The roles of anxiety in the change process warrant special consideration. The basic relationship of anxiety to the overall model of brain function and psychotherapy has been previously discussed (see Figure 6.1), so only a brief summary is presented here. Gray has posited the presence of a system that monitors the similarity between brain patterns related to current experience and brain patterns that have been associated with negative events in the past. When the system identifies similarity, the anxiety response is triggered. This involves behavioral inhibition, increased diffuse arousal, and increased attention to the environment. Anxiety itself likely blocks awareness of the source of the anxiety through diffuse brain arousal that interferes with a particular pattern standing out from other patterns and therefore gaining attention. Behaviors that reduce the similarity between current patterns and past distressing patterns likely reduce the anxiety reaction, and in this way maladaptive behaviors that avoid dealing with a problem are rewarded. These maladaptive patterns of experience and function present in therapy as anxiety that occurs for no obvious reason followed by behaviors that interfere with positive functioning.

When therapy reaches a road block whereby reasons for the anxiety and maladaptive behaviors are unclear, it becomes useful to recall that the anxiety response is part of a neural network. Previously discussed strategies for exploring neural networks can then be applied.

The application of neuroscience to clinical interventions rests on the premise that different parts of the brain carry out different tasks related to elements of cognition, emotion, and behavior. A client's words and actions during therapy provide information regarding which brain systems are active during therapy and the strengths and weaknesses in these different brain systems. An understanding of underlying brain processes can guide conceptualization of the client's functioning, choices of intervention, and communication with the client during interventions.

Neuropsychology is a field that links observed behaviors to the areas of the brain used in carrying out those behaviors (Lezak, Howieson & Loring, 2004). In its early days, a primary application of neuropsychological assessment involved the use of behavioral observations and tests to help determine the location of damage within the brain. These determinations guided surgical as well as rehabilitation interventions. In recent years, imaging techniques (see Appendix) have been developed that allow non-intrusive examination of brain structure and function, minimizing the need to rely on neuropsychological behavior-based tests for locating brain lesions. However, the idea that specific parts of the brain support specific behaviors remains a powerful guide to understanding the nature of clients' functioning and intervening to help them.

The basic concept underlying neuropsychological assessment is that each behavior relies on activity in a specific set of areas of the brain, and that each area of the brain is involved in only certain types of behavior.

Beyond offering a free-standing framework for conducting therapy, brain functions and systems can provide a framework within which traditional therapies can be understood and integrated. Since all change in psychotherapy is hypothesized to be based on changes in the way the brain takes in, processes, and responds to information from the world around the individual, it makes sense that traditional models of psychotherapy can be considered in light of brain systems involved (Kandel, 1998). Knowledge of brain systems can help elucidate processes of therapy within each traditional model while also making clear how different models relate to each other. The result can be an integration of the strengths of the various traditional models. This integration can facilitate shifting from one treatment model to another in a seamless way, thereby supporting more effective overall intervention. At the same time, communication between therapists operating within the confines of different traditional models can be facilitated, offering another way in which treatment can be enhanced.

Psychodynamic, behavioral, cognitive–behavioral, and Gestalt theories will be considered as examples during the present discussion. In addition, pharmacotherapy will also be discussed as a form of intervention. For current purposes, only selected elements of each school of intervention will be examined, since more complete analysis of connections between brain systems and the respective schools would be far more complex than the present venue permits.

Each psychotherapy theory can be considered within the neuroscience framework developed in previous chapters.

Neuroscience concepts can influence what information is gathered during the intake process. Various schools of psychotherapy support obtaining information in various specific areas of psychological and personal functioning, but consideration of brain function encourages collection of a broader range of information while maintaining awareness of how the various pieces of information relate to each other. Psychodynamic (Fenichel, 1945) and object relations (Mahler et al., 1975) theories emphasize gathering information regarding the family dynamics within which the patient developed. Behavior analysis (Bellack et al., 1990) emphasizes the identification of environmental stimulus events, description of problem behaviors, and delineation of consequences of behavior. Traditional cognitive behavioral therapy encourages the identification of irrational thoughts that occur in response to specific events and ideas (Beck, 1976). A brain-based model of psychotherapy directs the therapist to gather information related to each of these areas so a full understanding of brain-based behaviors related to problematic functioning can be obtained. A brain-based model provides for identification of all possible contributors to the current shape and function of the brain, and calls for as complete an understanding as possible of how these contributors interact.

The intake interview designed to support a neuroscience-based model of intervention includes information from the following areas:

• Genetics

• Biological events

• Early interpersonal patterns

• Later interpersonal patterns

• History of family structure and events

• Current behavioral functioning

Information from these areas might be collected in support of therapy based on any of the various schools of intervention, but using the brain to guide assessment leads to changes in the process of gathering intake information as well as in the content of intake interviews.

The previous chapter characterized the brain's processing of experience as a sequential flow of discrete neural events occurring in various locations throughout the brain as information moves from input to output. The description emphasized the “bits and pieces” aspect of brain function. At the same time, the brain's representation of each experience can also be conceived as a single, unique, integrated pattern that includes neurons from widely dispersed areas of the brain (Levine, 2000). Each moment of an experience is a neural network. Each experience is simultaneously bits and pieces of activity and a unified collection of brain processes. The neural network concept provides a framework within which details of various brain processes can be examined. The neural network concept can improve understanding of how individual parts of the brain influence the overall experience of life and how experiences in life are brought to the psychotherapy setting (Vaughan, 1997).

The neural network for any single experience is conceived to be composed of neurons from throughout the brain (see Figure 3.1). Two separate experiences are represented in Figure 3.1, with each experience including neurons from the same areas of the brain, but not sharing individual neurons. The schematic representation includes two sensory areas: an area related to cognitive processing and an area related to processing of emotions. Each individual experience has the potential to include elements from throughout the brain (see to Figure 1.1).

The previously presented description of the neural network concept briefly identified the special contributions of affect to neural network patterns and to memory processes. The connections between affect and memory should be clearly delineated.

The amygdala (see Figure 1.1) is a primary center for the processing of emotions (LeDoux, 2002; McGaugh, 2004). Multiple connections exist between the amygdala and the hippocampus, and there is strong evidence that the two areas of the brain work in tandem. LeDoux (1996) has suggested that hippocampal integrations would be affect-free without the connections between the amygdala and the hippocampus. However, the amygdala also has direct and indirect interconnections with sensory cortex and sensory receptor neurons, so ties between sensory information and emotion can be established both with and without conscious awareness and explicit memory systems (LeDoux, 1996).

It appears that the amygdala contributes to memory storage by activating memory consolidation processes in other parts of the brain when positive or negative emotion is present (McGaugh, 2004). Stimuli with positive or negative emotional valence are remembered more clearly than are neutral stimuli. For example, faces with either positive or negative expressions are remembered better than are faces with neutral expressions, and neural imaging of the brain indicates that increased amygdala activity accompanied by commensurate hippocampal activity parallels the differences in learning (Dolcos et al., 2003). Neutral stimuli are learned more effectively, as well, when followed by administration or stimulation of hormones or neurotransmitters associated with emotion and activation of the amygdala.

Chapters 12 to 16 examined aspects of clients' intrapsychic functioning and overt expression and behavior during psychotherapy in light of brain processes involved. At the same time that neuroscience concepts guide consideration of the client's processing and how to improve this processing, they can also guide understanding and use of the therapist's own brain functioning during therapy. The current chapter does not thoroughly explore the implications of neuroscience conceptualizations for therapist functioning. Rather, this chapter highlights some basic relevant implications that have been observed during the clinical process. General connections between neuroscience concepts and the therapist's functioning are described, the influences of the therapist's neural networks are outlined, limitations to reliance on intuition are identified, and ways to discuss with the client the therapist's neural networks are suggested. This chapter also addresses the implications for the client of the act of discussing the therapist's networks, describes the role of metaphor in the interaction between the client's and the therapist's neural networks, and highlights the importance of the therapist understanding as well as possible underlying patterns within the therapist that may shape the emergence of ideas and hunches into the therapist's conscious awareness.

A therapist's experiences during psychotherapy can be considered in light of all the aspects of neuroscience previously described in regard to client functioning. The therapist's functioning during therapy can be considered in light of the characteristics of input absorbed by the therapist, processing of information taken in, and outputs subsequent to this processing.

Each experience, whether current event or memory, is assumed to consist of a unique network of neurons from many parts of the brain: a neural network. Sensory systems, motor tracts, brain stem arousal systems, affect centers, hippocampal integration centers, anxiety responses, and frontal executive centers are all likely represented in a given neural network. These pieces of the neural network provide the framework through which experiences observable to the client, the therapist, and other people interacting with the client can be understood. Such experiences include the phenomena of cognition and affect, expressed behavior, shifts in attention, experience and demonstration of anxiety, and physiological responding. A specific network is likely to become active when enough of the neurons of which it is composed are stimulated at the same time. In a complementary fashion, other networks that share neurons with the network of immediate interest are likely to be triggered when enough shared neurons are simultaneously firing.

Using neural network concepts as needed

Psychotherapy cases can often be adequately represented by traditional psychotherapy theories. In such cases, interventions can be conceived and described in terms of the traditional theory being used, and neuroscience conceptualizations would be included only when they offer additional insight to the traditional theory being used. Consequently, time would not be spent helping the client develop an overall or in-depth understanding of the neural network model.

Previous chapters have provided a broad conceptualization of personal functioning relevant to psychotherapy. This conceptualization has been applied to psychological interventions in general, and connections have been identified between the current framework and traditional psychotherapies. The present neuroscience model of psychological therapies can also be used as the framework within which specific diagnoses or syndromes are treated.

Treatment of depression provides an opportunity to demonstrate how a neuroscience approach can be applied to psychological problems identified as part of a specific diagnosis. In this chapter, issues associated with the definition and diagnosis of depression will be discussed in light of a neuroscience approach. Genetic and developmental influences on the expression of depression will be discussed in terms of brain processes. Behaviors, thoughts, and emotions that characterize depression will be tied to brain function, and the treatment implications of brain anatomy and processes will be described. Specific applications of neuropsychological concepts and the concept of neural networks will be delineated. Techniques will be offered for integrating discussion of the brain into discussions with clients regarding depression, and implications of brain function for client improvement will be highlighted. In the course of the discussion of applying neuroscience to the treatment of depression, similarities to and differences from traditional models of intervention with depressed clients will be noted.

Definition of depression

A clear and specific definition of depression remains elusive (Klein et al., 2006; Maj & Sartorius, 1999).

Before exploring the clinical implications of brain systems and processes described in previous chapters it is worthwhile to summarize the ideas that have been presented thus far and organize these ideas within a framework that can guide conceptualization and intuition. Such an organizational framework can support a concrete and somewhat simplified view of brain functioning that can facilitate the application of neuroscience knowledge to psychotherapy intervention.

Information can be viewed as entering the brain through any of a number of sensory avenues to be integrated in multiple parallel centers, recombined in novel ways, and expressed through a variety of output pathways. Paths of influence within the brain flow from lower arousal mechanisms, up to mid-brain affect and integration systems, then to the higher cortex, and back again, in a continuous reciprocal flow. Connections can be direct as well as mediated by intervening connections as information flows up and down the brain. Each thought, experience, or action can be conceived as based on an underlying neural network composed of neurons from disparate parts of the brain, and each network can be understood to have connections with other networks through the sharing of neurons that compose each network. Implicit, procedural memory processes support emotional and non-emotional learning within and outside the awareness of the individual, while explicit, declarative memory systems relying on the hippocampus and associated frontal cortex systems support complex integration and rapid analysis of information in the brain.

Emotions are particularly potent elements of neural networks. They have a central role in therapists' brain-based conceptualizations during therapy while also serving as a valuable focus during discussions with clients. Concepts related to emotions in personal functioning were outlined in Chapter 5. These concepts can be applied by clinicians throughout the process of therapy. The present chapter addresses how such applications unfold during therapy and emphasizes how such understanding can be shared with clients.

Clinical observations suggest that clients often feel threatened by the intensity, unpredictability, and uncontrollability of emotions. Clients often feel weak and inadequate simply because they are experiencing emotions, and they often sense that something is wrong with them for having strong emotional reactions. There seems to be a tendency for clients to perceive that emotions are synonymous with the self, and as a result, when emotions are negative or unacceptable, clients become convinced, or at least suspicious, that their inner core is unacceptable. Clients express particular distress when their emotions do not match the declaratively developed conscious value system to which the individual client adheres. The client experiences his inner self as being incongruent with what he wants his self to be.

Explicit discussion of the nature and likely evolutionary function of emotions can allow clients to accept emotions and then both use and manage them more effectively. Explaining the important role of emotions in the activation of neural networks seems particularly useful in such discussion.

Memory can be defined as the process whereby “knowledge is encoded, stored, and later retrieved” (Kandel et al., 2000a, p. 1245). On its surface, such a definition hints the brain is a static recording device waiting to take in and store the input offered to it. This is not the case. Instead, the brain interacts with the environment, including the external world and the person's own body, in multiple dynamic ways and changes form in response to these interactions. The form the brain takes subsequently influences its interactions with the environment in the future. Stated another way, “Memory is thus the way the brain is affected by experience and then subsequently alters its future responses” (Siegel, 1999, p. 24). Psychotherapy can be viewed as a process of recognizing how the brain has been shaped by its past and then applying this recognition to develop better ways to use the brain in future interactions with the world.

Memory can be viewed at various levels, each of which can offer different insights into human function. Global effects of experience on brain development can be viewed as one aspect of memory. Intracellular processes have been identified that support various memory processes. Connections between cells support memory in several ways, each of which offers its own implications for the development and maintenance of memories. Important processes related to intercellular connection include the strengthening of individual connections, long-term potentiation, habituation, and sensitization.

In order to understand psychological functioning in children as well as in adults it is important to understand how the processes unfolding during brain development influence psychological functioning over the course of development. Until recently, differences between the workings of children's brains and adults' brains were poorly recognized (if they were acknowledged at all). Medieval painters captured the issue on canvas: Madonna and Child paintings in the fifteenth century often presented Mary holding a tiny mature adult man in her lap rather than an infant; the image of the infant was treated as if the child was a miniature adult.

It is now recognized that a child's brain functions much differently than does an adult's brain, but often the extent and nature of the differences between the adult's brain and the child's brain are not fully appreciated. Adequate appreciation should include recognition that children's brains absorb, perceive, process, and respond to experiences in ways that are different from the processing in adult's brains. Adequate appreciation of differences should also include understanding that much of the information held in the mature, adult brain was taken in and integrated when the brain was much less developed and, as a result, much of the information on which the adult brain relies for processing current experiences is immature in structure and activity.

With regard to psychotherapy, interventions with a child's brain call for different approaches than interventions with an adult's brain. This is due to the availability of different capacities and processes.

Basic elements of brain function previously outlined include the input–process–output neuropsychological conception of brain function, interactions between higher and lower levels of the brain, neural networks, explicit memory systems, implicit memory systems, affect systems, and anxiety systems. It is important to consider these elements interacting together as a finished product, but in order to understand the brain in psychotherapy it is crucial to understand how the end product was achieved.

The processes constituting brain development influence how different areas of the brain operate in psychotherapy for clients at various stages of maturation. The processes of brain development also influence how the brain encodes experiences during childhood and then recalls and applies these experiences during functioning in adulthood.

It is important to consider the influences of both genetics and experience on the development of brain function and personality. It is also important to understand the dual developmental processes of creating and then streamlining neural connections. Finally, it is important to recognize the influences of myelination on the integration and mature activation of brain systems. Consideration of these contributors to brain development can support a more complete understanding of how clients perceive events and respond to them in psychotherapy and throughout life.

Genetics

The genetic code with which each person is endowed at conception contains a range of potentials available to be realized (Gilliam et al., 2000; Kramer, 2005). Some of the characteristics embedded in the code can be activated independent of events in the environment surrounding the organism.