Brain based therapy

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  • 1.Brain Based Therapyby John ArdenDavid Waymer

2. Based on contemporary neuroscience andpsychotherapy research, the brain-based modelsheds new light on a question that has beguiledpsychotherapy from its beginning:How can a simple conversationor as Freudcalled it the talking cure change the brain? 3. OriginsIn the 1970s, Prozac, the DSM III and evidenced-based therapies all came into being within a fewyears of each other. These innovations provided away to think about, classify and treat mentalconditions, and became institutionalized in a modelArden refers to as the pax medicaThe pax medica medicalized psychology andpsychiatryPart of the success of Prozac was based on theappealing notion that it corrected chemicalimbalances in the brain, and well-controlled drugtrials seemed to prove the theory behind the product 4. OriginsIn the U.S one in 20 men, and almost onewoman in 10, uses an antidepressantBy contrast, about one in 20 adult Americanssees a psychiatrist, psychologist or social workerfor psychotherapyThe number of patients treated for depressionwith psychotherapy actually declined between1987 and 1997, a decade during whichprescriptions for antidepressants doubled 5. OriginsPharmaceutical companies have promoted theidea that chemical imbalance is the cause ofdepression, and massive marketing hasconvinced millions of patients that bymanipulating their neurotransmitters they cancure their depressionThis one-factor model underlies the dramaticsuccess of serotonin reuptake inhibitors (SSRIs).What it leaves out is that the brain is differentthan the liver or other organs in the body. Thebrain changes itself through experience,especially experiences of interpersonalconnection that rewire the brain from birth on 6. B.A.S.E.Arden and his colleagues created a model tohelp other psychotherapists make the changefrom the the old world of the pax medicareferred to as the BASE modela new model that incorporates currentneuroscience, developmental psychology,psychodynamic theory, cognitive psychology, andpsychotherapy researchBASE stands for brain, attunement, systems ofcare, and evidence-based treatment 7. Experienced therapists who incorporate the brain-based model into their practices learn to think aboutcase formulation in a different way, but typically donot have to master new techniquesWhat the brain-based perspective adds is a cross-disciplinary, biopsychosocial perspective that opens anew way of understanding the psychotherapeuticrelationshipthis new understanding results in a subtle shift intherapists attitudes toward patients and enhancestheir empathy and respect for client experience 8. Another quality that Arden and his colleaguesstress is a lack of perfection. Like the goodenough mother they think that being a goodenough therapist is better than being a perfectone. They say that imperfection gives patientsplenty of room to express the negative emotionsthat are often a key to improvement, and is morerespectful of the patients need to grow andeventually separate from the therapist 9. B is for BrainThe brain is an organ that lives or dies by virtueof its relationships with the brains around it. Ourgenetic endowment for connecting with others isprerequisite to all the brains other capacities andfeaturesThe brains neuroplasticity is at the heart ofbrain-based therapy 10. B is for BrainRobert Sapolsky (1996) showed some years ago that underprolonged stress the levels of the stress hormone cortisol stay highand paradoxically effect two important brain modules. Thehippocampus, which encodes new memories and normally helps turnoff the production of stress hormones, shrinks; while the amygdala, apart of the brain that stimulates the production of these agents, growsin volumeChronic stress creates a biological feedback loop, making it harder toremember things, harder to think clearly, and intensifying anxiety.Recent neuroimaging studies of anxious patients have pinpointedamygdalar hyperactivity as a common mechanism underlying socialanxiety disorder and common phobiasThe brain-based model incorporates these facts about stressarchitecture as well as other research that demonstrates the role ofstress in anxiety and depressive disorders. A goal of brain-basedtherapy is helping clients learn to manage stress and minimize theirallostatic load 11. Focus on getting control ofthe Brain Many studies support the idea that shifts in the balance of activity between the two cerebral hemispheres is associated with positive or negative affect. In one study, a senior Tibetan monk underwent an electrophysiological assessment during meditation As the meditation progressed, marked shifts occurred in hemispheric activation, with the monks left hemisphere (LH) becoming more active as the meditation progressed. Activation of the LH had been shown previously to be associated with emotions such as contentment and happiness Greater activation of the right hemisphere (RH), by contrast, has been associated with negative emotions such as sadness, anxiety and anger. Shifts to the RH are also associated with lower self- esteem in adults as well as depression 12. B is for BrainThe left- sided tendency to initiate approach behaviourscomplements the tendency of the right to initiate withdrawal. Giventhese findings, when working with anxious clients, we suggest thattherapists encourage the client to detach from the paradox of tryingnot to feel anxious.The capacity to stop or shut down anxious thoughts lies in the clientsright pre-frontal cortex, and overactivating this module ironically islikely to result in an increase in the anxious feeling the clients wantsto suppress.On the other hand, accepting and riding out anxious feelings andthoughts mindfully requires a shift from RH to LH functioning andusually results in these feelings subsiding more quickly. Labelingthese affective experiences in therapy also helps the client shift fromright to left pre-frontal activation and clients are likely to experiencethe positive affects and approach behaviours associated with thismove. 13. A is for AttunementIn successful psychotherapy, the clues to patterns ofpsychopathology are inferred from the clients subtleenactments and nonverbal communicationsA new narrative is co-constructed by the therapist andpatient. At the heart of the process is the deep needof the human brain for relatedness and reflection inthe glances, facial expressions and words of anotherpersonunderscores the finding from the research that justgetting clients to verbalize their feelings about thetherapists attunement to their experience producessignificantly better outcomes 14. S is for SystemsBringing the brain back into psychotherapy suggests theuse of interventions that traditionally are not considered tobe within the therapists purview. These interventions havelittle to do with meaning but powerfully affect the brain. Asnoted above, we find many psychological problems to bedown-stream effects of impairments in the brains capacityto regulate the neurodynamics of stressIf therapists ask, it almost inevitably turns out that sufferingclients have adopted behaviours and lifestyles thatunwittingly support this biological dysregulationExpanding the scope of psychotherapy to include thebehavioural determinants of brain health requires us toconsider how the sleep, eating and exercise habits ofclients are affecting their embodied minds 15. S is for Systemsresearch illustrates the role that sleep, for example, plays in the brains self-regulatory processes:Researchers have found a direct relationship between the levels of animportant neurochemicalbrain- derived neurotropic factor (BDNF)andslow-wave sleep (the most relaxing kind). The more slow-wave sleep, the moreBDNF in the brainBDNF is a naturally occurring fertility drug for neurons. It promotes enrichedsynapses and facilitates the creation of new neurons (neurogenesis) in keyareas of the brainDuring daytime activityand especially as a by-product of aerobic exerciseBDNF levels normally increase, and new synapses and neurons sprout inareas such as the hippocampus, facilitating the production of new memoriesand down-regulating the brains stress centers. Slow-wave sleep appears tocounterbalance this expansionist daytime growth and may play a role inconserving new memories encoded during the day. In a brain-based context, itmakes good sense to ask about sleep and exercise habits, and discuss theirlikely relationship to the clients presenting problems 16. S is for SystemsA systems issue of a different kind has to do with the role ofpsychotropic medication in many therapies. Patients have a right toexpect their therapists to have expertise about the side effects,limitations, and dosages of commonly prescribed medicationsA good working relationship with the prescribing provider and askingthe client about the experience of taking the medication are alsoimportant. It is also usually helpful for clients to understand howmedications affect their brain functions, beyond the one factorneurotransmitter hypothesis of the pax medicaRecent research, for example, suggests that increased BDNF and aresulting boost in hippocampal neurogeneis may underlie effectiveantidepressant treatmentTogether, the effects of joint psychotherapeutic-psychopharmacological depression treatment push and pull the brainback into a healthy allostatic balance 17. E is for EvidenceThe brain-based model vastly expands the evidence-basisfor psychotherapyImaging studies confirm the importance of exposure intreating anxiety. In a study of the effects of CBT on clientssuffering from a spider phobia, researchers used functionalmagnetic resonance imagery (fMRIs) to document the factthat exposure to spiders provoked hyperactivity in theamgydalas and fusiform gyri of arachnophobes anddecreased the activation of their medial orbitofrontalcortices (OFCs). The OFC is normally a major force indown-regulating amygdalar activation. Over time, exposurein the context of psychotherapy promo