Learner therapist (23)……What’s neuropsych got to do with it

Learner therapist (23)……What's neuropsych got to do with it!!

Torrey Orton

Oct. 7, 2012

 

Very recently I had a reason to have my head examined. Rather, I thought I had a number of reasons…forgetting short-term goals, losing the plot in conversations, slurring words, interrupted sleep, quick to anger under pressure, forgetting the names of common items. So I contacted a neurologist who has known me for ten years both professionally and personally, presented my wonders about encroaching dementia and got wired up for nuclear and CT scans of the brain. Result: all clear, no doubt in his mind that the symptoms are normal ageing stuff. In addition, he noted that his clinical impression of me pre-scans was what the scans confirmed…no cognitive impairment.

The thing about dementia is that it is one place we discover clearly that we are brain dependent. Demented person = slowly dying person as the organic systems break down and consciousness goes with them. Consciousness disappears before the body reaches its end. In this respect, we can clearly say that the brain as an organic entity causes our demise. There are a host of other organic dysfunctions which constrain consciousness in irreversibly causal ways.

This experience provides a personal entry to my agenda here. I've been wondering, with increasing intensity over the last year, what neuropsychology really has to offer psychotherapy that's new?! That wonder spreads back towards the biopsych and neuropsych domains, with a hope that they offer major intervention types or places I had avoided or ignored because I'm basically a relationship systems person. When I first undertook university psychology at the age of 43 in 1986 I believed (and still do) that all therapists should understand statistics to the extent of knowing what kinds of truth claims arise from that perspective and how they connect with individual, couple and family work. The same goes for neuropsych, which was just a glimmer at that time.

Five years ago I read The Neuroscience of Human Relationships. (Cozolino, W.W. Norton 2006 - a 428 page book of which 85 pages are references. Looking back today I had bookmarked the following paragraph:

…As our understanding of the brain continues to expand, we gain an increasing appreciation of the manner in which early experiences, both good and bad, become transformed (1) into the substance of our nervous system via the three messenger systems. As we have seen, early neglect, stress, and trauma impact all the developmental processes we have discussed in negative and destructive ways. Neglect and abuse decrease the growth of experience-dependent neural circuits, especially of the OMPFC, anterior cingulate, and insula cortex. Perhaps it may help us all to keep in mind that when we watch a child interacting with the world, we are witnessing the building and shaping of a brain in ways that will impact the individual throughout his or her life. (p. 301-302)

If you take out the references to the brain you get the basic understandings of late 20^th century therapy. The brain references add nothing to it other than asserting indirectly that there is some organic substrate (which has seldom been in doubt) to human experience, to conscious experience (which is what makes it human, by the way). And by the way, the building and shaping of a brain is an interdependent activity, not interactive nor transformatrive. That is, what a person (brain) learns is then brought to bear on the world in which he/she exists and shapes it, too, including the other persons in that world. And so back and forth and back and…

Five years later I attended a one day program ("Focussed Neuropsychotherapy: Applied Strategies for the treatment of anxiety") on May 2, 2012 presented by Dr Pieter Rossouw (see www.mediros.com.au). I hoped to find significant therapeutic innovations arising from the organic substrate. On the whole I will say there were none. A program titled "focussed", mirroring the generalist/clinical distinction in therapists by AHPRA, offered 90% standard issue evidence-based "strategies" for addressing anxiety which have no need of a neuropsych contribution to substantiate themselves. The neuropsych bit – brain education – I have been doing ever since I learned the amygdala was the name for our threat detection capacity. The program's encouragement to draw pictures of the limbic system and associated bits was not convincing to a long term user of the other strategies.

I took up this perception with the presenter offline so as not to disturb the other 50+ participants' gobbling up the "strategies". In response to my wonder what unique contribution neuropsych adds to the evidence-based approaches to anxiety management he volunteered that two neuropsych labelled therapist training programs in another state have been closed because that question could not be answered to the satisfaction of the providers…and maybe we could talk about it later. We have not. I have had other friables to attend to til now.

What is troubling, apart from my slight sense of deprivation at the lack of neuropsych therapeutic novelties, is the fake science that seems to accompany so much of my small reading in the domain. Some leading indicators of fake include: (1) addled causal attributions from brain scan screen patterns (lighting up in a new sense; see "transformed" in the previous quote from Cozolino); (2) covert meaning attributions from the history of thought about being human to brain functions and vice-versa (a relative of 1 above); (3) the straw man argument like cognitive therapy of anxiety is "top down" and neuropsych-informed is "bottom up", as Rossouw proposes below.

Dr. R concludes in a written-for-practitioners pre-reading article for the 02/05/12 workshop:

…Neurobiology reiterates an important psychotherapeutic principle (2): psychotherapy is not about a (albeit "good") bag of tricks, it is about the key role of the therapeutic relationship, empathy, and unconditional acceptance. These elements are not just important in the therapeutic process – neurobiology tells us they drive the efficacy of the process (1). These elements combined with a clear understanding of neurobiological information are the therapeutic makeup needed to facilitate change that has the capacity to facilitate new neural networks (1) – the ultimate aim of Neuropsychotherapy.

This is how he got there, roughly: by constructing a pseudo controversy about "top down" and "bottom up" therapy, claiming that CBT is the first and neuropsych will balance the equation. His argument runs…

In light of this debate Kabat-Zinn (2003) and later Siegel (2010) introduce the concept of mindfulness as an integrated approach (emotional-cognitive-spiritual and behavioural) and say that, when we "come to our senses", we become grounded in a mindful way of being that opens us to ourselves and to others. Siegel takes this concept further and says:

 

"A brain perspective on this experience of being fully present in the moment can shed some light on the path of bottom-up processing to liberate us from the prison of top-down" (Siegel 2010).

 

The key concept of a bottom-up (3) approach is the integration of the elements of "being" in the functionality of neural systems. For example neurobiological studies have clearly demonstrated the need for (1) a down-regulated amygdala response to facilitate synaptic communication.

 

This brings key psychotherapeutic principles like empathy and listening into play. Neurochemicals and neural communication change in the presence of these principles. Who the therapist is and the social environment of the therapeutic setting are more fundamental to facilitate new neural communications than hard core clinical information.

 

Neurobiological studies have demonstrated the need for (1) effective hippocampal firing for enhanced neural growth and new synaptic communication. Emotional safety and good nutrition are vital to facilitate effective hippocampal activity (2).

(emphasis supplied)

 

I don't know who this "top down" practitioner is, though there must be some handbook driven types in our trade, as in any. The rest would offer simple suggestions / techniques which augmented thought reconstruction (cbt) with exercise, meditative practices, sleep and eating regulation and task reduction or scheduling to "down regulate" stress. The more integrated therapists would include suggestions of sharing currently bothersome experiences with appropriate family members and/or friends. These amount to implementation of the biopsychosocialcultural (or spiritual) paradigm most health practitioners have claimed at least organisationally to support for 25+ years.

Ordinary language for everyday life

So whenever you hear or read someone touting the wonders of neuropsych for therapeutic applications consider the following linguistic adjustments to their spiels:

Replace 'neuronal' with 'perceptual'; replace 'neural networks' with 'habit(s)'; replace 'plasticity' with 'learning'; replace 'brain' with 'mind' and you will have what you already know about the mind or self in action with therapeutic assistance, or even without it.

Perhaps I'm churlish. The neuropsychs are just doing what most social scientists do: seek to extend a handful of insights and a sketch of a construct to every aspect of a human domain - in this case, psychotherapy. The move is made by explicit or implicit claims (mostly the latter) that the existing constructs are actually the new ones in mufti…or just outmoded because not evidence-based science. How could they do otherwise?

Maybe the unique neuropsych contribution will be available when every patient can be cheaply scanned for a few days or weeks (to get personally unique data) which can tell them and us that what they feel – anxious, etc. – is now confirmed as what they feel because blinking lights are attached?

The incommensurability category mistake – synaptic firing and everyday perception operate at different speeds and levels of integration

The experience of anxiety is fed by perceptions of danger which overwhelm existing capabilities. That overwhelm is at the level of everyday language and reflection and interaction…the daily world, not the neural, the neural-networking or the brain. That is, as with relativity physics, it may be so that everything is relative, but not in daily life. Newtonian physics applies there. The theories of that physics sit in the relative universe, but for us in our daily lives they are not supplanted by it.

Neurons and neural networks undoubtedly underpin our conscious and sub-conscious experience, but that experience is not accessible to direct inspection. Similarly, being on time in a particular place for a particular purpose with a particular person is a meaningful expectation and achievement – for people, that is. Maybe not for neural networks, except where their incapacities prohibit being on time, etc., for which we then excuse their human owners for an objective fault not of their making.

I close with a plea: please tell me what is uniquely noteworthy about neuropsych for my therapy? Help me out here.