How to Help Learning Stick for Clients

What Can Neuroscience Tell Us About Psychotherapy?

Magazine Issue
September/October 2013
How to Help Learning Stick for Clients

It’s usually easy to see when clients are tuned out or turned off, simply not absorbing what you’re trying to get across. What’s puzzling is when things seem to be really clicking in session—when you’re sure clients will return to report their success at having applied the new awareness and skills they’ve just acquired to their lives—and then you find that they haven’t followed through.

A study by David Atkins and colleagues, published in the June 2012 issue of Behaviour Research & Therapy, found that clients in couples therapy are less likely to recall communication skills learned during high levels of emotional arousal. As the authors report, “Greater emotional arousal predicts remembering fewer skills,” and “sustained emotional arousal may impact memory through encoding, retrieval, or both.” Other studies have also established how strongly stress hormones can affect learning and memory. However, in the June 2013 issue of Couple and Family Psychology: Research and Practice, couples therapist Brent Atkinson offers some practical suggestions for addressing this obstacle to therapeutic change. He proposes that combining our emerging understanding of brain science with the power of deliberate practice gives us effective tools for mitigating the power of emotionally charged situations. Keeping emotions in check would then prevent clients from losing access to the insights and skills they’ve presumably acquired in the consulting room.

“Many clients don’t have a basic level of mental fitness required to make changes,” says Atkinson. For these clients, despite their best intentions, being in conflicts with their partner or in other triggering circumstances results in flooding, or becoming overwhelmed by negative emotions. This often triggers diffuse physiological arousal (DPA)—activation of the autonomic nervous system’s alarm response, which initiates changes like increased heart rate, blood pressure, and levels of stress hormones like cortisol, all of which help prepare the body to deal with threats. In spite of the new insights and skills explored in therapy, the chance of new responses being tried out when a client’s nervous system has been hijacked by DPA are radically diminished. So before clients can make changes in their relationship with a partner, before therapy can really begin to have any real impact, the first order of business is to change clients’ relationship with their nervous system.

In Atkinson’s treatment model, the therapist first works with clients to get them motivated to tune up their nervous system, helping them understand why it’s important and introducing them to the concept of mindfulness. The couples then participate in an eight-week mindfulness course, and during concurrent couples therapy sessions, they practice extending the skills they’re learning to their relationships. If clients need help mindfully responding during stressful partner interactions, they listen to their partner’s criticisms via prerecorded voice messages, during which they practice using mindfulness skills to turn down their physiological and emotional arousal. As clients become more skilled at self-soothing, the therapist helps them to identify their typical sequence of conflict and to mentally rehearse how to respond more effectively when conflict arises—much like how athletes or musicians might engage in mental practice to enhance their skills.

Treatment models like Atkinson’s move the field of therapy away from a faith in the magical power of insight, or even the generalized benefits of the therapeutic alliance, toward a closer look at how to concretely make the process of emotional learning more efficient and sustainable. Since therapy outcome studies consistently show a discouraging overall finding—the average results of psychotherapy haven’t improved over the last 50 years—this new research certainly seems to be a step in the right direction.

– Tori Rodriguez

What Can Neuroscience Tell Us About Psychotherapy?

A client comes into therapy complaining of standard symptoms of depression: low mood, loss of appetite, difficulty concentrating. Some day in the near future, will therapists begin treatment, not by focusing on clients’ descriptions of their feelings, desires, and beliefs, but by directly assessing brain functioning and using techniques that stimulate activity in some parts of the brain and reduce it in others? Are we on the cusp of a fundamental shift in the methodology of psychotherapy?

The question of whether neuroscience will change psychotherapy was debated in the July/August issue of the Networker, “Searching for the Therapeutic ‘Aha’: Brain Science and Clinical Breakthroughs.” In the article “Therapy Isn’t Brain Science,” Steve Andreas argued that “brain science has yet to translate its findings into effective or practical recipes for therapists,” while in “Unlocking the Emotional Brain,” Bruce Ecker claimed that “the discoveries of brain science can help us create liberating breakthroughs for our clients.”

These contrasting perspectives reflect a larger conversation in the scientific community about the relevance of neuroscience. A recent article in Slate, for example, titled “The End of Neuro-Nonsense,” for example announces the decline of “neuro-hype,” the overenthusiasm for neuroscience that’s led to claims that it can be used not only to understand people’s thoughts and feelings, but to reliably predict and shape their behavior. In a recent blog post for the New Yorker, however, New York University psychologist Gary Marcus suggests that the pendulum might be swinging too far in the other direction, resulting in a “reckless backlash” against neuroscience. He gives examples of insights gleaned from neuroimaging, such as the recent finding that depressed and nondepressed people show different patterns of brain activity. Turning our backs on neuroscience, he warns, “might sacrifice important insights that could reshape psychiatry and medicine.”

A number of recently published books have deepened and intensified the neuroscience debate as well. In one of the of most discussed, Brainwashed: The Seductive Appeal of Mindless Neuroscience, Scott Lilienfeld, often a scathing critic of the therapy field, raises basic questions about the relevance of neuroscience. Although it has the potential to inform psychotherapy, he says he’s “surprised at how oversold it’s been given how little data are out there.”

Neurofeedback is an example of a technique whose practitioners have far more enthusiasm than the science supports, Lilienfeld says. During neurofeedback training, clients are given ongoing feedback about the activity in different parts of their brain as recorded by electrodes attached to the scalp, and are taught to regulate that activity in response to various stimuli. The technique has received attention for treating symptoms for a range of disorders, including attention-deficit hyperactivity disorder, anxiety, depression, and autism.

Lilienfeld thinks neurofeedback is “intriguing and worth pursuing . . . but not ready for prime time.” There simply isn’t enough empirical evidence to show that it works, he says. Yet he sees potential for the technique to address brain abnormalities in some disorders—the atypical reward circuitry observed in depression, for example. More generally, he believes neuroscience can inform treatment of various disorders, citing as an example a recent study suggesting that neuroimaging can be used to select the optimal treatment for those with major depression. Still, Lilienfeld insists that “it’s going to be incumbent on neuroscience researchers to show that we need to look directly at the brain” to understand mental disorders better. Brain-based techniques are often time-consuming and expensive, he explains, “so there’s a burden of proof to demonstrate . . . incremental validity above and beyond what we already have at our disposal.”

For practitioners of neuroscientific methods, the proof is often in clients’ dramatic responses to treatment. Sebern Fisher, a psychotherapist in Northampton, Massachusetts, who has a forthcoming book on neurofeedback, says she’s observed amazing recoveries using the technique. For her, the decision of whether to use neurofeedback rests on a key question: “Are rage, shame or fear driving the situation?” She says, “I know I can help people quiet those emotions,” and psychotherapy can then be much more effective.

Fisher points out that the principle behind neurofeedback and other brain-based methods—that certain mental disorders are caused by faulty brain circuitry—is starting to gain traction in the mainstream scientific community. She mentioned a recent TED Talk in which Thomas Insel, director of the National Institute of Mental Health, argues that we should view mental disorders as brain disorders. As a result of this shift, Fisher says, methods such as neurofeedback are moving “away from the fringes.”

Tantalized with the new doorway that neuroscience research offers into their work, some therapists, at this early stage, are certainly guilty of applying neuroscience-based techniques excessively and imprecisely, and of overreaching for general truths about the results. Nonetheless, there’s a growing consensus that when it comes to disorders of the mind, it’s important to look at the brain. Thus, it seems inevitable that as we expand our understanding of how the brain functions, we’ll look to understand what happens in therapy more and more in neuroscientific terms. In fact, the future of psychotherapy is likely to be dominated by the language, and possibly the technology, of neuroscience. But that day is not yet here, despite a bold prediction by Insel in a 2010 Scientific American article: “today’s developing science-based understanding of mental illness very likely will revolutionize prevention and treatment and bring real and lasting relief to millions of people worldwide.”

– Jennifer Richler

Tori Rodriguez

Tori Rodriguez, MA, LPC, is an Ayurvedic psychotherapist and health coach in Georgia.