2000). And because the production of BDNF (and other
neurotrophins) are under epigenetic control, physical,
emotional, and interpersonal experience all influence their
production and availability (Berton et al., 2006; Branchi et
al., 2004; Branchi, Francia, & Alleva, 2006).
Many researchers have found correlations between
hippocampal volume and symptoms of depression. While
most stressful illnesses correlate with reductions in
hippocampal volume, there is speculation that depression
may be a result rather than a cause of hippocampal
reduction. In other words, the symptoms of depression are
an experiential expression of a shutdown of neuroplasticity.
Thus, if our neurons become depressed, so do we. Since
depression is often a natural consequence of prolonged
stress, one mechanism of action linking the two may be the
catabolic impact of high levels of cortisol on the neurons
within the hippocampus. It is suspected that antidepressant
SSRIs and physical activity work to reverse the negative
impact of cortisol in the hippocampus by triggering BDNF
synthesis (Fernandes et al., 2008; Russo-Neustadt et al.,
2000; Warner-Schmidt & Duman, 2006). Direct
administration of BDNF has also been shown to have long-
lasting antidepressant effects (Hoshaw, Malberg, & Lucki,
2005).
While more maternal attention results in increased
growth and enhanced functioning throughout the pups’
brains, separation from mothers proves to have the opposite
effects. The same three areas that are upregulated with
more maternal attention are all downregulated by her
absence. Deprivation of maternal attention increases neural
and glial death, while reducing gene expression, impairing
their ability to learn. Maternal separation also results in
reduced inhibitory (GABA) receptors in the locus coeruleus,
increasing adrenaline secretion in reaction to stress while
reducing the antianxiety properties of benzodiazepine
receptors in the amygdala. Decreased cortisol receptors in
the hippocampus also impair the inhibitory feedback to the
stress system to shut down cortisol production. See Table
12.2 for the specific studies from which this information is
taken. So again we see results that parallel findings with
human subjects where early maternal deprivation through
separation or depression results in decreased brain
functioning, higher levels of anxiety, and difficulty with
subsequent attachment (Brennan et al., 2008; Tyrka et al,
2008).

TABLE 12.2
The Impact of Maternal Separation

Neural Growth and Plasticity

Increased neuronal and glial death1
Decreased neurotrophin levels in ventral hippocampus2
Decreased glial density3

Modulation of HPA Activity

Reduced GABA receptors in the locus coeruleus
Decreased GABA receptor maturity
Reduced benzodiazepine receptors in the central and lateral
amygdala and increased mRNA expression in the
amygdala4
Increased anxiety, fearfulness, and response to stress5
Increased LTP and LTD in amygdalo-hippocampal synapses6
Decreased exploratory behavior, avoidance of novelty, and
greater vulnerability to addiction7
Reduced gene expression8
Greater cortisol secretion in response to mild stress and
increased startle response and startle-induced sounds9
Reduced somatic analgesia and increased colonic motility
mimicking irritable bowel syndrome in humans10
Upregulation of glutamate receptors11

Modulation of Future Maternal Behavior

Decreased synaptic density in the medial prefrontal cortex
Decreased cell survival in maternal neural networks12
Decreased activation in the Bed nucleus of the stria
terminalis and nucleus accumbens13

The evidence from the handling studies is essentially the

same as for highly attentive mothers in neural health and
the modulation of anxiety, supporting the idea that they
may both represent the effects of greater amounts of
maternal attention. More glucocorticoid receptors, lower
cortisol levels, and greater brain activity reflect a brain
geared toward less anxiety, helplessness, and fear. In turn,
these pups are more resilient, engage in more complex
exploratory behavior, and are better learners than their
nonhandled siblings. Similar results have also been
discovered in parrots and pigs (see Table 12.3).

TABLE 12.3
The Impact of Human Handling on Rats, Pigs, and
Parrots

Modulation of HPA Activity

Rat pups
Increased concentrations of glucocorticoid receptors in the
hippocampus and frontal lobes1
Increased glucocorticoid receptor binding capacity in the
hippocampus2
Increased corticotrophin-releasing factor mRNA and
greater CRF levels3
Decreased inhibitory avoidance and increased object
recognition4
Lower levels of stress in reaction to a predatory odor5
Increased neurotrophin-3 expression and neuronal
activation in hippocampus and parietal lobes6
Low cortisol secretion in response to stress/high
exploratory behavior 7
Protection against age-related neuroendocrine and
behavioral decline with age8
Decreased helplessness behaviors9

Baby pigs
Lower basal and free plasma levels of cortisol10

Amazon parrots
Decreased serum cortisol levels in response to stress11
 These and other studies support the belief that the
reaction of the brain to maternal attention is not an abstract
theory but a well-documented phenomenon. The
consistency of behavioral, emotional, and biological findings
across species is too powerful to be discounted. In fact, over
900 genes have been discovered that are differentially
expressed based on the amount of maternal behavior
(Rampon et al., 2000; Weaver et al., 2006). And there is no
reason to believe that the maternal control of epigenetic
expression has not been conserved in primates and
humans.
Rhesus monkeys deprived of maternal contact
demonstrate reduced transcriptional efficiency of serotonin
and its receptors in the brain (Bennett et al., 2002). We do
know that low levels of caring maternal behavior in humans
correlate with more fearful behavior, less positive joint
attention, and right-biased frontal activation, all of which are
related to higher levels of stress and arousal (Hane & Fox,
2006). Self-esteem and locus of control have been found to
correlate with hippocampal volume, which we know is tied
to cortisol regulation (Pruessner et al., 2005). In my mind,
the parallels as well as the tendency for evolution to
conserve such mechanisms form a strong case for the
theory that what Meaney and his colleagues are finding in
rats is at work in humans.
In an exciting twist, it has been found that biological
interventions and enriched social and physical environments
can reverse the effects of low levels of maternal attention
and early deprivation on both HPA activity and behavior
(Bredy et al., 2004; Francis et al., 2002; Hood, Dreschel, &
Granger, 2003; Szyf et al., 2005; Weaver et al., 2005).
Unfortunately, chronic stress or trauma in adolescence and
adulthood can also reverse the positive effects of higher
levels of attention earlier in life, shaping a brain that
resembles one that was deprived of early maternal attention
(Ladd, Thrivikraman, Hout, & Plotsky, et al., 2005). These
studies all support the notion that our brains are capable of
continual adaptation in both positive and negative directions
and that successful psychotherapy, one that establishes a
nurturing relationship, may well be capable of triggering
genetic expression in ways that can decrease stress,
improve learning, and establish a bridge to new and
healthier relationships.
Keep in mind that the amount of attention that a mother
rat shows her pups exists in a broad adaptational context.
Highly stressed mothers demonstrate lower rates of licking
and grooming, which prepare her pup’s brains for living in a
stressful environment. In other words, under adverse
conditions, maternal behavior decreases, which programs
her offspring for enhanced reactivity to stress. This likely
increases the probability of survival while simultaneously
elevating the risk of physical and emotional pathology later
in life (Diorio & Meaney, 2007). The impact of neonatal
handling is also different for male and female pups,
reflecting their divergent adaptational roles and
contributions to the survival of their species (Park, Hoang,
Belluzzi, & Leslie, 2003; Ploj et al., 2001; Stamatakis et al.,
2008). All of this suggests that the level of maternal
behavior is interwoven into a matrix of adaptation choices
that vary based on external factors. The fact that processes
that are set in motion early in life can be modified by
subsequent experience demonstrates the ability to adapt to
a changing environment.
This work with rats has established guidelines for future
exploration into environmental programming in humans.
There are obvious limitations to research with humans that
requires physical examination of the brain. We will have to
rely on samples of opportunity and utilize careful
methodological controls to be certain of the quality of
results. One such study compared the brains of suicide
victims with normal controls and found lower mRNA levels of
BDNF and trkB in the suicide victims, both of which are
involved in neuronal health and plasticity. These data raise
the possibility that early environmental programming may
have made them susceptible to depression and suicide
(Dwivedi et al., 2003). A more recent study compared the
brains of suicide victims with and without histories of child
abuse and found that those with histories of early abuse
demonstrated decreased levels of glucocorticoid receptor
mRNA, receptor expression, and growth factor transcription
when compared to those without abuse (McGowan et al.,
2009). These studies are highly supportive of our ability to
apply animal research to humans.

Attachment and the Human Brain

What I do and what I dream include thee, as the wine

must taste of its own grapes.
—Elizabeth Barret Browning

It turns out that gene expression in response to close

contact is a twoway street. Giving birth and exposure to
children changes the brains of parents and caretakers in
ways that support bonding, attachment, and nurturance. A
primary discovery in mother rats has been the remodeling
and expansion of the hippocampus in preparation for
locating, storing, and retrieving greater amounts of food
(Pawluski & Galea, 2006). Contact with her pups causes
increased growth in the medial preoptic area, basolateral
amygdala, and parietal and prefrontal cortex as the brain
expands to incorporate these new beings into the self-
experience of the mother (Fleming & Korsmit, 1996; Kinsley
et al., 2006; Lonstein et al., 1998). Even virgin rats who are
given pups to care for experience increased dendritic
growth and neuronal excitation in superoptic areas (Modney,
Yang & Hatton, 1990; Modney & Hatton, 1994; Salm,
Modney, & Hatton, 1988). Thus, just as in children,
interpersonal contact changes the brains of parents.
It has been shown that when human mothers hear their
infants cry, there is an increase in activity in their right
medial prefrontal cortex and anterior cingulate—regions
known to mediate maternal response (Lorberbaum et al.,
1999). Watching a video of their own infant will stimulate
activity in the right anterior temporal pole, left amygdala,
and both right and left ompfc (Minagawa-Kawai et al., 2008;
Nitschke et al., 2004; Ranote et al., 2004).
It is likely that just as maternal attention triggers
epigenetic factors in children, caring for children may also
change genetic expression in their caretakers. The
grandmother gene hypothesis suggests that human women
experience early menopause to be available to help nurture
their grandchildren and avoid the risks inherent in mating
and childbirth, which rise with age for both mother and child
(Lee, 2003; Rogers, 1993; Turke, 1997). In essence, the
grandmother gene hypothesis suggests that early
menopause has been shaped by natural selection to
enhance the survival rate of a woman’s children’s children.
Sear, Mace, and McGregor (2000) studied tribal life in
rural Gambia where families live at the level of subsistence
and depend upon one another for basic survival. Their
lifestyle is likely similar to the social and environmental
context of most of our evolutionary history. The results of
their research show that nutritional status, height, and the
probability of survival of their young were significantly
correlated with the presence of postmenopausal maternal
grandmothers. On the other hand, the presence of fathers,
paternal grandmothers, or other male kin had a negligible
impact on either the nutritional status or survival rates of
offspring. Similar findings have been obtained in studies of
hunter-gatherer populations of Tanzania, premodern Japan,
Canada, and Finland, and contemporary urban populations
in the United States (Hawkes, O’Connell, & Jones, 1997;
Lahdenperä et al., 2004; Pope et al., 1993).
Besides the timing of menopause, is it possible that
women live longer because they are traditionally involved in
caring for their young? That is, is there a health benefit
involved in taking care of children because of the
neurobiological processes it stimulates in our brains and
bodies? Some interesting evidence that may support a
connection between child care and longevity comes from
looking at parenting responsibilities across different species
of primates. A longevity advantage for females does exist in
gorillas, orangutans, and humans, in which they are the
primary caretakers. On the other hand, in species such as
the owl and titi monkey, where the male is the primary
caretaker of infants, males tend to survive longer. In Goeldi
monkeys, where caretaking is shared, the longevity for both
genders is equivalent (see Table 12.4).
 
TABLE 12.4 Child Care and Longevity Across Primate
Species

Primate Female/Male Male Care

Survival Ratio
Chimpanzee 1.418 Rare
Spider 1.272 Rare
monkey
Orangutan 1.203 None
Gorilla 1.199 Pair-living, little direct
role
Gibbon 1.125 Protects and plays with
offspring
Human 1.052–1.082 Supports economically,
some care
Goeldi 0.974 Both parents carry
monkey infant
Siamang 0.915 Carries infant in second
year
Owl monkey 0.869 Carries infant from birth
Titi monkey 0.828 Carries infant from birth
 
Adapted from Allman, Rosin, Kumar, & Hasenstaub, 1998.

 
Given the amount of data supporting the beneficial
effects of secure attachment, caretaking, human touch, and
social support, it is plausible that nurturing, emotional
attunement, and physical contact have salubrious effects
that may provide primary caretakers with a survival
advantage. It is possible that attachment bonds, caretaking
experiences, and the neurochemicals and epigenetic
phenomena they impact may well enhance our health and
survival. Perhaps caring for our children and grandchildren
may be more supportive of health and longevity than
cholesterol medication and treadmills.
Interestingly, women who give birth after the age of 40
are almost four times more likely to live to be 100 years old
(Perls, Alpert, & Fretts,1997). While this is usually explained
in terms of the protective nature of birth-related hormones,
their enhanced longevity may be part of broader biological
and psychological processes involved in intense caretaking
(King & Elder, 1997). It is a good bet that taking care of a
child tells the brain and body to trigger epigenetic and
biochemical processes that enhance health and slow down
aging.

The Human Social Brain

 It is good to rub and polish our brains against those of
others.
—Montaigne

We have seen a great deal of evidence of the impact of

early nurturance on the shaping of the social brain and its
emotional circuitry. So when our early relationships are
frightening, abusive, or nonexistent, our brains dutifully
adapt to the realities of our unfortunate situations. However,
there is reason to believe that these circuits retain
experience-dependent plasticity throughout life, especially
in close relationships (Bowlby, 1988; Davidson, 2000).
Experience-dependent plasticity has been found in many
areas of the brain, including the prefrontal cortex and
hippocampus (Kolb & Gibb, 2002; Maletic-Savatic, Malinow,
& Svoboda, 1999). These structures, central to learning and
memory, are also key in shaping attachment schema.
Further, research is emerging that in the transition from
dating to marriage, there is a broad tendency to move from
insecure and disorganized attachment schema to
increasingly secure patterns (Crowell, Treboux, & Waters,
2002). On the other hand, social stress inhibits cell
proliferation and neural plasticity, while social support,
compassion, and kindness support positive neural growth
(Czéh et al., 2007; Davidson, Jackson, & Kalin, 2000).
While rats possess the basic mechanisms of bonding and
maternal behavior, our brains have more elaborate and
sophisticated mechanisms for attachment. In fact, the
human brain is criss-crossed with neural networks dedicated
to receiving, processing, and communicating messages
across the social synapse. The difference in humans is that
the environmental programming of these experience-
dependent circuits is far more lengthy and complex.
Networks of our complex social brains include brain regions,
neural systems, and regulatory networks listed in Table
12.5. These are the same circuits that therapists attempt to
influence in reshaping the brain in ways which lead to more
positive adaptation later in life. The idea that psychotherapy
is a kind of reparenting may be more than a metaphor; it
may be precisely what we are attempting to accomplish at
the level of the epigenome. This research establishes
attention, care, and nurturance as a way to influence the
very structure of our brain and places psychotherapy at the
heart of biological interventions. It is odd to think that Carl
Rogers may someday find a place next to Crick and Watson
in the pantheon of biologists.
Now let’s shift our attention to the structures of the
human brain that organize attachment, affect regulation,
and the modulation of stress. For a more in-depth
exploration of the social brain, see The Neuroscience of
Human Relationships (Cozolino, 2006). Keep in mind that,
just as in rats, these systems are also built by the
attachments they come to control. Thus, our learning
history comes to be reflected in the architecture of our
neural systems.

TABLE 12.5
Structures and Systems of the Social Brain

Cortical and Subcortical Structures

Orbital and medial prefrontal cortices (ompfc)
Cingulate cortex and spindle (Von Economo) cells
Insula cortex
Somatosensory cortex
Amygdala, hippocampus
Hypothalamus

Sensory, Motor, and Affective Systems

Face recognition and expression reading
Imitation, mirroring, and resonance systems
 Regulatory Systems
Attachment, stress and fear regulation (orbital medial
prefrontal cortex–amygdala balance)
Social engagement (the vagal system of autonomic
regulation)
Social motivation (reward representation and reinforcement)

Cortical and Subcortical Structures

The prehistorical and primitive period represents the

true infancy of the mind.
—James Baldwin

The ompfc, insula, and cingulate cortices—the most

evolutionarily primitive areas of the cortex—lie buried
beneath and within the folds of the later evolving cortex. In
fact, some neuroanatomists see these contiguous structures
as comprising a functional system called the basal forebrain
(Critchley, 2005; Heimer & Van Hoesen, 2006). The ompfc
sits at the apex of the limbic system. As a convergence zone
for polysensory, somatic, and emotional information, it is in
the perfect position to synthesize information from both our
internal and external worlds. In its position at the apex of
the limbic system, the ompfc’s inhibitory role in autonomic
functioning highlights its contribution to the organization of
behavior and affect regulation.
The ompfc allows us to translate the punishment and
reward values of complex social information such as facial
expressions, gestures, and eye contact into meaningful
information, associate it with our own emotions, and thus
organize attachment schema (O’Doherty et al., 2001;
Tremblay & Schultz, 1999; Zald & Kim, 2001). The ompfc
also mediates emotional responses and coordinates the
activation and balance of the sympathetic and
parasympathetic branches of the autonomic nervous system
(Hariri et al., 2000; Price, Carmichael & Drevets, 1996).
The cingulate cortex is a primitive association area of
visceral, motor, tactile, autonomic, and emotional
information that begins to participate in brain activity during
the second month of life (Kennard, 1955). It first appeared
during evolution in animals exhibiting maternal behavior,
play, and nursing, and when making sounds became
involved with communication between predator and prey,
potential mates, and mother and child (MacLean, 1985). The
caretaking and resonance behaviors made possible by the
cingulate also provide an important component of the
neural infrastructure for social cooperation and empathy
(Rilling et al., 2002; Vogt, 2005). Destruction of the anterior
cingulate in mammals results in mutism, a loss of maternal
responses, infant death due to neglect, and emotional and
autonomic instability (Bush, Luu, & Posner, 2000; Bush et
al., 2002; Paus, Petrides, Evans, & Meyer, 1993).
The anterior cingulate contains spindle-shaped neurons
that appear to have evolved in humans and great apes to
connect and regulate divergent streams of information
(Nimchinsky et al., 1995, 1999). These cells may provide the
neural connectivity necessary both for the development of
self-control and the ability to engage in sustained attention
to difficult problems (Allman et al., 2001, 2005). Spindle
cells are especially fascinating because they emerge after
birth and are experience-dependent. Early neglect, stress,
and trauma may negatively impact the development and
organization of the anterior cingulate and spindle cells,
resulting in lifelong cognitive deficits, and emotional
functioning may be based on the construction and health of
these structures (Cohen et al., 2006; Ovtscharoff, Helmeke,
& Braun, 2006).
The insula begins life on the lateral surfaces of the brain,
only to become hidden by the rapid expansion of the frontal
and temporal lobes. The insula is sometimes described as
the “limbic integration cortex” because of its massive
connections to all limbic structures, and its feed-forward
links with the frontal, parietal, and temporal lobes
(Augustine, 1996). It provides the brain with a means to
connect primitive bodily states with the experience and
expression of bodily awareness, emotion, and behavior (Carr
et al., 2003; Phan et al., 2002). In tandem with the anterior
cingulate, the insula allows us to be aware of what is
happening inside of our bodies and reflect on our emotional
experiences (Bechara & Naqvi, 2004; Critchley et al., 2004;
Gundel, Lopez-Sala, Ceballos-Baumann, 2004). Damage to
the right insula can result in anosognosia, a condition where
a patient seems unaware of and unfazed by severe paralysis
on the left side of the body (Garavan, Ross, & Stein, 1999).
Recent research suggests that the insula is involved with
mediating the entire range of emotions from disgust to love
(Bartels & Zeki, 2000; Calder et al., 2003).
The somatosensory cortex, located along the front of the
parietal lobes, processes information about bodily
experiences. It lies just behind the central gyrus and wraps
deep within the Sylvian fissure that divides the parietal from
the frontal lobes. Along with the insula and anterior
cingulate cortices, it contains multiple representations of
the body that process and organize our experience of touch,
temperature, pain, joint position, and our visceral state.
These different processing streams combine to create our
experience of our physical selves. It also participates in
what we call intuition or gut feelings by activating implicit
memories related to our experiences and helping us to
make decisions guided by feelings (Damasio, 1994). The
experience of our own bodies becomes the model for our
understanding and empathy with others (Damasio et al.,
2000).
Working in concert with the ompfc, the subcortical
amygdala is another core component of the social brain.
The amygdala achieves a high degree of maturity by the
eighth month of gestation, allowing it to associate a fear
response to a stimulus prior to birth (LaBar et al., 1995;
Ulfig, Setzer, & Bohl, 2003). As a primitive organ of
appraisal, the amygdala closely monitors signals of safety
and danger and mediates the fight-or-flight response via the
autonomic nervous system (Davis, 1997; Ono, Nishijo, &
Uwano, 1995; Phelps & Anderson, 1997). The ompfc can
inhibit the amygdala based on conscious awareness and
feedback from the environment (Beer et al., 2003). By the
same token, when we are frightened and our amygdala is
activated, it inhibits the ompfc and we have a difficult time
being rational, logical, and in control of our thoughts. The
amygdala also appears to contribute to our conscious
experience of both emotional and physical pain (Mitra &
Sapolsky, 2008; Neugebauer, Li, Bird, & Han, 2004). Since
the networks connecting the ompfc and the amygdala are
shaped by experience, our learning history of what is safe
and dangerous, including our attachment schema, is
thought to be encoded within this system.
The hippocampus is situated at the junction between the
cortex and limbic system on both sides of the brain. In lower
mammals like the rat, the hippocampus is a specialized
spatial map of foraging territory. In humans, the parietal
lobes evolved from the hippocampus and assist it in
complex visual-spatial processing. The human hippocampus,
along with its adjacent structures (parahippocampal gyrus,
dentate gyrus), have come to be specialized in the
organization of spatial, sequential, and emotional learning
and memory (Edelman, 1989; McGaugh et al., 1993; Sherry
et al., 1992; Zola-Morgan & Squire, 1990). In contrast to the
amygdala, the hippocampus is a late bloomer, continuing to
mature into early adulthood along with the dlpfc
connections upon which it relies (Benes, 1989). Our lack of
conscious memory for early childhood, known as childhood
amnesia, is likely due to the slow developmental course of
the hippocampus (Fuster, 1996; Jacobs et al., 2000;
McCarthy, 1995).
The hypothalamus is a small and ancient structure that
sits at the center of the brain below the thalamus and
halfway between the cortex and the brainstem. It has
extensive connections with the structures of the social brain
within the frontal lobes, limbic system, and brainstem. I
include the hypothalamus as part of the social brain
because it is centrally involved with the translation of
conscious experience into bodily processes and thus, the
transduction of early experience into the building of the
brain and body. Its various nuclei organize many bodily
functions such as temperature regulation, hunger, thirst,
and activity level. The hypothalamus is also involved in the
regulation of sexual behavior and aggression. As the head of
the HPA axis, it translates brain processes into hormonal
secretions from the anterior pituitary. Among the hormones
produced by the pituitary, follicle-stimulating hormone and
prolactin are involved in reproduction and nursing.
Adrenocorticotropic hormone, which is sent to the adrenal
glands via the blood stream, stimulates the production of
cortisol, which we will be discussing in depth later as it
relates to caretaking and early stress.

Sensory, Motor, and Affective Systems

Common Sense is that which judges the things given

to it by other senses.
—Leonardo da Vinci

It is in the temporal lobes that our senses are integrated,

organized, and combined with primitive drives and
emotional significance in a “vertical” linkup across all three
levels of the triune brain (Adams, Victor, & Ropper, 1997).
For example, the recognition of faces and reading their
expressions occurs in the top-down networks. Cells involved
in both reading and identifying facial expressions are
located in adjacent areas of the temporal lobes (Desimone,
1991; Hasselmo, Rolls, & Baylis, 1989). When we see faces,
the areas of the brain that become activated lie in a
processing stream dedicated to the identification of visual
stimuli (Lu et al., 1991). The association region of the
occipital lobe dedicated to the identification of faces is the
fusiform face area (Gauthier et al., 2000; Halgren et al.,
1999). These areas, in turn, are interconnected with other
clusters of cells that are responsible for eye gaze, body
posture, and facial expression as the brain constructs
complex perceptions and social judgments from basic
building blocks of visual information (Jellema, Baker, Wicker,
& Perrett, 2000).
Regions in the anterior (front) portions of the superior
temporal sulcus (STS) integrate information about various
aspects of the same person (form, location, and motion),
allowing us to identify others from different angles, in
various places, and while they are in motion (Jellema,
Maassen, & Perrett, 2004; Pelphrey et al., 2003; Vaina et al.,
2001). The STS also contains mirror neurons, which activate
either when we witness others engaging in behaviors or
when we ourselves subsequently engage in these actions.
By bridging neural networks dedicated to perception and
movement, mirror neurons connect the observed and the
observer by linking visual and motor experience. Resonance
behaviors (based on mirror systems) are the reflexive
imitation responses we make when interacting with others.
It is hypothesized that mirror systems and resonance
behaviors provide us with a visceral-emotional experience of
what the other is experiencing, allowing us to know others
from the inside out.

Regulatory Systems
 We gain our ends only with the laws of nature; we
control her only by understanding her laws.
—Jacob Bronowski

The body’s regulatory systems are involved in the

maintenance of internal homeostatic processes, balancing
approach and avoidance, excitation and inhibition, and fight
and flight responses. They also control metabolism, arousal,
and our immunological functioning. It is through these
systems that we regulate each other’s biological and
emotional states.

The Stress, Fear, and Attachment System

I’m not afraid of storms, for I’m learning how to sail

my ship.
—Louisa May Alcott

The HPA system regulates the secretion of hormones

involved with the body’s response to stress and threat. The
immediate reaction to stress is vital for short-term survival,
while the rapid return to normalization after the threat has
passed is essential for long-term survival. Prolonged stress
results in system damage and breakdown. The long-term
effects of negative parenting experiences, failures of
attachment, and early trauma are mediated via the HPA
system. In terms of fear, we turn again to the amygdala, as
it alerts a variety of brain centers that a fight-flight response
is required. In turn, the activation of the sympathetic branch
of the autonomic nervous system results in symptoms of
anxiety, agitation, and panic. The prime directive of the
amygdala is to protect us by pairing a stimulus with a fear
response, and it works so fast that this pairing can be
created far ahead of our conscious perception of threat.
Throughout our lives, but especially during childhood,
relationships with others regulate our stress and fear. A
secure attachment indicates that we have learned to
successfully utilize our relationships with others to quell our
fears and modulate our arousal.

The Social Engagement System

Communication leads to community, that is, to

understanding, intimacy and mutual valuing.
—Rollo May

The tenth cranial nerve, also called the vagus, is actually a

complex communication system between the brain and
multiple points within the body including the heart, lungs,
throat, and digestive system. Its afferent (sensory) and
efferent (motor) fibers allow for rapid continuous feedback
between brain and body to promote homeostatic regulation
and the optimal maintenance of physical health and
emotional well-being (Porges, Doussard-Roosevelt, & Maiti,
1994). The vagal system is a central component of the
autonomic nervous system. In the absence of external
challenge, the vagus works to enhance digestion, growth,
and social communication. When a challenge does arise, a
decrease in vagal activation facilitates sympathetic arousal,
high energy output, and the fight-flight response. Between
rest and all-out activation, the vagus allows us to maintain
continued engagement by modulating arousal during
emotional interpersonal exchanges. The vagal system
accomplishes this by modulating and fine-tuning
sympathetic arousal.
Like the attachment system described earlier, the
development of this engagement system and the fine-
tuning of the vagal brake to regulate affect appear to
depend on the quality of attachment relationships in early
childhood. This allows us to internalize what we learn from
experience with caretakers into moment-to-moment somatic
regulation. The vagal system also controls the primary
facial, mouth, and throat muscles involved in
communication, and links them with an awareness and
control of internal states, coordinating the cognitive and
emotional processing necessary for relationships.
The “tone” of the vagus refers to the vagal system’s
dexterity in regulating the heart and other target organs
(Porges et al., 1996). Inadequate development of this
experience-dependent vagal tone can impact all levels of
psychosocial and cognitive development (Porges et al.,
1994). Children with poor vagal tone have difficulty in
suppressing emotions in situations demanding their
attention, making it difficult for them to engage with their
parents, sustain a shared focus with playmates, and
maintain attention on important material in the classroom
(see Table 12.6 for more details).
Vagal regulation allows us to become upset, anxious, or
angry with a loved one without withdrawing or becoming
physically aggressive. We can hypothesize that many who
engage in domestic violence, child abuse, and other forms
of aggressive behavior may not have had the kinds of early
attachment relationships required to build an adequate
vagal system. Thus, good parenting not only teaches
appropriate responses in challenging interpersonal
situations, but it also builds vagal circuitry required to stay
engaged.
 
TABLE 12.6 Correlates of Vagal Tone

Higher Vagal Tone Correlates Lower Vagal Tone

With Correlates With
The ability to self- Irritability
regulateIrritability
Self-soothing capacity by 3 Behavioral problems at 3
months of age years of age
The range and control of Emotional dysregulation
emotional states
More reliable autonomic Distractibility
responses
Suppression of heart rate Hyper-reactivity to
variability environmental and
visceral stimulii
Enhanced attentional capacity  
and the ability to take in
information
Positive social engagement Withdrawal
Increased behavioral Impulsivity/acting out
organization
Consistent caretaking/secure Insecure attachment
attachment

The Social Motivation System

Interdependence is and ought to be as much the ideal

of man as self-sufficiency. Man is a social being.
—Mohandas Gandhi

Nelson and Panksepp (1998) postulated the existence of a

social motivation system modulated by oxytocin,
vasopressin, endogenous endorphins, and other
neurochemicals related to reward, decreased physical pain,
and feelings of well-being. While conserved from more
primitive approach-avoidance and pain regulation circuitry,
the social motivation system extends into the amygdala,
anterior cingulate, and orbital medial prefrontal cortex.
These circuits and neurochemicals are thought to regulate
attachment, pair bonding, empathy, and altruistic behavior
(Decety & Lamm, 2006; Seitz, Nickel, & Azari, 2006). In
other words, as Fisher (1998) suggested, the social
motivation system can be divided into three categories:
those involved in bonding and attachment (regulated by
peptides, vasopressin, and oxytocin), attraction (regulated
by dopamine and other catecholamines), and sex drive
(regulated by androgens and estrogens). The production of
these various biochemical elements, as well as the creation
of their receptors, are all subject to the influences of
experience early in life.
In addition, the dopamine reward system of the
subcortical area known as the ventral striatum is involved
with more complex analysis of reward and social motivation.
The ventral striatum becomes activated with an expectation
of a social reward, such as when we anticipate being given
candy or positive attention (Kampe et al., 2001; Pagnoni,
Zink, Montague, & Berns, 2002; Schultz et al., 1992). For
example, once the cortex has determined that we find
someone attractive, the ventral striatum becomes activated
when they look our way, giving the signal that the possibility
for being rewarded with a desirable outcome has increased
(Elliott, Friston, & Dolan, 2000; Schultz, Dayan, & Montague,
1997; Schultz, 1998). The activation of the ventral striatum
translates the anticipation of reward into a physical impulse
to approach. In this way, those whom we find attractive
actually exert what feels like a gravitational pull on us.

Summary
Recent research has provided us with new ways of
understanding how early experience builds the brain.
Maternal attention has been linked to the neurobiology of
systems related to learning and memory, stress regulation,
and attachment behavior. Although the human brain is far
more complex than those of the animals upon whom this
research has been conducted, findings in human research
across a broad array of disciplines demonstrate consistent
results in the areas of learning, resilience, and attachment.
The neural hubs and regulatory networks described here are
all built in an experience-dependent manner. That is, early
relationships shape the building of neural circuitry, which
guides how we are able to learn, react to stress, and attach
to others in ways that parallel those seen in the animal
research discussed earlier. As we learn more about the
complexities of the human brain, we will understand how
relationships build the brain, and how love becomes flesh.
Part V.

The Disorganization of Experience

Chapter 13

The Anxious and Fearful Brain

Fear is the oldest and strongest emotion of mankind.

—H. P. Lovecraft

All animals have been shaped by evolution to approach

what is life sustaining and avoid what is dangerous. The
success of rapid and accurate approach-avoidance decisions
determines if an organism lives to reproduce and carry its
genes forward to the next generation. Because vigilance for
danger is a central mechanism of the process of natural
selection, evolution may well favor an anxious gene (Beck et
al., 1979). Some anxieties appear to be hard wired, specific
to primates, and linked to both our present and past survival
needs. Fear of spiders, snakes, heights, and open and closed
spaces all harken back to the survival of our forest-dwelling
ancestors. From an evolutionary perspective, our complex
neural systems have all been sculpted to better serve the
prime directive of survival.
The neural circuitry involved in fear and anxiety,
although biased toward the right hemisphere, involves both
hemispheres and all levels of the triune brain. The most
primitive subcortical fight-or-flight circuitry, shared with our
reptilian ancestors, interacts with the most highly evolved
regions of the cortex. This results in the capacity to
experience anxiety about everything from an unexpected
tap on the shoulder to an existential crisis. The connection
between every kind of anxiety and the core biological
mechanisms of physical survival supports the philosophical
notion that all anxiety, at its core, may be the fear of death
(Tillich, 1974).
Anxiety and fear are the conscious emotional aspects of
the body’s ongoing appraisal of threat, telling us to be
prepared to take action. Anxiety can be triggered by
countless conscious or unconscious cues and has the power
to shape our behaviors, thoughts, and feelings. At its most
adaptive, anxiety encourages us to step back from the edge
of a cliff, or to check to see if we signed our tax forms
before sealing the envelope. At its least adaptive, anxiety
steers us away from taking important and appropriate risks,
pushing ourselves to reach personal goals, or engaging in
new and potentially beneficial behaviors.
The response to stress, or general adaptation syndrome
(Selye, 1979), results in a range of physiological changes
designed to prepare the body for fight or flight. Energy is
mobilized through increased cardiovascular and muscular
tone, whereas digestion, growth, and immune responses are
inhibited. As part of the stress response, a cascade of
biochemical changes occur in the hypothalamus, pituitary,
and adrenal glands (the HPA axis), as well as in the
sympathetic nervous system. These biochemicals mediate
the physical and psychological changes experienced during
stress. Increased levels of glucocorticoids, epinephrine, and
endogenous opioids are particularly relevant to a discussion
of the psychological impact of stress and trauma, in that
they alter attention, cognition, and memory. We experience
the effects of the general adaptation syndrome in situations
such as automobile accidents, at crucial moments during
sporting events, or when engaging in public speaking. The
dangers can be real, imagined, or experienced vicariously
as we watch others in stressful or dangerous situations.
With the expansion of the cerebral cortex and the
emergence of imagination, we have become capable of
being anxious about situations we will never experience. We
can now worry about monsters living under our beds and
the incineration of the earth resulting from the sun’s
expansion. Because our imaginal capabilities have allowed
for the construction of the self, we can also become anxious
about potential threats to our psychological survival.
Psychotherapists deal with a wide variety of anxiety
disorders based in the fear of a social death. The
expectation of rejection by another can result in social
withdrawal; the fear of forgetting one’s lines in a play can
result in stage fright. Systems of physical survival have
been conserved in the evolution of consciousness and the
ego, to be triggered when threats to these abstract
constructions are activated.
Consciously experienced anxiety provides the
opportunity to face and work through one’s fears. The
common wisdom of getting back on the horse that threw
you is advice clearly aimed at preventing the use of
avoidance to control anxiety. In fact, the reduction of
anxiety through avoidance reinforces the behavior and
makes the feared stimulus seem all the worse.
Unfortunately, anxiety can be paired with all kinds of
automatic and internal sensations, emotions, and thoughts,
which shape behavior outside of conscious awareness.
Compounding the problem, the left hemisphere interpreter
provides a rationale supporting and reinforcing avoidance:
“It’s inhuman to ride horses!” “Who needs planes?”
“Why go out when it’s so comfortable at home?” The
avoidance of thoughts and feelings associated with feared
stimuli both reflects and perpetuates a lack of integration
among neural networks. Facing one’s fears is a core
component of all forms of psychotherapy.
We see this, for example, with adult women who were
sexually or emotionally abused as children who sometimes
come to therapy with chronic and severe weight problems.
They do well on diets until they begin to be noticed by men,
associated in implicit memory with the pain and shame of
their childhood experiences. These negative emotional
reactions lead them to return to behavioral patterns
associated with an avoidance of such feelings, such as
eating. The act of eating is doubly reinforcing because it
provides nurturance, while gaining back the weight serves
to protect against sexual advances.
Thus, what started out as a straightforward survival-
based alarm system has also become a nuisance. This is
another downside of the design compromises between
speed and accuracy mentioned earlier (Mesulam, 1998).
Evolution designed a brain that reacts quickly to a variety of
subtle environmental cues. These same capabilities have
negative consequences when applied to a complex and
largely nonconscious psychological environment. An
understanding of the neuroscience of anxiety and fear is
helpful in both the conceptualization and treatment of most
clinical disorders. In the following pages, we will look at the
two loops of fear circuitry outlined by Joseph LeDoux, the
role of the amygdala in the regulation of fear and anxiety
proposed by Michael Davis, and Robert Sapolsky’s work on
the negative impact of long-term stress.

Fast and Slow Fear Networks

Fear is an emotion indispensible for survival.

—Hannah Arendt

Through his research with animals, LeDoux (1994)

demonstrated the existence of two separate yet interrelated
neural circuits which regulate fear. The conservation of
these systems during evolution allows us to apply these
findings to human experience (Phelps, Delgado, Nearing, &
LeDoux, 2004). The two systems (which we will call fast and
slow) each play a somewhat different role in our reaction to
danger. This model can be clinically useful for anxious and
fearful clients by helping them understand the
neurobiological mechanisms underlying their unsettling
experiences.
The reflexive fast system acts immediately, sending
information directly from the sense organs (eyes, ears, skin,
nose, tongue) through the thalamus to the amygdala. And
when I say fast, I mean fast: All of this processing can occur
in one twelfth of a second. The amygdala evaluates the
sensory input and translates it into bodily responses via its
many connections with the autonomic nervous systems. The
thalamus may aid in this rapid evaluation by maintaining
crude representations of potentially dangerous things often
encountered in the environment such as spiders, snakes,
and dangerous predators (Brosch, Sander, & Scherer, 2007).
These subcortical structures play an executive role in rapid
appraisal because the increased time it would take to
include the cortex might have too large a survival cost.
Simultaneously, the slow system sends sensory
information on to the hippocampus and cortex for further
evaluation. This system is slower because it contains more
synaptic connections and involves conscious processing.
Cortical circuits of memory and executive processing
examine the information more carefully, compare it to
memories of similar situations, and decide how to proceed.
The slow circuit aids in fear processing by contextualizing
the information in time and space. This slow system in
humans—with its apex in the prefrontal cortex—has the
additional task of making sense of the behavioral and
visceral reaction already set into motion by the fast
systems. In this way, our conscious executive functions
discover the decisions that have already been made by our
unconscious executives. We find ourselves already scared
when we initially perceive what is frightening us; or ecstatic
as our loved one comes into view. Figure 13.1 depicts the
neural circuits of the fast and slow fear networks.
 This dual circuitry helps us to understand why we often
react to things before thinking and then have to apologize
later on. In therapy, we often attempt to utilize the
conscious linguistic structures of the slow circuit to modify
or inhibit dysfunctional reflexes and emotional appraisals of
the fast circuit. Coupled with relaxation techniques and
enhanced awareness, exposure to a feared stimulus can
serve to enhance the regulatory input of the slow cortical
circuits by building new neural connections. Cognitive and
behavioral interventions therefore increase the ability of the
cortex to inhibit the amygdala.

FIGURE 13.1
Fast and Slow Fear Circuits

A depiction of the two pathways of information to the

amygdala—one directly from the thalamus and the other
through the cortex and hippocampus (adapted from LeDoux,
J. Emotion, memory, and the brain. Copyright ©1994 by
Scientific American, Inc. All rights reserved.)
 There are many examples of these two systems in action.
I walked into my garage one day to look for a tool when, out
of the corner of my eye, I saw a small brown object near my
foot. There are plenty of little critters in my neighborhood
and they often crawl, burrow, or fly into my house. I
immediately jumped back, my heart rate increased, my
eyes widened, and I became tense, ready to act. Moving
backward, I oriented toward the shape, saw that it looked
more like a piece of wood than a rodent, and began to relax.
After a few seconds, my heart rate and level of arousal were
back to normal; the potential danger had passed.
Analyzing this experience in terms of the two systems,
my peripheral vision saw the object and my amygdala
appraised it in an overgeneralized fashion to be a threat. My
amygdala activated a variety of sympathetic responses
including startle, increased respiration, and avoidance. In
the split second while my body was reacting, I reflexively
oriented my head toward the shape, which brought it to the
fovea of my retina, providing my hippocampus and cortex
with more detailed visual information, allowing them to
appraise it more accurately than my skittish amygdala. I
suppose that a species-specific fear accounts for such a
strong reaction to an animal weighing just a few ounces.
This example, trivial as it may be, leads to a more serious
application of LeDoux’s theory to interpersonal
relationships.
As the core of our social brain, the amygdala organizes
the appraisals of what we have learned from our
relationship history. In interpersonal situations, our
amygdala reflexively and unconsciously appraises others in
the context of our past experiences. From moment to
moment, the reflexive activations of our fast systems
(organized by past learning) shape the nature of our present
experience (Bar et al., 2006). This is a powerful mechanism
by which our early social learning influences our experience
of the present. So, by the time we become conscious of
others, our brain has already made decisions about them. In
the case of prejudice, skin color triggers a set of
assumptions upon which we evaluate other people (Olsson,
Ebert, Banaji, & Phelps, 2005). At the opposite extreme, love
at first sight is a sort of positive prejudice triggered by
emotional memories projected onto another person.

The Amygdala’s Role in Anxiety and Fear

No passion so effectually robs the mind of all its

powers of acting and reasoning as fear.
—Edmund Burke

The amygdala plays a central role in the activation of fear. It

has been conserved and expanded during evolution in order
to process increasingly complex cognitive, sensory, and
emotional input. Its central role in appraisal and the
triggering of the biochemical cascade of the fight-or-flight
response makes it vital for processing memory, emotional
regulation, bonding, and attachment. Electrical stimulation
of the amygdala’s central nucleus results in the experience
of fear, whereas destruction of the amygdala will eliminate
fear reactions altogether (Carvey, 1998). In fact, the
destruction of the amygdala in animals results in an inability
to acquire a conditioned fear response.
Although we are genetically programmed to become
anxious about things like snakes or abandonment, fear can
be learned by pairing any thought, feeling, or sensation with
a noxious stimulus, such as a loud noise or an electric shock
(Corcoran & Quirk, 2007). Learning to be anxious can occur
at conscious and unconscious levels related to both internal
and external stimuli. Like the hippocampus, the lateral areas
of the amygdala are capable of long-term potentiation (LTP)
involved in reinforcing connections among neurons.
Remember that LTP is the process through which the
association among neurons becomes strengthened and
learning is established. The amygdala can learn, throughout
life, to pair any stimulus (even physical affection or praise)
with fear.
As we saw earlier in our discussion of memory, the
hippocampus and amygdala organize interacting but
dissociable systems of memory. Bechara and colleagues
(1995) reported that a patient with bilateral (left and right)
amygdala damage was unable to acquire a conditioned
autonomic response to sensory stimuli. The patient was,
however, able to consciously remember the conditioning
situation because his hippocampi were still intact. Another
patient with bilateral damage to the hippocampus showed
no conscious memory for the conditioning situation but did
acquire autonomic and behavioral conditioning. The authors
concluded that the amygdala is “indispensable” for coupling
emotional conditioning with sensory information while the
hippocampus is required for conscious recollection (Bechara
et al., 1995).
The neural projections from the amygdala to numerous
anatomical targets cause the multiple physical expressions
of anxiety, fear, and panic. Projections from the amygdala to
the lateral hypothalamus result in sympathetic activation
responsible for increased heart rate and blood pressure. The
amygdala’s stimulation of the trigeminal facial motor nerve
even causes the facial expressions of fear (Davis, 1992).
The amygdala is also essential in reading the fearful facial
expressions of others (Baird et al., 1999). As you can see
from Figure 13.2, the amygdala is well connected, making
the fear response a powerful whole-body experience.

FIGURE 13.2
Some Targets of the Amygdala in the Fear Response

Some of the many anatomical targets of the amygdala in

the fear response, and their biological and behavioral
contribution.
 The triggering of the autonomic nervous system by the
amygdala causes a racing heart, sweating, and other
physiological symptoms as the body prepares for fight or
flight. In the absence of real external danger, this is
experience is called a panic attack. Sufferers often go to
emergency rooms thinking they are having a heart attack.
Individuals with panic disorder have increased neural
activity in the amygdala (Reiman et al., 1989).
Psychologically, victims report a sense of impending doom,
feelings of unreality, and the thought that they are going
crazy. Panic attacks are often triggered by stress or other
conflicts in the sufferer’s life, but he or she seldom makes
the connection between these events and the panic attacks.
Because the neural connections are contained within hidden
neural layers, they are experienced as “coming out of the
blue,” leaving victims struggling to comprehend what is
happening to them.
The amygdala’s tendency toward generalization results
in panic being triggered by an increasing number of internal
and external cues (Douglas & Pribram, 1966). Because panic
attacks are experienced as unpredictable and life
threatening, they result in a limitation of activities.
Agoraphobia, or fear of open spaces, develops as victims of
panic attacks associate fear with a broader variety of
situations. Hoping to avoid these attacks, sufferers restrict
their activities to the point where they eventually become
housebound. Simultaneously, the amygdala becomes
conditioned to respond faster in people who become phobic,
creating a vicious cycle of anxiety and fear (Larson et al.,
2006). The behavior of these individuals becomes so shaped
by fear that they come to avoid most of life. On the other
hand, those of us with a slower and less active amygdala
experience greater psychological well-being (van Reekum et
al., 2007). One gift of aging is that the amygdala also
appears to become less sensitive to fear as we grow older.
The development and connectivity of the amygdala have
many implications for both early child development and
psychotherapy. Without the inhibitory impact of the later-
developing hippocampal-cortical networks, early fear
experiences are unregulated, overwhelming full-body
experiences. Because the amygdala is operational at birth,
the experience of fear may be the strongest early emotion.
Part of the power of early emotional learning may be the
intensity of these unregulated negative affects in shaping
early neural infrastructure. The infant is very dependent on
caretakers to modulate these powerful experiences.
Amygdalaand hippocampus-mediated memory systems are
dissociable from one another, which means that early and
traumatic memories can be stored without conscious
awareness or cortical control. They will not be consciously
remembered, but instead will emerge as sensory, motor,
and emotional memories like traumatic flashbacks.
Another limbic structure closely connected to the
amygdala is the bed nucleus of the stria terminalis (BNST).
Like the amygdala, it is connected upward to the prefrontal
cortex, as well as down into the autonomic nervous system.
Unlike the amygdala, the BNST is sensitive to abstract cues
and is capable of long-term activation, suggestive of both its
later evolution and its role in anticipatory anxiety (Davis,
1998; Kalin et al., 2001). It appears that perhaps the
amygdala specializes in fear while the BNST evolved to deal
with the more complex triggers for anxiety that emerged as
our brains became capable of imagining multiple potential
outcomes. Interestingly, the BNST in rats is a structure that
grows in response to maternal responsibilities. We have to
wonder if, as the brain became specialized for caretaking,
the scaffolding we need to create around our children
pushed the evolution of a constant focus on potential
dangers.

The Locus Coeruleus and Norepinephrine

Worry gives a small thing a big shadow.

—Swedish proverb

One important descending projection from the amygdala

and BNST connects them with the locus coeruleus (LC). The
LC is a small structure with extensive projections throughout
the brainstem, midbrain, and cerebral cortex. It is, in fact,
connected with more parts of the brain than any other
structure so far discovered (Aston-Jones, Valentino,
VanBockstaele, & Meyerson, 1994). The LC is the brain’s
primary generator of norepinephrine (NE), which drives the
activity of the sympathetic branch of the autonomic nervous
system responsible for the fight-or-flight response. One
effect of NE is to enhance the firing of neurons that are
highly relevant to a present experience based on past
learning (past fear responses), while inhibiting those
involved in baseline activities.
This means that stimulation of the LC prepares us for
danger by activating circuits dedicated to attention and
preparation for action. NE activation makes us become
vigilant, scan for danger, and maintain a posture of tense
readiness. It also heightens our memory for danger, creating
a sort of “print now” command for amygdala memory
circuits (Livingston, 1967). The pathways containing these
traumatic memories become hyperpotentiated, meaning
that they are more easily triggered by less severe
subsequent stressors. This allows us to be reminded in the
future of similar dangers. During times of lowered
hippocampal-cortical involvement (e.g., intoxication or near-
sleep states), these stressful traumatic memories may
become disinhibited as intrusive images and flashbacks.
Translated into human and clinical terms, this means that
surges of NE during periods of safety may result in past
traumatic associations (anxiety, startle, visual images, etc.)
being brought to awareness, which overshadow current
experiences.
Stimulating the LC in animals results in a disruption of
ongoing behavior and triggering of an orienting reflex, like
the one I had to the small piece of wood. This is seen in
patients with PTSD who respond to trauma-related cues
decades after their traumatic experience. LC activity in
primates results in a high degree of vigilance while
interrupting sleep, grooming, and eating. Through a series
of connections, the central nucleus of the amygdala
stimulates the LC, which, in turn, is thought to be a major
control area of the sympathetic nervous system (Aston-
Jones et al., 1994). An understanding of the biochemistry
and functioning of the LC is an important component of any
theory of causes of anxiety disorders (Svensson, 1987).
Stress and the Hippocampus

Anxiety is a thin stream of fear trickling through the

mind. If encouraged, it cuts a channel into which all
other thoughts are drained.
—Arthur Somers Roche

The human brain is well equipped to survive brief periods of

stress without long-term damage. In an optimal state,
stressful experiences can be quickly resolved with good
coping skills and the help of caring others. However, people
often come to psychotherapy with long histories of anxiety,
which can have profound effects on the brain. Working with
rats and vervet monkeys, Sapolsky and his colleagues
demonstrated that sustained stress results in hippocampal
atrophy and a variety of functional impairments (Sapolsky,
1990; Sapolsky, Uno, Rebert, & Finch, 1990). His research is
particularly important because it may help explain some of
the negative long-term effects of childhood trauma.
The biological link between prolonged stress and
hippocampal atrophy appears to be mediated via the
catabolic influence of stress hormones. Glucocorticoids (GC)
such as cortisol are secreted by the adrenal gland to
promote the breakdown of complex compounds so that they
can be used for immediate energy. The first of these
hormones was found to break down complex sugars, hence
the name gluco corticoids. It was later found that they also
block protein synthesis, inhibiting both new neural growth
and the construction of proteins involved in immunological
functioning. Overall, long-term learning and biological well-
being are sacrificed for the sake of immediate survival. This
makes great sense when stressors are short-lived. But when
stress is chronic, high levels of cortisol put us at risk of
physical illness, learning dysfunctions, and memory deficits.
A number of roles of cortisol are seen in Table 13.1, along
with its impact on the brain and its relationship to a variety
of illnesses.
The focus on immediate survival supersedes all long-
term maintenance, akin to burning the furniture to survive
freezing in winter. Thus, these biological processes need to
be reversed as soon as possible after the crisis has passed
to allow the body to recover and return to functions of
restoration and repair. It is apparent that this system was
designed to cope with brief periods of stress in emergency
situations; it was not designed to be maintained for weeks
or years at a time. The complexities of cortical processing
and anticipatory anxiety are poorly matched with these
primitive stress systems.
Prolonged stress most affects two processes. First, it
inhibits protein production in order to maintain higher levels
of metabolism. Proteins are, of course, the building blocks of
the immunological system (leukocytes, B-cells, T-cells,
natural killer cells, etc.) and the suppression of protein
synthesis also suppresses our body’s ability to fight off
infection and illness. This is one of the primary reasons for
the high correlations found between prolonged stress and
disease. Second, sustained higher levels of metabolism
continue to pump sodium into neurons, eventually
overwhelming the cell’s ability to transport it out again. This
results in destruction of the cell membrane and consequent
cell death. This process has been found to be particularly
damaging to the hippocampus, resulting in a variety of
memory deficits and depression. Loss of volume in the
hippocampus is related to cumulative GC exposure
(Sapolsky et al., 1990). Sustained high levels of stress partly
explain why early negative experiences in parenting and
attachment have a lifelong impact on physical health,
mental health, and learning.

TABLE 13.1
 Stress and the Hippocampus

The Role of Cortisol

Breaks down fats and proteins for immediate energy
Inhibits inflammatory processes
Inhibits protein syntheses within the immune system
(leukocytes, B and T-cells, natural killer cells, etc.)
Suppresses gonadal hormones that support neural health,
growth, and learning

Chronic High Levels of Cortisol/Glucocorticoids Result

In
Decreased plasticity1
Dendritic degeneration2
Deficits of remyelination3
Cell death4
Inhibition of neurogenesis and neural growth5

High Levels of Cortisol Correlate With:

Impaired declarative memory and spatial reasoning6

Compromised Hippocampi Result In

Deficits of new learning7
Short-and long-term memory8

Individuals With Smaller Hippocampi Include

Adult victims of early trauma9
Post-traumatic stress disorder10
Temporal lobe epilepsy11
Schizophrenia12
Cushing’s disease (hypercortisolism) 13
 The hippocampus, rich in GC receptors, plays a negative
feedback role with the adrenal gland to inhibit GC
production. If the hippocampus detects too many GCs
together, it sends a message (via the hypothalamus or the
pituitary) to the adrenal gland to slow down GC production
(Sapolsky, Krey, & McEwen, 1984). The more receptors we
have, the greater our feedback abilities to decrease cortisol
production. Prolonged high levels of GCs increase the
vulnerability of the hippocampus to a number of potential
metabolic insults (Sapolsky, 1985; Woolley, Gould, &
McEwen, 1990). At this point it is unclear if decreased
volume reflects permanent damage to the hippocampus or
a reversible inhibition of the growth of new neurons. In
either case, less hippocampal mass means fewer GC
receptors, which, in turn, means less negative feedback to
the adrenal gland. Loss of volume in the hippocampus is
related to cumulative GC exposure (Sapolsky et al., 1990).
Early trauma results in hippocampal impairment, which
decreases our ability to inhibit the emotions triggered by
amygdaloid memory systems. Further, deficits in reality
testing and short-term memory will make the process of
integrating traumatic experiences into conscious awareness
more difficult. Longer periods of relationship building and
pragmatic interventions focused on stress reduction and the
development of coping skills may be necessary
prerequisites for successful long-term therapy with victims
of early stress and trauma. The hippocampus is also
exquisitely sensitive to oxygen deprivation, so patients who
have suffered metabolic disruptions, head trauma, or
seizures may have hippocampal compromise, as well as
mountain climbers, divers, or individuals with heart disease
(Lombroso & Sapolsky, 1998; Regard, Oelz, Brugger, &
Landis, 1989). High-dose cortisol administration for
autoimmune diseases may also result in hippocampal
damage (Sapolsky, 1996). All of these factors should be kept
in mind when taking histories of patients with cognitive and
neurological symptoms.
Impairment of the hippocampus from early chronic stress
may make the therapeutic process more difficult for many
clients. For example, Stein and his colleagues (Stein,
Koverla, Hanna, Torchia, & McClarty, 1997) found that adult
women who had experienced childhood abuse had
significantly reduced left hippocampal volume. They also
found that the amount of reduction was significantly
correlated with increased dissociative symptoms. This
relationship suggests that the left hippocampus may play a
role in integrating memories into a cohesive narrative. The
hippocampus is also thought to be involved in the flexible
incorporation of new information into existing structures of
memory (Eichenbaum, 1992). If this is the case, early abuse
may result in damage to neural structures required to create
new and more functional narratives.
Rats and humans differ in a number of ways besides
whisker length. The increased size of the human brain and
its additional processing capacity make it possible for us to
worry about many more potential dangers, both real and
imagined. In addition, our brains allow us to create complex
situations such as traffic jams and overburdened schedules,
generating ever-increasing levels of stress. Stressors such
as these, which are experienced as inescapable, tend to
have a greater sustained cortisol activation and negative
impact on the brain. Although we like to think of childhood
as a time of innocence and play, many children grow up in a
state of constant distress. We saw this clearly in the
attachment research where adults with anxious attachment
patterns demonstrated a lack of recall for long periods of
their childhoods. Parental physical or mental illness,
community violence, poverty, and many other factors can
contribute to this. Prolonged childhood stress can have
lifelong effects on functioning related to hippocampal
damage, immunological suppression, and other stress-
related impairments.

Learning Not to Fear

Courage is acting in spite of fear.

—Howard W. Hunter

It is an unfortunate twist of evolutionary fate that the

amygdala is mature before birth while the systems that
inhibit it take years to develop. This leaves us vulnerable to
overwhelming fear with little to no ability to protect
ourselves. On the other hand, evolution has also provided us
with caretakers who allow us to link into their developed
cortex until our own is ready. The way they protect us from
fear and modulate our anxiety becomes a model upon which
our own brain develops. Thus, we use proximity to our
parents as our key method of fear regulation, just as cold-
blooded animals use locomotion and change of location to
regulate their internal temperature. Our attachment
schemas come to reflect the success or failure of how we
and our parents navigate this process. We have seen from
the research with rats that maternal attention results in a
brain that is better equipped to learn as well as to
downregulate the immediate and long-term effects of stress.
It turns out that in dealing with fear, the ability to learn as
well as having a more resilient stress system are both
important for facing life’s challenges.
The hippocampus is constantly remodeled to keep
abreast of current environmental changes. On the other
hand, the amygdala’s role is to remember a threat,
generalize it to other possible threats, and carry it into the
future. Because the amygdala exhibits persistent dendritic
modeling, we are unable to completely forget painful and
traumatic experiences (Rainnie et al., 2004; Vyas, Bernal, &
Chattorji, 2003; Vyas, & Chattorji, 2004 ). The power of the
amygdala and its stubbornness in the face of the
hippocampus leads us to be biased toward anxiety and fear.
The phenomenon of spontaneous recovery of a phobia
demonstrates how the fear we hoped was long gone was
stored in our amygdala all along (Vansteenwegen et al.,
2005). Getting past our fears and phobias does not entail
forgetting to be afraid; rather, the extinction of fears
represents new learning organized by our slow systems of
the cortex and hippocampus. In other words, extinction
learning represents the formation of new neural associations
that somehow keep the memory stored in the amygdala
from triggering the sympathetic nervous system (Milad &
Quirk, 2002; Rau & Fanselow, 2007).
The ability of the prefrontal cortex in modulating
amygdala activity is believed to occur through the
development of descending inhibitory circuitry (Akirav &
Maroun, 2007; Ochsner et al., 2004). Evidence for this
includes the fact that this cortical-amygdala network
exhibits a reciprocal activation pattern where more cortical
activation results in less amygdala activation and vice
versa. This may not only be why our problem-solving
abilities can be shorted out by fear, but also why thinking
about and being prepared for a situation lessens our fears.
When we successfully use cognitive techniques to decrease
anxiety, we are likely building these descending cortical
networks to inhibit amygdala and autonomic activation
(Schaefer et al., 2002).
Learning not to fear, just like secure attachment, appears
to be a major contribution of the ompfc (Morgan, Romanski,
& LeDoux, 1993; Phelps et al., 2004). Electrical stimulation
of the homologous region in the cortex of rats results in both
amygdala inhibition and a reduction of conditioned fear
(Milad, Vidal-Gonzalez, & Quirk, 2004; Perez-Jaranay &
Vives, 1991; Quirk, Likhtik, Pelletier, & Paré, 2003). Even the
size of the ompfc in humans is positively correlated with our
ability to inhibit a fearful response (Milad, Quinn, et al.,
2005). Thus, it appears that top-down control of the
amygdala allows us to learn to discontinue a fearful
response to something that makes us afraid. In a study by
Kim, those who were taught to interpret a surprised face as
negative had greater amygdala activation while those who
were guided to see it as positive had more ompfc activation
(Kim et al., 2003). These studies support the notion that the
ompfc modulates the activation of the amygdala based on
contextual and motivational factors (Kim et al., 2005; Myers
& Davis, 2007; Ochsner et al., 2002; Phan et al., 2005). In
other words, the slow system regulates the fast system.
These top-down circuits organize, modulate, and direct
attention in ways that shape experience and reinforce the
existing emotional state (Bishop, 2007; Christakou, Robbins,
& Everitt, 2004). Anxiety is associated with a reduced top-
down control of threat cues just as there is a reduction of
control over negative stimuli in depression (Bishop et al.,
2004; Brewin & Smart, 2005). In other words, anxious
people tend to find danger while depressed people discover
the negative aspects of their environments. And while those
of us with more attentional control will still have a bias to
orient toward the threat, we will exert more top-down
control as we become conscious of the stimulus (Derryberry
& Reed, 2002). Once again, the slow system modulates the
fast system.
Thus, the balance of activation among the prefrontal
cortex and amygdala also guides visual attention based on
relevance, emotion, and motivation (Gazzaley et al., 2007;
Geday, Kupers, & Gjedde, 2007). This is one of the many
networks that may become dysregulated in PTSD, resulting
in disturbances of sensory processing and memory, and
even causing visual hallucinations (Gilboa et al., 2004;
Rauch, Shin, & Phelps, 2006). Dissociated PTSD patients
have greater activation in neural networks involved in the
representation of bodily states, suggesting a lack of
adequate top-down modulation of these networks by frontal
executive systems (Lanius et al., 2005). As one would
expect, the severity of PTSD symptoms is positively
associated with amygdala activation and negatively
correlated with ompfc size and responsivity (Shin, Rauch, &
Pitman, 2006; Williams et al., 2006).
As we saw in Figure 13.2, the central nucleus of the
amygdala is an output region that projects to sites in the
midbrain and hypothalamus responsible for generating
different aspects of the fear response. The connections of
the ompfc to the central nucleus of the amygdala are
particularly strong, especially to GABAergic (inhibitory)
neurons called intercalated cells (Freedman, Insel, & Smith,
2000; McDonald et al., 1999; Royer, Martina, & Paré, 1999).
It is now believed that it is within the descending networks
from the ompfc to the amygdala’s central nucleus that
extinction learning is remembered and carries out its
inhibitory influences (Gottfried & Dolan, 2004; Quirk &
Mueller, 2008). Because learning in this neural circuit
conforms to what is known about the neurobiology of
learning in general, the role of NMDA receptors, protein
synthesis, cortisol, and other factors that modulate learning
are likely involved in extinction learning (Elvander-Tottie et
al., 2006; Santini et al., 2004).
Research shows that subjects involved in the cognitive
appraisal of fearful faces show both a decrease in amygdala
activation and an increase in prefrontal activation (Hariri et
al., 2000, 2003). This same amygdala-prefrontal activity
shift occurs during activation of a placebo effect (Wager et
al., 2004) and recovery following the presentation of
negative emotional material (Jackson et al., 2003).
Individuals who manage to control their fear tend to have
more activation in right frontal regions than those who do
not (Johanson et al., 1998).
A deficit of extinction learning could be an alternative
description of PTSD. Sufferers with PTSD show amygdala
dysinhibition, making them vulnerable to the hallmark
symptoms of intrusion and arousal (Akirav & Maroun, 2007).
Patients with PTSD have also been shown to have smaller
subregions within their ompfc in regions where intercalated
cells are assumed to reside (Rauch et al., 2003). Also the
thickness and activity levels of these prefrontal regions in
patients with PTSD during extinction training correlates with
their symptoms, supporting the association between their
symptoms and deficits of cortically based extinction learning
(Milad, Orr, et al., 2005; Phelps et al., 2004).

The Recovery of Fears and Phobias Under Stress

Dangers bring fears, and fears more dangers bring.

—Richard Baxter

Jacobs and Nadel (1985) proposed the existence of two

systems of learning and memory involved in fears and
phobias. These two systems predicted and parallel LeDoux’s
model of fast and slow fear circuitry. The taxon system (fast
system or amygdaloid system) is responsible for the
acquisition of skills and rules, and the conditioning of
stimulus-response connections. This system is context free,
meaning that it contains no information about the time or
location in which the learning took place. Taxon learning
generalizes broadly and is primarily nonconscious. This is
the system in which early learning of fear, safety, and
attachment is organized and stored. The taxon system is
represented in what cognitive psychologists call implicit and
procedural memory.
The locale system—with the hippocampus and the cortex
at its core—is responsible for cognitive maps necessary for
external context, mental representations, and the pairing of
memories with the situations in which they were learned.
The development of the locale memory system parallels
that of hippocampal-cortical circuits. Thus, although there is
a great deal of learning during infancy (especially in the
networks of the fearful and social brains), there is no source
attribution or autobiographical narrative.
For example, a mother’s fearful look when strangers
approach may cause her child to develop a general wariness
of the world, but not recognize the source of this
apprehension in similar situations later in life. We enter
middle childhood with neural networks programmed by
early learning, experienced as basic emotional givens. In the
absence of trauma, learning in adults involves a balanced
integration of taxon and locale systems that connect
sensory, motor, and emotional aspects of memory to its
semantic and autobiographical components. For children
and traumatized adults, the taxon system may function
independently, resulting in an adaptive dissociation among
various systems of memory and conscious awareness.
Jacobs and Nadel contended that stress both changes the
inner biological environment activating the taxon system
and suppresses the inhibitory effects of the locale system.
These changes result in the emergence of earlier fears or
frightening experiences that had been successfully
inhibited. This theory certainly parallels the voluminous
research demonstrating the contribution of stress to the
emergence or worsening of psychiatric and physical
disorders. They suggested that stress impairs or
downgrades the functioning of the locale system, causing us
to fall back on the more primitive organization of taxon
(amygdaloid) systems. From a psychoanalytic perspective,
this process may be understood as regression to more
primitive self states and defense mechanisms. This process
also parallels the return of neonatal reflexes (the cortical
release signs previously discussed in patients with
Alzheimer’s disease or other forms of brain damage).
Despite the apparent extinction of a phobia or fear, the
original memory is maintained and can become reactivated
under stress. This neural explanation addresses the
Freudian notion of symptom substitution, in which one fear
or source of anxiety may be replaced by another after
successful treatment of the first. In other words, a new
trigger reactivates the still intact underlying neural circuitry,
another way of saying what we covered earlier—that
neurons within the amygdala exhibit persistent dendritic
modeling (Vyas et al., 2003). Because of this, Jacobs and
Nadel suggested that the therapist treating fears and
phobias may need to generate stress as a part of treatment
to activate and have access to these amygdala circuits. In
addition, treatment may need to be continued well after
behavioral manifestations are eliminated, as well as include
stress management training. If the overall level of stress can
be decreased, the likelihood of reactivating of primitive fear
circuitry decreases.
Successful psychotherapy for anxiety, fears, and phobias
has been shaped by the necessity of integrating fast and
slow circuits, taxon and locale systems, and affect and
cognition. Educating patients about panic leads to increased
participation of the cortex during anxiety states. Cognitive
therapy is all about utilizing the slow locale systems to
inhibit and modulate fast taxon systems that have been
shaped in maladaptive ways. Stress inoculation, or cognitive
preparation for future stress, leads to an increasing
opportunity for descending inhibition of the amygdaloid
circuits by the hippocampal-cortical networks. Exposure,
response prevention, and relaxation training result in the
counterconditioning of unconscious associations stored in
amygdaloid memory systems. This model of memory
applies to all clinical situations, regardless of the presence
of panic or anxiety disorders.

Drowning in a Sea of Doom

 There is no greater hell than to be a prisoner of fear.
—Ben Johnson

Tina’s cardiologist suggested that she see a psychotherapist

after a third visit to the emergency room. Each time,
seemingly out of nowhere, Tina would become breathless
and lightheaded; her heart would race until she felt as if it
were going to burst from her chest. Convinced she was
having a heart attack, Tina would call the paramedics. As
she waited for the ambulance, Tina reported feeling like she
was drowning in a “sea of doom.” She would imagine her
teenaged children growing up without her, and vividly
recollect her own mother’s death when she was a child.
These feelings and images, together with the fear of death,
would make her even more frightened. She told me that
waiting for the ambulance felt like “an eternity.”
Tina, who was actually in excellent health, was
repeatedly told she was having panic attacks. It took three
of these embarrassing episodes to convince her to seek
therapy. She came to my office feeling defeated and very
frightened, as if she was losing a lifelong battle to stay in
control. During our first session, I learned that Tina had a
difficult childhood, including abandonment by her father,
prolonged financial difficulties, and the death of her mother
when she was 15. Tina finished high school while living with
an aunt, put herself through college, and became a
successful real estate agent. A 4-year marriage had left her
with two children, now in their teens, to raise on her own.
Tina’s identity was that of a survivor and hard worker who
did not allow herself to depend on others. The panic attacks
had shaken her self-confidence and created a fear of
returning to the chaos, pain, and dependency of her
childhood. She had hoped for a medical explanation to avoid
revisiting her past.
I began treatment by educating Tina about her body’s
fear response and why it felt to her like she was having a
heart attack. Her racing heart, lightheadedness, rapid
breathing, and sense of danger were the result of the
amygdala’s multiple signals to prepare to fight or run.
Gaining conscious regulation of her amygdala’s alarm
circuitry was the first order of business. We discussed
strategies to ward off these attacks by slowing her
breathing and employing relaxation techniques. During
sessions, I would have Tina make herself anxious, and then
assist her in calming down. This provided her with a sense
of mastery in regulating amygdala activation.
Understanding what was happening in her body and
knowing that her life was not in danger relieved some of her
fear.
The second phase of treatment focused on addressing
the long-standing lifestyle issues that kept her in a chronic
state of stress. We examined the heavy burden of
responsibilities she carried and her lack of relaxation and
recreation. Tina’s financial fears led her to overbook her
work schedule to the point of exhaustion. I learned that Tina
constantly criss-crossed the Los Angeles freeway system,
traveling between 30,000 and 40,000 miles each year.
Between showing homes and shuttling her children from
school to their various activities, we calculated that she was
fighting traffic up to 6 hours a day, usually behind schedule.
She began to understand the panic attacks as her body’s
way of telling her to make some changes to reduce her level
of stress. Regular exercise, decreasing her sales territory,
and making alternative arrangements for some of her
children’s transportation proved to be the most helpful
solutions in these areas.
As these interventions became more routine, we
explored the impact of her childhood experiences on both
her self-image and lifestyle. Tina harbored the fear that she
would die like her mother, leaving her children alone in the
world. She tried to do everything she could for them, and
save all the money they would need to go to college, all the
time thinking that she would not be around much longer.
Her financial planning was detailed and over the years she
had followed through with it almost to the letter. The
problem was that it had originally been created for two
incomes; now she was doing it on her own. She came to see
that her fear of death might become a self-fulfilling
prophecy. Tina also came to realize that her heart was still
broken over her mother’s death, and that she had never
allowed herself to grieve her loss, a luxury she had felt she
could not afford. Opening herself to these feelings of loss
was the beginning of her therapy.

Summary
The fearful brain has two interconnected systems
responsible for different aspects of fear processing. The fast
or taxon system—with the amygdala at its core—makes
rapid, reflexive, and unconscious decisions to provide for
immediate survival. This system develops first and
organizes learning related to attachment and affect
regulation. It involves sensory, motor, and affective
memories typical of early life and later traumatic memories.
The slow or locale system, based in hippocampal-cortical
networks, contextualizes and makes conscious what is being
processed. The slow system’s job is to regulate the activity
of the amygdala by modulating its output based on a more
complex appraisal of potentially dangerous situations. This
system contextualizes experience in time and space, and
supports conscious awareness via cortical connectivity.
These two systems, reflecting both top-down and left-
right circuits, can become dissociated during prolonged
periods of stress or trauma. In psychotherapy, we attempt
to activate both fast and slow circuits, taxon and locale
systems, and implicit and explicit forms of memory to
inform and educate each about the other. When emotional
taxon networks are inhibited, we use techniques to trigger
them so that they can be activated and integrated with slow
locale circuits. When these same networks are out of
control, we recruit locale circuits to contextualize them in
time and space and allow them to be tamed by the
descending, inhibitory capabilities of cortical processes. The
overall goal is the activation and integration of both
systems.
Chapter 14

Trauma and Neural Network Dissociation

The beauty of the world has two edges, one of

laughter, one of anguish, cutting the heart asunder.
—Virginia Woolf

For each of us there is a point at which fear crosses the line

into trauma, causing severe disturbances in the integration
of cognitive, sensory, and emotional processing. The
psychological and neurobiological reactions to traumatic
experiences lie on a continuum of severity. As a general
rule, the earlier, more severe, and more prolonged the
trauma, the more negative and far reaching its effects (De
Bellis, Baum, et al., 1999; De Bellis, Keshavan, et al., 1999).
Unresolved trauma may result in symptoms of post-
traumatic stress disorder (PTSD), which reflect the
physiological dysregulation and dissociation of multiple
neural networks.

The Symptoms of Post-traumatic Stress Disorder

The best way out is always through.

—Robert Frost

Traumatic experiences result in a variety of well-understood

physiological and psychological reactions to threat, which
cause a number of predictable symptoms to emerge. These
symptoms tend to gradually diminish after the resolution of
the traumatic situation, as we gather support from others,
and repeatedly talk through the experience. These
conditions allow us to regain both neurobiological
homeostasis and a sense of emotional control.
Talking through the trauma with supportive others
creates the neurobiological conditions for the
reestablishment of neural coherence. Put another way,
constructing narratives in an emotionally supportive
environment supports the psychological and neurobiological
integration required to avoid dissociative reactions.
Narratives drive the integration of cognition, affect,
sensation, and behaviors, which can remain dissociated
especially when early trauma, such as child sexual abuse, is
never allowed to be discussed. The suffering of Holocaust
survivors and combat veterans is often exacerbated by the
political and social dynamics that encourage them to remain
silent about their horrifying experiences.
When trauma is severe or chronic the victim can develop
PTSD. PTSD is caused by the loss of the regulation of the
neurobiological processes responsible for appraising and
responding to threat. When this system becomes
dysregulated, the body reacts as if the past trauma is
continuing to occur. The three main symptom clusters of
PTSD—hyperarousal, intrusion, and avoidance—reflect the
loss of integration among neural networks controlling
cognition, sensation, affect, and behavior.
Hyperarousal reflects a stress-induced dysregulation of
the amygdala and autonomic nervous system, resulting in
an exaggerated startle reflex, agitation, anxiety, and
irritability. That jumpy feeling we get when we drink too
much caffeine gives us a taste of this experience. Chronic
hyperarousal leads one to experience the world as a more
dangerous and hostile place. Constant agitation and
wariness make us less desirable companions and can cut us
off from the healthful effects of relationships.
 Intrusions occur when traumatic experiences break into
conscious awareness and are experienced as if they are
happening in the present. There is no sense of distance from
the trauma in time or place, because the
corticohippocampal networks have not been able to
contextualize the somatic, sensory, and emotional
memories within networks of autobiographical memory.
Intrusions may manifest as flashbacks, resulting in a
veteran hitting the ground in response to a car backfiring, or
a rape victim having a panic attack while making love to her
husband. These are activations of subcortical systems cued
by stimuli reminiscent of the trauma. You may remember
from the chapters on memory and fear that the amygdala
both controls this activation and tends to generalize from
the initial stimuli to a wide variety of cues.
Avoidance is the attempt to defend against dangers by
limiting contact with the world, withdrawing from others,
and narrowing the range of thoughts and feelings.
Avoidance can take the form of denial and repression, and,
in more extreme instances, dissociation and amnesia. The
power of avoidance was highlighted by the research of
Williams (1994), who found that 38% of adult women who
had suffered documented sexual abuse as children had no
memory of the event. Compulsive activities can also aid in
avoiding negative affect, as can alcohol and drug abuse,
both so common in victims of trauma. Avoidance enables
short-term anxiety reduction while maintaining the lack of
neural network integration which perpetuates the illness.
When experienced in combination, these symptoms
result in a cycle of activation and numbing, reflecting the
body’s memory for, and continued victimization by, the
trauma (van der Kolk, 1994). Instead of serving to mobilize
the body to deal with new external threats, traumatic
memories trigger continuing frightening emotional
responses. Someone suffering from PTSD is in a continual
loop of unconscious self-traumatization, coping, and
exhaustion. When these symptoms are experienced on a
chronic basis, they can devastate every aspect of the
victim’s life, from physical well-being to the quality of
relationships to the victim’s experience of the world.
We have all heard the sayings “What doesn’t kill you
makes you stronger” and “Time heals all wounds.” These
bits of common wisdom conjure up pictures of difficult and
traumatic experiences that, once overcome, result in
greater levels of physical and emotional well-being.
Although trials and tribulations can certainly be important
learning experiences, they can also create permanent
biological, neurological, and psychological compromise.
Trauma produces widespread homeostatic dysregulations
that interfere with all realms of personal and interpersonal
functioning (Perry et al., 1995).
Support for the negative impact of trauma comes from
research showing that cumulative lifetime trauma increases
the likelihood of developing PTSD (Yehuda et al., 1995). A
history of previous assaults increases the chances of
developing PTSD following rape (Resnick, Yehuda, Pitman, &
Foy, 1995). Likewise, childhood abuse victims are more
likely to develop PTSD after adult combat exposure
(Bremner, Southwick, et al., 1993). It has also been found
that severe stress reactions during combat make
subsequent negative reactions to mild and moderate stress
more probable (Solomon, 1990).

The Neurochemistry of PTSD

Gulf War Syndrome is not one cause, not one illness. It

is many causes, many illnesses.
—Christopher Shays

States of acute stress result in predictable patterns of

biochemical changes including increases in norepinephrine,
dopamine, endorphins, and glucocorticoids, and a decrease
in serotonin. These changes are part of the body’s
mobilization to confront threat. When stress is prolonged or
becomes chronic, changes continue to occur in the baseline
production, availability, and homeostatic regulation of these
neurochemicals, resulting in long-term behavioral and
psychological alterations. Each of these substances has its
own role in the stress response and contributes in different
ways to the long-term impact of PTSD.
As we have seen, increased levels of norepinephrine (NE)
prepare us for fight-or-flight readiness and reinforce the
biological encoding of traumatic memory. Higher long-term
levels of NE result in an increase in arousal, anxiety,
irritability, and a heightened or unmodulated startle
response (Butler et al., 1990; Ornitz & Pynoos, 1989).
Besides being stronger, the startle response is also more
resistant to habituation in response to subsequent milder
and novel stressors (Nisenbaum, Zigmond, Sved, &
Abercrombie, 1991; Petty, Chae, Kramer, Jordan, & Wilson,
1994; van der Kolk, 1994). Being consistently startled
increases the victim’s experience of the world as an
unsettling and dangerous place, a good example of a
feedback loop between physiological and psychological
processes. In fact, drugs that block the impact of NE are
being used experimentally to determine if they may help
victims of PTSD decrease their physiological response to
reminders of their trauma (Brunet et al., 2008).
High levels of dopamine correlate with hypervigilance,
paranoia, and perceptual distortions when under stress.
Symptoms of social withdrawal and the avoidance of new
and unfamiliar situations (neophobia) are shaped by these
biochemical changes. Lower levels of serotonin have been
found in traumatized humans and animals after being
subjected to inescapable shock (Anisman, Zaharia, Meaney,
& Merali, 1998; Usdin, Kvetnansky, & Kopin, 1976).
Chronically low levels of serotonin are correlated with higher
levels of irritability, depression, suicide, arousal, and
violence (Canli & Lesch, 2007; Coccaro, Siever, Klar, &
Maurer, 1989).
Elevated levels of endogenous opioids, which serve as
analgesics to relieve pain in fight-or-flight situations, can
have a profoundly negative impact on cognition, memory,
and reality testing. Higher opioid levels also support
emotional blunting, dissociation, depersonalization, and
derealization, all of which provide a sense of distance from
the traumatized body (Shilony & Grossman, 1993).
However, when they become harmfully used as defenses,
they disrupt our ability to stay engaged in day-to-day life.
As we have seen, high levels of glucocorticoids have a
catabolic effect on the nervous system and are thought to
be responsible for decreased hippocampal volume and
related memory deficits (Bremner, Scott, et al., 1993;
Nelson & Carver, 1998; Watanabe, Gould, & McEwen, 1992).
The hippocampi of patients with PTSD related to childhood
physical and sexual abuse have been shown to be 12%
smaller than those of comparison subjects (Bremner et al.,
1997). Another study showed that right hippocampi were
8% smaller in patients with combat-related PTSD (Bremner
et al., 1995). Glucocorticoids sacrifice long-term
conservation and homeostasis for short-term survival.
Chronically high levels have negative effects on brain
structures and the immune system, resulting in higher rates
of learning disabilities and physical illness, which enhances
victims’ experience of being fragile and vulnerable
individuals.
These biochemical and neuroanatomical changes are
paralleled by such symptomatology as emotional
dyscontrol, social withdrawal, and lower levels of adaptive
functioning. Together, these and other negative effects of
trauma result in compromised functioning in many areas of
life. The impact of trauma depends on a complex interaction
of the physical and psychological stages of development
during which it occurs, the length and degree of the trauma,
and the presence of vulnerabilities or past traumas. The
impact of chronic trauma becomes woven into the structure
of personality and is hidden behind other symptoms,
making it difficult to identify, diagnose, and treat.

Expanding the Definition of Trauma

To the child…traumas are not experienced as events

in life, but as life defining.
—Christopher Bollas

Trauma is not limited to surviving life-threatening

experiences, as the standard diagnostic manual appears to
suggest (American Psychiatric Association, 2000). For a
young child, trauma may be experienced in the form of
separation from parents, looking into the eyes of a
depressed mother, or living in a highly stressful household
(Cogill, Caplan, Alexandra, Robson, & Kumar, 1986). For an
adolescent, trauma may come in the form of incessant
teasing by peers or caring for an alcoholic parent. For an
adult, chronic loneliness or the loss of a pet may be
traumatic.
There is increasing evidence that stress is possible even
before birth; an unborn child may become stressed as a
result of the shared biological environment with its mother.
Studies suggest that maternal stress is associated with
lower birth weight, increased irritability, hyperactivity, and
learning disabilities in children (Gunnar, 1992, 1998;
Zuckerman, Bauchner, Parker, & Cabral, 1990). Rats born to
stressed mothers show more clinging to the mother and
decreased locomotion and environmental exploration
(Schneider, 1992). Prenatal stress may also result in
permanent alterations in dopamine activity and cerebral
lateralization, making offspring more susceptible to anxiety
and impairing their functioning as adults (Field et al., 1988).
Children of Holocaust survivors have an increased
prevalence of PTSD despite similar rates of exposure to
traumatic events as children of non-Holocaust survivors.
This suggests that they experienced a transferred
vulnerability through interactions with their traumatized
parents (Yehuda, 1999).
Maternal depression may serve as a highly stressful or
traumatic experience for infants and children. Tiffany Field
and her colleagues found that infants of depressed mothers
show neurophysiological and behavioral signs of depression
and stress, including greater right frontal lobe activation,
higher levels of NE, lower vagal tone, and higher heart rates
and cortisol levels (Field & Diego, 2008b; Field, Diego, &
Hernandez-Reif, 2006). Just like their depressed mothers,
these infants engage in less interactive behaviors (e.g.,
orienting toward and gazing at others) vital for healthy
development. Infants of depressed mothers behave in this
way even with other adults, making it difficult for them to
successfully interact with nondepressed others (Field et al.,
1988).
In another study, it was found that depressed mothers
were angry at their infants more often, disengaged from
them more often, were more likely to poke them, and spent
less time in matching emotional states (Field, Healy,
Goldstein, & Guthertz, 1990). These results suggest that
infants are modeling their mother’s behavior, resonating
with their depressed moods, and reacting to the negative
behaviors directed toward them. Although we would not
consider these infants traumatized in the traditional sense,
the loss of maternal presence, engagement, and vitality
may all be experienced as life threatening. Fortunately, it
has been shown that interventions with depressed mothers
and their infants have positive results. For example,
remission of maternal depression and teaching mothers to
massage their infants on a regular basis improves the
infants’ symptoms and the mothers’ mood (Field, 1997).
The effects of early and severe trauma are extremely
widespread, devastating, and difficult to treat. Because of
the importance of a context of safety and bonding in the
early construction of the brain, childhood trauma
compromises core neural networks. It stands to reason that
the most devastating types of trauma are those that occur
at the hands of caretakers. Physical and sexual abuse by
parents not only traumatizes children, but also deprives
them of healing interactions and a safe haven. The wide
range of effects involved in the adaptation to early
unresolved trauma results in complex post-traumatic stress
disorder.

Complex Post-traumatic Stress Disorder

The other day I heard someone knocking on my

window. I’d rather be dead than hear that.
—A 10-year-old kidnapping victim

Complex PTSD occurs in the context of early, prolonged, and

inescapable trauma. It is called complex because of its
extensive effects on all areas of physiology, development,
and functioning (Herman, 1992; Navalta et al., 2004). The
enduring personality traits and coping strategies that
emerge in these situations tend to decrease positive
adaptation and increase an individual’s vulnerability to
future trauma. This can manifest through engagement in
abusive relationships, poor judgment, or a lack of adequate
self-protection. Long-term PTSD has been shown to correlate
with the presence of neurological soft signs, which suggest
subtle neurological impairments (Gurvits et al., 2000), and
may reflect a vulnerability to, or the impact of, the effects of
trauma (Green, 1981).
 For an adult under normal circumstances, a threat
triggers a fight-or-flight response. The threat is dealt with
and the flight-fight response soon subsides. Children are not
well equipped to cope with threat in this way. Fighting and
fleeing may actually be maladaptive because their survival
depends on relying on those around them. When a child
experiences trauma inflicted by a caretaker, or cries for help
but no help arrives, he or she may shift from fear and
hyperarousal to psychological and neurological dissociation
(Perry et al., 1995). This may also be true for those women
who are unable to outrun or outfight male attackers. The
symptoms of agitation shown by traumatized children are
often misdiagnosed as attention deficit disorder, while the
numbing response in infants can be misinterpreted as a lack
of awareness or sensitivity to pain.
Until recently, surgery was performed on infants without
anesthesia because their gradual lack of protest was
mistakenly interpreted as an insensitivity to pain rather than
lapsing into a state of shock (Zeltzer, Anderson, & Schecter,
1990). Survey research suggests that less than 25% of
physicians performing circumcision on newborns use any
form of analgesia (Wellington & Rieder, 1993), despite
physiological indications that neonates are experiencing
stress and pain during and after the procedure (Hoyle et al.,
1983). These practices appear to be a holdover of beliefs
that newborns either don’t experience or don’t remember
pain (Marshall, Stratton, Moore, & Boxerman, 1980). Thus,
our lack of appreciation for the possibility for traumatic
reactions in neonates and children likely leads us to miss
many PTSD reactions in the young.
Research with rats has demonstrated that exposure to
inescapable shock sensitizes their hippocampi to
subsequent releases of NE under stress (Petty et al., 1994).
This suggests that prolonged stress and trauma may cause
us to react more strongly to subsequent milder stress. This
may help to explain the coping difficulties seen in victims of
PTSD when confronted with mild to moderate stress (Petty
et al., 1994). Think back to Sheldon, who still suffered from
anxiety 60 years after his childhood experiences during
World War II.
Dissociation allows the traumatized individual to escape
the trauma via a number of biological and psychological
processes. Increased levels of endogenous opioids create a
sense of well-being and a decrease in explicit processing of
overwhelming traumatic situations. Derealization and
depersonalization reactions allow the victim to avoid the
reality of his or her situation, or watch it as a detached
observer. These processes can create an experience of
leaving the body, traveling to other worlds, or immersing
oneself into other objects in the environment. Many victims
of violence and sexual abuse report watching themselves
being attacked from a distance. Hyperarousal and
dissociation in childhood create an inner biopsychological
environment primed to establish boundaries between
different emotional states and experiences. If it is too
painful to experience the world from inside one’s body, even
one’s self-identity can become organized outside the
physical self.
Early traumatic experiences organize neuroanatomical
networking, thus impacting experience and adaptation
throughout development. The tendency to dissociate and
disconnect various tracks of processing creates a bias
toward unintegrated information processing across
conscious awareness, sensation, affect, and behavior.
General dissociative defenses resulting in an aberrant
organization of networks of memory, fear, and the social
brain contribute to deficits of affect regulation, attachment,
and executive functioning (van der Kolk et al., 1996). The
malformation of these interdependent systems results in
many disorders that spring from extreme early stress.
Compulsive disorders related to eating or gambling,
somatization disorders in which emotions are converted into
physical symptoms, and borderline personality disorder all
reflect complex adaptations to early trauma (Saxe et al.,
1994; van der Kolk et al., 1996).

I Am Not Crazy!

Demoralize the enemy from within by surprise, terror,

sabotage, assassination.
—Adolf Hitler

Jesse was referred to me by her neurologist after months of

extensive medical and neurodiagnostic testing. Her team of
doctors could find no physical cause for the debilitating pain
she experienced in her head and upper body. She had tried
alternative forms of treatment, such as chiropractics and
acupuncture, without much relief. Jesse came to see me at
the insistence of her husband, and she was not the least bit
happy about it. She sat down with her arms crossed and her
jaw set, glared at me, and said, “I am not crazy!”
For many years, life had been going well for Jesse. She
had a solid marriage and a happy and healthy 4-year-old
daughter. She found her work as an executive in a small
information technology firm interesting. She liked her
colleagues, and was a valued member of the team. About a
year before, she had started experiencing pain in her head,
hands, and back and began a fruitless search for a cure. The
pain became the center of her attention as her interest and
ability in being an executive, friend, wife, and mother
gradually diminished. By the time she came for therapy, she
was spending most of her days taking medication, sneaking
away for naps, and withdrawing to her room whenever she
could find an excuse. There was no longer any fun or
relaxation in her life, and her husband had become seriously
concerned.
 Given her resistance to therapy and fear of being seen as
crazy, developing a therapeutic relationship with Jesse was
slow going. She reluctantly began to share about her very
troubled childhood. Jesse felt she had obviously overcome
her traumatic past based on her later success at work and
in her marriage. Unfortunately, a common occurrence in her
childhood was to be locked in her room by her father as a
prelude to him beating her mother. She would lie in bed,
frozen by both of their screams, her mother’s cries for her,
and the long ominous silences that followed. As she told me
of her mother’s physical abuse at the hands of her father,
she remained confident that there was no connection
between her present physical pain and the emotional pain
of her youth.
Jesse would eventually begin to pound on the door and
yell for her mother. As she grew older, however, she gave
up her outward protests and instead lay in bed crying and
clutching her face and head. This clutching eventually
turned to self-abuse, which included driving her nails into
her head and shoulders, drawing blood, and eventually
scarring herself. She showed me some of her scars with a
combination of shame and pride. As she described these
experiences, I began to suspect that her pain symptoms
might well be implicit somatic memories of her traumatic
past. The stresses in her present life, including the fact that
her own daughter was reaching the age she had been when
she first became aware of the beatings, could all serve as
triggers for these memories. From a psychological
perspective, her physiological suffering could be seen as a
form of loyalty and continued connection to her mother.
I decided not to share these interpretations because of
Jesse’s resistance to the possible psychological origins of
her pain. Instead, I continued to encourage her to talk about
her childhood in as much detail as she could tolerate. She
went on to tell me about her teenage years, when she
nursed her mother through the final months of a prolonged
battle with cancer. Throughout my work with Jesse, I
avoided any talk of her physical pain and continued to
refocus her on sharing childhood experiences with me.
In the process of repeatedly sharing stories from her
childhood, her memories became increasingly detailed. Her
emotions too, became more available, and better matched
to the situations she described. Jesse expressed her rage at
her father for his violent behavior, and realized that she was
also angry at her mother for not leaving him when Jesse was
young. As she worked through these memories and put
them into the perspective of her current life, Jesse gradually
came to an understanding that instead of remaining loyal to
her mother through physical suffering, she could identify
with her by being a good parent to her own daughter.
As therapy progressed, we both came to notice that the
intensity of her pain and the time she spent focusing on it
gradually diminished. Without making a direct
interpretation, the connections in Jesse’s brain between her
physical and emotional pain were forged. Toward the end of
our last session, she thanked me for helping her, although
she didn’t understand how it happened. Jesse winked at me
and said, “You are a tricky fellow.”

Traumatic Memory

Memories are nothing but the lash with which

yesterday flogs tomorrow.
—Philip Moeller

It has long been recognized that high levels of stress impair

learning of new information (Yerkes & Dodson, 1908). This is
because the biochemical and hormonal changes triggered
by stress impair protein synthesis and other neuroplastic
processes required for memory encoding. Trauma can also
impair integration across the domains of memory, and is
capable of dissociating the usually integrated tracks of
sensation, emotion, behavior, and conscious awareness.
When NE is administered to rats after an aversive event,
low doses enhance memory retention whereas high doses
impair it (Introini-Collison & McGaugh, 1987); this supports
Yerkes and Dodson’s theory that moderate levels of arousal
enhance memory whereas high levels impair it. In a study
by Cahill and his colleagues (Cahill, Prins, Weber, &
McGaugh, 1994), subjects were read emotionally evocative
and neutral stories and shown related slides. Half of the
subjects were given propranolol (a drug that decreases the
effects of NE), and the others were not. Results
demonstrated that subjects who received propranolol had
significantly impaired memory for emotion-arousing but not
for neutral stories.
Activation of the amygdala and related physiological and
biological changes are at the heart of modulating traumatic
memory (Cahill & McGaugh, 1998). The release of
norepinephrine during the stress response serves to
heighten the activation of the amygdala, thus reinforcing
and intensifying traumatic memories (McGaugh, 1990).
Individuals with PTSD have had their amygdaloid memory
systems imprinted with trauma at such an extreme level
that their memories are resistant to cortical integration (van
der Kolk et al., 1996). This results in decreased attention to
and processing of external stimuli, giving the traumatic
memories more power (Lanius et al., 2001). When we think
of trauma overwhelming the defenses, we can also think in
terms of an intense activation of subcortical networks
serving to inhibit the participation of the hippocampus and
cortex in the memory process.
Traumatic experience can disrupt the storage (encoding)
of information and the integration of the various systems of
attention and memory (Vasterling, Brailey, Constans, &
Sutker, 1998; Yehuda et al., 1995; Zeitlin & McNally, 1991).
Memory encoding for conscious explicit memory can be
disrupted when the hippocampus is blocked or damaged by
glucocorticoids, or is inhibited by heightened amygdala
activation. This could lead to a lack of conscious memory for
traumatic and highly emotional events (Adamec, 1991;
Schacter, 1986; Squire & Zola-Morgan, 1991). Memory
integration can be impaired by disruption of the
corticohippocampal tracks dedicated to the integration of
new memories into existing memory networks. Remember
that these systems also provide contextualization in time
and space, and integration of sensory, affective, and
behavioral memory with conscious awareness.
Thus, although we may have very accurate physiological
and emotional memories for a traumatic event, the factual
information may be quite inaccurate given the inhibition of
corticohippocampal involvement during the trauma. Add to
this the tendency of the left hemisphere interpreter to
confabulate a story in the absence of accurate information,
and we may have what represents the underlying
mechanisms responsible for what has unfortunately been
referred to as false memory syndrome (PazAlonzo &
Goodman, 2008).

Traumatic Flashbacks and Speechless Terror

Memories are contrary things; if you quit chasing

them and turn your back, they often return on their
own.
—Stephen King

Flashbacks are frightening experiences commonly reported

by traumatized individuals. They are described as full-body
experiences of traumatic events, which include the
physiological arousal, sensory stimulation, and emotional
impact of the traumatic experience. In a sense, the victim of
a flashback is transported back to the event, and as far as
the brain is concerned, it is happening again. Flashbacks are
so intense that they overwhelm the reality constraints of the
present situation and send the victim into an all-too-familiar
nightmare.
The power of traumatic flashbacks was driven home for
me one day in a therapy session with a professional football
player who was nearly twice my size. When recalling his
early abuse, he began to cry softly as he spoke of one
particularly painful experience from childhood. He described
in agonizing detail his small body growing limp after
repeated blows from his father’s fists. Suddenly, he was
standing over me, breathing heavily, his arms down at his
sides. Despite my alarm, I managed to calmly ask him what
he was feeling. While looking into my eyes he said in a
child’s voice, “
Please don’t hurt me anymore.” His fear of me despite
the difference in our sizes was a stark demonstration of the
all-encompassing nature of flashbacks and their ability to
override contemporary reality.
Traumatic flashbacks are memories of a different nature
than are those of nontraumatic events. To begin with, they
are stored in more primitive circuits with less cortical and
left hemisphere involvement. Because of this, they are
strongly somatic, sensory, and emotional, as well as
inherently nonverbal (Krystal, Bremner, Southwick, &
Charney, 1998). The lack of corticohippocampal
involvement results in an absence of the localization of the
memory in time, so that when it is triggered, it is
experienced as occurring in the present. Flashbacks are also
repetitive and stereotypic, often seeming to proceed at the
pace at which the events originally occurred. This suggests
that although the cortex may condense and abbreviate
memories in narrative and symbolic form, these subcortical
networks may store memories in more concrete, stimulus-
response chains of sensations, behaviors, and emotions. In
a sense they become procedural memories, similar to
learning to play a piece of music note by note or a complex
dance routine step by step.
In flashbacks, the amygdala-mediated fear networks
biased toward the right hemisphere and subcortical systems
become dominant. The amygdala’s dense connectivity with
the visual system most likely accounts for the presence of
visual hallucinations as part of flashbacks. Bereaved
individuals often report seeing their loved ones sitting in
their favorite chair or walking across the room in a familiar
way. Those who have been attacked will sometimes think
they see their attacker out of the corner of their eye. This is
in contrast to the hallucinations in schizophrenia that
involve the temporal lobes and are usually auditory in
nature.
Rauch and colleagues (1996) took eight patients
suffering from PTSD and exposed them to two audiotapes:
One was emotionally neutral and the other was a script of a
traumatic experience. While they were listening to these
tapes, patients’ heart rates and regional cerebral blood flow
(RCBF) were measured via PET scans. RCBF was greater
during traumatic audiotapes in right-sided structures
including the amygdala, orbitofrontal cortex, insular,
anterior, and medial temporal lobe, and the anterior
cingulate cortex. These are the areas thought to be involved
with intense emotion.
An extremely interesting and potentially important
clinical finding was a decrease in RCBF in and around
Broca’s area (an area of the left inferior frontal cortex that
controls speech). These findings suggest an active inhibition
of language centers during trauma. Based on these results,
speechless terror—often reported by victims of trauma—
may have neurobiological correlates consistent with what
we know about brain architecture and brain–behavior
relationships. This inhibitory effect on Broca’s area may
impair the encoding of conscious semantic memory for
traumatic events. It will then naturally interfere with the
development of narratives that serve to process the
experience and lead to neural network integration and
psychological healing. Activating Broca’s area and related
left cortical networks of explicit memory may be essential in
psychotherapy with patients suffering from PTSD and other
anxiety-based disorders.

Activating Broca’s Area During a Flashback

Hope will never be silent.

—Harvey Milk

Jan, seeing me for a one-time consultation, reported that

she had suffered severe physical and sexual abuse
throughout her early childhood and into her late teens. She
told me over the phone that her flashbacks were increasing
in frequency to three or four a day. Although her therapist
had encouraged her to experience them and express her
emotions as much as possible, Jan felt like she was getting
worse instead of better. Expressing her feelings seemed to
only trigger more frequent and intense flashbacks. She
reported becoming less and less functional, which made her
decide that she needed a different approach to therapy.
Jan arrived at my office with a stack of diaries and The
Wall Street Journal under her arm. It was hard to believe
that this was the same person I had spoken to over the
phone. My first thought was that dissociation is an amazing
defense. Jan was a well-dressed woman in her mid-40s who
was obviously bright and had a good deal of self-insight. The
childhood experiences she recounted in my office were
horrendous, and I marveled at her very survival. Her
intelligence and sheer will to live were remarkable. It
seemed obvious, however, that her repeated reexperiencing
of these memories was not helping. The nature of these
memories was not changing over time, nor were the
emotions evoked by her memories diminishing. In this case,
each flashback seemed to retraumatize her anew.
She began by talking about her work, and then described
the psychotherapy and other forms of treatment in which
she had engaged. Approximately 10 minutes into the
session, as she was discussing the family members who had
abused her, she began to have a flashback. Jan reported
pain in various parts of her body and contorted as if what
she was describing was happening to her at that very
moment. She began to gag as the memory of the sexual
abuse from decades earlier was evoked. She was
reexperiencing these painful episodes not only visually in
her mind, but as somatic memories throughout her body.
As she curled into a fetal position on the couch and
gasped for breath, my mind raced trying to think of a way to
help. Remembering the research done by Rauch and his
colleagues, I decided to try to activate Broca’s area. I began
speaking to Jan in a firm but gentle voice, loud enough to
reach her in the midst of her traumatic reenactment but not
so loud as to frighten her and add to her trauma. I wondered
if it mattered which ear I spoke into, and which ear has a
more direct connection to the left hemisphere language
centers. I moved closer to her (careful not to get too close)
and repeated over and over, “This is a memory, it isn’t
happening now. You are remembering something that
happened to you many years ago. It was a terrible
experience but it is over. It is a memory. It is not happening
now.”
As I repeated these and similar statements, I was
concerned that Jan would be unable to breathe or that my
presence might cause her more fear. The words of one of
my supervisors flashed through my mind: “
Whatever you do, don’t panic.” I was also encouraged by
the fact that she had survived this many times. After 10
minutes (which seemed to me like 10 hours), she calmed
down and returned to the present. Jan reported that she
heard me speaking as if I were far away, but focused on my
voice and words as best she could. It was as if I were there
in the past with her, calling to her from a safe future where
she would be away from all these people who hurt her.
At the end of the session she thanked me and left; I
didn’t hear from her for a number of months. When she
called one afternoon, she reported that since her visit with
me, the nature of these flashbacks had changed. She said
she had wanted to wait before she called me because she
didn’t expect that the change would last. Given her many
years in a variety of unhelpful treatments, it was easy to be
sympathetic to her negative expectations. Jan described
that since our session, the flashbacks were less physically
intense and less frequent. On a few occasions she had even
been able to stop one that was coming on by thinking of my
words during the session: “This is just a memory. You are
safe now. No one can hurt you.”
Perhaps most interesting was that she was now able to
remember during her flashbacks that she was not a child,
that she was not to blame, and it was those who were
hurting her who were bad. Although her other therapists
had told her this in the past, only recently could she process
these thoughts during her flashbacks. I told her that I felt
these were signs that the experiences were beginning to be
connected to her conscious adult self, and that now she was
able to fight and care for herself even in the face of her
past. I encouraged her to keep talking throughout the
flashback experiences and bring with her as much
assertiveness, anger, and power as she could muster. After
a few minutes, we ended our conversation and I sat back,
struck at how neuroscience could indeed be applied to
psychotherapy.
It is impossible for me to know with any certainty
whether what I had done with Jan during our one meeting
had anything to do with the changes she experienced
during her flashbacks. If it did, perhaps the active ingredient
was the simultaneous activation of the verbal areas of the
left hemisphere along with the emotional centers of the
right hemisphere and limbic structures that stored the
flashbacks. Being simultaneously aware of inner and outer
worlds may support a higher level of cortical functioning and
increased network integration. In other words, this process
results in a memory configuration that is no longer implicit
only but instead becomes integrated with the
contextualizing properties of explicit systems of memory in
the cerebral cortex (Siegel, 1995).
Speechless terror, which has been recognized as part of
posttraumatic reactions since ancient times, now has a
neural correlate consistent with what is known about brain
functions. Why does Broca’s area become inhibited during
trauma? Why would evolution select silence in times of
crisis? Perhaps when one is threatened it is better to either
run or fight or simply keep quiet and hope to stay
undetected. In other words, evolution has taught the brain
to “Shut up and do something!” when in danger. The
freezing reaction of animals (being still and quiet when they
sense a predator) allows them to be less visible (because a
still and silent target is more difficult to detect). Spoken
language is sound, which primitive fear circuitry is able to
silence. Perhaps those early prehumans who hung around
for conversation and negotiation with predators didn’t fare
well enough to pass down as many genes as did those who
either kept quiet, fought, or ran away.

The Addiction to Stress and Self-Harm

Every form of addiction is bad, no matter whether the

narcotic be alcohol or morphine or idealism.
—C. G. Jung
Another clinical phenomenon with a possible biochemical
mechanism is what appears to be an addiction to stress
experienced by some patients with PTSD. While anxious and
ill at ease in normal daily life, they report feeling calm and
competent in risky or life-threatening situations. A socalled
normal life leaves traumatized persons a blank screen onto
which their dysregulated psyches can project fearful
experiences, keeping them in a state of vigilance and fear
(Fish-Murry, Koby, & van der Kolk, 1987). This may motivate
the creation of stress, making a traumatized person
vulnerable to creating new trauma. The new trauma would,
in turn, stimulate the production of endogenous opioids that
would lead to an increased sense of calm and well-being.
Paradoxically, trauma would lead to a sense of competency
and control.
Because these individuals are so physically worn down
by this lifestyle, they often present in therapy with
exhaustion, depression, and a variety of medical conditions.
It is as if they have a drug addiction, except that it is
completely unconscious and they are their own pharmacy.
Initial work with these patients should focus on helping
them reduce stress and learn to tolerate and understand the
anxiety triggered by the absence of stress. This can usually
be accomplished through a combination of stress-reduction
techniques, medication, and psychotherapy.
The addiction to stress has a related but more severe
variant: self-harm. Adults who engage in repeated self-harm
commonly describe childhoods that included abuse, neglect,
or a deep sense of shame. This correlation has led many
theorists to explore the psychodynamic significance of self-
harm as an ongoing negative attachment to destructive
parents. Along these lines, suicide has been described as
the final act of compliance with the parents’ unconscious
wish for the death of the child (Green, 1978). There appears
to be a strong association between self-harm and
attachment disorders because self-injurious behaviors are
often a response to abandonment and loss.
Endogenous opioids may also play a role in some
instances of self-harm and suicide (van der Kolk, 1988). This
opioid system, originally used to cope with pain, was
adapted by later-evolving networks of attachment to
reinforce the positive effects of bonding (Pitman et al.,
1990). Research has demonstrated that the frequency of
self-harm decreases when patients are given a drug to block
the effects of endogenous opioids (Pitman et al., 1990; van
der Kolk, 1988). Abstracting from the animal model, this
would suggest that the endorphins released during injury
reverse the feelings of distress activated by abandonment.
The analgesic effects of these morphinelike substances may
account for the reports describing a sense of calm and relief
after individuals cut, burn, or hurt themselves. Thus, self-
injurious behaviors may be reinforced by both psychological
factors and the endogenous opioid system.
Repeated suicide attempts are reinforced also by the
rapid attention of health care professionals, family, and
friends, which may boost endorphin levels triggered by the
arrival of loved ones. When woven into coping strategies as
a means of affect regulation, this attention-getting behavior
results in a kind of characterological suicidality (Schwartz,
1979). This behavior parallels the distress calls of primates
whose endorphin levels drop in the absence of the mother.
The reappearance of the mother results in a raising of these
endorphin levels and the infant discontinues its cry.
Characterological suicidality can come to serve a similar
biochemical regulatory purpose if this system was
inadequately formed during childhood. Although there are
many sound psychological explanations for the relationship
of childhood abuse with self-harm and suicidality, a
pharmacological intervention designed to block the impact
of endogenous endorphins may also prove helpful.
The Brain and Borderline Personality Disorder

Life began with waking up and loving my mother’s

face.
—George Eliot

According to Freud, participation in analysis requires

sufficient ego strength to withstand the stress of therapy
while simultaneously maintaining contact with reality. Based
on this assumption, Freud did his best to make sure that his
prospective clients were not psychotic. Psychotic individuals
are characterized by severe distortions of reality, thought
disorders, and decompensation under stress. They are also
unable to differentiate their transference and other
projective processes from external reality. Despite Freud’s
best efforts to screen out these clients from analysis, every
so often he got a surprise. People who appeared to be
neurotic would become psychotic during analysis. Freud
referred to these people as having psychic structures on the
borderline between neurotic and psychotic.
Over the years, the conception of a borderline psychic
structure has evolved into what is now called borderline
personality disorder (BPD). As we have already seen, BPD
may represent one variant of complex PTSD, an idea
supported by the frequent occurrence of early abuse,
trauma, and the presence of dissociative symptoms in
borderline individuals. Patients who carry this diagnosis are
characterized by the following:

1. Hypersensitivity to real or imagined

abandonment.
2. Disturbances of self-identity.
3. Intense and unstable relationships.
4. Alternating idealization and devaluation of
themselves and others (black-and-white
thinking).
 5. Compulsive, risky, and sometimes self-
destructive behaviors.

Although there are a number of theories concerning its

cause, many feel that the etiology of BPD stems from early
deficits in emotional regulation and problematic attachment
relationships. Research also suggests that affective
disorders in these patients and their parents occur above
chance levels. This may lead to a combination of parental
instability and biological difficulties of emotional regulation
within the child. Overall, both their reported history and
their symptoms suggest that early attachment was
experienced as traumatic, emotionally dysregulating, and
possibly life threatening.
I have come to feel that borderline individuals provide us
with a window into the intense and chaotic experience of
infancy. As we have seen ( and this is where our
neuroscientific knowledge comes in handy), the amygdala is
highly functional at birth. Remember that the amygdala is at
the center of neural networks involving both fear and
attachment. The hippocampal and cortical networks that
eventually organize and inhibit the amygdala grow gradually
through childhood. Because of this developmental timetable
and the prolonged dependence on others for survival, the
experience of relationships must sometimes be as
overwhelmingly frightening to infants as it is to patients
with BPD.
The symptoms that emerge in this disorder cause
patients to create problematic and chaotic relationships that
can lead them through a lifetime of abandonments. It is
even common for therapists to abandon these patients
because of their intense criticism and hostility. I find that
conceptualizing BPD patients essentially as frightened
children helps me take their attacks less personally and
maintain a therapeutic stance. I suspect that their primitive
fear, rage, and shame are a form of early implicit memory
activated by real or imagined criticism or abandonment.
When these memory networks are triggered during
treatment, they are so powerful that the patient is unable to
maintain contact with reality. We see the same phenomena
in PTSD flashbacks, most likely stored in the same implicit
memory systems. This confused Freud because he believed
everyone was either neurotic or psychotic. BPD was a horse
of a different color.
Examining BPD in light of the neuroscience we have
reviewed in previous chapters, here are a few of the
neurobiological processes that may explain how these
symptoms become encoded within neural networks:

1. Amygdaloid memory systems are primed during

early traumatic attachment experiences to react
to any indication of abandonment. A
sympathetic fight-or-flight reaction is triggered,
and baseline levels of stress hormones are
raised.
2. Orbitofrontal systems are inadequately
developed during attachment to engage in
healthy self-soothing and the successful
inhibition of the amygdala.
3. Orbitofrontal dissociation may result in
disconnection between right-and left-
hemisphere and top-down processing, partly
accounting for rapid and dramatic shifts
between positive and negative appraisals of
relationships.
4. The networks of the social brain are unable to
internalize images from early interactions with
caretakers that could provide self-soothing and
affect regulation.
 5. Rapid fluctuations between sympathetic and
parasympathetic states result in baseline
irritability and a low threshold for sympathetic
responses to real or imagined abandonment.
6. Chronic high levels of stress hormones
compromise hippocampal functioning,
decreasing the brain’s ability to control
amygdala functioning and exacerbating
emotional dyscontrol.
7. Amygdaloid dyscontrol heightens the impact of
early memory on adult functioning, increasing
the contemporary impact of early bonding
failures.
8. Hippocampal compromise decreases reality
testing and memory functioning, hindering the
maintenance of positive or soothing memories
during states of high arousal.
9. Early bonding failures lead to lower levels of
serotonin, resulting in greater risk of depression,
irritability, and decreased positive
reinforcement from interpersonal interactions.
10. Self-harm during dysregulated states results in
endorphin release and a sense of calm, putting
these individuals at risk for repeated self-
abusive behavior.

These are just some of the factors that may be involved

in the neurobiology of BPD. Because this diagnosis has so
far been outside the purview of neurology, little brain
research has been done with BPD patients. However,
neuropsychological findings with these patients do suggest
dysfunction in the frontal and temporal lobes (Paris,
Zelkowitz, Guzder, Joseph, & Feldman, 1999; Swirsky-
Sacchetti et al., 1993). Executive and memory functions
within these brain networks do not provide adequate
organization for these patients. We have learned that these
functions are built and sculpted in the context of early
relationships; it makes sense that they are impaired in BPD
patients. The central concepts in the treatment are structure
and limit setting, combined with flexibility and patience (just
as it is with raising children). The therapist must provide an
external scaffolding within which the client can rebuild these
brain networks of memory, self-organization, and affect
regulation. On another level, the therapist serves as an
external neural circuit to aid in the integration of networks
left disconnected during development.

Neural Network Integration

The patient discovers his true self little-by-little

through experiencing his own feelings and needs,
because the analyst is able to accept and respect
them.
—Alice Miller

Unresolved trauma disrupts integrated neural processing, so

that conscious awareness is split from emotional and
physiological experiences. In fact, dissociative symptoms
immediately following a traumatic event are predictive of
the later development of PTSD (Koopman et al., 1994;
McFarlane & Yehuda, 1996). Neurochemical changes and a
lack of integration of right and left hemisphere functions
may also impede interpersonal bonding and bodily
regulation (Henry, Satz, & Saslow, 1984). Children
victimized by psychological, physical, and sexual abuse
have been shown to have a significantly greater probability
of brainwave abnormalities in the left frontal and temporal
regions (Ito et al., 1993). Brainwave dyscoherence may put
individuals at higher risk for developing all forms of
psychiatric disorders (Teicher et al., 1997).
 The biochemical changes that occur secondary to trauma
enhance primitive (subcortical) stimulus–response pairing of
conditioned responses related to sensation, emotion, and
behavior. These same changes undermine cortical systems
dedicated to the integration of learning across systems of
memory into a coherent and conscious narrative (Siegel,
1996). As we understand more about the neurobiological
processes underlying PTSD, we will better learn how to treat
and possibly prevent this debilitating yet curable mental
illness. Therapies of all kinds, especially those within the
cognitive schools, have proven successful in the
reintegration of neural processing subsequent to trauma.
Systematic desensitization, exposure, and response
prevention can all enhance these integrative processes.

Summary
The brain’s reaction to trauma provides us with a window to
the functions and effects of neural network dissociation.
From the physiological symptoms of adult PTSD to the
characterological adaptations of long-term adjustment to
early trauma, we see the brain, body, and psyche
attempting to survive in the face of overwhelming
dysregulation.
The array of adaptations to stress and trauma are at the
core of the work of the psychotherapist. The safe
emergency of psychotherapy activates dissociated neural
networks and attempts to reintegrate them in the service of
decreased arousal and improved functioning. From the first
moments of life, stress shapes our brains in ways that lead
us to remember experiences most important for survival.
We need to expand our notion of trauma from the fields
of combat and catastrophic events to the small and
everyday interactions on which we depend for our survival.
Most of our learning is not traumatic but rather subtle,
nondramatic, and unconscious. The interactions between
parent and child, the politics of the schoolyard, and
experiences of small victories and defeats all contribute to
shaping who we will become. We need to always keep in
mind that as primates, attachment equals survival and
abandonment equals death. This may help us appreciate
the power of parental abuse and abandonment to shape
children for the rest of their lives.
Chapter 15

The Self in Exile: Narcissism and Pathological

Caretaking

Happiness is having a large, loving, caring, close-knit

family in another city.
—George Burns

Each of us is born twice: first from our mother’s body over a

few hours, and then again from our parents’ psyche over a
lifetime. As we have seen, the organization of the social
brain is initially sculpted via parent–child interactions. These
interactions shape the infrastructure of our moment-to-
moment experience of other people and of the world. As the
child’s brain continues to form, self-awareness and self-
identity gradually coalesce. Consciousness and identity are
complex functions constructed from the contributions of
multiple, primarily nonconscious, neural networks.
Pathological states highlight the fact that the self is a fragile
construction of the brain. Furthermore, there is considerable
flexibility in the location, experience, and organization of the
self within our imagination.
Victims of rape and torture frequently report out-of-body
experiences during their ordeal. A young woman named
Joanne described to me, in great detail, how she stood
behind a closet door, watching herself being raped from
across the room from where it was actually happening.
Another client, Mark, who had been brutally attacked while
getting into his car after work, told me that he watched
himself from across the street as he was repeatedly
stabbed. The perception of the self is also vulnerable to
alteration and distortion. Anorectic clients, with their bones
protruding through their skin and their health in serious
jeopardy, insist they look fat. Patients with multiple
personalities are perhaps the most complex example of the
plasticity of self, because they generate many different
subpersonalities associated with different experiences and
emotional states.
Narcissism, a common form of self disturbance, is often
related to a reversal of the mirroring process during
childhood. Narcissistic children’s social brains and sense of
self are not shaped by their own emerging emotions and
sensibilities; rather, they are determined by their parents’
need for nurturance, attunement, and affect regulation.
What emerges in the narcissist is what Winnicott called the
false self, a pseudo-adult embedded in the networks of the
left hemisphere interpreter, which filters out emotional input
from the right hemisphere and the body. In this chapter, we
explore the reversal of the mirroring process, and the adult
conditions of pathological caretaking and codependency
that emerge from these early suboptimal attachment
experiences (Bachar et al., 2008).

Silent Hammers

I cannot give you the formula for success, but I can

give you the formula for failure—which is…try to
please everybody.
—Herbert Swope

Jerry, a successful screenwriter, came to therapy

complaining of depression and exhaustion. His long work
hours and last-minute deadlines kept him in a constant
state of stress. His minimal personal life centered on his
girlfriend, Cara, whom he described as “high maintenance,”
likening their relationship to having a second job. Jerry
experienced his life as a relentless struggle to please Cara,
his boss, and everyone he knew. Despite his depression,
Jerry felt guilty about coming to therapy, and expressed fear
about wasting my time; he felt that he was the helper, not
the one who received help. “After all,” he said to me, “you
could be spending your time seeing someone who really
needs the help.”
After a few sessions, it became clear to me that Jerry had
spent the first half of his 39 years taking care of his
immature and self-centered parents. All of his subsequent
relationships appeared to fall into a similar pattern.
Although he described his romantic relationships in positive
terms, he also reported feeling deprived of attention and
nurturance. He seemed to be attempting to please others in
order to gain the love and attention he had always longed
for from his parents. His efforts would invariably end in
sadness, resentment, and withdrawal. Although he was
exhausted from trying so hard and failing so completely,
Jerry still maintained the hope that his efforts would
someday pay off.
Working with Jerry was both fascinating and frustrating.
He questioned nearly everything I said, revealing his
distrust of anyone’s ability to help him. On the other hand,
his flair for the dramatic resulted in entertaining stories in
almost every session. He had an uncanny ability to intuit my
interests, and I would often lapse into being the audience
for his one-man show. I soon realized that Jerry experienced
me as another person to entertain and take care of while he
waited to receive care in return. At the same time, he
resisted my every attempt to help him.
Jerry was hesitant to discuss his childhood, saying that
he remembered little of his life before he left for college.
Our sessions consisted primarily of stories of his interactions
with unappreciative others and his attempts to enlist my
understanding and support for his side of the story. He was
both comforted by my compassion and annoyed with my
continued suggestions that he pay attention to his inner
emotional world, especially when engaged with others. The
intensity of his defenses reflected his emotional
vulnerability and I needed to be careful not to move too
quickly. On the other hand, if I went too slowly, he might
become resentful and terminate therapy, as he had ended
so many other relationships.
At some point, I suggested that he write a screenplay
about himself. Jerry agreed and soon created a story about a
little man named Hal who sat at a control panel in his head.
Hal was a sort of ship’s captain at the helm of the U.S.S.
Jerry. When Jerry was alone, Hal would monitor the people in
Jerry’s life. A wall full of TV screens kept track of where they
were, what they were doing, and whether they were
thinking of Jerry. When he would come into contact with
another ship, like his girlfriend Cara, Hal would select a
holographic image of Jerry specifically for that person. Hal
had a screen to monitor Jerry from the perspective of the
other ship, to make sure that the hologram had the desired
effect. Hal’s purpose was best described by the show
business adage: “Give the people what they want.”
I was impressed by the clarity of the story of Hal. Jerry
was telling me that his sense of self was organized around
his theory of the minds of others. Nothing about Hal focused
on Jerry’s own thoughts, feelings, or needs. Jerry only knew
he needed to understand the needs of others; for him, this
was love; this was life. I realized Hal reflected the early
sculpting of Jerry’s social brain and how he survived
childhood. The story of Hal was a reflection of implicit
memory, symbolically representing the core emotional
drama from his early life. Despite the obvious nature of this
story, Jerry refused to entertain interpretations. He seemed
to have great difficulty experiencing the world from his own
point of view. In Jerry’s conscious experience, he was Hal.
 A few sessions later, Jerry used another metaphor to
illustrate his inner world. He described himself as a house
on a movie set with a perfectly detailed facade but no
finished interior; there was no true place to live. If you
looked behind the facade there were only exposed 2×4s and
bare floors. He said, “A good director knows how to place his
cameras to maintain the illusion of a real building.” In a
moment of receptivity and trust, he told me that his goal for
therapy was to finish building and decorating the interior
space so he could stop worrying about camera angles. Jerry
was tired of feeling like a fraud in a world of real people. I
could feel his inner world shifting as his emptiness surfaced
into consciousness.
I told Jerry, “As we grow, the story of who we are is
written in collaboration with those around us, especially our
parents. They watch us, listen to us, and try to help us put
into words what we struggle to express. This helps us to
write our story. When parents didn’t get this help as
children, or are suffering with some problem, they may look
to their children to help them find themselves.”
I think this is what may have happened with Jerry’s
parents. He learned to be sensitive to them and attend to
their needs when they should have been helping him write
his story. In a sense, Jerry’s story was written by default; in
serving others he was hoping to find himself, and after all
these years he was still searching. I suggested to Jerry that
his choice of a writing career may have been an expression
of his desire to write his story. Although there are many
good and honorable aspects to serving others, I told him
that it may be more important to write a new story where
his own needs would be balanced with the needs of others.
Jerry asked, “Is this why, when people ask me how I am,
the first thing I think about is how others in my life feel?” I
nodded as I watched the muscles in his face relax. A new
understanding of a familiar behavior was emerging, and his
inner world was being reorganized. After a period of silence,
he said softly, “I even do it with you, don’t I? I pay you to
take care of me, but I end up entertaining you and
protecting you from my needs and negative feelings.” The
session was over and he walked silently out of the office. I
wondered if he would be able to withstand the stress of
these insights enough to return for our next session.
He did come back, and uncharacteristically touched my
shoulder as he passed me on the way to his seat. “You’re
gonna think you’re pretty smart when I tell you this one.” I
noticed his voice had changed: It was no longer the voice of
an entertainer. Jerry was sharing this experience from a
different place within himself. On the previous Friday, he
had gone out with Cara and they didn’t get back to her
apartment until 3:00 A.M. The combination of alcohol and
exhaustion made him fall asleep as soon as his head hit the
pillow. After what seemed like only a few minutes, he was
jarred awake by the banging of hammers outside the
bedroom window. He picked up his throbbing head and saw
on the clock that it was not even 7:00 in the morning. Jerry
said, “I felt like my head was going to explode!”
Jerry’s face became increasingly tense as he described
the murderous fantasies passing through his mind. He
imagined going outside and punching out the entire team of
construction workers. Just as he was about to jump up and
run outside, Cara looked up at him with an expression of
exhausted rage and said, “I’m going to go out there and kill
those guys.” Apparently, they had been waking her up that
way for most of the week.
Falling back on the couch in my office and letting out a
sigh, Jerry began to describe how her words triggered
something altogether familiar within him. “When I heard
Cara’s anger I became a different person. My exhaustion
vanished. I felt energized and alive! I completely forgot
about the construction workers. My total focus
instantaneously shifted to making Cara feel better.” He
described jumping up as if well-rested and said, “A little
breakfast will make you feel better.” He became oblivious to
the sound of the hammers and bounded into the kitchen as
Cara pulled the pillows back over her head.
Ten minutes later, Jerry was at the stove brewing coffee,
frying eggs, and about to call out “Breakfast is served,”
when he again noticed the hammers. He said, “I was
amazed that I hadn’t heard them since I had gotten out of
bed.” He realized that they hadn’t stopped, but from the
moment he saw the anger on Cara’s face, he became
completely involved in activities to cope with her feelings,
utterly ignoring his own. He realized that attending to Cara’s
distress catapulted him out of his own.
As he stood, spatula in hand, these feelings triggered a
long-forgotten memory. He remembered coming home from
school to find his mother crying, head down in her arms on
the kitchen table. Jerry remembered his terror as he went
over and stood beside her. She didn’t respond when he
asked her what was wrong; she just continued sobbing. He
didn’t know what to do or who to call. His father had left
them months before, and his mother had grown more silent
and withdrawn with each passing week. He stood
motionless, not knowing if she was even aware of his
presence.
He tried to engage her in conversation, telling her about
his day at school. He even told some inappropriate jokes in
the hope of getting her angry enough to chase after him.
She remained silent, crushed by the weight of her sadness.
Jerry recalled growing increasingly desperate and afraid as
time passed. He stood motionless as the afternoon light
turned to dusk. He eventually came up with the idea to cook
for her and went over to the stove to fry her some eggs, the
only thing he knew how to make. After collecting what he
needed, he pulled a chair over to the stove, stood on it, and
started to cook. This seemed to get her attention. She came
over and they cooked together in silence.
 During our first few sessions, Jerry had mentioned his
parents’ divorce, his father’s drinking, and his mother’s
depression. He characterized his home as “a vault of
silence” with very little interaction or shared activities. The
family took no meals or vacations together; most of their
energy was used up in day-to-day survival. He spoke of
these things in passing, with little emotion and an insistence
that his childhood had no connection to his adult difficulties.
He said he had coped with his family situation by burying
himself in books and writing stories. This memory provided
evidence for what I had suspected; Jerry had grown up with
too much stress and too little parenting. He had lost himself
in everyone else’s stories but had not received the
emotional support and mirroring he needed to write his own.
Jerry came away from the experience of the hammers
and the memories they triggered with a new perspective.
He could see, from this and other childhood memories that
began to emerge, how he was constantly frightened by the
emotional instability and distance of his parents. It was also
clear that he, like Hal, was constantly monitoring the
feelings and needs of others. I found it especially fascinating
how his own anger, frustration, and exhaustion disappeared
in the face of Cara’s negative feelings. He later told me that
he figured this was why he felt so uncomfortable and
vulnerable when he wasn’t in a relationship. Never having
learned how to regulate his own feelings, it was safer to stay
in the minds of others.
The power of these insights was unsettling for Jerry, and
it took him many weeks to get back on track. As he regained
his equilibrium, we began to apply this new knowledge to
more aspects of his life. Thinking back on his romantic
partners, he realized that they were never as good at
anticipating or attending to his needs as he was to theirs.
This imbalance led him to feel unloved and uncared for. At
one point, he stood up abruptly and shouted, “I blamed
them for not being as sick as I am.” Jerry came to
understand that feeling like an empty shell was connected
to not knowing his own feelings. He said, “My feelings were
never important when I was a kid. It’s my feelings that are
going to furnish those empty rooms inside of me and I have
to have my own feelings to be whole.”
These experiences were a turning point in Jerry’s
treatment. We created a common language and used it to
explore Jerry’s inner world. Hal gradually replaced some of
the old monitors with new ones designed to track Jerry’s
own feelings. Eventually, Hal and his monitors became
unnecessary. At times, Jerry feared he was being too selfish
by considering his own needs. He did lose some friends who
relied on his constant and unilateral attention. Cara and
Jerry grew closer, however, and she admitted that she liked
Jerry better when he didn’t try to make her happy all the
time. Jerry slowly recovered from his pathological caretaking
and graduated to become a caring person.
Jerry’s difficulties highlight a number of principles related
to the development and organization of the brain that we
examined in previous chapters. During childhood, Jerry’s
brain adapted to a demanding and nonnurturing emotional
environment. From early in life, his survival depended on
being highly aware of the feelings and needs of his parents.
The neural systems of his social brain became
hypersensitive to his parents’ facial expressions, body
language, and behaviors. This hypersensitivity helped Jerry
monitor his parents’ emotions and behave in ways that
regulated their feelings and bonded them to him. Systems
normally used to help children come to experience
themselves were usurped to monitor other people in his life.
This was how Hal was born. Jerry’s mirroring skills continued
to be utilized in adulthood with his friends, employers, and
therapist through emotional caretaking and entertaining
stories.
Because Jerry didn’t have help processing and
integrating his own emotions during childhood, they
remained chaotic, frightening, and overwhelming long into
his adult years. Caretaking was reinforced not only by those
he attracted, but by the avoidance of his own disorganized
emotions by attending to the feelings of others. Caretaking
evolved into a form of affect regulation, as well as a way of
connecting to others via a false self (Hal). This was
demonstrated by the instantaneous inhibition of his feelings
of anger at the construction workers when he realized Cara
was awake and upset. From early in development, hidden
layers of neural processing organized the inhibition of his
own feelings and directed his social brain to focus on the
internal state of others. This neural network organization
was in place prior to Jerry’s development of self-conscious
awareness, making this way of experiencing the world
completely unconscious and an a priori assumption in his
life.
Jerry’s evolving sense of self was shaped via these
processes, through the eyes, minds, and hearts of others.
Left-hemisphere processing networks, which inhibit affect
and participate in the creation of stories about the self,
allowed Jerry to become a functional adult with a successful
writing career. His ability to describe himself symbolically,
first as a monitoring robot and then as a director planning
camera angles, reflected his subconscious awareness of his
self-organization. Without assistance in connecting these
insights to the organization of his conscious self, they
remained correct but useless bits of information contained
within dissociated neural networks.
Interpretations—such as the one Jerry made connecting
his cooking eggs for Cara and taking care of his mother—
triggered emotions of sadness and loss. Making his defenses
conscious appeared to activate the emotional networks that
the defenses had been inhibiting. The higher association
areas involved in the organization of conscious awareness
appear capable of the plasticity required for qualitative
changes of experience. Implicit memories of early childhood
—stored within networks of the social brain—were
experienced emotionally and expressed in a variety of ways
including Jerry’s distrust of the ability of others to help him.
These were echoes of his disappointment in his parents’
inability to assist him when he was young.
Jerry’s insecure attachment resulted in a complex array
of emotional and behavioral adaptations. His lack of
conscious recall for much of his childhood was one example.
Another was his unconscious expectation that the
expression of his needs would be met by more emotional
pain. All of Jerry’s struggle to attain love and caring
reflected his brain’s adaptation to a childhood full of
impingements and the absence of an integrated and
integrating other. Jerry’s parents did not assist him in
creating a narrative identity grounded in his own
experience. In therapy, I helped Jerry apply his considerable
creative skills to write his own story.

Interpretations and Neural Plasticity

There’s a world of difference between truth and facts.

Facts can obscure the truth.
—Maya Angelou

You may remember that interpretations are sometimes

referred to as the therapist’s scalpel. In making an
interpretation, the therapist points out an unconscious
aspect of the patient’s experience, such as a defense he or
she is using to avoid negative feelings. For a client who
employs humor to avoid feelings of abandonment after a
divorce, it might entail reminding him that he is
experiencing many symptoms of depression or that his eyes
are moist. For another who is enraged at a minor slight by a
coworker, an interpretation might consist of connecting her
present feelings to emotional memories of abuse from a
previous relationship. In both of these instances, the
therapist addresses what appears to be a disconnection
among different tracks of cognitive, emotional, sensory, and
behavioral processing.
When an interpretation is accurate and delivered in an
appropriate and well-timed manner, a number of things
occur. The client generally becomes quiet; there may be a
change in facial expressions, posture, and tone of voice.
Very often the client will begin to fully experience the
emotions against which he or she was defending. There is a
shift from fluent reflexive language to speaking in a slower
and more self-reflective manner. Some clients report
becoming confused or disoriented, whereas others describe
physiological symptoms of panic or grief. Borderline clients
can demonstrate extreme reactions to interpretations,
including losing emotional control and functional
decompensation. They may become extremely emotional,
bolt from the consulting room, and engage in self-injurious
behavior. Patients like these appear unable to cope with the
emotions released when their defenses are made conscious.
What might be happening in the brain during and after
an accurate and well-timed interpretation? Each
interpretation that hits home is like the death of a small
aspect of the false self. My suspicion is that it begins with
seeing past the products of the left hemisphere interpreter,
which disinhibits the activation of subcortical circuits
containing negative memories. In the process of working
through these new feelings, the client gradually regains
emotional equilibrium, allowing for plasticity and new
learning in prefrontal regions. The concurrent availability of
negative subcortical memories and the enhanced ability of
the cortex to create new connections allows neural networks
containing various components of a particular memory to
become integrated. Like breaking and resetting a bone that
has healed badly, memories become unstable and can be
reformed in a more positive way. This process allows painful
implicit memories to be accessed by cortical networks for
contextualization in time and space, and to be regulated
and inhibited where no longer necessary.
Bringing a defense to consciousness activates both the
cortical networks that organize the defense and the
subcortical networks that contain the negative memories
and associated affect. This disinhibition results in the
emotional and physiological arousal seen in therapy as the
amygdala becomes reactivated and alerts the body to the
old danger. This may also be the mechanism for regression
through the reactivation of old sensory-motor-affective
memories stored in normally inhibited amygdaloid systems.
There is most likely a shift in hemispheric bias from left to
right, correlated with the breakthrough of negative
emotions. This left-to-right shift may account for the
cessation of reflexive social language of the left hemisphere
interpreter and a shift to greater self-awareness.
Interpretations need to undergo a process called working
through, meaning they need to be stated, restated, and
applied to multiple situations and circumstances (parallel to
relapse prevention in cognitive therapies). This process
serves to connect new learning to multiple memory
networks, and may need to reach a certain critical mass of
connections throughout the brain to become reflexive.
Working through reflects the expansion and stabilization of
new associative matrices of memory. It is also reflected in
the construction of a new narrative containing altered
aspects of behaviors, feelings, and self-identity that serve as
a way to retain and reinforce new learning.

Pathological Caretaking

By the time a man is 35, he knows that the images of

the right man, the tough man, the true man which he
received in high school do not work in life.
 —Robert Bly

Jerry’s pathological caretaking is one possible expression of

a disturbance of self referred to as narcissism. Narcissism is
characterized by a two-sided existence: one reflecting an
inflated sense of self-importance, the other mired in
emptiness and despair. The origin of this formation of the
self occurs when a child looking for love and attunement
instead discovers the mother’s own predicament (Miller,
1981). The child, robbed of the possibility of self-discovery,
compensates by caring for the parent under a real or
imagined threat of abandonment.
Bright and sensitive children attune to and regulate the
parents’ emotions and come to reflect what the parents
want from them. These children will usually appear mature
beyond their years and find comfort in their ability to
regulate the feelings of the people around them. Because of
their power to regulate the affect of one or both parents,
these children are filled with a sense of inflated self-
importance. Miller and Winnicott call pathological caretaking
a particular manifestation of the false self, described by
Jerry as both a theatrical facade and an inner robot
monitoring others.
The other side of narcissism reflects aspects of the
child’s emotional world that have found no mirroring. This
true self, or the part that is unique to the individual and
searching for expression, is left undeveloped and eventually
forgotten. This emotional core (or inner child) secretly and
silently awaits parenting in each new relationship while
dutifully taking care of the other. This aspect of the
emotional self is the emptiness, loss, and shame of being
abandoned, and how survival was contingent on taking care
of others. This is the source of depression, the sense of
being a fraud, and lack of an emotional connection with life.
The development of the social brain (and the subsequent
formation of the sense of self) becomes dedicated to the
prediction of, and attunement to, the moods and needs of
the parent and others. This ability serves to ward off
abandonment anxiety while truncating the development of
an understanding, expression, and regulation of one’s own
feelings. Such children grow into self-awareness
experiencing others’ emotions as their own, and an
overwhelming sense of responsibility, or even compulsion,
to regulate the emotions of those around them. In Jerry’s
case, cooking breakfast for the upset women in his life
helped him avoid his own poorly understood and
dysregulated emotional world.
Thus, caretaking of others serves as a substitute for self-
soothing abilities and inner emotional organization.
Pathological caretakers come to therapy primarily because
they are depressed and exhausted by their inability to
create a boundary between themselves and the needs of
others. Although being with others is hard work, being alone
is even more difficult when they are not exhausted, because
they need to regulate others to avoid their internal world.
For these people, a battering or abusive relationship is far
less frightening than solitude. Caretakers are difficult clients
because they have learned during early attachment
relationships that help is not forthcoming when they are in
distress. Like Jerry, they have come to believe that it is best
to put their inner needs out of mind and keep “giving the
people what they want.”

Alice Miller: Archaeologist of Childhood Experience

I was not out to paint beautiful pictures…. I wanted

only to help the truth burst forth.
—Alice Miller

The central importance of parental relationships in shaping

the social brain is nowhere better articulated than in a
series of elegantly simple works by the Viennese
psychotherapist Alice Miller. Her work with what she called
gifted children targeted adults, like Jerry, who were raised
by parents whose emotional needs were greater than their
ability to attune to their children. Taking a stand against her
analytic colleagues, Miller reshaped the therapeutic role into
one of being an advocate for the child within her adult
patients. Reaching back through the years to reconnect with
long-forgotten childhood experiences, she reinterpreted
much of her clients’ adult behaviors as a reflection of their
adaptational histories. In observing the nonverbal
reenactment of implicit memory, Miller formed hypotheses
concerning what her clients had been exposed to, how their
young brains had adapted, and what it would take to
unearth the abandoned true self.
Miller’s archaeological view of memory included the
awareness that memory from different developmental
stages reflects different modes of processing and
understanding. In her role as advocate, she saw therapy as
a process in which therapists help clients unearth their
history, not from the point of view of the adult but from that
of the child. Memories in these implicit subcortical networks
do not change with time, but remain in their initial form as
they were experienced at a very young age. Miller
formulated this view from clinical experience rather than a
knowledge of the multiple systems of explicit and implicit
memory.
Miller used the term double amnesia to describe the
process by which these children have had to first forget
certain parts of themselves (e.g., feelings, thoughts, and
fantasies) that could not be accepted or tolerated in their
family. The second layer of forgetting is to forget that these
feelings have been forgotten. These two layers of forgetting
ensured that such children would not slip back into wanting
what could not be had. Given our knowledge of the multiple
systems of memory and their dissociability, Miller’s double
amnesia is most likely grounded in both the disconnection
between systems of implicit and explicit memory, and
constructing a self-narrative that excludes reference to
personal needs.
The lack of assistance in the construction of a self-
narrative, combined with the heightened anxiety and
vigilance necessary for survival with narcissistic caretakers,
leads to a deficit in the consolidation of autobiographical
memory. The memories are not repressed; rather, they are
unorganized by hippocampal cortical systems that would
allow them to be accessible to conscious consideration. In
this light, Miller’s work is a reconstruction of the past, based
on available conscious memory in combination with
nonverbal expressions from implicit systems of memory.
Such patients’ present experiences are examined for
emotional truths, then traced back through a hypothesized
trajectory. The patients’ considerable empathic ability can
be utilized to their advantage by asking how they think
some other child might feel in a situation similar to their
own. This method, used a number of times, is often
successful.
For Miller, gifted children are exquisitely sensitive to the
cues of parents and have the innate ability to mold
themselves to their parents’ conscious and unconscious
messages. These are the children who often come to be
called codependent and are overrepresented in the service
professions such as doctors, nurses, social workers, and
therapists. In essence, their jobs are an attempt to parlay
their defenses into a career. Jerry—with his sensitivity,
intellect, and wit—fit well in this category.
Although the gifted children described by Miller may be
quite functional, they often feel empty and devoid of vitality.
Because their vitality and true self are not acceptable, these
are inhibited and banished from awareness. This creates a
vulnerability, not only to disturbances in personality but also
to the unconscious transmission of “mirror reversal” to the
next generation. Parents who have not been adequately
parented themselves can look to their children for the
nurturance and care they were unable to receive years
before. Miller stated, “What these mothers had once failed
to find in their own mothers they were able to find in their
children, someone at their disposal who can be used as an
echo, who can be controlled, is completely centered on
them, will never desert them, and offers full attention and
admiration” (1981, Chapter 3).
Children’s instinct to bond with their parents drives them
to do so regardless of the terms and conditions. When such
children look into their mother’s eyes and find no reflection
but, rather, “the mother’s own predicament,” they will mold
themselves (if able) to their mother’s psychic needs.
Compulsive compliance—initially adaptive in response to
narcissistic or abusive caretakers—becomes maladaptive in
relationships with others, and in the development of the self
(Crittenden & DiLalla, 1988). Later in life, the gifted child’s
lack of rebellion becomes the problem. Unable to attend to
their own emotional memories, and thus unable to construct
the story of their lives, these children constantly search for
someone who needs nurturance.
Because he or she was completely helpless in childhood
to resist the coercion of the parents’ unconscious, Miller felt
that the child within the adult patient always needs an
advocate. Our brains are designed to adapt to the
environmental contingencies presented to us. Remember
that the child’s first reality is the parents’ unconscious,
transferred via right-hemisphere-to-right-hemisphere
attunement well before self-awareness and self-identity.
Because it is implanted in early implicit memory, it is never
experienced as anything other than the self. Miller was quick
to describe the tragedy for the parents who may be well
aware of the pain from their own childhood and may have
vowed to never make their children feel as they did. The
intergenerational transmission continues because it is
reflexive and unconscious, and because each generation, at
some level, protects the image of the parents and guards
against the pain of their own unfulfilled emotional needs.
Although patients do not generally have explicit memory
for early relationships with their parents, Miller posits that
these learning experiences are implicitly recorded in how
the patients think of and treat themselves. The strictness
and negativity in the patients’ self-image and superego will
expose their parents’ negative or indifferent attitudes
toward them years before (Miller, 1983). These implicit
emotional and behavioral memories—in the form of
attitudes, anxieties, and self-statements—contribute to the
continued repression of real emotions and needs.
Because children equate punishment with guilt, abuse
and neglect create a sense of innate badness. A teacher told
Dr. Miller that after seeing a film about the Holocaust,
several children in her class said, “But the Jews must have
been guilty or they wouldn’t have been punished like that”
(Miller, 1983, Chapter 9). This assumption of guilt on the
part of children both protects the parent and serves as the
developmental core of a negative self-image. Because this
self-image is organized and stored by implicit systems of
affective memory, the child’s later-developing identity forms
around this a priori negative core. Caretaking and
compulsive perfectionism reflect the ongoing attempt to
compensate for the certainty of unworthiness and
anticipation of abandonment.

René Magritte and His Mother

We must not fear daylight just because it almost

always illuminates a miserable world.
—René Magritte
A chilling example of the reversal of the mirroring process is
demonstrated in a painting by the surrealist René Magritte,
titled The Spirit of Geometry (see Figure 15.1). It depicts a
mother holding a child but with a startling twist: Their heads
and faces have been exchanged. Magritte was the eldest of
three boys in a middle-class household in turn-of-the-
century Belgium. His mother suffered from depression
throughout his childhood, and made multiple suicide
attempts. She was, in fact, locked in her room each night for
her own protection. As a young boy, René was locked in with
her to keep her company. One cold February morning, she
managed to slip out of her room and drowned in the Sambre
river. René was obviously not successful in making his
mother’s life worth living.
Based on his adult life, it is fair to assume that René was
a bright and sensitive child, and that he suffered from a lack
of positive maternal attention for most or all of his
childhood. To lose his mother to suicide at the age of 14
served as an additional blow to his sense of safety as a
child. This painting suggests that the young Magritte looked
into his mother’s eyes and found fatigue, depression, and
emptiness. In her eyes he read, “You be the mommy, I’ll be
the baby,” and he complied.
In retrospect, a biographer suggested that Magritte
himself seemed at peace only when he was “tormented by
problems” (Gablik, 1985). Much of the body of Magritte’s
surrealist work presents us with the message that the world
is not what it appears to be. His respectable middle-class
family had a dark and painful secret at its core, one that
became a central aspect of the young boy’s experience.
Although as an adult, Magritte repeatedly stated that his
early experiences had no bearing on his artistic work, it is
difficult to imagine that the loss, betrayal, and
abandonment of his childhood did not reverberate in his
many works, warning us not to be fooled by the
assumptions on which we depend.
Summary
The separation between the true and false selves reflects
the brain’s ability to develop dissociated tracks of
experience. Early trauma and stress in nonhealing
environments can even result in the formation of multiple
separate personalities, now referred to as dissociative
identity disorder (DID). It is logical to assume that these
different experiential states are encoded within different
patterns of neural network activation. The existence of
pathological caretaking, DID, and other disorders of the self
demonstrate its fragility and its inclination to adapt to
whatever social realities are presented to it.
The purpose of both the brain and the self is survival. For
each of us, the organization of our own self—including our
personality, defenses, coping styles, and the like—reflects
the conditions to which we have had to adapt. Put another
way, all aspects of the self are forms of implicit memory
stored in neural networks that organize emotion, sensation,
and behavior. These networks are sculpted in reaction to
real or imagined threats as the brain strives to predict and
control its physical and social environments.
Part VI.

The Reorganization of Experience

Chapter 16

The Evolutionary Necessity of Psychotherapy

The useless, the odd, the peculiar, the incongruous—

are the signs of history.
—S. J. Gould

The human brain is an amazing organ, capable of continual

growth and lifelong adaptation to an ever-changing array of
challenges. Our understanding of how the brain
accomplishes this mandate increases with each new
theoretical development and technological advance. At the
same time, we are uncovering some of natural selection’s
more problematic choices. If necessity is the mother of
invention, then evolution itself has created the necessity for
psychotherapy by shaping a brain that is vulnerable to a
wide array of difficulties.
Over the last century, psychotherapists have
demonstrated that many of the brain’s shortcomings can be
counterbalanced by the application of skillfully applied
techniques in the context of a caring relationship. Thus, in
our ability to link, attune, and regulate each other’s brains,
evolution has also provided us a way to heal one another.
Because we know that relationships are capable of building
and rebuilding neural structures, psychotherapy can now be
understood as a neurobiological intervention, with a deep
cultural history. In psychotherapy, we are tapping the same
principles and processes available in every relationship to
connect to and heal another brain.
 In this chapter we focus on the following eight
problematic aspects of brain functioning that cause many
people to come to psychotherapy:

1. The suppression of language and predictive

capacity under stress
2. Divergent hemispheric processing
3. The bias toward early learning
4. The tenacity of fear
5. The damaging effects of stress hormones
6. The speed and amount of unconscious
processing
7. The primacy of projection
8. Unconscious self-deception

This will serve as somewhat of a review in that it draws

on many of the neuroscientific findings previously
discussed. We will then apply some of these principles to a
case of PTSD.

The Suppression of Language and Predictive Capacity

Under Stress

When a man’s knowledge is not in order, the more of

it he has the greater will be his confusion.
—Herbert Spencer

When animals hear a strange and potentially threatening

sound, they freeze in their tracks, become silent, and scan
the environment for danger. The logic behind this primitive
reflex is quite clear—being still and silent make us less likely
to be seen or heard as we prepare to respond to a potential
threat. Research suggests that during these states of high
arousal, Broca’s area, responsible for speech production,
becomes inhibited.
 While this response may be a positive adaptation in
animals without language, it is a high price for humans to
pay for being frightened. Putting feelings into words and
constructing narratives about our experiences are integral
to emotional regulation, the interweaving of neural networks
of emotion and cognition, and the experience of a coherent
sense of self. Perhaps most important, a lack of language
can separate us from the healing effects of positive
connections with others. The loss of the ability to construct
narratives is especially problematic in situations where
individuals are forced into silence by their abusers, or after
enduring the “unspeakable horrors” of torture, war, or the
death of friends and family.
Losing the ability to verbalize feelings also interferes with
building descending inhibitory cortical networks down to the
amygdala. You may have had a traumatic experience like an
auto accident or robbery where you felt compelled to tell
the story over and over again in the following days and
weeks. In time, the pressure to tell others diminishes as the
emotions connected to the traumatic events slowly
dissipate. I suspect that telling the story builds circuitry,
which contributes to amygdala inhibition and the dissipation
of fear.
Just as putting words together to form sentences requires
sequencing and predicting what comes next, so does
moment-to-moment sensorimotor functioning. So, besides
its role in language, Broca’s area also contributes to
networks of prediction and anticipation. Thus, along with
loss of language, traumatized individuals may also
experience difficulties in the day-to-day navigation of life
that the rest of us handle unconsciously and automatically.
This inhibition of Broca’s area is exacerbated by the
amygdala’s ability to inhibit prefrontal functioning during
high states of arousal. This may be one of the reasons that
traumatized individuals seem to experience more than their
share of accidents, bad relationships, and misfortune. The
combined loss of words and decreased predictive abilities
enhance the long-term impact of the trauma by increasing
the probability of ongoing stress and revictimization.
The “talking cure” stimulates language networks and
encourages the creation of adaptive narratives about
traumatic experience. The therapist’s caring presence,
availability, and skill promote a moderate state of arousal,
which supports the neuroplastic processes necessary for
building descending inhibitory fibers to limbic and brain
stem centers. Putting feelings into words minimizes the
active inhibition of Broca’s area and supports the balance of
right and left hemisphere processing. In therapy, we
stimulate Broca’s area, disinhibit language, restore
predictive abilities, and support neuroplastic processes of
adaptive learning.

Divergent Hemispheric Processing

The mind is the last to know.

—Michael Gazzaniga

Over the course of primate and human evolution, the left

and right cerebral cortices have become specialized to
serve the formation of the conscious, linguistic self in the
left and the somatic, emotional self in the right. It is likely
that as the hemispheres differentiated, it became
increasingly necessary for one to take executive control of
conscious processing. There is considerable evidence that
the left hemisphere took on this function, along with a lead
role in maintaining moderate states of arousal and social
connectedness. The right hemisphere constantly provides
information to the left, but while we are awake, the left
hemisphere may or may not allow this input into
consciousness.
 The disruption of a proper integration and balance
between left and right hemisphere input can result in
dominance of one hemisphere or the other. As we have
seen, the overinhibition of the right hemisphere by the left
can result in alexithymia, while an underinhibition can result
in overemotionality, magical thinking, or auditory
hallucinations. The proper integration and balance of the left
and right prefrontal cortices are also necessary for the
regulation of mood. When people are traumatized, there is
an increased likelihood that the coordination between left
and right functioning will be disrupted. The PTSD symptoms
of intrusions are likely the clearest example of deficits of
right hemisphere infiltration of the left.
When trauma occurs in early development, the
hemispheres grow to be less coordinated and integrated,
resulting in problems in affective regulation and positive
social awareness. People with histories of childhood abuse
and neglect have been shown to have a smaller corpus
callosum and are more likely to suffer from symptoms of
PTSD (De Bellis et al., 1999; Teicher et al., 2004). Their
brains have fewer connecting fibers available to integrate
right and left processes, and their development is
characterized by a decreased lateral integration. As we have
also seen, the left and right prefrontal cortices are biased
toward positive and negative emotions, and a disturbance of
the homeostatic balance of the two can result in extremes
of depression and mania.
Therapists intuitively and intentionally seek to balance
the expression of affect and cognition. We encourage
overintellectualized and defended clients to be aware of and
explore their feelings. On the other hand, we provide clients
who are overwhelmed by anxiety, fear, or depression with
tools to use the cognitive capabilities of their left
hemispheres to counterbalance these emotions. The
common imbalance between affect and cognition in many of
our clients rests, in part, in the struggle between the
hemispheres to integrate and learn a common language.
The narratives we create in therapy strive to be inclusive of
the conscious and unconscious realities of both
hemispheres.

The Bias Toward Early Learning

In the practical use of our intellect, forgetting is as

important as remembering.
—William James

At birth, the more primitive structures of our brains

responsible for social and emotional processing are highly
developed, while the cortex develops slowly through the
first decades of life. Much of our most important emotional
and interpersonal learning occurs during our first few years
when our primitive brains are in control. We mature into
self-awareness having been programmed by early
experience with sensory and emotional assumptions that we
accept as truth. As a result, a great deal of extremely
important learning takes place before we are consciously
aware we are learning (Casey, Galvan, & Hare, 2005). For
most of us, the early interactions that shape our brains
remain forever inaccessible to conscious memory, reflection,
or modification. This artifact of evolution, expressed in the
sequential nature of our neural development, turns the
accidents of birth and the ups and downs of everyday life
into the beliefs and causes for which we suffer and die.
Early experiences shape structures in ways that have a
lifelong impact on three of our most vital areas of learning:
attachment, emotional regulation, and self-esteem. These
three spheres of learning establish our abilities to connect
with others, cope with stress, and feel we are loveable and
have value. Given how little control we have over our early
experience, and that anyone can have children regardless of
their competence or sanity, an incredible amount of human
brain building is left to chance. In addition, we have seen
that early experience shapes genetic expression, which
impacts our ability to learn, regulate our emotions, and
nurture our future children.
It is obvious that our dependency on early caretakers can
influence us in perfectly terrible ways. We see this in abused
and neglected children who often enter adolescence and
adulthood with a variety of symptoms. Explosive anger,
eating disorders, drug and alcohol problems, and other
forms of acting out are common. They also have identity
disturbances and a poor self-image, exacerbated by angry
feelings and antisocial behaviors. Like a veteran with PTSD,
the brains of these children become shaped to survive the
combat of their day-to-day lives, but are ill-equipped to
navigate peace.
In psychotherapy, we have tools that allow us to explore
early experiences with the possibility of coming to
understand our symptoms as forms of sensory, motor, and
emotional memory. Projection, transference, self-esteem,
and internal self-talk are all expressions of early implicit
memories from which we can get a view of early
unremembered interactions. Making the unconscious
conscious is, in part, coming to an awareness and
understanding of the impact of early experience. Once they
can be consciously thought about and placed into a
coherent narrative, we gain the ability to reintegrate
dissociated neural networks of affect, cognition, abstract
thinking, and bodily awareness. This process opens the door
to decreasing shame and increasing self-compassion while
creating the possibility for healing.

The Tenacity of Fear

 It is the perpetual dread of fear, the fear of fear, that
shapes the face of a brave man.
—Georges Bernanos

At birth, the amygdala, the executive center of our brain, is

fully developed. Its first job is to figure out who is safe and
who is dangerous. Although the amygdala begrudgingly
comes to share executive control with the prefrontal cortex,
it remains capable of hijacking the brain in states of distress
and fear. The amygdala’s job is to remember any and all
threats and to generalize these experiences to other signs
of danger. In other words, the amygdala never forgets. Its
tendency to generalize is why a panic attack outside the
home can lead to agoraphobia or why getting scratched by
a cat can soon morph into a fear of all furry animals.
Evolution has shaped our brains to err on the side of caution
and be afraid whenever it might be remotely useful. In
contrast, the hippocampus is constantly remodeled in
response to new information and can easily differentiate one
furry animal from another.
Fear makes our thinking and behavior more rigid. We
become afraid of taking risks and learning new things, which
results in a tendency for those who are sick to remain sick.
One recognized symptom of trauma is “neophobia” or the
fear of anything new. Once our brains have been shaped by
fear to perceive, think, and act in stereotyped ways, we
tend to remain in rigid patterns that are reinforced by our
very survival. Our internal logic is self-perpetuating, making
it difficult for us to find answers that are different from the
ones we already know. Our chance of learning then rests in
getting input from other people. However, relationships with
others are also difficult because fear may make us keep
them at arm’s length. When people are hurt or afraid, caring
relationships are not easily entered into nor easy to benefit
from. Openness and trust are fragile creatures, even with
the people we love most.
 The training of the therapist and the therapeutic context
are designed to enhance support and trust, and provide
consistent emotional availability. Within the consulting
room, therapists attempt to be amygdala whisperers and
work to reactivate networks of new learning in the
hippocampus and prefrontal cortex. Warmth, empathic
caring, and positive regard can create a state of mind that
enhances neuroplastic processes and increases the
likelihood of positive change. It now appears that therapists
help people get over their fears, not by erasing traumatic
memories but by building new connections to inhibit these
memories from triggering autonomic arousal.

The Damaging Effects of Stress Hormones

Man is an over-complicated organism. If he is doomed

to extinction he will die out for want of simplicity.
—Ezra Pound

For our more primitive cousins with smaller cortices and

simpler environments, danger is encountered and quickly
resolved. They either escape or get eaten, win or lose. But
when you add a huge cortex capable of building freeways
and information superhighways, the brain has to adapt to a
world of constant challenge where there is never any clear
resolution. A large cortex also adds a memory for the future
and endless possibilities for anticipatory anxiety. Beyond
this we now have a vast imagination capable of creating
frightening fantasies that our primitive brains are unable to
distinguish from reality.
Stressful situations trigger the release of the stress
hormone cortisol. Stress hormones are catabolic, which
means they break down complex compounds for immediate
energy. Cortisol’s motto is “live for today, for tomorrow we
may die.” As one of the glucocorticoids, its job is to break
down complex carbohydrates into usable energy for our
muscles. Another action of cortisol is to cut down on energy
dedicated to protein synthesis. Because neural growth and
our immune system depend on protein synthesis, prolonged
high levels of stress hormones impair our ability both to
learn and to remain healthy. The conservation of our
primitive stress system, well adapted for a simple life and a
small cortex, can leave our modern human brains bathed in
high levels of stress hormones for long periods of time. This
leads to compromises of brain maintenance, learning, and
immunological functioning. Because chronic stress inhibits
learning, successful psychotherapy depends on our ability to
downregulate stress in our clients. From specific stress
reduction techniques to the soothing effects of a supportive
relationship, stress modulation and success in
psychotherapy go hand in hand. Thus, stress reduction skills
should not be limited only to specific diagnoses, because
they are always necessary for psychotherapy to be
successful.

The Speed and Amount of Unconscious Processing

Man is ready to die for an idea provided that idea is

not quite clear to him.
—Paul Eldridge

In order to survive, animals have to be tough or fast. The

tortoise and the hare are good examples of these different,
but equally viable survival strategies. While our elaborate
cortices separate our brains from theirs, further down, all
three are pretty similar. Our expanded cortex does allow us
vast response flexibility over our more primitive cousins. Of
course, thinking through options takes time and in some
circumstances, a speedy reflex is far more adaptive.
Because of this, we have retained many primitive reflexes
and subcortical executive control of certain functions in the
service of survival. Our harelike brains allow us to make
rapid decisions and have knee-jerk responses.
While it takes approximately 500–600 milliseconds for an
experience to register in conscious awareness, the
amygdala can react to a potential threat in less than 50
milliseconds. This means that by the time we have become
consciously aware of an experience, it has already been
processed many times in our more primitive neural
networks, activating memories and triggering implicit
memories organized by past learning. This unconscious
backdrop shapes the perception of what is being consciously
attended to and constructs our experiences of the present
moment. (Nomura et al., 2003; Wiens, 2006). When we
finally become aware of the outcome of this process, we
experience it as if we are living in the present, and act with
free will based on conscious deliberation. There is extensive
evidence that this is not really the case. We actually live
about 500 milliseconds after the moment and our past
learning severely limits our free will. The illusions of free will
and control have obvious survival advantages, foremost of
which is the ability to be assertive and confident in complex
situations. The downside of this strategy is when we
become so sure of our personal beliefs that we are unable to
consider alternatives.
Ninety percent of the input to the cerebral cortex comes
from internal neural processing. This makes sense for rapid
appraisal and reflexive action based on past learning but
also results in cognitive distortions that can keep us
frightened, withdrawn, and confused. Think of the veteran
years after combat, who ducks when he hears a car backfire
or runs for cover as a news helicopter flies overhead. A
person who experienced early abandonment may, as an
adult, be perfectly capable of starting new relationships. At
a certain point, however, intimacy may trigger implicit
memories of insecure or disorganized attachment, leading
him to become frightened and flee from a potentially
healthy relationship (Koukkou & Lehmann, 2006). The
impulse to run, driven by implicit memories embedded in
primitive brain circuitry, can be overpowering and
inescapable. The true reasons for this behavior are so
accurately described by Christopher Bollas (1987) as the
“unthought known.”
Openness to questioning one’s assumptions, especially
when they are self-defeating and incorrect, is a key
predictor of positive outcome in psychotherapy. Once clients
begin to understand that what they assumed to be reality is
actually a personal fabrication, they either flee or become
fascinated. We attempt to get them to question their
thoughts, beliefs, and assumptions and to “act in,” that is,
to come to sessions and talk about their impulses with the
hope of integrating inhibitory cortical input with primitive
memories, emotions, and urges. Attachment schemas,
transference, and self-esteem are all examples of implicit
memories that shape and distort conscious awareness.
These very patterns of unconscious processing led Freud to
develop psychoanalysis and to create a therapeutic context
that supported an exploration of the unconscious.
Psychotherapy encourages being skeptical of the perceived
realities of our brains. Given how our brains work, this is a
sound strategy, one we share with research scientists and
Buddhist monks.

The Primacy of Projection

It is easy to spot an informed man—his opinions are

just like your own.
—Miguel De Unamuno

Human brains possess complex social networks which

become activated as we observe and interact with those
around us (Cozolino, 2006). Hours after birth, we begin to
focus on and imitate the facial expressions of our
caretakers. Mirror neurons begin to link observations and
actions, allowing us to (a) learn from others by watching
them, (b) anticipate and predict actions, and (c) activate
emotional states supportive of emotional resonance and
empathy. We also possess neural circuits that automatically
analyze the actions and gestures of others, generating a
theory of their mind—what they know, what their
motivations may be, and what they might do next. As with
mirror neurons, having an automatic theory of what is on
the mind of another allows us to predict behavior to ensure
our own individual safety while supporting group cohesion
and the spread of culture.
The existence of these sophisticated social neural
systems reflects the millions of years of natural selection
that have been refining our brain’s ability to read the
emotions, thoughts, and intentions of others. All of this
attention to others clearly shows us the importance of social
information processing to our very survival. As a result, we
are quick to think we know others because mind reading is
instantaneous and obligatory. In biblical terms, it is a
reflexive habit of the social brain to attend to the mote in
our brother’s eye and not to the beam in our own.
Unfortunately, evolution has not seen fit to invest much
neural circuitry into self-awareness. Projection is automatic
and lessens anxiety while self-awareness requires effort and
generates anxiety—which do you think is going to be the
norm?
Given that we use our internal expressions as implicit
models for how we understand others, it could be that what
Freud called the defense mechanism of projection is actually
a simple byproduct of how our brains interweave our
automatic theories of others’ minds with understandings of
ourselves. This may be why we often discover our own
truths in what we think and feel about others. And since our
individual identities emerge from dyads, perhaps the
separation of self and other is always a dicey distinction,
one that many cultures do not even bother with. This may
also be why self-analysis is generally not successful because
the logic of self-inquiry is so interwoven with our implicit
assumptions. The most naive observer can see many things
about us that we cannot see in ourselves. In close
relationships, we provide each other with another set of
eyes outside of our bodies that can reflect our lives to us in
ways that are impossible to perceive on our own.
In therapy, we teach our clients to ask themselves if the
pot is calling the kettle black: that is, are their thoughts and
feelings about others autobiographical? While in couples
therapy, we encourage our clients to stop mind reading and
learn to actually ask their partners what is on their minds.
We engage in a parallel process whenever we explore how
much of our reaction to a client is countertransferential. In
our training as therapists, we learn to question our
judgment and assumptions in light of our own personal
histories. We also learn to use mirror neurons and theory of
mind to enhance our attunement with our clients and
explore their inner worlds. Taking back our projections and
working with transference and countertransference in
therapy allows us to use our thoughts about others as
potential sources of personal information.

Unconscious Self-Deception

Men use thoughts to justify their wrongdoings, and

speech only to conceal their thoughts.
—Voltaire

Based both on neural architecture and everyday experience,

self-insight does not appear to have exerted a strong
pressure on natural selection. In fact, it may have been
selected against because real self-knowledge creates the
risk of doubt, hesitation, and demoralization. Defenses that
distort our reality can help us by decreasing anxiety, shame,
and depression. At the same time they can enhance social
coherence by putting a positive spin on the behavior of
those closest to us. This is most clearly seen in a mother’s
love. A wise judge once said that everyone he sends to
prison has “a mother with an innocent child.” Self-deception
not only decreases anxiety, it also increases the likelihood of
successfully deceiving others. If we believe our own
confabulations, we are less likely to give away our real
thoughts and intentions via nonverbal signs and behaviors.
Reaction formation, or behaviors and feelings that are
opposite of our true desires, is also quite effective. Freud’s
defense mechanisms and the attributional biases of social
psychology document an array of these distortions.
Secure attachment and ego strength are correlated with
our ability to hear feedback, accept our own limitations, and
use less reality-distorting defenses—humor instead of
repression and sublimation instead of denial. In
psychodynamic psychotherapy, we provide our clients not
only with interpretations, clarifications, and reflections but
also with an alternative perspective (our own) that they can
utilize to help discover themselves. Both client and therapist
need to engage in reality testing, although the definition of
reality can be slippery. This is why our own personal therapy
is so important to our clients. In today’s large social groups,
self-awareness has become increasingly important for
survival of the species, perhaps as important as self-
deception is to the survival of the individual. Distorting
reality to reduce one’s anxiety may allow the rich to get
richer and the righteous to feel justified, but in the long
term there are consequences to the environment and social
systems that have negative impacts on us all.
These ways in which the brain and mind have evolved
have created a wide variety of threats to our emotional and
physical well-being. I suspect that you have recognized
many of your clients’ problems in these discussions, and
perhaps some of your own. These legacies of evolution
make both clients and therapists vulnerable to dissociation
and distress and lead us to a common search for solutions.
Let’s take a look at a case study where we can examine how
these vulnerabilities can play out in life and in therapy.

Patrick

Man is born broken. He lives by mending.

—Eugene O’Neill

Patrick, a man in his mid-30s, came to therapy with the

complaint that his life was “unraveling.” Talkative and
obviously bright, Patrick was the kind of person who could
quickly launch into animated conversation. I felt
immediately drawn into his stories and found our sessions
interesting and enjoyable. I soon learned that he had grown
up on the Connecticut coast, that his father was a fisherman
with a “drinking problem,” and that both his parents had
died a few years earlier. A recent physical altercation during
a relationship breakup triggered him to take stock of his life.
“That’s just not me,” he said. “Something’s very wrong.”
Over our first few sessions, two things stood out to me; he
lived under a great deal of emotional pressure and alcohol
was a pervasive presence in his current life.
Patrick’s initial interest was to understand what had
happened in his last relationship and during the breakup.
Although he had the sense that some broader issues lay
beneath the surface, he was unable to articulate what they
might be. “That’s your job,” he told me with a smile. It was
clear from our discussions that alcohol had been a part of
Patrick’s life from the beginning. His father’s alcoholism had
many negative effects on him and everyone in his family.
Both Patrick and his ex-girlfriend drank heavily and alcohol
was always present during their disputes. It became very
clear that both Patrick and his father used alcohol to cope
with anxiety, sadness, and loss.
What turned out to be my first important intervention
was a matter-of-fact question about whether he felt he had
a drinking problem. Given his father’s addiction and all he
had told me about his lifelong relationship with drinking, I
expected to hear a “Duh!” and some sympathy for being so
slow witted. Instead, Patrick was surprised and taken aback
by my question. It seemed that he had never given any
serious thought to being an alcoholic himself. At first, I was
surprised by his surprise, and impressed by his brain’s
ability to compartmentalize different aspects of awareness.
The power and persuasiveness of his early learning to
normalize alcohol and deny emotions created a dissociation
enabling him to be unaware of the proverbial elephant in
the room.
Instead of being defensive, he began discussing his
relationship with alcohol like an investigator looking for
clues to a crime. He spontaneously shared that many
difficulties in his relationships seemed to occur while
drinking. Patrick could see that he used alcohol to deaden
his emotions and that it caused him difficulties in school, at
work, and in all of his relationships. As he listened to the
unfolding of his own narrative, he gradually became aware
of the fact that he shared his father’s addiction. By the
expressions on his face, it was clear that he was learning
about himself by listening to his story—a story he had lived
but never thought about. The role of alcohol in his father’s
life was clear but it never occurred to him to apply these
insights to himself. Patrick was in the process of using
language to integrate networks of emotion and thought, and
reevaluating past experiences from a perspective of
expanded self-awareness.
 Once the reality of his own alcoholism was firmly
established in conscious thought, he asked me what I
thought he should do. Again expecting a “Duh!” I said,
“Well, you could stop drinking, join Alcoholics Anonymous,
and try working the steps.” And again, Patrick reacted as if
this were a novel idea that he might try out. Based on past
experience, my expectation was that we would be working
through his resistance for quite a while before he would give
AA a try. But, true to his word, he stopped drinking, got
involved in AA, found a sponsor, and worked the steps.
(Note to beginning therapists—this sort of thing almost
never happens.) The openness, enthusiasm, and rapidity
with which Patrick gained awareness, explored, and tackled
the issue made me wonder what his life would have been
like with even a modicum of insightful parental guidance.
His obvious intelligence and drive could have been applied
to all kinds of challenges had he only been taught a
language for his feelings, learned to be self-aware, or
applied his problem-solving skills to his own life. His early
chronic stress, combined with the family silence and shame,
led him to inhibit language and conscious awareness.
Like many children of alcoholics, Patrick was great at
giving advice to others while remaining a complete mystery
to himself. His father’s drinking, financial difficulties in the
family, and problems with his siblings always took
precedence over his personal needs. There was almost no
time spent during his childhood on helping him learn how to
cope with negative emotions—a learned and not innate
ability. Like so many, he grew up alone, surrounded by
friends and family, with only the ability to act out his inner
emotional turmoil. His chaotic inner emotional world as well
as his coping strategies and defensive styles were set early
in life and held on into adulthood. The fear of both his
internal chaos and of confronting it kept him drinking and
running for decades.
 Once sober, the emotions and defenses behind his
addiction began to emerge. With the help of AA he learned
about the typical struggles and pitfalls of alcoholism. These
meetings eventually led him to explore the principles of
Adult Children of Alcoholics (ACA), which proved to be of
even more importance to him than the impact of his own
drinking. Over the following months, his impulsivity and
impatience, pathological caretaking of others, and inability
to navigate negative emotions became the focus of therapy.
Situation by situation, we deconstructed his assumptions
and searched for new ways of thinking, feeling, and
behaving. In essence, we were doing the work that should
occur in childhood during countless interactions with
parents. The tenacity of fear is impressive, causing many of
us to spend a lifetime avoiding the pain and confusion of
childhood.
During our sessions, Patrick mentioned his work in the
New York financial district during 2001. For some reason, I
had never thought to ask him how the terrorist attacks of
9/11 impacted him and, similarly, he never brought it up.
When I asked if and how he was affected, he offhandedly
mentioned that he lost many friends but didn’t think he had
suffered any ill effects. His tone of voice sounded hauntingly
similar to when he described his early family life so I asked
him to tell me about his experience and in response he told
me the following story:

I was living in New Jersey at the time and commuted

to Wall Street via ferry across the Hudson. I overslept
that morning, so instead of being at work at 8:30, I
was still crossing the river at 9. Halfway across, some
of us noticed smoke rising from downtown. People
began gathering at the front of the ship to see what
looked like a fire near the Trade Center. Minutes later,
a southbound plane tracking the Hudson passed low
overhead. We all watched as it passed over the Statue
of Liberty, banked hard left, and headed back toward
Manhattan.
As the second plane hit we were close enough to
the docks to see people running through the park. The
concussion shock from the explosion made everyone
move forward and back in a surreal way, like blades of
grass in the wind. When the plane hit the second
tower, we knew we were under attack. I was enraged
and anxious to reach the dock to see what I could do
to help. I remembered my father talking about Pearl
Harbor and how he and his friends stood in line at the
recruiting office the next morning.
As we approached the dock, the crowds rushed
forward to escape the carnage and chaos behind
them. But just before we reached the dock, the ferry
slowed and reversed direction to avoid being
swamped by the massive crowd. As we headed back
to New Jersey, I began thinking about the people I
knew who worked in the Trade Center and imagined
what it would be like to be in those buildings as they
burned. I remember feeling numb as I stared at the
huge plume of smoke rising above the city. When we
got back to Jersey we all stood in the terminal
watching the television as the buildings collapsed,
first one and then the other. Some of the women cried
and even some men; we stood there in shock, leaning
against one another for support.
The phones were down and there was nothing I
could do but imagine where my friends were and if
they had survived. Once I arrived back home, I
couldn’t take my eyes off the television. From time to
time I would see someone I knew, dazed and covered
with dust, staggering past the camera. I eventually
noticed that it had grown dark and I was hungry. I was
able to connect with my girlfriend later that night, and
the next day we drove south in a sort of waking coma.
 Eventually we found a hotel room and got drunk for a
few days.

Both Patrick’s reaction to the impact of 9/11 and his own

alcoholism were processed in a disassociated manner. This
defense paralleled how he dealt with his experiences and
feelings from childhood. Early in life he learned to stay away
from his emotions through denial, hypomanic activity, and
combative sports. Drinking, working, and socializing had all
become compulsive ways of avoiding or inhibiting his
feelings. His intellect allowed him to succeed in the
workplace and rationalize his unhealthy behaviors. But upon
awakening each day, he discovered the same sad,
frightening, and lonely world.
The many negative effects of having an alcoholic parent
are well known. The fear and uncertainty created by the
alternating presence and absence of the alcoholic combined
with an increased probability of extreme emotional reactions
can have a devastating impact on all aspects of
development. These children often learn not to be needy as
they develop a false self to take care of the parent and
maintain the artifice of a happy home. Unfortunately, they
never receive the help they need to articulate their
experiences and develop a comforting inner world. Their
early terror persists in networks of implicit memory but they
lack mechanisms for expression or social connection that
could heal them. Thus, they recreate the chaos from which
they are so desperately trying to escape by acting out their
emotions while establishing relationships with abusive or
empty others.
At first it was difficult for Patrick to focus on his own
feelings and personal issues. His initial attention kept
returning to the problems, shortcomings, and limitations of
his girlfriend. It was only after he became less agitated and
more self-reflective that he could see that he and his
girlfriend shared many of the same problems. Like most of
us, he found it easier to focus on her problems rather than
his own. His gradual improvement required that he reorient
his focus onto his own behaviors and feelings. Next Patrick
had to develop a language with which to describe and share
his inner world. And finally, over and over again, he had to
experience his life from the inside out, and learn to connect
with others as another human being rather than a caretaker
or raging alcoholic.

Summary
The sophistication of the human brain reflects millions of
years of evolutionary adaptation where old structures were
conserved and modified while new structures emerged and
expanded. Countless interactive networks and design
compromises created fertile ground for the disruption of
smooth integration of neural systems. The very complexity
of the development and functioning of the brain is also what
makes it such a fragile structure. Assuming that the trillions
of components arrive in their proper places and work
according to their genetic templates, there are a host of
other challenges to integrated psychological functioning.
The discontinuity of conscious and unconscious processes,
multiple memory systems, differences between the
hemispheres, hidden processing layers, and multiple
executive structures are all potential sources of dissociation
and dysregulation. Disruption in the coordination and
homeostatic balance of these neural systems is the
neurobiological substrate of psychological distress and
mental illness.
Evolution is driven by the physical survival of the species
and thus, much of the brain’s functioning is centered around
automatic fight-or-flight mechanisms as opposed to
conscious and compassionate decision making. Because of
this, the conscious and unconscious management of fear
and anxiety is a core component of our personalities,
attachment relationships, and identities. The considerable
degree of postnatal brain development and the
disproportionate emphasis on early childhood experiences
in the sculpting of the brain add to our vulnerability to
psychological distress.
Psychotherapists are trained to use their social brains as
a tool to connect to and modify the brains of their clients.
Through interpersonal neurobiological processes, therapists
serve as an external regulatory circuit to help reestablish
the optimal flow of energy and information. This is done for
the circuits within and among the cerebral hemispheres, and
through all levels of the neuraxis from the primitive lower
regions to the most recently evolved components of the
neocortex. It is through this increased integration that more
optimal mental processing is established and symptoms are
replaced with functional behavior.
Chapter 17

Teaching Old Dogs New Tricks: Stimulating

Neural Plasticity

It is not the strongest of the species that survive, not

the most intelligent, but the one most responsive to
change.
—Charles Darwin

Psychotherapy has survived for more than 100 years in the

absence of an accepted brain-based model of change. The
old view of the brain as a predetermined and static entity
necessitated that the development of psychotherapy be
independent from the biological sciences of even 20 years
ago. Fortunately, current neuroscientific findings do not
support neurological fatalism but find a brain capable of
constantly adapting to new challenges. In fact, therapists
have learned to utilize attachment, emotional attunement,
and narratives as tools to modify the brain.
Therapists often lament the fact that parents don’t do a
better job during their children’s early development, when
relationships have such a powerful impact on their brains.
But if we approach the brain from the perspective of
ongoing plasticity, what are we capable of in our consulting
rooms? How plastic is the brain? Can plasticity be enhanced,
and how much of an effect can the therapeutic relationship
have on the brain? These questions are central to
psychotherapy, because we rely on the brain’s ability to
change well after traditional sensitive periods have passed.
 Research on imprinting of parental figures in geese
(Lorenz, 1991) and the importance of periods of visual
exposure in the development of the occipital lobes in cats
(Hubel & Wiesel, 1962) have been standard fare in
undergraduate education and popular science for half a
century. Unfortunately, these studies have created the
impression that the timing of brain growth is entirely
predetermined by template genetics (DNA) and that early
experiences become indelibly etched into our neural
architecture (Rutter & Rutter, 1993). Extracting the concepts
of imprinting and critical periods from ethology and applying
them to human development turns out to be quite
misleading (Michel & Moore, 1995). We now know that
genetic expression is controlled by experiences throughout
life, and that changes in the environment, both good and
bad, continue to have positive and negative effects on us.
Also, our brains are more complex and expanded in regions
that maintain more neuroplastic properties. Thus, learning
in humans is far more complex and flexible than the original
conceptions of imprinting and critical periods led scientists
to believe (Hensch, 2004).
Recall that sensitive periods are times of exuberant
growth in neural networks, corresponding with the rapid
development of the skills and abilities to which they are
dedicated (Chugani, 1998; Fischer, 1987). Although there is
no doubt that these periods exist, what is in question is the
indelibility of learning during these times, as well as the
possibilities of modifying when they occur during
development. As neuroscience finds more examples of
neurogenesis and neuroplasticity, and epigenetic
programming taking place in mature brains, there is an
increasing recognition that we retain different kinds of
neural plasticity throughout life (
Bornstein, 1989).
The research on neural plasticity has historically focused
on the brain’s ability to adapt after early brain injury
(Goldman, 1971; Goldman & Galkin, 1978; Henry et al.,
1984). Today, plasticity is understood to be a basic principle
of healthy brains at any age. Rather than lacking plasticity,
the adult brain is now seen as having an increased tendency
toward neural stabilization while retaining the ability for new
learning. There also appears to be a shift in how information
is processed in a manner more appropriate to different
stages of life, which is another aspect of its plastic
reorganization (Cozolino, 2008; Stiles, 2000). This vital shift
in perspective has led to a rapid expansion of interest in and
exploration of the neurobiological mechanisms of lifetime
learning and change (Rosenzweig, 2001).

Use-Dependent Plasticity

Education is not a preparation for life; education is life

itself.
—John Dewey

You will remember that changes in synaptic strength in

response to an inner or outer stimulus are believed to be
the basis for learning. The process of long-term potentiation
(LTP) prolongs excitation of cell assemblies that are
synchronized and interconnected in their firing patterns
(Hebb, 1949). This is only a small piece of a vastly complex
set of mechanisms and interactions shaping the connection,
timing, and organization of the firing between the billions of
individual neurons woven into neural networks.
Plasticity reflects the ability of neurons to change the
way they relate to one another as they adapt to changing
environmental demands (Buonomano & Merzenich, 1998).
This can occur in the modulation of signal transmission
across synapses, changes in the organization of local neural
circuits, and in the relationship between different functional
neural networks (Trojan & Pokorny, 1999). It has been
demonstrated that portions of the cortex involved in sensory
and motor functions reorganize in response to changing
uses, after injury, and during skill learning (Braun et al.,
2000; Elbert et al., 1994; Karni et al., 1995). Violinists have
larger cortical representations in areas dedicated to the
fingers of the left hand than do non-string players (Elbert et
al., 1995), Braille readers demonstrate similar patterns of
cortical plasticity in sensory regions (Sterr et al., 1998a,
1998b); and cab drivers have larger hippocampi
incorporating more visual-spatial knowledge (Maguire et al.,
2006).
These and other studies have demonstrated use-
dependent plasticity in both cortical and subcortical regions.
Because of their early maturation and organization, sensory-
motor areas have been thought to have the earliest
sensitive periods and the most permanent neural
organization. The extensive plasticity discovered in these
regions suggests that executive and association areas of the
frontal cortex (which are characterized by their adaptation
to change) should demonstrate even more synaptogenesis,
altered synaptic connections, and potentially neurogenesis
(Beatty, 2001; Dalla, Bangasser, Edgecomb, & Shors, 2007;
Gould, Reeves, Graziano, et al., 1999; Hodge & Boakye,
2001; Mateer & Kerns, 2000). In fact, research has found a
continual increase in white matter volume in the frontal and
temporal lobes of males well into the fifth decade of life
(Bartzokis et al., 2001).
The activation and organization of the cortex appears
capable of continual change, with expansion and
contraction of cortical representation alternating with
varying amounts of stimulation and deprivation (Polley,
Chen-Bee, & Frostig, 1999). In other words, the brain is
capable of more and faster functional reorganization than
previously thought (Ramachandran, Rogers-Ramachandran,
& Stewart, 1992). Our ability to learn new skills and
information throughout life is clear evidence for ongoing
neural plasticity. The study of the speed, degree, and nature
of neural plasticity is a vast new scientific frontier, and the
potential to enhance plasticity has profound implications for
neurosurgery, education, neurorehabilitation, and
psychotherapy (Classen, Liepert, Wise, Hallett, & Cohen,
1998; Johansson, 2000).

Enhancing Plasticity

Life is growth. If we stop growing, technically and

spiritually, we are as good as dead.
—Morihei Ueshiba

As we learn more about the biological mechanisms of

sensitive periods, the possibility of controlling them begins
to emerge (Moriceau & Sullivan, 2004). What if
neuroscientists could learn how to reinstate sensitive
periods in adults during psychotherapy? Huang and his
colleagues (1999) found that the sensitive period of the
visual cortex was accelerated in certain genetically altered
mice. It turns out that a genetic variation in these mice
results in the earlier secretion of brain-derived neurotrophic
factor (BDNF), a neural growth hormone. Could BDNF
reestablish sensitive periods and be used to stimulate more
exuberant learning at any time during life?
Kang and Schuman (1995) found that BDNF and NT-3
(another neurotrophic factor) enhanced LTP activity when
introduced to the hippocampus of an adult rat. In a related
study, it was found that a strain of mice with higher levels of
N-methyl-D-aspartate (NMDA) receptors had enhanced
performance in learning and memory tasks (Tang et al.,
1999). NMDA, a neurotransmitter involved in the formation
of associations among neurons, is necessary for cortical
reorganization, and has the ability to specify certain
transcriptional processes related to neural plasticity
(Jablonska et al., 1999; Rao & Finkbeiner, 2007; Wanisch,
Tang, Mederer, & Wotjak, 2005). NMDA receptors have also
been shown to be necessary for the initiation of LTP in
monkeys (Myers et al., 2000).
This work has led to the suggestion that the use of D-
cycloserine, which enhances the activation of NMDA
receptors, may boost the effect of some forms of
psychotherapy. One study showed an improved effect of
exposure therapy with phobic individuals after using D-
cycloserine (Ressler et al., 2004). The effects of cholinergic
stimulation suggest it also plays a role in neural plasticity by
activating neural growth hormones (Cowan & Kandel, 2001;
Zhu & Waite, 1998). Future research with these biological
subcomponents of learning and memory may lead to
pharmacological interventions that could enhance the
brain’s ability to learn while taking piano lessons, preparing
for the GREs, or during certain critical phases of
psychotherapy (Davis, Myers, Chhatwal, & Ressler, 2006).
Just a few years ago, the conventional wisdom in
neuroscience was that we were born with all the neurons we
would ever have. More recent research has found an
increasing number of areas within the brain where new
neurons are generated. Stem cells, the basic structure for
many types of cells that are capable of renewing
themselves indefinitely, have so far been found in the
olfactory bulb and a portion of the hippocampus called the
dentate gyrus (Jacobs et al., 2000). When the biological
processes that stimulate stem cells are understood,
neurosurgeons may be able to trigger the growth of new
tissue in damaged areas (Hodge & Boakye, 2001).
The underlying biochemistry of the processes of neuronal
growth is also being investigated and may someday be
utilized to enhance and support plasticity (Akaneya,
Tsumoto, Kinoshita, & Hatanaka, 1997; Barde, 1989) and
treat neurodegenerative disorders such as Alzheimer’s and
Parkinson’s diseases (Carswell, 1993). The acceleration or
reestablishment of sensitive periods, the enhancement of
learning and memory via biochemical adjustments, and the
cultivation of new cells all suggest the future possibility of
intentional and strategic enhancement of neural plasticity.
While these potential biological interventions are causes for
hope, we are currently capable of enhancing plasticity
through our day-to-day behaviors and interactions.

Enriched Environments and Stimulating Lives

Intellectual growth should commence at birth and cease
only at death.
—Albert Einstein
It has been known for decades that enriched and
stimulating early environments can have a positive and
long-term impact on both neural architecture and
neurochemistry. Research has demonstrated that when rats
are raised in complex and challenging environments, they
show advances in many aspects of brain building (see Table
17.1). An enriching environment enables mammals to build
larger, more complex, and more resilient brains.

TABLE 17.1
The Impact of Enriched Environments in Experimental
Animals

Increases In
Weight and thickness of cortex1
Weight and thickness of hippocampi2
Length of neuronal dendrites3
Synapses among neurons4
Activity of glial cells5
Levels of neural growth hormones6
 Levels of neurotransmitters7
Level of vascular activity8
Level of metabolism9
Amount of gene expression10
Levels of nerve growth factor11

The effects of the environment in stimulating brain

growth are so robust that it occurs even in situations of
malnutrition. If rats are malnourished but placed in enriched
environments, they will have heavier brains than well-fed
but less-stimulated rats. These findings exist despite the
fact that the malnourished rats weigh significantly less
(Bhide & Bedi, 1982). Although nutritional and
environmental deprivation often go hand in hand, some
deficits may be reversed in adulthood. Placing adult rats in
enriched environments enhances synaptic plasticity and
ameliorates the effects of earlier nervous system damage
and genetically based learning deficits (Altman, Wallace,
Anderson, & Das, 1968; Kolb & Gibb, 1991; Maccari et al.,
1995; Morley-Fletcher, Rea, Maccari, & Laviola, 2003;
Schrott et al., 1992; Schrott, 1997).
Although controlled studies of nutritional and
environmental deprivation are not possible with humans,
some naturally occurring situations offer similar insights into
the power of environmental enrichment. A study of Korean
children adopted by families in the United States found that
environmental enrichment counteracted their early
malnutrition and deprivation. On measures of height and
weight, these children eventually surpassed Korean
averages, while their IQ scores reached or exceeded
averages for American children (Winick, Katchadurian, &
Harris, 1975). In a different study of postmortem brain
samples of older adults, a consistent relationship was found
between the length of dendrites in Wernicke’s area and the
subjects’ level of education (Jacobs et al., 1993). It has also
been suggested that an enriched environment may improve
poststroke recovery in humans (Ulrich, 1984).
The theory of cognitive reserve, which arose from these
observations, has triggered research comparing the brains
and cognitive functioning in later life of people with varying
levels of challenge and stimulation. The cognitive reserve
hypothesis suggests that stimulating lives build more neural
material, and the more you build, the more you can afford to
lose and still function in a competent manner later in life
(Richards & Deary, 2005; Stern, Alexander, Prohovnik, &
Mayeux, 1992). A number of these studies support the idea
that those who have had more education and challenging
occupations tend to have brains that age better and resist
the onset and progression of dementia.
It is believed that the cognitive declines associated with
normal aging are related to the gradual degeneration of
dendrites, neurons, and the biochemical mechanisms that
support neural health and plasticity (Jacobs, Driscoll, &
Schall, 1997; Morrison & Hof, 2003). People with more
cognitive reserve typically have had better diets, higher
quality educations, and more intellectually challenging jobs
than those with lower reserve (Stern et al., 2005; Whalley,
Deary, Appleton, & Starr, 2004). Factors like larger brain
size, early learning, and greater occupational attainment are
associated with greater cognitive reserve and seem to
mitigate the effects of Alzheimer’s disease, traumatic injury,
and the general impact of brain aging (Compton, Bachman,
Brand, & Avet, 2000; Kessler et al., 2003; Scarmeas et al.,
2004; Schmand et al., 1997; Staff, Murray, Deary, &
Whalley, 2004; Stern et al., 1995).
Skills most dependent upon frontal functions—such as
verbal fluency, controlled processing, and the abstract
thinking demanded by high-complexity occupations—appear
to contribute most to cognitive reserve(
 Ardila, Ostrosky-Solis, Rosselli, & Gomez, 2000; Le Carret
et al., 2003). So, while being a college professor does not
protect against cognitive decline, fortunately for me, it may
slow down some of its manifestations (Christensen,
Henderson, Griffiths, & Levings, 1997). About 25% of older
individuals showing no symptoms of Alzheimer’s disease
while alive show significant Alzheimer’s-related brain
pathology upon autopsy (Ince, 2001; Katzman et al., 1989).
Those with more education had a significantly greater
amount of plaques and tangles yet functioned as well as
others with less advanced disease (Alexander et al., 1997).
This suggests that individuals with more education can
sustain a greater amount of neural damage, and still
maintain the same level of cognitive functioning as those
with less education.
Studies have also found that expected age-related
intellectual decline can be halted or reversed in many older
adults by increasing environmental and social stimulation
(Schaie & Willis, 1986). The most probable explanation
would be that these experiences correlate with biological
processes that enhance plasticity, creating more elaborate,
complex, and flexible brains. Given that psychotherapy is an
enriched environment for social-emotional learning, we can
assume that the challenges we provide our clients build
more complex and resilient brains. Research has yet to
explore the possibilities of enhanced longevity and brain
health in those who engage in psychotherapy.

Moderate States of Arousal

I am always doing that which I cannot do, in order that

I may learn how to do it.
—Pablo Picasso
Something we do in all forms of psychotherapy that
enhances neural plasticity is pay attention to creating
moderate states of arousal in our clients. Regulating
subjective units of distress in systematic desensitization,
balancing confrontation and empathic attunement in
psychoanalysis, or crafting the “safe emergency” of Gestalt
therapy all reflect an appreciation for the delicate balance
between challenge and support. We intuitively understand
that people need to be motivated and aroused to learn,
while simultaneously free from the autonomic activation
that shuts down cortical plasticity. Knowing how to find and
keep clients in learning’s sweet spot is a vital element of the
art of psychotherapy.
The nontechnical story goes something like this: 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. At
the other extreme, states of high arousal and danger are no
time for new cortical learning but a call for immediate limbic
action. A state of mind somewhere between the two
appears optimal for new learning and problem solving
(Anderson, 1976). An attitude best described as interest,
enthusiasm, or curiosity is thought to stimulate positive
arousal. In secure attachment, the child is able to use the
parent as a safe haven and avoid experiencing autonomic
activation in response to stress. A similar process is likely to
take place in a secure therapeutic alliance, allowing clients
to verbalize their experience rather than defending
themselves or fleeing from the situation.
The formalization of this notion in experimental
psychology, described in a classic paper by Robert Yerkes
and John Dodson (1908), came to be known as the inverted-
U learning curve. Contrary to expectation, they found that
mice learned to avoid a moderate shock faster than one of
high or low intensity. They charted their finding on a graph
with arousal on the x-axis and learning (performance) on the
y-axis (see Figure 17.1). Over the years this same
phenomenon was found across species in a variety of
learning tasks (Broadhurst, 1957; Stennet, 1957). While this
research took place before we knew anything about the
neurochemistry of learning, it makes sense that this same
inverted-U pattern will be reflected in the underlying
neurobiological processes of learning (Baldi & Bucherelli,
2005).
We now know that learning depends on building new
dendritic structures, and on the ability of these structures to
interconnect. Building dendrites is dependent on the
synthesis of proteins guided by genetic transcription, while
neuronal firing shapes the architecture of these dendrites to
encode new learning. Not surprisingly, the hormones
secreted by the HPA axis in response to stress (cortisol,
norepinephrine, and endorphins), as well as other learning
mechanisms (NMDA receptors, BDNF secretion, etc.),
modulate learning on the same inverted U-shaped curve
(Hardingham & Bading, 2003; Parsons, Stöffler, & Danysz,
2007). At moderate states of arousal, amygdala activation
opens windows of modulated stimulation where top-down
plasticity is facilitated (Popescu, Saghyan, & Paré, 2007). At
moderate levels of arousal, these and many more systems
enhance learning, while at high and low levels they inhibit
new learning, in this same inverted-U pattern.

FIGURE 17.1
The Inverted-U Learning Curve
 Hippocampal neurons require low levels of cortisol for
structural maintenance, while higher levels of cortisol inhibit
their neuroplastic properties (Gould, Woolley, & McEwen,
1990). Cortisol impacts learning and plasticity by regulating
the protein synthesis required for dendritic growth and
patterns of neural connectivity such as LTP, LTD, and primed
burst potentiation (a low-threshold version of LTP) in this
same pattern (Diamond, Bennett, Fleshner, & Rose, 1992;
Domes et al., 2005; Lupien & McEwen, 1997; Roozendaal,
2000). High levels of stress also trigger endorphin release,
which impedes both protein synthesis and the consolidation
of explicit memory (Introini-Collison & McGaugh, 1987). See
Table 17.2 for a sample of findings supporting this pattern of
the biochemistry of arousal and its effects on learning.
Overall, the various neural systems dedicated to learning
and arousal are tightly interwoven. They work together to
activate plasticity and learning when it is needed to adapt to
challenge, and turn it off in the absence of challenge or
when the body needs to be mobilized for immediate
survival. The inverted-U learning curve reflects both the
underlying neurobiological processes and the many overt
manifestations of learning seen in the laboratory, classroom,
and consulting office. By understanding these principles, we
can use them to optimize neural plasticity in the service of
positive brain change.
 TABLE 17.2
The Inverted-U Curve of Learning and Arousal

mRNA expression1
Cortisol levels
Verbal memory2
Social memory3
Spatial memory4
Hip prime burst potentials5
Long-term potentiation6

Norepinephrine levels
Olfactory plasticity7

Endorphin levels
Protein synthesis and memory consolidation8

Attachment Plasticity

Organic matter, especially nervous tissue, seems

endowed with a very extraordinary degree of
plasticity.
—William James

Attachment in infancy is usually conceptualized as

relationship specific, while attachment in adulthood is
thought of as a general aspect of character. Early
attachment patterns may become generalized and self-
perpetuating because of their impact on our neurobiology,
our ability to regulate our emotions, and the expectations
we have of ourselves, others, and the world. The sensory,
emotional, and behavioral systems influenced by early
attachment experiences can shape our brains in ways that
make the past a model for creating the future.
We have learned a great deal from attachment research:
how our primitive bonding instincts regulate anxiety, how
categories of attachment reflect a parent’s behavior and a
child’s reaction to stress, and how attachment schemas are
carried into adulthood, affecting our choice of partners, the
nature of our relationships, and the way we parent our own
children. The enthusiasm we have about the power of
attachment categories to explain emotional development
often fails to acknowledge the considerable fluctuation of
attachment styles over time. In our search for a
straightforward explanation of intimate human relationships,
it is easy to overlook the instability of attachment.
In an attempt to support the predictive power of
attachment schemas, fluctuation and change are attributed
to measurement problems or uncontrolled external variables
such as positive and negative life events or changing
relationships. But we seldom consider that an attachment
schema should change because we think of it as a
personality trait. As we saw in the animal research, maternal
attention to rat pups was mediated by the environment in
ways that made the pups a better fit to the environment to
which the mother was responding. Perhaps because our
brains are so much more complex, it takes greater effort
and time for us to change, but the role of attachment may
be essentially the same in humans.
In human subjects, we see that a decrease in security or
the maintenance of insecurity during adolescence is more
likely to occur in the presence of psychological, familial, or
environmental stressors. Adolescents who see their mothers
as supportive are more likely to gain security, while
maternal depression correlates with a shift from secure to
insecure attachment (Allen et al., 2004; Hamilton, 2000;
Weinfield, Sroufe, & Egeland, 2000). Overall secure
attachment, while not impervious, appears more resistant to
change than insecure attachment, while negative life events
operate to maintain insecure attachment (Hamilton, 2000;
Kirkpatrick & Davis, 1994; Thompson, 1982). These findings
certainly parallel the animal literature. The major
implication for psychotherapy from all of these findings is
that insecure attachment is subject to change as a result of
positive social input (Pilowsky et al., 2008). As shown in
Table 17.3, the consistency of attachment ratings, primarily
secure versus insecure, is 24–64% depending on the study.
This may be bad news for those interested in attachment as
a stable trait, but good news for those of us in the business
of change.
As a psychotherapist who is very interested in positive
change, the messiness of the attachment construct and the
variability of the data come as good news. I want
attachment schemas to be a malleable form of implicit
memory, so relationships with clients can alter them in a
salubrious manner. In this way, psychotherapy becomes a
guided attachment relationship for the purposes of assisted
homeostasis (moderate states of arousal) and eventual
repair of insecure attachment schemas (Amini et al., 1996;
Cappas, Andres-Hyman, & Davidson, 2005; Corrigan, 2004;
Siegel, 1999).
 
TABLE 17.3 Attachment Plasticity

Time Span Percentage of Subjects Source

with Same Attachment
Classification
6 months 62 (N=100) Vaughn et al.,
during 1979
infancy
7 months 53 (N=43) Thompson,
during Lamb & Estes,
infancy 1982
2 years 60 (N=189) Egeland &
during Farber, 1984
infancy
3.5 years 24 (N=223) Vondra et al.,
during 2001
childhood
Childhood to 63 (N=30) Hamilton,
adolescence 2000
Childhood to 42 (N=84) Lewis, Feiring,
adolescence & Rosenthal,
2000
Childhood to 39 (N=57) Weinfield et
adolescence al., 2000
Childhood to 64 (N=50) Waters et al.,
adulthood 2000
17 weeks 55 (N=33) Lawson et al.,
during 2006
adulthood
20 sessions 34 (N=29) Travis et al.,
of adult 2001
therapy
 
These studies reflect an array of ages, target populations,
and methods of assessing attachment.

 
Although there is evidence of organized attachment
schemas by our first birthday, they do not appear to be set
in neural stone. These naturally occurring changes and the
fact that we attach and reattach with many people
throughout our lives suggests that the underlying neural
systems maintain their plasticity. If you doubt this, ask
grandparents whether they feel attached to their
grandchildren. In support of the neuroplasticity of
attachment networks, research suggests that adults can
create secure attachment for their children despite negative
experiences in their own childhood. Earned autonomy,
through the subconscious integration of early negative
experiences, results in the ability to serve as a safe haven
for one’s own children.
Thus, the powerful shaping experiences of childhood can
be modified through personal relationships, psychotherapy,
and increased self-awareness. The ability to consciously
process stressful and traumatic life events appears to
correlate with more secure attachment, flexible affect
regulation, and an increased availability of narrative
memory. The integration of neural circuitry across cognitive,
behavioral, sensory, and emotional domains is the likely
neuroanatomical substrate of this earned autonomy. A
healing relationship with a secure partner or with a good-
enough therapist, in which past pain can be processed and
resolved, supports earned autonomy and neural integration.

The Power of a Healing Relationship

Being deeply loved by someone gives you strength, while
loving someone deeply gives you courage.
—Lao Tzu
Because our brains are social organs interwoven with the
brains of those around us, relationships have a direct impact
on the biology of the brain. Psychotherapy is successful in
large part because of the therapist’s empathic abilities and
the client’s belief in the therapist’s humanity and skill.
Through the instillation of optimism and hope, a therapist
(or any healer) uses powerful mechanisms of mind to shape
the functioning of the brain. The mind’s impact on the brain
has been studied in a variety of fields from social
neuroscience to psychoneuroimmunology, and referred to
as the effects of expectancy, placebo, or self-fulfilling
prophecy. These are all examples of the mind leading the
brain via the power of relationships.
The term placebo, Latin for “I shall please,” reflects the
ancient idea that response to an inactive treatment results
from the patient’s desire to live up to the doctor’s
expectations. The placebo effect has been expanded to
include sugar pills and other nonactive treatments, in
contrast to what are considered to be active chemical
compounds. More generally, the placebo effect is the
expectation for illness outcome based on what the patient is
led to believe by the doctor. Moerman and Jonas (2002)
suggested renaming it “the meaning response,” reflective of
the fact that the placebo effect is mediated via the meaning
assigned to it by the patient. Until modern times, medicine
men and women, shamans, and witch doctors understood
and utilized this phenomenon in their role as tribal healers
(Frank, 1963). Similarly, the expectancy effect is likely at
play in the fact that ill Chinese Americans born during
inauspicious years have significantly shorter life spans. The
size of this effect is proportional to how strongly they hold
on to traditional cultural beliefs (Phillips, Ruth, & Wagner,
1993). Placebo effects are seen as a nuisance in Western
science, and the patients benefiting from them are
pathologized as weak minded, impressionable, or
malingering.
Modern technological medicine has led to a decline in the
use of the meaning response as the role of the doctor has
shifted from healer to technician. This is especially ironic
given that placebo control groups are a staple of the
research upon which their clinical decision making should be
based. Don’t the time, money, and effort expended in this
standard of research methodology support the power of
patient expectancy to impact symptom expression? Perhaps
doctors have become far too impressed with their
technology while neglecting the power of their humanity.
 In a similar manner, expectancy and placebo effects are
usually relegated to the category of nonspecific effects in
psychotherapy outcome research. I would argue that these
effects are in fact specific—that is, we know exactly what
social and psychological factors lead to healing. Carl Rogers
outlined them well during the 1960s as warmth, acceptance,
caring, and unconditional positive regard. Epidemiologists
call them social support, network connectivity, and shared
spiritual beliefs. We will someday be able to specify and
measure the neuroanatomical and biochemical mechanisms
of positive human interactions.
Different activation patterns in the brain during
successful placebo response reflect the multiple neural
pathways involved in mind–brain regulation. In neuroscience
terms, the placebo effect is an example of top-down cortical
modulation of mood, emotion, and immune activity
(Beauregard, 2007; Ocshner et al., 2004). The placebo
effect relies heavily upon the prefrontal lobes to integrate
social experiences with positive affect and an optimistic
state of mind. In the same way that a mother can shape a
child’s brain by stroking his hair and telling him that things
will get better, a doctor can influence a client’s immune
system by presenting an optimistic prognosis and projecting
confidence about the proposed treatment.
The placebo effect is a social phenomenon that likely
activates the same reward systems (dopamine-serotonin-
endorphin) triggered by loving touch and the anticipation of
positive connections and feelings (Esch & Stefano, 2005;
Fricchione & Stefano, 2005). The amygdala, which regulates
our experience of fear and pain, is inhibited by positive
emotions and activated by negative emotions (Neugebauer
et al., 2004). We know, for example, that placebo and opioid
analgesia share a common neural pathway, which strongly
suggests we are capable of opioid self-administration
(Pariente et al., 2005).
 There are many examples of the social, top-down
regulation of emotion. When a woman holds her husband’s
hand in the face of threat, fear activation is attenuated. Not
surprisingly, the better she feels about the relationship, the
greater the soothing effect of his hand will be (Coan,
Schaefer, & Davidson, 2006). Soothing touch is obviously
powerful, but so too is a soothing facial expression or a kind
word communicated in an attuned emotional state. Some
evidence for this has been found when levels of arousal (as
measured by skin conductance) were monitored
simultaneously in clients and therapists during sessions.
During states of matched arousal, there were significantly
more positive social and emotional interactions between
client and therapist than when they were out of sync (Marci,
Ham, Moran, & Orr, 2007).
Even in Parkinson’s disease, it is believed that the
anticipation of positive reward (a frontal-cortical process)
stimulates the release of dopamine from the nucleus
accumbens (a subcortical region called the ventral
striatum). Because dopamine depletion is the central cause
of Parkinsonian symptoms, this release of dopamine results
in symptomatic improvement. See Table 17.4 for an outline
of studies that have demonstrated changes in neural
activation related to the placebo effect.

TABLE 17.4
The Impact of Positive Expectancy (Placebo) on Brain
Activation

Major Depression
Increased activity in prefrontal, anterior cingulate,
premotor, parietal, posterior insula, and posterior
cingulate1
 Decreased activity in subgenual cingulate,
parahippocampus, and thalamus2

Pain Disorders
Increased activity in lateral and orbital PFC, anterior
cinglate, cerebellum, right fusiform gyrus,
parahippocampus, and pons3
Increased activity in the right dorsolateral cortex,
anterior cingular cortex, and midbrain4
Increased bilateral orbitofrontal activity and anterior
cingulate cortex contralateral to pain stimulus5
Reduced activity in anterior cingulate cortex, anterior
insula, and thalamus6
Increased activity in the prefrontal cortex7
Activated endogenous opioids in dlpfc, anterior insula,
and nucleus accumbens8

Parkinson’s Disease
Reduced activity in subthalamic nuclei9
Increase in striatal dopamine10

When physicians encourage their peers to use the

placebo effect to enhance illness outcome, the suggestions
are very similar to the basic principles of client-centered
therapy. For example, an article in the Journal of Family
Practice suggested a “sustained partnership” with patients
characterized by an interest in the whole person, knowing
the patient over time, caring, sensitivity and empathy, being
viewed as reliable and trustworthy, adapting medical goals
to the needs of the patient, and encouraging full
participation by the patient (Brody, 2000). Another
physician in a piece from the British Medical Journal asked,
“For a thousand years the action of the placebo has made
vast numbers of patients feel better. Have we today
provided a consultation in which the placebo does not act?”
(Thomas, 1987, p. 1202). These are the aspects of
traditional healing still employed by psychotherapy that
appear to have been lost in modern technical medicine.
The implications of the power of the placebo effect to
change the brain are profound. Our awe of technical
medicine leads us to underestimate the importance of the
doctor’s role as healer, and patients’ abilities to contribute
to their own healing through the modulation of their
endogenous biochemistry. There are many ways in which
the power of the placebo effect could be harnessed and
used to increase the effectiveness of medical treatment
including increasing visits, encouraging and supportive
interactions, and shaping patients’ experiences by telling
them what positive outcomes they should expect (Walach &
Jonas, 2004; see Table 17.5 for a list of their suggestions).
Ironically, we are only required to tell clients of the many
risks and negative side effects, which likely guide their
response to treatment in the opposite direction.

TABLE 17.5
Leveraging the Placebo Effect in Medical Treatment

Increase frequency of contact

Determine what treatments your patient believes in Align
beliefs among patient, doctor, family, and culture Be sure
you believe in the treatment you are administering Inform
patients about what they can expect
Deliver treatment in a warm and caring way
Listen and provide empathy and understanding
 Touch the patient
 
Findings from the medical research supporting the power
of specific doctor-patient interactions. Adapted from
Walach and Jonas (2004).

All of the “givens” of classical healing and psychotherapy

have been squeezed out of modern Western medicine.
Perhaps these nonspecific ingredients of a healing
relationship will someday be interwoven with the technical
aspects of modern medicine.

Summary
The power of psychotherapy to change the brain rests in our
ability to recognize and alter unintegrated or dysregulated
neural networks. As knowledge of neural plasticity and
neurogenesis increases, so will our ability to impact and
alter the brain. The possibility exists that sensitive periods
can be reinstated in the context of psychotherapy, and that
stress can be utilized in a controlled manner to “edit and re-
edit” emotional memories (Post et al., 1998). Although the
practical application of these principles to humans remains
on the distant horizon, the possibilities of the involvement of
psychotherapy in brain sculpting are evident. It is certain
that psychotherapists are already enhancing plasticity
without the help of genetic manipulation or chemical
interventions.
Therapy is a safe emergency because of the supportive
structure in which difficult emotional learning takes place. A
client’s sense of safety is enhanced by the therapist’s skill,
knowledge, and confidence, which support emotional
regulation and maintaining moderate states of arousal. It is
quite possible that the caring, encouragement, and
enthusiasm of the therapist also reinforce learning, neural
growth, and plasticity through the enhanced production of
dopamine, serotonin, and other neurochemicals (Barad,
2000; Kilgard & Merzenich, 1998; Kirkwood, Rozas,
Kirkwood, Perez, & Bear, 1999). Successful therapeutic
techniques may be successful because of their very ability
to change brain chemistry in a manner that enhances neural
plasticity.
In the recent shift to neural optimism, critical periods of
neural development are being reconsidered as important
but, perhaps, not the final word on neural structure. The
impact of enriched environments has demonstrated the
brain-building capacity of positive experiences throughout
the life span. More recent research in neural plasticity (e.g.,
use-dependent plasticity, neurotransmitter alteration, stem
cell implantation) suggests that new experiences, and future
potential biological interventions, may be capable of
providing us with many tools with which to rebuild the brain.
Psychotherapy is on the verge of an exploding new
paradigm: the psychotherapist as neuroscientist.
Chapter 18

The Psychotherapist as Neuroscientist

In this field we are merely at the foothills of an

enormous mountain range…unlike other areas of
science, it is still possible for an individual or small
group to make important contributions.
—Eric Kandel

Psychotherapists are applied neuroscientists who create

individually tailored enriched learning environments
designed to enhance brain functioning and mental health.
We are skilled at teaching clients to become aware of
unconscious processing, take ownership of their projections,
and risk anxiety in the service of emotional maturation
(Holtforth et al., 2005). In our work, illusions, distortions,
and defenses are exposed, explored, and tested or modified
with understandings closer to reality. Implicit memory—in
the form of attachment schemas, transference, and
superego—are made conscious and explained as
expressions of early experiences. We use a combination of
empathy, affect, stories, and behavioral experiments to
promote neural network growth and integration.
Through all of this work, subcortical networks that store
memories of fears, phobias, and traumas are activated and
made accessible for integration with cortical inhibitory
circuitry. This essential integration allows for linkage among
explicit and implicit circuits, conscious awareness, and the
control of negative memories, sensations, and emotions.
Regardless of the client’s particular problem, psychotherapy
teaches a method to help us better understand and use our
brains. And as the dialogue between psychotherapy and
neuroscience continues to evolve, an increasing number of
scientific findings will be applied to both theory and clinical
practice.
Important factors in the therapeutic process have been
identified as an empathic and supportive relationship,
maintenance of moderate states of arousal, activation of
both cognition and emotion, and co-construction of
narratives. A safe and empathic relationship establishes an
emotional and neurobiological context conducive to neural
plasticity. It also serves as a scaffold within which a client
can better tolerate the stress required for neural
reorganization. We have already seen that birds are able to
learn their songs after sensitive periods when exposed to
other birds singing, but are unable to learn the same songs
heard from a tape recorder (Baptista & Petrinovich, 1986).
Under certain conditions, birds require positive social
interactions and nurturance in order to learn (Eales, 1985).
And the stronger the relationship between human trainers
and their birds, the greater the learning will be for both
(Pepperberg, 2008). These studies, combined with what we
know about changes in biochemistry during interpersonal
interactions, suggest that a positive and attuned
relationship enhances neural plasticity and learning. The
nearly insatiable drive of adolescents to be in constant
contact with one another may reflect the underlying drive
for neural stimulation during this crucial developmental
period. Emotional expression and modulation have been
incorporated into psychotherapy because of their impact on
these underlying biological processes.
The importance of the activation of both emotion and
cognition is recognized by most psychotherapists. Releasing
emotions associated with painful memories, facing a feared
situation, or experimenting with new interpersonal
relationships all involve some sort of stress, anxiety, or fear.
Although this way of thinking has been accepted clinically,
we now have considerable evidence to support the idea that
moderate levels of arousal optimize the production of
neurotransmitters and neural growth hormones that
enhance LTP, learning, and cortical reorganization (Cowan &
Kandel, 2001; Zhu & Waite, 1998).
Trauma undoubtedly changes us in many ways, from our
startle response to our attachments and self-identity.
Dissociation in reaction to trauma represents a breakdown
of neural integration and plasticity. In therapy, we use
moderate levels of arousal to access cortical mechanisms of
plasticity in controlled ways with specific goals. The safe
emergency of therapy provides both the psychological
support and the biological stimulation necessary for
rebuilding the brain. Much of neural integration and
reorganization takes place in the association areas of the
frontal, temporal, and parietal lobes serving to coordinate,
regulate, and direct multiple neural circuits of memory and
emotion.
The importance of the co-construction of narratives is
grounded in the coevolution of the cerebral cortex and
language, reflecting the evolution of our brains as social
organs. Language within significant relationships has
shaped the brain during evolution and continues to do so
throughout our lives. Because of this, narratives embedded
within an emotionally meaningful relationship (like
psychotherapy) are capable of resculpting neural networks
throughout life. Through the use of autobiographical
memory, we can create narratives that bridge processing
from various neural networks into a cohesive story of the
self. Narratives allow us to combine—in conscious memory—
our knowledge, sensations, feelings, and behaviors
supporting underlying neural network integration.
The co-construction of narratives with parents serves as
a medium of transfer of the internal world of the parent to
the child, from generation to generation. These narratives
reflect the implicit values, problem-solving strategies, and
worldviews of the parents. They also serve to define us to
ourselves and others, and guide us through our complex
social world. The more inclusive our narratives are in terms
of blending sensation, emotion, and cognition, the greater
our ongoing ability to integrate multiple neural networks.
Research in attachment has demonstrated that the
coherence and inclusiveness of narratives correlate with
both attachment security and self-reflective capacity (Main,
1993; Fonagy, Gergely, Jurist, & Target, 2002).
In the process of evolution, different levels of language
have emerged that appear to parallel different layers of
consciousness:

1. A reflexive social language (of the left

hemisphere interpreter) serves the purpose of
creating a logically cohesive and positive
presentation to others. This language evolved
from grooming and hand gestures with the
primary goal of group affiliation and
coordination.
2. An internal language, also reflexive, allows us to
have private thoughts, plan and guide behavior,
and deceive others. There is an aspect of
internal language that preserves early learning
expressed through critical voices in our heads,
reflecting early shame experiences.
3. A third language, one of self-reflection, appears
to be far less reflexive and arises in states of
openness, low defensiveness, and safety.

Although the first two levels of language occur

spontaneously, self-reflective language requires higher
levels of neural network integration, affect regulation, and
cognitive processing. Reflexive language keeps us in the
present moment, while reflective language demonstrates
our ability to escape from the present moment, gain
perspective on our thoughts and feelings, and make
decisions about what we would like to change and how to
change it. Attaining and utilizing this level of language is
one goal of psychodynamic psychotherapy.
Three levels of language sharing a common lexicon can
result in a great deal of confusion. Many people report
feeling crazy because of the simultaneous and contradictory
beliefs they struggle with on a day-today basis.
Psychotherapy often involves sorting out these audio tracks
in order to provide us with a clearer idea of just what is
going on in there. The co-construction of narratives, in the
context of a healing relationship, which sort out these inner
contradictions may well be the optimal context for
significant plasticity in socioemotional neural networks.

Diagnosis and Treatment

The principal activities of brains are making changes

in themselves.
—Marvin L. Minsky

Functional brain imaging has opened a window to the living

human brain in the acts of motor tasks, imagining a feared
situation, being empathic, or telling a lie. An examination of
areas activated during these and many other behaviors has
enhanced our understanding of which neural networks
participate in various human functions. Although the
application of scanning technology to psychopathology is
still in its infancy, there have already been many important
and provocative findings. As scanning techniques become
more precise and the hardware more affordable, they will no
doubt become incorporated into the practice of
psychotherapy.
Neuroimaging has the potential to aid in diagnosis,
treatment selection, and the prediction of treatment
outcome (Etkin et al., 2005; Linden, 2006). As part of an
initial assessment, it could help therapists pinpoint areas of
neural activation and inhibition. Treatment planning will
eventually come to include specific psychotherapeutic and
pharmacological interventions to enhance the growth and
integration of affected networks. Regular scans during the
course of therapy may someday be a useful adjunct to
psychological tests, as ways of fine-tuning the therapeutic
process and measuring treatment success.
Associations between psychiatric symptoms and changes
in the relative metabolism of different areas of the brain are
in the process of being uncovered. We have already seen
lower levels of metabolism in the left prefrontal cortices of
depressed patients (Baxter et al., 1985, 1989) and
increased metabolism in the right prefrontal and limbic
region of patients with PTSD (Rauch et al., 1996). The
importance of the right frontal region in PTSD is supported
by clinical evidence such as the onset of PTSD after injury to
the right frontal area (Berthier, Posada, & Puentes, 2001)
and a “cure” of PTSD symptoms after a right frontal lobe
stroke (Freeman & Kimbrell, 2001). The inhibition of Broca’s
area during intense fear states is already a focus of
cognitive-behavioral therapies, and a reactivation of the
language centers may become a standard measure of
success in the treatment of PTSD and other anxiety-related
disorders. All of these findings support the existence of
specific circuitry involved in the recognition, reaction, and
regulation of anxiety and fear in the aftermath of traumatic
experiences.
The focus of this new work, however, is somewhat
different than the old localization theories that attributed
disorders of behavior to specific areas of the brain. We now
understand that each region of the brain participates in
multiple neural systems with highly complex interactions
and homeostatic functions. Thus, it is actually the
relationship between clinical symptoms and relative activity
levels of specific neural networks that are salient. The
neurobiology of obsessive-compulsive disorder (OCD) has
been of particular interest in this regard. A neural circuit
thought to mediate OCD includes the ompfc and subcortical
structures called the caudate nucleus, globus pallidus, and
thalamus. This cortical-subcortical circuit, involved with the
primitive recognition of and reaction to contamination and
danger, becomes locked into an activation loop in patients
with OCD (Baxter et al., 1992). It is hypothesized that the
ompfc, or some other component of the OCD circuit,
activates the circuit with a worry signal, decreasing
inhibition of the thalamus, which in turn excites the ompfc
and caudate (Baxter et al., 1992). The result is a feedback
loop that is highly resistant to inhibition or shutting down.

Network Homeostasis and Treatment Outcome

The constant conditions which are maintained in the

body might be termed equilibria.
—Walter Cannon

Considerable evidence supports the idea that the

reregulation of neural networks parallels some of the
symptomatic changes we witness in psychotherapy. In
general, decreases in fear and anxiety correlate with
activation reductions in bottom and right hemisphere
regions. In OCD, there is a reduction in activation in a region
dedicated to the control and inhibition of impulses (ompfc).
In the successful treatment of social and spider phobias,
there is a decrease in activation in limbic and primitive
cortical areas and in right hemisphere processing,
paralleling the decreased fear activation that goes along
with symptom reduction. In situations where there is a
deficit in cognitive processing such as in schizophrenia and
brain injury, we see symptom reduction correlated with
increased frontal activation. Keep in mind that the
correlations do not prove causal relationships; changes in
brain activation patterns could also be secondary to
symptomatic changes, or both could be due to some third
unknown factor.
Patterns of brain activation in both panic disorder and
PTSD are a bit more complex. In both of these disorders,
sensory and memory networks are hijacked by the
amygdala and become internal sources of fear. While
studies have not yet focused on changes in brain activation
related to positive treatment outcome, we can speculate
that positive treatment response would correlate with
decreased activation in the amygdala, sensory motor areas,
and the cerebellum (Bryant et al., 2008; Pissiota et al.,
2002), along with increased ompfc activation (Phan et al.,
2006; Williams et al., 2006). There would also be a
decreased activation in regions dedicated to
autobiographical memory, and an increase in the processing
of information from the current external environment
(Sakamoto et al., 2005).
Psychotherapy outcome research with a number of
disorders has found changes in brain activation paralleling
symptomatic improvement. In each case, treatment seems
to have reestablished a homeostatic balance between
interactive neural networks that were previously out of
balance. Table 18.1 outlines the studies that have been
performed to measure the neural correlates of successful
therapy across a variety of patient populations.
 
TABLE 18.1
Successful Psychotherapy and Changes in Neural
 Activation

Diagnosis and Result

Treatment
OCD
BT vs. Both: Decreased metabolism in right
fluoxetine caudate1
BT vs. BT: Left ompfc activation correlated with
fluoxetine positive response
Fluoxetine: changes in the opposite
  direction2

BT vs. controls Decreased CBF in right caudate3

CBT Decreased metabolism in right caudate
CBT and Increased bilateral grey matter4
fluoxeitine
Increased right parietal white matter5
 

Social phobia
CBT vs. Both: decreased amygdala, hippocampal,
citalopram and adjacent cortex activation
CBT: decreased periaqueductal gray
  activation

Citalopram: decreased thalamic activation6

 

Spider phobia
CBT Decreased activation in parahippocampal
gyrus and dlpfc7
CBT Decreased PFC activation biased toward
right hemisphere8
CBT Decreased activation in the insula and
 anterior cingulate9
Post-
traumatic
stress
disorder
EMDR (case Increased activation in anterior cingulate
study) and left frontal lobe10
Panic
disorder
CBT vs. CBT: RH decreases in inferior temporal and
frontal regions
Antidepressant LH increases in inferior frontal, medial
s temporal, and insula
Antidepressants: RH decreases in frontal
  and temporal lobes

LH increases in frontal and temporal

  lobes11

CBT Decreased activation in right hippo

campus, left ACC, left cerebellum and
pons
Increased activation in medial prefrontal
  cortex12

Major
depressive
disorder
CBT vs. CBT: decreased frontal activation /
paroxetine increased limbic
Paroxetine: changes in the opposite
  direction13

CBT vs. Both: decreased bilateral opfc and left

venlafaxine mpfc activation and increased activation
 in right occipital-temporal cortex14
IPT vs. IPT: increased activation in right posterior
venlafaxine cingulate and right basal ganglia
Venlafaxine: increased activation in right
  posterior temporal and right basal
ganglia15
IPT vs. Both: decreased activation in prefrontal
paroxetine cortex
Both: increased activation in inferior
  temporal and insula16

IPT vs. Both: symptom reduction with decreased

paroxetine frontal activation
Both: positive correlation with cognitive
  symptoms17

Schizophrenia
Cognitive Increased frontal activation with improved
rehab performance18
Cognitive Increased activation in right inferior frontal
rehab cortex and occipital lobe19
Traumatic
brain injury
Cognitive Global activation increase in 3 of 5
rehab patients20
 
The results shown in this table should be considered
preliminary because of small sample sizes and variations in
methodology.
 
BT, behavior therapy; CBT, cognitive-behavioral therapy;
IPT, interpersonal therapy; EMDR, eye movement
desensitization and reprocessing. Adapted and expanded
from Roffman et al. (2005).

 
Functional scan studies have demonstrated that
improvement of OCD symptoms is correlated with
decreased activation of the ompfc and caudate nucleus
(Rauch et al., 1994). Especially interesting to
psychotherapists is the fact that these changes in brain
metabolism are the same whether patients are successfully
treated with psychotherapy or medication (Baxter et al.,
1992; Schwartz et al., 1996). Although psychotherapy and
medication are the first choices for treatment, they are not
always successful. Scan-guided psychosurgery for patients
who do not respond to any other forms of treatment can
disrupt runaway feedback by severing neural links within
the OCD circuit (Biver et al., 1995; Irle, Exner, Thielen,
Weniger, & Ruther, 1998; Rubino et al., 2000).
Because symptoms can have multiple underlying causes,
diagnoses aided by neural network activity could improve
diagnostic accuracy. Increased specificity will naturally lead
to increasingly specific psychotherapeutic and
pharmacological interventions. Tourette’s syndrome—a
disorder characterized by involuntary vocalizations and
motor tics—often occurs in individuals who also suffer with
OCD, enuresis, or ADHD. This is not a coincidence, because
these disorders share underlying neural circuitry and
neurotransmitters (Cummings & Frankel, 1985). They all
stem from problems with the inhibition of subcortical
impulses by the frontal cortical areas. Thus, structural,
biochemical, and regulatory abnormalities in these
interrelated top-down networks can result in all four
conditions. When this circuit is more fully understood,
symptoms of OCD, ADHD, enuresis, and Tourette’s
syndrome may all become subsets of some future diagnosis
referred to by the neural networks responsible for these
functions.
In anxiety and depression, some studies show that
therapy achieves results through increased cortical versus
subcortical activation, while others show changes in the
activation patterns within the frontal lobes (Porto et al.,
2009). And while psychotherapy and medication can both
lead to symptom reduction, there is only partial
neuroanatomical overlap in how they achieve their results
(Roffman et al., 2005). In other words, the same results can
be achieved by different treatment strategies and through
changes in the balance among different neural networks.
This is in no way bad news for psychotherapy. Cognitive
therapy by experienced therapists is equally efficacious as
medication in moderate to severe depression (DeRubeis et
al., 2005). For depressed patients with a history of child
abuse, psychotherapy has been shown to be more effective,
with the addition of medication showing small benefits
(Nemeroff et al., 2003).

The Centrality of Stress

It’s not stress that kills us, it is our reaction to it.

—Hans Selye

Although some stress is a normal part of life, early,

prolonged, or severe stress can result in significant and
long-term impairments in learning, attachment, and
physiological regulation (Glaser, 2000; O’Brien, 1997;
Sapolsky, 1996). Stress plays a role in the expression and
severity of most, if not all, psychiatric and medical
disorders. Therefore, assessing and targeting stress as a
focus of psychotherapeutic intervention should always be an
aspect of healing relationships. Since therapists are trained
to think in terms of diagnostic categories and treatment
modalities, stress often flies under our diagnostic radar.
Understanding and working to regulate our clients’ stress is
central to psychotherapeutic success because of its impact
on neuroplastic processes.
An emerging concept in treatment involves buffering
victims of stress from neural compromise by altering their
neurochemistry. One way of accomplishing this is to block
the secretion or uptake of norepinephrine and
glucocorticoids soon after a traumatic experience (Brunet et
al., 2008; Liu et al., 1997; Meaney et al., 1989; Watanabe,
Gould, Daniels, Cameron, & McEwen, 1992). It has also been
found that the neurotransmitter neuropeptide-Y is found in
higher concentrations in the amygdalas of individuals who
respond more favorably to high levels of stress (Morgan et
al., 2000). Artificially increasing levels of neuropeptide-Y
may buffer the nervous system from some of the damaging
effects of stress.
Chemical blockade or disruption of particular amygdala
circuits may decrease some of the symptoms of PTSD such
as the startle and freeze responses (Goldstein, Rasmusson,
Bunney, & Roth, 1996; Lee & Davis, 1997). It has even been
suggested that stimulation of the amygdala could lead to
the extinction of conditioned fear (Li, Weiss, Chaung, Post, &
Rogawski, 1998). Understanding the role of LTP and other
forms of plasticity in the amygdala, as well as its role in fear
conditioning, may provide another avenue for future
interventions in psychosis and PTSD (LaBar, Gatenby, Gore,
LeDoux, & Phelps, 1998; Rogan & LeDoux, 1996; Rogan,
Staubli, & LeDoux, 1997).
We have seen that higher levels of maternal attention in
rats decrease the pups’ subsequent HPA activation in
response to stress (Liu et al., 1997). Although I doubt that
encouraging human mothers to lick their children will be of
much help, human infants demonstrate the same pattern in
response to maternal massage (Field et al., 1996), and
within securely attached relationships (Spangler &
Grossman, 1993). Maternal depression, separation, and
deprivation are severe stressors for infants, resulting in a
variety of negative biological, emotional, and social
consequences (Gunnar, 1992). Aggressive treatment of
depression in new mothers, along with teaching them how
to massage and better interact with their infants, may
counteract some of the negative impact of maternal
depression. Therapy focused on resolving a mother’s
attachment difficulties or past trauma prior to giving birth
may also be helpful in reducing stress in their infants,
children, and adolescents (Trapolini, Ungerer, & McMahon,
2008).
An increased appreciation of the effects of maternal
separation may guide us as to the advisability of optional
infant–mother separation. Where separation is unavoidable
in cases of illness and death, the ability to lessen the impact
of stress hormones via interpersonal and chemical
interventions may prevent problems later in life. Given the
amount of exposure in our society to stressful events such
as abuse, neglect, abandonment, and community violence,
the impact of severe stress on mothers and the developing
brains of their children should be a serious public health
concern (Bremner & Narayan, 1998).
Research findings suggest that early stress leads to a
vulnerability to depression later in life (Widom, DuMont, &
Czaja, 2007). This, in part, is mediated by deficient
organization of frontal circuitry, and the establishment of
lower levels of excitatory neurotransmitters and growth
hormones during sensitive developmental periods. Early
childhood experiences leading to a bias toward right
hemisphere activation may also play a role in the long-term
development of depression. As we discussed in the chapter
on laterality, magnetic stimulation of the left hemisphere of
depressed patients and the right hemisphere of patients
with mania has shown promising results and may serve as a
future alternative to electroconvulsive therapy (Grisaru et
al., 1998; Klein et al., 1999; Teneback et al., 1999; Pascual-
Leone et al., 1996).
In line with these findings, activation of the left
hemisphere through sensory stimulation results in a higher
degree of self-serving attributions and positive affect (Drake
& Seligman, 1989). Relative left frontal activation appears
linked to a state of mind of “self-enhancement,” which may
decrease the risk for psychopathology and be manipulated
by changes in attitude or practices such as mindfulness
meditation (Tomarken & Davidson, 1994). The more we
understand the relationship between laterality and affect,
the more we may be able to incorporate techniques of
selective activation of right and left hemispheres into
multimodal treatments for mood disorders and other
psychiatric difficulties.
PTSD is primarily mediated and maintained by
neurobiological processes outside conscious control. The
activation of Broca’s area in the face of high levels of affect
appears to be an important mechanism of action in most
interventions with patients suffering from PTSD and other
anxiety disorders. We know that the ompfc modulates and
inhibits amygdala activity, the very circuit we are activating
when we help clients to employ cognition to inhibit their
fears.
Despite new theories connecting neural communication
and psychopathology, no major form of psychotherapy has
emerged with the stated goal of neural network integration.
This being said, techniques such as the caloric test and the
eye movements used in EMDR seem to involve left-right and
top-down integration as an active element. Previously, we
discussed the phenomenon of sensory neglect, which occurs
when there is damage to the right parietal lobe (assumed to
be responsible for the integration of sensory and motor
information from both sides of the brain). In the caloric test,
stimulation with cold water to the left ear results in rapid
side-to-side eye movements while activating regions of the
right temporal lobe (Friberg et al., 1985). Although there has
been one report of permanent remission of sensory neglect
with this treatment, for most the cure is only temporary
(Rubens, 1985). The bilateral activation of attentional
centers in reaction to the caloric test results in increased
integration of previously dissociated attention and
information-processing systems (Bisiach et al., 1991).
In the treatment of PTSD with EMDR, past traumatic
events are recalled and subjected to a protocol that involves
focusing attention on ideas, self-beliefs, emotions, and
bodily sensations. In addition, EMDR uses periodic
stimulation through watching the therapist’s hand going
back and forth or having the legs touched alternately
(Shapiro, 1995). This bilateral and alternating (side-to-side)
stimulation may serve to activate attention centers in both
temporal lobes in a manner similar to the caloric test.
Alternating activation may, in fact, enhance neural network
connectivity and the integration of traumatic memories into
normal information processing.
Techniques such as EMDR may thwart or reverse the
brain’s tendency toward neural network dissociation
secondary to trauma. Bilateral stimulation may enhance the
reconsolidation of traumatic memories with cortical-
hippocampal circuits providing contextualization in time and
place. Activation of these same circuits creates the
possibility of building descending inhibitory links to
subcortical sensory-affective memory circuits (Siegel, 1995).
Thus, the right-left stimulation of attention may
simultaneously trigger integration of affect with cognition,
sensation, and behavior throughout the brain.
Once the relationships among neural circuits are more
fully understood, psychotherapists may employ these and
other noninvasive techniques to stimulate the brain in ways
that enhance neural network integration. Could activation of
right hemisphere emotional regions during therapy with
alexithymic patients aid in the integration of emotional
processes with left hemisphere linguistic circuitry? Could
activation of the left hemisphere during emotional
dyscontrol in borderline patients enhance their ability to
gain cognitive perspective and emotional regulation?
For conditions involving too much emotional inhibition,
new learning may be stimulated by creating moderate
levels of affect in therapy; this learning, in turn, may create
a biochemical environment more conducive to the
integration of emotional circuitry into consciousness (Bishof,
1983; Chambers et al., 1999). This may be the underlying
neurobiology of Freud’s belief that the presence of affect is
necessary for change. Simultaneous activation of neural
networks of emotion and cognition may result in a binding
of the two in a way that allows for the conscious awareness
and integration of emotion.

Treatment Rationales and Combinations

Sometimes I lie awake at night, and ask, “Where have

I gone wrong?” Then a voice says to me, “This is
going to take more than one night.”
—Charles Schulz

The fundamental premise put forth in this book is that any

form of psychotherapy is successful to the degree to which
it positively impacts the underlying neural network growth
and integration. I expect future research to continue
supporting this basic hypothesis. Furthermore, evolving
technologies will provide us with increasingly accurate ways
of measuring activity within the brain and a greater
understanding of exactly what it is we are measuring. My
hope is that including neural network activity in our case
conceptualization may help to establish a common language
for us to select, combine, and evaluate the treatments we
provide. It will, one hopes, help us to move past debates
between competing schools of thought to a more inclusive
approach to psychotherapy.
One long and hard-fought debate about treatment
continues between supporters of psychopharmacology and
psychotherapy despite empirical support for both
approaches, individually and in combination. Brain
functioning offers us a way to look more deeply into the
effects of both talk and medication in regulating the brain
and stimulating neuroplasticity. Patients who come to see
me for psychotherapy are often adamant in their refusal to
consider medication. Some feel frightened or shamed if I
suggest the use of drugs as an adjunct to psychotherapy. At
the same time I know that many discount talk therapy and
will only seek help from therapists who will prescribe
medication. All clients could benefit from education about
brain functioning and the potential (even synergistic) power
of both interventions. On the one hand, the therapeutic
alliance supports positive expectancy, medication
compliance, and psychological well-being. On the other,
medication can help to achieve a state of body and mind
that allows clients to benefit from psychotherapy.
Many patients who suffer brain damage resulting from
accidents participate in multimodal rehabilitation programs
that include physical, cognitive, and psychosocial
interventions. The general approach to rehabilitation after
brain injury is to first assess which systems have been
damaged and which have been spared. The next step is to
develop a program that plays to the patients’ strengths and
attempts to compensate for their weaknesses. Traffic and
industrial accidents often result in damage to the frontal
cortex, making disorders of attention, concentration,
memory, executive functioning, and emotional regulation
common in neurological rehabilitation. These same
difficulties are common in many forms of psychological
distress and psychiatric illness.
 The traditional split between mind and brain has resulted
in the separate development of the fields of psychotherapy,
neuropsychology, and rehabilitation. When psychological
difficulties are conceptualized in the context of a brain–
behavior relationship, applying techniques from cognitive
rehabilitation in psychotherapy becomes an interesting
possibility. For example, abnormalities of frontal lobe
functioning have been found in OCD, depression, and ADHD.
Because these disorders share many symptoms afflicting
patients with brain injury, psychotherapy patients with
these and other psychiatric diagnoses may benefit from the
strategies of cognitive rehabilitation (Parente & Herrmann,
1996).
An example of this was given in an earlier chapter, when
I discussed how the simple memory strategies I used to
assist my patient Sophia in remembering her appointments
helped us to establish a solid alliance. My working
assumption was that a combination of decreased
hippocampal volume due to chronic stress and
hypometabolism in the temporal lobes related to depression
created real, brain-related memory dysfunctions (Bremner,
Scott, et al., 1993; Brody et al., 2001). The success of
cognitive-behavioral treatments with depressed and anxious
patients underlines the importance of focusing on basic
issues of reality testing, focused attention, and emotional
regulation in order to support prefrontal functioning
(Schwartz, 1996).
Findings with borderline clients of damage or dysfunction
of the frontal and temporal lobes support the use of
cognitive rehabilitation techniques with this population
(Paris et al., 1999; Swirsky-Sacchetti et al., 1993). This may
help explain why borderline patients require increased
levels of structure to scaffold their erratic executive control
and emotional instability. Manipulation and organization of
the physical environment, sensory stimulation, and the type
and amount of activity all impact brain functioning.
Psychoeducation and enlisting family and friends in the
therapeutic process (as utilized extensively in rehabilitation
after brain damage) are also potential mechanisms of
change. A good example of this is dialectical behavioral
therapy (Linehan, 1993), which combines exposure,
cognitive modification, skills development, and problem-
solving skills to support prefrontal functioning.
Diagnostic and treatment approaches focused on
cognitive deficits serve to decrease shame and help to
create a stronger treatment alliance. Highly structured skill-
building techniques, in the context of support and
understanding, may provide disorganized patients the
opportunity for early and clearly measurable success
experiences. As our understanding of neural networks
related to memory, affect, and behavior expands, prosthetic
aids to these systems will be created and applied in the
psychotherapy context. Increasing interdisciplinary
coordination of this kind will require more comprehensive
training for psychotherapists, not only in neuroscience but
also in cognition, memory, and rehabilitation science.
Removing the traditional barriers between psychotherapy
and rehabilitation may lead to a higher quality of care and
greater treatment success.

Why Neuroscience Matters to Psychotherapists

In science the important thing is to modify and

change one’s ideas as science advances.
—Herbert Spencer

The psychotherapist as healer exists within a long tradition

of rabbis, priests, medicine women, and shamans. At the
same time, findings in social neuroscience make it clear that
we are also in the current scientific mainstream. In contrast
to technological medicine, we understand our profound
personal role in the healing relationship while
simultaneously respecting the subjective experience of our
clients. In the absence of a brain-based model of change,
the leaders of our fields have learned to stimulate and guide
neuroplastic processes to help build, integrate, and regulate
our clients’ brains. But why does an academic
understanding of neuroscience make any difference to our
work? Here are a few thoughts.
On a practical level, adding a neuroscientific perspective
to our clinical thinking allows us to talk with clients about
the shortcomings of our brains instead of the problems with
theirs. The truth appears to be that many human struggles,
from phobias to obesity, are consequences of brain
evolution and not deficiencies of character. Identifying
problems that we hold in common and developing methods
to circumvent or correct them is a solid foundation upon
which to base a therapeutic alliance.
As we come to better understand the neural correlates of
mental health and emotional well-being, we may be able to
use this knowledge to aid us in diagnosis and treatment.
Neuroscience may also someday provide us with a rationale
for an informed eclecticism as well as additional means of
evaluating outcome. We will be able to see which
combination of treatments impacts targeted neural
networks and how changes in the activation of these circuits
correspond with symptom expression. Neuroscience can
also provide a common language to communicate with
physicians, pharmacologists, and neurologists who may also
be treating our clients. Finally, if you are anything like me,
you might find a neuroscientific perspective to be an
exciting addition to many case conceptualizations.
Some therapists bristle at the integration of neuroscience
and psychotherapy, calling it irrelevant or reductionistic. I
think I understand their perspective and concerns—if you
have a model of therapy that works, why bother with the
brain? Would Rogers, Kohut, or Beck have been better
therapists if they had been trained as neuroscientists?
Probably not. On the other hand, it is hard for me to grasp
how the brain could be irrelevant to changing the mind. And
while I dislike reductionism as much as the next person,
doesn’t a tendency toward reductionism say more about the
thinker than the nature of natural phenomena? Our
knowledge of neuroscience highlights the fact that we
primates have complex and imperfect brains and should
remain skeptical about what we think we know. In other
words, primates would be wise to doubt their beliefs and
remain open to new ideas.
It is humbling and more than a little frightening to realize
that we rely on what may be the most complex structure in
the universe with little knowledge of how it works. But even
though we are only at the dawn of understanding the brain,
an appreciation of its evolutionary history, developmental
sculpting, and peculiarities of design can surely encourage
us to begin to use it more wisely. Practical things—like
understanding the neural damage resulting from drugs,
stress, and early deprivation—should influence everything
from personal decision making to public policy. The neural
network dissociation that often results from exposure to
combat should make us pay closer attention to those whom
we put in harm’s way. Even our tendencies to distort reality
in the direction of personal experience and egocentric needs
should lead us to examine our beliefs and opinions more
carefully.
We now know that mind and brain are indivisible and that
disorders traditionally thought of as psychological need to
be reconceptualized to include their neurobiological
mechanisms. And if brain dysfunction is central to a client’s
difficulties, the “most illuminating interpretation” may not
be as valuable as a little accurate neurobiological
knowledge (Yovell, 2000).
Self-awareness is a relatively new phenomenon in
evolutionary history. Psychotherapy increases neural
integration through challenges that expand our experience
of and perspective on ourselves and the world. The
challenge of expanding consciousness is to move beyond
reflex, fear, and prejudice to a mindfulness and compassion
for ourselves and others. Understanding the promise and
limitations of our brains is but one essential step in the
evolution of human consciousness.
In conclusion, our brains are inescapably social, their
structures and functioning deeply embedded in the family,
tribe, and society. And while the brain has many
shortcomings and vulnerabilities, our ability to link with,
attune to, and regulate each other’s brains provides us with
a way of healing. This is why the power of human
relationships is at the heart of psychotherapy. From my
perspective, the value of neuroscience for psychotherapists
is not to explain away the mind or generate new forms of
therapy, but to help us grasp the neurobiological substrates
of the talking cure in an optimistic and enthusiastic
continuation of Freud’s Project for a Scientific Psychology.
Credits

Table 6.1: 1. Davidson and Fox, 1982 2. Canli et al., 1998 3.

Wheeler, Davidson, & Tomarken, 1993 4. Davidson & Fox,
1982; Harmon-Jones & Allen, 19985. Tomarken, Davidson,
Wheeler, & Dass, 1992 6. Coan, Allen, & Harmon-Jones,
2001; Davidson et al., 1990; Ekman & Davidson, 1993; 7.
Urry et al., 2004 8. Fox & Davidson, 1988 9. Harmon-Jones &
Allen, 1998 10. Harmon-Jones & Sigelman, 2001 11. Harmon-
Jones & Sigelman, 2001 12. Davidson et al., 199013. Fox &
Davidson, 1986 14. Canli et al., 1998 15. Davidson & Fox,
198216. Wheeler et al., 1993 17. Kalin, Shelton, Davidson, &
Kelley, 2001 18. Fox & Davidson, 1988 19. Davidson & Fox,
1989
Table 7.1: 1. Minagawa-Kawai et al., 2008; Nitschke et al.,
2004 2. Berthoz et al., 2002; Mitchell, Banaji, & Macrae,
2005 3. Mitchell, Macrae, & Banaji, 2006 4. Gusnard et al.,
2002 5. Goel & Dolan, 2001 6. Frey & Petrides, 2000; Nobre
et al., 1999 7. Ongur & Price, 2000 8. Bechara et al., 1998;
Gallagher et al., 1999; Gehring & Willoughby, 2002;
Kringelbach, 2005; Krueger et al., 2006; O’Doherty, 2004 9.
Bechara et al., 1994; O’Doherty et al., 2002 10. Matsumoto &
Tanaka, 2004 11. McGuire et al., 1996 12. Dias, Robbins, &
Roberts, 1996; Simpson, Drevets, et al., 2001; Simpson,
Snyder, et al., 2001; Quirk & Beer, 2006 13. Malloy et al.,
1993; Teasdale et al., 1999; Beer et al., 2006 14. Koechlin,
Ody, & Kouneiher, 2003; 15. Dias et al., 1996; Fuster, 1997;
Nagahama et al., 2001 16. Knight & Grabowecky, 1995 17.
Rezai et al., 1993; Petrides, Alivisatos, & Frey, 2002 18.
Henson, Shallice, & Dolan, 1999 19. Levesque, Eugène,
Joanette, Paquette, et al., 2003 20. Pascual-Leone et al.,
1996 21. Kroger et al., 2002; Malloy et al., 1993; Teasdale et
al., 1999 22. Mitchell et al., 2006 23. Gray, Braver, & Raichle,
2002
Table 7.3: 1. Tamm, Menon, & Reiss, 2006 2. Bush et al.,
1999; Tamm, Menon, Ringel, & Reiss, 2004 3. Tamm et al.,
2004 4. Rubia et al., 1999 5. Yu-Feng et al., 2007 6. Tamm et
al., 2004 7. Zang et al., 2005 8. Yu-Feng et al., 2007 9. Lou,
Henriksen, & Bruhn, 1984 10. Lee et al., 2005 11. Castellanos
et al., 2002 12. Casey, Castellanos, & Giedd, 1997 13. Li et
al., 2007 14. Markis et al., 2007 15. Mackie et al., 2007 16.
Ashtari et al., 2005
Table 8.1: 1. Dehaene, Molko, Cohen, & Wilson, 2004 2.
Victor & Roper, 2001 3. Sirigu et al., 1996 4. Colby, 1998;
Driver & Mattingley, 1998 5. Newman et al., 2003 6. Rorden,
Mattingley, Karnath, & Driver, 1997; Snyder & Chatterjee,
2004 7. Karnath, 1997; Ungerleider & Haxby, 1994 8.
Schwartz et al., 2005 9. Battelli et al., 2001; Claeys et al.,
2003 10. Griffiths et al., 1998 11. Snyder & Chatterjee, 2004
12. Anderson & Mountcastle, 1983 13. Pia et al., 2004

Table 8.2: 1. Griffiths et al., 1998 2. Chochon et al., 1999 3.

Newman et al., 2003 4. Uddin et al., 2005 5. Dehaene et al.,
2003 6. Molko et al., 2003 7. Chochon et al., 1999 8. Molko et
al., 2003; Rushworth, Krams, & Passingham, 2001 9.
Newman et al., 2003 10. Newman et al., 2003 11. Antal et al.,
2008 12. Grefkes & Fink, 2005; Wolpert, Goodbody, & Husain,
1998 13. Wolpert et al., 1998 14. Jonides et al., 1998 15.
Wagner et al., 2005 16. Marshuetz et al., 2000; Van Opstal,
Verguts, & Fias, 2008 17. Husain & Nachev, 2007 18. Astafiev
et al., 2003 19. Mountcastle, 1995 20. Orban et al., 1999 21.
Castelli, Glaser, & Butterworth, 2006; Fias et al., 2003;
Lemer et al., 2003 22. Fias et al., 2007 23. Ruby & Decety,
2001 24. Iaccoboni et al., 2004; Jackson & Decety 2004 25.
Vogeley et al., 2004
Table 12.1: 1. Bredy et al., 2003; Champagne et al., 2008 2.
Weaver, Grant, & Meaney, 2002; Weaver, Meaney, & Szyf,
2006 3. Garoflos et al., 2008; Menard, Champagne, &
Meaney, 2004 4. Liu et al., 2000 5. Zhang et al., 2005 6.
Menard et al., 2004 7. Weaver et al., 2004 8. Caldji, Diorio, &
Meaney, 2003 9. Caldji, Diorio, Anisman, & Meaney, 2004;
Caldji et al., 1998 10. Braun & Poeggel, 2001 11. Champagne
et al., 2003 12. Champagne et al., 2001, 2003, 2006 13.
Cameron, Fish, & Meaney, 2008
Table 12.2: 1. Zhang at al., 2002 2. Marais et al., 2008 3.
Leventopoulos et al., 2007 4. Caldji et al., 2000; Hsu et al.,
2003; 5. Rees, Steiner, & Fleming, 2006 6. Blaise et al., 2007
7. Brake et al., 2004 8. Kuhn & Schanberg, 1998 9. Kalinichev

et al., 2002 10. Coutinho et al., 2002 11. Weaver et al., 2006
12. Ovscharoff & Braun, 2001 13. Akbari et al., 2007

Table 12.3: 1. McCormick et al., 2000; Meaney et al., 1988,

1991; O’Donnell et al., 1994; Smythe, Rowe, & Meaney,
1994 2. Sarrieau, Sharma, & Meaney, 1988 3. Plotsky &
Meaney, 1993 4. Kosten, Lee, & Kim, 2007 5. Siviy &
Harrison, 2008 6. Garoflos et al., 2007 7. Vallée et al., 1997 8.
Vallée et al., 1999 9. Costela et al., 1995; Tejedor-Real et al.,
1998 10. Weaver et al., 2000 11. Collette et al., 2000
Table 13.1: 1. Krugers et al., 2006 2. Wantanabe, Gould, &
McEwen, 1992 3. Alonso, 2000 4. Sapolsky, 1990 5.
Dranovsky & Hen, 2006; Kelly, Mullany, & Lynch, 2000;
Pham et al., 2003; Prickaerts et al., 2004 6. Kuhlmann, Piel,
& Wolf, 2005; Kirschbaum et al., 1996; Newcomer et al.,
1994, 1999 7. West, 1993; Lupien et al., 1998 8. Bremner,
Scott, et al., 1993 9. Bremner, Southwick, et al., 1993;
Vythilingam et al., 2002 10. Bremner et al., 1995; 1997;
Bremner, 2006; de Lanerolle et al., 1989 11. Villarreal et al.,
2002 12. Falkai & Bogerts, 1986; Nelson et al., 1998 13.
Bourdeau et al., 2002; Condren & Thakore, 2001
Table 17.1: 1. Bennett, Diamond, Krech, & Rosenzweig,
1964; Diamond et al., 1964 2. Kempermann et al., 1998;
Walsh, Budtz-Olsen, Penny, & Cummins, 1969 3. Kolb &
Whishaw, 1998 4. Kolb & Whishaw, 1998 5. Kolb & Whishaw,
1998 6. Ickes et al., 2000 7. Nilsson et al., 1993 8. Sirevaag &
Greenough, 1988 9. Sirevaag & Greenough, 1988 10.
Guzowski, Setlown, Wagner, & McGaugh, 2001 11.
Torasdotter et al., 1998
Table 17.2: 1. Fujikawa et al., 2000 2. Abercrombie et al.,
2003; Andreano & Cahill, 2006; Domes et al., 2005 3.
Takahashi et al., 2004 4. Conrad, Lupien, & McEwen, 1999;
Kerr, Huggett, & Abraham, 1994; Park et al., 2006; Yau et
al., 1995 5. Diamond et al., 1992 6. Pavlides et al., 1995 7.
Sullivan, Wilson, & Leon, 1989 8. Introini-Collison &
McGaugh, 1987
Table 17.4: 1. Mayberg et al., 2002 2. Mayberg et al., 2002
3. Kong et al., 2006 4. Pariente et al., 2005 5. Petrovic et al.,

2002 6. Wager et al., 2004 7. Wager et al., 2004 8. Zubieta et

al., 2005 9. Benedetti et al., 2004 10. Fuente-Fernandez et
al., 2001
Table 18.1: 1. Baxter et al., 1992 2. Brody et al., 1998 3.
Nakatani et al., 2003 4. Schwartz et al., 1996 5. Lazaro et al.,
2009 6. Furmark et al., 2002 7. Paquette et al., 2003 8.
Johanson et al., 2006 9. Straube et al., 2006 10. Levin,
Lazrove, & Van der Kolk, 1999 11. Prasko et al., 2004 12.
Sakai et al., 2006 13. Goldapple et al., 2004 14. Kennedy et
al., 2007 15. Martin et al., 2001 16. Brody, Saxena, Stoessel,
et al., 2001 17. Brody, Saxena, Schwartz, et al., 2001 18.
Penades et al., 2002 19. Wykes et al., 2002 20. Laatsch et al.,
1999
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 THE NORTON SERIES ON INTERPERSONAL
NEUROBIOLOGY
 
Allan N. Schore, PhD, Series Editor
Daniel J. Siegel, MD, Founding Editor
 
The field of mental health is in a tremendously
exciting period of growth and conceptual
reorganization. Independent findings from a variety of
scientific endeavors are converging in an
interdisciplinary view of the mind and mental well-
being. An interpersonal neurobiology of human
development enables us to understand that the
structure and function of the mind and brain are
shaped by experiences, especially those involving
emotional relationships.
The Norton Series on Interpersonal Neurobiology
will provide cutting-edge, multidisciplinary views that
further our understanding of the complex
neurobiology of the human mind. By drawing on a
wide range of traditionally independent fields of
research—such as neurobiology, genetics, memory,
attachment, complex systems, anthropology, and
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health professionals a review and synthesis of
scientific findings often inaccessible to clinicians.
These books aim to advance our understanding of
human experience by finding the unity of knowledge,
or consilience, that emerges with the translation of
findings from numerous domains of study into a
common language and conceptual framework. The
series will integrate the best of modern science with
the healing art of psychotherapy.