The neurobiological contribution to psychotherapy

Authored by Henry Strick van Linschoten

Understanding of emotions

Emotions are widely held to involve a subjective element, sometimes distinguished as a feeling. However, if emotions are also identified with observable bodily phenomena the question then arises as to how we can be sure that the subjective, emotional state corresponds to, let alone matches, the physiological dimension of that state – whether the emotion is definable as a facial expression, as substances in the blood, or as activity in certain parts of the brain.

While there is some controversy over whether emotions originate in the cerebral cortex, in evolutionarily older parts of the brain such as the midbrain or in multiple and connected parts of the body-mind, Panksepp (1998) and Panksepp & Biven (2012) are major proponents of the view that seven basic emotions can be identified in all mammals, and that they have a basis in the brainstem. Panksepp has studied emotions throughout his career, and is an influential voice. Panksepp’s research and theory strongly suggests that all mammals share these emotional systems.

Some of the problems of understanding emotions through neuroscience are set out in Miller (2010).

Following are some sources about the contribution of neurobiology to understanding emotions:

• Larsen et al. (2008) describes in systematic detail the psychophysiology of emotions. It reviews the research evidence for the different theories of parts of the nervous system involved in emotions. It also deals with the question of lateralization, and discusses differences between the left and right hemispheres as regards specialization on positive vs negative emotions, as well as specialization between approach and avoidance motivation. This chapter follows the more classical theorization about emotions, and does not even refer to Panksepp.
• LeDoux (1998) is an important monograph about emotional neuroscience. Based in part on original research, LeDoux reviews historical views about how emotions originate in the nervous system. He has an enlightening discussion of MacLean’s brain theories. He discusses localization of emotions, emotional mechanisms, and emotional memories. LeDoux & Phelps (2008) is a more recent and much shorter summary, with similar views, and references to the literature. It has an extensive discussion of fear.
• Panksepp & Biven (2012) is the latest book in which Panksepp sets out his views about the neurobiological basis of emotions. Panksepp’s views are based on a lifetime of original research, mostly with animals. While they are deeply anchored in research evidence, the overall vision and a number of accents he puts have not been accepted by the great majority of neurobiology researchers, especially his views that emotions at a primary level must be understood sub-cortically, and that non-human animals have substantially the same emotional systems and emotions as humans.
• Damasio (1994, especially Ch. 7) has an especially good chapter on emotions in a complete book devoted to discussing the mind-body problem, and advocating non-dualistic views of mind and body.
• Lindquist et al. (2012) is a meta-analytic review of the latest research evidence about the brain basis of emotions that allows a more refined view of the different ideas about emotions as represented by classical researchers, Panksepp and Damasio.
• Tooby & Cosmides (2008) is a review by two of the most respected evolutionary psychologists of the evolutionary backgrounds to different emotions. This view does not directly contradict, but is additional to the more purely neurobiological views of emotions, as it provides explanations at a different level and in a different, evolutionary, time frame.

Affect regulation

Affect regulation plays a key role in psychotherapy, and is seen by many as a major element in a range of mental disorders, as described in Greenberg (2002), Schore (2003a, 2003b, 2012), Linehan (1993) and Rothschild (2000). Schore (2012) explains how interpersonal neurobiological findings contribute to understanding the mechanisms of affect regulation, and offers promise of how this may influence psychotherapeutic practice. Gross (2007) is an extensive and very complete review volume, with a strong emphasis on neurobiology, but also its developmental underpinnings.

A number of brain parts contribute to emotional regulation: locations in the prefrontal cortex, the anterior cingulate cortex and the amygdala. In Panksepp’s view the brainstem contributes significantly – which fits in well with other brainstem functions. The autonomic nervous system is usually engaged, and most emotions include facial expressions, which are generated by parts of the motor system. It has been reported that different parts of the brain are active for different emotions. (On all these points see Larsen et al. (2008)). As regards the lateral hemispheres, there is an often-stated view that the right hemisphere of the cerebral cortex is more active in processing emotion. Coan & Allen (2004) summarise the difficulties with doing appropriately conclusive brain studies on this point.

Please view Dr Ruth Lanius’s video in this module for an exploration of the function and anatomy of the intrinsic brain networks (central executive, salience and default-modes) and the importance of being able to move flexibly between these in maintaining affect regulation.

Localisation of brain functions and brain modularity

Much cognitive neuroscience reports the outcome of research into locations or parts of the nervous system that are involved in particular experiences, cognitions, emotions, behaviours or functions. This is not new. Franz (1901) offers an overview of all the research that was done in the 1890s in this regard. Whilst the research, especially that supported by the increasingly sophisticated brain imaging techniques, provides real evidence of association and statistical correlation of brain activity with certain other activities, stimuli or phenomena, there are severe limitations on the conclusions one can draw (even in the most-researched areas such as fear) as there is no access to what the activity consists of and what it means.

The highest level meaningfulness of ‘localisation’ research is also modified by the main two conflicting theories about brain functioning: modularity and distributed processing. Modularity is the idea that the human mind, at least in part, and for at least a number of significant functions, is composed of innate modules which have been evolutionarily selected and have a substantial degree of independent functioning. Massive modularity at its most radical represents the view that the mind only has independent modules and very many – maybe thousands. Distributed processing (or connectionism) differs in suggesting that the human mind is characterised by a general problem-solving capability. In this view, the cerebral-cortical regions function as a single connected network, with different activities occurring in parallel but all of these with the potential to influence each other. This view may go back to William James and Hughlings Jackson.

The concept of modularity mainly originates in the work of Fodor (1983; 2000), and is now supported by most evolutionary psychologists in the more extreme form of massive modularity. Confer et al. (2010)reviews some of the general background. The discussion about modularity becomes at times very technical and difficult to follow but touches on issues of substance that continue to be controversial. Distributed processing is less of a “school” than modularity, but may be seen as a partly-owned designation for those scientists who are not convinced by the stronger views of modularity. Shallice & Cooper (2011) provide a nuanced but somewhat advanced view of the issues, especially in Chapters 2 and 3.

The lateralisation of the brain

Questioning the differences between the two brain hemispheres began in the second half of the 19th century with the work of Broca and Wernicke, who studied aphasia (a neurologically caused inability or impaired ability in language comprehension or ability to speak – whilst the physical capability seems to be present – vocal chords, etc.) This area of investigation developed following research done in the 1960s by Roger Sperry and Gazzaniga with human patients whose corpus callosum had been severed as a treatment for severe epilepsy.

There is little doubt that there are small differences in the exact size and shape of left and right hemispheres in most people. There also appears to be a degree of specialisation between the two sides, although there are also nuclei and locations where the two sides simply seem to function as a back-up, so that when one side is damaged or destroyed, the other one will take over the functions. The specialisation between the hemispheres is most pronounced for language function, with the left hemisphere being primary for explicitly semantic processing, and the right hemisphere for the emotional (affective) content of speech and perhaps qualitative aspects designated as “prosody”. This does mean, however, that in listening to speech both hemispheres are activated and co-operate.

As regards emotional lateralisation, rather than the often-quoted view that the right brain is primary for processing emotions, there is considerable evidence suggesting that the right hemisphere is primary for negative, and the left hemisphere for positive emotions (e.g. Larsen et al., 2008). It may also be that anger leads to a higher activity level in the left than in the right hemisphere (Coan et al., 2001). To the extent that it is possible in psychotherapy to primarily address one side preferentially, it seems to make a real difference which of these views is correct. Schore (2003a, 2003b, 2012) is amongst those who are very convinced of the great theoretical and practical therapeutic importance of hemispheric lateralisation. Coan & Allen (2004) set out a number of conceptual problems with much of the research conducted. The (relative) skeptics about lateralisation do not dispute that there are small differences and a degree of specialisation in the brain; they believe that the cortical left-right specialisation as far as known is more complementary than absolute, and that there is more plasticity in the brain than often assumed.

Please view Dr Iain McGilchrist’s videos in this module for an elaboration of the different functions of the right and left-brain hemispheres and clinical examples showing the functions of lateralisation.

Some major disorders with a clear biological origin

There are some “mental disorders” in DSM-5 for which a major genetic causality is established: Huntington’s disease, Down’s syndrome and some other neurodevelopmental disorders. There is a shift towards considering autism spectrum disorder as substantially genetically caused. And, as opposed to most other mental disorders, the neurocognitive disorders (dementias) all are linked with clearly visible and diagnosable changes in the brain. Beyond that there is much speculation around genetic causes, observable changes in the brain either of the size or the activity of particular brain locations and hypotheses about links with neurotransmitters, but little certainty. For autism spectrum and the potential genetic influences on other disorders, the multiple genes with small influences have not been determined, though some are speculated about (Plomin et al., 2013).

Neurocognitive disorders

The neurocognitive disorders (thus renamed in DSM-5; the old and still much-used name is dementias) are bound to have a steadily increasing degree of attention, as they affect more and more people all over the world. Neurocognitive disorders are not normal forms of ageing, but are identified forms of disease with observable biological signs. It used to be that an accurate diagnosis often had to await autopsy, but with the new brain-imaging techniques (often using MRI followed by PET) the differentiation between the major types of neurocognitive disorder is rapidly improving.

The neurocognitive disorders are a clear example of the time delay between fully knowing what a disease consists of and being able to find ways of curing or even substantially slowing down the disease progression.

Metaphors – utility and pitfalls

Using metaphors in psychotherapy has a long and distinguished history. Hypnosis uses metaphor to a great extent, and Freud made much use of the words of energy and force taken from physics. Probably the biggest metaphoric use of language in neuroscience is the words used for body components that are personified, or are used as homunculi. This happens for human parts as much as for animals and even cells; it may be more common for living organisms, but is not completely absent for purely material substances either (“the acid ate up the paper in no time”). A lighthearted set of ideas about metaphors for psychoanalysts is available in Friedman (2009).

There is nothing wrong with using words metaphorically, as long as the awareness of their metaphorical status is strong enough to avoid using them as links in real causal arguments. Interestingly enough, the effectiveness of using metaphor for communication, for rhetorical purposes, to explain or to influence or even to hypnotise does not seem to depend on a quality of truthfulness or appropriateness of correspondence it might or might not have. Visualisations of being in a special place, of growing to large proportions or becoming invisible, of being on fire or on the surface of a star do not have less potential power than ones that would stay closer to the laws of nature. The same is of course true for the very basic but powerful placebo effect.

Accordingly, it is difficult to put limits on the metaphorical use of neuroscientific words or narratives in a psychotherapeutic context according to whether something is proven or there is research evidence for it. One restraint may be the issue of misrepresentation to a client; when using official serious-sounding scientific language, it would seem that in certain contexts a client would consider that what you are saying is intended to be factual, truthful, and based on some form of objective evidence. The therapist must be guided here by their conscience and their ethical standards. More easily, when writing books or articles, or speaking in a professional forum, one would usually expect a psychotherapist to clarify it when they use words and ideas metaphorically rather than in their surface meaning. Similarly, if one uses ideas in order to reach conclusions for work or treatment which are based on causal reasoning, it remains of the utmost importance not to be confused, and to be sure that the reasoning continues to be based for every part of it on evidence, facts, and the supported ideas of other professionals. Anything else would be a risk of betraying one’s professional standards.

An interesting article about the use of “evidence” by psychotherapists is Milton (2002). Some books about metaphors in psychotherapy are Combs & Freedman (1990) and Stott et al. (2010). Lakoff & Johnson (1980) is one of the standard works on metaphor.

References

Coan, J.A. & Allen, J.J.B. (2004). Frontal EEG asymmetry as a moderator and mediator of emotion. Biological Psychology 67: 7-49.

Coan, J.A., Allen, J.J.B. & Harmon-Jones, E. (2001). Voluntary facial expression and hemispheric asymmetry over the frontal cortex. Psychophysiology 38: 912-925.

Combs, G. & Freedman, J. (1990). Symbol, Story and Ceremony: Using Metaphor in Individual and Family Therapy. New York: W W Norton.

Confer, J.C., Easton, J.A., Fleischman, D.S., Goetz, C.D., Lewis, D.M.G., Perilloux, C. & Buss, D.M. (2010). Evolutionary psychology: controversies, questions, prospects, and limitations. American Psychologist 65: 110-126.

Cozolino, L. (2010). The Neuroscience of Psychotherapy: Healing the Social Brain (2nd edition). New York: W W Norton.

Damasio, A. (1994). Descartes’ Error: Emotion, Reason, and the Human Brain. New York: Penguin.

Fodor, J. A. (1983). The Modularity of Mind: An Essay on Faculty Psychology. Cambridge, MA: MIT Press.

Fodor, J.A. (2000). The Mind Doesn’t Work That Way: The Scope and Limits of Computational Psychology.Cambridge, MA: MIT Press.

Frank, J.D. & Frank, J.B. (1991). Persuasion and Healing: A Comparative Study of Psychotherapy (3rd edition). Baltimore, MD: The Johns Hopkins University Press.

Franz, S.I. (1901). Localization of brain function. Psychological Review 8: 418-425.

Friedman, L. (2009). Tractatus metaphorico-psychoanalyticus (with apologies to L.W.). Psychoanalytic Inquiry 29: 12-17.

Greenberg, L.S. (2002). Emotion-Focused Therapy: Coaching Clients to Work Through Their Feelings.Washington, DC: American Psychological Association.

Gross, J.J. (Ed.) (2007). Handbook of Emotion Regulation. New York: The Guilford Press.

Gross, J.J. (2008). Emotion regulation. In M. Lewis, J.M. Haviland-Jones & L. Feldman Barrett (Eds.) (2008). Handbook of Emotions (3rd edition). New York: Guilford Press.

Lakoff, G. & Johnson, M. (1980). Metaphors We Live By. Chicago, IL: Chicago University Press.

Larsen, J.T., Berntson, G.G., Poehlmann, K.M., Ito, T.A. & Cacioppo, J.T. (2008). The psychophysiology of emotion. In M. Lewis, J.M. Haviland-Jones & L. Feldman Barrett (Eds.) (2008). Handbook of Emotions (3rd edition). New York: Guilford Press.

LeDoux, J. (1998). The Emotional Brain: The Mysterious Underpinnings of Emotional Life. London: Phoenix.

LeDoux, J.E. & Phelps, E.A. (2008). Emotional networks in the brain. In M. Lewis, J.M. Haviland-Jones & L. Feldman Barrett (Eds.) (2008). Handbook of Emotions (3rd edition). New York: Guilford Press.

Lindquist, K.A., Wager, T.D., Kober, H., Bliss-Moreau, E. & Barrett, L.F. (2012). The brain basis of emotion: a meta-analytic review. Behavioral and Brain Sciences, 35: 121-202.

Linehan, M.M. (1993). Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York: The Guilford Press.

Miller, G.A. (2010). Mistreating psychology in the decades of the brain. Perspectives on Psychological Science, 5: 716-743.

Milton, M. (2002). Evidence-based practice: issues for psychotherapy. Psychoanalytic Psychotherapy 16:160-172.

Panksepp, J. (1998). Affective Neuroscience: The Foundations of Human and Animal Emotions. Oxford: Oxford University Press.

Panksepp, J. (2008). The affective brain and core consciousness: how does neural activity generate emotional feelings? In M. Lewis, J.M. Haviland-Jones & L. Feldman Barrett (Eds.) (2008). Handbook of Emotions (3rd edition). New York: Guilford Press.

Panksepp, J. & Biven, L. (2012). The Archaeology of Mind: Neuroevolutionary Origins of Human Emotions.New York: W W Norton.

Plomin, R., DeFries, J.C., Knopik, V.S. & Neiderhiser, J.M. (2013). Behavioral Genetics (6th edition). New York: Worth Publishers.

Rose, S., Lewontin, R.C. & Kamin, L.J. (1984). Not in Our Genes: Biology, Ideology and Human Nature.London: Penguin Books.

Rothschild, B. (2000). The Body Remembers: The Psychophysiology of Trauma and Trauma Treatment.New York: W W Norton.

Rutter, M. (2006). Genes and Behavior: Nature-Nurture Interplay Explained. Malden, MA: Blackwell Publishing.

Schore, A.N. (2003a). Affect Dysregulation and Disorders of the Self. New York: W W Norton.

Schore, A.N. (2003b). Affect Regulation and the Repair of the Self. New York: W W Norton.

Schore, A.N. (2012). The Science of the Art of Psychotherapy. New York: W W Norton.

Shallice, T. & Cooper, R.P. (2011). The Organisation of Mind. Oxford: Oxford University Press.

Siegel, D.J. (2010). The Mindful Therapist: A Clinician’s Guide to Mindsight and Neural Integration. New York: W W Norton.

Siegel, D.J. (2012). Pocket Guide to Interpersonal Neurobiology: An Integrative Handbook of the Mind.New York: W W Norton.

Stott, R., Mansell, W., Salkovskis, P., Lavender, A. & Cartwright-Hatton, S. (2010). Oxford Guide to Metaphors in CBT: Building Cognitive Bridges. Oxford: Oxford University Press.

Tooby, J. & Cosmides, L. (2008). The evolutionary psychology of the emotions and their relationship to internal regulatory variables. In M. Lewis, J.M. Haviland-Jones & L. Feldman Barrett (Eds.) (2008). Handbook of Emotions (3rd edition). New York: Guilford Press.